Two Years of Retrospective Study on the Incidence of Tuberculosis in Dir Lower Valley, Khyber Pakhtunkhwa, Pakistan

Abstract

Background: Pakistan has high tuberculosis (TB) burden with alarming mortality and morbidity, and its rate increases day by day, especially in remote areas where access of quality health is not available. Objective: The objective of the study was to determine the incidence rate of pulmonary TB in the Dir valley among the suspected patients according to age-, gender-, and location-wise prevalence of the disease. Methods: A retrospective descriptive study was designed from January 2015 to December 2016. All the 556 people registered are suspected patients of pulmonary tuberculosis sputum smear (PTB-SS) positive, whereas the remaining cases were diagnosed with extra-pulmonary TB and hence excluded from the study. Results: The ratio of PTB-SS-positive cases was higher in females (50.5%, n = 281) compared with males (49.5%, n = 275). Furthermore, in the age group 1 to 20 years, the percentage of PTB-SS-positive cases was 28.1% (n = 156), in 21 to 40 years 40.3% (n = 224), in 41 to 60 years 18.7% (n = 104), in 61 to 80 years 11.2% (n = 62), and at age group >81 years, it was 1.8% (n = 10). No difference was found in the years 2015 and 2016 regarding PTB-SS-positive cases registration. Age and health care facilities (P < .000) and treatment outcome (P < .000) have a strong relationship. No significant relation was found with other demographics variables (P > 0.05). Conclusion: It was concluded from our finding that TB was considerably increased in the general population of District Dir (Lower), and proper supervision, diagnosis, treatment, and awareness of rapid prophylactic measures are needed to eradicate the issue.

Introduction

Tuberculosis (TB) has harmful effects on the human health, with high morbidity and mortality rates during the last few decades. TB has such alarming situation; according to the World Health Organization, 9 million TB cases have been reported annually and 1.5 million deaths occurred every year.¹ In 2011, the WHO reported 1.4 million deaths (990 000 among HIV-negative people and 430 000 HIV-associated TB deaths). Geographical distribution of TB prevalence was recorded in 2010 with Asia on top 59%, followed by Africa 26%, Eastern Mediterranean Region 7%, Europe 5%, and America 3%.² Pakistan is on the sixth position among the developing countries where TB is accounted to be more than 50%. The lack of therapeutic approaches and proper diagnostic procedures and disinformation of health care personnel increase the risk of TB among the people.^3,4

Worldwide, the WHO is struggling to eliminate TB, but a big hurdle in the eradication of TB is drug resistance and multiple drug resistance.⁵ Nowadays, many diagnostic procedures are available for the detection of TB; sputum smear microscopy is still widely used which is unable in case of drug resistance.^6-8

Mycobacterium tuberculosis is the main causative agent of TB that is also called tubercles bacillus, discovered by Robert Koch in 1882. TB usually affects the lungs (pulmonary TB), but if not treated, it can spread to other parts of the body (nonpulmonary TB). Cough (sometimes blood in sputum), fatigue, loss of appetite, chest pain, night sweats, and breathlessness are the general symptoms of TB.^9-11

M tuberculosis is a gram-positive bacteria which is noncapsulated, non–spore forming, sessile, and usually straight or slightly curved rod, and has genetic material with a high content (61%-71%) of guanine (G) plus cytosine (C). M tuberculosis is an acid fast-staining bacteria and needs distinctive laboratory stain known as Ziehl-Neelsen’s stain as the unsaponifiable wax (mycolic acid) forms a semipermeable membrane around the cell that makes it acid fast. The Bacillus Calmette Guerin (BCG) vaccine is used to protect children against the severe form of TB, but in some cases, BCG is recommended in adults for drug-resistant TB.¹²

The route of transmission from person to person involves the transfer of mucous droplets via coughing, laughing, sneezing, spitting, and breathing. These droplets that contain the M tuberculosis are shifted by air to the noninfected person and ultimately reach the alveoli of the lung by traversing the mouth and then nasal passage, thus causing the infection.¹³

Methods

The current research was conducted to investigate the prevalence of TB among the people on the basis of age, gender, and center of pulmonary tuberculosis (PTB) cases at DHQ Hospital Timergara and to make aware of people about the TB infection in the District Dir (Lower) Khyber Pakhtunkhwa, Pakistan.

A 2-year retrospective observational study was planned between January 2015 and December 2016 at District Dir Lower.

Participants were included as per inclusion criteria, and patients were divided into many groups according to the disease condition and smear outcome, that is, New (N), Relapse (R), Treatment failure (F), Treatment after default (D), and other (O). New cases (N) are those patients who were previously not diagnosed for TB infection. Relapse (R) includes those patients who finalized the TB treatment and announced cured for TB but found smear positive for TB. Treatment failure (F) includes patients whose smear is found positive at the end of treatment. Treatment after default (D) includes patients who are previously announced default from treatment smear is found positive. Other (O) includes those patients who did not fall in the above categories. The demographics of the participants such as age, gender, type of TB, and previous history were collected on the prescribed data collection form. The local population was categorized into 5 age groups for age-wise analysis including 1 to 20, 21 to 40, 41 to 60, 61 to 80, and 81 to 100 years.

A total of 556 patients were enrolled in the study period comprising 275 (49.46%) males and 281 (50.54%) females. All the suspected patients had come with common symptoms, that is, prolonged cough, night sweat, moderate fever, chest pain, and so on. For the suspected patients of PTB, sputum smear microscopy was performed. Those with positive sputum smear were considered PTB-SS positive, whereas the rest of the patients were excluded.

The data were collected from District Headquarter Hospital Timergara with the connection of different TB centers located in District Dir Lower. Demographic information of the patients were recorded, and obtained data of PTB-SS-positive cases were also further analyzed to check the disease for the gender-, age-, and year-wise analysis. The treatment outcomes, TB care facilities, patient types, and anatomical sites were also analyzed descriptively.

The data were analyzed through IBM SPSS version 21. Demographics of patients were analyzed by descriptive statistics, and frequencies were presented in table. The Fisher exact test was used to find the association between the variables like age, gender, and TB care facilities; the chi-square test was also used. Their associations were shown and expressed through graphs and tables.

Ethical approval was obtained from the respective hospital and TB center.

Results

Gender-wise Distribution of PTB Cases

In the current study, a total of 556 patients of TB were registered at District Headquarter Hospital District Dir (Lower), and the number of males and females was 275 and 281, respectively. The high number of patients was recorded during 2016 up to 374, whereas the least number up to 182 was recorded in 2015. On the basis of percentage, a high prevalence of TB was recorded in 2016, whereas approximately half of it was reported in 2015. The prevalence of TB was high in females (50.5%) as compared with males (49.5%) in both years as shown in Table 1 and Figure 1.

Table 1.

Demographics (N = 556).

	n (%)
Gender
Male	275 (49.5)
Female	281 (50.4)
Age
1-20 years	156 (28.1)
21-40 years	224 (40.3)
41-60 years	104 (18.7)
61-80 years	62 (11.2)
81-100 years	10 (1.8)
TB care facilities
DHQ Timergara	246 (44.2)
Civil Hospital Samar Bagh	76 (13.7)
Pakistan Anti-TB Association (Ouch)	76 (13.7)
RHC (Lal Qila)	46 (8.3)
RHC (Munda)	13 (2.3)
RHC (Talash)	19 (3.4)
THQ (Chakdara)	20 (3.6)
PPM ACD	60 (10.8)
Type of cases confirmed
Bacteriologically confirmed	556 (100)
Number of cases reported year-wise
2015	182 (32.7)
2016	374 (67.3)

Note. TB = tuberculosis.

Figure 1.

Gender-wise distribution of TB patients in TB care facility.

Note. TB = tuberculosis.

Age-wise Distribution of PTB Cases

Age-wise analysis of the data shows that the high number of cases (40.3%) was recorded in the age group 21 to 40 years. Furthermore, the second high prevalence rate (28.1%) was found in the teenage 1 to 20 years. In the age group 41 to 60 years, occurrence was 18.7%; in the age group, 61 to 80 years, it was 11.2%; and a very low prevalence rate (1.8%) was found in people who were above 81 years (Table 1 and Figure 2).

Figure 2.

TB in different age groups reported in different TB care facility.

Note. TB = tuberculosis.

TB Health Care Facilities–wise Distribution

According to the health care facility distribution, it was shown that incidence rate of TB was high in DHQ Hospital Timergara (44%) with an almost equal incidence in both Civil Hospital Samar Bagh and Pakistan Anti-TB Association (Ouch) of 13.7%, followed by PPM ACD, RHC Lal Qila, THQ Chakdara, RHC Talash, and RHC Munda with 10.8%, 8.3%, 3.6%, 3.4%, and 2.3%, respectively, as shown in Tables 1, 2, 3, and 4 and Figure 3.

Table 2.

Association Between TB Facilities and Age, Gender, and Yearly Distribution of TB Cases.

Statement	n (%)	Age-wise	Gender-wise	Year-wise
DHQ Timergara	246 (44.2)	0.00a,*	13.21b	16.42b,*
Civil Hospital Samar Bagh	76 (13.7)
Pakistan Anti-TB association (Ouch)	76 (13.7)
RHC (Lal Qila)	46 (8.3)
RHC (Munda)	13 (2.3)
RHC (Talash)	19 (3.4)
THQ (Chakdara)	20 (3.6)
PPM ACD	60 (10.8)

Note. TB = tuberculosis.

^aFisher exact test.

^bChi-square test.

^*Statistical significance <0.5.

Table 3.

Relation of TB Care Facility and Treatment Outcomes.

Outcomes of the given treatment	TB care facility								Total
	DHQ Hospital Timergara	Civil Hospital Samar Bagh	Pakistan Anti-TB Association (Ouch)	RHC Lal Qila	RHC Munda	RHC Talash	THQ Chakdara	PPM ACD
Cured	84	6	28	19	3	10	4	36	190
Treatment completed	7	5	2	2	0	1	3	1	21
Treatment failed	1	0	0	0	0	1	0	0	2
Treatment incomplete	1	0	0	0	0	0	0	0	1
Lost to follow-up	2	0	0	1	1	0	0	0	4
Died	0	0	1	0	0	0	0	0	1
Treatment continued	151	65	45	24	9	7	13	23	337
Total	246	76	76	46	13	19	20	60	556

Table 4.

Chi-Square Tests.

	Value	df	Asymp. Sig. (2-sided)
Pearson chi-square	90.470a	42	.000
Likelihood ratio	78.341	42	.001
Linear-by-Linear association	14.810	1	.000
Number of valid cases	556

^aForty cells (71.4%) have expected count less than 5. The minimum expected count is .02.

Figure 3.

Outcomes of the given treatment.

Treatment Outcome of PTB Cases

Treatment outcome–wise distribution is shown in Figure 3, which indicates that the treatment of maximum number of patients (60.61%) is still continued followed by the ratio of cured people which made a total of 34.17%. Those patients whose treatment completed, lost to follow-up, treatment failed, treatment incomplete, and died are 3.8%, 0.7%, 0.4%, 0.2%, and 0.2%, respectively, as shown in Table 1 and Figure 3.

Discussion

In 2011, the incidence of all types of TB cases was estimated 231 per lakh of populations as detection rate was 64% of all types of TB in Pakistan.¹⁴ In the year 2014, the estimated TB prevalence in Pakistan was 342 per 100 000 and incidence was 275 per 100 000 of total population of the area. Overall, in the country, the prevalence of detected cases of all types of TB was 58%, although in 2014, its rate was 298 446.¹⁵ The exact information as well as the data also must require on the frequency and occurrence of TB is essential for the operational TB control program. In our study, the prevalence of TB cases was resolute to deliver the model epidemiological information for people of District Dir Lower, Khyber Pakhtunkhwa as well as for the National Tuberculosis Control Programme (NTP). The outcomes of the existing study will be very supportive to control and get rid of the disease. Preventive planning for TB control, the epidemiological research is need of the time.¹⁶

Variables like both gender and age are known in incidence and prevalence of TB .The gender difference is such an indicator which conveys the consideration to both male and female. As reported, the disease rate is high in female than in male patients. 50.5% female and 49.5% in male disease burden was recorded, in male remained diagnosed for Pulmonary TB. The results of our study are similar to other studies that stated a great prevalence of TB in female population.^17-19 A question is raised that why the females are more prone to the development of the disease? The answer might be that the females are extra immune deficient.²⁰ Long and his team in Vietnam conducted a study, reported that women put off nearly twice as long to visit the health care centre from the onset of cough when relate to men.²¹ Roundabout cases of the women ignored their illness; as a result, they become too sick.²² Mortality rate increases due to delay in the diagnosis and treatment of TB and its spread to healthy individuals. Unfortunately, in some societies, the existence of TB infection in women may lead to divorce, and if single, creates problems to find a life partner.²³ In epidemiology of TB, an important feature is age, basis the high incidence as in age 1–20 years are 28.1% was reported. Ayaz et al conducted a study in Peshawar Khyber Pakhtunkhwa and recorded a high prevalence of 68.96% in age 10 to 20 years. In the current study, the disease load was also reported high in age 21 to 40 years. Our results are in line with the outcome of others who stated large a number of cases in the creative and most economically significant age groups.²⁴ In District Lower Dir, Ahmad et al described 39.69% cases of smear-positive PTB in age 15 to 34 years.¹ Regional TB center in Buraidah Central Hospital, Qassim, reported by Chattu et al at high No. of cases 43.3% in age among 16 and 30 years.²⁸ Ibn et al (2012), in Nigeria, carried out a study and also reported a great number of TB cases (49.5%) in the productive and economically imperative age 16 to 35 years. Millennium Development Goals (MDG) were set by the WHO to stop progression of the disease and decrease the widespread incidence of TB by 2015 and eradicate the disease from the surface of the world by 2050. Subsequently, in 1990, the prevalence and death rate of the disease are reduced more than 50%.

Conclusion

In the current study, only the sputum smear microscopy was performed. Hence, no culture or other test was performed. Therefore, we cannot assume the degree of latent/asymptomatic TB infection. Hence, further studies are recommended.

The incidence and total reported cases of the TB were high at Dir Lower. The majority of cases of the TB were observed in female patients of Dir Lower where a maximum number of the cases were mutually recorded in age 21 to 40 years. Advanced research is recommended to discover the epidemiology and obstacles to access health care center, and to make available the health care facility at doorstep.