Surveillance Evaluation Report of Tuberculosis in

District Bhawalpur-2018

By

Dr Ammara Tahir

Table of Contents:
S.No Description Page No

1 Introduction

2 Objectives

3 Rationale

4 Methods

5 Result

6 Discussion

7 Conclusion

8 Recommendations

9 References

10 Tables

11 Graphs

INTRODUCTION
 Tuberculosis (TB) is a debilitating infectious disease caused by Mycobacterium
Tuberculosis that is an airborne pathogen. It’s disseminated through cough, sneeze or
oral droplets of diseased person. Weak immune system and poor socio-economic status
have always been risk factors for TB but in current scenario HIV, and drug resistant strains
of Mycobacterium Tuberculosis are major contributors towards resurgence of TB. TB is
multisystemic disease that can either be present as pulmonary or extra pulmonary
tuberculosis. It’s clinically manifested as active TB and sub clinically as latent
tuberculosis. Tuberculosis with all its complexities effects around 9 million people and
causes death of 1.5 million people annually. One of the major factors contributing towards
high mortality is non availability of proper surveillance system. Most of the cases go
undiagnosed or be a target of late reporting, resulting in elevation in death rate. CDC
necessitates that in order to control morbidity and mortality of disease on going evaluation
of surveillance system is mandatory. Maintenance of a system that not only guides for
immediate management of detected cases, but also detects epidemic, pandemic, risk
factors and minor trends, contributing towards occurrence of disease. Evaluation of
policies regarding treatment, prevention and control of disease is necessary to cope up
with ever modifying bacteria. The evaluation of disease surveillance system is necessary
to stay updated on treatment strategies, fund allocation and epidemiological research
(German et al., 2001; Horsburgh, Barry, & Lange, 2015; Jilani, Avula, & Siddiqui, 2019).

Tuberculosis is an ages old menace affecting human kind as an epidemic since

18th and 19th century. Work of Theophile Laennec and Antoine Villemin helped
understand pathogenesis of disease. Robert Koch identified tubercle bacillus as
causative agent of TB in 1882, followed by development of tuberculin skin test by
Clemens von Pirquet in 1907, moreover he demonstrated latent TB in children after a
period of three years. The uphill progress was followed by introduction of BCG in World
War I and discovery of streptomycin and isoniazid in 1944 and 1952 respectively. Despite
of all the progress and discoveries, we haven’t been able to overcome this completely.
World TB day is celebrated on 24th march each year to commemorate discovery of
Mycobacterium tuberculosis by Robert Koch (24th March, 1882), with the aim to “unite to
end TB” by making efforts to strengthen the existing system and to implementing better
strategies to face future threats (Daniel, 2006; Salinas, 2016).
 Mycobacterium tuberculosis, though most dominant etiological agent to cause TB,
it’s not the only one, a small percentage of cases showed incidence of disease through
M.africanum, M.canetti,M. caprae, M. microti, and M. pinnipedii. M. bovis was also
accounted for 1.4 % of TB cases in 2016.

According to CDC surveillance case definition, TB is a chronic Mycobacterium

tuberculosis infection, pathologically signified by granuloma formation, infection mostly
occurs in lungs, but may also be present in other organs. Active tuberculosis shows clear
signs and symptoms while latent TB is the dormant one with subclinical signs and
symptoms. Active TB manifests itself with the symptoms of persistent cough, cough with
blood, chest pain, lethargy, fever, and weight loss with appetite suppression. Around 10
% patient population suffers from active TB while rest suffers from latent TB. In latent TB
bacillus lays with in the granulomas with diminished metabolism that not only reduces its
growth rate but also its susceptibility to drug. Bacillus continuously fights against the
immune system and may or may not be able to suppress it. HIV co-infection is a major
risk factor regarding reactivation of bacillus. Tuberculin skin test and interferon gamma
release assay can be used for diagnosis of latent TB.

TB is an airborne disease, contracted through aerosolized cough droplets. The

threat for incidence of TB persists as long as infected case exists in the population. This
can be controlled through timely diagnosis and proper administration of drugs. Drug
resistant strains and comorbidities like HIV are also responsible for poor control of TB.
Care on the hand patient and health care provider is also particularly important to avoid
dissemination of disease. Surgical masks should be used by patients while medical staff
should wear high efficiency-particular-air filter respirator (Dodd & Schlesinger, 2017).

GLOBAL SCENERIO

In 2014, 23% (1.7 billion) of world population that accounts for a quarter of humanity was
exposed to TB. In 2016 the number of affected people dropped down to 10.4 million. 10%
of them were those who were in closed contact with HIV patients. Most of TB patients
were adults and males showing a share of 90% and 65% respectively. Number of death
also improved as mortality decreased to 24% (1.7 million in year 2000 dropped to 1.3
million in2016) in non - HIV patients. While in HIV infected patients number of death
decreased from 0.5 million to 0.4 million. Out of that 0.4 million, 32 % were reported from
Africa and 50 % from South East Asia. Out of various reasons reviewed for world wide
spread of disease, factors like; HIV, poor nutrition, shabby living circumstances, and silica
dust majorly and diseases like chronic kidney disease and diabetes mellitus were found
contributing to incidence of disease. Extensive travel to countries where disease is
prevalent as epidemic, illicit drug use, immigration, occupation as a health care provider
also lead to generation of disease.

In 2016 among newly occurred cases 4.1% were found to be resistant, while 19 %
of old cases were also drug resistant. 25 % of patient belonged to India and 12 %
belonged to China, while Russian federation had 10 % of affected population. Initially
introduction of combination therapy decreased disease incidence by 50% but mono drug
therapy lead to drug resistant strains. These strains lead to major outbreaks worldwide.

 Multiple drug resistant TB-(MD-TB) resistant to isoniazid and rifampicin too.

 Extensively drug resistant TB- its multiple drug resistant TB further resistant
to flouroquinolones in combination with resistance against at least one of
the second line treatment drugs i.e. amikacin, capreomycin and kanamycin.

These caused an outrageous turn to chemotherapy and treatment of disease. TB

is still a “global health emergency” with an incidence rate of 3% per year in high economic
countries. While Asia shares 58% of all cases and 28% of all reported cases concentrate
in Africa (Pareek, Greenaway, Noori, Munoz, & Zenner, 2016). Multiple drug resistant TB
is imposing a great financial burden, as in Africa MD-TB effects 3% of population but more
than one third of their whole nation tuberculosis budget is being consumed by this 3%.
These resistant strains are causing a great socio economic stress and it necessitates new
research and development of new drug. Newer treatment options like bedaquiline,
delamanid and linezolid are also being explored to overcome the pressing issue of drug
resistant strains (Dheda et al., 2014; Dheda et al., 2017). Among many factors
contributing to global emergence of TB globally, there exists a group of modified strain
called Mycobacterium tuberculosis Beijing family. It’s the predominant type in East Asia,
and it’s related to emergence of different outbreaks in various regions of world. These
strains are most probably an adaptation to increased density of human population (Luo
et al., 2015).

In order to control this disease, vaccines like bacillus Calmette–Guérin (BCG) can
be used. WHO short course chemotherapy strategy DOTS that was introduced in mid 90s
showed positive results. DOTS, emphasized strengthening of diagnosis, observation and
evaluation of treatment outcomes, efficient supply of short course chemotherapy and
direct observation of treatment.

All this global scenario further accentuates the importance of surveillance system.
As even with available data, many cases go, unreported, undiagnosed. Especially in
countries and places where health care is costly, where government doesn’t support a
mandatory disease reporting system or where patients prefer food over drugs due to poor
socio economic status and ignorance. Even interventions like DOTS cannot be effective
without proper surveillance and evaluation. WHO aims to decrease current morbidity
status to 50% and to drop mortality rate up to 75 percent till 2025 in regions like South
Africa, India and China. CDC committed to eliminate TB in U.S and to lower incidence of
TB in children below 5 years of age. CDC also aims to initiate complete examination and
treatment of immigrants in order to control spread of disease. Thus in order to fight this
war against TB, a strong and stable political support is required along with an effective
monitoring system. Review and regularization of surveillance system on national and
global level is extremely important (Glaziou, Floyd, & Raviglione, 2018; Houben et al.,
2016).

PAKISTAN SCENERIO

According WHO report released in 2015, Pakistan ranks 5 th among countries

highly afflicted by TB. Among every 100,000 of population 341 suffer from TB, which
makes around 510,000 -730,000 individuals victim of active TB at any time. In 2013,
298,446 cases were reported. Biological confirmation was available for 111,628 case,
111, 8279 were smear negative while 52,646 were notified as extra pulmonary cases.
10% of affected population constituted of children below 15 years of age, 75% were
between 15-55yrs. About 60% of cases were reported from Punjab, 20% and 13%
belonged to Sindh and Khaybar pakhtunkha respectively. Baluchistan notified minimum
number of patients.

In 2013 mortality rate was 69 deaths per 100,000 no, now it has reached down to
27 deaths /100,000 population. 32% of effected population was found to be drug resistant,
3.7% were newly notified cases, and 18.1% were retreatment cases.
 In 2001 Pakistan aimed to diminish TB by using WHO DOTS program and TB was
declared as National Emergency. Both Federal and Provincial government committed to
the aim.

Primary health care units are the foundation of national health program and policy
implementation occurs here. Provincial TB control program and National TB control
program are responsible for technical support, policy guidelines, review, monitoring,
evaluation and coordination. Pakistan advocates the global aims of eliminating TB by
2025. For materialization of this dream three things are very important.

 Innovative TB Care methodologies

 Formulation of bold policies and well-established support system
 Incorporation of intensified research and innovation

The national TB control program, developed a strategic plan “Vision 2020”, that focuses
on following points

 To increase effectiveness and efficiency of TB control program through

increasing investment and accountability towards TB control activities
 It aims to minimize the diagnostic delay, improving the treatment in terms
of duration and innovation, implying preventive measures and to improve
accessibility of DOTS and Drug resistant –TB treatment
 Introduce and invest in better and cost effective, diagnostic and
management tools
 Make TB DOTS and other services approachable to all
 To make research a first priority

NTB programs envisions a TB free Pakistan in 2025, with a mission to make TB treatment
universally accessible and to decrease the prevalence to 50% as compared to that
presented in 2012.

The objective is to

 Increase funding
 Increase reporting of cases
  Reduce prevalence each year (at least 5% reduction in a year)
 Present more stable and structured technical and managerial interventions

To achieve these goals a surveillance system established on district, provincial and

federal level was introduced

District health care system not only improves implementation of interventions, but also
promotes coordination between managerial and technical services and ensures service
delivery through basic health care units.

Provincial control program, develops province specific strategies and policies. It’s also
responsible for monitoring and supervising the system. It provides technical and logistic
support and also enhances coordination

Federal or national TB control program provides technical support on provincial level.

Engages and generate resources. It’s involved in policy formation and disease
surveillance. It’s also responsible for international representation.

NTB control program follows and presents standard diagnostic and treatment criteria. It
shows standard preventive care too. Through all these efforts Pakistan is trying to
eradicate TB through better surveillance, reporting and efficient treatment and preventive
strategies (NTP, 2015).

PROVINCIAL SCENERIO (PUNJAB)

Punjab is the most densely populated province of Pakistan. According to data base
provided on Provincial TB control program website, 56% of Pakistan population is
resident in Punjab. This shows that 181/100,000 cases of TB have been reported in
Punjab. In year 2000 initiative of TB control services was taken in Punjab and a network
of 559 diagnostic centers was established. Global funds were generated and utilized to
initiate program in 32 districts. 895 private sector practitioners were trained to improve
compliance to TB-DOTS program and spu8tum smear microscopy was introduced in 114
private labs.

Till now Punjab TB control program has worked to achieve minimum development goal
since quarter 2 2008, expanded DOTS to 36 districts, trained several physicians,
paramedics and microbiologist. Established 559 peripheral and 36 district diagnostic
centers. Established reference labs along with internal and external quality system.

Various initiatives have been started including:

 Core DOTS
 Childhood TB
 Hospital DOTS Linkages & TB/HIV Co-Infection.
 TB DOTS in Prisons
 Parastatal Organizations: Railways, PESSI,Wapda
 Drug Resistance TB
 Public Private Mix (PPM-1)
 NGO Model (PPM-2)
 Private Hospital’s Sector (PPM-3)
 Parastatal Sector (PESSI, Railway) (PPM-4)

Furthermore an android application for mandatory reporting of TB has been introduced to

improve the surveillance system. Real time monitoring application for timely reporting and
rectification of issues has also been introduced.

DISTRICT SCENERIO

DEMOGRAPHY

Bahawalpur district is known as “Princely state”, it covers 24,830 km². It’s located in the
south of Punjab, with India on its south and south east, Bahwalnagar on north east,
Vehari, Lodhran, Multan situated on its north, Rahimyar khan on west and Muzaffargharh
on north-west. District Bahawalpur has 15 health facilities, including 11 RHC and 4 THQ.
Bahawalpur is the capital city. A study conducted in 2014 showed 969 TB patients were
reported in Chest Disease Unit of Bahawal Victoria Hospital Bahawalpur. 690 cases were
selected from sample population 283 were smear positive while the rest were smear
negative. Only one case presented with drug resistant TB. Only 468 patients were treated
successfully, 14 remained untreated, 114 didn’t follow up and 35 patient died during
course of treatment (Atif et al., 2018).

Rationale

 Pakistan shows higher prevalence of TB as compared to neighboring

countries.
 Large pockets of disease have been identified in the area moreover
continuous influx for patients from periphery puts Bahawalpur on threat
 It’s evident that south Punjab is high burden area for incidence of TB
because of poverty, ignorance, poor compliance and sanitary conditions. In
order to overcome the mortality and morbidity effective surveillance is
necessary. A thorough evaluation of surveillance system is required in order
to present true number of patient affected.

Objective:

 Evaluation of current surveillance system for assessment of epidemiological

indices of disease, disease notification, estimation of prevalence and
annual death rate with estimation of risk factors affecting the disease.
 To identify strength and weakness of existing system
 To suggest new recommendations for future actions.

METHODOLOGY:

According to CDC recommendation for evaluation of surveillance system, it is necessary

to engage the stake holders and to describe system to be evaluated. In order to evaluate
the TB surveillance system a study design was formulated as per guidelines of CDC.

Study design: Descriptive evaluative study

Study duration: 1st to 10th of September 2019

Place of study: District Bahawalpur

Study tool: A semi structured questionnaire was designed for face to face interview and
analysis of data. Interviews were conducted to engage the stake holders i.e. District TB
focal person, Medical officers of BHU and RHC. Private practitioners were also involved,
patients and their parents were also interviewed.

System Attributes Assessments / Credible Evidence: Some of the system attributes

like simplicity, flexibility, acceptability and stability were assessed qualitatively, while the
remaining attributes including data quality, sensitivity, and predictive value positive,
representativeness and timeliness were assessed quantitatively.

Sources of Data: Interviews with the below mentioned stakeholders and surveillance
data were the main sources of data for this evaluation. Interactive discussions &
Interviews: These were held with the identified stakeholders at the provincial and district
level by using a standardized semi-structured questionnaire developed on the basis of
CDC guidelines. Information’s about the functioning of the existing surveillance system
were collected through these interactive discussions and interviews.

Identification of Stake Holders:

To collect information the interview were conducted from Focal persons,Program

managers, Assistant program managers, Deputy Program managers, Medical
Superintendents of the hospitals and Medical officers.

Data Quality Control Procedures:

Selected subgroups of the respondents were interviewed by the principal investigator
and the results compared as a check for the data quality. The training of the
interviewers and the field supervisors were conducted on the questionnaire with an
emphasis on standardization of the meaning of the questions asked. All the staff were
trained on issues of complete recording of information as per the questionnaire with
preservation of all forms so that no forms are lost in the field. All data were kept
confidential. All pertinent steps were taken to ensure data confidentiality
and anonymity.
Data Preparation:
The questionnaires were filled up by hand by the interviewers in the field
and reviewed by the field supervisor to correct any omissions or errors being recorded.
Coding of the responses was done by the field supervisor in consultation with the
Principal and the Deputy investigators. Double entry of the data was done.
Data Analysis: The collected data of interviews and discussions was organized and
analyzed, followed by interpretation for drawing inferences. A comprehensive analysis
of the surveillance data obtained through desk and field reviews was also done. Graphs
and tables were produced to describe variations in the functioning of the system. All
attributes as per the updated CDC guidelines for evaluating Surveillance system was
used by given a numerical score:
1-Good. 2-Fair. 3-Poor.Results of evaluation based on System Attributes:

Rationale:

To evaluate the system in order to observe if disease is being monitored effectively and
efficiently for the welfare of patient. To identify strength and weakness of system and also
suggest improvements to fill the gaps in the system.

List of the Stake Holders;

S. No Designation

1 District health officer

2 District Focal person

3 DHIS System

4 DHQ Hospital

5 THQ Hospital
 6 RHC

7 BHU

8 LHW

9 LHS

10 PPHI

11 Private center

Result: The surveillance was evaluated by pursuing the CDC guidelines for evaluating
public health surveillance systems. The surveillance data provided by the Provincial
office and the interview data was reviewed. Most of the system attributes were
assessed qualitatively, while only two attributes i.e. sensitivity, and predictive value
positive were assessed quantitatively. The grading criteria of the system attributes were
given in the box below and the results of each one of the attributes were described
below the box. The results for these system attributes were transcribed by following the
CDC guidelines and the measures considered for evaluation were graded as poor, fair
and good.
CONCLUSION:

Due to the global endeavor to eradicate TB, substantial funds have been invested by

The system has the capacity for growth and attempts have been made to develop. The
evaluation revealed that this system in the province is very useful in early detection of
an outbreak, monitor disease over time, place & person and provide information for
action to policy makers. The system was found to be useful in obtaining its eradication
aims, and was also found to be simple to execute. The system has enough flexibility to
allow other diseases without drastic changes in time, human resources or finances. The
reporting set-up is mainly reliant on the public sector. There are issues about the
insufficient participation of the private sector in the surveillance network. It was noticed
that the existing staff has been overworked, which may hamper their capability to
sustain a good quality of surveillance. It was observed that the Focal Persons in each
district were mostly aware about the surveillance and has taken part in the surveillance
activities, which greatly impacts the monitoring and supervision at the district level.

Lack of oversight of the system has been observed from the government side. It was
also observed that the roles and responsibilities at different levels are not clear which at
times creates confusion while fixing the responsibility. There is no proper plan with the
government that how this system will be absorbed and regularly financed in-order to
sustain the existing system. In spite of all these hurdles and challenges, the system has
been doing well in creating sufficient levels of awareness of surveillance among the staff
of the public health sector, leading to timely case detection, investigation, proper
specimen collection, handling and transportation.

RECOMMENDATIONS:

One of the objectives of the evaluation of this surveillance system was to give some
useful recommendations which can help the policy makers in bringing some
improvements in the existing surveillance system. Therefore, the following actions are
recommended;
1. Though the health department is the owner of the system and data, but there is no
clear oversight from the government side to look after the system. Therefore, strong and
vigilant oversight from the government is recommended.

2. It is recommended to define clearly the roles and responsibilities of each

administrative level, individual health workers and health facilities that are the primary
sources of information.

3. A realistic plan is needed so that it is fully absorbed and financed by the Ministry of
Health thereby assuring its sustainability.

4. Establishment of a surveillance cell is recommended at the health department to

have an integrated approach for surveillance activities of different diseases.

5. Additional human resource for surveillance and epidemiological response capacity is

suggested at the district health department.

6. Trainings/refresher trainings should be conducted at regular intervals regarding case

definition, diagnosis, management and surveillance for all the related staff like general
practitioners, health/faith healers, medical/house officers working in the pediatrics,
medical, orthopedic and neurology units of the major hospitals.

7. Development of a policy and planning for functional integration with other systems
like DHIS, Diseases surveillance system and involvement of private sector, general
practitioners and laboratory for making the system more effective.

8. Establishment of a regular feedback and communication mechanism between all

levels and stakeholders (District – Provincial & all reporting sites).

9. The data should be critically reviewed at the provincial office for evidence based
decision making. Regular desk and field reviews should be carried out for the
monitoring and evaluation of the system.

10. It is suggested that posters having definition of TB, necessary instructions and
reporting site contact name and number should be displayed at all general practitioners,
health/faith healers clinics.
11. There is also little evidence of a systematic effort to identify and map non-formal
health care providers for inclusion in the surveillance network. Necessary measures are
recommended in this regard.

12. The devolution process has not yet fully clarified the financial issues for different
health programs. These should be reviewed and the gaps should be addressed.

LIMITATIONS:

There were certain limitations in conducting this evaluation. It was not possible to
include or visit more districts for field review due to lack of resources & time. Most of the
data was taken from the Provincial & district offices and it was not possible to validate or
cross check all the data. I have just relied on the data provided electronically by the
Provincial TB office. Despite all these limitations, the evaluation was a useful learning
experience and will provide a baseline for future evaluations.

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