Background: Tuberculosis is a global health emergency and is a big challenge to diagnose and manage it. Family physicians being first contact health persons should be well competent to diagnose and manage the patients with tuberculosis. Aims: This study was aimed to assess the level of understanding about Mantoux Test amongst Family Physicians in Karachi, Pakistan and to determine the difference of level of understanding by gender and number of tuberculosis patients seen in a month. Methods: A cross sectional survey was conducted among 200 Family Physicians working in Karachi; the largest city and economic hub of Pakistan. Family Physicians who attended Continuous Medical Education sessions were approached after taking consent. Pre-tested, self administered questionnaire was filled consisting of: basic demographic characteristics, questions regarding knowledge about Mantoux Test, its application and interpretation. Data of 159 questionnaires was analyzed for percentages, as rest were incomplete. Chi square test was used to calculate the difference of understanding levels between various groups. Results: Almost two thirds of respondents were males and above 35 years of age. Majority of Family Physicians were private practitioners and seeing more than five tuberculosis patients per month. Overall, a big gap was identified about the knowledge of Mantoux Test among study participants. Only 18.8% of Family Physicians secured Excellent (≥ 80% correct responses). This poor level of understanding was almost equally distributed in all comparative groups (Male = 20.8% versus Female = 15.9%; p - 0.69) and (Seen < 5 tuberculosis patients per month = 18.6% versus seen ≥ 5 tuberculosis patients per month = 19.3%; p - 0.32). A huge majority of Family Physicians (92%) however, showed keen interest in obtaining further knowledge regarding Mantoux Test and amongst them 72% suggested Continued Medical Education sessions as preferable mode of updating themselves. Conclusion: Our study revealed an overall major deficit in understanding and interpretation of Mantoux Test amongst Family Physicians which needs to be addressed. Continues Medical Education sessions for Family Physicians should be organized in regular basis for upgrading their knowledge in this regards. Background and hurdles which are encountered in tackling this dis- Tuberculosis (TB) was declared a global health emer- ease mainly include late and improper diagnosis and gency by World Health Organization (WHO) . management . Like many countries in the developing According to WHO Global TB Report, Pakistan suffers world the public health care system in Pakistan is neither from the eighth-highest burden in the world, with a TB very efficient nor very accessible. However, there is a very prevalence of 263/100,000 population and TB deaths esti- strong private health sector, particularly in the cities and mated at 34/100,000 population . In a survey, con- a major bulk of the population consults these private fam- ducted in Karachi, Pakistan, Marsh et al has reported TB ily physicians (FP's). According to an estimate 80% of TB as a second leading cause of adult death . The setbacks patients in urban Pakistan initially report to private FP's for their diagnosis and treatment . However research * Correspondence: firstname.lastname@example.org 2 focusing on TB management by the FP's is almost non- Family Medicine/Community Health Sciences, Aga Khan University, Karachi, Pakistan existent. The few studies that have been conducted in Full list of author information is available at the end of the article © 2010 Ali et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attri- bution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Ali et al. Asia Pacific Family Medicine 2010, 9:8 Page 2 of 4 http://www.apfmj.com/content/9/1/8 Pakistan revealed that the knowledge and practices completely. Each correct response was marked as one regarding diagnosis and management of TB is very unsat- point, those who responded five to seven questions cor- isfactory amongst FPs [6,7] which can leads to drug resis- rectly were labeled as 'Good' while those who responded tance and increased mortality . correctly to eight and more questions were labeled as Clinical research on the MT has shown that a diagnosis 'Excellent'. of active case of tuberculosis is never made solely on the Data of 159 questionnaires was analyzed using the sta- results of this test . Ali et al  has reported that 44% tistical software package SPSS Version 16, remaining of healthy health care workers had a positive MT; out of were not included because of incompleteness of the them none developed active disease even after one year of forms. Percentages and their 95% CIs were calculated for follow up. Thus, tuberculin response in TB-endemic area each variable. Chi square test was used to measure the can not be used as a diagnostic marker for active TB . significant difference between various groups (Male vs. Hence; starting treatment just on the basis of positive MT female and < 5 TB pts vs. ≥ 5TB pts seen by FP per test is never recommended. month), keeping the level of significance (α) at 0.05. Out Family physicians being first contact health persons of total 159 respondents 60% were males and 73.5% were should be well competent and updated to diagnose and seen more than five TB patients per month. manage the tuberculosis particularly in countries where tuberculosis is one of the major health problems. Several Results studies that have been conducted in Pakistan assessed the Level of knowledge about MT amongst FPs and their knowledge regarding TB and its management, but none knowledge differences by sex and number of TB patients of them have particularly focused on the knowledge and seen per month are summarized in Table 1. About 30% of the interpretation of MT by the FPs. We therefore con- FP's reported the use of MT as a diagnostic tool for detec- ducted this study to assess the in-depth knowledge, inter- tion of active case of TB. More than half of the respon- pretation and application of the MT test amongst FPs in dents did not know the correct response regarding the Karachi. Results of this study will help and guide to for- cutoffs for positivity of MT for both HIV and Non-HIV mulate and implement the interventions for FPs in this patients. More than two thirds of the respondents also regards. did not know the correct possible causes of a negative MT result. Similarly, majority of responses were not cor- rect for other questions. Overall, less than one-fifth of the Methods A questionnaire-based study was conducted among FPs study participants achieved the score of ≥ 80 and this who attended Continuous Medical Education sessions; poor knowledge was equally prevalent in all compared which were arranged specifically for FPs in Karachi, Paki- groups (Male = 20.8%, Female = 15.9%; p - 0.69) and stan. After taking consent to participate in the study, a (Seen < 5 TB patients per month = 18.6%, seen ≥ 5 TB self-administered questionnaire was distributed to all patients per month = 19.3%; p - 0.32). (200) FP's. Full confidentiality of the information gath- Regarding the interest to seek further knowledge about ered was ensured to all the study participants and also the subject, almost 92% of the respondents shown their assured that the results of this study would not be pre- keen interest. Amongst them, 72% had preference for sented on individual level. Even though, no harm was continuing medical education sessions (CME) for updat- expected to occur to any of the study participant, study ing themselves while the second most preferred option questionnaire and proposal was reviewed and approved reported as scientific medical journals and newsletters. by the Research Committee of the department of Family (Figure 1). Medicine, Aga Khan University, Karachi. Questionnaire, consisting of basic demographic charac- Discussion teristics about the participants and questions regarding To the best of our knowledge this study is so far the first their knowledge about MT and its application and inter- of its kind conducted in high endemic country, Pakistan pretation were filled by the respondents. Face and con- which specifically focused on the knowledge of MT tent validity of the questionnaire was obtained through a among private FPs who are supposed to be the first con- review process with experts in the filed. After incorporat- tact health care providers for the community in general. ing the identified inconsistencies and inaccuracies, the This study revealed that there is an overall major deficit questionnaire was pre-tested on a group of family medi- in the understanding and interpretation of the MT cine residents (trainees) to identify any problem relating amongst FP's of either sex and irrespective of the number to question design, flow and interpretation. Feedback of TB patients they see per month. given were incorporated accordingly. A total of 10 ques- In this study, over one-fourth of the respondents did tions were asked from the study participants and about not know the correct route of administration of MT and 20 minutes were needed to respond the questionnaire about one-third of FPs has reported that they use MT as a Ali et al. Asia Pacific Family Medicine 2010, 9:8 Page 3 of 4 http://www.apfmj.com/content/9/1/8 Table 1: Level of understanding about MT amongst FP's and their differences by gender and number of TB patients seen in a month Questions FPs responded Gender (%) p-value Number of TB patients p-value correctly (%) seen in a month (%) Male Female < 5 ≥ 5 Should MT be used as a diagnostic test to 66.6 64.6 68.3 0.38 64.9 68.3 0.56 detect active TB? What is the route of administration of 73.0 67.7 78.3 0.05 75.3 70.7 0.17 M.T.? How many tuberculin units should be 29.6 33.3 25.9 0.13 29.9 29.3 0.57 injected? After how many hours tuberculin 62.9 66.7 59.1 0.15 59.8 66.0 0.19 reaction should be read? How tuberculin reaction should be 61.7 67.7 55.7 0.08 55.7 67.7 0.02 measured? What is the cutoff for positivity of MT in 41.5 44.8 38.2 0.19 34 49.0 0.02 non HIV patients? What is the cutoff for positivity of MT in 31.4 31.1 31.7 0.54 28.9 33.9 0.20 HIV patients? How will you manage an asymptomatic 50.9 57.3 44.5 0.04 46.4 55.4 0.08 patient with MT ≥15 mm? Does negative MT exclude TB? 89.3 85.4 93.2 0.04 89.7 88.9 0.45 What are the causes of negative M.T.? 30.2 33.3 27.1 0.19 30.9 29.5 0.26 Overall score Good 57.9 60.4 55.4 0.26 51.5 64.3 0.07 screening tool to detect active TB. Nearly three-fourths were seeing more than five patients per month however of FPs did not know the number of tuberculin units that this difference is not noteworthy. are injected during MT and around 60% of FP's did not Despite the widespread use of MT by the FPs, major know that a MT reading > 10 mm is taken as positive in gaps regarding its knowledge and clinical interpretation non-HIV patients in Pakistan. About half of the respon- and application were identified. Less than one fifth of the dents said they would start anti-tuberculosis treatment study participants scored at the level of ≥ 80% and this on an asymptomatic patient with MT readings of 15 mm low figure was equally documented among all study or more. About three-fourths of the respondents gave groups. Khan  and Manalo  also reported poor incorrect answers for the causes of negative MT and this knowledge about MT among first contact health persons poor understanding was equally prevalent in all compara- in high endemic TB prevalent countries. tive groups. Overall, proportions of correct responses of However, it was encouraging to note that aver 90% of some of the questions were reported higher by FPs who the FP's showed interest in gaining more knowledge about MT and its interpretation and clinical application. Ali et al. Asia Pacific Family Medicine 2010, 9:8 Page 4 of 4 http://www.apfmj.com/content/9/1/8 4. Khan JA, Malik A: Tuberculosis in Pakistan. Are we losing the battle? J Pak Med Assoc 2003, 53:320-321. 5. Marsh D, Hashim R, Hassany F, et al.: Front-line management of pulmonary tuberculosis: an analysis of tuberculosis and treatment practices in urban Sindh, Pakistan. Tuber Lung Dis 1996, 77:86-92. 6. Shah SK, Sadiq H, Khalil M, Noor A, Rasheed G, Shah SM, Ahmad N: Do private doctors follow national guidelines for managing pulmonary tuberculosis in Pakistan? East Mediterr Health J 2003, 9:776-788. 7. Khan J, Malik A, Hussain H, Ali NK, Akbani F, Hussain SJ, Kazi GN, Hussain SF: Tuberculosis diagnosis and treatment practices of private physicians in Karachi, Pakistan. East Mediterr Health J 2003, 9:769-775. 8. Butt T, Ahmad RN, Kazmi SY, Rafi N: Multi-drug resistant tuberculosis in Northern Pakistan. J Pak Med Assoc 2004, 54:469-472. 9. Centre for Disease Control and Prevention: Division of Tuberculosis Elimination (DTBE). Fact Sheet [http://www.cdc.gov/TB/pubs/ Being a multi-response question, sum is not 100% tbfactsheets/skintesting_eng.htm]. [Cited 2009 Mar 6] 10. Ali NS, Hussain SF, Azam SI: Is there a value of Mantoux test and Figure 1 Preference of respondents to obtain further knowledge erythrocyte sedimentation rate in pre-employment screening of about MT. health care workers for tuberculosis in a high prevalence country? Int J Tuberc Lung Dis 2002, 6:1012-1016. 11. Hussain R, Toossi Z, Hasan R, Jamil B, Dawood G, Ellner JJ: Immune Almost two thirds expressed the need to obtain this response profile in patients with active tuberculosis in a BCG vaccinated area. Southeast Asian J Trop Med Public Health 1997, information through CME. 28:764-773. 12. Manalo FMC, Pineda AV Jr, Montoya JC: Knowledge, Attitudes and Conclusion Practices for Tuberculosis among Filipino Family Physicians: A Comparative Analysis by Practice Setting and Location. Phil J Microbiol In spite of study participants practicing in urban Pakistan Infect Dis 1998, 27:6-12. and attending CMEs, a big gap was identified about the understanding of MT. We can assume even more unsatis- doi: 10.1186/1447-056X-9-8 factory knowledge about this important topic from FPs of Cite this article as: Ali et al., Family physicians understanding about Man- toux test: A survey from a high endemic TB country Asia Pacific Family Medi- rural and remote settings who does not have opportunity cine 2010, 9:8 to upgrade their medical knowledge. Continuous update on the recent evidence based knowledge should be incor- porated through CME sessions, lectures, seminars, work- shops and hand outs and booklets. More research work at larger scale is also suggested in this important topic amongst FPs in Pakistan. Competing interests The authors declare that they have no competing interests. Authors' contributions NSA conceived and designed the study and prepared the manuscript. KJ developed and administered the questionnaires and managed the data. AKK analyzed and interpreted the data and provided intellectual feedback through- out the study. All authors read and approved the final manuscript. Acknowledgements We are very much indebted to all study participants who agreed to participate in the study. We are also grateful to Mr. Iqbal Azam, Assistant Professor - Biosta- tistics, Department of Community Health Sciences, Aga Khan University, for the review and comments on this manuscript. Author Details 1 2 Family Medicine, Aga Khan University, Karachi, Pakistan and Family Medicine/ Community Health Sciences, Aga Khan University, Karachi, Pakistan Received: 18 November 2009 Accepted: 31 May 2010 Published: 31 May 2010 T © T Ah h s 2 ii ia s s 0 arti P i1 sa 0 an ci A cfll O ie ic F et i p sa e a avai m n l; l i A liy c cce lable M en e s s d s ee B f arti ici ro nm e icle o 2010, : h Med d ttp:/ istri C 9 / e bu :8 w nw tte ra w d l Lt .apf un dd .m ejr th .com e te /crm onte s o nft th /9e /1 C /8 reative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. References 1. WHO/TB/94.177: TB a global emergency. Geneva, WHO; 1994. 2. Global tuberculosis control: surveillance, planning, financing: WHO report 2008. . WHO/HTM/TB/2008.393 3. Marsh DR, Kadir MM, Husein K, Luby SP, Siddiqui R, Khalid SB: Adult mortality in slums of Karachi, Pakistan. J Pak Med Assoc 2000, 50:300-306.
Asia Pacific Family Medicine – Springer Journals
Published: May 31, 2010