Ewa Rowińska-Zakrzewska1, Maria Korzeniewska-Koseła2, Kazimierz Roszkowski-Śliż3

1Emeritus Professor, MD, PhD, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland

2Department of Epidemiology and Tuberculosis, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
Head: Associate Professor M. Korzeniewska-Koseła, MD, PhD

3Third Department of Lung Diseases, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
Head: Prof. K. Roszkowski-Śliż, MD, PhD

The epidemiological situation of tuberculosis in Poland: Part I. According to notification rates, the incidence of tuberculosis varies in different regions of Poland: is this true?

Sytuacja epidemiologiczna gruźlicy w Polsce: Część I. Rejestrowana zapadalność na gruźlicę jest różna w poszczególnych regionach Polski — czy to prawda?

The authors declare no finacial disclosure

Introduction

Epidemiological aspects of tuberculosis posed a vast problem in the second half of the 20th century in Poland. In the years 1957–1960 the incidence rate amounted to 290.4–289.3/100,000 [1]. In April 1959 this situation provided the impetus for passing the law on tuberculosis control. The staff of the National Institute of Tuberculosis drew up the National Tuberculosis Control Programme, which determined the objectives, methods and measures to improve the situation. The Programme was approved by the Ministry of Health. The main unit to control tuberculosis became the National Institute of Tuberculosis and Lung Diseases, and in other regions of the country, Regional and Local Outpatient Clinics of Lung Diseases [2].

The Programme implemented free of charge prevention, diagnosis, therapy and rehabilitation for TB patients. The law also provided long-term, payable sick leave for the period of treatment to all insured patients. It also confirmed obligation of BCG vaccination of neonates [2].

During consecutive years a distinct decrease in TB incidence was noted. In 2008 the problem of TB was included into the law on infections and infectious diseases. The law was amended in July 2012, which resulted in an efficient system of TB notification and directing patients to appropriate centres for treatment [3, 4].

Between the years 2010 and 2012 the incidence rate of tuberculosis was only 19.7–22.2/100,000. Nevertheless, the prevalence of tuberculosis in Poland, apart from the Baltic countries, Bulgaria, Romania and Portugal, is one of the highest in the European Union [5, 6]. In addition, the incidence of tuberculosis in Poland is different in various regions [1, 5]. Between 2010 and 2012, in some regions, the incidence rate was as low as 10.9/100,000 and in others as high as 30.2/100,000 [1, 7, 8].

Similar differences also occur in other countries, but they are usually caused by different ethnic or geographical origins of patients, or by HIV epidemic [9–11]. In Poland foreigners constitute barely 0.6% of all tuberculous patients, and according to official data, HIV infections affect a small proportion of tuberculous patients [1, 12, 13].

The objective of the study

The objective of the study was to compare the groups of patients reported in particular regions and to assess whether the differences in the degree of disease severity, its type, location and the age of patients confirm a real difference between particular regions in respect of TB epidemiology.

Material and methods

The material of the study consisted of data from the National TB Register (reports of Regional Administration Units for Control of Epidemics and Hygiene Promotion, and Regional Outpatient Clinics of Lung Diseases), published mainly in Bulletins of the Department of Epidemiology and Tuberculosis, and data from the Central Statistical Office of Poland (GUS, Główny Urząd Statystyczny), also available in Bulletins [1, 7, 8].

The regions with the highest incidence of TB were compared to those with the lowest incidence. Only those regions with a relatively small variability of TB incidence rates during the study period (2010–2012) were selected. Finally, the material included three regions of incidence from 25.6 to 30.2/100,000 population (the Silesian, Łódź, Lublin regions) — Group I; and five regions with incidence rate from 10.9 to 19.0/100,000 population (the Wielkopolska, Podlasie, Opole, Małopolska and Kuyavia and Pomerania regions) — Group II.

The groups of patients registered in particular regions between 2010 and 2012 were analysed. The comparison of Group I and II included:

1. The proportion of patients with bacteriologically confirmed TB.

2. The prevalence of drug resistance of tubercle bacilli.

3. The proportion of relapses.

4. The occurrence of severe or chronic forms of TB.

5. The proportion of extrapulmonary TB and its location.

6. The distribution of the patients’ ages.

Data are presented separately for each region, taking into account all patients registered during three years, and jointly for all regions from the group.

To determine the statistical significance of the relations between the variables, the chi-squared test was used. P < 0.05 was assumed as a significant value.

Results

The mean TB incidence rate in the regions from Group I during the study period was 29.5/100,000 and it was significantly higher than the rate for Group II, which amounted to 14.8/100,000. However, in regions with registered higher incidence, significantly fewer cases were bacteriologically confirmed. This may indicate inadequacies in diagnosis in Group I. Nevertheless, the incidence rates of bacteriologically confirmed TB in this group were still significantly higher than relevant rates for Group II; thus, both selected groups met the criteria for the comparison of regions with higher and lower incidence of TB (Table 1).

The proportion of sputum-positive patients with tubercle bacilli resistant to one drug was found markedly more often in the group of regions with higher TB incidence; however, the distribution of multidrug resistant TB was comparable in both groups (Table 2).

The proportion of relapses of TB (or recurrences) was comparable in both groups (Table 3).

The proportion of patients diagnosed due to the occurrence of symptoms was significantly higher in regions from Group I, compared to Group II (p < 0.0001).

Fibro-cavernous TB was diagnosed markedly more frequently in patients registered in regions from Group I than from Group II (Table 4).

The occurrence of acute forms of TB was sparse and it was comparable in both groups. The exception was caseous pneumonia, which occurred significantly more frequently in Group I, but it concerned almost exclusively the Łódź region (Table 5).

Extrapulmonary TB was equally frequent in both groups. However, it should be emphasised that the changes typical for primary tuberculosis (exudative pleuritis and lymphonodular tuberculosis in the chest) were found significantly more often in Group I than in Group II (Table 6).

In contrast, in Group II, significantly more often tuberculosis of the peripheral lymph nodes was found, which is mainly a disease of adult patients [14].

Because tuberculous pleuritis and lymphonodular tuberculosis in the chest are usually related to early age, the age brackets in the two analysed groups were compared (Table 7). It was found that Group I, compared to Group II, included markedly more children with TB, whereas Group II included significantly more elderly patients, above 65 years of age.

Discussion

The presented data show that the differences in the epidemiology of tuberculosis in various regions of Poland are real. In the regions with higher incidence rates (Group I), severe forms of TB occur more often, particularly fibro-cavernous TB and caseous pneumonia.

The proportion of patients with TB diagnosed due to the occurrence of symptoms in Group I was higher, and the resistance of tubercle bacilli to at least one drug was found more frequently than in Group II. Pleural effusion and enlargement of the lymph nodes in the chest, typical of primary TB, were also found more often in Group I. The occurrence of lymphonodular tuberculosis in the chest and exudative pleuritis in youngsters was found in another paper by Polish authors [15]. The relation between these forms of TB and early age was also observed by researchers from Germany and Estonia [16, 17]. Tuberculosis of the peripheral lymph nodes, typical for adults [14], was found more often in patients from Group II.

According to those facts, we found in Group I a higher proportion of young patients, compared to Group II. At the same time, in Group II, TB was found significantly more frequently in patients above 65 years of age. Such age distribution is typical of other environments with worse epidemiological situation [18].

Conclusions

Based on the presented data, it was found that the epidemiological situation is very different in various regions of Poland. The fundamental problem, however, is to find reasons for this phenomenon. A possible cause of this situation will be presented in a following publication.

Conflict of interest

The authors declare no conflict of interest.

Address for correspondence: prof. dr hab. n. med. Ewa Rowińska-Zakrzewska, Instytut Gruźlicy i Chorób Płuc w Warszawie, tel.: 22 431 21 77, e-mail: monika.szturmowicz@gmail.com

DOI: 10.5603/PiAP.2014.0043

Praca wpłynęła do Redakcji: 12.02.2014 r.

References:

1. Korzeniewska-Koseła M. (red.). Gruźlica i choroby układu oddechowego w Polsce w 2010 roku. IGiChP, Warszawa, 2011.

2. Szczuka I. Program i organizacja zwalczania gruźlicy w Polsce. W: Rowińska-Zakrzewska E. (red.). Gruźlica w praktyce lekarskiej. Wyd. Lek. PZWL, Warszawa 2000; 246–254.

3. Augustynowicz A., Wrześniewska-Wal I. Ograniczenie autonomii pacjenta w diagnozowaniu i leczeniu gruźlicy. Pneumonol. Alergol. Pol. 2013; 81: 130–136.

4. Augustynowicz-Kopeć E., Demkow U., Grzelewska-Rzymowska I. et al. Zalecenia Polskiego Towarzystwa Chorób Płuc dotyczące rozpoznawania, leczenia i zapobiegania gruźlicy u dorosłych i dzieci. Pnemonol. Alergol. Pol. 2013, 81: 323–379.

5. Korzeniewska-Koseła M. Gruźlica w Polsce w 2011 roku. Przegl. Epidemiol. 2013; 67: 375–378.

6. ECDC and World Health Organization: Tuberculosis surveillance and monitoring in Europe 2013, ECDC, Stockholm 2013; 1–215.

7. Korzeniewska-Koseła M. (red.). Gruźlica i choroby układu oddechowego w Polsce w 2011 roku. IGiChP, Warszawa 2012.

8. Korzeniewska-Koseła M. (red.). Gruźlica i choroby układu oddechowego w Polsce w 2012 roku. IGiChP, Warszawa 2013.

9. Chouaid C. Epidemiologie de la tuberculose en France, hors metropole: enjeux et perspectives. Rev. Mal. Respir. 2012; 29: 856–857.

10. Cadelis G., Rossigneux E., Millet J., Rastogi N. Etude epidemiologique comparative de la tuberculose des sujets migrants et natifs en Guadoelupe de 2006 a 2011. Rev. Mal. Respir. 2012; 29: 858–870.

11. Trends in tuberculosis – United States, 2010, MMWR 2011; 60: 333–337.

12. Jagodziński J., Zielonka T.M. Obcokrajowcy leczeni na gruźlicę w Mazowieckim Centrum Leczenia Chorób Płuc i Gruźlicy w Otwocku. Pneumonol. Alergol. Pol. 2010; 29: 399–406.

13. Łucejko M., Grzeszczuk A., Rogalska M., Flisiak R. Incidence of tuberculosis and mycobacteriosis among HIV-infected patients — clinical and epidemiological analysis of patients from north-eastern Poland. Pneumonol. Alergol. Pol. 2013; 81: 502–510.

14. Fontanilla J.M., Barnes A., Fordham von Reyn C. Current diagnosis and management of peripheral tuberculous lymphadenitis. Clin. Infect. Dis. 2011; 539: 555–562.

15. Rowińska-Zakrzewska E., Korzeniewska-Koseła M., Roszkowski-Śliż K. Gruźlica pozapłucna w Polsce w latach 1974–2010. Pneumonol. Alergol. Pol. 2013; 81: 121–129.

16. Forssbohm M., Zwahlen M., Loddenkemper R., Rieder H.L. Demographic characteristics of patients with extrapulmonary tuberculosis in Germany. Eur. Respir. J. 2008; 31: 99–105.

17. Pehme L., Hollo V., Rahu M., Altraya A. Tuberculosis during fundamental societal changes in Estonia with special reference to extrapulmonary manifestations. Chest 2005; 127: 1289–1295.

18. Hollo V., Amato-Gauci A., Kodmon C., Manissero D. Tuberculosis in the EU and EEA/EFTA countries — what is the latest data telling us? Eurosurveillance 2009; 14: 44–47.