1. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care International Pain Policy Fellowship, Cohort III Country Report Directions and Template Madison, Wisconsin 6-10 August 2012

2. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Country Report:Bangladesh Team Members: Rumana Dowla, MBBS, MPH, DipPallMed Masters iin Palliative Medicine, Cardiff University, UK Chair person, Bangladesh Palliative & Supportive Care Foundation Specialist, Palliative Medicine, United Hospital Farzana Khan, MBBS, MPH PhD in Palliative Care (Student), Lancaster University, UK Medical Officer, Centre for Palliative care, Bangabandhu Sheikh Mujib Medical University

3. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Bangladesh

4. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Bangladesh

5. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Bangladesh Currency: Bangladeshi taka Population: 150,493,658 (2011) World Bank Capital: Dhaka GDP: US$ 110.6 billion (2011) World Bank Official language: Bengali

6. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1. Cancer pain and palliative care Total Cancer Patient : 24,847 Confirmed diagnosis : 18,829 cases Male 10,847 (57%) Female 6018 (43%) Male Lung 25.5% Female Breast 25.6% 38% constitute ca lung in male and breast and cervical cancer female. Ref Cancer Registry NICRH 2005-2007

7. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1. Cancer pain and palliative care Death (2009) Proportion with moderate/s evere pain Number of deaths with moderate/ severe pain Cancer91,49480%73,196 Ref: Global access to pain relief initiative, PPSG

8. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Breast (females) Cervix uteri (females) LiverColorectalLungProstate (males) Female s MalesFemal es MalesFemal es Male s 27.229.83.54.14.04.58.730.41.9 a. What is the estimated prevalence and types of cancer in your country, mortality, and the prevalence of pain? Top causes of mortality in the NICRH, by age & sex distribution, 2010 Age standerdized incidence per 100000 persons of common cancers in Bangladesh, 2008:

9. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care MaleFemaleBoth Sexes Ca-lung44.44Ca-breast16.13Ca-lung30.59 Acute myeloid leukemia7.41Chorio-carcinoma9.68Acute myeloid leukemia5.88 Non-Hodgkin lymphoma 5.56Adenocarcinoma6.45Non-Hodgkin lymphoma 5.88 Ca-stomack5.56Ca-colon and Ca- rectum 6.45Ca-stomach5.88 Adenocarcinoma3.70Ca-lung6.45Adenocarcinoma4.71 Ca-prostate3.70Non-Hodgkin lymphoma 6.45Ca-colon and Ca- rectum 3.53 Ca-gallbladder3.70Ca-stomach6.45Acute lymphatic leukemia 2.35 Acute lymphatic leukemia 1.85Acute lymphatic leukemia 3.23Squamous cell carcinoma.35 Ca-colon and Ca- rectum 1.85Acute myeloid leukemia3.23Ca-gallbladder2.35 Ca-gallbladder1.85Ca-gallbladder3.23Fibrosarcoma2.35 Total patients=54Total patients=31Total patients=85 a. What is the estimated prevalence and types of cancer in your country, mortality, and the prevalence of pain? (…Continued)

10. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care

11. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care There is no national cancer control policy yet, but a plan was made by a task force made in collaboration with Government and WHO. Consultative meetings were held and a report was produced, but no follow up could be find out. b. Is there a national cancer control policy, plan, or program? If so, when did it start? What is the name of the office and person in charge? Are objectives for pain relief and palliative care included? Is availability of opioid analgesics specifically addressed?

12. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.There is no documental evidence Bangladesh Government has endorsed the WHO method for relief of cancer pain 2.Doctors and nurses were sent for 6 wks from NICRH to IPM Kerala 3. introduced WHO guideline. 4. But the Government has not yet sponsored or endorsed training programs in cancer pain relief, palliative care and the medical use of opioid analgesics At NICRH morphine license is being worked on-8.5 c. Has the government endorsed the WHO method for relief of cancer pain? Has the government sponsored or endorsed training programs in cancer pain relief, palliative care and the medical use of opioid analgesics?

13. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care d. Describe in brief terms the availability of pain relief and palliative care services in the country and comment on the extent to which the needy population has access to such services, including children. How well is pediatric cancer pain treated? Do pediatric patients have access to opioid analgesics in the class of morphine? 1. 1.Sanisphere an international consultant appointed by UICC (Union against Cancer) estimated that there are approximately 7000 new cases of childhood cancer 2.Then among the children who start the treatment there is 30- 50% drop out 3 estimated between year 2000 to 2006 3.Services for children ASHIC Foundation BSMMU NICRH 4.Yes,in these centers morphine is prescribed for pain … ASHIC foundation has morphine license; NICRH and BSMMU Paed Haemato-oncology Ref:Sanisphere (2006) ‘Overall situation of childhood cancer in Bangladesh’ International Consultant appointed by UICC.

14. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care d. Describe in brief terms the availability of pain relief and palliative care services in the country and comment on the extent to which the needy population has access to such services, including children. How well is pediatric cancer pain treated? Do pediatric patients have access to opioid analgesics in the class of morphine? Director General of Health Service Bangladesh supported by WHO published and Annual Report of National Institute of Cancer Research Hospital in 2005 Total number of patients =7516 Paediatric Patients = Age 0-15 years were 218 only 4.0% Among them, Boys =139 Girls=79 64.2% of these cases constituted- Lymphoma -Retinoblastoma -Leukemia Sanisphere Int. Conducted a study funded by UICC( Union Against Cancer ) 5 According to their study approximately there are New cases = 7000 per year Diagnosed cases =1000-1500per year Treated =700 patients Fully Treated =350-500 patients

15. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care d. Describe in brief terms the availability of pain relief and palliative care services in the country and comment on the extent to which the needy population has access to such services, including children. How well is pediatric cancer pain treated? Do pediatric patients have access to opioid analgesics in the class of morphine? During the practicum stay at BSMMU Haemato-oncology Department the following cases were seen commonly and listed in order of frequency almost similar to the USA list discussed earlier. 1.Acute Lymphoblastic Leukemia(ALL) 2.Acute Myloblastic Leukemia(AML) 3.Non- Hodgkins Lymphoma(NHL) 4.Hodgkins Lymphoma (HL) 5.Wilms Tumor 6.Neuroblastoma 7.Ewings Sarcoma. Ref:Dowla. R (2007) Observing paediaric cancer patients their management and to ascertain role of palliative care in a hospital in Bangladesh;

16. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care d. Describe in brief terms the availability of pain relief and palliative care services in the country and comment on the extent to which the needy population has access to such services, including children. How well is pediatric cancer pain treated? Do pediatric patients have access to opioid analgesics in the class of morphine?

17. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.Centre for Palliative Care, BSMMU – 20 beds Indoor, OPD – 6 days/week, 24 hrs Telephone service, Home care, Training centre with BCCPM & BCCPN courses, introductory courses for doctors, nurses, community volunteers, family members. Next course- policy makers & DNC officers 2.Bangladesh Palliative & Supportive Care Foundation – 4 in- patient bed, mainly homecare;24 hour telephone service Caregiver training,awareness program,nurses course,Gpfocus 3.Amader Gram –,OPD,home-care,cellphone based reporting 4.Ashic paediatric palliative care foundation – 6 beds 5.National Cancer Research hospital – 4 beds 6.Shanti oncology & Palliative Care – 2 beds 7.Delta Medical College & Hospital – 4 beds e. Identify non-governmental organizations that have a focus on pain relief and palliative care and mention their relevant activities. Is there a national palliative care association?

18. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 2. HIV/AIDS pain and palliative care

19. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care First HIV Case in the country in 1989 Bangladesh –low prevalence<1% among most risk population(MRP) In general population <1% Among IDUs 5.3% in Dhaka city (9 th Surveillances) Estimated number of HIV infected cases is 7500 HIV Epidemiology 2011 New HIV infected 445 New AIDS cases 251 Death 84 Under ART 810 Cumulative cases as of 2011 Total reported cases 2533 Total AIDS cases 1101 Total death :325 a. What is the estimated prevalence of HIV/AIDS in your country, mortality and the prevalence of pain?

20. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care First HIV Case in the country in 1989 Bangladesh –low prevalence<1% among most risk population(MRP) In general population <1% Among IDUs 5.3% in Dhaka city (9 th Surveillances) Estimated number of HIV infected cases is 7500 a. What is the estimated prevalence of HIV/AIDS in your country, mortality and the prevalence of pain? Death (2009) Proportion with moderate/ severe pain Number of Deaths with moderate/ severe pain HIV11950%60 Source: Global Access to pain relief Initiative PPSG

21. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.Yes, there is a national policy on HIV/AIDS and STD related issues 2.Name of the office: National AIDS/STD Programme (NASP) National AIDS/STD Programme (NASP) is one of the wings of Directorate General of Health Services (DGHS) under the Ministry of Health & Family Welfare (MOHFW) responsible for coordinating with all stakeholders and development partners involved in HIV/AIDS programme activities throughout the country. http://www.bdnasp.net 3.Project Manager-Line Director is the task collaborator 4.Pain relief and palliative care are included-for next plan 5.Availability of opioid analgesic is not specifically addressed b. Is there a national AIDS policy, plan, or program? If so, when did it start? What is the name of the office and person in charge? Are objectives for pain relief and palliative care included? Is availability of opioid analgesics specifically addressed?

22. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.There are different programs 2.Serving most at risk population and general population 3.Under the national responses the Govt of Bangladesh has program following packages -sex workers packages -Injecting drug user packages -Men who have Sex with Men (MSM) 1.People living with HIV (PLHIV) packages 2.Opioid Substitution therapy (OST),Methadone project under process with NAS World Bank b. Is there a national AIDS policy, plan, or program? If so, when did it start? What is the name of the office and person in charge? Are objectives for pain relief and palliative care included? Is availability of opioid analgesics specifically addressed?

23. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.The government has endorsed the WHO method for relief of HIV/AIDS pain 2.The government has not sponsored or endorsed training programs in pain relief, palliative care and the medical use of opioid analgesics related to this. c. Has the government endorsed the WHO method for relief of HIV/AIDS pain? Has the government sponsored or endorsed training programs in pain relief, palliative care and the medical use of opioid analgesics?

24. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.ICDDRB – 6 beds 2.Jagori- OPD & counselling services 3.Awareness is lacking 4.Many NGOs are working in this field d. Describe in brief terms the availability of pain relief and palliative care services in the country for HIV/AIDS patients and comment on the extent to which the needy population has access to such services, including children. How well is pediatric pain treated? Do pediatric patients have access to opioid analgesics in the class of morphine?

25. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Bangladesh Bangladesh has a strong political history and commitment to the HIV response  The national Strategic Plan for HIV and AIDS Responses for 2011- 2015  Basic approaches  -DIC and IHC based services  -Peer Education  -Outreach Services  Harm Reduction  -Capacity Building  -Advocacy and Communication  Community participation and self help group  Referral HIV prevention services

26. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 3. Opioid availability (This information, to the extent that it is available, should be obtained from the national office for narcotics control, i.e., the “Competent Authority,”[1] and from pain and palliative care programs.) See Country Profiles at http://www.painpolicy.wisc.edu/internat/countryprofiles.htm http://www.painpolicy.wisc.edu/internat/countryprofiles.htm 1] United Nations. Competent National Authorities Under the International Drug Control Treaties, 2006. New York, NY: United Nations; 2007. http://www.youtube.com/watch?v=hK2OVonGRDI&feature=related