INT J TUBERC LUNG DIS 19(2):151–156 Q 2015 The Union http://dx.doi.org/10.5588/ijtld.14.0200 E-published ahead of print 16 December 2014 Anti-tuberculosis drug resistance in Bangladesh: reflections from the first nationwide survey S. M. M. Kamal,* Md. A. Hossain, † S. Sultana, ‡ V. Begum, § N. Haque, † Md. J. Ahmed, ¶ T. M. A. Rahman, # Md. K. A. Hyder,** Md. S. Hossain,* M. Rahman, ¶ R. A. Chowdhury, †† K. J. M. Aung, ‡‡ Md. A. Islam, §§ Md. R. Hasan, ¶¶ A. Van Deun ## *National Tuberculosis Reference Laboratory, National Institute of Diseases of the Chest and Hospital (NIDCH), Dhaka, † National TB Programme, Directorate General of Health Services, Ministry of Health & Family Welfare, Dhaka, ‡ National Professional Offices-World Health Organization (NPO-WHO), Dhaka, § NPO-WHO, TB CARE-II, Dhaka, ¶ Tuberculosis CARE-II, University Research Company, Dhaka, # Bangladesh Unnayan Parishad (BUP), Dhaka, Bangladesh; **WHO South East Asia Regional Office, New Delhi, India; †† Department of Microbiology, University of Dhaka, Dhaka, ‡‡ Damien Foundation, Dhaka, §§ BRAC, Dhaka, ¶¶ NIDCH, Dhaka, Bangladesh; ## Institute of Tropical Medicine, Antwerp, Belgium SUMMARY OBJECTIVE: To determine the prevalence of tuberculo- sis (TB) drug resistance in Bangladesh. DESIGN: Weighted cluster sampling among smear- positive cases, and standard culture and drug suscepti- bility testing on solid medium were used. RESULTS: Of 1480 patients enrolled during 2011, 12 falsified multidrug-resistant TB (MDR-TB) patients were excluded. Analysis included 1340 cases (90.5% of those enrolled) with valid results and known treatment antecedents. Of 1049 new cases, 12.3% (95%CI 9.3–16.1) had strains resistant to any of the first-line drugs tested, and 1.4% (95%CI 0.7–2.5) were MDR-TB. Among the 291 previously treated cases, this was respectively 43.2% (95%CI 37.1–49.5) and 28.5% (95%CI 23.5–34.1). History of previous anti-tubercu- losis treatment was the only predictive factor for first- line drug resistance (OR 34.9). Among the MDR-TB patients, 19.2% (95%CI 11.3–30.5; exclusively previ- ously treated) also showed resistance to ofloxacin. Resistance to kanamycin was not detected. CONCLUSION: Although MDR-TB prevalence was relatively low, transmission of MDR-TB may be increasing in Bangladesh. MDR-TB with fluoroquino- lone resistance is rapidly rising. Integrating the private sector should be made high priority given the excessive proportion of MDR-TB retreatment cases in large cities. TB control programmes and donors should avoid applying undue pressure towards meeting global targets, which can lead to corruption of data even in national surveys. KEY WORDS: prevalence; drug resistance; tuberculosis; survey; Bangladesh BANGLADESH, a developing country in South-East Asia, has a population of over 155 million, making it one of the most densely populated countries in the world. Bangladesh ranks sixth among the high tuberculosis (TB) burden countries. In 2011, the estimated TB burden was as follows: annual inci- dence of all cases 225 per 100 000 population, incidence of new smear-positive cases 100/100 000, prevalence of all cases 411/100 000 and TB mortality 45/100 000. These rates correspond to 340 000 incident TB cases (all forms), 148 000 new smear- positive cases and 68 000 deaths due to TB. 1 In 2011, 148 198 patients (all forms) were notified, of whom 98 948 (67%) were new smear-positive cases. The male:female ratio for new smear-positive cases was 2:1. On a national scale, the treatment success rate in new sputum smear-positive cases registered during 2010 was 92%, indicating that multidrug-resistant TB (MDR-TB) should not be a major problem in new cases. As expected, the treatment success rate reported among previously treated cases registered in the same year was lower (80%). The full extent of the anti-tuberculosis drug resistance problem in Bangladesh is not known, as no national survey has been conducted before. Damien Foundation (DF), one of the partners implementing the National Tuberculosis Programme (NTP) in mainly rural areas, has reported low and decreasing levels of drug resistance in Greater Mymensingh. In 1995, the prevalence of MDR-TB among new smear-positive cases was 0.7%, while among all cases (new plus previously treated, or Correspondence to: Armand Van Deun, Institute of Tropical Medicine, Antwerp, Belgium. Fax: ( þ 32) 3 247 6633. e-mail: AVanDeun@theunion.org Article submitted 6 April 2014. Final version accepted 9 September 2014. [A version in French of this article is available from the Editorial Office in Paris and from the Union website www.theunion.org]