• Zia ul Haq Institute of Public Health and Social Sciences, KMU Peshawar-Pakistan
  • Saima Afaq Department of Health Sciences, University of York, York-United Kingdom
  • Farhad Ali Khattak Khyber College of Dentistry, Peshawar-Pakistan.
  • Sana Hussain Gandhara University, Peshawa-Pakistan
  • Sheraz Fazid Institute of Public Health and Social Sciences, KMU Peshawar-Pakistan
  • Abid Rahim Khyber College of Dentistry, Peshawar-Pakistan
  • Muhammad Zeeshan Haroon Department of Community Medicine Ayub Medical College, Abbottabad
  • Kamran Siddiqi Hull York Medical School, University of York, York-United Kingdom



Cardiometabolic, South Asia, Low- and middle-income countries, TB-diabetes comorbidity


Background: With the rise of non-communicable diseases (NCDs) in a country that is already facing high tuberculosis (TB) burden, TB multi-morbidity is likely to pose a significant public health challenge in Pakistan. Data were analysed to determine the prevalence of TB and explore the distribution and determinants of multi-morbidity associated with TB in the population of Khyber Pakhtunkhwa -a province of Pakistan. Methods: This is a secondary analysis of data gathered as part of the KPIPHS survey conducted in 2016-17 in both the rural and urban areas of Khyber Pakhtunkhwa, Pakistan. An interviewer-administered questionnaire was used to collect data, from adults, on demographics, education and socioeconomic status, physical and mental health, reproductive health, child health, health-related quality of life, and self-reported cardiometabolic diseases including Diabetes, hypertension, renal disorders, cardiac failure, angina, and stroke. Results: A total of 20,715 participants were recruited in the survey including 52.8% (n=10,943) males and 47.2% (n=9,772) females with a mean age of 41 (13.1) years. Data on TB status was available for a total of 14452 participants. The prevalence of TB in Khyber Pakhtunkhwa was found to be 0.49% (n=72) including an almost equal number of males and females [48% (n=34) vs 51% (n=36)], respectively. The mean age of the patients with TB was 47.5 (11.6) years. A higher proportion of people with TB had cardiometabolic diseases compared to people without TB (45.9% vs. 30.9%). Amongst the cardiometabolic disorders, self-reported hypertension (OR: 1.81, 95% CI 1.08–3.02, p=0.02), Diabetes (OR: 3.99, 95% CI 1.95-8.18, p=<0.002), and angina (OR: 3.88 95% CI 1.20–12.49, p=0.02) were positively associated with the occurrence of TB. In the adjusted analysis, only self-reported Diabetes was positively associated with the occurrence of TB (OR: 3.33, 95% CI 1.61-6.88, p=0.001). Conclusion: There is a higher burden of self-reported cardiometabolic diseases among people with TB, suggesting that this high-risk group should be screened for cardiometabolic diseases, especially Diabetes.


National TB data [Internet]. National TB Control Programme - Pakistan. National TB Programme; 2020 [cited 2022 Dec 17]. Available from:

Home [Internet]. National TB Control Programme - Pakistan. National TB Programme; 2020 [cited 2022 Dec 22]. Available from: [cited2022Dec17].Available from:

Stubbs B, Vancampfort D, Veronese N, Kahl KG, Mitchell AJ, Lin P-Y, et al. Depression and physical health Multimorbidity : Primary data and country-wide meta-analysis of population data from 190,593 people across 43 low- and middle-income countries. Psychol Med. 2017;47:2107–17.

France EF, Wyke S, Gunn JM, Mair FS, McLean G, Mercer SW. Multimorbidity in primary care: a systematic review of prospective cohort studies. Br J Gen Pract [Internet]. 2012 Apr;62(597):e297-307. Available from:

Van Kampen SC, Wanner A, Edwards M. International research and guidelines on post- tuberculosis chronic lung disorders: a systematic scoping review. BMJ Global Health. 2018;3.

Noubiap JJ, Nansseu JR, Nyaga UF. Global prevalence of diabetes in active tuberculosis: a systematic review and meta-analysis of data from 2•3 million patients with tuberculosis. The Lancet Global Health. 2019;7.

Duarte R, Lönnroth K, Carvalho C. Tuberculosis, social determinants and co- morbidities (including HIV). Pulmonology. 2018;

Lönnroth K, Roglic G, Harries AD. Improving tuberculosis prevention and care through addressing the global diabetes epidemic: from evidence to policy and practice. Lancet Diabetes Endocrinol [Internet]. 2014 Sep;2(9):730–9. Available from:

Viswanathan V, Kumpatla S, Aravindalochanan V, Rajan R, Chinnasamy C, Srinivasan R, et al. Prevalence of diabetes and pre-diabetes and associated risk factors among tuberculosis patients in India. PLoS One [Internet]. 2012 Jul 26;7(7):e41367. Available from:

Baker MA, Harries AD, Jeon CY, Hart JE, Kapur A, Lönnroth K, et al. The impact of diabetes on tuberculosis treatment outcomes: a systematic review. BMC Med [Internet]. 2011 Jul 1;9(1):81. Available from:

Shahdadi H, Salarzaee M, Balouchi A. Quality of life of diabetic patients with smear positive PTB in southeastern Iran: A cross-sectional study in a poor region of Iran. Indian J Tuberc [Internet]. 2018 Apr;65(2):159–63. Available from:

Shahdadi H, Salarzaee M. Balouchi A Quality of life of diabetic patients with smear positive PTB in southeastern Iran: A cross-sectional study in a poor region of Iran.

Mayosi BM, Burgess LJ, Doubell AF. Tuberculous pericarditis. Circulation [Internet]. 2005 Dec 6;112(23):3608–16. Available from:

Khyber Pakhtunkhwa integrated population health survey (KP-iphs) 2016-17. Khyber Med Univ J [Internet]. 2019 Dec 29; Available from:

WHO (2014). Pakistan: Health Profile.

National TB Control Program. (2014) National Strategic Plan “Vision 2020.”

Qadeer E, Fatima R, Yaqoob A, Tahseen S, Haq U, Ghafoor M, et al. Population based national tuberculosis prevalence survey among adults (> 15 years) in Pakistan. PloS one. 2010;11(2).

Shah SK, Dogar OF, Siddiqi K. Tuberculosis in women from Pashtun region: an ecological study in Pakistan. Epidemiol Infect [Internet]. 2015 Apr;143(5):901–9. Available from:

Stevenson CR, Forouhi NG, Roglic G, Williams BG, Lauer JA, Dye C, et al. Diabetes and tuberculosis: the impact of the diabetes epidemic on tuberculosis incidence. BMC Public Health [Internet]. 2007 Dec;7(1). Available from:

Miandad M, Nawaz-Ul-Huda S, Burke F, Hamza S, Azam M. Educational status and awareness among tuberculosis patients of Karachi. J Pak Med Assoc [Internet]. 2016 Mar;66(3):265–9. Available from:

Gebrecherkos T, Gelaw B, Tessema B. Smear positive pulmonary tuberculosis and HIV co-infection in prison settings of North Gondar Zone, Northwest Ethiopia. BMC Public Health [Internet]. 2016 Oct 18;16(1):1091. Available from:

Mehmood K, Junaid N. Prevalence of undiagnosed type 2 diabetes mellitus in Pakistan: Results of screen-diabetes disease registry. J Pak Med Assoc [Internet]. 2018 Aug;68(8):1171–8. Available from:

Shah N, Shah Q, Shah AJ. The burden and high prevalence of hypertension in Pakistani adolescents: a meta-analysis of the published studies. Arch Public Health [Internet]. 2018 Dec;76(1). Available from:

Basir MS, Habib SS, Zaidi SMA, Khowaja S, Hussain H, Ferrand RA, et al. Operationalization of bi-directional screening for tuberculosis and diabetes in private sector healthcare clinics in Karachi, Pakistan. BMC Health Serv Res [Internet]. 2019 Mar 6;19(1):147. Available from:

Wongtrakul W, Charoenngam N, Ungprasert P. Tuberculosis and risk of coronary heart disease: A systematic review and meta-analysis. Indian J Tuberc [Internet]. 2020 Apr;67(2):182–8. Available from:

Chung W-S, Lin C-L, Hung C-T, Chu Y-H, Sung F-C, Kao C-H, et al. Tuberculosis increases the subsequent risk of acute coronary syndrome: a nationwide population-based cohort study. Int J Tuberc Lung Dis [Internet]. 2014 Jan;18(1):79–83. Available from:

Hasanain AF, El-Maghraby KM, Zayed AA, Nafee AM, Abdel-Aal SM, Bakkar SM. Latent tuberculosis infection among patients with coronary artery stenosis: A case-Control study. International Journal of Mycobacteriology. 2018;7(2).

Huaman MA, Ticona E, Miranda G, Kryscio RJ, Mugruza R, Aranda E, et al. The relationship between latent tuberculosis infection and acute myocardial infarction. Clin Infect Dis [Internet]. 2018 Mar 5;66(6):886–92. Available from:

Seegert AB, Rudolf F, Wejse C, Neupane D. Tuberculosis and hypertension-a systematic review of the literature. International journal of infectious diseases. 2017;56:54–61.

Tahir Z, Akhtar AM, Yaqub T, Mushtaq MH, Javed H. Diabetes mellitus among tuberculosis patients: a cross sectional study from Pakistan. African health sciences.

Amin S, Khattak MI, Shabbier G, Wazir MN. Frequency of pulmonary tuberculosis in patients with diabetes mellitus. Gomal Journal of Medical Sciences. 2011;9(2).

Yurteri G, Saraç S, Dalkýlýç O, Ofluoðlu H, Demiröz ÖF. Features of pulmonary tuberculosis in patients with diabetes mellitus: A comparative study. Ch Hop Ýst Turk. 2004;1:5–8.

Jeon CY, Murray MB. Diabetes mellitus increases the risk of active tuberculosis: a systematic review of 13 observational studies. PLoS Med [Internet]. 2008 Jul 15;5(7):e152. Available from:

van Crevel R, Dockrell HM, TANDEM Consortium. TANDEM: understanding diabetes and tuberculosis. Lancet Diabetes Endocrinol [Internet]. 2014 Apr;2(4):270–2. Available from:

Ukwaja KN, Modebe O, Igwenyi C, Alobu I. The economic burden of tuberculosis care for patients and households in Africa: a systematic review [Review article]. Int J Tuberc Lung Dis [Internet]. 2012 Jun 1;16(6):733–9. Available from:



Most read articles by the same author(s)