Study of Tuberculosis in Population of Bahawalpur.

By

Maria Bashir

Session 2009-13

A thesis submitted in partial fulfillments of the requirements for the degree of BS (Hons)

Zoology

Department of Life Sciences

The Islamia University, Bahawalpur

   It is Allah Who causeth the seed-grain and the date-stone to split and sprout. He causeth the living to issue from the dead, and He is the one to cause the dead to

issue from the living.That is Allah; then how are ye deluded away from the truth? He it is that cleaveth the daybreak (from the dark): He makes the night for rest and tranquillity, and the sun and moon for the reckoning (of time): such is the judgment and ordering of (Him), the Exalted in Power, the Omniscient.

(SURAH AL-AN’AM 95- 96)

CERTIFICATE

To,

The Controller of Examination,

Islamia University,

Bahawalpur.

We, the supervisor committee, certify that the content and forms of this thesis submitted by Maria Bashir have been found satisfactory and recommended that it may be proposed for evaluation by the External Examiner for the award of BS Degree.

Supervisor

Evaluation committee Chairman

Evaluation committee Member

External examiner

Examination Incharge

Department of Life Sciences

DEDICATION

Dedicates to those

Loving like flowers

Beautiful like rainbow

Fine like fragrance

Nice like dew drops

Gifted me love

Made me confident

Trained me at every step

My heart my soul

And ideal personality

My mother and my late father

And mother like elder sister.

ACKNOWLEDGEMENTS

I bow my head to Almighty ALLAH, the most merciful, compassionate, gracious and

beneficent,Who is entire source of all knowledge and wisdom endowed to mankind, who guide

us from the darkness to light in every movement of hopelessness and help us in every hour of

difficulty. This humble piece of work has been completed only due to the grace of Allah, All

glory to him whoblessed me with health and all the senses of working under pressure. Trembling

lips and wet eyes praise for the Holy Prophet (PBUH) the most learned scholar of all times,

(who helped us to recognize our Creator) for enlighten our conscience with the essence of faith

in Allah and who is forever a torch of guidance and knowledge for the whole Dr.Sadaf Zhara

for her excellent supervision during my entire research tenure. I am highly humanity. I feel

highly obliged in my deepest and sincerest gratitude to my reverend research supervisor thankful

to her for very lenient attitude throughout my research work. I learned much more under her

guidance. I feel proud to be a student of such a nice, kind and much disciplined supervisor. I am

highly indebted for her pains taking and untiring efforts and spending his very precious time for

me. I always pray to Allah to keep her under his patronage. It is a time of great honor for me to

express my deep sense of obligations to the adorable and eminent Dr. Muhammad Shafiq ch

chairman, Department of Life Sciences for providing all the facilities and conducive atmosphere

during my research work. I could not have accomplished this task without his kind assistance,

encouraging guidance, valuable suggestions, enthusiastic cooperation and vital instructions.

I cordially acknowledge and deem to express unbind thanks to my friend Anum Saghir who

always assisted and encouraged me in every moment of scorching life.Special thanks from the

core of my heart for my sweet friend Hala Shikrani.I never forget the ever remembering and

charming company and love of my friends Sidra Hayyat, Amara, Maryam Amin, Maria

Iqbql, Huma Khan and Mnahal Shabbir who make me able to believe that friendship is most

beautiful and valuable relation in the life. I am greatly indebted to affectionate my sisters Ayesha

and Maryam for their prayers, love and moral support at every step of my life. Words are

lacking to express my deep sense of affections for my dear brother Abdullah who always remain

with me.

ABSTRECT

List of Contents

Chapters Number Chapter Titles Page Numbers

01 Introduction 01

02 Review of Literature 06

03 Materials and Methods

11

04 Results and Discussions

15

05 References 40

List of figures

S. no Title of figure Page. no

Introduction

Tuberculosis (TB) is one of the leading causes of mortality, accounting for 26% of preventable

adult deaths in the developing world (Small et al., 1996 and Rajeswari et al., 1999). The World

Health Organization estimates that between 1.5 and 2 million people die each year from TB. An

estimated one third of the world's population (1.86 million) is infected with Mycobacterium

tuberculosis, and during the last decade the incidence of tuberculosis infection has increased

even in industrialized countries (Dye et al., 1999). Indeed, estimates are that there is a TB-

related death every minute. Varying levels of endemicity of tuberculosis infection have been

reported worldwide, and South-east Asia seems to be the most afflicted: 44% of its population is

reported to be M. tuberculosis infected (Dye et al., 1999). Delayed presentation is considered as

a reason for growing burden of TB in developing countries (WHO report, 2006).

One of the objectives of 'Stop TB' program is to make diagnosis and treatment of TB universally

available and accessible ( WHO and stop TB Partnership., 2011-15). The financial estimates of TB

control for the 22 high-burden countries largely differ. Due to low spending and poor political

attention TB control programs have been widely suffered particularly in 22 highly endemic

countries (WHO. Switzerland, 2001. and Netto et al., 1999 and WHO, 1997-98 Annual Reports

and Ahlburg, 2000 and WHO, the Stop TB Initiative 2000 Report). The performance has been

very well wherever TB was the focus of attention of the governments and private agencies

(Netto et al., 1999 and World health report 2000. Geneva).

Mycobacteria are members of the bacteria family. These organisms can cause a variety of

diseases. Some Mycobacteria are called tuberculosis because they cause TB or diseases similar

to TB. In the United States the vast majority of TB cases are caused by an organism called

Mycobacterium tuberculosis. M. tuberculosis organisms are also called tubercle bacilli. Other

Mycobacteria that can cause tuberculosis disease include M. bovis, M. africanum, M. microti,

and M. canetti. TB is spread from person to person through the air. When a person with

infectious TB disease (TB that can be spread) coughs, sneezes, speaks, or sings, tiny particles

containing M. tuberculosis may be expelled into the air. These particles, called droplet nuclei,

are about 1 to 5 microns in diameter—less than 1/5000 of an inch. Droplet nuclei can remain

suspended in the air for several hours, depending on the environment. If another person inhales

air that contains these droplet nuclei, transmission may occur. Transmission is the spread of an

organism such as M. tuberculosis from one person to another (U.S. Department of health, 2008).

Close contact with tuberculosis (TB) cases is a major risk factor for Mycobacterium tuberculosis

(Mtb) infection and close contacts to TB cases have a higher incidence of TB disease than the

general population in the first year after exposure (Guwatudde et al., 2003), although the risk

may differ across different locations and populations. These differences may be due to the

variations in the TB prevalence in the location, population density, socio-economic

development, infectiousness of TB patients and the extent of contact (Kumar et al., 2011;

Pretorius et al., 2009). Accurate detection and adequate treatment of latent tuberculosis

infection (LTBI) are fundamental elements needed to reduce the incidence of tuberculosis,

particularly in low-incidence areas and among high risk individuals such as contacts of a TB

patient.

TB caused by organisms that are able to grow in the presence of a particular drug, TB that is

resistant to at least one first-line anti-tuberculosis drug is known as drug-resistance TB. Multi

drug-resistant TB (MDR TB)–TB that is resistant to at least the drugs isoniazid and rifampin; MDR

TB is more difficult to treat than drug-susceptible TB. Extra pulmonary TB – TB disease that

occurs in places other than the lungs, such as the lymph nodes, the pleura, the brain, the

kidneys, or the bones; most types of extra pulmonary TB are not infectious. Latent TB infection

(LTBI) – refers to the condition when a person is infected with tubercle bacilli but has not

developed TB disease. Persons with LTBI carry the organism that causes TB but do not have TB

disease symptoms and they cannot spread TB germs to others. Persons with LTBI usually have a

positive result to the Mantoux tuberculin skin test or the Quanti-FERON-TB Gold test (U.S.

Department of health, 2008).

TB can occur in different places in the body, such as the lungs, kidneys, skin, brain, or bone.

Cutaneous TB comprises only a small proportion (b1%-2%) of all cases of TB nevertheless,

bearing in mind the high prevalence of TB in many developing countries, these numbers become

significant. When dialysis patients are infected by bacilli of the Mycobacterium tuberculosis

complex, they are 10-25 times more likely than immune competent people to develop active

tuberculosis (Mazurek et al., 2003 and Al-Jahdali et al., 2010 and Weir et al., 2003 and Hussein

et al., 2003 and Smirnoff et al., 1998). The higher TB incidence observed in patients on dialysis is

attributed to the lowered cellular immunity caused by the state of chronic renal failure

(Passalent et al., 2007).

Based on TB control program data, age distributions of TB incidence show adolescence to be a

period of increasing incidence (Donald et al., 2004 and Wood et al., 2011). Knowledge of

prevalent TB in adolescents is relevant to public health programs since these cases represent a

source of transmission. Resulting new infections in turn present a high risk of progressing to

active TB (Ferebee et al., 1970). It has been shown that occurrence of TB in high burden settings

are often due to exposure outside of the home environment (Verver et al., 2004). Adolescents

are also an important target group for TB vaccine trials (Brennan et al., 2012).

Some areas in the country have much higher figures, such as Northern Pakistan where a

prevalence figure of 554/100,000 cases was observed (Hussain et al., 1998). Report of 2002

mentions the case notification rate for Pakistan was 23/100,000 in the year 2001. Globally

Pakistan has been ranked 8th in terms of estimated number of cases by WHO, with an incidence

of 175/100,000 persons (Global Tuberculosis Control, WHO. 2003).

Pakistan has been ranked fifth among the 22 highest-incidence countries of TB. In this country

1.5 million people suffer from TB, and more than 210 000 new cases occur each year (WHO,

1997). According to a 2008 estimate there were 15000 Multi drug resistance (MDR) TB patients

in Pakistan (Global TB Database; 2010). Pakistan is among the 27 countries with high burden of

MDR TB (WHO, 2010). At present, only 1 per cent of central government expenditure is spent

on health care, and over half the country has little or no access to health care. Until recently

there were no official guidelines for tuberculosis control in Pakistan, and there is serious

concern that drug resistance is likely to increase at an alarming rate. TB is considered to be a

major cause of ill health (Khan. 1995).

People can only access these facilities if they are aware of the symptoms of disease, seek early

care, and adhere to treatment. Early diagnosis and adherence to treatment may decrease

emergence of drug resistant strains.

Literature review

Bhaskar et al., (1996) detected the presence of antibodies directed against Mycobacterium

tuberculosis antigens. The sensitivity of the assay was increased from 78% (reported earlier), to

90.2% for pulmonary tuberculosis and 85.7 % for extra-pulmonary tuberculosis. The specificity

of the test was determined by testing the sera of apparently healthy controls, and patients with

other respiratory tract infections and rheumatoid arthritis. Among the apparently healthy

controls, 7.3 % tested positive. None of the sera from the patients with other diseases gave

positive agglutination.

Banda et al., (1998) determined the prevalence of pulmonary tuberculosis (PTB) in

patients with short duration of cough. Ninety-eight adult out-patients (60 men, 38

women; mean age 32 years) at Queen Elizabeth Central Hospital, Blantyre, Malawi, who

had cough for 1–3 weeks which was unresponsive to a course of antibiotics, were

successfully screened by microscopy and culture of 2 or 3 sputum specimens and chest

radiography; 34 (35%) had PTB. Ten patients were sputum smear-positive and 24 were

smear-negative and culture-positive. Nine patients (26%) with microbiologically

confirmed tuberculosis (TB) had chest radiograph abnormalities consistent with TB,

compared with 5 (8%) of patients with no microbiological evidence of TB. Certain

classes of patients with a short history of cough would benefit from PTB screening

strategies with the emphasis on sputum examination rather than chest radiography. The

classes include (i) patients with other features of TB whose cough has not improved with

antibiotic therapy, (ii) seriously ill patients, and (iii) patients in high risk institutions such

as prisons and refugee camps.

Alvi et al., (1998) investigated the prevalence of pulmonary tuberculosis (TB) in the

Shimshal Valley, a remote village in Northern Pakistan. The total population of the

village was 1077, of whom 231 cases were studied. Overcrowding affected 75% of the

study population. The prevalence of smear positive pulmonary TB in the village studied

was 554 per 100 000 population, and the prevalence of active smear-negative TB was

estimated at 1949/100 000. The prevalence of active pulmonary TB increased with age

and the only risk factor for active TB was age over 45 years. Of the 21 cases with a past

history of pulmonary TB, only 38% had completed a full course of chemotherapy.

Asimos et al., (1999) studied the purified protein derivative (PPD) test surveillance and

respiratory protection practices of emergency medicine (EM) residents, along with

the prevalence of PPD test conversion and the development of active tuberculosis (TB) in

EM residents. A total of 89.3% (n = 2,985) of residents eligible to complete the survey

completed at least part of it. The majority of residents are PPD-tested once a year.

The prevalence of PPD test conversions in EM residents was between 1.4% (36/2,575)

and 2.0% (52/2,575). Of the residents who PPD test-converted, the ED was most often

the perceived area of TB source exposure (n = 15). Two residents (0.08%) reported

having developed active TB, including chest radiographic findings or clinical infection,

which equals a 0.14% (95% CI = 0.005 to 0.31) risk of developing active TB over a

three-year residency. Half of all the residents do not routinely wear National Institute for

Occupational Safety and Health (NIOSH)-approved particulate filtration respirator (PFR)

masks in patient encounters at risk for TB exposure.

Miller et al., (2000) identified 526 tuberculosis cases reported in Los Angeles County

over a 6-month period. Of 313 persons who completed our questionnaire, 72.7% had

cough, 48.2% for 12 weeks, and 52.3% had fever, 29.4% for 12 weeks. Among those

with pulmonary disease, only 52.4% had cough for 12 weeks. In a multivariate model,

persons with significant symptoms typical of tuberculosis disease (defined as cough or

fever for 12 weeks, weight loss, or hemoptysis) were associated with lack of medical

insurance, negative tuberculin skin test, diagnosis during a process other than screening,

and non-Asian race.

David et al., (2000) studied the potential risk of tuberculosis transmission if modified the policy

for release of patients from the “airborne precautions” category from three negative acid-fast

bacillus (AFB) smears to two, or even one. Over a 4-year period, respiratory cultures from 42

patients grew Mycobacterium tuberculosis. Of these, 36 patients (81%) had a positive AFB smear

result on the first submitted specimen. One additional patient (2%) had a first smear-positive

finding on the second submitted specimen, and no patients had a first smear-positive result on

the third submitted specimen. Respiratory cultures from five patients (12%) grew M.

tuberculosis without ever having a positive AFB smear result.

Sokolove et al., (2000) demonstrated the clinical presentation of emergency department (ED)

patients with active pulmonary tuberculosis (TB). During the study period, 44 patients with

active pulmonary TB made 66 contagious ED visits. Multiple contagious ED visits were made by

12 patients (27%; 95% CI = 15% to 43%). Chief complaints were pulmonary 33% (95%CI = 22% to

46%), medical but nonpulmonary 41% (95% CI = 29% to 54%), infectious but nonpulmonary 14%

(95% CI = 6% to 24%), and traumatic/orthopedic 12% (95% CI = 5% to 22%). At least one TB risk

factor was identified in 57 (86%; 95% CI% = 76 to 94%) patient visits and at least

one TBsymptom in 51 (77%; 95% CI = 65% to 87%) patient visits. Cough was present during only

64% (95% CI = 51% to 75%) of the patient visits and hemoptysis Rathi et al., (2002) Estimated

the prevalence of and identify risk factors associated with tuberculin skin test (TST) positivity

among household contacts of acid-fast bacilli (AFB) sputum smear-positive pulmonary

tuberculosis cases The prevalence of TST positivity among household contacts of AFB sputum

smear-positive index patients was 49.4%. The final multivariate generalized estimating

equations (GEE) model showed that contact’s age and sleeping site relative to the index case,

the intensity of the index case’s AFB sputum smear positivity and the contact’s Bacille Calmette-

Guérin (BCG) scar status were independent predictors of TST positivity among household

contacts of AFB sputum smear-positive index cases during 8% (95% CI = 3% to 17%).

Walley et al., (2001) enrolled 497 adults with new sputum-positive tuberculosis. 170 were

assigned DOTS with direct observation of treatment by health workers; 165 were assigned DOTS

with direct observation of treatment by family members; and 162 were assigned self-

administered treatment. The trial was done at three sites that provide tuberculosis services

strengthened according to WHO guidelines for the purposes of the research, with a standard

daily short-course drugs regimen (2 months of isoniazid, rifampicin, pyrazinamide, and

ethambutol, followed by 6 months of isoniazid and ethambutol). Within the strengthened

tuberculosis services, the health-worker DOTS, family-member DOTS, and self administered

treatment strategies gave very similar outcomes, with cure rates of 64%, 55%, and 62%,

respectively, and cure or treatment-completed rates of 67%, 62%, and 65%, respectively.

Harries et al., (2002) studied the rate, pattern and treatment outcome of childhood TB case

notifications in Malawi in 1998. There were 22, 982 cases of TB registered in Malawi in 1998, of

whom 2739 (11.9%) were children. Children accounted for 1.3% of all case notifications with

smear-positive pulmonary TB (PTB), 21.3% with smear-negative PTB and 15.9% with extra-

pulmonary TB (EPTB). Estimated rates of TB in children were 78/100 000 in those aged less than

one year, 83/100000 in those aged 1-4 years and 33/100 000 in those aged 5–14 years. A

significantly higher proportion of TB cases was diagnosed in central hospitals. Only 45% of

children completed treatment. There were high rates of death (17%), default (13%) and

unknown treatment outcomes (21%). Treatment outcomes were worse in younger children and

in children with smear-negative PTB. Treatment completion was best (76%) and death rates

lowest (11%) for the 127 children with smear-positive PTB.

Deun et al., (2002) studied the efficiency of numbers of microscopic fields screened and the

sputum collection scheme used for diagnostic smear examination. Acid-fast bacilli were found in

99.6% of 1,412 positive and in 79.3% of 576 scanty slides in the first 100 fields. Examination of a

third specimen yielded a maximum of 2.7% positives incrementally. The most efficient strategy,

using three morning specimens, yielded 94.2% positives on the first and 1.0% on the third

sputum; although 10% of suspects did not return, only1.5% of the positives were among them

and more cases were confirmed and treated. The positive predictive value of a single positive or

scanty smear was very high (99.2%).

Kisa et al., (2002) studied the 6844 respiratory specimens obtained from previously untreated

patients suspected of having pulmonary tuberculosis between 1998 and 2001 were evaluated

retrospectively. A total of 785 (11%) specimens from 353 patients were positive for

Mycobacterium tuberculosis complex. For 76% (270/353) of these patients the organism was

detected from sputum specimens collected sequentially for daily basis. Mycobacterium

tuberculosis was isolated in the first, second and third samples of the majority (98%, 195/199) of

patients who had three or more sputum samples sent to the laboratory.

Hussain et al., (2003) studied to assess the prevalence of and identify factors associated with

latent Mycobacterium tuberculosis (MTB) infection in prisoners of North West Frontier Province

(NWFP). A stratified random sampling technique was used to select a sample of 425 from a total

of 6607 male prisoners aged 18-60 years from the five central prisons of NWFP, Pakistan

(Peshawar, Dera Ismail Khan, Haripur, Kohat, and Mardan). Overall prevalence of latent MTB

infection among prisoners was 48% (204/425). Using multiple logistic regression, a prisoner’s

age, educational level, smoking status, duration of current incarceration, and average

accommodation area of 60 ft2 or less in prison barracks were found to be statistically significant

(P < 0.05) predictors of latent MTB infection.

Yassin et al., (2003) reviewed the laboratory registers of 42 tuberculosis (TB) diagnostic centres

in the southern region of Ethiopia to determine the value of submitting serial sputum samples

for the diagnosis of pulmonary TB (PTB) and estimate the proportion of suspects that are smear

positive. A total of 15,821 TB suspects submitted three smears each (47 463 smears) in 2000

with a median of 228 per centre. The smear positivity rate (two or more positive smears) was

25%, with a range of 16.8-36.4% per zone. This exceeds the international recommendations of

examining 10 suspects to identify one case. A total of 4099 (26%) of the suspects had at least

one positive smear with 3753 (91.6%) of the first specimens being positive. A further 303 (7.4%)

were negative in the first specimen but had a positive second specimen and 42 (1%) suspects

had two negative specimens followed by a positive third smear. The value of the third sputum is

negligible as 99% of the cases were identified from the first and second specimens.

Elizabeth et al., (2003) studied the increasing global burden of tuberculosis (TB) is linked

to human immunodeficiency virus (HIV) infection. There were an estimated 8.3 million

(5th-95th centiles, 7.3-9.2 million) new TB cases in 2000 (137/100 000 population;

range, 121/100 000-151/100 000). Tuberculosis incidence rates were highest in the WHO

African Region (290/100 000 per year; range, 265/100 000-331/100 000), as was the

annual rate of increase in the number of cases (6%). Nine percent (7%-12%) of all new

TB cases in adults (aged 15-49 years) were attributable to HIV infection, but the

proportion was much greater in the WHO African Region (31%) and some industrialized

countries, notably the United States (26%). There were an estimated 1.8 million (5th-95th

centiles, 1.6-2.2 million) deaths from TB.

Shah et al., (2003) studied that Jail inmates may be at increased risk of contracting tuberculosis

(TB). We studied 386 detainees (mean age 17.7 years) in Karachi juvenile jail to determine the

prevalence of TB and possible risk factors for contracting TB. We found a 3.9% prevalence of TB

among the inmates, significantly higher than the estimated 1.1% prevalence in the general

population of Pakistan. Positive family history of TB was a significant risk factor for TB. Poor

adherence of previously diagnosed patients to anti-TB treatment was found.

Hussain et al., (2003) random sampling technique was used to select a sample of 425 from a

total of 6607 male prisoners aged 18–60 years from the five central prisons of NWFP, Pakistan

(Peshawar, Dera Ismail Khan, Haripur, Kohat, and Mardan). Overall prevalence of latent MTB

infection among prisoners was 48% (204/425). Using multiple logistic regression, a prisoner’s

age, educational level, smoking status, duration of current incarceration, and average

accommodation area of 60 ft2 or less in prison barracks were found to be statistically significant

(P < 0.05) predictors of latent MTB infection.

Butt et al., (2003) determined the frequency and antimicrobial susceptibility pattern of extra-

pulmonary tuberculosis in Rawalpindi. Mycobacteria were isolated from 291 pulmonary

specimens and 98 extra-pulmonary specimens. The frequency of extra-pulmonary tuberculosis

was 25.2%. The commonest source of isolation was pus (44.9%, frequency 11.3%), followed by

lymph nodes (13.3%, frequency 3.3%) and pleural fluid (13.3%, frequency 3.3%). Of the extra-

pulmonary isolates 13.3% were resistant to a single drug, 21.4% were multi-drug resistant and

9.2% were resistant to all the four drugs.

Thorson et al., (2004) estimated the gender-specific prevalence of tuberculosis (TB)

through screening. A population-based survey of 35,832 adults was performed within an

existing sociodemographic longitudinal study in Bavi district, northern Vietnam. Cases

were identified by a screening question about prolonged cough and further diagnosed

with sputum examination and a chest X-ray. The estimated prevalence of pulmonary TB

among men was 90/100,000 (95% CI 45–135/100,000) and among women 110/100,000

(95% CI 63–157/100,000). Case detection in the district was estimated to 39% (95% CI

20–76%) among men and 12% (95% CI 6–26%) among women.

Dharmalingam., (2004) reviewed of 33 patients with tuberculosis of the spine from January 2000

to April 2002 revealed that the mean age was 36.5 and peak incidence is in the second decade

of life (27.3%). There were 24 males and 9 females. The majority of the lesions involved the

thoracic spine (30.3%), followed by the lumbar spine (27.2%). Skip lesions was seen in 12.1% of

cases. The erythrocyte sedimentation rate was normal in 9.1% of patients. Neurological

involvement was seen in 51.5% of patients. Concomitant tuberculosis of the lung was 66.6%.

The radical surgical debridement and grafting rate was 39.3%.

Cailhol et al., (2005) identified the independent risk factors associated with extra pulmonary

tuberculosis (EPTB). Risk factors for EPTB vary according to area of birth. Women born in Asia or

North Africa were at a higher risk of developing an EPTB than men. In Sub-Saharan Africa, age

was associated with EPTB. Human immunodeficiency virus infection was an independent risk

factor for EPTB in the European groups only with an OR of 2.48 (CI 99% 1.84–3.34).

Mabaera et al., (2006) determined the number of slides required to identify one additional case

of sputum smear positive tuberculosis (TB) from the third smear. A total of 52 909 records of

examinees were available. In Mongolia, of 15,103 suspects, 1,717 (11.4%) were positive. Of

these, 0.7% were positive for the first time on the third smear examination. In Zimbabwe, of 25

693 suspects, 3,452 (13.4%) were positive and 4.5% were positive only on the third smear

examination. The expected number of slides required to detect one additional case on the third

examination was 1153.3 for Mongolia and 132.6 for Zimbabwe.

Huong et al., (2006) investigated the yield of sputum smear microscopy and sex differences in

the National Tuberculosis Control Programme in the north of Vietnam. The average daily

workload per technician was 4.4 examinations in district and 5.3 examinations in provincial

laboratories. To find one smear-positive case, 9.7 suspects were examined and 29.3 smears

done. The smear-positive rate (mean 10.3%) was higher among men (11.6%) than among

women (8.4%, P = 0.001). There were more men than women among tuberculosis (TB) suspects

(male: female ratio 1.36, 95%CI 1.19-1.54), but even more so among smear-positive patients

(1.89, 95%CI 1.64–2.14), irrespective of specimen quality and number of smears examined.

Three smears were examined for 18 055 suspects (61.7%). The incremental gain was 33.5% and

4.9% for the second and third smear examination, respectively; 186 (95%CI 160–221) smears

needed to be examined to find one additional case of TB with a third serial examination.

Hirao et al., (2007) investigated to assess the feasibility of completing the diagnosis of

tuberculosis (TB) in 1 day by collecting only on-the-spot specimens. Two hundred and twenty-

four patients (224) with chronic cough had 135 ⁄ 672 (20%) positive on-the-spot smears and 47 ⁄

224 (21%) positive morning smears. The same-day and internationally recommended

approaches identified 44 and 45 of the 78 patients with positive cultures, respectively.

Katamba et al., (2007) estimate the workload required to identify one additional case of TB with

a third serial sputum smear examination. In Moldova, 9% (1141/12 525) and in Uganda 20%

(7280/36054) of suspects met the TB case definition with at least one positive sputum smear.

The incremental yield from the third examination was 4% in Moldova and 3% in Uganda. To

detect one additional TB case on a third smear, 273 examinations (95% CI 200-389) in Moldova

and 175 (95% CI 153-222) in Uganda were thus required.

Mabaera et al., (2007) determined the frequency of single scanty or positive sputum smear

results and its impact on the surveillance definition of sputum smear-positive tuberculosis (TB).

The dataset comprised 128 808 examinees with valid information from 23 laboratories in

Moldova, all 31 in Mongolia, 30 in Uganda and 23 in Zimbabwe, each covering at least one

calendar year. The reason for the examination was diagnostic for 89,362, of which 15.2% (n =

13,577) were defined as laboratory cases with at least one bacillus on at least one examination

cases were confirmed by another examination in 72.6% (n = 9861). Of the 9,014 cases who had a

full set of three examinations, confirmation was obtained in 92.4% (n = 8325).

Ozkutuk et al., (2007) evaluated the contribution of each specimen to the final detection of TB

suspect patients with culture-proven disease. AFB were detected from one or more sputum

specimens with direct microscopy in 42% of the cases. An analysis of results of smear

examination showed that 97% of AFB were detected from the first specimen and only 3% were

obtained from the second smear. The third specimen did not have any additional diagnostic

value for the detection of AFB by microscopy.

Horie et al., (2007) studied the prevalence of tuberculosis (TB) in Hanoi, Vietnam, in 2003/2004.

A random selection was carried out involving 11,624 subjects from 20 communes within the city.

On chest X-ray examination, 317 subjects (2.73%) showed abnormal lung opacity, of which 17

were sputum smear-positive, two concentrated smear positive and three culture-positive, all

with active TB. The prevalence of sputum smear-positive pulmonary TB was 146 per 100,000 in

persons aged -15 years (95%CI 65–228).

Khan et al., (2007) studied 1494 women and 1561 men with suspected tuberculosis attending

the Federal Tuberculosis Centre in Rawalpindi, Pakistan. Of enrolled patients, 133 (4%) declined

to participate. The primary outcome measure was the proportion of instructed and non-

instructed women testing smear positive. Instructed women were more likely to test smear

positive than were controls (Risk ratio 1 63 [95% CI 1 19–2 22]). Instructions were associated∙ ∙ ∙

with a higher rate of smear-positive case detection (58 [8%] in controls vs 95 [13%] in the

intervention group; p=0.002), a decrease in spot-saliva submission (p=0.003), and an increase in

the number of women returning with an early-morning specimen (p=0 02). In men, instructions∙

did not have a significant effect on the proportion testing smear positive or specimen quality.

Yang et al., (2008) investigated the epidemiological features of pulmonary tuberculosis in

Sichuan Province, China, for the period 2000-2006. From 2000 to 2006, the incidence rate of

pulmonary tuberculosis increased from 54 to 103/100 000, the mortality rate increased from

0.02 to 0.30/100 000, and the case-fatality rate increased from 0.04% to 0.29%. The age groups

20-24, 65-69, and 70-74 years had higher incidences. There were more cases and deaths in

males compared to females. Peasants contributed the most to caseloads (64%) and deaths

(69%) in the total population.

Mdivani et al., (2008) reported the prevalence and risk factors for drug-resistant TB. A cross-

sectional prospective survey of patients with suspected pulmonary TB was carried out at four

sentinel sites (Tbilisi, Zugdidi, Kutaisi, and Batumi) in Georgia between January 1, 2001 and

December 31, 2004. Among 1422 patients with suspected pulmonary TB, 996 (70.0%) were

culture positive; 931/996 (93.5%) had drug susceptibility testing performed. Overall, 64.0% of

patients (48.3% of new and 85.3% of retreatment cases) had positive cultures for

Mycobacterium tuberculosis resistant to _1 first-line antituberculosis drugs. The overall

prevalence of MDR-TB was 28.1% (10.5% of newly diagnosed patients and 53.1% of retreatment

cases). In multivariate analysis, risk factors for MDR-TB included: being a retreatment case

(prevalence ratio (PR) = 5.28, 95% CI 3.95— 7.07), history of injection drug use (PR = 1.59, 95%

CI 1.21—2.09), and female gender (PR = 1.36, 95% CI 1.12—1.65).

Barsegian et al., (2008) investigate the prevalence of latent tuberculosis in this cohort using a

tuberculosis specific ELISpot (T-SPOT_.TB) test and to compare the performance of this test to

that of the TST. There have been few attempts to quantify the prevalence of latent tuberculosis

infection amongst German healthcare workers, due to inadequacy of the current tuberculin skin

test Ninety-five healthy participants working in departments of radiology were examined by

ELISpot, lymphocyte transformation test and TST. For cellular in-vitro tests, tuberculosis-specific

peptides and purified protein derivate (PPD) were used as antigens. These tests were combined

with a questionnaire on prior tuberculosis exposure. Out of 95 healthcare workers, only one

(1%) was defined as positive by T-SPOT.TB, 92 (97%) by PPDeELISpot, 78 (82%) by

PPDelymphocyte transformation test and 32 (34%) by TST. Multivariate analysis showed that the

TST was significantly affected (P < 0.0001 and P ¼ 0.001, respectively) by foreign birth and prior

skin testing. The T-SPOT.TB test results were independent of foreign birth, prior skin testing and

prior vaccination against tuberculosis. In contrast to the TST, T-SPOT.TB appears to be an

accurate and useful tool to track tuberculosis infection in this at-risk group. With only one of 95

participants having acquired latent tuberculosis, these preliminary results argue for a low

incidence of latent tuberculosis in German radiologists.

Shanaube et al., (2009) determined risk factors associated with positive QuantiFERON-TB Gold

In-Tube (QFT-GIT) and tuberculin skin test (TST) results and the level of agreement between the

tests; to explore the hypotheses that positivity in QFT-GIT is more related to recent infection

and less affected by HIV than the TST. A total of 2,220 contacts were seen. 1,803 individuals had

interpretable results for both tests, 1,147 (63.6%) were QFT-GIT positive while 725 (40.2%) were

TST positive. Agreement between the tests was low (kappa = 0.24). QFT-GIT and TST results

were associated with increasing age (adjusted OR [aOR] for each 10 year increase for QFT-GIT

1.15; 95% CI: 1.06–1.25, and for TST aOR: 1.10; 95% CI 1.01–1.20). HIV positivity was less

common among those with positive results on QFT-GIT (aOR: 0.51; 95% CI: 0.39–0.67) and TST

(aOR: 0.61; 95% CI: 0.46–0.82). Smear positivity of the index case was associated with QFT-GIT

(aOR: 1.25; 95% CI: 0.90–1.74) and TST (aOR: 1.39; 95% CI: 0.98–1.98) results. We found little

evidence in our data to support our hypotheses.

Atiq-ur-Rehman et al., (2009) compared the diagnostic yield of AFB positivity with sputum

induction to spontaneous sputum examination in suspected cases of pulmonary tuberculosis.

Among 164 patients, 32 patients (19.5%) were not expectorating spontaneously. Sputum

induction was successful in 22 (68.75%) cases and AFB smear was positive in 03 (9.37%) and AFB

culture was positive in 7 (21.8%) of these cases. One hundred and thirty two (80.5%) patients

were already expectorating and both Day-1 (spontaneous) and Day-2 (induced) sputum samples

were available. Day-1 (spontaneous) sputum specimens revealed AFB smear positive results in

20 (15.15%) patients, and AFB culture positive results in 24 (18.18%) patients. Smear positivity

on Day-2 (induced) sputum samples was 21.21% (28) with 27.27% (36) culture positivity.

Hatherill et al., (2010) measured the agreement between nine structured approaches for

diagnosing childhood tuberculosis; to quantify differences in the number of tuberculosis cases

diagnosed with the different approaches, and to determine the distribution of cases in different

categories of diagnostic certainty. Tuberculosis case frequency ranged from 6.9% to 89.2%

(median: 41.7). Significant differences in case frequency (P < 0.05) occurred in 34 of the 36 pair-

wise comparisons between structured diagnostic approaches (range of absolute differences:

1.5-82.3%). Kappa ranged from 0.02 to 0.71 (median: 0.18). The two systems that yielded the

highest case frequencies (89.2% and 70.0%) showed fair agreement (K : 0.33); the two that

yielded the lowest case frequencies (6.9% and 10.0%) showed slight agreement (K : 0.18).

Wilmer et al., (2011) investigated that two negative acid-fast bacillus (AFB) smears may be as

effective as three when screening patients with suspected Mycobacterium tuberculosis for

respiratory isolation purposes. However, current recommendations in Canada, the United States

and Europe still support a three-smear approach. There were 8347 respiratory specimens from

5168 patients in the five-year period. Of these patients, 2.2% (116 of 5168) were AFB smear

positive, of whom 55.2% (64 of 116) were culture positive for Mycobacterium tuberculosis.

Overall 89% (57 of 64) of patients were identified as being AFB smear positive by the first smear,

7.8% (five of 64) were identified by the second smear and 3.2% (two of 64) were identified by

further smears.

Chung et al., (2011) studied to evaluate the usefulness of the QuantiFERON-TB Gold In-Tube

assay (QFT-IT) and compare this assay with the tuberculin skin test (TST) for diagnosing TPE in

settings where tuberculosis is endemic and bacillus Calmette–Guérin vaccination is mandatory.

The TST and QFT-IT test were conducted prospectively with 101 patients presenting with

clinically suspected TPE. Of the 97 evaluable subjects, 54 had TPE. The sensitivity, specificity,

positive predictive value, and negative predictive value were, respectively, 76.9%, 61.1%, 74.1%,

and 64.7% for QFT IT; 72.5%, 71.7%, 77.1%, and 66.7% for TST; and 83.7%, 45.7%, 68.3%, and

66.7% for QFT-IT plus TST. Thus, the QFT-IT test may be more useful than the TST for diagnosing

TPE.

Trauer et al., (2011) reviewed the tuberculin skin test (TST) for the diagnosis of latent

tuberculosis infection (LTBI), interferon-gamma release assays (IGRAs) are more specific for this

diagnosis. The characteristics of one such IGRA, the QuantiFERON-TB Gold Whole Blood In-Tube,

make it feasible for use in a remote setting. This study performed 62 IGRAs with this test on

individuals testing positive by TST, in a clinical setting over 3,000 km from the testing laboratory.

Of these, 42 patients (68%) recorded negative results, 19 (31%) were positive, with only 1 result

(2%) indeterminate. Negative, and therefore discordant in this study, test results were more

common in those known to have been previously vaccinated with bacille Calmette-Guérin.

Taurer et al., (2011) described emergency department (ED) presentations of children with

tuberculosis (TB) disease and assess the utility in children of TB screening tools developed for

adults. Sixty children (29 with confirmed TB and 31 with probable TB) were identified after

presentation to the ED, representing 35% of all children diagnosed with TB at the two hospitals

during this interval. Eighty-eight percent were previously healthy. Fifty-five percent were

Hispanic, 30% were black or African American, 12% were Asian, and 3% were white. Forty-four

(73%) had intrathoracic disease (37 pulmonary parenchymal or pleural disease, four miliary

disease, two endobronchial, one pericarditis). Sixteen (27%) had extrathoracic disease (eight

meningitis, five cervical lymphadenopathy, two gastrointestinal, one interstitial keratitis), 11 of

whom also had abnormal chest radiographs, including all eight children with TB meningitis. Most

(76.7%) were diagnosed at the time of their first ED visit or during their first hospital admission,

12% after their second ED visit, 10% after their third ED visit, and one patient after six ED visits

to various facilities. In 33 case (55%), the diagnosis was suspected in the ED because of

epidemiologic risk factors (15), radiographic evaluation (11), or symptoms (7). Hemoptysis (12%)

and night sweats (10%) were uncommon. Neither cavitary lesions (seen in two children) nor

apical lesions (seen in 42%) predominated. The five screening tools validated for adults with

pulmonary disease were 77% to 98% sensitive in identifying children with intrathoracic TB and

50% to 100% sensitive for extrathoracic TB.

Rosilawati et al., (2011) develop an assay system of a radioisotope (32P)-based PCR dot-

blot hybridization technique and evaluation of the assay directly for TB sputum samples

to detect mutation at codon 306 of embB gene of Mycobacterium tuberculosis related

with ethambutol (EMB) resistance. One hundred and sixteen of sputum samples were

used in this study. Bacterial genome in sputum samples was extracted and tested for

mutation at codon 306 of embB gene by the developed PCR dot blot assay using a

radioisotope (32P)-labeled oligonucleotide. The positive results were confirmed by DNA

sequencing. All 116 sputum samples were PCR positive for M. tuberculosis.

Daniel et al., (2011) determined the prevalence and risk factors associated with drug

resistant tuberculosis (TB) in South West Nigeria. Among the 88 patients who had drug-

susceptibility test result, there were 50 males and 38 females. Of the 88 patients, 55 (62.5%)

had strains resistant to at least one or more anti-drugs. The proportion of TB cases with resistance

to a single drug was 12.7%. The multi-drug resistant TB (MDR-TB) rate was 76.4%. The

only significant factor for the development of drug resistance and MDR was the history of

previous anti TB treatment (P<0.01). Other factors such as age [OR 0.86 (0.35-2.13); P=0.72]

and gender [OR 1.24 (0.49-3.14); P=0.62] were not significantly associated with drug

resistance TB.

Hu et al., (2012) studied the prevalence of latent tuberculosis infection (LTBI) and the

risk factors among contacts of pulmonary TB, in Shanghai, China. A total of 45

diagnosed TB patients from each of 7 Shanghai districts were chosen and approximately

3 contacts per case were randomly selected. A structured questionnaire was used to

acquire socio-demographic information and to assess the degree of exposure to index

cases. LTBI screening was performed by T-SPOT.TB assay. Of 969 enrolled contacts,

39% were men, average age was 45 ± 19.1 years, and 76.3% were household contacts.

LTBI was identified in 29.6% of subjects. Those contacting smear-positive TB patients

were 2.24 times (95%CI, 1.586–3.162) more likely to develop LTBI than those

otherwise; household contact significantly increased the likelihood of LTBI by 1.52 times

(95%CI, 1.061–2.180).

Abdallah et al., (2012) investigated the epidemiological factors of tuberculosis (TB) in

eastern Sudan. The socio-demographic and clinical data was retrieved from the database

at Kassala hospital during the year of 2011. A total of 670 patients were registered at

Kassala hospital with clinical, laboratory and radiological evidence proven TB.

Pulmonary TB accounted for 73.4% while extra-pulmonary TB was reported in 26.6% of

all TB patients. The mean age (SD) was not significantly different between the cases and

controls (670 in each arm).

Mahomed et al., (2013) studied to determine the prevalence of active TB and performance of

specific screening tests for TB in adolescents in a high burden setting. Adolescents aged 12-18

years were recruited from high schools in a rural town in South Africa. Participants were

screened for active TB using symptoms, household TB contact, positive interferon gamma

release assay (IGRA) and positive tuberculin skin test (TST). Of 6363 adolescents recruited, 21

were newly diagnosed with TB of whom 19 were culture positive. After exclusions, the derived

prevalence of smear positive TB was 16/5682 ¼ 3/1000 (95% confidence interval (CI) 1e4/1000).

The sensitivity of TST and IGRA for active TB were 85% (95% CI 62e100%) and 94% (95% CI

79e100%) respectively.

Gran et al., (2013) studied there is no diagnostic gold standard for latent TB infection (LTBI), but

both blood based interferon-gamma release assays (IGRA) and the tuberculin skin test (TST) are

used. A total of 387 HCW working in clinical and laboratory departments in three major

hospitals in the Western region of Norway with possible exposure to TB were included in a

cross-sectional study. A total of 13 (3.4%) demonstrated a persistent positive QFT, whereas 214

(55.3%) had a positive TST (>= 6 mm) and 53 (13.7%) a TST >= 15 mm. Only ten (4.7%) of the

HCW with a positive TST were QFT positive. Origin from a TB-endemic country was the only risk

factor associated with a positive QFT (OR 14.13, 95% CI 1.37 - 145.38, p = 0.026), whereas there

was no significant association between risk factors for TB and TST >= 15 mm. The five HCW with

an initial positive QFT that retested negative all had low interferon-gamma (IFN-gamma)

responses below 0.70 IU/ml when first tested.

Montes et al., (2013) studied The resistance of 139 Mycobacterium tuberculosis (MTB)

isolates from the city of Monterrey, Northeast Mexico, to first and second-line anti-TB

drugs was analysed. A total of 73 isolates were susceptible and 66 were resistant to anti-

TB drugs. Monoresistance to streptomycin, isoniazid (INH) and ethambutol was observed

in 29 cases. Resistance to INH was found in 52 cases and in 29 cases INH resistance was

combined with resistance to two or three drugs. A total of 24 isolates were multidrug-

resistant (MDR) resistant to at least INH and rifampicin and 11 MDR cases were resistant

to five drugs. The proportion of MDR-TB among new TB cases in our target population

was 0.72% (1/139 cases). The proportion of MDR-TB among previously treated cases

was 25.18% (35/139 cases).

Hwang et al., (2013) studied the hemoptysis due to pulmonary tuberculosis (TB)

frequently develops in Korea where the prevalence of TB is intermediate. This study is

designed to identify the risk factors contributing to rebleeding after bronchial artery

embolization (BAE) in patients with TB. They retrospectively evaluated risk factors and

the time for rebleeding after BAE in 72 patients presenting with hemoptysis. The overall

immediate success rate of BAE was 93.1% (67 of 72 patients). Of the 29 patients (40.3%)

who showed rebleeding after BAE, 13 patients experienced rebleeding within 1 month,

and 14 patients between 1 month to 1 year. The existence of a shunt in angiographic

finding, aspergilloma, and diabetes mellitus were risk factors of rebleeding after BAE in

multivariate analysis.

Akhavan et al., (2013) studied to evaluate the frequency of positive results for Mycobacterium

tuberculosis in samples referred to an academic hospital in an 8 year period. A total 26817

samples were analyzed and the results showed that the frequency of Mycobacterium positive

samples in hospitalized patient’s samples was 2412 (9%) with microscopy and 1573 (6%) with

culture method. In the out patients, it was 897 (10.2%) and 417 (4.7%) with microscopy and

culture methods, respectively. Form 75 samples from the prison, 9 (12%) were positive with

microscopy method. Culture method yielded only one (1.3%) positive result in these samples.

Rehman et al., (2013) studied the efficacy and diagnostic yield of third sputum smear among

pulmonary TB patients. A total of 7785 TB suspects submitted three sputum samples making a

total of 23,355 slides for checking acid-fast bacilli using smear microcopy examinations. The

smear positivity rate was 11.8%. About 12% suspects fulfilled the case definition of having one

positive smear confirmed by a second smear, while, only 2.5% suspects fulfilled the case

definition based on third smear in combination with first or second. A total 1164(15%) suspects

had at least one positive smear; of these 896(77%) were positive in first smear, 190(16%) were

negative in first smear but positive in second and 78(6.7%) were positive in third smear after

two negative smears.

Study Area

The study was conducted from January 2013 to August 2013 at TB clinic of Bahawalpur which

is situated inside Multani Gate of Bahawalpur City. The Bahawalpur city is situated at 112m

above the sea level with N=29.400 E=71.700 latitude and longitude respectively. It is situated

90 km from Multan, 420 km from Lahore, 270 km from Faisalabad and about 700 km from the

national capital, Islamabad. Since the city is located in a desert environment there is little

rainfall. Weather conditions reach extremes in both summer and winter. The average temperature

in summer is 33 °C (91 °F) June is hottest month when average temp 41°C on rare occasion

shoots to 51°C and 18 °C (64 °F) in winter. January is the coldest month when temperature falls

below freezing point. Wind and sand dunes are frequent during summer. The average rainfall is

20 to 25 cm annually.

Material and methods.

Material Required

Carbol Fuchsine stain

Acid alcohol 3% v/v or Sulfuric acid 25%

Methyline blue

Slides

Siprit lamp

Microscope

METHDOLOGY

Study is conducted in TB Clinic, where patients have to visit for diagnosing their TB. Individuals

identified as suspected TB cases are investigated for acid-fast bacilli (AFB) in their sputum. A

TB suspect defined as any person who presented with symptoms or signs suggestive of TB, in

particular cough of long duration (more than 2 weeks).

All TB suspects two sputum specimens are collected as;

1) On the spot specimen and

2)A early morning specimen on the next day.

All sputum specimens were examined for AFB using the Ziehl-Neelsen stain (Shah et al., 2003

and Nyirenda 2006). Individuals with at least 2 positive smear results were diagnosed as sputum

smear-positive active pulmonary TB cases, and were registered for the DOTS programmed. The

samples were read and classified according to WHO guidelines ( WHO 1997).

Diagnostic criteria for sputum smear negative pulmonary TB cases were: at least 3 sputum

specimens negative for AFB, no response to a course of broad-spectrum antibiotics and a

decision by a clinician to treat with a full course of anti-TB chemotherapy. The patients who

came were asked to fill the questionnaires which have Information about gender, age, close

contact with family, previous TB history, present address and associated medical data such as

tuberculin skin test and chest radiography finding. Data was analyzed by simple statistical tests

including------------ to find out the prevalence, dispersion, gender and age class ratios in the

human population of Bahawalpur City during January 2013 to July, 2013.