Tuberculosis in Pakistan

Thirty high-TB-burden countries account for 87% of global cases, with incidence rates exceeding 150 per 100,000 people. Two-thirds of these cases are concentrated in just eight countries: India, Indonesia, China, the Philippines, Pakistan, Nigeria, Bangladesh, and the Democratic Republic of the Congo. In contrast, England has been classified as a low-incidence area (<10/100,000) since 2017, reporting a rate of 7.3 per 100,000 in 2021. Despite this classification, disparities persist, with 72.8% of TB cases occurring in individuals born outside the UK (36.3/100,000). In 2020, 12.7% of TB patients in England had at least one social risk factor, such as alcohol or drug misuse, homelessness, or imprisonment. Latent TB infection (LTBI) remains a concern, with a 5-10% risk of progression to active TB, typically within five years.[3] See also: TB and Diabetes mellitus

In 2020, 48.6% of TB cases in England were pulmonary, with symptoms including cough, fever, night sweats, and weight loss. The WHO’s ‘End TB’ strategy promotes new diagnostic tools, such as Xpert MTB/RIF, though its sensitivity is lower in smear-negative or extrapulmonary cases. The Xpert MTB/RIF Ultra, introduced in 2017, offers improved sensitivity, particularly for CNS disease and HIV-positive patients. Advanced resistance profiling is available through the FluoroType MTBDR assay and the emerging FluoroType XDR-TB. Point-of-care strategies, including urinary lipoarabinomannan detection, aim to decentralize diagnostics in low-resource settings. For MDR/RR-TB, all-oral regimens are now recommended, avoiding injectables. In England, NICE advises LTBI treatment for patients under 65 with close contact history to drug-sensitive pulmonary or laryngeal TB, though hepatotoxicity risks must be considered in those aged 35-65. Treatment typically involves rifampicin and isoniazid, with WHO-endorsed regimens like weekly rifapentine facing accessibility challenges in Western Europe due to licensing issues.[3]

A study examined the implementation of various Public-Private Mix (PPM) approaches across Pakistan’s four provinces, assessing their contribution to tuberculosis (TB) case notifications and treatment outcomes compared to the public sector within the National TB Program (NTP). Analyzing data from 122 districts, the study included all new and relapse TB cases, revealing that pulmonary TB was more prevalent (79.2%), with clinically diagnosed cases (43.5%) outnumbering bacteriologically confirmed cases (32.5%). Private hospitals played a significant role in detecting bacteriologically confirmed and relapse cases. The overall treatment success rate for PPM-notified cases was 90.6%, with the highest success in NGO facilities (94.9%) and the lowest in parastatal facilities (46.7%). PPM cases had better treatment completion rates (69.4% vs. 64.5%), but also higher unfavorable outcomes (9.4% vs. 6%), with parastatal facilities showing the worst failure rate (53.3%).[1] See also: TB and dialysis

The findings highlight the vital role of PPM in TB case detection across different demographics and regions, emphasizing the effectiveness of GPs, NGOs, and private hospitals in improving treatment outcomes. To enhance TB control efforts, these successful PPM models should be expanded, while parastatal facilities require urgent reforms due to their poor performance. Strengthening PPM implementation is essential for identifying undiagnosed TB cases and curbing the epidemic in Pakistan.[1] See also: TB Predictive Modelling

Smoking remains a significant risk factor for tuberculosis and a major public health concern in Pakistan. However, another study unexpectedly found no statistical association between tuberculosis and diabetes comorbidity, despite existing evidence that diabetic patients face a higher risk of developing TB compared to non-diabetic individuals. With the rising prevalence of diabetes mellitus (DM), particularly in middle- and low-income countries, this trend poses a growing challenge to TB control efforts, emphasizing the need for integrated strategies to address both diseases effectively.[2] See also: Lin TB Lab

References:

1. Ullah, W., Wali, A., Haq, M.U., Yaqoob, A., Fatima, R. and Khan, G.M., 2021. Public–private mix models of tuberculosis care in Pakistan: a high-burden country perspective. Frontiers in public health, 9, p.703631.

2. Khalid N, Ahmad F, Qureshi FM. Association amid the comorbidity of Diabetes Mellitus in patients of Active Tuberculosis in Pakistan: A matched case control study. Pak J Med Sci. 2021;37(3):816-820.

3. Meghji, J., Kon, O.M. and Ainley, A., 2023. Clinical tuberculosis. Medicine, 51(11), pp.768-773.