A. D. Muynck ( GTZ I SHAIP, Islamabad. )
At the end of the nineteenth century, the scientific world became very excited about the discovery of the TB bacilli by Koch. The understanding of the infectious nature of the disease was thought to enable a rapid control.
At the end of the twentieth century, we have a plethora of diagnostic means and drugs, we have even sequenced the complete germ of M. tuberculosis. This knowledge has revealed important clues about the metabolic pathways of M. tuberculosis and is likely to provide important insight leading to vaccine development. Unfortunately, regardless of these enormous scientific advances, TB as a public health problem has never been more significant. One third of the world population is infected. Every year 8 million new pulmonary TB cases are added, and 3 million TB patients die.
The projection for the next decade are 90 million TB cases and 30 million deaths.
What is the situation in Pakistan?
There is little reliable epiderniological data available for Pakistan. but TB is considered to be one of the major causes of ill health in the country.
At present the annual incidence rate of infectious TB cases is estimated to be between 85-100/100,000 persons. In Pakistan. each year between 110,000 and 130,000 new TB cases are added to the existing nuniber of infectious individuals. The prevalence figures are estimated to be twice this amount, with some areas in the country having a much higher prevalence, for example Northern Pakistan where recently a figure of 554/100,000 cases has been reported.
As in other developing countries, young age groups are affected the most.
The national case holding figures were low and reniain low. There is major defaulting in the initial phase as well. Irregularity of follow-up visits has been shown to be a major risk factor for defaulting. The determinants of defaulting can be divided into 2 groups: patient related and service related. DOTS could provide a suitable answer to the defaulting problem but, with the exception of promising pilot projects, the generalized implementation of DOTS strategies is still awaited.
The National Tuberculosis Control Program (NTP) plans to integrate TB control services into the PHC system. So far however, the overall integration is lacking, as the PHC system itself needs to be strengthened.
Studies carried out recently have shown that 80% of TB patients first consult a private practitioner. In addition, further evidence reveals that up to 96% of the TB patients diagnosed in the TB Centre of Rawalpindi have previously consulted other care providers. Research has shown that some private practitioners function rather poorly in the screening, diagnosis, treatment and monitoring of their TB patients and that their adherence to the NTP strategy is very low. In order to obtain an adequate TB control programme, private practitioners have to be fully involved as partners.
These issues (compliance, integration into PHC, involvement of private practitioners) were the themes of an August 1999 workshop in Islamabad, organized by the Health Services Acadmy and the National TB Control Program. This workshop brought together scientists programme managers and field workers and resulted in the formulation of a set of recommendations1 to strengthen the NTP in Pakistan.