See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/316503664

Textbook of Community Medicine and Public Health, Chapter 18 - Tuberculosis and

its Control in the Context of Pakistan

Book · January 2017

CITATIONS READS
0 11,689

1 author:

Ghulam Nabi Kazi

International Union Against Tuberculosis and Lung Disease
44 PUBLICATIONS 195 CITATIONS

SEE PROFILE

All content following this page was uploaded by Ghulam Nabi Kazi on 30 April 2023.

The user has requested enhancement of the downloaded file.

 Textbook of
Community Medicine
and Public Health

Editors

Saira Afzal
MBBS, MPhil, MCPS, FCPS, PhD Post Doctoral Fellow (US)
Chairperson and Head, Department of Community Medicine,
Professor of Community Health Sciences,
King Edward Medical University, Lahore

Sabeena Jalal
MBBS, MSc (Harvard), PhD (Karachi University),
Fulbright Scholar, Grand Challenges Grantee,
Assistant Professor, Community Health Sciences,
Bahria University Medical & Dental College, Karachi

Karachi | Lahore | Islamabad | Sukkur | Faisalabad | Peshawar | Abbottabad

 Textbook of Community Medicine and Public Health

by

Saira Afzal/Sabeena Jalal

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by
any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Copyright Holders.

This book is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, resold, hired out or otherwise circulated
without the publisher’s prior consent in any form of binding or cover other than that in which it is published and without a similar
condition including this condition being imposed on the subsequent purchaser.

Medical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures, equipment
and the use of drugs become necessary. The editors, contributors and the publishers have, as far as it is possible, taken care to
ensure that the information given in this text is accurate and up-to-date. However, readers are strongly advised to confirm that
the information, especially with regard to drug usage, complies with the latest legislation and standards of practice. Neither the
publisher nor the authors assume any responsibility for any loss or injury and/or damage to person or property arising out of or
related to any use of the material contained in this handbook.

Copyright © 2017
All Rights Reserved

First Edition.................................2017

Copyright Page

152/O, Block-2, P.E.C.H.S., Karachi-75400.

Tel: +92-21-34310030, [email protected]
www.paramountbooks.com.pk

ISBN: 978-969-637-312-4
Printed in Pakistan
Back Title

Paramount Books (Pvt.) Ltd.

152/O, Block-2, P.E.C.H.S., Karachi-75400.
Tel: +92-21-34310030, [email protected]
www.paramountbooks.com.pk
 v

Foreword—I

Health is a fundamental human right, a just and equitable access to safe and quality basic healthcare will enable the
vulnerable populations to protect themselves from preventable diseases. Disease prevention and health promotion
necessitate efforts and endeavors ranging from individual behaviors and practices, to customizing health services,
instituting community action, introducing health reforms, involving other sectors, and bringing policy change to gain the
desired health outcomes. Health practitioners ought to comprehend and then employ this broad approach to tackle the
range of determinants of health.
It is heartening to see a new textbook of Community Medicine & Public health being developed after such a long time
to quench the knowledge thirst of the undergraduate medical students. Health sector has been very dynamic in the
recent years witnessing constitutional amendments, reforms, transitions, changing disease patterns and of course the
demographics of the country. There is certainly a need to transfer the fresh knowledge to the undergraduate students and
to familiarize them with the latest concepts of health system of 21st century. This particular field of medicine has evolved
immensely since last 100 years in the sub-continent as well as globally; starting from the primitive concepts of preventive
medicine and later as community medicine, transforming into modern notions of public health, which now entails a
wide range of sub-specializations such as health systems, health policy, health financing, health reforms, health education
and promotion, infectious diseases, non-communicable diseases, epidemiology & biostatistics, nutrition, global health
security, maternal and child health, environment and occupational health, bioethics etc.
This lucidly compiled text book by Dr Saira Afzal and Dr Sabeena Jalal is indeed a praiseworthy effort and a credible
addition for the undergraduate medical education in Pakistan and this region. The chapters and the contents are most
contextual and present all the dimensions to the difficult concepts of the subject. Topics covered have touched upon
almost all the important aspects and facets of health system, and that too written by worthy and renowned authors like
Drs Ghaffar Billoo, Mehtab Karim, Rashid Jooma, Babar Tasneem Shaikh, Ghulam Nabi Kazi and others. I am pleased
to see that the contents of this book very well cover and synchronize with the National Health Vision 2016-2025. Health
system of this country is very resilient; all it needs is a visionary leadership, relevant and sustained policies and a dedicated
workforce.
I strongly recommend this book to undergraduates. Moreover, it is helpful for FCPS and PhD fellows, health managers,
researchers, NGO professionals and anyone showing interest in learning the intricacies of public health.

Dr Assad Hafeez
DG Health, Ministry of National Health Services, Regulations & Coordination
Executive Director, Health Services Academy
Islamabad.
x

Contributors
1. Aamir M. Jafery 10. Asadullah Khan
MBBS, FCPS, FRCS, MBE MBBS, MCPS, FCPS, FCPS (BD), FRCS
Professor at the Center of Biomedical Ethics and Culture, Principal and Dean Health Sciences,
SIUT, Karachi Bahria University Medical & Dental College, Karachi

2. Abdul Gaffar Billo (Sitara-e-Imtiaz) 11. Azra Rizwan

Professor emeritus, MBBS
Dept. of Paediatrics and Child Health,
Aga Khan University, Karachi 12. Babar Tasneem Shaikh
MBBS, MBA, MPH, PhD, FRCP Edin
3. Adnan Jabbar Senior Technical Advisor-HPSIU
MBBS, PhD Immunology, Minstry of NHSR&C, Islamabad
Diplomate American Board of Oncology,
Diplomate American Board of Internal Medicine 13. Bhavita Kumari
Section Head of Medical Oncology,
Aga Khan University Hospital, Karachi MBBS, MPH (DUHS)
Lecturer, APPNA Institute of Public Health,
Jinnah Sindh Medical University, Karachi
4. Afshan Asghar
MBBS, FCPS 14. Farah Asad Mansuri
Senior Lecturer, oncology dept., SIUT Karachi
MBBS, MCPS, FCPS
Professor Dept. of Community & Family Medicine,
5. Ali Bahadur Kazi
aibah University,
Master in Public Policy, Harvard, Al Medinah Munawara, Saudi Arabia
Master in Economics, Andrew Young School of Public
Policy, Georgia State University, USA. 15. Farhat Jafri
MBBS, MPH, DPA
6. Ali Faisal Saleem
Professor & Head, Dept. of Community Health Sciences,
Assistant Professor, Vice Principal & Secretary Academic Council,
Paediatrics Infectious Diseases, Karachi Medical & Dental College, Karachi
Department of Paediatrics and Child Health
Aga Khan University, Karachi 16. Ghulam Nabi Kazi
MBBS, MPH (Boston University), EMPA (UMKC, in
7. Amanullah Khan
process)
MPH, University of Tulane, USA Former TB Manager, World Health Organization,
PhD, University of San Francisco, USA Pakistan
Professor Emeritus, FMH College of Medicine and
Dentistry, Pakistan 17. Huma Mamun Mahmud
MBBS, MCPS, FCPS (Nephrology)
8. Amenah A. Agunwamba
Sc. D., MPH 18. Hussain Bux Kolachi
Society, Human Development and Health,
Harvard School of Public Health MBBS, M. Phil Community Medicine (Punjab
University)
Professor Community Medicine, Isra University,
9. Anum Akhlaq
Hyderabad, Sindh
MBBS,
Aga Khan University, Karachi 19. Kamran Hameed
MBBS, FCPS, FRCP
Rheumatologist, Dr Ziauddin Hospital, Karachi
 xi
20. M Rafiq Khanani 30. Nighat Mannan
MBBS, MPhil, PhD MBBS, M Phil & PhD Fellow (DUHS)
Professor and Chairman of Pathology and Microbiology Professor & Head of the department of Physiology,
Departments, Bahria University Medical & Dental College, Karachi
Dow University of Health Sciences, Karachi
31. Qudsia Anjum
21. M Imran Khan MBBS, MCPS (FM), FCPS (CM), FCPS (FM),
MBBS, MSc, PhD (Johns Hopkins University) MRCGP (Int)
Specialist Family Medicine Dubai, UAE
22. Mazhar Malik, Associate Editor, JPMA, Pakistan
MBBS, MCPS, FCPS
HOD/Prof. of Psychiatry, Department of Psychiatry and 32. Rashid Jooma
Behavioral Sciences MBBS, FRCS
Rawal Medical and Dental College, Rawal Institute of Neurosurgeon,
Health Sciences, Islamabad Aga Khan University Hospital, Karachi
International Associate Member RCPsych, London
33. Razia Iftikhar
23. Mehtab Karim Professor of Obstetrics and Gynaecology,
PhD, Al-Tibri Medical College & Hospital Isra University,
Professor CHS and Head of the department of Karachi Campus
Reproductive Health,
Aga Khan University Medical College, Karachi 34. Saadiyah Rao
MBBS, MSc (Public Health Research),
24. Muhammad Abdul Samad University of Edinburgh-UK
MBBS (KU), PGDPA (KU),
MSc. International Health (University of Aberdeen) 35. Sabeena Jalal
Managing Director at Shaheen Research Group
MBBS, MSc (Harvard), PhD (Karachi University),
Fulbright Scholar, Grand Challenges Grantee
25. Muhammad Athar Khan Assistant Professor, Community Health Sciences,
MBBS, MCPS, DPH, DCPS-HCSM (MPH), MBA, Bahria University Medical & Dental College, Karachi
PGD-Statistics, DCPS-HPE
Associate Professor 36. Saeed Ullah Channa
Department of Community Medicine
MBBS
Liaquat College of Medicine & Dentistry, Karachi
37. Saifuddin Rafai
26. Muhammad Shahid
MBBS
MBBS, MCPS, FCPS
Consultant Internal Medicine,
38. Saira Afzal
Indus Hospital, Karachi
MBBS, MPhil, MCPS, FCPS, PhD Post Doctoral Fellow
27. Musarat Ramzan (US)
Chairperson and Head, Department of Community
Professor & Head of the Department of Community Medicine, King Edward Medical University, Lahore
Medicine, Wah Medical College
Examiner & trainer of MCPS and FCPS
39. Sameera Ali Rizvi
28. Najib Ullah Khan MBBS, MSc (Epidemiology & Biostatistics)
Lecturer, Aga Khan University Hospital, Karachi
MBBS

29. Nasreen Aslam Shah 40. Sampath Tekannon

M.Phil & Ph.D. Social Work Meritorious Professor MBBS

Chairperson, Department of Social Work &
Director, Centre of Excellence for Women’s Studies,
University of Karachi
xii
41. Sara Salman 52. Syed Aley Hasan Zaidi
MBBS, MPA, MPH-Master of Public Health BSs, MBBS, MA (IR), M Phil, FCPS, FRCP (Edin), PhD
Head of Sindh Office, World Health Organization Life Fellow Royal Society of Medicine (London),
Chairman, Department of Pathology and Vice Dean,
42. Shabnam Kanwal Postgraduate Medical Institute, Baqai Medical University,
Karachi
MBBS
53. Syed Mamun Mahmud
43. Shafi M Jatoi
FCPS (Urology), FEBU (Paris), PGD (Biomedical
MBBS, FCPS Ethics) Consultant Urologist
Professor of Ophthalmology & Director Academics
Liaquat University of Medical and Health Sciences,
54. Syed Tipu Sultan
Jamshoro
MBBS, DA (London), FFARCSI, FCPS (Hon)
Formerly, Principal and Dean Health Sciences,
44. Shahadat Hussain Ch.
Bahria University Medical & Dental College, Karachi
MBBS, FCPS (Cardiology), FACC, MCPS-HPE
Associate Professor & Head, of Department of 55. Tahir Masood
Cardiology, Quaid e Azam Medical College/ Bahawal
Victoria Hospital, Bahawalpur Dean & Professor of Paediatrics,
Institute of Child Health, Children’s Hospital, Lahore
45. Shaheen Moin
56. Talat Roome
MBBS, FCPS, FRCP
PhD, Post-doc (USA), Fulbright Fellow, (USA)
Formerly, Principal and Dean Health Sciences,
(Charles Wallace Scholar, UK) Assistant Professor, Dow
Bahria University Medical & Dental College, Karachi
International Medical College, Karachi
46. Shaheen Zafar
57. Tazeen Saeed Ali
MBBS, FRCOG
PhD (Medical Sciences), MSc (Epidemiology),
Consultant Gynecologist
BScN, RN, RM Pakistan Associate Professor, Sonum,
Aga Khan University, Karachi
47. Shahid Hussain
Senior Journalist, Writer and Thinker 58. Usman Ahmed Raza
MBBS (Khyber), MS (Harvard) Visiting faculty, Prime
48. Shakeel Ahmed Institute of Public Health, Peshawar
MBBS, MCPS, FCPS, MRCPCH, FRCP (Glasgow),
FRCPCH (UK) 59. Waqar H. Kazmi
Professor & Head of the department of Paediatrics MD (Tufts, Boston),
Bahria University, Medical & Dental College, Karachi Principal, Prof of Nephrology & Director Research,
Karachi Medical & Dental College, Karachi
49. Shamsul Arafin
MBBS, RBP (USA), MPhil 60. Waqar Saeed
Associate Professor, Sir Syed Medical & Dental College, MBBS, Family Physician
Karachi
61. Yasmeen Mumtaz
50. Sobia Haqqi
MBBS, MPH (Birmingham University), FCPS
MBBS, MCPS, FCPS (Community Medicine)
In-charge, Department of Psychiatry, Ex. In-charge, Department of Community Medicine
Ziauddin University, Karachi DUHS, Karachi

51. Sohrab Ali 62. Zarka Samoon Mahmud

MBBS, MIPH (University of Sydney Australia) MBBS, MRCP
MSc (Epidemiology and Biostatistics) Senior Instructor,
Aga Khan University Karachi, Pakistan Aga Khan University Hospital, Karachi
 xiii

Contents

Section 1 Health and Disease .................................................. 1

Chapter 1 Concept of Public Health ...................................................................................3
Chapter 2 Healthy Person, Healthy Nation and a Healthy World ...............................9
Chapter 3 Concept of Disease...............................................................................................23
Chapter 4 Health Indicators..................................................................................................33
Chapter 5 Primary Health Care and Primary Health Care Planning ........................53
Chapter 6 Society and its Effects on Health: The Social Determinants of Health ...75

Section 2 Health Systems.......................................................... 91

Chapter 7 Health Policy ........................................................................................................93
Chapter 8 Devolution in Health Sector .............................................................................103
Chapter 9 Health Information Systems .............................................................................109

Section 3 Epidemiology ............................................................ 117

Chapter 10 Epidemiology .......................................................................................................119
Chapter 11 Study Designs .......................................................................................................137

Section 4 Demography .............................................................. 149

Chapter 12 Demography and Population Dynamics ........................................................151

Section 5 Biostatistics ................................................................ 169

Chapter 13 Basic Biostatistics ................................................................................................171

Section 6 Emerging and Re-Emerging Diseases ................. 197

Chapter 14 Emerging, Re-emerging and Hospital Acquired Infections ......................199
Chapter 15 Personal Hygiene .................................................................................................205

Section 7 Infectious Diseases/Communicable Diseases .... 215

Chapter 16 Parasitic Diseases and Contaminants .............................................................217
Chapter 17 Vaccine-Preventable Diseases ..........................................................................265
Chapter 18 Tuberculosis and its Control in the Context of Pakistan ...........................293
xiv
Chapter 19 Acquired Immunodeficiency Syndrome ........................................................301
Chapter 20 Polio ........................................................................................................................307
Chapter 21 Hepatitis ................................................................................................................315
Chapter 22 Dengue Fever ........................................................................................................325

Section 8 Immunology .............................................................. 333

Chapter 23 Vaccination ............................................................................................................335
Chapter 24 Immunology and Immunization .....................................................................341
Chapter 25 Vaccine Safety ......................................................................................................355

Section 9 Non Communicable Diseases .............................. 365

Chapter 26 Introduction to Non-Communicable Diseases ............................................367
Chapter 27 Obesity–A Public Health Problem ...................................................................369
Chapter 28 Hypertension ........................................................................................................381
Chapter 29 Cardiovascular Diseases .....................................................................................387
Chapter 30 Tobacco and Health ...........................................................................................393
Chapter 31 Kidney Diseases of Public Health Importance .............................................399
Chapter 32 Introduction to Carcinomas ..............................................................................405
Chapter 33 Common Neurological Disorders ....................................................................419
Chapter 34 Rheumatic Fever ..................................................................................................441
Chapter 35 Rheumatology ......................................................................................................447
Chapter 36 Community Ophthalmology .............................................................................453
Chapter 37 Diabetes Mellitus .................................................................................................457
Chapter 38 Breast Cancer .......................................................................................................459
Chapter 39 Smokeless Tobacco .............................................................................................471
Chapter 40 Snakebite ...............................................................................................................473

Section 10 Nutrition and Health .............................................. 483

Chapter 41 Community Nutrition .........................................................................................485
Chapter 42 Growth Charts .....................................................................................................497

Section 11 Reproductive Health ............................................... 503

Chapter 43 Sexually Transmitted Diseases .........................................................................505
Chapter 44 Mother and Childcare .........................................................................................519
Chapter 45 Family Planning....................................................................................................525
 xv
Chapter 46 Reproductive Health ..........................................................................................531
Chapter 47 Infertility ...............................................................................................................567
Chapter 48 Maternal Mortality (MM) ..................................................................................573

Section 12 Child Health .............................................................. 575

Chapter 49 Child Health ..........................................................................................................577
Chapter 50 Integrated Management of Neonatal and Childhood Illness (IMNCI) ..587
Chapter 51 School Health Service ........................................................................................605

Section 13 Environment And Health ....................................... 615

Chapter 52 Introduction to Environmental Health ..........................................................617
Chapter 53 Hospital Waste Management .............................................................................653

Section 14 Occupational Health ............................................... 665

Chapter 54 Occupational Health and Safety ......................................................................667

Section 15 Mental Health ........................................................... 681

Chapter 55 Introduction to Mental Health..........................................................................683
Chapter 56 Mental Health .......................................................................................................685
Chapter 57 Suicide.....................................................................................................................693
Chapter 58 Sample of Health Advocacy on Mental Health .............................................699
Chapter 59 Sample of Health Advocacy on Suicide ..........................................................701

Section 16 Ethics........................................................................... 703

Chapter 60 Introduction to Bioethics ..................................................................................705
Chapter 61 Bioethics: Challenging The New Normal .....................................................709
Chapter 62 The Menace of Counterfeit Medicine .............................................................727
Index ........................................................................................................................ 731
 Chapter

Tuberculosis and its Control in the Context

18
of Pakistan
Ghulam Nabi Kazi

LEARNING OBJECTIVES: indicating infection by TB bacteria but neither ill with the
disease nor transmitting it. The people so infected with
• To understand the epidemiology of Tuberculosis TB bacteria have a 10% lifetime risk of falling ill with TB.
• To discuss MDR Tuberculosis However, people with compromised immune systems,
HIV, malnutrition, diabetes, or tobacco users have a
• To describe the Stop TB and End-TB strategies much higher risk of falling ill.2 During 2015, there were
• To recall Tuberculosis Management an estimated 10.4 million new TB cases worldwide, of
which 5.9 million were men, 3.5 million women and 1.0
• To identify World Health Organization’s role in million children. People living with HIV accounted for 1.2
Tuberculosis Control million of all new TB cases. Six countries including India,
Indonesia, China, Nigeria, Pakistan and South Africa
accounted for 60% of the new cases. Furthermore, in 2015,
1. INTRODUCTION there were an estimated 480,000 new cases of multidrug-
1.1 History: Tuberculosis is an ancient disease. The resistant TB (MDR-TB). There were an estimated 1.4
causative organism for Tuberculosis, namely Mycobacterium million TB deaths in 2015, and an additional 0.4 million
Tuberculosis has almost always been present in the human deaths resulting from TB disease among people living
population as evidenced by pathological signs found in with HIV. Although the number of TB deaths fell by 22%
bony fragments of Egyptian mummies from 2400 BC. between 2000 and 2015, TB consistently remains one of the
Initially the disease was termed as phthisis and consumption top 10 causes of death worldwide in 2015.3 Furthermore,
in Greek literature, and around 460 BC, Hippocrates TB kills more women than all causes of maternal mortality
identified phthisis as the most widespread disease of his combined.4 The occurrence of TB in children and
time. Tuberculosis infection with M. tuberculosis usually adolescents is considered an indicator of a failure in TB
results from inhalation of infected droplets produced by a control and prevention efforts, as pediatric cases often
coughing patient of pulmonary Tuberculosis. On March 24, represent a sentinel event or recent transmission of the
1882, Robert Koch identified the Mycobacterium Tuberculosis, disease from the adult community or family members.5
enabling the fight against the disease to materialize. The Although Tuberculosis attacks persons from all socio-
World Health Organization accordingly observes World economic groups, it is widely perceived to be an indicator
TB Day on the 24th March every year. The discovery of poverty. Furthermore, it perpetuates poverty by infecting
of radiation by Rontgen in 1895, enabled physicians to persons in their most productive years.
determine the progress and severity of a patient’s disease. 1.3 Declaring of Global Emergency: Tuberculosis
In 1907 in the third major landmark, Calmette and Guerin was declared as a global emergency by the World Health
discovered the BCG vaccine significantly aiding in the Organization (WHO) in 1993, as its epidemic was growing
control of the disease, particularly in children. Proper and becoming more dangerous following the emergence
treatment for tuberculosis was initiated during the early of multidrug-resistant (MDR) TB. The HIV pandemic
forties initially with Sulphonamide and the Penicillin also represented a massive threat resulting in a dramatic
group, and subsequently in 1943, with the discovery of increase in the number of cases with worsening of the
Streptomycin. From 1949, to 1963; anti-Tuberculosis drugs treatment outcomes. The Directly Observed Therapy Short
such as Para-Aminosalicylic Acid, Isoniazid, Pyrazinamide, course (DOTS) strategy essentially entailed governmental
Cycloserine, Ethambutol and Rifampicin and other drugs.1 commitment translated into proper financing, proper
1.2 Global Situation: Currently, it is estimated that monitoring and record keeping, significant shortening
nearly one-third of the world’s population has latent TB, in the duration of medication provided free along with

307
308 Section VII Infectious Diseases/Communicable Diseases

diagnosis through sputum smear microscopy, was sustained financing, early case detection and diagnosis
recommended by WHO in 1995 and quickly adapted by and provision of standardized treatment under super-
most countries of the world. vision, and ensuring effective drug supply with proper
monitoring.
1.4 National Situation: As mentioned above,
Pakistan has a huge burden of Tuberculosis, MDR- b. Address TB-HIV, MDR-TB, and the needs of poor
Tuberculosis and TB-HIV coinfection cases. The country’s and vulnerable populations by scaling up all preven-
Founder Governor General Mr. M. A. Jinnah was himself a tion and management activities, addressing the needs
victim of Tuberculosis that hastened his end, allowing him of TB contacts particularly in the poor and vulnerable
to guide the destiny of the newly created state for only ten population.
months. It has therefore been postulated that Tuberculosis
c. Contribute to health system strengthening based on
drastically transformed and adversely impacted the course
primary health care with improved policies, training
of our national history.
of care providers, adequate financing and supplies,
Mass BCG campaigns were launched in 1950, making it strengthening infection control, upgrading laboratory
the first communicable disease control program in the networks, and adapting successful approaches from
country. Unfortunately, the program never functioned in other fields and sectors.
a sustainable manner and was heavily dependent on donor
d. Engage all care providers involving all public, volun-
support. In hindsight, it seems paradoxical that although
tary, corporate and private providers using public pri-
Tuberculosis kills, or economically shatters hundreds of
vate mix (PPM) approaches.
persons daily in Pakistan, tangible efforts to control this
disease along scientific lines are there only since 2001, e. Empower people with TB, and communities through
although we had the life-saving drugs to cure TB, and a partnership pursuing advocacy, communications and
cost-effective strategy of Directly Observed Treatment social mobilization, and fostering community partic-
Short-Course (DOTS) for their use. However, since then ipation in TB care, prevention and health promotion.
the fight against the disease has been both unremitting and
f. Enable and promote program based operational re-
rewarding at the same time.
search, and advocate for participation in research to
Incidence and control measures: It is estimated that in 2015, develop new diagnostics, drugs and vaccines.7
510,000 new cases of Tuberculosis emerged, out of which
2.3 Anti-tuberculosis drugs: Chemotherapy
331,809 cased were notified with a treatment coverage of
remains the most powerful weapon in Tuberculosis control
63%. The TB treatment success rate for the previous year
by not only reducing the morbidity and mortality but
stands at 93%, which is good by international standards.6
inducing the epidemiological impact by cutting the chain of
transmission effectively. To prevent multi-drug resistance,
it is necessary to carefully administer quality drugs using
2. DISCUSSION
standardized regimens on a regular basis. Fixed dose
2.1 Basic Principles of Tuberculosis Control: combinations of medicines are preferred as they are more
Primarily, TB Control programs endeavor to rapidly detect convenient to patients and logistically more feasible for
and cure the infectious cases or the sputum smear positive national level programs. Since 2012, Pakistan is employing
pulmonary TB patients, on a priority basis. The targets a 6-month regimen using the four first line drugs of choice
for TB control have essentially remained to achieve, a) 70 including two bactericidal drugs Rifampicin and INH and
percent case detection rate, and b) 85 percent treatment two bacteriostatic drugs, Ethambutol and Pyrazinamide.
success rate with a view to lower the incidence, prevalence The medicines can be taken at home provided there is
and mortality caused by the disease. However, from a direct observation of treatment (DOT) preferably by a
scientific as well as ethical and human rights dimension, health worker, while in case of complicated or multi-drug
it is mandatory to detect and treat other non-infectious resistant instances, the patient may need hospitalization.
forms of Tuberculosis such as pulmonary smear negative,
2.4 Salient Features of the National and Provincial
childhood tuberculosis and extra-pulmonary cases with
Response to Tuberculosis:
the same zeal.
Although historically, TB control remained a low priority
2.2. Global TB Control Strategy: The World
in Pakistan; however, the National TB Control Programme
Health Organization (WHO) subsequently recommended
(NTP) along with its provincial counterparts was revived
the Global Stop TB strategy, developed through the
by allocating funds for the DOTS implementation. The
collective wisdom of the international community, and
Government of Pakistan took TB control efforts on a war
the use of which could effectively prevent most of the
footing, and declared TB as a National Emergency through
mortality associated with the disease. The six components
the “Islamabad declaration” in 2001. Thus, Pakistan made
of the Stop TB strategy are outlined below:
commendable progress and expanded the DOTS coverage
a. Pursue high-quality DOTS expansion and enhance- from 4% in the year 2000, to 50% by December 2003.8 The
ment by securing political commitment and adequate NTP has traditionally been responsible for developing
 Chapter 18 Tuberculosis and its Control in the Context of Pakistan 309
policy guidelines and supporting the provinces in the discarded and the work is entrusted by the district health
provision of technical support, coordination, monitoring officer to any member of his team.
and evaluation, and operation research. The provincial TB
2.4 Multi Drug Resistant Tuberculosis: After
Control Programs (PTPs) are responsible for the actual
achieving country-wide DOTS coverage in government
care delivery process including program planning, training
hospitals and health facilities in 2005, the National and
of care-providers, case detection, case management,
Provincial TB Control Programmes expanded the scope
monitoring and supervision. As mentioned above, the
of their activities to include Multi-Drug Resistance
overall objective of NTP/PTPs is to reduce mortality,
Tuberculosis (MDR-TB) interventions as recommended
morbidity and disease transmission. After the devolution
in the new Stop TB Strategy. MDR-TB indicating
of the Health Sector in 2011, the national program has
resistance to first line anti-TB drugs (rifampicin and
been retained to coordinate GFATM financial and logistic
isoniazid), is emerging as a major public health problem
support in the provinces. The national targets are to detect
globally including Pakistan, with an adverse impact on
70% of all the estimated cases and cure at least 85% of the
interventions for Tuberculosis Control. Around 0.5 million
newly detected sputum smear positive pulmonary TB
cases of MDR -TB emerge globally every year because of
cases. Substantial governmental commitment coupled
under-investment in basic strategies to control TB, poor
with strong technical leadership in the program resulted
management of the supply and quality of anti-tuberculosis
in a clear vision, which was translated into medium term
drugs, improper treatment of TB patients and transmission
strategic plans for the periods 2001 – 2005, 2005 to 2010
of the disease in congregate settings.11 With an annual
and then for 2010 - 2015.9
estimated burden of 9,700 cases, Pakistan is projected fourth
The program has achieved steady progress since 2001, after India, China and the Russian Federation. Currently
onwards, without compromising on the quality of case MDR-TB is a major threat to public health in Pakistan
detection, case management and laboratory services. It has as evidenced by some studies.12,13,14,15,16,17,18 Pakistan has
also been successful in involving tertiary care hospitals, the at least 60 hospitals across all the provinces that can offer
private sector including non-governmental organizations, quality MDR-TB management; given the trained staff and
and inter-sectoral organizations in service delivery and equipment. Delayed diagnosis, poor management, high
bringing about community mobilization. default rate and low treatment success pose a serious threat
of further MDR-TB transmission; making TB control
As of 2014, the national and provincial programs had
more difficult and unaffordable.
mobilized sufficient grant resources, developed its Vision
2020, provided free diagnosis and treatment through a Furthermore, a countrywide representative drug resistance
network of 1,257 TB care facilities to hundreds of thousands survey (DRS) was conducted in 2012 that revealed
of patients, ensured quality assurance and culture DST somewhat alarming results. Even prior to that a study
services in 1355 Peripheral, 112 intermediate, 6 BSL-2, 4 was conducted in a specified annual cohort of notified
BSL-3, 5 provincial and1 national reference labs. 46 X-perts smear positive new and re-treatment cases, by the Aga
machines installed and 2,170 Lab staff trained. MDR-TB Khan University (AKU) that revealed 1.8% primary
cases are managed in 18 PMDT sites and provided social resistance,7 while another study depicted a steady increase
support. Eleven hospitals have been upgraded for infection in resistance among Mycobacterium Tuberculosis isolates,
control measures and a Drug Resistance survey conducted. with documentation of 22 XDR cases.8 The WHO has
More than 2000 private practitioners have been involved estimated an annual incidence of 9,700 MDR-TB among
and are contributing towards 20% of TB case notification. notified cases estimating that 3.2% of new TB cases and
Collaboration with the private sector, Pakistan Chest 21% of re-treatment cases are MDR.19
Society, National Rural Support Program and military
In response to a resolution by the 62nd World Health
hospitals have also yielded positive results. TB/HIV co-
Assembly, Pakistan decided to treat 80% of the estimated
infection is being managed at 16 sentinel sites with the
annual incidence of smear positive MDR cases by 2015.
collaboration of the National AIDS Control Program
This has expedited interventions such as development of
(NACP). An E-surveillance system has been implemented
the national guidelines/operational guidelines and other
to manage online case based data in 114 districts. The
resources for the treatment and management of Drug
future plan of the program includes upscaling all these
Resistant Tuberculosis,20 grant applications to the Green
efforts and developing legislations to declare Tuberculosis
Light Channel (GLC) and subsequent treatment of several
as a notifiable disease and ban over the counter sale of anti-
thousand cases. Initially the MDR-TB care was initiated in
tuberculosis drugs from all the provincial assemblies.10
four major institutions namely the Ojha Institute of Chest
2.5 Mainstreaming Tuberculosis control Diseases Karachi, Gulab Devi Hospital Lahore, Indus
services: TB services are integrated into the primary Hospital Karachi and Lady Reading Hospital Peshawar.
public health care system at district level. Thus, there is no Simultaneously a training plan was launched for provincial
verticality about the program and is fully merged within and district level officers enabling thirty hospitals, smaller
the horizontal health systems. The previous practice of health facilities and laboratories to diagnose, treat and
having dedicated district TB control officers has been provide social support to around 80% of the estimated
310 Section VII Infectious Diseases/Communicable Diseases

MDR-TB cases using both hospital and community-based microscopy remains the most viable and cost effective
models with support from the Global Fund to Fight AIDS, option for national or provincial programs being fast and
TB and Malaria (GFATM). MDR-TB patients require inexpensive, it may not be the most effective diagnostic
prolonged periods of comprehensive quality care ranging test and the diagnosis may need to be confirmed through
from 2 years or more, by qualified medical and paramedical some other means such as sputum culture that has since
teams. The National Reference Laboratory has been long been considered a ‘gold standard’, while Xpert MTB/
functional since September 2009, and is conducting TB Rif has emerged as another diagnostic tool particularly in
culture and drug susceptibility testing for first line drugs. TB-HIV, DR-TB, or childhood Tuberculosis where the
routine tests are inconclusive.
2.6 XDR – TB or Extensively drug-resistant
Tuberculosis: XDR-TB is defined as TB that has
developed resistance to at least rifampicin and isoniazid 3. OPERATIONAL RESEARCH
(resistance to these first line anti-TB drugs defines Multi-
drug-resistant tuberculosis, or MDR-TB), as well as
FINDINGS:
to any member of the quinolone family and at least one Operational research remains a core component of the
of the following second-line anti-TB injectable drugs national strategic and operational plans to be somewhat
(kanamycin, capreomycin, or amikacin). XDR-TB can consistent with international developments that are rapidly
develop when the second-line drugs used to treat MDR-TB changing the complexion of the disease and the mechanism
are also misused or mismanaged and rendered ineffective. of its control. The NTP has constituted national and
With resistance to first and second-line drugs, treatment provincial research groups, and developed partnerships
options become seriously limited. A few sporadic cases of with the Pakistan Medical Research Council, in addition
XDR-TB have been reported in Pakistan. to developing linkages with international academic and
The programmatic management of MDR-TB & research institutions. The WHO supported the program
XDR-TB can be enhanced by strengthening advocacy, through its initiatives of Tropical Diseases Research
communication and social mobilization, the quality of (TDR) and Research in Priority Public Health Areas,
basic TB and HIV/AIDS control with uninterrupted supply involving more than twenty research studies relating to
of quality assured anti-TB drugs, expand MDR-TB & various aspects of DOTS expansion, defaulter tracing,
XDR-TB surveillance to better understand the magnitude drug management, external quality assurance, treatment
and trends of drug resistance and links with HIV, develop support, and drug side effects. Two new methodologies for
and implement infection control measures, strengthen indirect estimation of disease burden have been piloted.
laboratory services for timely diagnosis, carry out resource The research findings were translated into policy through
mobilization at all levels and promoting research and the necessary changes in protocols and guidelines. Some of
development. It is also important to be cognizant of, and the key research findings are summarized below:
adopt all ethical measures in the management of drug 3.1 TB Control overview: Ibrahim et al 2002,
resistant tuberculosis. critically examined existing literature including the WHO
2.7 Tuberculosis and HIV coinfection: TB- reports and found that even though the Directly Observed
HIV co-infection is the main reason for failure to meet Treatment Strategy (DOTS) short course is cost effective
Tuberculosis (TB) control targets in high HIV settings. and universally recommended, it is still beyond the
TB is a major cause of death among people living with financial reach of several highly endemic countries. They
HIV. Pakistan has developed a strategy for creating a identified barriers in the DOTS implementation in the 22
collaborating mechanism for the control of TB and HIV/ high burden countries and concluded that the increasing
AIDS programmes, to reduce the burden of TB among caseload, morbidity and mortality due to TB in high
people living with HIV, and reducing the burden of HIV burden countries pose a major challenge and threat to the
among TB patients. Sixteen sentinel sites have been health systems, as well as to international security.21
strengthened through collaborative efforts of the NTP and In a review article Qayyum and Rizvi, 2003, pointed out
the National AIDS Control Program (NACP) and non- that the World Bank had recognized the DOTS strategy
government partners for screening, care and support of as one of the most cost-effective health interventions, and
TB/HIV co-infected patients. recommended that effective TB treatment should be a
2.8 Prevention of Childhood TB: Although the part of the essential clinical services package available in
best prevention of childhood TB lies in curing the existing primary health care (PHC) to take on the overwhelming
infectious TB cases in all age groups, BCG vaccination can TB case-load remaining within available resources.22
be effective in minimizing the intensity and side effects 3.2 Knowledge of General Private Practitioners:
of Tuberculosis, although not providing any effective The private sector is regarded as the first point of entry
immunity. The general nutritional status of children can to the health care delivery system for most users, and
also help in boosting the immunity of children. most of private providers are not following the NTP
2.9 Diagnostic options: While sputum smear guidelines.23,24,25 A 2003 survey conducted by the NTP/
PTP in Lahore and Rawalpindi districts found that less
 Chapter 18 Tuberculosis and its Control in the Context of Pakistan 311
than 3% of General Practitioners (GPs) were following and hemoptysis is 21% of patients due to these diagnostic
the national guidelines for diagnosis and management of delays. The diagnostic delay was statistically significant in
TB, while 90% of GPs were relying on chest radiography those patients who consulted private practitioners, and the
for diagnosis.26,27 This position was during the early days consequences were particularly severe in those patients
of DOTS implementation and has undergone significant who consulted late.37
improvement since then.
3.3 Role of Medical Colleges: Khan et al 2002, 4. ROLE OF THE WORLD HEALTH
have highlighted the critical role of medical colleges in
TB control as medical opinion leaders and trend setters,
ORGANIZATION (WHO):
in shaping the attitudes of their peers and of the next The WHO is a strong technical partner of the NTP and
generation of physicians, apart from their role as referral has been supporting the Program ever since its inception
centers treating many patients with Tuberculosis. They, 2001. Even prior to that, it was supporting the government
however, noted that most medical colleges in the country during the planning phase from 1999-2001. The support is
lack a structured curriculum on Tuberculosis, and many mainly focusing on the capacity building of the NTP, PTPs
doctors get their MBBS degree without ever having seen a and districts using the following strategies:
single TB patient. Citing a study which found that only 5%
of medical graduates could write the correct prescription • Around 40 national/provincial technical officers,
for a TB patient, they have suggested massive changes program officers and sociologists were recruited for
in the undergraduate medical curriculum coupled with monitoring and evaluation (M&E) activities at all
changes in the methods of teaching and training about TB, levels from 2003-2010, with USAID support. These
to bring them in line with the national guidelines for the officers have played a pivotal role in bringing about
diagnosis and treatment of Tuberculosis.28 Subsequently a significant improvement in the program indicators
training modules on TB Control have been included in including CDR and TSR. Subsequently these officers
the curricula of medical colleges and generally made highly have been financed through Global Funds for AIDS,
accessible for all practicing doctors. TB and Malaria (GFATM) grants. Monitoring,
evaluation and surveillance remain the main area of
3.4 Knowledge of communities: Several the WHO support.
researchers have found the knowledge of communities
concerning the cause and risk factors to be quite deficient, • The WHO revised the existing recording and
29,30
with long delays in diagnosis and delays particularly in reporting tools in 2008, which were adopted by NTP
rural females.31,32 and introduced in January 2010, all over the country.

3.5 Prisons: Studies on jail inmates have revealed a • NTP is supported by arranging WHO Joint Technical
significantly higher prevalence of TB in prisons as compared Review Missions to identify and address key challenges
to the general population of Pakistan indicating that they with the help of technical and funding partners.
were more vulnerable to contracting the disease.33,34,35 • As mentioned earlier, WHO has fostered operational
Accordingly, through the TB REACH projects the jail research by technically supporting all the studies
inmates in the prisons of the Punjab have been targeted. including the National Prevalence Survey, Incidence
3.6 Tuberculosis in Children: Mehnaz and Arif, Study and National Drug Resistance Survey in
2005, have highlighted the importance of a modified addition to several operational research studies of
version of the Kenneth Jones Scoring Chart (KJSC) in the lesser magnitude mostly funded by USAID.
absence of any gold standard for diagnosing Tuberculosis • The WHO has also been supporting a public-private
in children.36 Subsequently the NTP produced guidelines mix in TB-DOTS in Pakistan with the help of leading
for diagnosing and managing Tuberculosis in children in private sector institutions, and capacity building of the
association with the Pakistan Pediatric Association, which national staff through exposure to international and
are being implemented in several districts of the country. national meetings.
3.7 Delays Analysis: Habibullah et al 2004, carried • Strategic Planning: The 65th World Health
out a cross-sectional study to determine the average Assembly held in 2012, called upon the WHO to
duration from onset of symptoms to the diagnosis and present a medium-term action plan for the period
treatment of Tuberculosis, reasons for diagnostic delay, its 2015-2025, concerning effective Tuberculosis Control
consequences, and association of variables to formulate using a human-rights-based-approach to the 67th
recommendations. A total of 115 patients were randomly World Health Assembly in 2014. The WHO HQ,
selected from two major chest clinics of Karachi. The Regional and Country offices accordingly developed
study determined the average time from onset of initial this plan, which will strategize the way for eliminating
symptoms to diagnosis and treatment of Tuberculosis to Tuberculosis by 2050.
be 120 days, largely attributable (64% of the patients) to
medical practitioners, resulting in loss of weight in 40% Mention is also warranted of the WHO End-TB Strategy.
The Sustainable Development Goals (SDGs) for 2030
312 Section VII Infectious Diseases/Communicable Diseases

were adopted by the United Nations in 2015. One of the REFERENCES

targets is to end the global TB epidemic. The WHO End
TB Strategy, approved by the World Health Assembly in (Endnotes)
2014, calls for a 90% reduction in TB deaths and an 80% 1. F. Kobarfard, Tuberculosis and Traditional Medicine:
reduction in the TB incidence rate by 2030, compared Fighting the Oldest Infectious Disease Using the
with 2015. The strategy provides a unified response to Oldest Source of Medicines, Iranian Journal of
ending TB deaths, disease, and suffering. It builds on three Pharmaceutical Research, Volume 3, Number 2,
strategic pillars focusing on integrated patient centered TB Spring 2004, pp 71-72
care and prevention, bold policies and supportive systems
and intensified innovation and research. Consistent with 2. WHO factsheet, http://www.who.int/mediacentre/
the End-TB Strategy, there is a growing realization that factsheets/fs104/en/ accessed on October 26, 2015
global progress will ultimately depend on major advances 3. The Global Tuberculosis Report 2016, World Health
in TB prevention and care in these countries. Worldwide, Organization, Geneva
the rate of decline in TB incidence remained at only 1.5%
from 2014 to 2015. This needs to accelerate to a 4–5% 4. WHO, Tuberculosis control, Jim Yong Kim, Aaron
annual decline by 2020 to reach the Đrst milestones of the Shakow, Arachu Castro, Chris Vande, Paul Farmer,
End TB Strategy.38 http://www.who.int/trade/distance_learning/gpgh/
gpgh3/en/index5.html accessed on October 26, 2016
5. Global tuberculosis control: A short update to the
5. CONCLUSION: 2009 report. Geneva, World Health Organization,
Colossal research and development is being carried out 2009 (WHO/HTM/TB/2009.426).
globally into different dimensions of Tuberculosis Control 6. The Global Tuberculosis Report 2016, World Health
with an estimated funding requirement of US$ 2 billion Organization, Geneva
annually. Funding during the decade 2005–2014 never
exceeded US$ 0.7 billion per year. In 2016, four new 7. WHO HQ website: http://www.who.int/tb/strategy/
diagnostic tests were reviewed and recommended by stop_tb_strategy/en/index.html accessed on October
WHO: the loop-mediated isothermal ampliĐcation test for 25, 2016
TB (known as TB-LAMP), two-line probe assays (LPAs) 8. Karam Shah, National TB control programme
for the detection of resistance to the Đrst line anti-TB drugs Pakistan, Pak J Chest Med Mar 2004; 10(1):5-8.
isoniazid and rifampicin, and an LPA for the detection of
resistance to second-line anti-TB drugs. A next-generation 9. P. Metzger, N.A. Baloch, G.N. Kazi and K.M.
cartridge called Xpert Ultra and a new diagnostic platform Bile, Review: Tuberculosis control in Pakistan:
called GeneXpert Omni are in development; with their reviewing a decade of success and challenges, Eastern
assessment by WHO planned for 2017. There are nine Mediterranean Health Journal, Vol. 16 Supplement,
drugs in advanced phases of clinical trials for the treatment 2010, pp 33-39
of drug-susceptible TB, drug-resistant TB or latent TB 10. National TB Control Pakistan, http://ntp.gov.pk/
infection (LTBI). These are bedaquiline, delamanid, cmsPage.php?pageID=7 accessed on October 25,
linezolid, PBTZ169, pretomanid, Q203, rifampicin (high- 2016.
dose), rifapen tine and sutezolid. There are 13 vaccine
candidates in clinical trials, including candidates for 11. WHO Guidelines for the programmatic management
prevention of TB infection and candidates for prevention of drug-resistant tuberculosis; Emergency Update
of TB disease in people with LTBI.39 Tackling latent TB is 2008, viewed at page xvii.
the only legitimate pathway for TB elimination. However, 12. A Javaid et al, Primary Drug Resistance to Anti-
the TB high burden countries need to perform at their tuberculosis drugs in NWFP Pakistan; Department
very best to make the world a safer place. of Pulmonology, PGMI, Lady Reading Hospital
Let us hope the imaginative implementation of this plan Peshawar, TB Control Program, NWFP, Department
helps our children to see a world devoid of Tuberculosis of Pulmonology, Ayub Teaching Hospital Abbottabad,
– a highly challenging undertaking requiring sustained Department of Microbiology, Aga Khan University
efforts and commitment by governments and all other Hospital, Karachi. (JPMA 58:437;2008)
stakeholders. Despite the enormity of the undertaking, 13. A Javaid et al, Prevalence of primary multi-drug
the effort is well worth it. While the obstacles may appear resistance to anti-tuberculosis drugs in Pakistan; INT
insurmountable at present, rapid advances in technology J TUBERC LUNG DIS 12(3):326–331
offer sufficient hope. Pakistan that has achieve tremendous
14. R Hasan et al, Trends in Mycobacterium Tuberculosis
gains within the realm of Tuberculosis Control cannot
resistance, Pakistan, 1990-2007; International Journal
afford to sit on its laurels, but should intensify its efforts
of Infectious Diseases (2009) 13, e377-e382
towards a better future, and economic development in a
society free from this affliction. 15. Seema Irfan, Qaisar Hassan, Rumina Hasan;
 Chapter 18 Tuberculosis and its Control in the Context of Pakistan 313
Assessment of Resistance in Multi Drug Resistant Medical Colleges in the control of Tuberculosis, Pak J
Tuberculosis Patients; Department of Pathology Chest Med Dec 2002;8(4):1-2.
and Microbiology, the Aga Khan University, Karachi
29. Ali SS, Rabbani F, Siddiqui UN, Zaidi AH, Sophie
(JPMA 56:397;2006)
A, Virani SJ, Younus NA., Tuberculosis: do we know
16. Sohail Akhtar, Fakhir Raza Haidri, Abdul Majeed enough? A study of patients and their families in an
Memon, Drug Resistant to tuberculosis in a tertiary out-patient hospital setting in Karachi, Pakistan, Int J
care setting in Karachi; Baqai Institute of Chest Tuberc Lung Dis. 2003 Nov; 7(11):1052-8.
Diseases, Baqai Medical University, Dr. Ziauddin
30. Ali Khan Khuwaja, Naushaba Mobeen, Knowledge
Hospital, Karachi (JPMA 57: 282; 2007)
about tuberculosis among patients attending family
17. R Iqbal, Pattern of Drug Resistance in Tuberculosis; practice clinics in Karachi, J Liaquat Uni Med Health
Pakistan Medical Research Council, Tuberculosis Sci Aug 2005;44(2):44-7.
Research Center, Institute of Chest medicine, King
31. M. Agboatwala, G.N. Kazi, S.K. Shah and M. Tariq,
Edward Medical College, Mayo Hospital, Lahore (Pak
Gender perspectives on knowledge, and practices
J Med Res. Vol. 44, No.4, 2005)
regarding tuberculosis in urban and rural areas in
18. Muhammad Khurram, Hamama Tul Bushra Khaar, Pakistan, East. Med. Health J. Vol. 9, No 4, 2003 pp.
Muhammad Fahim, Multidrug- resistant tuberculosis 732-740,
in Rawalpindi, Pakistan, J Infect Dev Ctries 2012;
32. Muhammad Khalid, Shamshad Rasul, Saulat UIIah
6(1):29-32
Khan, Saqib Saeed, Malik Nadeem Imran, Gender
19. Country profile, Pakistan. Global TB report 2011, differences in delays to Tuberculosis diagnosis
WHO. and treatment outcome, Pak J Chest Med Dec
2004;10(4):11-6.
20. The National Guidelines for Drug Resistant
Tuberculosis Management viewed at http://www.ntp. 33. S.A. Shah, S.A. Mujeeb, A. Mirza, K.G. Nabi and Q.
gov.pk/downloads/mdr/National%20Guidelines%20 Siddiqui, Prevalence of pulmonary tuberculosis in
for%20the%20Management%20of%20Drug%20 Karachi juvenile jail, Pakistan, Eastern Mediterranean
Resistant%20Tuberclosis%20(DR-TB).zip Health Journal, Vol. 9, No. 4, 2003 pp. 667-674
21. Ibrahim KM, Khan S, Laaser U., Tuberculosis control: 34. Rao NA., Prevalence of pulmonary tuberculosis in
status, challenges and barriers ahead in 22 high Karachi central prison, J Pak Med Assoc. 2004 Aug;54
endemic countries, J Ayub Med Coll Abbottabad. 2002 (8):413-5.
Oct-Dec;14(4):11-5.
35. Hussain H, Akhtar S, Nanan D, Prevalence of and risk
22. Shahina Qayyum, Nadeem Rizvi, DOTS: community factors associated with Mycobacterium tuberculosis
participation to fight Tuberculosis, Pak J Chest Med infection in prisoners, North West Frontier Province,
Dec 2003;9(4):7-10. Pakistan, Int J Epidemiol. 2003 Oct; 32 (5):799-801.
23. Pakistan social and living standards measurement (PSLM) 36. Aisha Mehnaz, Fehmina Arif, Applicability of scoring
survey, 2004-2005.Islamabad, Pakistan, Federal Bureau chart in the early detection of tuberculosis in children,
of Statistics, Statistics Division, Ministry of Finance, J Coll Physicians Surg Pak Sep 2005;15(9):543-6.
2005.
37. Sultana Habibullah, Ashraf Sadiq, Tehzeeb
24. Shah SK et al, Do private doctors follow national Anwar, Munir Ahmed Sheikh, Diagnostic delay in
guidelines for managing pulmonary tuberculosis in Tuberculosis and its consequences, Pak J Med Sci Sep
Pakistan? Eastern Mediterranean health journal, 2003, 2004;20(3):266-9.
9(4):776-88.
38. WHO End-TB Strategy, WHO Geneva, 2015
25. Arif K et al, Physician compliance with national
39. Ibid
tuberculosis treatment guidelines: A university
hospital study. International journal of tuberculosis and lung
diseases, 1998, 2: 225-30.
26. Khan JA et al, Knowledge, attitude and misconceptions
regarding tuberculosis in Pakistani Patients. Journal of
Pakistan Medical Association, 2006, 211-4.
27. Khan IM et al, Urging health system research:
Identifying gaps and fortifying tuberculosis control in
Pakistan. Croatian medical journal, 2002, 43:480-4.
28. Saulat Ullah Khan, Shamshad Rasul Awan, The role of
 314 Section VII Infectious Diseases/Communicable Diseases

View publication stats