Control of tuberculosis by community health workers in Bangladesh

Abstract

Background: Tuberculosis remains a major public-health problem in Bangladesh, despite national efforts to improve case identification and treatment compliance. In 1984, BRAC (formerly the Bangladesh Rural Advancement Committee), a national, non-governmental organisation, began an experimental tuberculosis-control programme in one thana (subdistrict). Community health workers screened villagers for chronic cough and collected sputum samples for acid-fast bacillus (AFB) microscopy (phase one). Positive patients received 12 months of directly observed therapy. Phase two (1992-94) included another nine thanas and, in phase three (1995), eight more thanas were included. From 1995, the treatment was an 8-month oral regimen.

Methods: In 1995-96, we analysed all programme data from 1992 to 1995. First we analysed phases two (12-month therapy) and three (8-month therapy) separately for proportion cured, died, treatment, failed, defaulted, migrated, and referred. Second, we did a cross-sectional survey of tuberculosis cases in more than 9000 randomly selected households in two phase-two thanas and one non-programme thana, and analysed the follow-up of all patients treated in the programme thanas.

Findings: In the phase-two analysis, 3497 (90%) of 3886 cases identified had accepted 12-month treatment. In phase three, all of 1741 identified cases accepted the 8-month regimen. 2833 (81.0%) and 1496 (85.9%) in phases two and three, respectively, were cured; 336 (9.6%) and 133 (7.6%) died. The relapse rate 2 or more years after treatment was discontinued was higher than the early relapse rate. The drop-out rate was 3.1%. In the cross-sectional survey, the prevalence of tuberculosis in the two programme thanas was half of that in the comparison thana, where only government services were available (0.07 vs 0.15 per 100 [corrected]).

Interpretation: The BRAC tuberculosis-control programme has successfully achieved high rates of case detection and treatment compliance, with a cure rate of at least 85% and a drop-out rate of 3.1%. The prevalence survey suggested that at least half of all existing cases had been detected by the programme.

PIP: In 1984 the Bangladesh Rural Advancement Committee (BRAC), a national nongovernmental organization, began an experimental tuberculosis control program in 1 thana (subdistrict). In phase 1 community health workers screened villagers for chronic cough and collected sputum samples for acid-fast bacillus (AFB) microscopy. Positive patients underwent a 12-month therapy. Phase 2 during 1992-94 included 9 other thanas, and in phase 3 in 1995 8 more thanas were included. Between 1984 and 1994 the treatment regimen consisted of 30 streptomycin injections on alternate days for 2 months and 300 mg of isoniazid and 150 mg of thiacetazone daily for 12 months. From 1985 the treatment was an 8-month oral regimen of isoniazid, pyrazinamide, ethambutol, and rifampicin daily for 2 months, then isoniazid and thiacetazone daily for 6 months. During 1995-96 program data were analyzed from 1992-95. First the 12-month therapy of phase 2 and the 8-month therapy of phase 3 were analyzed separately for proportion cured, deceased, treatment failed, defaulted, migrated, and referred. Then a cross-sectional survey of TB cases was carried out in more than 9000 randomly selected household in 2 phase-2 thanas and 1 nonprogram thana. The follow-up of all patients in the program thanas was analyzed. In the phase-2 analysis 3497 (90%) of 3886 cases identified had accepted the 12-month treatment. In phase 3 all of 1741 identified cases accepted the 8-month treatment regimen. 2833 (81%) and 1496 (85.9%) in phases 2 and 3, respectively, were cured; 336 (9.6%) and 133 (7.6%) died. 2 or more years after treatment was concluded, the relapse rate was higher than the early relapse rate. The drop-out rate was 3.1%. In the cross-sectional survey the prevalence of TB in the 2 program thanas was half of that in the comparison thana, where only government services were available: 0.07 vs. 0.15 per 1000. High rates of case detection and treatment compliance were achieved, with a cure rate of at least 85% and a low drop-out rate. At least half of all existing cases had been detected by the program.