Fifth-largest burden in the world, 140 deaths a day — and the only place in this section where a national programme tells WHO no, twice.
Pakistan's NTP explicitly refuses two WHO recommendations. The 4-month paediatric regimen "should not be used in routine program setting", and the 6-month TB meningitis regimen was rejected for insufficient evidence in favour of 12 months. Elsewhere in this section national bodies adapt WHO guidance. Here they decline it.
Every recommendation here carries a divergence badge.Same as international guidelinePakistan-adaptedLocal data onlyNational guideline outdated
Pakistan revised its National TB Management Guidelines in 2024, but the clinical document is not publicly available — the national programme websites no longer host a document library. This page is therefore built on the current National Strategic Plan 2024–2026 from the Ministry of National Health Services, the 2020 PMDT guidelines for drug-resistant TB, and the published summary of the 2024 paediatric updates.
Decision-support only, and an unusual sourcing caveat. Where drug-resistant TB regimen detail comes from the 2020 PMDT edition, it is badged as outdated — that edition predates the BPaLM regimen Pakistan has since adopted. Check your PMDT site's current protocol before prescribing.
🔬 Beta — pending clinical sign-off. Built on the National Strategic Plan 2024–2026, the 2020 PMDT guidelines and the published summary of the 2024 paediatric updates. Verify before acting.
Step 1 · The scale, and the gap
WHO Global TB Report 2025 · National Strategic Plan 2024–26
Top five in the world, and 140 deaths a day Local data only
Estimated cases, 2024
670,000
Share of global TB burden
6.3% — fifth worldwide
Position in Eastern Mediterranean Region
Largest contributor
Deaths
≈ 140 per day
Estimated incidence
264 per 100,000
Notified incidence
145 per 100,000
Share of the global gap between estimated and diagnosed cases
7.2%
The missing half. Those last three lines are the story. For every two people Pakistan diagnoses, roughly one more has TB and is not counted — walking around, infectious, untreated. Pakistan alone accounts for 7.2% of the world's missing TB cases.
Treatment works — until the organism is resistant Local data only
Drug-sensitive TB treatment success has been above 90% since 2012, and the 2020 cohort reached 94%. That is a genuinely good programme result. For pre-XDR and XDR-TB in the same period, treatment success was 67%.
That 27-point drop is the argument for everything in step 5 — and for not creating resistance in the first place, which is what step 6 is about.
Step 2 · Finding it
National Strategic Plan 2024–26 · NTP 2024 paediatric updates
What the programme says, and what actually happens Pakistan-adapted
Policy. The NTP has adopted WHO's diagnostic recommendations, including rollout of Xpert MTB/RIF Ultra in key health centres, and endorses computer-aided diagnosis software for reading digital chest X-rays in TB screening for people aged 15 and over.
Practice, in the programme's own words.The diagnosis of TB is still mainly based on smear microscopy because of the limited coverage of Xpert testing, and partial use of specimen transport systems.
There are 475 operational Xpert machines across 424 sites nationally, of which 33 are XDR machines and 33 sit in the private sector. Most are in tertiary hospitals and district or tehsil headquarters hospitals. In spite of decentralising Xpert to tehsil level, many patients still have no access to it.
What that means for you. So: request Xpert where you can get it, and know that a negative smear in a symptomatic patient does not exclude TB. If your facility has no Xpert, the specimen transport system is the route — use it rather than treating smear-negative as TB-negative.
Why it is flagged: WHO recommends rapid molecular testing as the initial diagnostic. Pakistan has adopted that as policy while its own strategic plan records that practice is still mainly smear microscopy. The honest position is both.
Diagnosing children Same as international guideline
Xpert MTB/RIF Ultra as the initial diagnostic tool for TB in children.
Stool and gastric aspirate specimens can be tested by Xpert Ultra — useful where a child cannot expectorate.
Computer-aided diagnosis software for digital chest X-ray applies to adults and adolescents aged 15 and over, not younger children.
Step 3 · Check the glucose
Pakistani bidirectional screening data
Screen every TB patient for diabetes Local data only
Among 6,312 people tested at TB treatment initiation in Pakistan, 1,516 — 24% — were newly diagnosed with diabetes. Not known diabetics: newly diagnosed.
Pakistan has both a top-five TB burden and one of the highest diabetes prevalences in the world, and the two feed each other. Diabetes raises TB risk and worsens TB treatment outcomes; TB worsens glycaemic control. Bidirectional screening programmes exist here for exactly this reason.
In practice. A TB diagnosis is one of the highest-yield opportunities you will get to find undiagnosed diabetes. Check a fasting glucose at treatment initiation — and remember the national diabetes guideline does not diagnose on HbA1c.
The diabetes side of this is covered in our type 2 diabetes pathway, including why the national guideline does not diagnose on HbA1c.
Step 4 · Which patient, and what Pakistan does differently
WHO versus NTP, side by side
Select a category. Each shows what WHO recommends and what the Pakistani programme actually does.
Step 5 · Preventive treatment
WHO 2022 · NTP 2024
TB preventive treatment Same as international guideline
WHO and the NTP both endorse a range of options: 6 or 9 months of daily isoniazid, 3 months of weekly rifapentine plus isoniazid (3HP), and 3 months of daily isoniazid plus rifampicin (3HR), with 1HP and 4R as further alternatives.
This is one area where Pakistani and WHO guidance align, which is worth knowing — the divergences in this pathway are specific, not general.
Step 6 · Where TB collides with the rest of your practice
Cross-pathway
Two things this pathway shares with the rest of the site
Rifampicin destroys hepatitis C treatment
Rifampicin is a potent P-gp inducer and is contraindicated with sofosbuvir-based direct-acting antivirals. Pakistan has both the world's largest hepatitis C burden and a top-five TB burden, so co-infection and co-treatment are routine rather than theoretical. Sequence the two; do not run them together.
A respiratory fluoroquinolone given empirically for pneumonia has antimycobacterial activity. In a patient whose "pneumonia" is actually TB, it blunts the clinical picture, delays the diagnosis, and selects for fluoroquinolone-resistant TB — which matters enormously here, because fluoroquinolone susceptibility is exactly what determines BPaLM eligibility.
Can I use the WHO 4-month regimen for a child with non-severe TB?
Not in a routine programme setting. Pakistan's NTP states the WHO-recommended 4-month regimen (2HRZ(E)/2HR) should not be used in routine programme settings, restricting it to specialised paediatric care. This is a national body declining a WHO recommendation rather than adapting it.
How long is TB meningitis treated in Pakistan?
Twelve months — 2HRZE followed by 10HR. The NTP rejected WHO's 6-month 6HRZEto option for insufficient evidence and maintains the longer standard.
Is BPaLM available in Pakistan?
It has been adopted, but access lags policy. BPaL(M) started in September 2022 in four PMDT sites in Punjab, and the National Strategic Plan targets scaling it from 1,862 to 4,589 patients across 2024–2026. Which regimen a patient actually gets depends on which PMDT site they reach.
Should I rely on a negative smear to exclude TB?
No. Pakistan's own National Strategic Plan states that diagnosis is still mainly based on smear microscopy because Xpert coverage is limited. There are 475 Xpert machines across 424 sites, mostly in tertiary and district hospitals. A negative smear in a symptomatic patient does not exclude TB — use the specimen transport system to get an Xpert.
How big is Pakistan's TB burden?
An estimated 670,000 cases in 2024 — 6.3% of the global total, fifth worldwide, and the largest contributor in the Eastern Mediterranean Region. TB kills around 140 people a day in Pakistan.
Why is the notification gap important?
Estimated incidence is 264 per 100,000 against notified incidence of 145. Pakistan accounts for 7.2% of the global gap between estimated and diagnosed cases — meaning a very large number of infectious people are undiagnosed and untreated.
Should TB patients be screened for diabetes?
Yes. Among 6,312 people tested at TB treatment initiation in Pakistan, 24% were newly diagnosed with diabetes. Pakistan has both a top-five TB burden and one of the world's highest diabetes prevalences, and each worsens the other.
Can I treat TB and hepatitis C at the same time?
Not with rifampicin and a sofosbuvir-based regimen. Rifampicin is a potent P-gp inducer and is contraindicated with sofosbuvir-based direct-acting antivirals. Sequence the two rather than running them together.
Sources
National Strategic Plan for Tuberculosis Prevention, Care and Control in Pakistan, January 2024 – December 2026. Ministry of National Health Services, Regulations and Coordination, Government of Pakistan. Source of the Xpert coverage figures, the smear-microscopy reality statement, the BPaL(M) rollout status and targets, and the treatment success rates.
National Guidelines for the Programmatic Management of Drug-Resistant Tuberculosis (PMDT), 2020 Edition. Source of the 9–11 month shorter all-oral regimen composition. NOTE: this edition predates BPaLM and is badged accordingly on this page.
Pediatric Tuberculosis: Key Updates from WHO Consolidated Guidelines 2022 and National TB Control Program, Pakistan Guidelines 2024. Pakistan Pediatric Journal. Source of the two NTP refusals of WHO recommendations, the paediatric diagnostic recommendations, and the TB preventive treatment options.
WHO Global Tuberculosis Report 2025 — source of the 670,000 cases, 6.3% global share, top-five ranking, and the 7.2% share of the global diagnostic gap.
Pakistani bidirectional TB–diabetes screening data — 6,312 people tested at TB treatment initiation, 24% newly diagnosed with diabetes.
SOURCING NOTE: the Revised National TB Management Guidelines 2024 — the clinical document itself — are not publicly retrievable. The national programme websites no longer host a document library, and five separate routes were attempted. Where drug-resistant TB regimen detail derives from the 2020 PMDT edition it is badged as outdated, because that edition predates BPaLM.