PREVELANCE OF PULMONARY TUBERCULOSIS (TB) AMONG

THE POPULATION OF PARACHINAR DISTRICT KURRAM,

KHYBER PAKHTUNKHWA

SUBMITTED BY:
JASMIN
ENROLLMENT NO: ZOL-20PCR/2019

Supervisor
Ma’am Sakina Bibi

DEPARTMENT OF ZOOLOGY
GOVERNMENT GIRLS DEGREE COLLEGE NO:1 PARACHINAR

(Affiliated with)
SHAHEED BENAZIR BHUTTO WOMEN UNIVERSITY PESHAWAR
Session 2019-2023
 ABSTRACT

Background: Tuberculosis (TB) is a global health problem. In 2014, an estimated 9.6 million
people developed TB and 1.5 million died from the disease. Currently, 22 high burden countries
account for over 80% of world’s TB cases. Prevalence estimates presented by the World Health
Organization (WHO) for Pakistan were based on indirect estimation from notification data,
assumptions about duration of TB disease, and expert opinion, because there was no recent
nationally representative TB prevalence estimate available.

Materials and Method: The study of Prevalence of Pulmonary Tuberculosis will be conducted
in Parachinar, District Kurram Khyber Pakhtunkhwa. The study design is cross-sectional. About
300 patients attended TB center for treatment and diagnosing were recruited for the study. Their
age ranges from 9 months to 80 years.

Result: There were 59.33% male and 40.66% female. The highest prevalence of pulmonary
tuberculosis (TB) was found in the adults of age 41 years to 60 years and the least was found in
the age of 1 year to 20 years. Among them there were 92.66% pulmonary tuberculosis and 7.3%
was extra-Pulmonary Tuberculosis. There were 80.66% participants that were not addictive to
smoking before TB and 8.33% were found who had a history of smoking before TB. 68.6%
participants were using pulmonary medicine while 31.33% participants did not know about use
of pulmonary medicine.

Conclusion: Concluded that the prevalence of pulmonary tuberculosis (TB) is higher in male,
accounts 59.33%. Furthermore, 48.66% prevalence was found in the age group 41 years to 60
years. 31.33% participants were not aware using the pulmonary medicine and 39.33 were living
or working in air polluted areas.
 CHAPTER # 01
INTRODUCTION

We give a brief summary of the proposed research project in this chapter. The chapter
describes a detail overview of Tuberculosis (TB), Primary tuberculosis, Reactivation
tubercolusis, Epidemiology of tuberculosis. The chapter also covers risk factors of TB and
Clinical presentation of TB.

1.1 OVERVIEW
Mycobacterium tuberculosis, also known as is the causative agent of tuberculosis (TB), an
infectious airborne bacterial illness. TB is a major worldwide health issue affecting people.
Ninety-five percent of tuberculosis deaths occur in developing nations, and the disease mostly
affects young age groups during the reproductive era. After HIV, tuberculosis is the second most
common infectious illness globally in terms of mortality. Millions of people have tuberculosis
infections every year. (Ahmad et al., 2015)

38% of all instances have been attributed to China and India (26% and 12%, respectively).
The most alarming rates of tuberculosis were seen in South Africa, wise, and Swaziland, where
the prevalence is one new case for per 100 persons annually. In 2010, 59% of TB cases were
recorded in Asia, compared to 26% in Africa, 7% in the Eastern Mediterranean, 5% in Europe,
and 3% in the Americas. Asia accounted for 58% of recorded TB cases in 2012, followed by the
African Region (27%), Eastern Mediterranean (8%), Europe (4%), and the Americas 3%(Ahmad
et al., 2015).

TB is a disease affecting people from all over the world. An estimated 9.6 million persons
contracted tuberculosis in 2014, and 1.5 million of those cases resulted in death. Currently,
almost 80% of TB cases worldwide are concentrated in 22 high-burden nations. Because of
insufficient coverage and inadequate monitoring methods, notification numbers in these nations
frequently do not accurately represent the total number of cases in the nation. Therefore, it is still
essential to evaluate the disease burden directly using TB prevalence surveys in order to
comprehend the scope and spread of the illness and to help establish effective control strategies
in these environments. Out of 22 high burden countries, Pakistan was in fifth place in 2011 in
terms of the total number of TB cases. All types of tuberculosis (TB) were estimated to have an
incidence and prevalence rate of 231 (95% confidence interval (CI), 189 277) and 364 (95% CI,
154–611) per 100,000 people, respectively.(Qadeer et al., 2016).

Since a current nationally representative TB prevalence estimate was not available, the
World Health Organization (WHO)'s prevalence estimates for Pakistan were based on expert
opinion, assumptions about the duration of the disease, and indirect extrapolation from
notification data.(Qadeer et al., 2016).

One of the top five heavy burden nations (HBC) is Pakistan. Effective in 2001, the DOTS
strategy for tuberculosis was put into effect and in only five years, it had spread to encompass the
majority of the public health sector. The extension of DOTs coverage in the private health sector,
children TB, and programmatic management of drug-resistant TB were the subsequent focal
points of the National TB Control Programmed (NTP).(Tahseen et al., 2020).

Planning TB control plans, analyzing their impact on population health, as well as

assessing whether around the world the goals for disease burden reductions are met all depend on
quantifying the burden of tuberculosis (TB) and monitoring patterns over time. The current
worldwide objectives for 2015 are as follows: the MDGs aim for TB incidence to decline by that
year, and the Prevention of TB Partnership targets, which are also part of the MDGs, call for a
halving of TB prevalence and mortality rates by that year as compared (Onozaki et al., 2015).

1.1.1 Primary Tuberculosis

Primary TB can cause parenchyma involvement in any part of the lung, unlike
reactivation tuberculosis, which typically affects the superior and dorsal segments. There is just a
modest preference for the higher lobes in the first infection; both the anterior and posterior
segments may be affected. Except in individuals who are underweight or have other immune
system deficiencies, cavitation is uncommon and the consolidation of air space appears as a
uniform density with ill-defined edges. Less than 3% of instances had mild involvement at the
beginning, which is most frequently observed in toddlers under the age of two to three; however
it can also occur in adults. A characteristic of primary TB is swelling of the hilar or paratracheal
lymph nodes. Bilateral hilar adenopathy may be present in 15% of the patients. Unilateral
adenopathy is more prevalent. Equally prevalent are unilateral hilar adenopathy and unilateral
hilar and paratracheal adenopathy. Severe hilar adenopathy might indicate a challenging course.
(Lyon & Rossman, 2017).

1.1.2 Reactivation Tuberculosis

While any lung segment may be affected by reactivation TB, the illness is often
suggested by its specific distribution. Lesions are seen in the superior segment of the lower lobes
or the apical or posterior segment of the upper lobes in 95% of instances of localized pulmonary
TB. (Lyon & Rossman, 2017). Almost infrequently is the anterior section of the upper lobe the
only place that is clearly involved. It is advisable to leave the documenting of lesion activity to
bacteriological and clinical examination, despite the fact that some radiologists try to describe a
lesion's activity based only on its radiographic appearance. All too frequently, a lesion that
radiography reports as stable or inactive develops into symptomatic TB.(Burman et al., 2006).

1.1.3 Epidemiology
According to the WHO (J. Khan et al., 2015), An estimated 1.7 billion people (23% of
the world's population) have latent tuberculosis (TB) and are at risk of acquiring active illness at
some point in their lives, according to the WHO. An estimated 1.7 billion people (23% of the
world's population) have latent tuberculosis (TB) and are at risk of acquiring active illness at
some point in their lives, according to the WHO (J. Khan et al., 2015). The illness is the primary
cause of death and one of the biggest threats to global human health, especially in less developed
economies (Ahmad et al., 2015; Onozaki et al., 2015). According to J. Khan et al. (2015), TB
killed an estimated 1.3 million people (range: 1.2–1.4 million) globally in 2017 among HIV-
negative people and an additional 0.3 million people (range: 2.66–3.35 million) among HIV-
positive people. 1993 saw the WHO proclaim tuberculosis a worldwide emergency (M. A. Khan,
2020).

Out of 30 nations with a high burden of tuberculosis (TB)(M. A. Khan, 2020; ul Manan,
Naqvi, Mushtaq, & Shafqat, 2018), which accounted for 87% of the TB cases worldwide [8].
Pakistan has a national TB prevalence of 5% Pakistan came in fifth place, accounting for 87% of
tuberculosis cases globally [8]. The countrywide TB prevalence in Pakistan is 5% (Tahseen et
al., 2020). With assistance from the WHO, the Ministry of Inter-Provincial Coordination,
Government of Pakistan, and the National TB reduce Programmed (NTP) have been
collaborating to effectively reduce tuberculosis. Chest radiography, sputum smear microscopy,
and symptom screening are all included in the programmed. By lowering the prevalence of
tuberculosis in the general population by 50% by 2025, NTP hopes to achieve TB-free Pakistan,
which would mean free treatment for the illness in Pakistan(M. A. Khan, 2020).

Tuberculosis is the biggest cause of death globally. The current study aimed to assess the
prevalence of TB in the Buner area. In this study, 3378 patients were examined in the six tehsils
of district Buner: Daggar, Gadezi, Salarzai, Chamla, Gagra, and Chagarzai. Tehsil Daggar 2201
had the highest illness burden (65.15%), followed by Gadezai 347 (10.27%) and Chagarzai 258
(7.63%). The illness load was higher in females (1753, 51.89%) than in males (1625, 48.10).
Cough (58.76%) was the most common symptom in 1985, followed by hemoptysis (43%) and
fever (39%). The majority of patients2703 (80.01%) believed that TB transmitted by touch,
whereas 675 (19.98%) believed it travelled through the air. 2580 patients (76.37%) took their
doses on a regular basis, whereas 798 (23.62%) did so infrequently. The prevalence of TB was
high in the second and fourth quarters of the year (28.59% and 60%, respectively).The frequency
of TB in district Buner was associated with awareness, illiteracy, and smoking.(Akhtar, Saeed,
Khan, & Rafiq, 2015).

1.2 RISK FACTORS OF TB

The following are the most typical TB risk factors:

1.2.1 Diabetes Mellitus

Patients with diabetes mellitus (DM) are more likely to progress from latent to active TB.
A diagnosis of diabetes also raises the likelihood of developing from the initial infection to
active TB. Case-control studies have shown that persons with diabetes had a 2.44 to 8.33 time’s
greater risk of contracting TB than those without. A comprehensive evaluation of 13
observational studies found that diabetes triples the probability of acquiring TB (relative risk =
3.11; 95% CI: 2.27-4.26)..(Silva et al., 2018). Some studies have revealed that individuals with
DM are more likely to acquire multidrug-resistant tuberculosis (MDR-TB), although there is
currently no explanation for that link(Sharif et al., 2016)In fact, several studies have found no
higher incidence of MDR-TB in DM patients..(Dorman et al., 2012; Silva et al., 2018).

1.2.2 Smoking
Cigarette smoke's role in tuberculosis pathogenesis is linked to ciliary dysfunction, a
reduced immune response, and defects in macrophage immune response, with or without a
decrease in CD4 count, which increases susceptibility to Mycobacterium tuberculosis infection.
(Uddin, Khan, Ahmad, Rehman, & Arif, 2018). The alveolar macrophage interacts with the
bacillus via complement receptors 1, 3, and 4. Activated lymphocytes produce cytokines and
attract macrophages, fibroblasts, and other lymphocytes. TNF-α, released by macrophages in
response to exposure to M. tuberculosis antigens, is the primary cytokine responsible for
granuloma formation. TNF-α stimulates both macrophages and dendritic cells. Nicotine, through
the α7 nicotinic receptor, lowers TNF-α production by macrophages, inhibiting its protective
function and favoring TB growth.(Burman et al., 2006; Silva et al., 2018).

1.2.3 Illicit drug use

It is projected that one out of every twenty individuals, or a quarter of a billion persons
aged 15 to 64, ingested at least one illegal substance in 2015. This is equivalent to the total
populations of France, Germany, Italy, and the United Kingdom. Over 29 million persons who
use drugs are thought to have drug use problems; 12 million of them are injectable drug users,
with 14% living with HIV. As a result, drug use's health implications remain catastrophic, with
an estimated 207,400 drug-related fatalities in 2014. Cocaine is the most often used illegal
substance. In 2015, 18.3 million individuals used cocaine (either in powder or as crack cocaine),
accounting for 0.3-0.4% of the world's population. The severity of the harm caused by illegal
drug use is illustrated by the estimated 7.4 million illicit drug users seeking treatment via health
care systems and the 1 million disability-adjusted life years lost in 2014 due to drug-related
premature mortality and disability.(Silva et al., 2018).

1.2.4 Malnutrition
Malnutrition (including micro- and macro-deficiency) has been linked to an increased
risk of tuberculosis due to a weakened immune system. Malnourishment can result from
tuberculosis due to a lack of hunger and metabolic abnormalities. (Narasimhan, Wood,
MacIntyre, & Mathai, 2013).

1.2.5 Pulmonary Medicine

Pulmonary Medicine Veterinary studies showed that those with diabetes infected with M.
tuberculosis had a greater bacterial burden, which accelerated the spread of the disease. Diabetic
patients' decreased production of IFN-and other cytokines, as well as lower T-cell immunity and
chemotaxis in neutrophils, are likely to contribute to an increased risk of acquiring active
tuberculosis(Narasimhan et al., 2013).

1.2.6 Indoor Air Pollution

More than 80% of people in underdeveloped nations cook with solid fuels. Firewood or
biomass smoke has previously been identified as an independent risk factor for tuberculosis in
case control studies undertaken in India and Brazil. There is less data on the mechanism by
which biomass smoke causes chronic lung illnesses; however, animal studies have indicated that
acute wood smoke impairs macrophage phagocytic activity, surface adherence, and bacterial
clearance. Furthermore, biomass burning has been observed to emit big particulate matter (PM),
including as carbon monoxide (CO), nitrogen oxide, formaldehyde, and polyaromatic
hydrocarbons, which can deposit deeply into the alveoli and cause significant(Lienhardt et al.,
2002; Narasimhan et al., 2013).

1.2.7 Environmental and Host related Risk Factors

In humans, TB develops in two stages: first, a vulnerable individual gets infected, and
then, depending on a number of conditions, the illness may develop years or decades later.
Because infection acquisition is frequently separated from disease development and involves
distinct physiologic pathways, risk variables for infection differ significantly from risk factors
for disease development following infection. This has significant implications for TB prevention
and control (Lienhardt et al., 2002).The risk of infection among people exposed to someone with
an infectious tuberculosis case is primarily determined by the combined action of three factors:
1) the infectivity of the source case (which is itself a function of microbial virulence and the
density of bacilli in the sputum), 2) the intensity of the susceptible person's exposure to the case,
and 3) the susceptibility of the exposed person to infection (Lienhardt et al., 2002; Silva et al.,
2018). Factors reported to influence the risk of mycobacterium infection include age, sex,
crowding, socioeconomic conditions, urbanization, racial/ethnic group, and human
immunodeficiency virus infection (Silva et al., 2018). Age, sex, crowding, socioeconomic
situations, urbanization, racial/ethnic group, and human immunodeficiency virus infection have
all been linked to an increased risk of mycobacterium infection (Silva et al. 2018). Silva et al.
(2018). Mycobacterium tuberculosis can cause illness in individuals at any time by reactivation
of a previously acquired (latent) infection or external re-infection (Lienhardt et al., 2002).
1.3 CLINICAL PRESENTATION
1.3.1 Symptoms and Signs
Pulmonary TB usually develops gradually and without a clear beginning date. The illness
manifests in a variety of ways, ranging from skin positive with negative X-rays to severe TB.
Typically, until the illness is moderately or far progressed, as shown by alterations on the
roentgenogram, symptoms are modest and frequently related to other factors, such as heavy
smoking, hard labour, pregnancy, or other disorders (Lyon & Rossman, 2017).

Symptoms might be classified as constitutional or pulmonary. The frequency of these

symptoms varies depending on whether the patient has primary or reactivation TB. Patients with
primary TB are far more likely to be asymptomatic or mildly symptomatic. The most common
constitutional sign is fever, which begins mildly but becomes more severe as the disease
advances. Typically, the fever appears in the late afternoon and may not be accompanied by
obvious symptoms. Sweating occurs during defervescence, most commonly during sleep—the
typical "night sweats.”(Burman et al., 2006; Lyon & Rossman, 2017).
 CHAPTER # 02
REVIEW OF LITERATURE

A retrospective analysis was carried out from January 1, 2013 to December 31, 2013.
Sputum smear microscopy was performed on all suspicious instances. Of the entire 1378
probable cases, 612 (44.41%) tested positive for tuberculosis. Females are more vulnerable to
tuberculosis infection than males (56.21 and 43.79%, respectively). The greatest rate of new
pulmonary tuberculosis cases (23.54%) was reported among those aged 15 to 24, while the
highest rate (47.26%) was recorded in the fourth quarter. Based on our findings, we determined
that tuberculosis has grown greatly in the general population of District Dir (Lower). Proper
management, treatment, diagnosis, and awareness are required to control and eliminate the
condition.(Tauseef et al., 2015).

In 2010-2011, a countrywide cross-sectional survey was performed using multistage

cluster sampling among adults (15 years old) in 95 clusters. All consenting individuals were
tested for cough and had a chest X-ray. Participants with probable tuberculosis provided two
sputum samples for smear microscopy, culture, and molecular testing, if indicated. The TB
prevalence estimates were modified to account for missing data and the cluster design. Of the
131,329 eligible people, 105,913 (81%) took part in the survey, with 10,471 (9.9%) being
qualified for a sputum test. We discovered 341 bacteriologically positive TB patients, of which
233 had sputum smear-positive TB. The adjusted prevalence estimates for smear and
bacteriologically positive TB were 270/100,000 (95% confidence interval (CI) 217-323), and
398/100,000 (95% CI 333-463), respectively. Only 61% of the confirmed TB cases tested
positive for symptoms (cough lasting more than two weeks), whereas the other TB cases were
found based on X-ray abnormalities. The frequency of tuberculosis rose with age and was 1.8
times greater in males than in women. The prevalence-to-notification ratio for smear-positive
tuberculosis was 3.1 (95% CI 2.5-3.7), which was greater in males than in women and increased
with age (Sabira, et al., 2020).

National TB prevalence studies in Asia reveal that significant reductions in TB disease

prevalence may be accomplished within a decade, that males face a greater burden than women,
and that the pandemic is ageing. Comparing nations reveals that some countries can achieve
more in TB control with existing tactics and technologies. However, with many prevalent
patients failing to disclose characteristic TB symptoms, all nations confront the challenge of
developing and implementing techniques that will result in early diagnosis and treatment of
infections. Between 1990 and 2012, 21 surveys were conducted in 12 countries, with published
findings for 18 of them. Except for two polls in Thailand, participation rates were at least 80%, if
not higher. The prevalence of bacteriologically-positive tuberculosis among adults aged ≥15
years varied widely among countries (1.2 per 1000 population in China in 2010 to 15 per 1000
population in Cambodia in 2002). However, age and gender distribution patterns were consistent
with a progressive increase in disease rates by age, with men accounting for 66-75% of prevalent
cases. Except for two polls in Thailand, participation rates were at least 80%, if not higher. The
prevalence of bacteriologically-positive tuberculosis among adults aged ≥15 years varied widely
among countries (1.2 per 1000 population in China in 2010 to 15 per 1000 population in
Cambodia in 2002). However, age and gender distribution patterns were consistent with a
progressive increase in disease rates by age, with men accounting for 66-75% of prevalent
cases..”(Burman et al., 2006; Lyon & Rossman, 2017).

Hospital, Rawalpindi; Fauji Foundation Hospital, Rawalpindi; and Pakistan Institute of

Medical Sciences, Islamabad. The study was done in one year, from January 2017 to January
2018. 55 asymptomatic healthcare the study comprised workers of both genders aged 18-50 with
at least one year of experience in relevant areas. Participants with active TB were excluded.
Subjects' whole blood was drawn, and plasma was tested for interferon gamma levels using the
IGRA (Interferon Gamma Release Assay). In this research of 55 healthcare personnel, there was
a significant frequency of latent TB (22/40.0%). When the LTBI distribution was analyzed by
occupational groups, the most often afflicted were sanitary workers 3 (100.0%), nurses 5
(50.0%), and doctors 6 (43%).(Ejaz, et al., 2016).

It was a cross-sectional study. The samples were collected from pulmonology and
microbiology departments of three hospitals; i) Military Hospital, Rawalpindi, ii) Fauji
Foundation Hospital, Rawalpindi and iii) Pakistan Institute of Medical Sciences, Islamabad. The
study was completed in one year from January2017 to January 2018. Fifty-five asymptomatic
healthcare Workers of both genders between theages of 18-50 years with a working tenure of at
least one year in concerned departments were included and those with active tuberculosis were
excluded from the study. Whole blood from subjects was collected and plasma was checked for
interferon gamma value by IGRA(Interferon gamma release assay). In this study of total 55
healthcare workers a high prevalence 22 (40.0%) of latent tuberculosis was found. When LTBI
distribution was analyzed within occupational categories, the most frequently affected were
sanitary workers 3 (100.0%), nurses 5 (50.0%), doctors 6 (43%) and nursing assistants 2 (40%)
(Muhammad Ashraf et al., 2018).

This study was done at Ayub Teaching Hospital Abbottabad Programmatic Management
of Drug Resistant Tuberculosis (PMDT) location. A total of 635 sputum samples were obtained
from clinically suspected drug-resistant tuberculosis patients and tested using the GeneXpert
MTB/Rif assay. Of the 635 samples collected, 468 individuals with a history of Cat-I were
examined, and 27 (5.76%) were determined to be rifampicin resistant. Similarly, out of 137 Cat-
II samples, 9 (6.56%) were rifampicin resistant. Furthermore, 30 close contacts with MDR-TB
were evaluated using the GeneXpert MTB/Rif assay, and 4 (13.3%) were determined to be
rifampicin resistant.(Muhammad Ashraf et al., 2018).

There is a significant frequency of Pre-XDR TB among patients registered at the PMDT

site at Nishtar Medical Hospital in Multan. Similarly, XDR-TB cases were reported and recorded
throughout this time frame. To avoid drug-resistant tuberculosis, new TB patients must be
continuously monitored and treatment compliance emphasized. There is also a need to prohibit
the over-the-counter selling of antitubercular medications, particularly second-line treatments
(Burman William J et al., 2019).

Retrospective research was conducted to investigate the frequency and seasonality of

PTB among suspected tuberculosis patients identified at Tehsil Head Quarter Hospital Serai
Naurang, District Lakki Marwat, Khyber Pakhtunkhwa, Pakistan, between April 2015 and March
2018. Out of 2467 registered and suspected cases of PTB, 239 (9.69%) tested positive. During
the research period, females had a higher prevalence of the condition (60.67%) than males
(39.33%). The age group 15-30 (years) had the largest proportion of illness (37.24), followed by
the age groups 46-60 (19.67), above 60 (18.41), 31-45 (17.16), and 5-14 (7.11).During the
research period, no patients with PTB under the age of 5 were identified. Overall, 92.47% of
positive cases were beyond the age of 15. The number of suspected patients and PTB-positive
cases fluctuated annually, and they were associated (Naveed et al., 2018).

This cross-sectional study was carried out to investigate the prevalence and associated
risk factors of bovine tuberculosis (bTB) among big ruminants in five districts (Peshawar,
Nowshera, Charsadda, Mardan, and Swabi) in the central zone of Khyber Pakhtunkhwa (KPK),
Pakistan. A convenience sampling strategy was used to collect 2400 big ruminants, which were
then evaluated for Mycobacterium bovis infection using the comparative cervical intradermal
tuberculin test (CCIT). A pre-form questionnaire was used to collect information on
socioeconomic status, risk factors, and farming methods. The results showed that the prevalence
of bovine TB was 5.88 %( Jehangir et al., 2016).
 CHAPTER # 03
MATERIALS AND METHOD
This chapter provides a thorough description about the material and method of our
research that were utilized to access the findings. The subjects addressed include study area,
study design, study duration, data collection, questionnaire survey, statistical analysis, and
hypothesis.

3.1 STUDY AREA

The study of TB has been conducted in Parachinar, District Kurram, and Khyber
Pakhtunkhwa (KPK). Kurram is a district in Kohat Division of KPK province in
Pakistan.The Pashto word Kuramá, which stems from the Sanskrit Krumu, is whence the
name Kurram originates. Geographically, it encompasses Pakistan's Kurram Valley, a
valley in the country's northwest. The capital of Kurram Agency is Parachinar which is
the administrative headquarter of Kurram valley, and the largest city of federally
Administered Tribal location Area of Pakistan where inhabitants are Turi and
Bangashtribes. From the Afghan capital Kabul the distance of Parachinar is 110
kilometer and it ispositioned on the neck of Pakistani territory to the west of Peshawar
and the neighboringprovince of Afghanistan as shown in figure 3.1. The relevant data is
collected from both urban and rural area of Parachinar.
 Figure
3.1: Map of Parachinar, District Kurram, Khyber Pakhtunkhwa

3.2 STUDY DESIGN AND DURATION

The research was aimed to explore the prevalence and risk factors of TB in the
population of District Kurram Tehsil Upper Kurram from March 2023 to August 2023
and used a questionnaire to achieve research objectives and data represented in the form
of tables. The focus of our research is to find the prevalence and associated risk factors
of TB among the people of Parachinar. For this, we have selected the questionnaire
method as the research tool working for the thesis as it helps to collect possible available
information.The most common method of generating primary data is through a
questionnaire. This method gives more information in a limited time to identify risk
factor of TB.

3.3 STUDY CENTER

The data was collected in ZANANA HOSPITAL PARACHINAR.

3.4 DATA COLLECTION

Data and information were collected from a total 300 patients, 150 of these patients were
identified for TB. The questionnaire was filled out from TB positive patients. Their age
ranges from 1 year to 80 year.
3.5 QUESTIONNAIRE SURVEY
A structured questionnaire will be used to determine the prevalence and risk factors that
are responsible for Pulmonary Tuberculosis, which included Demographic Data (Name, Age,
Location, Gender) and modified structured questions which are based on literature about the
prevalence and major risk factors related to Pulmonary TB such as smoking, Diabetes, Illicit
drugs, exposure, contact with TB patients, Malnutrition, Pulmonary Medicine, Working areas.

3.6 STATISTICAL ANALYSIS

The Data from questionnaire will be fed into Microsoft Excel so as to build database. The
database was then imported to STATA (V.13) to carry out further statistical analysis. Treating
negatives as controls, risk factors assessment was carried out using Chi-square test. Person’s chi-
squares (X2) is a statistical test applied to sets of categorical data to evaluate how likely it is that
any observed difference between the sets arose by chance. An association was considered
significant if the P-values as <0.005.

3.7 HYPOTHESIS
The level and burden of Pulmonary Tuberculosis in female as compare to male in Upper Kurram.
 CHAPTER # 04
RESULTS

This chapter contrasts the results with findings from related studies and goes into
considerable depth about some of the methods used to arrive at the conclusions. The
subjects addressed include prevalence of TB among the people of Parachinar, risk
factors of TB. The findings are then fully discussed, and they are shown in the figures
and tables that follow.

4.1 PREVALENCE OF TB IN PARACHINAR

This study's objective was to identify the prevalence and risk factors of Tuberculosis
among the people of Parachinar. This disease is present in people throughout the world
and reported in Parachinar city and surrounding areas. However, people in Parachinar do
not have enough knowledge about this disease. About 300 adults were interviewed
through a questionnaire in hospitals in Parachinar. Among them 150, patients were
identified with Tuberculosis disease as shown in table 4.1.

Table4.1: Distribution of collected data

TB No. of Patients Percentage %
Negative 150 50%
 Positive 150 50%
Total 300 100%

4.2 Risk factors

The following risk factors for Tuberculosis:

4.2.1 GENDER AS A RISK FACTORS FOR TUBERCULOSIS

In this study the most noteworthy level of Tuberculosis is available in male (59.33%) while
around (40.66%) female is impacted by tuberculosis. The outcomes show that male is at more
serious risk for tuberculosis. (Table 4.2.1)

Table 4.2.1 Tuberculosis and gender

Gender Frequency Percentage%

Male 89 59.33%
Female 61 40.66%
Total 150 100%

4.2.2 AGE AS A RISK FACTORS FOR TUBERCULOSIS

Out of 150 participants, 59.33% were male and 40.66% were female. There were 17
participants whose ages from 1 year to 20 years, 49 participants age were from 21to 40 years, 73
participants age from 41 year to 60, and 11 participants were aged from 61 year to 80 year.

TABLE 4.2.2 Age and Tuberculosis

Age Frequency Percentage%

1-20 17 11.33%
21-40 49 32.66%
41-60 73 48.66%
 61-80 11 7.33%
Total 150 100%

4.2.3TYPES OF TB
Out of150 participants, the Pulmonary TB was noted in 92.66% patients whereas Extra
Pulmonary TB was noted only 7.3%.

Table 4.2.3 Pulmonary and Extra pulmonary Tuberculosis

Variables Frequency Percentage%

Pulmonary TB 139 92.66%
Extra pulmonary TB 11 7.3%
Total 150 100%

4.2.4DIAGNOSED OR HAVE PAST MEDICAL HISTORY OF DM

Out of 150 participants, 19.33% were diagnosed with Diabetes Mellitus and 80.66% were
not diagnosed with DM.

Table 4.2.4 Diagnosed with DM

Diagnosed with DM Frequency Percentage%

Yes 29 19.33%
No 121 80.66%
Total 150 100%

4.2.5 TO SMOKING REGULARLY IS A RISK FACTOR FOR TUBERCULOSIS

Out of 150 participants, 31.33% were smoking regularly and 68.66% were not addictive
or smoke cigarette.

Table 4.2.5 Smoking regularly

 Smoking regularly Frequency Percentage%
Yes 47 31.33%
No 103 68.66%
Total 150 100%

4.2.6 HISTORY OF SMOKING BEFORE TB

There were 19.33% patients that had a history of smoking before getting TB and 80.66%
were not smoke before TB.

Table 4.2.6 Smoking before TB

Smoking before Tb Frequency Percentage%

Yes 29 19.33%
No 121 80.66%
Total 150 100%
4.2.7 USING PULMONARY MEDICINE IS A RISK FACTOR FOR TB
Out of 150 participants, only 68.66% patients were used pulmonary medicine
prescribed by pulmonologist whereas 31.33% patients were not known about their
prescription and medicine.

Table 4.2.7 Using pulmonary medicine

Using Pulmonary Frequency Percentage%

medicine
Yes 103 68.66%
No 47 31.33%
Total 150 100%

4.2.8LIVING OR WORKING IN AIR POLLUTEDAREAS

Out of 150 patients, 39.33% patients live and work in air polluted air and 60.66%
are not live or work in air polluted air.

Table 4.2.8 Working polluted areas

Working polluted area Frequency Percentage%

Yes 59 39.33%
No 91 60.66%
Total 150 100%

4.2.9EXPOSURE TO CHEMICAL OR INFECTIOUS SUBSTANCES

There are 8.66% patients that have a history exposure to chemical and infectious
substances and 91.33% have no knowledge of exposure to chemical and infectious
substance.

Table 4.2.9 Chemical or infectious substances

Chemical substances Frequency Percentage%

 Yes 13 8.66%
No 137 91.33%
Total 150 100%

4.2.10 USE OF ILLICIT DRUGS (CANNABIS, HERION, COCAINE):

Out of 150 participants, only 15 participants were addictive or use illicit drugs and
135 participants are not addictive to use illicit drugs.

Table 4.2.10 Use illicit drugs

Use illicit drugs Frequency Percentage%

Yes 15 10%
No 135 90%
Total 150 100%

4.2.11 DIAGNOSED WITH MALNUTRITION IS RISK FACTOR TB

Out of 150 participants, only 5 participants were diagnosed with malnutrition and
145 participants were not diagnosed with malnutrition.

Table 4.2.11 Diagnosed with malnutrition

Diagnosed with Frequency Percentage%

Malnutration
No 145 96.66%
Total 150 100%
Table4.3: Statistics of risk factors in Patients with TB
Risk Factors Yes n (%) No n (%)
Diagnosed or have past 29(19.33%) 121(80.66%)
medical history of DM
To smoking regularly is the 47(31.33%) 103(68.66%)
risk factor for TB
History of smoking before TB 29(19.33%) 121(80.66%)
Using pulmonary medicine is 103(68.66%) 47(31.33%)
the risk factor for TB
Living or working in air 59(39.33%) 91(60.66%)
polluted areas
Exposure to chemical or 13(8.66%) 137(91.33%)
infectious substances
Use of illicit drugs 15(10%) 135(90%)
Diagnosed with malnutrition 5(3.33%) 145(96.66%)
 is the risk factor for TB

CHAPTER # 05
DISCUSSION

The aim of the current study was to find out the prevalence of Pulmonary Tuberculosis
(TB) among males and females of different age groups. For this purpose, I took data from
different participants of age 1 year to 80 years. There were 59.33% male and 40.66% female.
The highest prevalence of Pulmonary tuberculosis (TB) was found in the adults of age 41 years
to 60 years and the least was found in the age of 1 year to 20 years. Among them there were
92.66% pulmonary tuberculosis and 7.3% was extra-Pulmonary Tuberculosis. There were
80.66% participants that were not addictive to smoking before TB and 8.33% were found
whohad a history of smoking before TB. 68.6% participants were using pulmonary medicine
while 31.33% participants did not know about use of pulmonary medicine.(Silva et al., 2018)

Research by Razia Fatima et al. (2) "Population Based National Tuberculosis Prevalence
Survey among Adults (>15 Years) in Pakistan, 2010-2011" The adjusted prevalence estimates
for smear and bacteriologically positive tuberculosis were 270/100,000 (95% CI 217-323), and
398/100,000 (95% CI 333-463), respectively. Only 61% of the confirmed TB cases tested
positive for symptoms (cough lasting more than two weeks), whereas the other TB cases were
found based on X-ray abnormalities. The frequency of tuberculosis rose with age and was 1.8
times greater in males than in women. The prevalence-to-notification ratio for smear-positive
tuberculosis was 3.1 (95% CI 2.5-3.7), which was greater in males than in women and increased
with age. (Silva et al., 2018)

Pakistan ranks fifth among high-burden nations for TB. Extrapulmonary tuberculosis
(EPTB) has steadily increased, accounting for 20% of all recognized TB cases. There is
relatively little information on the epidemiology of EPTB. This study aimed to evaluate the
demographic features, clinical symptoms, and treatment results of EPTB patients in Pakistan.
The study sheds light on the demographics, clinical symptoms, and treatment results of EPTB.
Further research is required to explain major differences seen between provinces, unique risk
variables, and issues regarding EPTB management.(Ahmad et al., 2015)

In our study, pulmonary TB was more prevalent than extrapulmonary tuberculosis. 252
(84%) of the patients had pulmonary TB, whereas 48 (16%) had extrapulmonary tuberculosis.
Out of 300 patients, only 96 (32%) were educated, while 204 (68%) were illiterate. The bulk of
patients' socioeconomic class was categorized as "poor". 213 (71%) patients were impoverished,
72 (24%) were middle class, and just 15 (5%) were from upper middle class families.(Lizss et
al., 2015)

Mycobacterium tuberculosis causes pulmonary tuberculosis (TB). A retrospective

research was conducted to investigate the frequency and seasonality of PTB among suspected
tuberculosis patients identified at Tehsil Head Quarter Hospital Serai Naurang, District Lakki
Marwat, Khyber Pakhtunkhwa, Pakistan, between April 2015 and March 2018. Out of 2467
registered and suspected cases of PTB, 239 (9.69%) tested positive. During the research period,
females had a higher prevalence of the condition (60.67%) than males (39.33%). The age group
15-30 years had the largest proportion of illness (37.24), followed by the age groups 46-60
(19.67), more than 60 (18.41), 31-45 (17.16), and 5-14. During the research period, no patients
with PTB under the age of 5 were identified. Overall, 92.47% of positive cases were beyond the
age of 15. The number of suspected patients and PTB-positive cases fluctuated annually, and
they were connected. The monthly/seasonal incidence of the illness revealed that the late summer
season (September) had the largest number of positive cases, 43 (17.99%); nevertheless, July
(hot summer) and November (fall) had the fewest number of positive cases, 13 (5.44%) of the
total positive cases. Data collected across the research period indicated that females had a greater
risk of sickness than males in 10 of the 12 months of the year.(Lienhardt et al., 2002)

In our study, pulmonary TB was more prevalent than extrapulmonary tuberculosis. 252
(84%) of the patients had pulmonary TB, whereas 48 (16%) had extrapulmonary tuberculosis.
Out of 300 patients, only 96 (32%) were educated, while 204 (68%) were illiterate. The bulk of
patients' socioeconomic class was categorized as "poor". 213 (71%) patients were poor, 72
(24%) were middle-class, and just 15 (5%) were from upper-middle-class families. In our study,
pulmonary TB was more prevalent than extrapulmonary tuberculosis. 252 (84%) of the patients
had pulmonary TB, whereas 48 (16%) had extrapulmonary tuberculosis. Out of 300 patients,
only 96 (32%) were educated, while 204 (68%) were illiterate. The bulk of patients'
socioeconomic class was categorized as "poor". 213 (71%) patients were impoverished, 72
(24%) were middle class, and just 15 (5%) were from upper middle class families.(Sabira, et al.,
2020)

TB was shown to be strongly linked with male gender, married persons, smoking,
drinking, personal and family history of TB, asthma, and diabetes (OR: 1.08, 1.96, 1.21, 4.26,
2.07, 3.16, 3.43 and 3.67) with P-value < 0.005(Ejaz, et al., 2016).
 CHAPTER # 06
CONCLUSION AND RECOMMENDATION

In my study I concluded that the prevalence of pulmonary tuberculosis (TB) is higher in male,
accounts 59.33%. Furthermore, 48.66% prevalence was found in the age group 41 years to 60
years. 31.33% participants were not aware using the pulmonary medicine and 39.33 were living
or working in air polluted areas.

Limitation
 Due to lack of time and resources the study was limited to TB center Parachinar and
could not include large population.
 Limited to individual who has the history of TB and registered with TB center
Parachinar.

Recommendation
 Recommended to carry out the same study on large population using diagnostic method
of different age groups individuals.
 I recommended prevention, education, awareness, modern screening for early detection
of TB and advance TB therapy.