1 INTRODUCTION

Tuberculosis (TB) is an endemic disease in Pakistan and is caused by the bacteria Mycobacterium tuberculosis.¹ TB is spread through air droplets and most usually affects the lungs, although it can also harm the kidneys, spine, and brain.² The people infected with tuberculosis(5-10%) go on to develop symptoms and the disease.³ TB manifests in two states: latent tuberculosis infection (LTBI) and active tuberculosis disease.⁴

Tuberculosis affects all regions of the planet. Tuberculosis kills over 2 million people each year, and the rise of drug-resistant Mycobacterium tuberculosis has exacerbated the problem.⁵ In 2022, the WHO's South-East Asian Region reported the most new tuberculosis cases (46%), followed by the African Region (23%), and the Western Pacific (18%). Approximately 87% of new TB cases occurred in the 30 countries with the highest TB burden, with Pakistan, Bangladesh, China, Democratic Republic of the Congo, India, Indonesia, Nigeria, and the Philippines making up more than two-thirds of the global total.³ Despite TB being a preventable and treatable infection, it continues to claim millions of lives. with the latest World Health Organization (WHO) estimate of 510,000 new TB cases in Pakistan each year.¹ Pakistan is ranked fifth among high-burden TB countries in the world and prevalence, incidence, and deaths stand at 348,276 and 34 per 100,000 people per year, respectively, making it critical to raise awareness and educate the public about the disease to protect the larger community.⁶

Several studies suggest that younger people⁷ aged 10–25 are at a higher risk of developing TB as a result of reduced immunity levels and lack of essential nutrients.⁸ Although no direct link has been established, studies have highlighted the potential impacts of climate change impacting and exacerbating TB risk factors. These include malnutrition, HIV/AIDS, poverty, overcrowding, and diabetes.⁹ Furthermore, The lack of an integrated system to control the spread of TB has led to a rise in multidrug-resistant strains of TB (MDR-TB) which are resistant to isoniazid and rifampicin, the two essential first-line drugs used for the treatment of TB.⁷ According to one study, prior TB infection is one of the leading causes of MDR-TB infection.¹⁰ Delayed diagnosis, incorrect or inappropriate antibiotic use, person-to-person transmission, limited follow-up care, and the absence of a social support system are key variables leading to drug resistance.⁸ Despite recent preventive and control measures, TB remains a major public health concern. Accordingly, this article aims to examine the causes, implications, and potential solutions for the rise of TB in Pakistan.

2 FACTORS CONTRIBUTING TO INCREASED TB PREVALENCE IN PAKISTAN

The increasing tide of TB cases can be attributed to various factors. Firstly, socioeconomic factors play a significant role shown by the large population and overcrowding in urban areas, which have led to inadequate living conditions, crowded living spaces, and poor ventilation. These conditions create an environment that facilitates the transmission of TB.¹¹ Moreover, poverty and limited access to healthcare services contribute to malnutrition and weakened immune systems among this population, increasing their susceptibility to TB.¹²

Lack of awareness and its associated aspects are other significant factors contributing to the spread of the disease in Pakistan. Misconceptions and stigmatization surrounding TB, discourage individuals from seeking medical assistance, resulting in delayed diagnosis and treatment, increasing the potential for further disease spread.¹³ Additionally, sociocultural factors, including traditional healing practices and gender-related barriers, hinder the effectiveness of TB control efforts.¹⁴

Inadequate healthcare infrastructure further contributes to the rise in TB cases. Pakistan's healthcare system faces significant challenges in terms of accessibility, quality, and availability of TB diagnostic and treatment services, particularly in rural areas. Shortages of skilled healthcare providers, testing facilities, and proper management of the drug supply chain resulted in delayed diagnosis and inadequate treatment. Insufficient financial resources allocated to healthcare, including TB control programs, hinder the capacity to effectively address the growing burden of TB.¹⁵ Moreover, the fragmentation of the healthcare system between the public and private sectors presents challenges in coordinating a comprehensive and effective response to TB.¹⁶

Lastly, the rise of MDR-TB poses a significant concern. Pakistan carries a substantial burden of drug-resistant TB, including MDR-TB and extensively drug-resistant TB (XDR-TB). Treating MDR-TB and XDR-TB is more challenging and costly, requiring specialized drugs and longer treatment durations.⁷

3 IMPLICATIONS OF THE RISING TIDE OF TUBERCULOSIS

TB has been shown to interfere with the health-related quality of life (HRQOL), including individuals’ physical, social, mental, emotional, and financial domains.¹⁷ The two main mental health issues linked to TB are anxiety and depression. Both are attributed to poor treatment adherence, resulting in erratic therapy and decreased treatment success rates.¹⁸ According to a Pakistani study, the prevalence of sadness and anxiety among TB patients was 43 and 47 percent, respectively.¹⁹ Lack of protocol adherence leads to treatment failures at teaching hospitals, as shown by a cohort from Peshawar in 2012–2013, tertiary care settings in Pakistan had a treatment success rate of only 78.7% raising concerns regarding these facilities ²⁰ According to Dr. Sharaf Ali Shah, Vice Chair of Stop TB Pakistan, the country has documented 611,000 cases of TB in the last two years, with 48,000 HIV-negative and 2100 HIV-positive individuals falling victim to the disease. However, just slightly more than half of TB cases were documented.²¹

Depression on the other hand is a common mental disorder that leads to low mood, loss of self-interest, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration.²² WHO estimates that around 300 million individuals are currently living with depression, and without a doubt, the majority of those in this category are those suffering from TB or some other chronic condition.²³ This can result in employment loss and, in some cases, feeling excluded from family and community. As a result, it is not surprising that individuals with TB frequently battle psychological comorbidities.²⁴ TB spread within communities can have serious consequences for both individuals and public health. The lack of an integrated system to combat TB has increased MDR-TB, which is resistant to first-line TB medication. Delays in diagnosis, insufficient treatment regimens, poor follow-up, and a lack of a social support program all play a pivotal role in the emergence of drug resistance. TB treatment is difficult to administer globally for various reasons, including a lack of resources. It is especially difficult for healthcare workers in developing countries with limited resources.

4 EFFORTS AND RECOMMENDATIONS

Pakistan has come a long way in managing TB and is still making several efforts through unique sets of measures to eradicate TB from the country. The National Tuberculosis Control Program (NTP) was established in 1995 and is the main government agency to maneuver TB control in the country.²⁵ The NTP aims to eradicate TB by 2035 through several strategic measures, such as targeting high-risk communities, running awareness campaigns, improving access to health services, launching screening programs, and creating contact tracing networks.²⁶ The Public-Private Mix (PPM) strategy involves healthcare professionals providing TB care to individuals who have the disease or are suspected of having it. In 2014, NTP initiated a national implementation trial of the PPM strategy, using commercial providers in the search for missing tuberculosis cases.16 WHO also adopted a TBIC (TB infection control) strategy in 2009 to limit the risk of TB transmission in healthcare settings. TBIC standards incorporate these measures, and the usage of TBIC approaches in facilities treating MDR-TB patients has increased as the programmatic management of drug-resistant tuberculosis (PMDT) has expanded.²⁷

Furthermore, Pakistan has adopted the WHO-suggested DOT (Direct Observed Therapy) strategy for treatment of TB patients under supervision, hence improving the adherence of treatment and minimizing the risk of drug resistance. Public awareness campaigns are conducted and led by the government and NGOs to enlighten the community about TB symptoms, transmission, and preventive measures. These programs aim at the advancement of awareness about TB and eliminating the stigma surrounding the condition. Additionally, these campaigns strive for early detection as well as seeking treatment for TB.²⁸ The government of Pakistan partners with international institutions, such as the WHO, the Global Fund, and the United States Agency for International Development USAID, to qualify for financial resources, and technical assistance as well as expertise for the TB control programs. TB control measures by the government involve setting up TB centers throughout the country and ensuring that all TB patients, both in rural and urban areas, have access to healthcare facilities.²⁹

However, despite implementing TB control strategies across the country, the issue remains unresolved, demanding a multi-faceted approach. Since there is a shortage of medical supplies, especially in rural areas, targeted TB intervention programs for rural populations should be initiated and implemented by engaging community healthcare workers in those areas.³⁰ Besides, creating awareness regarding environmental management, such as ventilation, natural light, and adequate cleanliness, can help lower the occurrence of TB infection. Protective masks, ventilation systems, and regular screening of healthcare professionals can also help reduce the spread of TB.^{31, 32} Moreover, the administrative efforts needed to control the spread of TB infection in healthcare settings should be employed, which include managing the infection, conducting risk assessments, developing a plan, and ensuring laboratory processing. The most crucial thing that the public and private healthcare sectors need to address is stopping the spread of MDR-TB.³³ Healthcare providers should raise sickness awareness, implement DOTS for low-income patients to prevent the emergence of MDR-TB, and employ active cough surveillance, molecular sputum testing, and safe separation. The use of masks and the early detection of close relationships are also critical.^{34, 35} Moreover, the Sustainable Development Goals (SDGs) need to be reviewed to get rid of TB as a goal in Pakistan. One of the health goals of the United Nations SDGs up till 2030 is the eradication of TB. Since TB is more prevalent in low-income settings due to subpar living conditions, SDGs 1 (no poverty), 3 (good health and wellbeing), 6 (clean water and sanitation), and 8 (economic growth) can be applied to the social and economic improvement in the country; hence TB can effectively be eliminated. Nevertheless, it is important to conduct regular appraisals regarding the impact of special SDGs on the elimination of TB in Pakistan.^{36, 37}

In addition, the control of LTBI in Pakistan is also crucial to controlling active TB infection. Pakistan should formulate a separate plan for the control of LTBI, like detecting high-end cases and implementing screening and testing programs among high-risk populations such as household TB contacts, healthcare providers, and people living with HIV. Additionally raising awareness and collaborating with international organizations to construct low healthcare costs and ensure adequate healthcare provisions are all necessary to control latent TB.³⁸ Apart from that, a strategy aiming at stigma reduction related to TB patients is also vital since this is a key to successful TB control measures. Targeted awareness campaigns, storytelling, community engagement, education, healthcare worker training, and interactive workshops are the techniques that can be used to eliminate discrimination, increase early detection, and better manage TB.³⁹

5 CONCLUSION

In conclusion, it is imperative to make efforts to eradicate TB in Pakistan due to the rising cases. Several factors including poverty, treatment barriers, noncompliance with therapy, and societal stigma contribute to the rapid spread of TB in this country. Despite TB being common, the reporting rate is shockingly low. Pakistan faces additional challenges due to inadequate funding and system impediments such as a lack of medical supplies. Communities continue to suffer because of limited access to diagnosis and treatment facilities; as a result, to improve outcomes, the Pakistani government must allocate more budget, prioritize, and provide strategies and resources to address the root causes of TB. TB eradication begins with destigmatization, education, prevention, early detection, and effective treatment. Furthermore, there is an urgent need for ongoing research, advocacy, and collaboration among stakeholders.

AUTHOR CONTRIBUTIONS

Hamid Ullah: Writing—review and editing. Hafsa Ahmed: Conceptualization; Writing—original draft. Ariba Salman: Supervision; Writing—original draft. Rabia Iqbal: Writing—original draft. Sayed Jawad Hussaini: Resources; Writing—original draft. Abdullah Malikzai: Writing—review and editing.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

TRANSPARENCY STATEMENT

The lead author Abdullah Malikzai affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.