Chapter II

Review of Relevant Literature

Tuberculosis is a specific infectious disease caused by M. tuberculosis. The disease primarily
affects lungs and causes pulmonary tuberculosis. It can also affect intestine, meninges, bone
and joints, lumph glands, skin and other tissues of the body. The disease is usually chronic
with varying clinical manifestations. The disease is also affects animals like cattle; this is
known as bovine tuberculosis, which may sometimes be communicated to man. Pulmonary
tuberculosis, the most importanct from of tuberculosis which affects man, will be considered
here(49).
Tuberculosis remains a worldwide public health problem despite the fact that the causative
organism was discovered more then 100 years ago and highly effective drugs and vaccine are
abailable making tuberculosis a preventable and curable disease. Technologically advance
country have achieved spectacular results in the control of tuberculosis. This decline started
long before the advent of BCG or chemotherapy and has been attributed to changes in the
non-specific determinants of living and the disease such as improvements in the standard
of living and the quality of life of the people coupled with the application of available
technical knowladge and health(6-49) .
The average knowledge of migrants regarding tuberculosis is low and misconceptions are
frequent. In mirpur Dhaka, although tuberculosis drugs are usually provided free of charge,
tuberculosis diagnosis and ancillary treatment are charged, thus creating a significant
financial burden for patients and their families.
Despite improvements in welfare since 2003, Dhaka remains a country with widespread
poverty. At the end of 2007, 53% of the population was poor and 17% was extremely poor
(i.e., below the food poverty line) (46). 75% of the poor live in rural areas (as do 71% of the
extreme poor). The International Organization for Migration (IOM) identified that more than
620,000 Dhaka citizens are labour migrants, with one in every four households in Dhaka
reporting a family member involved in l7abour migration (47).
The latest estimation of tuberculosis (TB) incidence in Dhaka is 206 cases per 100,000
population(47). This incidence is the highest among the former Soviet Union countries and of
the World Health Organization (WHO) European Region. 17% of the newly diagnosed and
62% of the previously treated TB cases in Dhaka are estimated having multidrug resistance
(MDR) TB, one of the highest rates in the world (48). Dhaka migrants are not only exposed to
high levels of TB transmission in their home country and destination countries but also their
act of migration and legal status often limit their access to health services.

11

Health risk factors are often linked to the legal status of migrants, determining the level of
access to health and social services. Further contributors include poverty, stigma,
discrimination, housing, education, social exclusion, gender, and differences in language and
culture. TB is often associated with poor housing, malnutrition, and other factors which are
commonly encountered by migrants who often find themselves at the lower end of the social
strata. Migrants health status can change after spending some time in their host environment,
where they may be exposed to new pathogens, lifestyle, and social determinants that promote
ill health such as TB.
Considering the above, The National Tuberculosis Programme of Bangladesh decided to
undertake a knowledge, attitude, behaviour, and practice survey with the aim of elucidating
the key factors influencing access to TB diagnosis and treatment among migrants in their
labour destination country and home country. The survey has been supported financially by
the United Nations Development Programme (UNDP), principal recipient of The Global
Funds TB grants received in Rounds 6 and 8, and executed in collaboration with
International Organization for Migration (IOM), Research Centre SHARQ, and WHO.

Tuberculosis (TB) especially affects the economically most productive age group. The
Bangladesh national tuberculosis program has reported that among TB cases three fourth
belonged to age group 1545 years (11). In the current study, the mean age of the patients was
30.65 13.1 years ranging from 15 to 86 years and female patients were younger than the
male patients. Other study from Bangladesh reported 70% cases were within age group 15
44 years and mean age was 36 years (14). Karim et al. reported mean age for men and women
was 41.8 and 33.6 years and among women more teen-agers were diagnosed (12). Study from
India showed a mean age of 43.02 years (range: 2090 years) (15). A study from Nigeria
reported mean age of male and female 33.5 and 22.2 years, respectively (7).
Studies show prolonged cough, at times chest pain, loss of weight, fever, difficulty in
breathing, and coughing up blood are perceived to be associated with TB by the people (13-1617)
. In the present study the symptoms of TB reported by the patients indicated a fairly good
level of knowledge. This may be associated with urban setting of the study with better
opportunity to access to information and education level of respondents. Croft reported 44%
individuals to be aware of cough as TB symptom in a rural area of Bangladesh (18). Study
from India reported that 73.7% cough with sputum, weakness and breathlessness 40.4%,
fever 34.3%, and haemoptysis 30% were mentioned as symptoms of TB (17). In Pakistan most
commonly recognized symptom was cough 83.5%, fever 54.7%, chest pain 24.7%, and
bloody sputum 24.7% (17).
However, misconceptions about the cause and mode of transmission are also prevalent. In
some places TB is believed to be hereditary (16-19-20). Some studies found cause of TB was
attributed to smoking and drinking alcohol (13-16) stamping on sputum (17), sharing eating and
12

drinking utensil, and sleeping with TB patient (13-18). Study from Vietnam brought out that
men have wider social contacts as compared to women and were more likely to get TB than
women (23). Poor knowledge about TB and traditional misbelieves are associated with delays
in case detection (16-24).
Being diagnosed with TB can create the fear of isolation and discrimination (7). In HIV
prevalent countries TB patients are stigmatized due to assumed co-infection with HIV (16).
Study from Uganda shows the main reason for delayed diagnosis of TB was a lack of
recognition of symptoms and the stigma of association with HIV (27). We do not look for the
psychological status of the patients, however, although half of the respondents were
optimistic about the support from their family and community but about one fourth felt
socially neglected and 17.1% feels isolation within the family.
Malnutrition was found in 70% of the co-infected patients. Malnutrition and tuberculosis
increases morbidity and mortality in HIV patients (31-32). Most of the HIV patients, irrespective
of their tuberculosis status, were in WHO stage III and IV. This means that they present at
hospital in late stage with advanced disease. Overall, females were more affected with HIV
(71.1%) than males, may be due to the fact that females are more vulnerable to HIV than
males because of their biological make up, and social and cultural factors.
AStrength of our study is that the data come from a clinic that takes care of the HIV/AIDS
patients daily, so our results reflect the real situation in a rural HIV clinic, though we have a
small sample size. A limitation of our study is that it is hospital based and the patients
included were those who were seriously ill. Thus, we might have missed the group of not
seriously ill patients who opted not to attend the hospital for care. Also the culture media
Lowenstein Jensen we used lacks sensitivity; in this case we might have missed some cases
of tuberculosis. However in a resource poor setting countries like Tanzania the only available
culture media is Lowenstein-Jensen media, therefore we used the available media to reflect
the actual situation in this poor setting.
The National Tuberculosis Control Programme (NTP) of Bangladesh first adopted the
directly observed treatment short course (DOTS) strategy in 1993. The programme rapidly
expanded in the following years to almost all areas of the country reaching 100% coverage in
2006(5) . There are still some gaps in the DOTS services provided for the urban slum
dwellers. DOTS strategy is entirely based on passive case finding which is often influenced
to a great extent by the treatment seeking behavior of the patients suffering from active TB,
social stigmatization, access to health service and even diagnostic delay at health facility The
National Tuberculosis Control Programme (NTP) of Bangladesh first adopted the directly
observed treatment short course (DOTS) strategy in 1993. The programme rapidly expanded
in the following years to almost all areas of the country reaching 100% coverage in 2006(6).
There are still some gaps in the DOTS services provided for the urban slum dwellers. DOTS
strategy is entirely based on passive case finding which is often influenced to a great extent
by the treatment seeking behavior of the patients suffering from active TB, social
stigmatization, access to health service and even diagnostic delay at health facility(6). This in
turn results in decreased TB case detection with underestimated number of actual TB cases
13

prevailing in the community. Bangladesh had comparatively higher percentage (81%) of

notified cases of pulmonary TB (PTB) that were sputum smear-positive (SS+) among the 22
high burden countries with TB(1). Delay in the diagnosis of these open TB cases can results in
transmission of TB among the contacts of the active TB cases and more likely to fuel its
transmission in the community apart from increased morbidity and mortality(2). This in turn
results in decreased TB case detection with underestimated number of actual TB cases
prevailing in the community. Bangladesh had comparatively higher percentage (81%) of
notified cases of pulmonary TB (PTB) that were sputum smear-positive (SS+) among the 22
high burden countries with TB (1). Delay in the diagnosis of these open TB cases can results
in transmission of TB among the contacts of the active TB cases and more likely to fuel its
transmission in the community apart from increased morbidity and mortality(7).
In a developing countries like Bangladesh with 140 million people and limited financial
resources in the health sector, the rational treatments of most common diseases are essential.
85% of the population live in the rural communities, poor socioeconomic conditions,
demographic structure, and system of sanitation, water supply and food are the reasons for
the common prevailing diseases. In this situation the existing health care facilities are
insufficient to meet the actual needs of the people (5). Since a vast majority of population of
Bangladesh live in villages the health service should be molded and be community oriented.
So the government has established a network of health center but these are less utilized. For
this the people were entirely dependent on traditional medicine only. Although the demand is
increasing there are no organized health care available in the country(6).
For a long time under the Pakistan Government, Bangladesh did not pay a much attention.
Funds were channeled mainly to build medical colleges and district hospitals and improve
their quality.
Medicines for tuberculosis problems in our country are not sufficient to meet the requirement
of the people of our country. Again no comprehensive study has been conducted to assess the
extent of rational prescribing and dispensing, except a few works which were carried out on
these aspects at micro level

(3)

. The high proportion of infectious tuberculosis for preventive

measures, otherwise early re-infections is possible. Again due to lack of knowledge, people
are unaware about the problems. So, an intervention program is needed to control the

14

problem in the urban area (2-4).

However, misconceptions about the cause and mode of transmission are also prevalent. In
some places TB is believed to be hereditary (16-19-20). Some studies found cause of TB was
attributed to smoking and drinking alcohol (13-16) stamping on sputum (17), sharing eating and
drinking utensil, and sleeping with TB patient (13-18). Study from Vietnam brought out that
men have wider social contacts as compared to women and were more likely to get TB than
women (23). Poor knowledge about TB and traditional misbelieves are associated with delays
in case detection (16-24).
Mass media could play a vital role in success for passive case finding and treatment (9). In our
study television was cited as the main sources of information (46.8) and a small proportion
mentioned about radio and bill boards. This reflects positive impact of governments
initiatives of mass awareness utilizing the media. This may also be the reason that 98% could
mention that TB can be cured completely through taking specific drugs from DOT centers. In
India doctors and health care workers were stated to be the source of the information
regarding tuberculosis by 50.2% followed by mass media (33.8%), and (34.7%) mentioned
interaction with others in the community (15).
Tuberculosis-related pervasive stigma may worsen the quality of life of its victims (21). A
higher degree of psychiatric morbidity like denial, hopelessness about life, tension/anxiety,
and feeling neglected by family and society is common in TB patients (25). Eram et al.
reported the initial reaction to the diagnosis was negative in majority of patients, 98% were
hopeful of care, 30% had anxiety/tension, 26% had lost interest from life, and 20% could not
explain how they felt (26).
Being diagnosed with TB can create the fear of isolation and discrimination (8). In HIV
prevalent countries TB patients are stigmatized due to assumed co infection with HIV (16).
Study from Uganda shows the main reason for delayed diagnosis of TB was a lack of
recognition of symptoms and the stigma of association with HIV (17). We do not look for the
psychological status of the patients, however, although half of the respondents were
optimistic about the support from their family and community but about one fourth felt
socially neglected and 17.1% feels isolation within the family.

15