FAST implementation in Bangladesh: high frequency of unsuspected tuberculosis justifies challenges of scale-up

Abstract

SUMMARY Setting Bangladesh – National Institute of Diseases of the Chest and Hospital, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders and Chittagong Chest Disease Hospital. Objective To present operational data and discuss the challenges of implementing FAST (Find cases Actively, Separate safely and Treat effectively) as a TB transmission control strategy. Design FAST was implemented sequentially at three hospitals. Results Using Xpert MTB/RIF, 733/6028 (12.2%, 95%CI [11.4,13.0]) patients were diagnosed with unsuspected TB. Patients admitted with other lung diseases with a prior TB history had more than twice the odds of being diagnosed with unsuspected TB as those without a TB history (OR 2.6, 95%CI 2.2–3.0, p<0.001). Unsuspected MDR-TB was diagnosed in 89/1415 (6.3%, 95%CI [5.1,7.7]) patients. Patients with unsuspected TB had nearly five times the odds of being diagnosed with MDR-TB than those admitted with a known TB diagnosis (OR 4.9, 95%CI 3.1–7.6, p<0.001). Implementation challenges include staff shortages, diagnostic failure, supply-chain issues and reliance on external funding. Conclusion FAST implementation revealed a high frequency of unsuspected TB in hospitalized patients in Bangladesh. Patients with a prior TB history have increased risk. Ensuring financial resources, stakeholder engagement and laboratory capacity are important for sustainability and scalability.

Availability and price changes of potential medicines and equipment for the prevention and treatment of COVID-19 among pharmacy and drug stores in Bangladesh; findings and implications

“…Encouragingly for patients, prices of essential antibiotics in private pharmacies in Bangladesh, including model stores, were not much higher than international prices in a recent study by , with only limited price increases between 2003 and 2019 44 . The increase in cases with dengue 21 , and the continued challenges with tuberculosis in Bangladesh, with patients typically seeking help from non-qualified practitioners before seeking help from qualified professionals, also needs addressing [45][46][47][48] . Encouragingly, whilst there are still cases of malaria in Bangladesh, co-ordinated activities have reduced these by more than 50% in 2016 versus 2010 49 .…”

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“…To address the remaining barriers to respiratory isolation of hospitalized TB patients, "FAST (Find cases Actively by cough surveillance and rapid molecular sputum testing, Separate safely, and Treat effectively based on rapid drug susceptibility test)" is an option to decrease the time to respiratory isolation [32,33] although the substantial cost of rapid molecular testing could be a barrier to NHI reimbursement. Alternatively, environmental controlsthe second level in the hierarchy of TB control-with adequate ventilation (>6-12 air changes per hour) or upper room ultraviolet germicidal irradiation (to disinfect the air) can be applied to reduce the concentration of infectious droplet nuclei in hospital indoor air, and decrease risk of nosocomial transmission [6,34].…”

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“…Although randomised controlled trials are desirable for reducing selection bias and confounding, controlled before and after studies may have to be relied upon, but with greater attention to the comparability of before and after intervention groups, the time periods being compared and intervention and control groups where relevant. An alternative approach is the study of quality improvement interventions for intermediate processes, such as the steps that make up FAST [ 41 ]. However, ultimately the effectiveness in preventing TB infection in HCWS needs be tested directly [ 42 ].…”