Abstract
Background
Tuberculosis (TB) remains a major public health challenge in Bangladesh, which ranks among the world’s high-burden countries. While previous studies have examined TB outcomes in specific populations, comprehensive national data on age-stratified outcomes, particularly comparing children and adult cohorts, remain scarce. This study aimed to (1) analyze trends in TB notifications; (2) compare treatment outcomes across age groups, sex, treatment history, and disease types; and (3) identify potential risk factors for unsuccessful outcomes.
Methods
We analyzed Bangladesh’s National TB Program (NTP) data (2019–2021), including 494,685 confirmed cases of TB. Treatment outcomes were categorized per WHO definitions. Analyses included: (1) temporal assessment of notification patterns; (2) comparative evaluation of treatment outcomes stratified by demographic, clinical, and health system characteristics; and (3) identification of associated factors for unsuccessful outcomes through multivariable modified Poisson regression, reporting adjusted relative risks (aRR) with 95% confidence intervals.
Results
Between 2019 and 2021, 494,685 people with tuberculosis (TB) were reported to the NTP of Bangladesh. Notifications increased by 64% from 2019 to 2020 and by 83% from 2020 to 2021. Analysis of 300,974 patients demonstrated a treatment success rate exceeding 95.0% in both adults and children. Among children aged under 5 years, mortality reached 5 × 4%, with an overall unsuccessful outcome rate of 7 × 7%. Extrapulmonary TB was associated with poorer outcomes compared to pulmonary TB in both children (mortality: 2.3% vs 1.1%) and adults (aRR: 2.01; 95% CI:1.92–2.10). Rural health facilities had higher loss to follow-up in children (2.5% vs 0.7% in urban areas). In adults, mortality increased markedly with age, from 1.0% in those aged 18–30 years to 6.4% in individuals aged 60 years and older (aRR:3.53; 95% CI: 3.32–3.76). Male sex was independently associated with a higher risk of unsuccessful treatment (aRR 1.58; 95% CI:1.52–1.65), as were previous TB history (aRR:1.74; 95% CI:1.63–1.86) and receipt of retreatment (aRR:1.71; 95% CI:1.43–2.06) or second-line regimens (aRR:1.78; 95% CI:1.48–2.13).
Conclusion
Bangladesh’s TB program showed resilience but revealed critical gaps. Children < 5 and adults ≥60 had worse outcomes, signaling age-specific care deficiencies. Persistent male disparities suggest access or biological differences. Rural facilities excelled with adults but struggled with children with TB retention. High retreatment failure rates demand better drug-resistant TB management. Key priorities: 1) age-specific protocols, 2) gender-sensitive interventions, 3) improved rural children’s care, and 4) enhanced drug-resistant TB services. Addressing these gaps is vital for achieving the END TB targets.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12879-026-12664-5.
Keywords: Tuberculosis, Infectious disease, Pulmonary TB, Extrapulmonary TB, Treatment outcome, Bangladesh
Introduction
Tuberculosis (TB) remains a critical global health challenge, with an estimated 10.6 million cases and 1.3 million deaths in 2022 alone [1]. Despite global efforts to end the TB epidemic, progress has been uneven, particularly in high-burden countries. Bangladesh ranks among the 30 countries with the highest TB burden, accounting for 3.4% of global cases, yet faces persistent gaps in age-specific outcome data [2]. While children with TB typically represent 10–15% of cases in high-burden settings, children face disproportionate diagnostic delays and mortality risks—a 2022 meta-analysis found 6.2% mortality in under-5s versus 3.1% in older children [3, 4].
In 2014, the World Health Assembly endorsed the ‘End TB Strategy,’ which aims to eliminate the global tuberculosis epidemic by 2030 [5]. The systematic monitoring and evaluation of tuberculosis treatment outcomes serves as a cornerstone for achieving the ambitious targets outlined in the WHO’s End TB Strategy, which seeks to reduce TB deaths by 95% and incidence by 90% by 2035 [6].
The National Tuberculosis Program (NTP) of Bangladesh has achieved notable gains in expanding access to diagnosis and treatment, with treatment success rates exceeding 90% in recent years [2]. However, the COVID-19 pandemic caused disruptions to TB services, leading to declines in case detection, delayed diagnoses, and interruptions in treatment adherence globally and within Bangladesh [7–9]. Understanding the extent of service recovery and treatment outcomes during the pandemic and post-pandemic period is essential to guide targeted interventions and sustain progress toward national and global TB control targets.
Treatment outcome data serve as a critical feedback mechanism for national TB programs, informing evidence-based decisions on resource allocation, quality improvement, and targeted interventions for high-risk populations [10, 11]. Globally, the average treatment success rate for TB is around 86%, with considerable variation across regions [12]. In the WHO Eastern Mediterranean Region, several countries consistently report success rates above 90%, reflecting strong programmatic performance [12, 13]. By contrast, settings burdened by high levels of drug-resistant TB, HIV co-infection, and systemic health challenges often report substantially lower success rates [10, 14, 15]. Unsuccessful outcomes not only reflect individual clinical challenges—such as drug resistance, comorbidities, or healthcare access barriers—but also signal programmatic weaknesses in TB control, emphasizing the need for enhanced adherence support, early detection of treatment failure, and integrated patient-centered care to optimize outcomes.
In Bangladesh, the NTP was extended and strengthened at the Upazila level in 2019 [16]. In coordination with the NTP, WHO is providing human resources, technical, and logistical support to strengthen the national response to TB control in the 64 districts of Bangladesh [16]. The program includes the early detection of drug-sensitive and drug-resistant (DR) tuberculosis, as well as timely and quality treatment for all patients. Since 2019, the WHO and health partners of Bangladesh have been working to protect TB progress from any setback.
While previous studies have focused on the burden of TB and its associated risk factors, comprehensive analyses that integrate temporal trends, treatment outcomes, and age-stratified risks at a national level remain limited in Bangladesh. This study aimed to describe TB notification trends and treatment outcomes in Bangladesh between 2019 and 2021, identify subpopulations at higher risk of unsuccessful treatment, and evaluate the impact of demographic and clinical factors using adjusted statistical models.
Methods and materials
Study design
We conducted a retrospective analysis using routine surveillance data from all patients treated for tuberculosis (TB) in Bangladesh between Jan 1, 2019, and Dec 31, 2021. Eligible cases included individuals with documented clinical and epidemiological information recorded in the national electronic TB management system. All confirmed cases with TB were managed in accordance with the National Tuberculosis Treatment Guidelines, which align with WHO recommendations [17, 18]. Clinical definitions and treatment outcome classifications followed national standards adapted from WHO criteria [18]. The NTP in Bangladesh systematically collects these data from TB treatment centres nationwide, and all variables included in this analysis were derived from the standardised surveillance dataset.
Database and data collection methods: e-TB Manager
We extracted electronic medical records from the national e-TB Manager database for the period between January 1, 2019, and Dec 31, 2021. The database, maintained by the National Tuberculosis Program (NTP) of Bangladesh, captures comprehensive epidemiological, demographic, clinical, and laboratory data on all notified cases with TB. Each case undergoes review and validation at multiple administrative levels. Mortality was verified by cross-referencing individual patient records in accordance with WHO-defined protocols.
The e-TB Manager platform, developed through the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) program with technical support from USAID, serves as an integrated, web-based system for TB surveillance and case management. It consolidates data on case reporting, diagnosis, treatment, laboratory results, medication use, and treatment outcomes. The platform adheres to WHO case definitions for pulmonary (PTB) and extrapulmonary TB (EPTB). For this study, we used anonymised data from the 2019–2021 surveillance period with formal permission from the NTP of Bangladesh.
Definitions of tuberculosis and types
Tuberculosis (TB) was defined in accordance with WHO guidelines and classified as either microbiologically confirmed or clinically diagnosed [17, 18]. Microbiological confirmation required (1) isolation of Mycobacterium tuberculosis by culture, (2) detection via nucleic acid amplification testing (e.g., GeneXpert MTB/RIF), or (3) identification of acid-fast bacilli in clinical specimens when culture was unavailable or inconclusive. The diagnosis of Pulmonary Tuberculosis, an infectious disease of the lungs, relied on chest X-ray findings and microbiological confirmation through sputum analysis. Extrapulmonary TB (EPTB) was defined by radiographic, histopathological, or compelling clinical evidence of disease at non-pulmonary sites, such as lymphatic, meningeal, or osteoarticular involvement. Cases with concurrent pulmonary and extrapulmonary involvement, including pleural or miliary TB, were not included in the EPTB category. Previous TB treatment status was ascertained through documented medical history. This classification framework ensured consistency with global reporting standards while preserving epidemiological and clinical relevance.
Diagnostic classification of tuberculosis notifications
Tuberculosis (TB) diagnosis in the dataset was categorized into two principal groups: bacteriologically confirmed and clinically diagnosed cases. Among the 290,510 individuals included, 194,176 (66.8%) had bacteriologically confirmed TB, while 96,334 (33.2%) were diagnosed clinically. Bacteriological confirmation—considered the diagnostic gold standard—requires detection of Mycobacterium tuberculosis via smear microscopy, culture, or molecular methods such as GeneXpert MTB/RIF. Although this approach offers high diagnostic specificity, its availability remains limited in many high-burden, resource-constrained settings. In such contexts, clinical diagnosis—based on symptoms, radiological imaging, or histopathology—is frequently employed, particularly in cases of children with TB, extrapulmonary disease, or paucibacillary presentations where bacteriological confirmation is often unfeasible. While clinical diagnosis enables prompt initiation of treatment, it carries inherent risks of overdiagnosis and misclassification. Expanding laboratory diagnostic capacity remains essential; however, the pragmatic application of clinical acumen is equally critical for ensuring timely and equitable TB care. Bridging this diagnostic divide will require investment in scalable, point-of-care technologies and the refinement of clinical algorithms to enhance both accuracy and accessibility in pursuit of global TB elimination.
Unsuccessful treatment outcomes for tuberculosis
Tuberculosis (TB) treatment outcomes are critical for assessing the effectiveness of therapeutic interventions and informing public health strategies. According to established WHO guidelines, outcomes are classified as cured, completed, failed, died, lost to follow-up, and not evaluated or transferred [18]. A patient is considered cured if they had bacteriologically confirmed pulmonary TB (PTB) with a positive sputum acid-fast bacilli (AFB) smear or culture at treatment initiation, and the sputum becomes smear- or culture-negative in the final month and on at least one prior occasion. Treatment completion is recorded when a patient finishes treatment without evidence of failure, provided the patient has no sputum smear or culture results from the last month, and the latest result was negative. Treatment failure occurs when the sputum AFB smear or culture remains positive at month five or later during treatment. Patients who die from any cause before or during treatment are classified as ‘died.’ Loss-to-follow-up is defined as a patient who interrupts or does not start treatment for at least two consecutive months or more. Successful treatment encompasses cured and completed cases, while Unsuccessful outcomes include failure, death, or loss to follow-up. These definitions ensure standardised assessment across cohorts and facilitate comparability with global TB surveillance metrics.
The data
In accordance with WHO guidelines, the analysis of treatment outcomes was restricted to a defined cohort from the e-TB manager database to ensure validity. Exclusions comprised patients whose outcomes were indeterminate, including those currently on therapy, those not yet initiated on treatment, and transfers to other units, absent treatment recommendations, which preclude standardized outcome verification. After excluding 193711 patients, we analyzed 300974 patients. The exclusion of patients will not introduce bias because a large number of patients were analyzed to identify the factors associated with unsuccessful treatment outcomes. After excluding 193711 patients who did not have a documented treatment outcome (e.g., those still on treatment, awaiting initiation, or transferred out), a cohort of 300974 people with TB remained for analysis. The potential for selection bias introduced by these exclusions was taken into consideration. However, the very large sample size provides sufficient power to robustly identify factors associated with unsuccessful outcomes within this well-defined cohort.
Statistical analysis
We conducted descriptive analyses to examine the distribution of TB-related variables, presenting categorical data as frequencies and percentages. Trends in treatment outcomes were assessed by determining the proportion of patients with unsuccessful outcomes. Treatment outcomes were dichotomised as follows: (1) unsuccessful, defined as treatment failure, death, loss to follow-up, transfer out, or unknown outcome; and (2) successful, defined as cure or treatment completion. Age-stratified analyses were performed separately for children and adult TB populations. Prior to multivariable modeling, we assessed potential multicollinearity among predictor variables by computing variance inflation factors (VIFs). This diagnostic step ensured the robustness of our regression estimates by identifying and addressing any problematic correlations between explanatory variables. To identify potential predictors of unsuccessful treatment outcomes among adult TB patients, we applied a modified Poisson regression model with robust error variance to estimate adjusted relative risks (aRRs), accounting for potential confounders. This approach was chosen to avoid overestimation of risk that can occur with odds ratios in common outcomes. The aRR reflects the ratio of the probability of unsuccessful treatment in the exposed group compared with the unexposed group, holding all other covariates constant. All statistical tests were two-sided, with significance set at p ≤ 0 × 05. Analyses were performed using R version 4.4.3.
Results
TB notifications
Between 2019 and 2021, the National Tuberculosis Program (NTP) of Bangladesh reported a total of 494,685 notified cases of TB. Annual notifications rose substantially over the study period, with 87,646 cases reported in 2019, 143,503 in 2020, and 263,536 in 2021 (Fig. 1). This reflects a 64% increase in notifications from 2019 to 2020 and a further 83% rise from 2020 to 2021, indicating a marked recovery in TB detection following early pandemic disruptions. In accordance with WHO definitions of successful and unsuccessful tuberculosis treatment outcomes, a total of 300,974 patients were included in the analysis, comprising 14,518 children aged 2–17 years and 286,456 adults. Notably, no cases of HIV co-infection were identified among TB patients during the study period.
Fig. 1.
Flowchart of participant selection for analysis of TB treatment outcomes
Monthly trends in TB notifications revealed distinct seasonal and inter-annual variations (Fig. 2). In 2019, notifications peaked in February (11 × 34% of annual cases) and declined steadily toward December (7 × 87%), potentially reflecting increased healthcare engagement early in the year or the impact of targeted diagnostic campaigns. In 2020, the peak shifted to March (10 × 74%), likely influenced by initial COVID-19-related service disruptions. From June onwards, notifications stabilized at approximately 8 × 0–8 × 6% per month, suggesting resilience in TB case detection amid pandemic-related constraints.
Fig. 2.
Monthly trends in TB notifications for years 2019, 2020, and 2021
In 2021, a bimodal distribution emerged, with peaks in January (9 × 10%) and November (8 × 94%). The relatively elevated and stable monthly notification rates throughout the year (~8.3–8.9%) may reflect an expanded diagnostic capacity and more consistent access to TB services during the post-pandemic recovery period. These trends underscore the NTP’s progressive restoration and strengthening of TB surveillance and diagnostic systems during and after the COVID-19 crisis.
Child TB patient characteristics by treatment outcome
Analysis of 14,518 children with TB, presented in Table 1, revealed a 97.2% treatment success rate, with 2.8% experiencing unsuccessful outcomes (death, treatment failure, or loss to follow-up). A breakdown of child TB characteristics by aggregated outcome category (successful vs. unsuccessful) is provided in Supplement S2. Infants and young children (0–4 years) faced the highest risk, with 7.7% unsuccessful outcomes—driven by a 5.4% mortality rate—highlighting their heightened vulnerability. Extrapulmonary TB demonstrated poorer outcomes than pulmonary TB, with higher mortality (2.3% vs. 1.1%) and loss to follow-up (1.6% vs. 0.6%), likely reflecting diagnostic and management challenges. Treatment complexities were evident in retreatment cases, which had a 6.1% mortality rate-fourfold higher than first-line regimens—and second-line regimens for drug-resistant TB, which showed 3.9% mortality. Rural health facilities reported nearly double the proportion of unsuccessful outcomes (4.7%) compared to urban centers (2.4%), primarily due to higher loss to follow-up (2.5% vs. 0.7%), suggesting systemic gaps in resource-limited settings. Males had marginally higher mortality (1.7% vs. 1.4% in females), while children with a history of previous TB infection faced elevated mortality risk (2.9% vs. 1.5% in new cases).
Table 1.
Child TB patient characteristics by treatment outcome
| Variable | Treatment outcomes—successful (n = 14109, 97.2%) | Treatment outcomes—unsuccessful (n = 409, 2.8%) | Row Total (%) | |||
|---|---|---|---|---|---|---|
| Cured (n, %) | Treatment completed | Death due to TB | Treatment Failed | Missed/Lost to follow-up/Transferred/Not evaluated | ||
| Gender (n = 14518) | ||||||
| Female | 3433 (44.6%) | 4064 (52.7%) | 108 (1.4%) | 25 (0.3%) | 75 (1.0%) | 7705 (53.1%) |
| Male | 2807 (41.2%) | 3805 (55.8%) | 117 (1.7%) | 18 (0.3%) | 66 (1.0%) | 6813 (46.9%) |
| Age group (n = 14518) Average age (SD) = 12.58 (3.83) years | ||||||
| 0–04 Years | 114 (13.9%) | 641 (78.4%) | 44 (5.4%) | 2 (0.2%) | 17 (2.1%) | 818 (5.6%) |
| 05–09 Years | 209 (11.8%) | 1502 (84.6%) | 34 (1.9%) | 1 (0.1%) | 30 (1.7%) | 1776 (12.2%) |
| 10–14 Years | 4209 (51.6%) | 3779 (46.3%) | 96 (1.2%) | 22 (0.3%) | 51 (0.6%) | 8157 (56.2%) |
| 15–17 Years | 1708 (45.3%) | 1947 (51.7%) | 51 (1.4%) | 18 (0.5%) | 43 (1.1%) | 3767 (25.9%) |
| Location of health facility where TB notifications were registered (n = 14503) | ||||||
| Upazila Health facilities (Semi-urban or rural) | 647 (29.9%) | 1401 (64.8%) | 43 (2.0%) | 15 (0.7%) | 55 (2.5%) | 2161 (14.9%) |
| City Health facilities (Urban) | 5593 (45.3%) | 6468 (52.3%) | 182 (1.5%) | 28 (0.2%) | 86 (0.7%) | 12357 (85.1%) |
| Registration Year (n = 14518) | ||||||
| 2019 | 1547 (42.9%) | 1953 (54.1%) | 58 (1.6%) | 11 (0.3%) | 38 (1.1%) | 3607 (24.8%) |
| 2020 | 2632 (43.3%) | 3294 (54.2%) | 83 (1.4%) | 16 (0.3%) | 47 (0.8%) | 6072 (41.8%) |
| 2021 | 2061 (42.6%) | 2622 (54.2%) | 84 (1.7%) | 16 (0.3%) | 56 (1.2%) | 4839 (33.3%) |
| Treatment Stage (n = 14515) | ||||||
| Initial regimen with first-line drugs | 6141 (43.3%) | 7659 (54.0%) | 209 (1.5%) | 42 (0.3%) | 134 (0.9%) | 14185 (97.8%) |
| Retreatment regimen with first-line drugs | 19 (16.7%) | 87 (76.3%) | 7 (6.1%) | 0 (0.0%) | 1 (0.9%) | 114 (0.8%) |
| Second-line treatment regimen (MDR TB or Tuberculous Meningitis or Bone TB or CNS TB) | 77 (37.7%) | 112 (54.9%) | 8 (3.9%) | 1 (0.5%) | 6 (2.9%) | 204 (1.4%) |
| Types by clinical manifestation of TB (n = 14512) | ||||||
| Pulmonary | 6140 (64.9%) | 3117 (33.0%) | 107 (1.1%) | 33 (0.3%) | 59 (0.6%) | 9456 (65.1%) |
| Extra-pulmonary | 98 (1.9%) | 4752 (93.9%) | 118 (2.3%) | 10 (0.2%) | 81 (1.6%) | 5059 (34.9%) |
| Types by history of Tuberculosis (286329) | ||||||
| New TB | 6146 (43.1%) | 7726 (54.2%) | 218 (1.5%) | 42 (0.3%) | 135 (0.9%) | 14267 (98.3%) |
| Previous TB | 92 (37.6%) | 141 (57.6%) | 7 (2.9%) | 1 (0.4%) | 4 (1.6%) | 245 (1.7%) |
Adult TB patient characteristics by treatment outcome
A total of 286,282 adults with TB (mean age, 47.9 years [SD, 16.1]) were included in the analysis; baseline characteristics are presented in Table 2. This study reported a 95.78% treatment success rate (n = 274,373) and 4.22% unsuccessful outcomes (n = 12,083) among adult TB patients. Among adults with TB included in the analysis, the overall treatment success rate was 95.78% (n = 274,373), comprising 65.1% who were cured and 30.7% who completed treatment. Notable gender disparities were observed: males had higher mortality (4 × 0% vs 1 × 8%) and failure rates (0 × 4% vs 0 × 2%) compared to females, although overall treatment success was similar across sexes.
Table 2.
Adult TB patient characteristics by treatment outcome
| Variable | Treatment outcomes—successful (n = 274373, 95.78%) | Treatment outcomes—unsuccessful (n = 12083, 4.22%) | Row Total (%) | |||
|---|---|---|---|---|---|---|
| Cured | Treatment completed | Death due to TB | Treatment Failed | Missed/Lost to follow-up/Transferred/Not evaluated | ||
| Gender (n = 286456) | ||||||
| Female | 80992 (65.5%) | 39177 (31.7%) | 2228 (1.8%) | 234 (0.2%) | 984 (0.8%) | 123615 (43.2%) |
| Male | 105501 (64.8%) | 48703 (29.9%) | 6489 (4.0%) | 681 (0.4%) | 1467 (0.9%) | 162841 (56.8%) |
| Age group (n = 286282) Average age (SD) = 47.87 (16.13) years | ||||||
| 18–30 | 31278 (55.8%) | 23446 (41.8%) | 554 (1.0%) | 245 (0.4%) | 531 (0.9%) | 56054 (19.6%) |
| 31–40 | 33300 (65.6%) | 16161 (31.8%) | 745 (1.5%) | 164 (0.3%) | 418 (0.8%) | 50788 (17.7%) |
| 41–50 | 39975 (69.7%) | 15502 (27.0%) | 1297 (2.3%) | 173 (0.3%) | 417 (0.7%) | 57364 (20.0%) |
| 51–60 | 41645 (68.7%) | 16218 (26.7%) | 2136 (3.5%) | 155 (0.3%) | 504 (0.8%) | 60658 (21.2%) |
| 60+ | 40211 (65.5%) | 16495 (26.9%) | 3955 (6.4%) | 178 (0.3%) | 579 (0.9%) | 61418 (21.5%) |
| Location of health facility where TB notifications were registered (n = 286456) | ||||||
| Upazila Health facilities (Semi-urban or rural) | 173567 (66.9%) | 75376 (29.1%) | 7789 (3.0%) | 750 (0.3%) | 1817 (0.7%) | 259299 (90.5%) |
| City Health facilities (Urban) | 12926 (47.6%) | 12504 (46.0%) | 928 (3.4%) | 165 (0.6%) | 634 (2.3%) | 27157 (9.5%) |
| Registration Year (n = 286456) | ||||||
| 2019 | 38798 (59.7%) | 23214 (35.7%) | 2049 (3.2%) | 224 (0.3%) | 715 (1.1%) | 65000 (22.7%) |
| 2020 | 76796 (65.3%) | 35791 (30.4%) | 3690 (3.1%) | 369 (0.3%) | 952 (0.8%) | 117598 (41.1%) |
| 2021 | 70899 (68.3%) | 28875 (27.8%) | 2978 (2.9%) | 322 (0.3%) | 784 (0.8%) | 103858 (36.3%) |
| Treatment Stage (n = 286330) | ||||||
| Initial regimen with first-line drugs | 180131 (65.8%) | 82342 (30.1%) | 8124 (3.0%) | 829 (0.3%) | 2167 (0.8%) | 273593 (95.6%) |
| Retreatment regimen with first-line drugs | 2049 (30.1%) | 4261 (62.6%) | 342 (5.0%) | 26 (0.4%) | 133 (2.0%) | 6811 (2.4%) |
| Second-line treatment regimen (MDR TB or Tuberculous Meningitis or Bone TB or CNS TB) | 4247 (71.7%) | 1226 (20.7%) | 247 (4.2%) | 59 (1.0%) | 147 (2.5%) | 5926 (2.1%) |
| Types by clinical manifestation of TB (n = 286424) | ||||||
| Pulmonary | 185612 (76.0%) | 49098 (20.1%) | 6798 (2.8%) | 866 (0.4%) | 1771 (0.7%) | 244145 (85.2%) |
| Extra-pulmonary | 863 (2.0%) | 38770 (91.7%) | 1918 (4.5%) | 48 (0.1%) | 680 (1.6%) | 42279 (14.8%) |
| Types by history of Tuberculosis (286329) | ||||||
| New TB | 180232 (65.8%) | 82492 (30.1%) | 8167 (3.0%) | 837 (0.3%) | 2186 (0.8%) | 273914 (95.7%) |
| Previous TB | 6209 (50.0%) | 5323 (42.9%) | 544 (4.4%) | 77 (0.6%) | 262 (2.1%) | 12415 (4.3%) |
Age-stratified analysis revealed a clear trend of worsening outcomes with increasing age. Mortality increased from 1 × 0% among individuals aged 18–30 years to 6 × 4% in those aged over 60 years. Treatment success also varied by type of health facility, with urban health centers achieving higher success rates (96.0%) compared to city hospitals (93.6%).
Temporal analysis showed a modest but consistent improvement in treatment outcomes over time, with treatment success increasing from 95.4% in 2019 to 96.1% in 2021. First-line regimens achieved the highest treatment success (95.9%), followed by retreatment regimens (92.7%) and second-line regimens used primarily for drug-resistant TB (92.4%).
Disease type also influenced outcomes. People with pulmonary TB had a markedly higher cure rate (76 × 0%) compared to people with extrapulmonary TB (2 × 0%), although the latter demonstrated a high treatment completion rate (91 × 7%). Patients with newly diagnosed TB had better outcomes than those previously treated, with success rates of 95 × 9% and 92 × 3%, respectively.
Age-stratified analysis of unsuccessful TB outcome
The age-stratified analysis revealed distinct epidemiological patterns in the burden and management of tuberculosis (Fig. 3). TB incidence exhibited a J-shaped curve across age groups, with the lowest rates observed in adolescents (≤17 years) and a progressive rise beginning in young adults (18–30 years), peaking among individuals aged 60 years and older (Panel A). Sex disparities were pronounced, with males consistently demonstrating higher TB rates than females across all age categories (Panel C).
Fig. 3.
Age-stratified analysis of unsuccessful TB outcome
Geographical variations in TB presentation emerged, with urban health facilities (City Health Complexes) reporting higher case volumes compared to rural/semi-urban facilities (Upazila Health Complexes), particularly among adults aged 31–60 years (Panel F). Disease localization trends varied by age: extrapulmonary TB predominated in younger populations (≤30 years), while pulmonary TB became increasingly prevalent with advancing age, accounting for > 70% of cases in those ≥60 years (Panel H).
Treatment outcomes differed significantly by regimen type. Patients receiving second-line or retreatment regimens faced elevated TB rates compared to those on initial first-line therapy, with the disparity most marked in the 41–60 age group (Panel J). A history of previous TB infection was associated with persistently higher case rates across all age groups, although the gap between new and recurrent TB cases narrowed slightly in the oldest cohort (≥60 years) (Panel L).
Adjusted analysis of adult TB using Poisson regression
We investigated the Variance Inflation Factor (VIF), and the results are given in the supplement. The VIF measures the degree to which predictors in a regression model are linearly related to one another (multicollinearity). The previous/New TB status (VIF value: 2.444) suggests a significant overlap with other predictors, which may lead to inflated standard errors. This may require model refinement (e.g., combining categories or excluding redundant variables). Gender (1.027), age group (1.013), location of treatment facility (1.027), treatment regimen (1.565), and site of disease (1.047) exhibit minimal multicollinearity, indicating that these variables contribute independently to the model. This suggests model refinement by excluding the history of the TB variable (previous/new TB status) from the model.
Unadjusted and adjusted analyses of adult tuberculosis treatment outcomes were performed using a Poisson regression model; results are presented in Table 3. After adjusting for potential confounders, male sex remained independently associated with a higher risk of unsuccessful tuberculosis treatment outcomes compared with females (adjusted risk ratio [aRR] 1 × 58; 95% CI 1 × 52–1 × 65). A clear age-dependent gradient in risk was observed, with individuals aged 60 years or older exhibiting the highest likelihood of unsuccessful outcomes (aRR 3.53; 95% CI = 3.32–3.76) relative to the 18–30-year-old reference group. Treatment at rural or semi-urban facilities (Upazila Health Complexes) was associated with a substantially lower risk of unsuccessful outcome (aRR 0 × 65; 95% CI = 0 × 61–0 × 68) compared with urban health centres. Patients receiving retreatment regimens—either with first-line (aRR 1.71; 95% CI = 1.43–2 × 06) or second-line drugs (aRR 1.78; 95% CI = 1.48–2.13)—had significantly higher risks than those on initial first-line treatment. Extrapulmonary TB was also associated with increased risk compared to pulmonary TB (aRR 2 × 01; 95% CI = 1 × 92–2 × 10), and patients with a prior history of TB had a higher likelihood of unsuccessful outcomes (aRR 1 × 74; 95% CI = 1 × 63–1 × 86).
Table 3.
Factors associated with unsuccessful TB treatment among adult patients
| Variables | Categories | Unadjusted RR (95% CI) | Adjusted RR (95% CI) |
|---|---|---|---|
| Gender | Female | Reference | |
| Male | 1.90 (1.83–1.98) | 1.58 (1.52–1.65) | |
| Age groups | 18–30 | Reference | |
| 31–40 | 1.10 (1.02–1.18) | 1.22 (1.13–1.31) | |
| 41–50 | 1.39 (1.29–1.49) | 1.60 (1.49–1.72) | |
| 51–60 | 1.94 (1.82–2.07) | 2.21 (2.07–2.36) | |
| 60+ | 3.23 (3.05–3.43) | 3.53 (3.32–3.76) | |
| Location of treatment facility | City Health complex (Urban) | Reference | |
| Upazila Health Complex (Semi-urban or rural) | 0.628 (0.598–0.660) | 0.647 (0.614- 0.681) | |
| Treatment stage | First-line drugs | Reference | |
| Retreatment regimen with first-line drugs | 1.81 (1.66–1.97) | 1.71 (1.43–2.06) | |
| Second-line treatment regimen | 1.88 (1.72–2.06) | 1.78 (1.48–2.13) | |
| Types of clinical manifestation of TB | Pulmonary | Reference | |
| Extrapulmonary | 1.62 (1.55–1.69) | 2.01 (1.92–2.10) | |
| History of TB | New TB | Reference | |
| Previous TB | 1.74 (1.63–1.86) | ||
Bold faces present the significant factor at 5% significance level.
Discussion
This study presents a comprehensive national evaluation of tuberculosis (TB) notification trends and treatment outcomes in Bangladesh from 2019 to 2021, capturing both the resilience of the country’s TB control efforts and the persistent challenges that persist. A marked rise in TB notifications—64% from 2019 to 2020 and a further 83% from 2020 to 2021—likely reflects recovery from early COVID–19–related service disruptions, coupled with improvements in surveillance and diagnostic capacity. These trends align with global observations of programmatic rebound during the post-pandemic period, as reported by WHO [1]. The improvement of TB control systems in Bangladesh—through the expansion of the Directly Observed Therapy, Short-course (DOTS) strategy, stronger laboratory capacity, and intensified case-finding activities—likely contributed to this recovery. Broader DOTS coverage, greater community outreach, and increased collaboration with NGOs and private providers have helped raise case detection rates and improve TB notification across the country.
Treatment outcomes during the study period were highly encouraging. Among 286,456 adults and 14,518 children with TB, treatment success rates reached 95.8% and 97.2%, respectively. These figures exceed the global average of 86% reported by the WHO in 2022 [12, 19] and are comparable to the success rates achieved in high-performing programs in the Americas and the Eastern Mediterranean regions [20–22]. This performance suggests effective program delivery, bolstered by mechanisms such as community-based DOTS and digital adherence technologies. However, it is important to note that national success rates may be inflated by the exclusion of individuals with drug-resistant TB or those lost to follow-up before registration.
Despite overall success, the analysis revealed key vulnerabilities in specific subpopulations. Among children, the highest rate of unsuccessful outcomes—particularly mortality—was concentrated in those under five years of age. This finding is consistent with prior studies that have identified young children as being especially susceptible to rapid disease progression and diagnostic delays [23–25]. Children with extrapulmonary TB or those undergoing retreatment also had worse outcomes, highlighting the operational and clinical complexity of managing these cases in low-resource settings [26, 27]. While many of these cases achieved treatment completion in the absence of bacteriological cure, this outcome remains consistent with WHO guidelines [28], although it raises concerns regarding diagnostic accuracy and long-term disease monitoring.
In the adult population, treatment success remained high across most subgroups but varied significantly by age, sex, disease site, and treatment regimen. Male patients experienced higher rates of death and treatment failure than females, mirroring global evidence of gender disparities in TB burden and outcomes [29, 30]. Mortality increased sharply with advancing age, reaching 6.4% among patients aged ≥60 years, likely reflecting delayed diagnosis, higher rates of comorbid conditions, and increased clinical severity at presentation [31, 32]. Notably, treatment success was lower in urban health centres compared with rural Upazila Health Complexes, possibly due to greater patient load, fragmented follow-up, or overburdened services.
The lower success rates observed in patients receiving retreatment or second-line regimens are consistent with the ongoing global challenge of drug-resistant TB (DR-TB). As seen in other high-burden countries, second-line regimens were associated with success rates approximately 7–8% lower than those of first-line therapy [33, 34], emphasising the need for earlier detection of drug resistance, enhanced adherence support, and regimen optimization. Poor outcomes were also disproportionately concentrated among key vulnerable groups—particularly older adults, men, and patients with extrapulmonary or recurrent TB—highlighting structural and clinical barriers to effective care. These findings are consistent with those of previous studies, which have reported similar disparities in treatment outcomes [35, 36].
Taken together, these findings highlight the overall strength of Bangladesh’s TB programme, while identifying critical gaps among children, older adults, males, and those receiving complex regimens. Tailored strategies for these groups—including expanded diagnostic tools, improved treatment monitoring, and decentralised care delivery—will be essential to sustain progress toward WHO’s End TB targets.
This study benefits from a large, nationally representative dataset with comprehensive stratification by demographic and clinical subgroups, as well as the use of adjusted statistical models to identify potential predictors of unsuccessful treatment outcomes. However, several limitations should be noted. The retrospective design and reliance on routinely collected surveillance data introduce the possibility of missing or inaccurately recorded variables. Incomplete bacteriological confirmation, particularly in extrapulmonary TB, may have led to outcome misclassification. The study population was skewed toward older adults, who may have higher comorbidity burdens and mortality risks. Additionally, heterogeneity in treatment regimens and modifications due to drug resistance or comorbidities limits the interpretability of treatment effects. Finally, incomplete documentation in national TB reports precluded more granular analysis of factors contributing to mortality.
Conclusion
This national cohort study highlights Bangladesh’s resilience in sustaining tuberculosis (TB) case detection despite challenges of the pandemic, while also revealing critical gaps in care for vulnerable populations. Three major findings require urgent policy attention: first, high mortality rates among children under 5 years and adults aged 60 years and older point to deficiencies in age-specific TB management; second, a nearly threefold increased risk of poor outcomes among patients receiving retreatment regimens underscores persistent challenges in the management of drug-resistant TB; and third, the elevated risk among males and disparities between rural and urban settings reflect ongoing inequities in healthcare access. These findings offer both a warning and a path forward. To close these outcome gaps, Bangladesh should build on its surveillance gains by prioritising rapid diagnostics for child and drug-resistant TB, implementing gender-sensitive strategies, and strengthening health systems in underserved areas. Targeted action on these priorities can help transform Bangladesh’s TB program into a model for other high-burden countries striving to meet the WHO End TB targets.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
We appreciate the statistical advice provided by the University of Sharjah’s College of Health Sciences.
Abbreviations
- TB
Tuberculosis
- WHO
World Health Organization
- aRR
Adjusted Risk Ratio
- NTP
National Tuberculosis Program
- VIF
Variance inflation factor
Author contributions
MJS and AH contributed to the study concept, literature search, and design. AH, MJS, AR, AT, SRS, MAM, HRK, and HMR contributed to the data acquisition. AH and MJS accessed the data and contributed to the data analysis. AH and MJS contributed to the data interpretation. AH drafted the manuscript. All authors contributed to the critical revision of the manuscript.
Funding
This research did not receive funding from any public, commercial, or not-for-profit agency.
Data availability
The data underlying this study were obtained from the National Tuberculosis Program’s surveillance system with permission from the Directorate General of Health Services, Bangladesh. To support research transparency and reproducibility, an anonymized dataset has been deposited on the Open Science Framework (OSF) platform at https://osf.io/vbqpy. Researchers seeking access to the full dataset or wishing to discuss collaboration opportunities may contact the corresponding author.
Declarations
Ethics approval and consent to participate
This study used routinely collected programmatic data for tuberculosis surveillance. All data were fully de-identified prior to analysis, and individual informed consent was not required. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. The study was approved by the Ethics Committee of the General Health Services, Ministry of Health and Family Welfare, Bangladesh (Reference No. 13,074).
Clinical trial number
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data underlying this study were obtained from the National Tuberculosis Program’s surveillance system with permission from the Directorate General of Health Services, Bangladesh. To support research transparency and reproducibility, an anonymized dataset has been deposited on the Open Science Framework (OSF) platform at https://osf.io/vbqpy. Researchers seeking access to the full dataset or wishing to discuss collaboration opportunities may contact the corresponding author.