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Muhabbat Ali
Roll no 14
T.B is a specific
communicable disease
TUBERCULOSIS. (and other
variants of MYCOBACTERIUM).
Historical Context
HIPPOCRATES (460 B.C), the father of medicine called it phthisis,
which means to dry up.
 The disease was also referred to as Captain of men of death
and The Great White Plague.
IN 1882 ROBERT KOCK, discovered the causative agent. In 1895
Roentgen discovered X-rays.
 In 1907, Pirquet discovered the TUBERCULIN TEST.
 Soon after the First World War, the BCG vaccination evolved by
French scientist, CALMETTE and GUERIN was tested in 1972 and
its success led to large implementation of prevention.
 Remarkable progress in T.B control was with the discovery of
Streptomycin (1944), PAS (1946) and Isoniazed (1951).
Tuberculosis (TB) is a contagious disease.
Like the common cold, it spreads through
the air. Only people who are sick with TB in
their lungs are infectious. When infectious
people cough, sneeze, talk or spit, they
propel TB germs, known as bacilli, into the
air. A person needs only to inhale a small
number of these to be infected.
Left untreated, each person with active TB
disease will infect on average between 10
and 15 people every year.
Introduction cont..
Someone in the world is newly infected
with TB bacilli every second.
Overall, one-third of the world's
population is currently infected with the
TB bacillus.
5-10% of people who are infected with
TB bacilli (but who are not infected with
HIV) become sick or infectious at some
time during their life. People with HIV
and TB infection are much more likely
to develop TB
 Prevalence and mortality rates appear to be falling in
all six WHO regions.
 Thus, the Americas, the eastern Mediterranean, and
Southeast Asia appear likely to meet the Millennium
Development Goals target, set in conjunction with the
Stop TB Partnership and the World Health Assembly,
of halving tuberculosis prevalence and tuberculosis-
related mortality between 1990 and 2015.
 This target will probably not be met by the African
and European regions.
Some 22 high-burden countries collectively account
for 80% of the global tuberculosis burden.
According to the 13th annual tuberculosis report of
the World Health Organization (WHO) — published on
World TB Day, March 24, 2009 — there were an
estimated 9.27 million new cases of tuberculosis
worldwide in 2007.
 Although this figure represents an increase from
9.24 million in 2006, the world population has also
grown, making the number of cases per capita a
more useful measure of the problem; this figure
peaked in 2004 at 142 per 100,000 and fell to 139
per 100,000 in 2007.
Situation in PAKISTAN
Pakistan ranks 6th among the countries of
the Eastern Mediterranean Region (EMRO) of
World Health Organization (WHO), in terms of
TB disease burden.
 Every year about 250,000 new cases are
included in the country's TB burden.
 Despite the fact that the government, with
huge support from international health
agencies, considered TB an emergency in
2001, given TB a priority and implemented
DOTS all over the country; the case detection
rate is still low (27% in 2004).
Determinants of
In spite of available modern technology
for prevention and control of tuberculosis,
the disease poses a major public health
problem in Pakistan.
Followings are key determinants
regarding this problem.
Etiological agent
Mycobacterium tuberculosis, an acid fast
gram positive, non-motile, aerobic rod
shaped organism, which grows with
difficulty in special medium.
Source of infection
sputum or excreta of T.B patient
containing Tubercle bacilli.

milk obtained from cows suffering

from udder tuberculosis.

tuberculosis materials from carcasses

of slaughtered tuberculosis animals or
from laboratories or operation theatre.
 Droplet infection - Direct by the infectious patient by
coughing or sneezing etc.
Food, handled by a tuberculosis patient or utensils used by
him may also be transmitted by common dinning from the
same utensils or by eating food left over by the patient.
 Common HOOKA smoking may also spread the infection.
 Flies may carry infection from sputum to food.
Kissing and fondling by the tuberculoses patient especially of
 Direct inoculation of tubercle bacilli may taken place in
butchers, surgeons ( infected knife) and laboratory workers
(needles) this is, however, uncommon.
Environmental factors
Unhygienic conditions such as overcrowding favors close
Diet- malnutrition
Socio-economic conditions-more in poor socio-economic strata
Mental state- more in inmates of mental hospitals, jails etc.
Inter-current infections and concomitant diseases-diabetes,
repeated pregnancies and use of corticosteroid etc.
Endocrine disorders such as hypothyroidism
Certain occupational diseases like anthracosis and silicosis
People who deal with public in overcrowded places show higher
incidence of disease like bus conductors, post office counter
clerks, barbers etc
Government of Pakistan endorsed the DOTS strategy, following
WHO’s declaration of TB as a global emergency in 1993
 The National TB Control Programme (NTP) Pakistan adopted
DOTS (Directly Observed Treatment, Short course) strategy in
The national guidelines were developed and few pilot projects
were also started.
However, the program became dormant due to abolition of the
Federal Directorate for Tuberculosis Control in 1996. Therefore
the progress during the first three years (i.e. 1995 – 1998)
remained slow, because of its vertical approach, lack of
consensus between federal and provincial units, and non-
availability of funds from regular health budget.
 In 1998 the roles and relationship between the federal and
provincial tuberculosis control program were re-defined and
What is Public Private
The concept of public-private mix model (PPM) in
health care has emerged in the past decade with a
view that a large majority in the developing countries
utilizes private sector as a source of health care.
This partnership between governmental and private
for-profit or not-for-profit organizations emerged as a
novel approach to improve the system of health care
service delivery.
 PPM model has been successful and also received
attention in terms of tuberculosis control in many
developing countries.
Besides effectiveness as a strategy it also has
financial benefits in control of tuberculosis for the
Capacity building of the Private physicians to
diagnose and treat the patient of Tuberculosis
through PPP, ultimately increasing case detection
and registration and treatment of patients.
Increase compliance/follow up of diagnosed
patients by giving them counseling sessions by
Lady Health Workers.
Health Education Sessions in primary, middle and
high school of the District Rajanpur for Primary
Prevention awareness in students.
Cases which have been treated be kept under
supervision for sufficiently long period and rehabilitated
to prevent further relapses e.g. nature of jobs etc.
Vocational training should be provided to them.
Milk should be tubercle bacilli free.
Mass BCG vaccination is perfectly safe and effective. 4
– 5 times lower risk in BCG vaccinated children as
compared to non vaccinated children in England. BCG
vaccination can be given to people of all ages. The
most important group is new born infant.
 Good nutrition will lead to improvement in resistance
against T.B.
District monitoring team will be formed to monitor the
overall process.
Prioritizing the
Capacity building of the Private
physicians to diagnose and
treat the patient of
Tuberculosis through PPP,
ultimately increasing case
detection and registration and
treatment of patients.
Rationale for the
Majority of the population (more than 75%) of
Pakistan attends private sector for their health
problems which is also true for Tuberculosis.
 The great dependence of people on the private
sector is due to the relative inefficient and
inadequate government health care sector.
 To complicate this problem, these private
practitioners may not follow the standard criteria in
TB case management. This is partly due to poor
regulation of the practice health care sector
It is important to involve private practitioners in
detection and treatment of tuberculosis. Also linking
private practitioners with public sector would improve
the practices and enhance TB control.
 It would standardize and improve the diagnostic
techniques, decrease maltreatment, partial treatment.
There is sufficient evidence that privately practicing
physicians in Pakistan lack sufficient knowledge to
manage a typical case of tuberculosis.
This is true for disadvantaged communities where
tuberculosis is highly prevalent especially under poor
housing conditions.
For the reasons cited above select an intervention to
involving private practitioners in improving the CDR in
district Rajanpur
Decrease the burden of Tuberculosis

To enhance the TB case detection through
Public Private Mix (PPM) model by involving
private practitioners in collaboration with
National TB Control Program, (NTP) in district
Rajanpur in 12 months period.
To provide timely diagnosis of at least
sputum-smear positive (infectious) TB patients
(those most at risk of death and transmitting
To enhance awareness and information
regarding prevention and control of T.B
Steps in Implementation the
The scale of the project will be of a pilot nature
and the expected outcomes of the Intervention
will show how the private physicians behaved in
collaborating with the government and how do
they practice the standard guidelines for the
management of tuberculosis.
Only those Private physicians, who are treating TB
patients at their private practice, will be given
invitations to attend training workshop on the
Tuberculosis-Directly Observed Treatment Short
course (DOTS) based on the guidelines of World
Health Organization.
. Their knowledge of the TB-DOTS prior to and after the
training was assessed through a questionnaire which
addressed the key issues in the management of TB.
 At the end of the training a written consent of voluntary
participation in the Project will be taken from all the
participants and an introduction about the project will be
provided. The PPs will also be informed that they should
refer suspected TB cases for sputum microscopy and
register the patients with the NTP.
. The PPs will be given an incentive for every TB
diagnosed sputum smear positive patient.
A field coordinator will monitor and facilitate
the whole process. The PPs will also visit
regularly by the Project team as well as by the
district NTP coordinator.
 TB patients' data will be collected from all
participating PPs during the study period of 12
months regarding number of suspected TB
cases, new sputum smear positive cases, and
patients' demographic and socioeconomic
 On the other side for the comparison, NTP
data of the study area regarding number of
new sputum smear positive TB cases will be
collected from NTP office.
The project coordinator of the field will take
the TB1 forms from the physicians where
patients will be registered with the district
TB Coordinator office of Rajanpur.

The Anti Tuberculosis Treatment (ATT) will

be originally given to the physicians by the
district TB coordinator office upon
submitting the profile of the patients.
These drugs will be given for a period of two
months initially for the intensive phase of the
treatment and latter for six months for
continuation phase.
The laboratory charges for three sputum AFB
smear testing were paid on a two monthly
basis by the project.
The physicians will be seen by the coordinator
every week and data will be taken from them
and shared with the NTP coordinator who then
visited the physicians accordingly.
Based on indicators
Number of trainings conducted.
Number of PPs trained.
Number of new cases detected.
Number of new cases Registered.
Number of patient got treatment.
Number of patients completed the
Number of patients not completed the