TB infection starts when an individual inhales droplet nuclei carrying tubercle bacilli, which then enter the alveoli of the lungs (Smith, Armitige, & Wanger, 2003). The alveolar macrophages ingest these tubercle bacilli, and most of them are either eliminated or suppressed. The primary cause of lung infection, often referred to as PTB, is mostly attributed to Mycobacterium tuberculosis (MTB) (Chandra, Grigsby, & Philips, 2022). The primary symptoms of PTB include a persistent cough lasting more than 2 weeks, nocturnal sweats, mild fever, lack of appetite, hemoptysis (presence of blood in sputum), and weight loss (Lee, Hartman, & Kornfeld, 2009). In 2013, a total of 9 million individuals globally infected with tuberculosis (Organization, 2013). Furthermore, a total of 1.1 million cases of tuberculosis were reported among individuals who are infected with the human immunodeficiency virus (HIV) (Obeagu & Obeagu, 2023). In 2013, a total of 510,000 women succumbed to tuberculosis, while 180,000 women were diagnosed with HIV. among 2013, the incidence of tuberculosis (TB) among children was estimated to be 555,000 (Patel, Raizes, & Broyles, 2020). Therefore, the number of children who tested negative for HIV and died from tuberculosis in the same year was 80,000 (Getahun, Gunneberg, Granich, & Nunn, 2010).

Pakistan is among the top five nations with a high burden of disease. The implementation of the DOTS approach for tuberculosis (TB) began in 2001 and, over a span of five years, it was extended to include a significant portion of the public health sector (Rizvi, Naqvi, & Abbas, 2015). The National TB control program (NTP) then prioritized the extension of Directly Observed Treatment, Short-course (DOTs) coverage in the private health sector, as well as the treatment of juvenile TB and drug-resistant TB at a programmatic level (Kabra et al., 2015). In 2011, the estimated occurrence of all forms of tuberculosis (TB) in Pakistan was 231 cases per 100,000 people, with a 64% rate of identifying patients for all kinds of TB (Qadeer et al., 2016). In 2014, Pakistan reported an estimated tuberculosis prevalence of 342 cases per 100,000 people, with an incidence rate of 275 cases per 100,000 population (Razzaq, Zahidie, & Fatmi, 2022). The overall tuberculosis (TB) case detection rate was 58%, with a total of 298,446 recorded cases in the nation in 2014 (Malik, 2020). The objective of this research was to find out the tuberculosis infection rate among native people in two across two tehsils of Okara district, Pakistan.

Aim of the study

The aim of this research was to assess the occurrence and distribution, based on age and gender, of AFB (Acid-Fast Bacillus) positive cases, infection site (pulmonary, extra-pulmonary), MTB (Mycobacterium tuberculosis), and RR (Rifampicin Resistance) in two tehsils of Okara district, Pakistan.

Study Design

The research was done from January 2019 to June 2023 in two tehsils of Okara district. Retrospective observational research was devised. Pakistan is situated in South Asia and has an estimated occurrence of 510,000 cases of tuberculosis, with a low occurrence of HIV. 68% of the predicted tuberculosis (TB) cases were reported in 2016. The private health sector, which includes general practitioners (GPs) providing TB care, accounted for 27% of all reported TB cases. In 2016, around 1300 health care facilities (HCF) had developed microscopy services for TB detection. Additionally, 73 HCF had implemented GeneXpert (Cepheid, Sunnyvale, CA, USA) for TB diagnosis, and TB culture was conducted in 16 labs. Conventional recording and reporting technologies are used to document and save data for every notified tuberculosis (TB) patient in TB registers. At the district level, a distinct tuberculosis (TB) registry is kept to document TB cases that have been reported by general practitioners (GPs). While TB registries do include designated columns for noting the location of TB illness, such as AFB, MTB, and RR.

Data source and collection

The data was gathered from the tuberculosis unit of THQ hospital Depalpur and DHQ Hospital Okara. Additionally, the demographic data of the patients was documented. The collected TB data was further examined to examine the illness in terms of gender, age, and year. Initially, we compiled distinct lists of tuberculosis (TB) patients in the Tehsil of District Okara area. These lists included the number of cases reported for acid-fast bacilli (AFB), Mycobacterium tuberculosis (MTB), and rifampicin resistance (RR) from January 2019 to June 2023. Subsequently, the list was sent to the corresponding TB program for the purpose of gathering data, with instructions to make further selections from this list depending on the level of excellence and comprehensiveness of the data documented in the TB registries. The data collecting period is from January 2019 to June 2023. All HCF workers were instructed to ensure that the data is full and to document any missing data before duplicating the TB registers.

Data management

The tuberculosis registries were received at the TB centers of District Okara. A custom-designed electronic file, created using EpiData Manager V4.4.2.1, was used for inputting data. Data for several characteristics, including as Age, Gender, AFB, Infection Site (Pulmonary, Extra pulmonary), MTB, RR history of TB treatment, illness site, test findings, and treatment outcomes, were recorded in a case-based manner. The analysis includes all tuberculosis cases recorded from January 2019 to June 2023. The study utilized standard definitions to categorize individuals into different age groups: Children (ages 1-15 years), Young Adults (ages 16-30 years), Middle-Aged Adults (ages 31-45 years), and Older Adults (ages 46-60 years). The analysis included both new and previously treated cases of tuberculosis (TB) that were confirmed through bacteriology (B+) or diagnosed clinically, using data from the TB registers. The cases were classified according to the main illness sites, specifically labeled as Infection Site, AFB, Infection Site, MTB, and RR. The cases of tuberculosis were categorized based on the location of infection: pulmonary and extrapulmonary disease sites.

Age and gender wise distribution of TB +ve cases

In the current study the data was collected from two Hospitals of district Okara a total of 289 in 2019, 298 in 2020, 450 in 2021, 697 in 2022, and 345 in 2023 patients of TB were registered at THQ Hospital Depalpur and the TB patients was registered in DHQ hospital Okara was 525 in 2019, 158 in 2020, 156 in 2021, 168 in 2022, and 83 in 2023.  THQ Hospital Depalpur documented a total of 2079 individuals diagnosed with tuberculosis, with the largest proportion (39.50%) being within the 46-60 age range, closely followed by the 16-30 age group (31.94%). The percentage of children between the ages of 1 and 15 who had TB was 8.46%, while adults between the ages of 31 and 45 made up 20.10% of the overall number of TB cases.

Table 3.1: Age and wise distribution of TB +ve cases, n (%) from 2019 to 2023 at THQ Hospital Depalpur.

Table 3.2: Age and wise distribution of TB +ve cases, n (%) from 2019 to 2023 at

DHQ Hospital Okara

In THQ Hospital Depalpur, the gender distribution in 2019 was 44.99% male and 55.01% females. In 2020, it was 48.65% males and 51.35% females. In 2021, it was 49.55% males and 50.45% females. In 2022, it was 45.91% males and 54.09% females. In 2023, it was 45.50% males and 54.50% females. The DHQ hospital in Okara documented a total of 1090 individuals with tuberculosis. The age group with the largest proportion of TB cases was the 46-60 age group, accounting for 32.57% of the cases. It was followed by the 01-15 age group with 19.82% of the cases, the 31-45 age group with 32.39% of the cases, and the 16-30 age group with 15.22% of the cases. The data shows that the distribution of TB varies across various age groups on a yearly basis. In DHQ hospital Okara, the proportion of females was 69.71% and male were 30.29% in 2019. In 2020, the proportion of females decreased to 57.60% while males increased to 42.40%. Similarly, in 2021, the proportion of females was 55.12% and males were 44.88%. In 2022, the proportion of females was 55.35% and males were 44.65%. Finally, in 2023, the proportion of females increased to 69.88% while males decreased to 30.12%. The number of patients registered at THQ Hospital Depalpur was highest in 2022 and lowest in 2023. Conversely, in DHQ Hospital Okara, the number of patients registered was highest in 2019 and lowest in 2023.

Pulmonary vs. Extra-Pulmonary Infection Sites

The number of patients registered at THQ Hospital Depalpur was highest in 2022 and lowest in 2023. Similarly, at DHQ Hospital Okara, the number of patients registered was highest in 2019 and lowest in 2023. At THQ Hospital Depalpur, the number of tuberculosis (TB) patients with pulmonary infection was higher than those with extra-pulmonary infection. THQ Hospital Depalpur recorded TB cases with both Pulmonary and Extra Pulmonary infections. In THQ hospital Depalpur, the ratio of patients with pulmonary and extra pulmonary conditions was as follows: in 2019, 88.58% had pulmonary conditions and 11.42% had extra pulmonary conditions; in 2020, 84.89% had pulmonary conditions and 15.11% had extra pulmonary conditions; in 2021, 91.33% had pulmonary conditions and 8.67% had extra pulmonary conditions; in 2022, 93.83% had pulmonary conditions and 6.17% had extra pulmonary conditions; and in 2023, 92.75% had pulmonary conditions and 7.25% had extra pulmonary conditions. In DHQ hospital Okara, the ratio of patients with pulmonary and extra pulmonary conditions was as follows: in 2019, 84.57% had pulmonary conditions and 15.43% had extra pulmonary conditions; in 2020, 77.21% had pulmonary conditions and 22.79% had extra pulmonary conditions; in 2021, 73.07% had pulmonary conditions and 26.93% had extra pulmonary conditions; in 2022, 77.97% had pulmonary conditions and 22.03% had extra pulmonary conditions; and in 2023, 79.51% had pulmonary conditions and 20.49% had extra pulmonary conditions. In general, both institutions reported a greater occurrence of pulmonary tuberculosis patients in comparison to extrapulmonary tuberculosis cases. THQ Hospital Depalpur consistently exhibited a higher proportion of pulmonary TB cases and a larger overall number of patients. In contrast, DHQ Hospital Okara demonstrated a relatively higher percentage of extrapulmonary TB cases, suggesting distinct variations in the locations of TB infection and the number of patients between the two hospitals.

Table 3.3: Distribution of Pulmonary vs. Extrapulmonary TB, AFB Positive Cases by Gender, MTB Positive Cases, and RR Cases from 2019 to 2023 at THQ Hospital Depalpur.

AFB positive: Acid-Fast Bacillus positive, MTB: Mycobacterium tuberculosis, DH: Drug History, DM: Diabetes Mellitus, DL: Dyslipidemia, RR: Rifampicin Resistant.

Figure 3.5: Variations in MTB +ve cases (DH, DM, DL) from 2019 to 2023 at THQ Hospital Depalpur.

Table 3.4: Distribution of Pulmonary vs. Extrapulmonary TB, AFB Positive Cases by Gender, MTB Positive Cases, and RR Cases from 2019 to 2023 at DHQ Hospital Okara.

AFB positive: Acid-Fast Bacillus positive, MTB: Mycobacterium tuberculosis, DH: Drug History, DM: Diabetes Mellitus, DL: Dyslipidemia, RR: Rifampicin Resistant.

AFB Smear Status and Microbiologic Diagnosis

AFB smears are regarded as the first stage in the diagnosis of tuberculosis (TB). The level of contagion of a tuberculosis patient is closely correlated with the quantity of droplet nuclei containing M. tuberculosis (tubercle bacilli) that are released into the atmosphere, often by actions like coughing. During the period from 2019 to 2023 at THQ hospital Depalpur, a significant number of patients tested positive for AFB and were diagnosed with tuberculosis. In 2022, the highest number of TB cases was reported, with a total of 210 instances, accounting for 30.12% of all cases. Out of these, 111 cases were males, making up 52.85% of the total, while 99 cases were females, accounting for 47.15%.

In 2023, a total of 78 cases (22.60%) of TB patients were diagnosed as AFB + ve, with 45 cases (57.70%) being males and 33 cases (42.30%) being females. During the period from 2019 to 2023 at DHQ hospital Okara, a significant number of AFB positive individuals were diagnosed with tuberculosis. Specifically, in 2019, there were 134 cases, accounting for 25.52% of the total cases. Out of them, 75 cases (55.97%) were men and 59 cases (44.03%) were females. In 2023, a total of 26 instances of TB patients were diagnosed as AFB + ve, accounting for 31.32% of the minimum number of cases. Out of them, 16 were males, making up 61.54% of the cases, while 10 were females, accounting for 38.46%.

Demographic Characteristics of MTB, and RR Patients

Between 2019 and 2023, the THQ Hospital Depalpur saw a notable fluctuation in the quantity of tuberculosis patients and their diagnostic classifications. In 2019, a total of 289 people was diagnosed with Mycobacterium tuberculosis (MTB). Among these patients, 28 (19.85%) had a history of drug use (DH) and were diagnosed with MTB. Additionally, 50 (35.46%) had diabetes mellitus (DM), and 63 (44.68%) had dyslipidemia (DL). Out of a total of 298 patients in 2020, 12 (12.24%) were diagnosed with DH, 33 (33.67%) had DM, and 53 (54.08%) had DL. In 2021, the total number of patients increased to 450, with 22 (17.88%) instances of DH, 40 (32.52%) cases of DM, and 61 (49.59%) cases of DL. In 2022, of the 697 patients, 29 (13.80%) were diagnosed with DH, 61 (29.04%) had DM, and 120 (57.14%) had DL. In 2023, out of a total of 345 patients, 9 (11.53%) were diagnosed with DH, 22 (28.20%) had DM, and 47 (60.25%) had DL. The DHQ Hospital Okara observed a notable disparity in the quantity of tuberculosis patients and their diagnostic classifications with the use of MTB. In 2019, among a total of 525 individuals, 20 (14.92%) were diagnosed with DH, 40 (29.85%) had DM, and 74 (55.22%) were found to have DL. Out of the 158 patients seen in 2020, 11.11% were diagnosed with DH, 24.44% had DM, and 64.44% had DL. In 2021, there were a total of 156 patients. Among them, 10 patients (19.23%) had DH, 11 patients (21.15%) had DM, and 31 patients (59.61%) had DL. In 2022, among a total of 168 individuals, 7 (12.06%) were diagnosed with DH, 14 (24.13%) had DM, and 37 (63.79%) were found to have DL. In 2023, out of a total of 83 patients, 2 (7.69%) were diagnosed with DH, 7 (26.92%) had DM, and 17 (65.38%) had DL. These statistics demonstrate varying rates of diagnoses for MTB, DM, DL, and DH across the five-year period. The THQ Hospital Depalpur documented incidences of tuberculosis (TB), including 3 instances of rifampicin-resistant TB (RR-TB) in both 2020 and 2021, 2 instances in both 2022 and 2023, and no instances in 2019. The DHQ Hospital in Okara has identified one case of rifampicin-resistant tuberculosis (RR-TB) year from 2019 to 2022, with no reported cases in 2023.

This research aimed to establish the prevalence of cases involving infection sites in the lungs and other areas beyond the lungs. The purpose was to gather essential epidemiological data for the population residing in two tehsils in Okara district, as well as for the National Tuberculosis Control Programme (NTP). The findings of the ongoing investigation will be very beneficial in managing and eliminating the condition. Epidemiological studies is crucial for the proactive planning of tuberculosis prevention. A total of 2079 cases were recorded at THQ hospital Depalpur, with 1894 (91.10%) being pulmonary tuberculosis patients and 185 (8.90%) being extrapulmonary tuberculosis patients. At DHQ hospital Okara, a total of 1090 cases were registered, with 877 (80.46%) being pulmonary tuberculosis patients and 213 (19.54%) being extrapulmonary tuberculosis patients. Both hospitals exhibited a greater incidence of pulmonary tuberculosis patients compared to extrapulmonary tuberculosis cases. Nevertheless, THQ Hospital Depalpur consistently exhibited a higher proportion of pulmonary tuberculosis cases and a larger overall number of patients, while DHQ Hospital Okara demonstrated a relatively higher percentage of extrapulmonary tuberculosis cases. This suggests distinct variations in the locations of tuberculosis infection and the number of patients between the two hospitals.

Our investigation found that out of all the reported cases, 650 patients (31.26%) in THQ Hospital Depalpur and 315 cases (28.90%) in DHQ Hospital Okara tested positive for AFB. Our analysis shows that there were varying rates of diagnoses for MTB, DM, DL, and DH over the course of five years. The THQ Hospital Depalpur documented incidences of tuberculosis (TB), including 3 instances of rifampicin-resistant TB (RR-TB) in both 2020 and 2021, 2 cases in both 2022 and 2023, and no cases in 2019. The DHQ Hospital in Okara has identified one case of rifampicin-resistant tuberculosis (RR-TB) year from 2019 to 2022, with no reported cases in 2023. Both gender and age are typically recognized as determinants when considering the incidence and prevalence of TB. The gender discrepancy serves as an indication that draws attention to both males and females. The condition was more prevalent among female patients than male patients, based on gender. The disease burden in females was 53.10%, while in males it was 46.90% for TB diagnosis at THQ Hospital Depalpur. At DHQ Hospital Okara, 63.66% of cases were detected in females and 36.34% in male. The results of our study align with previous research that has shown a significant prevalence of tuberculosis in the female community.

What is the reason for the increased susceptibility of females to illness progression? Due to their higher susceptibility to immunological deficiencies, females have a greater level of immune deficiency. A research done (Long, 2000) found that women took almost twice as long as males to seek medical attention at hospitals or healthcare centers after the beginning of cough. Occasionally, women also disregarded their sickness, leading to a quick progression of the disease and a decline in their health. The mortality rate of TB and the transmission of the illness to uninfected persons are significantly heightened by delays in both diagnosis and treatment. Women are disproportionately affected by the social stigma associated with TB diagnosis, which may have a detrimental impact on their well-being. In some groups, the occurrence of tuberculosis infection in women may lead to divorce, and if they are unmarried, it might provide challenges in finding a suitable life mate. Women in several communities participate in employment outside of their residences, especially in the domestic or agricultural sectors, in order to provide essential revenue for their households. Tuberculosis in women results in employment and income loss.

The Tuberculosis was found to be more prevalent among patients over the age of 60, with 39.50% of cases reported in THQ Hospital Depalpur and 32.57% of cases reported in DHQ Hospital Okara. Age is a crucial factor in the epidemiology of tuberculosis. The age group with the highest frequency was 40-60 years, with a documented rate of 39.50% at THQ Hospital Depalpur. DHQ Hospital Okara had a lower prevalence rate of 32.57%. The present investigation also observed a significant illness burden among individuals aged 40-60 years. Our results align with the findings of previous studies that have found a high number of cases in the age groups that are both productive and economically significant.  A study conducted by (Uddin, Khan, Ahmad, Rehman, & Arif, 2018) found that 39.69% of patients in District Lower Dir had smear positive pulmonary tuberculosis (PTB) in the age range of 15-34 years. A further investigation carried out by (Uddin et al., 2018) at the Regional TB center at Buraidah Central Hospital Qassim revealed a significant proportion of cases, namely 43.3%, occurring among individuals aged 16 to 30 years. A research conducted by (Omotosho et al., 2014) in Nigeria revealed a significant number of tuberculosis (TB) cases, namely 49.5%, among individuals aged 16-35 years, who are considered to be in the productive and economically significant age group. The World Health Organization (WHO) established a Millennium Development Goal (MDG) to halt the advancement of tuberculosis (TB) and decrease the prevalence of the TB pandemic by 2015, with the ultimate objective of eradicating the illness worldwide by 2050. Since 1990, the disease's prevalence and death have fallen by almost 50%.

The prevalence of tuberculosis was found to be high in District Okara among all the reported cases. A high prevalence of tuberculosis (TB) was observed among female patients in Okara, with the bulk of cases occurring in the age group of 40-60 years.

Additional study is advised to investigate the epidemiology and barriers to accessing healthcare centers, as well as to deliver healthcare services directly to individuals' homes.

1. Chandra, P., Grigsby, S. J., and Philips, J. A. "Immune Evasion and Provocation by Mycobacterium tuberculosis." Nature Reviews Microbiology, vol. 20, no. 12, 2022, pp. 750-766. DOI: 10.1038/s41579-022-00650-6.
2. Getahun, H., Gunneberg, C., Granich, R., and Nunn, P. "HIV Infection—Associated Tuberculosis: The Epidemiology and the Response." Clinical Infectious Diseases, vol. 50, no. Supplement_3, 2010, pp. S201-S207. DOI: 10.1086/651486.
3. Kabra, S., Triasih, R., Lestari, T., Kal, M., Tsogt, B., Dorj, G., et al. "Priority Activities in Child and Adolescent Tuberculosis to Close the Policy-Practice Gap in Low-and Middle-Income Countries." In Pathogens, vol. 32, 2015, pp. 166-169. DOI: 10.3390/pathogens5020166.
4. Lee, J., Hartman, M., and Kornfeld, H. "Macrophage Apoptosis in Tuberculosis." Yonsei Medical Journal, vol. 50, no. 1, 2009, pp. 1-11. DOI: 10.3349/ymj.2009.50.1.1.
5. Long, K. M. "Women's Health Perceptions Over the Life Course." University of North Carolina at Chapel Hill, 2000. DOI: N/A.
6. Malik, A. A. "Diagnosis and Prevention of Active TB Disease." Emory University, 2020. DOI: N/A.
7. Obeagu, E. I., and Obeagu, G. U. "Human Immunodeficiency Virus and Tuberculosis Infection: A Review of Prevalence of Associated Factors." International Journal of Advanced Multidisciplinary Research, vol. 10, no. 10, 2023, pp. 56-62. DOI: 10.5603/oj.gm.2023.0078.
8. Omotosho, B., Adebayo, A., Adeniyi, B., Ayodeji, O., Ilesanmi, O., Kareem, A., et al. "Tuberculosis Treatment Outcomes and Interruption Among Patients Assessing DOTS Regimen in a Tertiary Hospital in Semi-Urban Area of South-Western Nigeria." Nigerian Journal of Medicine, vol. 23, no. 1, 2014, pp. 51-56. DOI: N/A.
9. Organization, W. H. Global Tuberculosis Report 2013. World Health Organization, 2013. DOI: N/A.
10. Patel, P., Raizes, E., and Broyles, L. N. "Human Immunodeficiency Virus Infection." In Hunter's Tropical Medicine and Emerging Infectious Diseases, pp. 232-266, Elsevier, 2020. DOI: N/A.
11. Qadeer, E., Fatima, R., Yaqoob, A., Tahseen, S., Ul Haq, M., Ghafoor, A., et al. "Population Based National Tuberculosis Prevalence Survey Among Adults (> 15 Years) in Pakistan, 2010–2011." PLOS ONE, vol. 11, no. 2, 2016, e0148293. DOI: 10.1371/journal.pone.0148293.
12. Razzaq, S., Zahidie, A., and Fatmi, Z. "Estimating the Pre-and Post-Diagnosis Costs of Tuberculosis for Adults in Pakistan: Household Economic Impact and Costs Mitigating Strategies." Global Health Research and Policy, vol. 7, no. 1, 2022, 22. DOI: 10.1186/s41256-022-00214-4.
13. Rizvi, M., Naqvi, B. S., and Abbas, A. "Financial Burden of Pulmonary Tuberculosis (TB) in Pakistan." World Journal of Pharmaceutical Research, vol. 4, no. 2, 2015, pp. 65-78. DOI: N/A.
14. Smith, K. C., Armitige, L., and Wanger, A. "A Review of Tuberculosis: Reflections on the Past, Present and Future of a Global Epidemic Disease." Expert Review of Anti-Infective Therapy, vol. 1, no. 3, 2003, pp. 483-491. DOI: 10.1586/14787210.1.3.483.
15. Uddin, S., Khan, F. U., Ahmad, T., Rehman, M. M. U., and Arif, M. "Two Years of Retrospective Study on the Incidence of Tuberculosis in Dir Lower Valley, Khyber Pakhtunkhwa, Pakistan." Hospital Pharmacy, vol. 53, no. 5, 2018, pp. 344-349. DOI: 10.1177/0018578718765572.