Tuberculosis Control in Pakistan: Critical

Analysis of its Implementation

Introduction
Tuberculosis (TB) constitutes a major public health challenge. Due to the emergence of lily, increased
migration and the deterioration of the health services in many countries, the incidence has risen so
drastically in recent years, that TB was declared a global emergency by WHO in 19931. Without
increased investment in intervention strategies, the global tuberculosis situation is expected to worsen
in the near future2.
Epidemiology of TB in Pakistan
There is little reliable epidemiological data available for Pakistan, although TB is considered to be a
major cause of ill health3. The annual incidence rate of infectious TB cases is estimated to be between
85-100/100,000 persons. Annually around 120,000 new TB cases are being added to the existing
number of infectious individuals. Some areas in the country have much higher figures, such as
Northern Pakistan where a prevalence figure of 554/100,000 cases was observed4.
As in other developing countries, young age groups are affected the most. Male patients outnumber
females in most age groups, except in the adolescents. Based on Burden of Disease estimates, TB
represents 5% of the total DALYs (disability adjusted life years): which indicates that the burden of
tuberculosis in Pakistan. is substantially higher than the world average of 3%5.
Historical Review of TB control activities in Pakistan
The first survey was carried out in 1962. The results triggered a collaborative effort between MoH.
WHO and UNICEF for a twenty year TB control programme. that focussed on establishing specialised
TB centres and special TB wards at the DHQ Hospitals. In 1985 UNICEF withdrew its financial
support. WHO declared TB a global emergency in 1993 and the GoP endorsed the DOTS strategy. In
1994 the MoH. in collaboration with WHO. revised the TB control policy. National policy and
technical guidelines were drafted: however, to date there is no draft yet for operational guidelines. In
1995 the MoH decided on the location of 5 DOTS pilot sites, but only 1 site became operational. A
highly centralised and vertical live-year development plan was prepared by the Federal NTP. Since the
Provinces expressed certain reservations with regard to the plan, it was not approved. In 1996 the
Directorate for TB Control of Pakistan was abolished and the MS of the TB Centre in Rawalpindi made
responsible for National TB Control programme, but without any additional support. In 1998 Pakistan
was declared I of the 16 countries without an appropriate NTP. Recently it was decided that each
province would be responsible to plan and manage its own NTP under Federal NTP guidelines.
Funding for the plans will be provided through SAPP II.
Critical Analysis of the NTP
Given the magnitude of the TB problem in Pakistan as well as the size of the country, a vertical TB
control programme is financially prohibitive and difficult to sustain. Integration of the TB control
programme in PHC has recently been opted for, as a solution to its technical and managerial
deficiencies. Hereto, a network of laboratories needs to be created as well as a system for ensuring
quality of sputum smear microscopy put in place.
The Objectives of the NTP
Policy
The two major objectives are:
a) To increase the cure rate of positive cases to at least 85%; sputum smear
b) To increase the detection of new cases to 70%, once the first objective is reached.
Federal role in the NTP
Provision of a policy framework, technical assistance, supervision, surveillance, co-ordination. research
and development and advocacy.
Provincial role in the NTP
Planning, accessing funds, management of programme, implementation of E)OTS through integration
with the P1-IC.
Practice
The NTP has been unable to come close to, let alone achieve, its ambitious objectives. TB control
activities in Pakistan have suffered during the last five years because of the dilemma of either
managing the programme from the federal level or handing it over to the provinces. A decision in
favour of the latter option was taken as late as mid-1998. Under this arrangement the roles of the
provinces and the federal government have been well defined. The provinces have been given the
responsibility of independently developing and implementing their own TB control programmes. TB
control activities suffered in the past as there were no funds earmarked for TB control in the provinces.
District managers were expected to support TB control activities from their already insufficient regular
budgets. For the fiscal year 1999-2000 the federal government has indicated support and earmarked
funds for all the provinces as well as for the federal component. Health sector reform is a major driving
foice for improving the health systems throughout the world6. Proponents of this reform believe
services to be more cost-effective and sustainable if they are integrated into and delivered through a
comprehensive district health care system.
Programmatic reforms in the health sector of Pakistan have over the years improved public health
services through better targeting of populations, funds and services. The TB Control Programme is one
example. Recently there has been an effort on the part of the provincial health departments to introduce
structural and management reforms in the health sector in order to improve the efficiency of service
delivery and resources development.
Interest in the control of tuberculosis has been further renewed through a recent policy initiative to
strengthen PHC services through an integrated approach. The Social Action Programme, with multi-
donors’ support. has also pushed TB high on the agenda, and the programme priorities of Provincial
Health Departments have been redefined.
Screening and Diagnosis
Policy
According to the NTP guidelines, detection of pulmonary TB should be based on sputum examination7.
From TB suspects at least 3 specimens should be collected and examined.
Criteria for “AFB caseness” consist of 2 positive smears OR one AFB+ sputum as well as radiographic
abnormalities consistent with active pulmonary tuberculosis. OR if determined by a competent medical
officer.
The diagnosis of a “Smear-Negative” TB case is made if the following 3 criteria are met: At least 3
specimen AFB- sputum by microscopy
• Radiographic abnormalities consistent with active tuberculosis
• Clinical evidence substantiated by a competent medical officer.
Practice
In Pakistan TB detection and diagnosis is generally based on X-ray, clinical impression and blood
examination rather than on sputum examination. Some clinicians rely on Mantoux results, although
tuberculin is rarely available.
The network of laboratories able to correctly carry out sputuni examinations, is inadequately developed
with virtually non-existent supervision. Consequently many laboratory results are not reliable. These
unreliable test outcomes weaken the trust of the clinicians in the laboratory results and strengthen their
belief in clinical impression. ESR and/or X-ray as diagnostic tools.
Many centres start TB treatment even when no sputum is available: in the Rawalpindi study8 no
sputum was available for 6.2% of the patients. In Delhi, lndia9 it was found that for only 12% of the TB
suspects, a sputum examination was advised.
In practice the number of diagnostic AFB exams is limited to two. A recent study has shown the
sensitivity of 2 AFB exams to be 93% of that of 3 AFB exams 10. PCR (Polymerase chain reaction),
although more sensitive and specific than smear microscopy, is prohibitively expensive11, and is not
routinely used in Pakistan. As a routine exani, the ELISA test for detecting tubercular antigen in sputum
has not yet been implemented in the country.
Contact Tracing Policy
Bacteriological examination of all the contacts with a smear positive index case. Especially children
and young adults should undergo 3 sputum examinations.
Practice
In Pakistan only some specialised centres routinely perform contact tracing, although not appropriately.
Since the NTP guidelines do not detail the mechanisms of contact tracing; this is an area that needs
attention, especially for operational guideline preparation.
Treatment Regimens
Policy
The NTP proposes short course chemotherapy for all sputum positive cases for 8 months duration. The
guidelines distinguish 3 main categories of patients:
• Category I patients are new AFB smear positive cases;
Category II refers to smear positive re-treatment and failures after a full short chemotherapy course;
Category Ill refers to sputum smear-negative and extra-pulmonary cases and to children who are unable
to produce sputum.
The recommended treatment strategies for these three categories are described in
Table. NTP guidelines recommend daily dosages according to weight.
Practice
General practitioners and specialists have a poor awareness of the WHO guidelines12,13 and do not
adhere fully to the national treatment guidelines. Almost all treatment centres are using strengths and
combinations of drugs that differ from the accepted guidelines.
This situation is not unique to Pakistan. Unsatisfactory practices of private care providers have also
been observed in India14. In Delhi 102 different regimens were being reported, 51% of the patients
were over-treated and only 20% of the care providers did emphasise the importance of regular
treatment.
Follow up of Patients
Policy
Patients should be monitored at regular intervals through:
Sputum smear examination
Regularity of drug intake, to be monitored by DOT
Prompt recovery of defaulters
Sputum has to be examined at 2,5 and 8 months after the start of treatment. For monitoring purposes, a
single sputum specimen smear examination is sufficient. If the sputum results of a sputum smear
positive patient are negative at months 5 and 8, he/she should be discharged from treatment after
completion of the treatment course. If the sputum result is positive at 5th or 8th month. then the
treatment must be changed to sputum smear positive retreatment regimen.
No post-treatment follow-up is necessary for patients who have successfully completed their treatment.
Given that Rifampicin is part of the intensive phase treatment scheme, careful supervision is necessary
and no Rifampicin containing regimens should be given to patients who are taking the drugs at home
without supervision. When outpatients fail to attend more than two consecutive follow-up
appointments during the intensive phase, they should be traced within a week of missing their second
appointment. This means that a visit should be paid to the home of a TB patient who did not attend the
scheduled appointment for drug supply.
Practice
In Pakistan low treatment adherence prevails. In the sixties Sloan and Sloan observed dropout rates of
66% in Sindh15, similar rates were found in the recent Rawalpindi cohort study8. A characteristic of
case holding in Pakistan, is the important very early defaulting. Several studies have shown behavioural
factors16, including social stigma17, to contribute to non-adherence to treatment. Research has shown
irregularity of attendance during the initial phase to be a major determinant for treatment adherence not
only in the initial phase, but also in the continuation phase8. Incorporating DOT in the initial phase can
thus have an important impact on early, as well as late defaulting. So far Pakistan has only launched a
few pilot DOTS projects in selected districts18, but the DOT strategy needs far greater support than it
has received thus far. Some centres hospitalise patients during the initial 2 months of treatment, to
guarantee very close DOT supervision.
No firm data is available on defaulter tracing mechanism in Pakistan, but it is strongly suspected to be
rather deficient. The objective is to bring the patient back to regular treatment in order to cure the
disease, avoid development of resistance, and avoid spreading the disease in the community.
Drug Resistance and Re-Treatment
Policy
Drug resistance is one of the consequences of low adherence to treatment. Sputum positive patients
who have previously taken anti-tuberculosis drugs for I month or more must be suspected of
discharging tubercie bacilli resistant to INH and/or other drugs. Such patients must be started on re-
treatment regimen (2 SHRZFJ I HRZE/5 HRE).
Practice
In Karachi resistance rates to the four first line anti-TB drugs were found to be 27% to INH, 15% to
Ethambutol, 11% to Rifampicin and 13% to Streptomycin; MDR (multi drug resistance) was 8%19. The
guidelines for re-treatment of resistant TB cases are based on WHO recommendations rather than on
local studies.
Involvement of Private Practitioners
Policy
There is no explicit policy for involvement of private practitioners in the treatment and follow-up of TB
patients.
Practice
tighty percent of the lB patients consult a private practitioner first20; these findings have been
confirmed in the PMRC health seeking behaviour study. I Hassan has found an even higher figure of
96%. Marsh has demonstrated poor performance of some private practitioners in screening, diagnosing,
treating and monitoring their TB patients20. Ekbal21 has discussed the main errors in drug prescribing
practices as:
Starting with a single drug, adding a single drug to a failing regimen, inappropriate prescription,
ignoring DOTS, extensive prescription of combined anti-TB drugs and insufficient instructions to
illiterate patients.
The fact that most TB patients first contact a private practitioner has been revealed by several surveys.
In spite of this, official policies are directed towards detection, treatment and follow-up of TB patients
at public sector health facilities only. Public sector managers should be more innovative and develop
public - private collaboration. One way could be to train GPs in opportune diagnosis. treatment and
follow-up of TB patients and encourage them to refer these patients to the laboratories of THQ
hospitals for sputum examination and registration.
Integration of TB control into PHC services
Policy
The official policy is to integrate TB control services into the PHC services. A network of laboratories
will be established, i in each REIC and THQ hospital. Sputum collection and smear fixation will be
done at BHU level, once personnel have been adequately trained. I luman and material resources will
be integrated into the PHC. NTP plans to ensure a continuous drug supply by establishing a system for
national procurement, storage, and delivery and monitoring of anti-TB drugs. Continuous supervision
will enable prompt detection of deficiencies in implementation, motivation and skills of staff.
Practice
Pakistan has a relatively well-developed health care infrastructure. The centres have, in theory,
sufficient manpower: a recent World Bank report6 even speaks of overstaffing, niainly of general
practitioners. But many rural areas lack female doctors, which limits the access of female patients to
care. Contrary to NTP mandate, to date only sporadic training sessions for stafi of public services have
been held. There is limited involvement of the THQH in TB control activities and no involvement of
the BHUs in case detection or follow-up.
Generally the laboratories at the RHC and THQH do not function due to either failure of necessary
reagents, or insufficient training of laboratory technicians. Most of the time, however, the reason for the
poor functioning of the laboratory is the lack of requests for sputum examination by the medical
practitioners.
Many RHC and THQH have no regular TB drug supply, or the stock consists of a few selected drugs
only. The danger is that the patients do not buy the other drugs and consequently resistance develops.
Visits to several first and second line centres in Pakistan have shown that the drug supply is very
irregular, partial and insufficient.
Regular supervision of the TB program activities is one of the weakest elements of the system. The
concept of supervision as continuous education has not been introduced yet. There is normally no back
referral of diagnosed TB cases by the specialised centres.
Reporting System
The IUATLD (International Union Against Tuberculosis and Lung Disease) recognises a reliable
information system to be the key element for the success of national TB control programmes22.
Experience from several countries shows the data generated by the NTP to be more reliable and
complete than that generated by HMIS (Health Management Information System) and more suitable
for programme management. Following IUATLD both information systems should complement each
other; therefore NTP should collect the relevant TB data and communicate it to the HMIS managers at
all levels of the health system.
Policy
The NTP has planned to introduce a standard system of registration and reporting, to monitor the
results of treatment and to assess progress of the programme by means of ongoing quarterly analysis.
A series of standardised records have been created:
TB treatment card; TB appointment card; District TB register: TB laboratory register: TB smear
examination request/report form; TB culture/sensitivity Test Request/Report form; TB referral/Transfer
form; Quarterly order form for TB treatment supplies: Quarterly order form for TB laboratory supplies.
The case finding, smear conversions at follow-up, and final results of treatment have to be reported to
the NTP on a quarterly basis. A cohort analysis has to be carried out. A feedback mechanism will also
be established.
Practice
At present there is no uniform system of recording and reporting in the public sector. The HMIS has a
different format from that suggested by NTP. In some areas where DOTS is implemented a dual system
exists. The method of recording and collecting information differs from one centre to another and is
generally not in accordance with WHO guidelines. Case definitions for pulmonary and extra pulmonary
cases may differ and cohort analyses are computed differently as well. Data is as yet not being used for
the planning and management of TB services. No reliable national data is available concerning TB case
detection and TB case holding. The quality of the HMIS data is inferior to the recommended NTP
recording, it is not standardised and generally not in accordance with WHO recommendations.
NGO’s
Policy
The NTP proposes to strengthen co-operation and co-ordination with NGO’s23. The latter are expected
to play a crucial role in enhancing patient education and community assistance.
Practice
The majority of NGOs are working in isolation, involved mainly in the treatment and drug provision.
Some NGO’s have not yet adopted the NTP Guidelines. Little effort has been undertaken to streamline
the NGO’s’ efforts.
Role of Communities
Policy
Four main roles for the communities are envisioned:
To encourage the TB suspects to promptly visit a health facility for assessment.
To support the diagnosed cases to complete treatment.
To improve general understanding of the disease and its prevention.
Practice
To supervise treatment.
The national policy makers perceive the community as a natural partner for public sector development.
However, hardly any sustainable model has been designed and practised in the health sector and almost
none for either reduction or control of TB. In pilot projects going on in Balochistan and NWFP
provinces. LHWs are being used to implement the DOTS, with encouraging outcomes. However, to
fully realise the additional benefits obtained from community participation, the NTP may have to
design some culturally appropriate, socially acceptable and sustainable partnerships between the people
and the public health sector of this country.
Political Commitment
A strong political commitment is essential for the success and sustainability of any TB control
programme.
Practice
The political commitment at the federal and provincial levels is rather weak, although interesting pilot
projects are at present being undertaken in the provinces of Balochistan and NWFP.
Future Strategies and Recom mendations
The weaknesses and shortcomings at each level of the NTP need prompt political, technical and/or
managerial solutions.
At the political level: TB should be given much greater importance, and commitment, as well as
support and resources. The Federal NTP unit should be made fully operational.
At the technical level: All care providers working in both the public and private sectors should be
updated on the NTP guidelines. District and Tehsil headquarter hospitals should be equipped to carry
out reliable sputum exams. Laboratories should adhere to quality control principles. DOTS will have to
be applied throughout the country, and lessons learned from patient counselling experiences should be
incorporated in patient management. The communities should be involved in the DOTS scheme.
At the managerial level: The NTP has to be strengthened, and specific tasks for all levels (federal,
provincial, district and community) have to be planned. The activities have to be implemented,
monitored and assessed with clearly defined indicators. Following the lessons learned from
neighbouring countries, private practitioners should be involved. The co-operation with NGO’s has to
be strengthened. The public should be much better informed, and the message that the disease is
curable should he spread through all means of communication. There is a need for continuous
laboratory supplies, as well as for a continuous drug supply system. There is a need for a drug
resistance surveillance system. The personnel in charge of Tehsils and districts should be trained in data
management and analysis, so that programme management will become more evidence based.
At the comniunity level: Strategies to overcome the stigma attached to TB have to be developed.
At the individual care level: The continuity of the care has to be addressed in the context of the socio-
economic constraints of the households and communities. Specific treatment should be given free of
charge, and efficiency improved by reducing the number of visits to the least required, and by
following up the patients as close to their homes as possible.
At the research level: Operational research is needed to find solutions for the constraints and to
continuously optimise the programme output.
Behavioural research is needed to create awareness of the TB problem24 and to contribute to its
destigmatisation; as well as to develop a socially acceptable DOTS programme. Socio-economic
research is needed to quantify the burden of disease, the cost of defaulting and the benefits of DOTS.
Epidemiological research is needed to determine the magnitude and spread of the disease, and the drug
resistance in order to analyse the risk-factors for the incidence of infection and disease, and to
determine the nosocomial risk.
Therapeutical research is needed to find more cost-effective ways of treatment.

References
1.WHO/TB/94.177. TB a global emergency. Geneva, WHO 1994.
2.MeKinney J, Jacobs Jr W, Bloom B. Persisting problems in tuberculosis. In: Emerging Infections, NY
Academic press, 1998. pp. 51-146.
3.Khan KS. Setting health care priorities in Pakistan, J. Pak. Med. Assoc., 1995, 45: 222-27.
4.Alvi A, Uussain S. Shalt W, et al. Prevalence of pulmonary tuberculosis on the roof of the world. Int i
Tubercle Lung Dis, 1998,2 : 909-13.
5.World Bank. Health, Nutrition and Population Unit, South East Asia Region. Pakistait’ towards a
health sector sti ategy. Report No. 16. 695 Pak., 1998.
6.World Bank, World Development Report 1993. Washington. World Bank, 1993.
7.Hussain R. Toossi 7., Hasan R, et al. Immune response profile in patients with active tuberculosis in a
BCG vaccinated area. Southeast Asian J. Trop. Med Public Health, 1997, 28 : 763-64.
8.De Muynck A. Hussain M. Await M. Afzal R. Gender and Tuberculosis: a retrospective cohort study
in TB Centre, Rawalpindi, Pakistan. In: De Muynck A, Siddiqi S, Ghafiar A Sadiq H (Eds.)
Strenghtening of TB Control at district level, USA Monograph No 2, 1999, pp. 102 -12.
9.Singla N, Sharma PP. Singla R Jam RC. Survey of knowledge, attitudes and practices for tuberculosis
among general practitioners in Delhi, India. Int Tuberele Lung. Dis., 1998, 2: 384-89.
10.Valenti MP, Declere E Oyedele SO. Role of the third smear in TB diagnosis. lnt. J. Tubercle Lung.
Dis.. 1998, 2(suppl): s292-s93.
11.Roos BR, Vait Cleeff M, Githui WA, et at. Cost effectiveness of the polyrnerase chain reaction
versus smear examination for the diagnosis of tuberculosis in Kenya: a theoretical model. Int. i.
Tubercie Lung Dis., 1998:2: 235-41.
12.Arif K, Ali A. Amanullah S et al. Physician compliance with national tuberculosis treatment
guidelines: a university hospital study. Int J Tubercle Lung Dis., 1998, 2 : 225-30.
3.Akhtar T, lmran M. Management of tuberculosis by practitioners of Peshawar. J Pak Med Assoc
1994, 44: 280-82.
14.Pathania V. Almeida J, Kochi A. TB patients and private for-profit health care providers in India.
Global TB Programme, Geneva WHO, 1997.
15.Sloan JP & Sloan MC. An assessment of default and non-compliance in tuberculosis control in
Pakistan. Trans R. Soc. Trop. Med. Ryg., 1981, 75: 7 17-18.
16.Liefooghe R. The human dimension in TB control: myth or reality? In: Meulemans II. (edi
Tuberculosis in Pakistan: The forgotten plague, Acco Leuven S, 1999.
17.Liefooghe R, Michiels N, Habib S. et al, Perception and social consequences of tuberculosis: a focus
group study of tuberculosis patients in Sialkot, Pakistan. Soc. Sci. Med, 1995, 41 685-92.
18.Ainir K, Hussain K DOTS’ WHO recommended tuberculosis control strategy l’ak. J. Health, 1996,
33 12-13.
19.Hussain R, Hasan R, Khurshid M, et al. Pulmonary tuberculosis in a BCG vaccinated area:
relationship of disease severity with immunological and hematological parameters and drug resistance.
Southeast Asian J. Trop. Med. Public Health, 1996, 27: 257-62.
20.Marsh D, 1-lashim R, Hassany F, et al. Front-line management of pulmonary tuberculosis: an
analysis of tuberculosis and treatment practices in urban Sindh, Pakistan. Tubercle. Lung Dis., 1996,
77: 86-92.
21.Ekbal 1. Networks Drug Bulletin, May/Aug 1998
22.Trébucq A, Alt Khaled N, Guinafon M et al. Information management in national tuberculosis
control programmes and national health information system. Int. J. Tubercle Lung. Dis., 1998, 2: 852-
56.
23.Khan A, Khan H, Ali A. Tuberculosis Control in Pakistan Pak J Health, 1997, 34: 20-24.
24.Uplekar M, Rangan Sb. Tackling TB. The search for solutions. Bombay, The Foundation for
Research in Community Health, 1996.