Essay on tuberculosis

Dr. Tauseefullah Akhund M.B.B.S, MPH (Sydney), (Australia)

Since past couple of decades Pakistan is having a huge influx of refugees from Afghanistan. There is no data of them; who comes who goes. TB has been highly prevalent in these people and highly ignored too. The exponential influx of refugees in last five to seven years has made the coverage of DOTS very difficult. There are more than 3 million Afghan refugees situated in Pakistani state North West Frontier Province (NWFP) with annual rate of TB infection 1.7% (Ibrahim and Laaser, 2002). Ibrahim and Laaser (2002) also describe that NTP covers only 8% of population and condition is getting worse with continuing influx of refugees. A tuberculin survey carried out in 1985 among 4108 Afghan refugee children suggested that there were 13.8% children with TB, though the figure matched with similar incidence in Afghani children in Afghanistan (Spinaci et al, 1989). In 1998, an Italian NGO counted 20,000 cases of pulmonary TB and 40,000 extra pulmonary TB cases (Ibrahim and Lasser, 2002).

The increasing number of refugees has also created high number of drug resistant cases due to their non-compliance or lack of interests. DOTS highly relies on government of Pakistan to reach to the millions of refugees. The stringent laws and military interruption not only affects NTP to reach to the refugees, they also stop refugees to come to NTP. The similar condition like refugees is seen in prisoners in Pakistan, where utterly poor infrastructure, poor hygienic condition and ignorance by health workers have made TB a common disease among inmates. The surveillance should be improved in refugee camps. The refugee camps should be registered and so should be refugees. Regular health check ups should be carried out in these enlisted camps. In case of exchange of refugees Afghanistan government and their health department should be approached by Pakistan for not missing out a single person treatment.

TB is one of the opportunistic infectious diseases in HIV/ AIDS patients. With the widespread pandemic of HIV the number of TB cases have risen. TB in HIV patients is also difficult to treat. Eleven million adults are estimated to suffer from both TB and HIV (Ferrari, 2004). HIV or AIDS decreases immunity of a person making vulnerable for the infectious diseases. The worrisome picture of TB in HIV is that it is difficult to treat TB in HIV patients and it often causes drug resistance. The overlap of TB and HIV suggests that for the success of DOTS, NTP has to collaborate with anti-HIV or anti-AIDS agencies.

Surveillance is one of the most important obstacles in the success of DOTS and NTP. In WHO’s goal of detecting 85% cases and treating 70% of them, the treatment is close to 85% goal, but the case detection is as low as 37% (Hampton, 2004).  The situation in Pakistan is bad for the case detection. The conditions like refugees, civil conflicts, poverty, overcrowding and so forth are making the detection of TB cases very difficult. Dye et al (2003) reviewed the growth of case detection from 1995-2000 and estimated case detection by year 2010. The figure for most developing countries shows that the case detection rate is very low. Pakistan had also very bad figure, only 9% cases detected in DOTS in year 2000. Although it is estimated to reach as high as 40-50% in next five years, Dye et al (2003) fear that then the figure will plateau rather than reaching WHO estimated detection rate. There are several hypotheses responsible for such low case detection in Pakistan. The study argued that the missing TB cases might not exist at all; cases are not registered in private or public health systems; or if they are, they don’t get referred to DOTS. However, there are some other factors responsible for the reduced detection of TB cases. One such important factor is expertise of the health professionals who carry out the smear tests/ sputum tests. The lack of their training often leads to miss out TB cases.