Romana Shehzadi ( Medical Students, Section of Pulmonary Medicine, The Aga Khan University Hospital, Karachi )
Muhammad Irfan ( Medical Students, Section of Pulmonary Medicine, The Aga Khan University Hospital, Karachi )
Tatheer Zohra ( Medical Students, Section of Pulmonary Medicine, The Aga Khan University Hospital, Karachi )
Javaid Ahmed Khan ( Medical Students, Section of Pulmonary Medicine, The Aga Khan University Hospital, Karachi )
Syed Fayyaz Hussain ( Medical Students, Section of Pulmonary Medicine, The Aga Khan University Hospital, Karachi )
Abstract
Objective: To assess the knowledge of General Practitioners (GPs)in NWFP and northern areas of Pakistan regarding diagnosis and management of tuberculosis.
Methods: A cross-sectional survey of general practitioners (GPs) from North West Frontier Province (NWFP) and northern areas of Pakistan was done. The sampling strategy was convenience sampling. The data was collected on a structured questionnaire after taking verbal consent.
Results: Out of 88 GPs 43% regarded sputum microscopy and 22% chest radiograph as confirmatory tests for the diagnosis of pulmonary TB. During follow up of pulmonary TB patients, 32% doctors considered chest radiograph as the best investigation while sputum microscopy was chosen by only 28%. Eighty seven percent of GPs correctly identified TB as a droplet infection but 6 % considered sexual contact to be the main mode of spread of this disease. Two third of the prescriptions, written for a 60 kg man with newly diagnosed smear-positive pulmonary TB, were not in line with national guidelines. Only 3% of the GPs knew all the five components of DOTS.
Conclusion: Severe deficiencies were seen in the management of TB by GPs of Northern areas of Pakistan. National TB control Program must take appropriate measures to educate and train the GPs in TB management. Without involving the GPs, TB control will remain a problem in Pakistan (JPMA 55:174;2005).
Introduction
Tuberculosis (TB) was declared as a global emergency by WHO in 1993.1 Pakistan accounts for 44% of total TB burden in East Mediterranean Region and ranks 6th among the highest burden countries. While 210,000 new TB cases occur each year, only one in four cases is ever diagnosed in the country.2
North West Frontier Province (NWFP) and the Northern area (NA) are situated in the northern part of Pakistan, both regions with high TB prevalence. The prevalence of pulmonary TB in a village from Northern Area was reported to be 557/ 100,000 for smear positive and 1949/100,000 for smear negative cases.3 Similarly a study conducted on prisoners in NWFP showed that 48% of the male prisoner's had latent tuberculosis.4
Major problems encountered in Pakistan are late and improper diagnosis, prescription of inadequate treatment regimens, poor supervision of the therapy leading to irregular intake of drugs and poor follow-up. This in turn leads to failure, relapse and emergence of multidrug resistance tuberculosis (MDR-TB) which is increasing at an alarming rate in Pakistan.5
General practitioners are the backbone of any health care system, as they are dealing with the major bulk of the patients. In Pakistan, over 80% of patients suffering from TB first go to a private practitioner for diagnosis and treatment.6 These practitioners may not be well aware of the WHO guidelines7,8 and are ill-equipped to deal with TB patients with over two-thirds reported to prescribe inappropriate treatment regimens.9 Partial treatment with inappropriate regimens in terms of dosage and duration is probably the most important factor leading to increase MDR-TB in Pakistan.10 Adequate knowledge regarding diagnosis and a proper prescription written by a practicing physician is as important as treatment compliance by the patient.11 It is therefore important to audit the prescribing habits and assess the knowledge of physicians regarding the diagnosis and management of TB. This study was designed to assess the knowledge of GPs in NWFP and Northern Areas of Pakistan regarding diagnosis and management of TB.
Methods
This was a cross-sectional study and was conducted in the year 2003 targetting the GPs of NWFP and NA of Pakistan. It recruited GPs from Gilgit, Hunza, Skardu, Haripur, Abbotabad and Peshawar. The data was collected on a structured questionnaire after taking verbal consent. A sample of 88 GPs was surveyed using convenient sampling method. The results were analyzed using SPSS version 10.5.
Results
Out of 88 GPs only 7(8%) were aware of the WHO estimation of the number of new TB cases each year in Pakistan. During medical school 77(87.5%) GP's had formal sessions on chest radiograph interpretation, 55(62.5%) performed tuberculin test and Zeihl-Neelson staining of sputum. Sixty eight (77.3%) GP's were confident in diagnosis and management of pulmonary TB. According to 77(87.5%), TB was a droplet infection while 5(5.7%) considered it as a sexually transmitted disease. Rest of them thought that it spreads through breast milk and sharing utensils. In response to a question regarding the choice of the best test to confirm the diagnosis of pulmonary TB, 38 (43.2%) considered sputum microscopy as the best test while 19 (21.6%) considered chest X- ray and the rest chose either tuberculin test or PCR or ESR. For follow-up of a case being treated with anti-TB therapy, 28(31.8%) considered chest X-ray and 25 (28.4 %) sputum microscopy as the best test.
Regarding the management of a female who becomes pregnant while receiving anti-TB therapy, 60 (68.2%) suggested that it would be appropriate to continue the same treatment avoiding streptomycin. Nine (10.2%) suggested termination of pregnancy, 7 (8%) suggested discontinuation of therapy while the remaining suggested discontinuation of breast feeding or didn't respond. When the GPs were asked to write a prescription for a 60 kg newly diagnosed smear-positive case of pulmonary TB, only 31(35.2%) were able to write a prescription with correct drugs, dose and duration for initial phase and 26(29.5%) for continuation phase of the therapy. Regarding the knowledge of components of Directly observed therapy short course (DOTS), only 3 (3.4%) GPs knew all the components of DOTS.
Discussion
Complete cure from TB require compliance not only of patients but also of physicians.11 Until this study no information was available on the knowledge of GPs of Northern Area regarding management and diagnosis of TB. Although their knowledge regarding the transmission of TB is adequate but less than half considered sputum microscopy as the best test for confirmation of pulmonary TB. GPs are under using sputum examination for diagnosis and treatment monitoring.
Of greater concern were poor prescribing practices of GPs. Only 35.2% were able to write a correct prescription for the initial phase and 29.5% for continuation phase of anti-TB treatment. Similar deficiencies in knowledge and practices have been found in other studies.12-14 Error in anti TB drug prescribing is not confined to developing countries alone. In a study from Baltimore, USA, prescription errors were found in 15.4% of patients with pulmonary TB.15 This poor management not only compromises patient outcome but also exposes other family members to unnecessary risk.16 These inappropriate regimens may lead to increase in prevalence of MDR-TB in a community already overburdened by TB. It is universally accepted that partially treated patient with inappropriate drugs is worse than untreated one,16 since chronic cases are the ones who excrete MDR organisms and increase the community burden of TB.
The most disappointing state of affairs revealed in the study was regarding the knowledge about DOTS. Despite the expansion and implementation of DOTS, only 3.4% of the GPs knew all the components of DOTS, making it difficult to achieve the target of National Tuberculosis Control Programmes (NTP) i.e., 100% DOTS coverage by year 2005.
The study revealed poor knowledge of GPs regarding the diagnosis and management of TB in NWFP and NA of Pakistan. Keeping in mind the results of this study the gaps in the knowledge and practices need to be addressed. In order to prevent errors in diagnosis and management of TB, GPs must be educated via regular continuing medical education, seminars and training programs regarding diagnosis and management of TB, DOTS strategy and National TB Control Programs (NTP). Dosage charts and simple booklets providing information on TB diagnosis and management should be made available to GPs in these areas as well. Apart from this there should be an active involvement of GPs in NTP. Prescriptions of anti-TB treatment must be audited to ensure that they are in line with national TB guidelines, with the help of similar studies in other parts of the country as well. DOTS program need to be expanded and implemented rapidly and linkages need to be establish between GPs and DOTS.
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