Finding missing TB cases among rural women in Sindh – Empowering women to increase their access to diagnostic & treatment services

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Finding missing TB cases among rural women in Sindh – Empowering women to increase their access to diagnostic & treatment services

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis (MTB) bacteria. Tuberculosis generally affects the lungs, but can also affect other parts of the body. Most infections show no symptoms, in which case it is known as latent tuberculosis. About 10% of latent infections progress to active disease which, if left untreated, kill about half of those affected. The classic symptoms of active TB are a chronic cough with blood-containing mucus, fever, night sweats, and weight loss. It was historically called consumption due to weight loss. TB Infection of other organs can cause a wide range of symptoms.

Tuberculosis is spread from one person to others through the air when people who have active TB in their lungs cough, spit, speak, or sneeze, release TB bacterias in air in the form of droplets and people present around can inhale  and can get infected .People with latent TB do not spread the disease. Active infection occurs more often in people with HIV/AIDS and in those who smoke or have low immunity. Diagnosis of active TB is based on microscopic examination of sputum and chest X-rays, Diagnosis of latent TB relies on the tuberculin skin test (TST) or blood tests.

Prevention of TB involves screening those at high risk, early detection and treatment of cases, and vaccination with the bacillus Calmette-Guérin (BCG) vaccine. Those at high risk include household, workplace, and social contacts of people with active TB. Treatment requires the use of multiple antibiotics over a long period of time ( about six months) Antibiotic resistance is a growing problem with increasing rates of multiple drug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB).

Pakistan, with an estimated 510 000 new TB cases emerging each year and approximately 15 000 developing drug-resistant TB cases every year is ranked fifth among high-burden countries worldwide and it accounts for 61% of the TB burden in the WHO Eastern Mediterranean Region. The country is also estimated to have the fourth highest prevalence of multidrug-resistant TB (MDR-TB) globally. Key reasons for the emergence of the drug resistant form of TB include: delays in diagnosis, unsupervised, inappropriate and inadequate drug regimens, poor follow-up and lack of a social support program for high-risk populations.

The biggest challenge to end TB in Pakistan is low case notification rates, in spite of efforts of federal and provincial governments, and other stakeholders. The TB notification rates have remained static for the last several years, and every year about one third of total new cases are missed, either they are not diagnosed and treated or treated but not reported.

According to scientific studies, one TB case if not diagnosed and treated, produces about 10 to fifteen new TB case in a year.

Tuberculosis is the leading infectious cause of death in women worldwide. Lack of empowerment, poverty, and malnutrition make women more vulnerable to Tuberculosis. Fear of stigma associated with TB has also a greater impact on women than men.

Females are 48% of the Sindh province Population. they are victims of Patriarchy, a custom related to having a societal system that encourages male dominance in society, and that male figure or figures of the family act as an authority and have all the rights to make decisions, not only their own and that of the family but also the decisions related to the women who are apart. Lack of empowerment, poverty, and malnutrition make women more vulnerable to Tuberculosis. Fear of stigma associated with TB has also a greater impact on women than men.

According to World Health Organization (WHO) in 2017 in Pakistan, adult males were reported 1.3 times higher compared to adult females. While in Sindh province according to data from the provincial TB control program, there was a significant difference in TB case notification among males and females during last three years (2016- Male TB patients 51% against Female TB patients 49%, 2017- Male TB patients 53% against Female TB patients 47%, 2018 Male TB patients 53% against Female TB patients 47%).

In rural districts of Sindh, the gap between male and female case notification is even bigger females contributing less than 45% of reported cases in some districts. Social, economic, cultural factors leading to barriers in accessing health care services may have caused under notification of TB in women in Sindh province. Women in rural areas generally are reluctant to seek health care services from male health care providers and prefer female health care providers due to social and cultural factors.

There is a dearth of female health care providers offering TB care both in public and private sectors in Sindh and Pakistan. There are 4069 female doctors registered in Sindh but according to some estimates, 50% do not practice and leave the profession after marriage, only 50% Female doctors work in public and private sector Most of female doctors attend only women presenting with pregnancy related problems or Gynecological issues , they hardly get any time for other common medical problems of women. Therefore women suffering from common diseases such as TB often remain undiagnosed and untreated . Moreover Female doctors are not trained  on National guidelines for diagnosis and treatment of TB.

Bridge Consultants Foundation under the TB REACH Wave 7 project tried to address  issue of low TB case notification rates among women in four selected districts of Sindh province by engaging Female doctors, providing them training on TB DOTs and empowering rural women to increase their access to TB diagnosis and treatment services. Our intervention motivated female private practitioners to provide TB care and empowered women through increased awareness about TB enhanced their access to TB diagnostic and treatment services, which resulted in increased TB case notification among women and decreased the gap in TB case notification rate between men and women.

We developed and implemented the TB REACH W7 project from Feb 2020 to Mar 2021 with the support of UNOPs/Stop TB Partnership and provincial TB Control Program Government of Sindh, in four selected districts of Sindh including Badin  , Kambar Shahdadkot, Shikarpur, and Sujawal. The main objective of the project was Active TB Case Finding among Women in rural districts of Sindh province of Pakistan by addressing Barriers to TB Care Access. In these selected districts overall TB case notification rate was below 50% and contribution of women was under 45%.

Following strategies were used to achieve the objectives


  • Engagement of female private practitioners and train them on national guidelines to diagnose and treat TB cases among women.
  • Providing assistance to engaged female private practitioners in the documentation of TB cases, to notify to Provincial TB control Program according to approved documenting tools
  • Investigation of women and children attending clinic of project female private practitioners.
  • Engagement of women in the community, by providing awareness about TB through trained female outreach workers.
  • Verbal screening of women at their residence and collection of sputum specimen from presumptive TB cases.
  • Contact screening of presumptive TB cases at household
  • Organization of Chest camps at hot spots in the community to find TB cases
  • Registration of diagnosed TB patients with female private practitioners and follow up till completion of treatment, to prevent loss to follow up

The project was formally launched on 1st Feb 2020 and Active TB case finding among women is in progress we have conducted following three main interventions.

Intervention one: we have trained 96 Female Health Care Providers (FHCPs) and one hundred three paramedics on revised National TB management guidelines  We screened women and children for TB who visited clinics of these FHCPs in all the four project districts. Sputum specimens of TB presumptive were collected for microscopy and all the collected specimen-transported by project outreach workers (ORWs) to designated private or government sector labs. TB patients diagnosed were registered for TB treatment at project FHCPs clinics.

All pulmonary TB cases which were registered for treatment were tested on gene expert to exclude Drug-resistant TB cases.

Intervention Two: ORWs with the help of paramedics identified the residence of TB presumptive. They visited 7771 homes of TB presumptive for contact screening. The ORWs screened Household members of presumptive and took sputum specimens for TB testing. All the diagnosed patients were registered at project female private practitioners for ATT.

Intervention Three: Total 45 chest camps were arranged in the community at hot spots from where more cases were reported.  TB patients diagnosed from these camps were registered for treatment at the clinics of FHCPs.

The project organized 69 Advocacy sessions in the community in which 2601 Ladies from the very poor community participated. This resulted in the capacity building of females through increased knowledge regarding TB as a disease. These sessions empowered women at the community level by creating awareness and helped them in bringing TB patients and presumptive to chest camps and FHCP clinics.

In the project through all these interventions overall we have screened verbally a total of 268015 women for TB. Out of which 15598 under went sputum microscopy for AFB smear. Out of 15598, a total of 1183 all form TB case were diagnosed and registered for treatment. All registered cases are being followed up by outreach workers to document outcome.