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Objective: The aim of this study is to describe the epidemiological and clinical aspects of patients who applied to the Bursa Nilufer Tuberculosis Dispensary by investigating the trends in epidemics over three decades.
Method: In this retrospective observational study, the records of all tuberculosis cases (1630 patients) treated in the last 30 years (1985-2014) at the Bursa Nilufer Tuberculosis Dispensary were examined and statistically analyzed.
Results: Males comprised 65.2% of the patients. The ages of the patients ranged from 1 to 87 years, and the mean age was 37.4 (95% CI: 36.6-38.2). Among the cases, 86.7% were new infections and 74.1% were pulmonary tuberculosis. In the last decade, the education level, the percentage of patients who had received a BCG vaccination, the proportion of women and active employees among them increased (p<0.05), while it decreased among men (p<0.05). Clinical symptoms accompanying TB such as weakness, anorexia, weight loss, and cough, decreased to a statistically significant degree (p<0.05). In the last decade, the mortality rate was 3.6% and increased compared with previous decades (p<0.05). Mortality was higher among patients who were elderly, male, did not have a BCG scar or had a chronic disease (p<0.05).
Conclusion: This study adds information about the change of TB epidemics in Turkey in the last 30 years. Further studies are needed to determine the risk factors associated with tuberculosis mortality and to evaluate the effectiveness control programs of this disease.
(TB) is a disease that primarily affects the lungs, but it can spread
to extrapulmonary organs through lymphogenic and hematogenous routes.1
Approximately one-third of the world population has an asymptomatic and
non-infectious latent infection. About 10% of these asymptomatic
patients progress to active disease and approximately 45% of
individuals with the active disease die if it is not treated.[1,2]
The World Medical Association emphasizes that poverty fuels the spread of tuberculosis by causing limited access to primary health care services, inducing malnutrition, and inadequate living conditions; therefore, tuberculosis should be considered as a disease of poverty and inequality.
Despite notable progress in the past decade, tuberculosis is still a public health concern in most of the countries within the World Health Organization (WHO) European Region. Countries outside of the European Union (EU) and European Economic Area (EEA) still suffer from high rates of TB and multidrug-resistant TB, while EU/EEA countries have a significant number of TB cases among vulnerable population groups, such as people of foreign origin and prisoners. In 2014, an estimated 340 000 incident cases of TB (range 320 000–350 000) occurred in the WHO European Region, equivalent to 37 cases (35–38) per 100 000 population. This number represents about 3.6% of the total burden in the world. About 83% of incident TB cases in 2014 occurred in the 18 high-priority countries. Turkey is one of the 18 high-priority countries.
The first data regarding the epidemiological situation of tuberculosis in Turkey pertained to the year 1950. TB mortality, which was 204/100.000 in 1950, decreased to 8.8/100.000 in 1980 and 1.6/100.000 in 2000. While the tuberculosis incidence was 177/100.000 according to the values for 1960, it dropped to 24/100.000 in 2002. In Turkey, the estimated TB prevalence was 22/100.000, the incidence was 18/100.000, and the mortality was 0.61/100.000 for 2014.
In Turkey, the TB control program began in 1918 under the guidance of Tuberculosis Control Associations, which were voluntary organizations, and have been maintained via vertical structuring within the Ministry of Health and provincial organizations. Public Health Law (No. 1593, 1930) designated tuberculosis as a notifiable disease and made its treatment free of charge. In Turkey, information regarding the patients comes primarily from the records of Tuberculosis Control Dispensaries (TCDs). Valuable information resources are also the general death records and the results of epidemiologic studies. Since 2007, the Department of Tuberculosis Control has collected information regarding patients registered at the TCDs and has published them as reports.
TCDs are the health institutions that provide diagnosis, treatment, follow-up and control, patient notification, registration, archiving and statistics, immunizations, screening, drugs, training, health education activities, social welfare, coordination, and consultancy. The TCD follows the guidelines of "Stop TB Strategy" and the "International Standards for Tuberculosis Care" adopted by the WHO.
Bursa Nilufer Tuberculosis Control Dispensary was established as the Bursa Tuberculosis Control Association in 1948 and was included among public interest associations in 1949. Since its service building moved from the city center to the Nilufer district in 2003, the Association has provided services as the Nilufer Tuberculosis Control Association Dispensary.
The dispensary case series are relevant for determining the current situation of tuberculosis in Turkish.
In this study, we analyzed socio-demographic characteristics, the clinical findings, diagnosis and treatment processes and treatment results of the patients who applied to Bursa Nilüfer Tuberculosis Control Dispensary (NTCD) in a period of thirty years.
is the fourth most populous city (1.8 million) in Turkey and is located
in Northwestern Anatolia in Turkey. Nilufer is one of the three central
districts of Bursa which was established on the western side of the
city. Nilufer is the newest and most planned and organized district of
Bursa; it is the most rapidly urbanizing area of the city, and its
population is slight over 300.000. The Nilufer ranks the first place
amongst the districts of Bursa significantly contributing to the
economy of Turkey and Bursa. The first Organized Industrial Zone of
Turkey has been established within the district of Nilufer in 1961.
There are twenty-three Family Health Centre, one Community Health
Center, one Tuberculosis Control Dispensary and two public hospitals in
This descriptive study was carried out between June 2014 and February 2015. The files of all cases (1662 people) receiving tuberculosis treatment in Nilufer Tuberculosis Control Dispensary (NTCD) were reviewed, comprising the treatments of the last 30 years (1985-2014). Thirty-two patients who had started treatment of tuberculosis were later diagnosed carriers of another disease and then excluded from this study. Therefore only the data of 1,630 patients were evaluated.
TB cases were diagnosed both in Dispensary and public hospitals. Pulmonary TB was diagnosed by X-ray, smear microscopy of sputum and sputum culture. The most commonly used media for the isolation of tuberculosis were solid egg-based (Löwenstein–Jensen, Ogawa) and agar-based (Middlebrook 7H10 or 7H11) media; manual liquid synthetic (Middlebrook 7H9) and automated liquid media (Bact/Alert 3D, MGIT 960, VersaTREC). Non-pulmonary TB was diagnosed only in hospitals. According to legislation in Turkey, patients diagnosed of TB in hospitals referred to the regional dispensary for receiving TB treatment. In 30 years there was no change in the definitive TB diagnosis (X-ray, smear microscopy of sputum and sputum culture) in Dispensary; but there is no information in defining TB diagnosis methods in the hospitals in the dispenser records.
In this study, were retrospectively examined the tuberculosis patient registers, tuberculosis patient monitoring vouchers, patient examination forms and computer records. The data obtained were included in a data collection form consisting of 48 questions. The patients’ socio-demographic information (age, gender, marital status, educational status, profession, work conditions, social security status), the presence of chronic disease, TB history, the history of contact with a tuberculosis patient, the presence of a Bacillus Calmette-Guérin (BCG) scar, symptoms accompanying the diagnosis, case description, reason for examination, TB locations and treatment result were examined in this form. The underlying concepts and definitions used in this study were based on the "T. R. Ministry of Health Tuberculosis Diagnosis and Treatment Guidelines 2011". The occupations of working patients were classified according to the International Standard Classification of Occupations ISCO 08.
Drug resistance has been evaluated in patients since mid-1990’s. TB resistance was determined by drug susceptibility testing. In the laboratory, drug susceptibility testing of TB isolates was performed by the proportion methods (agar based MB 7H10/11, Löwenstein Jensen); automated fluid systems (MGIT 960, VersaTREK) and molecular methods (Real-time PCR, reverse hybridization). Multidrug-resistant TB is resistant to at least isoniazid and rifampin. Patients with the following characteristics were considered at risk of MDR-TB:
• Failure of retreatment regimens,
• Chronic TB cases,
• Exposure to a known MDR-TB case,
• Failure of first-line chemotherapy,
• Relapse and return after default without recent treatment failure, and
• History of using poor or unknown quality TB drugs.
TB treatment has been changing for the last 30 years period in the dispensary. In the first two decades nine-month treatment regimens were applied (in the first two months isoniazid, rifampin, pyrazinamide, and ethambutol or streptomycin and then for 7 months isoniazid and rifampin). In the last decade, a six-months standard TB treatment was applied. Standard TB treatment includes the use of 4 drugs: rifampin, pyrazinamide, isoniazid, and ethambutol given for two months, followed by a rifampin/isoniazid continuation phase for an additional four months.
The permission for the study was received from Uludağ University, Faculty of Medicine, Ethics Committee (dated June 10, 2014, and numbered 2014-12/3).
The research data were evaluated using the SPSS 18.0 software package. The descriptive statistics, chi-square test, chi-squared test for trend and Fisher's exact test were employed in the data analysis. A p-value less than 0.05 was considered significant.
|Table 1. Gender and age distribution of the cases according to ten-year periods|
|Table 2. Socio-demographic characteristics of the cases according to ten years periods.|
|Table 3. Distribution of some variables related to diagnosis and treatment according to ten-year periods.|
|Table 4. Distribution of gender, age group, and involvement site among cases according to contact history, BCG scar presence and relapse.|
|Table 5. Distribution of gender, age group and treatment success among cases according to involvement site.|
|Table 6. Distribution of the bacteriology of pulmonary TB cases according to ten-year periods.|