Prevalence and Determinants of Tuberculosis in Bangladesh
Added on 2019-12-28
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Systematic review on
“Prevalence and
Determinants of
Tuberculosis in Bangladesh”
“Prevalence and
Determinants of
Tuberculosis in Bangladesh”
ABSTRACT
Key background literature: Tuberculosis is an infectious air borne disease. Tuberculosis (TB)
has emerged as the next global public health crisis. This is because it is responsible for ill health
among millions of people every year. TB occurs in all parts of the world. Bangladesh is a lower
middle income country. The rate of tuberculosis per 100, 000 population in Bangladesh has
increased in the past years. In the 2011, the rate was 225 incident cases per 100, 000 of
population. This has increased to 227 cases per 100, 000 of population
Rationale: As the number of cases of tuberculosis is increasing in Bangladesh and the problem is
being aggravated by the TB stigma, there is a need to find out the underlying reasons associated.
Aims: The overall aim of this systematic review is to investigate TB and its associated stigma in
Bangladesh.
Methods: In the present study, systematic literature review study design has been employed.
Search strategy comprised of key search terms, boolean operators, electronic databases.
Findings: Tuberculosis is prevalent in Bangladesh in the poorer sections, urban slums and
prisons. There are a number of determinants of the disease such as social contact pattern, lack of
awareness and knowledge, inequitable distribution of health benefits, health system delay and
high prevalence of TB in prisons. TB is highly stigmatized in the country which results into
delay in diagnosis and initiation of treatment thus leading to increased prevalence of the disease.
Conclusion: The results of this review suggest that various determinants are responsible for high
prevalence of TB in Bangladesh. There is a n the prevalence of TB is increasing in Bangladesh
owing to the various determinants.
Implications: There is a need to take steps to raise awareness and increase knowledge about the
disease. Health system delay should be tackled. Provision of treatment services for TB should be
made equitably accessible.
2
Key background literature: Tuberculosis is an infectious air borne disease. Tuberculosis (TB)
has emerged as the next global public health crisis. This is because it is responsible for ill health
among millions of people every year. TB occurs in all parts of the world. Bangladesh is a lower
middle income country. The rate of tuberculosis per 100, 000 population in Bangladesh has
increased in the past years. In the 2011, the rate was 225 incident cases per 100, 000 of
population. This has increased to 227 cases per 100, 000 of population
Rationale: As the number of cases of tuberculosis is increasing in Bangladesh and the problem is
being aggravated by the TB stigma, there is a need to find out the underlying reasons associated.
Aims: The overall aim of this systematic review is to investigate TB and its associated stigma in
Bangladesh.
Methods: In the present study, systematic literature review study design has been employed.
Search strategy comprised of key search terms, boolean operators, electronic databases.
Findings: Tuberculosis is prevalent in Bangladesh in the poorer sections, urban slums and
prisons. There are a number of determinants of the disease such as social contact pattern, lack of
awareness and knowledge, inequitable distribution of health benefits, health system delay and
high prevalence of TB in prisons. TB is highly stigmatized in the country which results into
delay in diagnosis and initiation of treatment thus leading to increased prevalence of the disease.
Conclusion: The results of this review suggest that various determinants are responsible for high
prevalence of TB in Bangladesh. There is a n the prevalence of TB is increasing in Bangladesh
owing to the various determinants.
Implications: There is a need to take steps to raise awareness and increase knowledge about the
disease. Health system delay should be tackled. Provision of treatment services for TB should be
made equitably accessible.
2
TABLE OF CONTENTS
ABSTRACT....................................................................................................................................2
CHAPTER 1- INTRODUCTION ...................................................................................................5
1.1 Introduction ...........................................................................................................................5
1.2 Background ...........................................................................................................................5
1.3 Rationale of the study ...........................................................................................................7
1.4 Research Question ................................................................................................................8
1.5 Aims and Objectives of study ...............................................................................................8
1.6 Scope of dissertation..............................................................................................................8
1.7 Conclusion ............................................................................................................................9
Chapter 2- literature review ..........................................................................................................10
2.1 Introduction..........................................................................................................................10
2.2 Prevalence and transmission of pulmonary tuberculosis ....................................................10
2.3 Lack of Knowledge of regarding tuberculosis leads to its increased prevalence ...............14
2.4 Spread of tuberculosis in Bangladesh..................................................................................17
2.4 Multi-drug resistant tuberculosis- nursing practice guidelines............................................18
2.5 Tuberculosis control ............................................................................................................19
CHAPTER 3- METHOD ..............................................................................................................21
3.1 Introduction .........................................................................................................................21
3.2 Research design ..................................................................................................................21
3.3 Inclusion and exclusion criteria ..........................................................................................22
3.4 Searching strategy ...............................................................................................................23
3.5 Screening strategy ..............................................................................................................26
3.6 Data extraction ....................................................................................................................27
3.7 Quality Appraisal ................................................................................................................27
3.8 Ethical issues .......................................................................................................................28
3.9 Analysis ...............................................................................................................................29
3.10 summary ............................................................................................................................30
CHAPTER 4- RESULTS ..............................................................................................................31
4.1 Introduction .........................................................................................................................31
4.2 Summary of the selected studies .........................................................................................33
3
ABSTRACT....................................................................................................................................2
CHAPTER 1- INTRODUCTION ...................................................................................................5
1.1 Introduction ...........................................................................................................................5
1.2 Background ...........................................................................................................................5
1.3 Rationale of the study ...........................................................................................................7
1.4 Research Question ................................................................................................................8
1.5 Aims and Objectives of study ...............................................................................................8
1.6 Scope of dissertation..............................................................................................................8
1.7 Conclusion ............................................................................................................................9
Chapter 2- literature review ..........................................................................................................10
2.1 Introduction..........................................................................................................................10
2.2 Prevalence and transmission of pulmonary tuberculosis ....................................................10
2.3 Lack of Knowledge of regarding tuberculosis leads to its increased prevalence ...............14
2.4 Spread of tuberculosis in Bangladesh..................................................................................17
2.4 Multi-drug resistant tuberculosis- nursing practice guidelines............................................18
2.5 Tuberculosis control ............................................................................................................19
CHAPTER 3- METHOD ..............................................................................................................21
3.1 Introduction .........................................................................................................................21
3.2 Research design ..................................................................................................................21
3.3 Inclusion and exclusion criteria ..........................................................................................22
3.4 Searching strategy ...............................................................................................................23
3.5 Screening strategy ..............................................................................................................26
3.6 Data extraction ....................................................................................................................27
3.7 Quality Appraisal ................................................................................................................27
3.8 Ethical issues .......................................................................................................................28
3.9 Analysis ...............................................................................................................................29
3.10 summary ............................................................................................................................30
CHAPTER 4- RESULTS ..............................................................................................................31
4.1 Introduction .........................................................................................................................31
4.2 Summary of the selected studies .........................................................................................33
3
4.3 Findings of the study ...........................................................................................................33
4.4 Summary .............................................................................................................................36
CHAPTER 5- DISCUSSION .......................................................................................................37
5.1 Introduction .........................................................................................................................37
5.2 Main results and comparison with existing literature ........................................................37
5.3 Implications of findings and their significance for public health policy ............................41
5.4 Critical evaluation of the present review ............................................................................42
CHAPTER 6- CONCLUSION ....................................................................................................44
6.1 Conclusion ..........................................................................................................................44
6. 2 Future research .................................................................................................................44
references ......................................................................................................................................46
APPENDIX 1.................................................................................................................................54
APPENDIX 3.................................................................................................................................63
4
4.4 Summary .............................................................................................................................36
CHAPTER 5- DISCUSSION .......................................................................................................37
5.1 Introduction .........................................................................................................................37
5.2 Main results and comparison with existing literature ........................................................37
5.3 Implications of findings and their significance for public health policy ............................41
5.4 Critical evaluation of the present review ............................................................................42
CHAPTER 6- CONCLUSION ....................................................................................................44
6.1 Conclusion ..........................................................................................................................44
6. 2 Future research .................................................................................................................44
references ......................................................................................................................................46
APPENDIX 1.................................................................................................................................54
APPENDIX 3.................................................................................................................................63
4
CHAPTER 1- INTRODUCTION
1.1 Introduction
This chapter will discuss the aspects related to tuberculosis in Bangladesh and stigma
associated with it. Key background literature will be provided on TB in Bangladesh and stigma
related to it. The introduction chapter will also provide an explicit and convincing rationale
behind carrying out this systematic review. Aim and objectives of the review will be clearly
stated in this chapter.
1.2 Background
1.2.1 What is tuberculosis and drug-resistant tuberculosis?
According to World Health Organization, Tuberculosis is an infectious disease which
affects the lungs (Tuberculosis (TB), 2016). It is caused by Mycobacterium. Its transmission
from one person to another takes place via droplets from the throat or lungs of people who have
respiratory disease in the active state (Tuberculosis (TB), 2016). In healthy people, the immune
system acts as a barrier and fights the bacteria. Therefore, Mycobacterium tuberculosis shows no
symptoms. Symptoms of active TB of lungs includes coughing, night sweats, fever, chest pains,
weakness, weight loss etc. the bacteria which is responsible for causing TB can develop
resistance to the antimicrobial drugs which are administered for curing the disease (World Health
Organization, 2016). Multi drug resistant TB (MDR TB) is defined as a type of TB infection
which is cause by bacteria that shows resistance to treatment with most powerful first line TB
drugs (What is multidrug-resistant tuberculosis (MDR-TB) and how do we control it? 2015).
1.2.2 Tuberculosis: A global health crisis
Tuberculosis (TB) has emerged as the next global public health crisis. This is because it
is responsible for ill health among millions of people every year (Global tuberculosis report,
2014). The death toll from the disease it unacceptably high and the current efforts prove to be
insufficient to control the disease. Moreover, XDR TB has also emerged as a form of TB which
is resistant to most TB drugs thus increasing the burden of this disease (Global tuberculosis
report, 2014). This highly contagious airborne disease may become difficult to be controlled as
the nations are not prepared to meet the threat posed by this disease (Lienhardt et.al., 2012). In
the year 2014, TB killed 1.5 million people. In the year 2013, nine million people contracted TB.
Of them, half million infections were of drug resistant TB. Moreover, the problem is likely to
5
1.1 Introduction
This chapter will discuss the aspects related to tuberculosis in Bangladesh and stigma
associated with it. Key background literature will be provided on TB in Bangladesh and stigma
related to it. The introduction chapter will also provide an explicit and convincing rationale
behind carrying out this systematic review. Aim and objectives of the review will be clearly
stated in this chapter.
1.2 Background
1.2.1 What is tuberculosis and drug-resistant tuberculosis?
According to World Health Organization, Tuberculosis is an infectious disease which
affects the lungs (Tuberculosis (TB), 2016). It is caused by Mycobacterium. Its transmission
from one person to another takes place via droplets from the throat or lungs of people who have
respiratory disease in the active state (Tuberculosis (TB), 2016). In healthy people, the immune
system acts as a barrier and fights the bacteria. Therefore, Mycobacterium tuberculosis shows no
symptoms. Symptoms of active TB of lungs includes coughing, night sweats, fever, chest pains,
weakness, weight loss etc. the bacteria which is responsible for causing TB can develop
resistance to the antimicrobial drugs which are administered for curing the disease (World Health
Organization, 2016). Multi drug resistant TB (MDR TB) is defined as a type of TB infection
which is cause by bacteria that shows resistance to treatment with most powerful first line TB
drugs (What is multidrug-resistant tuberculosis (MDR-TB) and how do we control it? 2015).
1.2.2 Tuberculosis: A global health crisis
Tuberculosis (TB) has emerged as the next global public health crisis. This is because it
is responsible for ill health among millions of people every year (Global tuberculosis report,
2014). The death toll from the disease it unacceptably high and the current efforts prove to be
insufficient to control the disease. Moreover, XDR TB has also emerged as a form of TB which
is resistant to most TB drugs thus increasing the burden of this disease (Global tuberculosis
report, 2014). This highly contagious airborne disease may become difficult to be controlled as
the nations are not prepared to meet the threat posed by this disease (Lienhardt et.al., 2012). In
the year 2014, TB killed 1.5 million people. In the year 2013, nine million people contracted TB.
Of them, half million infections were of drug resistant TB. Moreover, the problem is likely to
5
grow more as the funds which are required for prevention, diagnosis and treatment of TB
worldwide are $ 1.7 billion short (Foster, 2015). There is meagre level of investment in research
on vaccines and new treatment. The scale on which people are suffering from the disease and
dying is alarming. However, potential for wide consequences is the matter of concern of public
health advocates. Various surveillance studies and outbreak investigations indicate increasing
prevalence of extensively drug resistant (XDR) form of tuberculosis in the world (Ellner, 2008).
The scale of spread of tuberculosis has become comparable with HIV/ AIDS. The disease
has become a top killer among various infectious diseases all over the world (Global tuberculosis
report, 2014). Though significant advances have been made against TB throughout the mid 20
century. However, by the end of century, the disease followed a rising trend (Sotgiu et.al., 2014).
The alarming stage of TB came when doctors documented new strains of TB which showed
resistance to a number of indicated medicines (Sharma et.al., 2011). Centre for Disease Control
and Prevention states that spread of MDR TB and extensively drug resistant TB has become a
global security health concern (Frieden, 2015). Funding and maintaining the supply of expensive
drugs or treatment of TB has become a struggle (Kimbrough et.al., 2012). According to WHO,
one of the health targets of the newly adopted Sustainable Development goals is to end TB
epidemic by the year 2030 (Tuberculosis, 2016).
1.2.3 Prevalence of TB
TB occurs in all parts of the world (Gupta et.al., 2015). In the United States and Western
Europe, TB is relatively well controlled. However, it is widely spread across Asia, Latin
America, Eastern Europe and Africa. According to WHO, more than 95 per cent of deaths due to
TB take place in low and middle income countries. Most severe burden is carried by Africa with
281 cases per 100, 000 population in the year 2014 (Tuberculosis, 2016). In 2014, 6 countries
that had the largest number of incident cases of TB were India, People's Republic of China,
Pakistan, South Africa, Nigeria and Indonesia.
Bangladesh is a lower middle income country. The rate of tuberculosis per 100, 000
population in Bangladesh has increased in the past years. In the 2011, the rate was 225 incident
cases per 100, 000 of population. This has increased to 227 cases per 100, 000 of population
(Incidence of tuberculosis (per 100,000 people), 2016). Every year, TB causes death of 80, 000
6
worldwide are $ 1.7 billion short (Foster, 2015). There is meagre level of investment in research
on vaccines and new treatment. The scale on which people are suffering from the disease and
dying is alarming. However, potential for wide consequences is the matter of concern of public
health advocates. Various surveillance studies and outbreak investigations indicate increasing
prevalence of extensively drug resistant (XDR) form of tuberculosis in the world (Ellner, 2008).
The scale of spread of tuberculosis has become comparable with HIV/ AIDS. The disease
has become a top killer among various infectious diseases all over the world (Global tuberculosis
report, 2014). Though significant advances have been made against TB throughout the mid 20
century. However, by the end of century, the disease followed a rising trend (Sotgiu et.al., 2014).
The alarming stage of TB came when doctors documented new strains of TB which showed
resistance to a number of indicated medicines (Sharma et.al., 2011). Centre for Disease Control
and Prevention states that spread of MDR TB and extensively drug resistant TB has become a
global security health concern (Frieden, 2015). Funding and maintaining the supply of expensive
drugs or treatment of TB has become a struggle (Kimbrough et.al., 2012). According to WHO,
one of the health targets of the newly adopted Sustainable Development goals is to end TB
epidemic by the year 2030 (Tuberculosis, 2016).
1.2.3 Prevalence of TB
TB occurs in all parts of the world (Gupta et.al., 2015). In the United States and Western
Europe, TB is relatively well controlled. However, it is widely spread across Asia, Latin
America, Eastern Europe and Africa. According to WHO, more than 95 per cent of deaths due to
TB take place in low and middle income countries. Most severe burden is carried by Africa with
281 cases per 100, 000 population in the year 2014 (Tuberculosis, 2016). In 2014, 6 countries
that had the largest number of incident cases of TB were India, People's Republic of China,
Pakistan, South Africa, Nigeria and Indonesia.
Bangladesh is a lower middle income country. The rate of tuberculosis per 100, 000
population in Bangladesh has increased in the past years. In the 2011, the rate was 225 incident
cases per 100, 000 of population. This has increased to 227 cases per 100, 000 of population
(Incidence of tuberculosis (per 100,000 people), 2016). Every year, TB causes death of 80, 000
6
Bangladeshis. Also, 190, 000 new cases of tuberculosis occur per year in the country. Every
hour, 9 people die due to TB in Bangladesh. The cases of TB occur mostly among poor people
(Post-2015 Development Agenda, 2016). This suggests that TB is a big problem in Bangladesh.
However, there is scope for effectively tackling this problem.
1.2.4 TB stigma- What does it mean?
Stigma is a social determinant of health. This begins when a particular trait of a person or
a group is considered to be undesirable. TB is highly stigmatized which results into considerable
discrimination towards the sufferers (Chang and Cataldo, 2014). There are various factors which
are associated with TB which themselves create stigma. These include poverty, refugee status,
homelessness, HIV, drug and alcohol misuse etc. Fear of infection is one of the most common
cause of stigma. Once TB is identified, the person is set apart and linked to undesirable
stereotypes. These lead to discrimination and unfair treatment. In Bangladesh, stigma is one of
the major socio- cultural barriers in access TB care. This is because people delay obtaining care
and treatment for TB because of the fear of being discriminated and socially excluded. They
avoid going to the doctor for getting tested for TB. This is as detection of the disease is
considered to be undesirable in the society in Bangladesh. Therefore people avoid to go to the
doctors even if they have been experiencing the symptoms of the disease due to the fear of being
excluded from the society. This leads to the growth of the problem in the country (Ahmed et.al.,
2013). The present systematic review aims to investigate tuberculosis in Bangladesh and stigma
associated with it. This is important to be done as spread and transmission of disease within the
country can be tackled to a great extent by eliminating the stigma associated with it.
1.3 Rationale of the study
Tuberculosis is a growing public health problem all over the world. It has been a major
health problem for Bangladesh since long. According to World Health Organization (2016),
Bangladesh ranks 6th on the list of 22 countries which bear the highest burden of TB in the world
(Tuberculosis Control Programme, 2016). For a lower middle income country, it is even more
important to tackle the problem. There has been an increase in the cases of tuberculosis in the
year 2014. It leads to death o several people every year with the emergence of new cases as well.
It is estimated that every day approximately 875 new cases and 180 TB deaths occur in the
nation (National Tuberculosis Control Program (NTP), 2016). Moreover, stigma associated with
7
hour, 9 people die due to TB in Bangladesh. The cases of TB occur mostly among poor people
(Post-2015 Development Agenda, 2016). This suggests that TB is a big problem in Bangladesh.
However, there is scope for effectively tackling this problem.
1.2.4 TB stigma- What does it mean?
Stigma is a social determinant of health. This begins when a particular trait of a person or
a group is considered to be undesirable. TB is highly stigmatized which results into considerable
discrimination towards the sufferers (Chang and Cataldo, 2014). There are various factors which
are associated with TB which themselves create stigma. These include poverty, refugee status,
homelessness, HIV, drug and alcohol misuse etc. Fear of infection is one of the most common
cause of stigma. Once TB is identified, the person is set apart and linked to undesirable
stereotypes. These lead to discrimination and unfair treatment. In Bangladesh, stigma is one of
the major socio- cultural barriers in access TB care. This is because people delay obtaining care
and treatment for TB because of the fear of being discriminated and socially excluded. They
avoid going to the doctor for getting tested for TB. This is as detection of the disease is
considered to be undesirable in the society in Bangladesh. Therefore people avoid to go to the
doctors even if they have been experiencing the symptoms of the disease due to the fear of being
excluded from the society. This leads to the growth of the problem in the country (Ahmed et.al.,
2013). The present systematic review aims to investigate tuberculosis in Bangladesh and stigma
associated with it. This is important to be done as spread and transmission of disease within the
country can be tackled to a great extent by eliminating the stigma associated with it.
1.3 Rationale of the study
Tuberculosis is a growing public health problem all over the world. It has been a major
health problem for Bangladesh since long. According to World Health Organization (2016),
Bangladesh ranks 6th on the list of 22 countries which bear the highest burden of TB in the world
(Tuberculosis Control Programme, 2016). For a lower middle income country, it is even more
important to tackle the problem. There has been an increase in the cases of tuberculosis in the
year 2014. It leads to death o several people every year with the emergence of new cases as well.
It is estimated that every day approximately 875 new cases and 180 TB deaths occur in the
nation (National Tuberculosis Control Program (NTP), 2016). Moreover, stigma associated with
7
TB makes the infected people delay seeking help. This increases the probability that the will
become seriously ill as well as transmit the infection to others. Stigma acts as a barrier in
accessing TB care thus aggravating the condition.
As the number of cases of tuberculosis is increasing in Bangladesh and the problem is
being aggravated by the TB stigma, there is a need to find out the underlying reasons associated.
There is a requirement of determining factor in Bangladesh and increasing alertness regarding it.
There is a need to explore the concealed gaps of current health strategy in Bangladesh so that it
can be recovered and impact of TB in society can be improved. However, before taking any step
further, it is essential to develop a clear idea of the prevalence and determinants of TB in
Bangladesh. But, very few studies have been conducted till now to find out the causes of TB
stigma in Bangladesh. Therefore, there is a need to gather the available findings and put them
together so that research gaps can be identified. This will help in reforming the current heath
strategy for controlling TB in Bangladesh. This systematic review will therefore investigate the
causes of TB stigma in Bangladesh.
1.4 Research Question
What is the prevalence of TB and its determinants in Bangladesh?
1.5 Aims and Objectives of study
The overall aim of this systematic review is to investigate TB and its associated stigma in
Bangladesh. Therefore, the systematic review was conducted to fulfil the following objectives:
a) To review all systematic works to address current prevalence rate and determinants of
TB in Bangladesh
b) To systematically review literature to find out the determining factor associated with TB
in Bangladesh
c) To systematically review literature to identify the gaps in the current strategy in
Bangladesh
1.6 Scope of dissertation
The dissertation will comprise of the following chapters:
8
become seriously ill as well as transmit the infection to others. Stigma acts as a barrier in
accessing TB care thus aggravating the condition.
As the number of cases of tuberculosis is increasing in Bangladesh and the problem is
being aggravated by the TB stigma, there is a need to find out the underlying reasons associated.
There is a requirement of determining factor in Bangladesh and increasing alertness regarding it.
There is a need to explore the concealed gaps of current health strategy in Bangladesh so that it
can be recovered and impact of TB in society can be improved. However, before taking any step
further, it is essential to develop a clear idea of the prevalence and determinants of TB in
Bangladesh. But, very few studies have been conducted till now to find out the causes of TB
stigma in Bangladesh. Therefore, there is a need to gather the available findings and put them
together so that research gaps can be identified. This will help in reforming the current heath
strategy for controlling TB in Bangladesh. This systematic review will therefore investigate the
causes of TB stigma in Bangladesh.
1.4 Research Question
What is the prevalence of TB and its determinants in Bangladesh?
1.5 Aims and Objectives of study
The overall aim of this systematic review is to investigate TB and its associated stigma in
Bangladesh. Therefore, the systematic review was conducted to fulfil the following objectives:
a) To review all systematic works to address current prevalence rate and determinants of
TB in Bangladesh
b) To systematically review literature to find out the determining factor associated with TB
in Bangladesh
c) To systematically review literature to identify the gaps in the current strategy in
Bangladesh
1.6 Scope of dissertation
The dissertation will comprise of the following chapters:
8
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