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 Table of Contents  
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 215-217

Combatting drug-resistant tuberculosis in the midst of the ongoing COVID-19 pandemic: A formidable challenge for Bangladesh

1 Independent Medical Educationist, Researcher and Consultant, Public Health and Medical Education Issues; Department of Pharmacology and Therapeutics, Bangladesh Medical College and Hospital, Dhaka, Bangladesh
2 Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia, Kem Perdana Sungai Besi, Kuala Lumpur, Malaysia

Date of Submission30-Apr-2022
Date of Acceptance13-May-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
Prof. Mainul Haque
Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia, KEM Perdana Sungai Besi, Kuala Lumpur 57000
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aihb.aihb_78_22

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How to cite this article:
Rashid TJ, Haque M. Combatting drug-resistant tuberculosis in the midst of the ongoing COVID-19 pandemic: A formidable challenge for Bangladesh. Adv Hum Biol 2022;12:215-7

How to cite this URL:
Rashid TJ, Haque M. Combatting drug-resistant tuberculosis in the midst of the ongoing COVID-19 pandemic: A formidable challenge for Bangladesh. Adv Hum Biol [serial online] 2022 [cited 2022 Nov 30];12:215-7. Available from: https://www.aihbonline.com/text.asp?2022/12/3/215/348186

The world is currently in the midst of an ongoing pandemic, COVID-19, caused by the severe acute respiratory syndrome coronavirus 2 virus. The onslaught of the virus has ravaged millions of lives across the globe. As per the World Health Organization (WHO) dashboard status on the pandemic, globally, as of 25 April 2022, 507,501,771 confirmed cases of COVID-19, including 6,220,390 deaths, were reported to the WHO.[1] In South-East Asia, Bangladesh is home to 164 million [Sample Vital Registration System (SVRS) is a regular survey system of Bangladesh Bureau of Statistics (BBS)] and has a healthcare system already burdened with communicable and non-communicable diseases.[2] The country is challenged with combatting COVID-19 in addition to the overall disease burden. Tuberculosis (TB) is one of the major infectious diseases in Bangladesh.[3] Bangladesh is dealing with the usual drug-susceptible form and the resistant form of TB, like many other low-income countries around the globe. In 2020, geographically, the most significant number of new TB cases occurred in the South-East Asian region (43%), followed by the African region (25%) and the Western Pacific (18%).[4] TB is the 13th leading cause of death worldwide and the second leading infectious killer after COVID-19 (above HIV/AIDS). Eight countries accounted for two-thirds of the total, with India leading the count, followed by China, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa.[4] As per the WHO estimate of 2018, in Bangladesh, the incidence and mortality were 221 and 29/100,000 people, respectively, and the overall estimated (2015–2016) prevalence of TB was 260/100,000.[2]

Bangladesh falls in the 30 high TB burden countries and 30 high multidrug-resistant (MDR)-TB burden countries. As per epidemiological categorisation of countries (severely endemic, highly endemic, endemic, upper moderate, lower moderate and low), Bangladesh falls in the endemic category with 100–299 new and relapse cases per 100,000 population.[5] According to World Bank development indicators, detecting all forms of TB in Bangladesh was 27% in 2000 and 64% in 2020.[6]

The WHO uses five categories to classify cases of drug-resistant TB: (i) isoniazid-resistant TB, (ii) rifampicin-resistant (RR)-TB, (iii) MDR-TB (bacteria that do not respond to isoniazid and rifampicin), (iv) pre-extensively drug-resistant TB (pre-XDR-TB) and (v) extensive drug-resistant TB (XDR-TB). Pre-XDR-TB is TB resistant to rifampicin and any fluoroquinolone (a second-line anti-TB drug) class. The XDR-TB is TB resistant to rifampicin, plus any fluoroquinolone, plus at least one of the drugs – bedaquiline and linezolid.[7] MDR-TB remains a public health crisis, a health security threat and a major hindrance to effective TB control.[7],[8],[9]

Globally, in 2020, 71% (2.1/3.0 million) of people diagnosed with bacteriologically confirmed pulmonary TB were tested for rifampicin resistance, up from 61% (2.2/3.6 million) in 2019 and 50% (1.7/3.4 million) in 2018. Amongst these, 132 222 cases of MDR/RR-TB and 25,681 cases of pre-XDR-TB or XDR-TB were detected in 157,903. The global coverage of testing for resistance to fluoroquinolones remained much lower, at just over 50% worldwide in 2020. Levels were still lower (not much above 25%) in the WHO regions of the Americas, South-East Asia and the Western Pacific.[4] RR/MDR-TB epidemics are likely to be driven by direct transmission. The most critical risk factor for MDR-TB is a history of previous treatment. Other risk factors vary according to the setting but include hospitalisation, incarceration and HIV infection.[10] The 2010–2011 Bangladesh Drug Resistance Survey showed MDR-TB prevalence to be 7% overall, 1.4% in new and 28.5% in previously treated patients. A sentinel surveillance system showed the proportion of MDR-TB was 2.3% amongst new and 13.8% amongst previously treated TB patients.[11],[12]

In the Sustainable Development Goal (SDG) era, the WHO has developed the End TB Strategy 2016–2035, intending to end the global epidemic of TB by 2035.[13],[14],[15] All countries worldwide have committed to achieving the universal health coverage (UHC) target of SDG 3.8 by 2030.[16] New multisectoral strategies and an End TB Strategy have been adopted in Bangladesh's 2016 National TB Control Program (NTP) Vision like other low- and middle-income countries (LMICs).[17],[18] Bangladesh and other countries in similar predicament will require strengthening the entire TB management process, including improved case detection, the establishment of universal drug susceptibility testing and rapid treatment initiation.[19],[20],[21],[22] The struggle to lower the incidence and prevalence of drug-resistant TB makes it a hard-to-reach target for countries such as Bangladesh and other LMICs,[23],[24],[25] primarily because detection of drug resistance requires bacteriological confirmation of TB and testing for drug resistance using rapid molecular tests, culture methods or sequencing technologies.[26]

The WHO has published consolidated guidelines on treating drug-susceptible and drug-resistant TB, though reports stated 15% of MDR/RR-TB died and 26% of XDR-TB cases.[27] Bangladesh NTP launched the programmatic management of drug-resistant TB in 2008 with a 20-month regimen, which was later followed by the successful implementation of a shorter 9-month regimen called 'Bangladesh Regimen' in 2017. Bangladesh introduced bedaquiline and delamanid in 2016 to demonstrate success in the management of pre-XDR, XDR and MDR cases.[2]

During the pandemic, there have been both supply- and demand-side disruptions to TB diagnostic and treatment services during the pandemic, such as reduced health system capacity to continue to provide services, less willingness and ability to seek care in the context of lockdowns and associated restrictions on movement, concerns about the risks of going to healthcare facilities during a pandemic and stigma associated with similarities in the symptoms related to TB and COVID-19. Sentinel studies have found that MDR cases appropriately diagnosed are not always reported to NTP with significant programmatic implications.[11]

Amongst various interventions/approaches proposed for effective TB control are active case detection, usage of rapid diagnostics, social, financial protection for the poor and vulnerable, targeted communication programmes, expansion of public–private mix, etc.[17] Furthermore, scaling up the use of molecular diagnostic tests and continuous surveillance system for monitoring and evaluation of drug-resistant TB control is crucial for overall success.

In conclusion, we have documented the current status of drug-susceptible TB and drug-resistant TB case detection, diagnosis, prevention and control, highlighting factors causing hindrances to the effective management of the disease. Such factors negatively impact the success of TB control, especially within the context of the ongoing pandemic and the numerous hurdles that the healthcare system of any country in the same category as Bangladesh has to overcome to attain SDG goals and UHC for all. We have reiterated specific rewarding interventions that can facilitate better TB control. All stakeholders involved in the TB control intervention have to collaborate to ensure safe, efficacious and quality management of drug-resistant TB.

Financial Support and Sponsorship

This editorial was not funded.

Conflicts of Interest

The authors declare there are no conflicts of interest.

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World Health Organization. WHO Global Lists of High Burden Countries for Tuberculosis (TB), TB/HIV, and Multi-Drug/Rifampicin-Resistant TB (MDR/RR-TB), 2021–2025. Available from: https://cdn.who.int/media/docs/default-source/hq-tuberculosis/who_globalhbcliststb_2021-2025_backgrounddocument.pdf?sfvrsn=f6b854c2_9. [Last accessed on 2022 Apr 25].  Back to cited text no. 5
World Bank. Tuberculosis Case Detection Rate (%, all forms) – Bangladesh. Available from: https://data.worldbank.org/indicator/SH.TBS.DTEC.ZS?locations=BD. [Last accessed on 2022 Apr 25].  Back to cited text no. 6
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