Al-Azhar Assiut Medical Journal

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 16  |  Issue : 4  |  Page : 319--326

Comparative study of the pattern of tuberculosis in Suez and Damietta Chest Hospitals in the period 2007–2016


Fares Mohammed Oaf1, Ezzat Atwa Risk2, Abd El Monem El-Shabrawi Metwally1, Kamel Abd-Elghafar Elghonemy1, Mokhles Abdel Fadil Zineldin1, Abdel-Fatah Ahmed Abdel-Khalek3,  
1 Department of Chest Diseases, Al-Azhar Faculty of Medicine, Cairo, Egypt
2 Department of Chest Diseases, Vice Dean Faculty of Medicine, Damiett, Egypt
3 Department of Chest Disease, Damiett, Egypt

Correspondence Address:
Mokhles Abdel Fadil Zineldin
Al Radwan Street, Atay Al Baroud, Beheira 22951
Egypt

Abstract

Background Tuberculosis (TB) is an infectious disease affecting the world population for thousands of years. Aim The aim was to study and compare the pattern of TB in Suez and Damietta Chest Hospitals through the period from 2007 to 2016. Patients and methods This is a retrospective study that was carried out at Damietta and Suez Chest Hospitals and dispensaries and included all cases of TB from January 2007 to December 2016. Data were collected from TB registration units. Direct observed therapies strategy in chest hospitals and dispensaries started since January 1999. Results A total of 1208 (62.3%) cases were men and 732 (37.7%) were women. The highest rate of infection was reported in age group of 20–29 years (45.7%); the lowest affected age group was that greater than 60 years (5.1%). Type of TB was pulmonary in 76.1% and extrapulmonary in 23.9%. The main presenting symptom was cough presented in 50.8%, hemoptysis in 20.3%, chest pain in 14.7%, and fever in 14.2%. The sputum smear was positive in 89.3% and negative in 10.7%; and there was significant increase of positive smear in Damietta when compared with Suez Governorates (92.1 vs. 86.2%, respectively). The most common extrapulmonary lesion was pleural effusion (40.5%); then lymph node (19.4%) and the least was cold abscess (2.6%). Diabetes was reported in 11.5% and prolonged corticosteroid therapy in 6.5%. The condition at discharge was improvement in 85.5%, failure in 6.6%, relapse in 4.8%, and death in 3.1%. Both groups were comparable as regards the studied variables. Conclusion There was progressive decrease of total TB cases in both Damietta and Suez Governorate from 2007 to 2016 and both governorates were comparable.



How to cite this article:
Oaf FM, Risk EA, El-Shabrawi Metwally AM, Elghonemy KA, Zineldin MF, Abdel-Khalek AFA. Comparative study of the pattern of tuberculosis in Suez and Damietta Chest Hospitals in the period 2007–2016.Al-Azhar Assiut Med J 2018;16:319-326


How to cite this URL:
Oaf FM, Risk EA, El-Shabrawi Metwally AM, Elghonemy KA, Zineldin MF, Abdel-Khalek AFA. Comparative study of the pattern of tuberculosis in Suez and Damietta Chest Hospitals in the period 2007–2016. Al-Azhar Assiut Med J [serial online] 2018 [cited 2020 Mar 29 ];16:319-326
Available from: http://www.azmj.eg.net/text.asp?2018/16/4/319/256776


Full Text



 Introduction



Tuberculosis ((TB)) is a communicable disorder caused by Mycobacterium tuberculosis. The tuberculous bacilli were initially isolated in 1883. However, bacilli have been affecting the population globally for thousands of years. Throughout the Industrial Revolution, which was associated with environmental crowding and general poverty, the highest registered morbidity and mortality happened in late 1700s and early 1800s [1].

WHO builds annual rounds of global TB infection. It included data from 204 countries and 182 members of United Nations in 2012. These data represented 99% of TB infections all over the world. TB infection had been decreasing for many years, for example, at a rate of 2.2% from 2010 to 2011 [2].

Mortality rate is very high if no treatment was considered. Around 70% of patients have died during 10 years in sputum smear-positive and HIV-negative infections of pulmonary TB [3].

There are many risk factors that change the incidence of TB, such as vulnerability to TB and low socioeconomic status (poverty, housing, nutrition, and access to healthcare) [4]. TB remains a chief worldwide health problem. It leads to ill-health in millions of people annually and is the second principal reason of death from an infectious disease worldwide after the HIV. It is estimated that there were nearly nine million new infections in 2011 and 1.4 million TB mortalities (990 000 among HIV-negative people and 430 000 HIV-linked to TB deaths). This is regardless of the accessibility of drugs that will cure most patients with TB. Short-course schedules of first-line drugs that can cure about 90% of cases have been in existence since 1980s [2].

 Aim



The aim of this work was to study and compare the pattern of TB in Suez and Damietta Chest Hospitals through the period from 2007 to 2016.

 Patients and methods



This is a retrospective study that was carried out at Damietta and Suez Chest Hospitals and dispensaries to include all cases of TB from January 2007 till December 2016 According to ethics committee approval. The materials in this study were collected from TB registration units in Damietta and Suez Governorates. Directly observed therapy short course (DOTS) in chest hospitals and dispensaries started since January 1999. The collected data included TB registration code, name, age group, sex, residence, laboratory diagnosis (sputum examination, culture result, and radiology), regiment of treatment, sputum examination at 0, 2 months, and at the end of initial phase of treatment, the final outcome.

Indicators were measured every year to determine National Tuberculosis Program (NTP) quality and effectiveness. These indicators included (a) incidence rate (case notification rate): for new cases, new and relapse cases, all cases and new smear-positive pulmonary cases; (b) new pulmonary TB cases with no smear result; (c) new adult smear-positive cases; (d) retreatment TB cases; (e) new extrapulmonary TB cases; (f) new TB cases with no smear conversion result; (g) sputum conversion rate at the end of the initial phase of treatment; (h) cure rate; (i) treatment completion rate; (j) death rate; (k) treatment failure rate; (l) default rate; (m) transfer outrate; and (n) retreatment failure rate (chronic TB rate).

Data analysis

A descriptive analysis of data was performed. Unpaired Student’s t-test was used for comparison of independent data that followed a normal distribution. The Student’s t-test for repeated measurements was used for paired data, if they followed a normal distribution. Otherwise, the Wilcoxon rank sum test was applied and χ2 which was used to compare between more than two percentages; the SPSS statistical program was used. Statistical significance was set at P less than 0.05. The analysis was performed using the SAS software (SAS Institute, Cary, North Carolina, USA) version 9.1 for Windows, test of proportion (Z-test) which was used to compare between two percentages (P1 and P2) [5]. A P value less than 0.05 means statistical significance.

 Results



As regards sex distribution, 1208 (62.3%) cases were men and 732 (37.7%) were women and there was no significant difference between Damietta and Suez Governorates (men presented 62.5% and 62.4% of Damietta and Suez Governorates, respectively) ([Table 1]). Regarding age group, the highest rate of infection was reported in the age group of 20–29 years (45.7%); then 10–19 years (10.2%); while the lowest affected age group was that greater than 60 years (5.1%). There was no significant difference between Damietta and Suez as regards age group distribution ([Table 1]). As regards the type of TB, it was pulmonary in 1476 (76.1%) cases and extrapulmonary in 464 (23.9%) cases; and there was no significant difference between Damietta and Suez Governorates as regards the type of TB (pulmonary TB represented 76% in Damietta and 76.2% in Suez Governorate) ([Table 2]). As regards the main presenting symptom in the present study, cough was the most common presented in 50.8% of cases, followed by hemoptysis in 20.3%, chest pain in 14.7%, and fever in 14.2% and there was no significant difference between Damietta and Suez as regards the main presenting symptom ([Table 2]). As regards the results of smear in sputum smear, it was positive in 1318 (89.3%) cases and negative in 158 (10.7%) cases; and there was significant increase of positive smear in Damietta when compared with Suez Governorates (92.1 vs. 86.2%, respectively) ([Table 2]). As regards extrapulmonary lesion, the most common was pleural effusion (188 cases; 40.5%), then lymph node (19.4%) and the least was cold abscess (2.6%), then urinary (2.8%), and there was no significant difference between Damietta and Suez Governorates as regards extrapulmonary lesion ([Table 3]). As regards diabetes, it was reported in 224 (11.5%) cases and prolonged corticosteroid therapy was reported in 126 (6.5%) cases; and there was no significant difference between Damietta and Suez Governorates as regards diabetes or prolonged corticosteroid therapy ([Table 4]). As regards the condition at discharge, improvement was reported in 85.5%, failure in 6.6%, relapse in 4.8%, and death in 3.1%, and there was no significant difference between Damietta and Suez Governorates ([Table 5]).{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}

 Discussion



TB is a problem of global importance; it is a medical, social, and economic disaster of immense magnitude that is occurring over the world (WHO, 2005).

TB infects about nine million new patients and causes two million deaths every year worldwide. The estimated incidence of TB has declined by 1.3% per year in the world since 2002 (141/105 in 2002 compared with 128/105 in 2010), but some countries, especially in Asia and in Sub-Saharan Africa are still particularly affected [6],[7].

In the early 1990s TB control in Egypt faced many problems, the most important of these problems were refusal by tuberculous patients to be hospitalized for their treatment, high defaulter rate, increasing levels of resistance against antituberculous drugs, and insufficient and deficient health education to both community and health staff [8].

DOTS means that a trained healthcare worker or other designated individuals provide prescribed antituberculous drugs and watches the patient while swallowing each dose [9].

The main goals of TB treatment are to cure individuals with the disease and to minimize the transmission of mycobacterium TB to others in the community [10].

The present work was designed to study and compare the pattern of TB in Suez and Damietta Chest Hospitals through the period from 2007 to 2016. This is a retrospective study that was carried out at Demietta and Suez Chest Hospitals and dispensaries to include all the cases of TB from January 2007 till December 2016. The materials in this study were collected from TB registration units in Demietta and Suez Governorates.

In the present work, there was progressive decrease of total TB cases in both Damietta and Suez Governorates from 2007 to 2016. However, Damietta showed an increase in 2009 when compared with previous years, then declined again; while the lowest number of cases in Suez Governorate registered was in 2007 and 2013.

This decline attitude is similar to that reported in developed countries, for example France, where it was reported that the number of notified TB cases has been decreasing for several decades and reached 10 new cases per 100 000 inhabitants in 2004 [11].

In the present work, 1208 (62.3%) cases were men and 732 (37.7%) were women and there was no significant difference between Damietta and Suez Governorates as regards sex distribution (men presented 62.5 and 62.4% of Damietta and Suez Governorates, respectively). No six differences among studied years was obtained in either Damietta or Suez Governorates (i.e. men represented the higher percentage in each year from the start to the end years).

The high prevalence of TB in men could be explained by the fact that men are more active and are exposed to stress more than women. Also, many women may not seek medical advice due to factors related to illiteracy, cultural, and traditional attitudes which may neglect the females’ health status. Higher TB notification rates among men may partly indicate differences in exposure due to more frequent social contacts, risk of infection, and progression from infection to disease caused by gender differences in association with other risk factors for TB such as alcohol abuse and smoking which are associated with pulmonary TB [12].

The results of the present study are comparable to those reported by Floyd et al. [13] which found that male cases were 80.2% and female cases were 19.8%. In addition, Abu Shabana et al. [12] reported that TB was common among men (82.2%) than women (10.4%). Also, this in agreement with the results found by Abdel Hameed and Abd El Hakim [14] in a study done over four governorates (Cairo, Port Said, Zagazig, and Damietta) studying circumstantial evidences and the predisposing factors of pulmonary TB and they reported that 83% of cases were men and 17% were women.

In addition, Borgdorff et al. [15] provide compelling evidence that sex differences in TB prevalence represent real epidemiological differences, and are not merely a product of differences in access to healthcare. Using survey data from 29 studies in 14 countries around the world, Borgdorff et al. [15] found greater numbers of TB cases among men than women in almost all cases. In some world regions, such as Southeast Asia, and the Western Pacific, TB case rates were twice as high in men as in women.

In the present study, regarding age group, the highest rate of infection was reported in the age group of 20–29 years (45.7%), then 10–19 years (10.2%), while the lowest affected age group was that greater than 60 years (5.1%). There was no significant difference between Damietta and Suez as regards age group distribution. In Damietta Governorate the highest infected age group was 20–29 (45.4%) followed by 30–39 (12.0%) and the lowest was those greater than 60 years (5.1%). There was no significant difference between different years as regards age group distribution. A similar pattern of age distribution was observed in Suez Governorate. El Zeheiry [16] conducted a retrospective study in the Dakahlia Governorate, Egypt, to review the TB situation. He found that TB was common among the middle-aged group from 15 to less than 30 years. Similar results were drawn in the El-Minia Governorate (1997–2010) where the highest prevalence of TB occurred among the age group 15 to less than 30 years (30.92%), and the lowest prevalence occurred in extremes of age [17]. Finally, Abu Shabana et al. [12] reported that their work revealed that the highest prevalence (by age) of TB was among individuals aged 15 to less than 30 years (67.9%), and the lowest prevalence was among those of age extremes. This could be explained by the increased prevalence of smoking behavior among this active age group in our society. Moreover, poverty, malnutrition, physical, mental, and occupational stress and more exposure to infection are other contributing factors.

In the present study, TB lesion was pulmonary in 1476 (76.1%) cases and extrapulmonary in 464 (23.9%) cases; and there was no significant difference between Damietta and Suez Governorates as regards the type of TB (pulmonary TB represented 76% in Damietta and 76.2% in Suez Governorate). TB infection reported a nearly similar distribution through years in both Damietta and Suez Governorates. However, there is a fluctuation through years between pulmonary and extrapulmonary lesions. These results are comparable to those reported by Svensson et al. [18] who reported that a total of 205/349 (59%) of the patients had lung TB with no signs of extrapulmonary infection, while the remaining 144/349 (41%) patients had TB with some form of extrapulmonary manifestations. The different percentages were attributed to the difference between countries as regards the pattern of infection and healthcare access or reporting system. In addition, Zidan et al. [19] in a hospital-based study reported that as regards the proportion of extrapulmonary to pulmonary TB cases in this study it was nearly 1 to 1 as pulmonary TB cases were 209 (54.4%) patients while extrapulmonary TB cases were 175 (45.6%) patients.

In the El-Minia Governorate, out of the 7860 cases diagnosed during the period of the study, 66.43% of cases were pulmonary TB and 33.56% were of the extrapulmonary form [17].

In a study done in El-Behira Governorate (1996–2010), out of the 10 035 cases diagnosed during the period of the study, 78.8% of cases were pulmonary TB and 21.2% were of the extrapulmonary form [20].

In Benha Chest Hospital (2002–2006), pulmonary cases (73.9%) were significantly higher than extrapulmonary cases (26.1%) during all years of the study [21]. In Port Said Governorate 86.5% of cases were pulmonary TB, but (13.5%) were extrapulmonary TB and the statistical analysis between pulmonary and extrapulmonary cases was highly significant all over the years [22].

The high proportion of pulmonary cases compared with the extrapulmonary ones could be explained by the fact that TB occurs almost exclusively from inhalation of droplet nuclei containing M. tuberculosis. In Egypt, pulmonary tuberculous cases decreased from 11 040 in 1997 to 7900 in 2001 and decreased from 8232 in 2002 to 5378 in 2004 [23].

These results are inconsistent with those reported by Abu Shabana et al. [12] who state that there was a significant increase in extrapulmonary cases (from 5.7 to 15.1%) with a significant decrease in pulmonary cases (from 94.3 to 84.9%) before and after DOTS, respectively. This indicates more control of the pulmonary cases. Moreover, the increase in the extrapulmonary cases may be a false increase explained by more availability of diagnostic facilities such as specified radiographies or biopsy procedures, which are necessary to detect extrapulmonary TB. Increased life expectancy which may be associated with reactivation of a latent tuberculous lesion from pulmonary sites and more physical contact with infected animals may also be implicated.

The possible explanation for this contradiction may be attributed to the fact that they summed all cases before and after DOTS. Unfortunately, we did not. In addition, different attitudes toward notification and patients seeking medical advice may be the responsible factors.

As regards the main presenting symptom in the present study, cough was the most common presented in 50.8% of cases, followed by hemoptysis in 20.3%, chest pain in 14.7%, and fever in 14.2% and there was no significant difference between Damietta and Suez as regards the main presenting symptom. These results are comparable to those reported by Hussein et al. [24] who reported that cough and sputum production were common symptoms in both young and elderly patients. This result was in agreement with other authors [25],[26]. In our study, the higher frequency of hemoptysis in young patients was probably related to the higher frequency of lung cavitations in them. This was in agreement with other authors [27],[28]. In addition, Zidan et al. [19] reported that cough was the presenting symptom in 40.6%, fever and sweating in 34.9%, weight loss in 29%, hemoptysis in 14. 8%, and chest pain in only 2.3%. Finally, this is in agreement with the results reported by Kreider and Rossman [29] who stated that the most frequently reported symptoms of active pulmonary TB included cough (23–47%), fever (18–79%), weight loss (7–24%), and hemoptysis (8–9%).

As regards diabetes, it was reported in 224 (11.5%) cases and prolonged corticosteroid therapy was reported in 126 (6.5%) cases, and there was no significant difference between Damietta and Suez Governorates as regards diabetes or prolonged corticosteroid therapy. These results are comparable to those reported by Chaudhry et al. [30] who reported a rate of 7.17% of diabetes in the Eastern Saudi Arabia region in both Saudi and non-Saudi populations.

In addition, Hussein et al. [24] in the Sohag Governorate reported that diabetes mellitus was the most frequent comorbidity in both young and old age groups, without statistically significant difference between both groups. Diabetes was reported in 21.8% in the older age group (≥50 years) and in 20.2% of the younger age group (<50 years). The possible explanation for this higher percentage of diabetes can be attributed to different sociocultural factors between both Damietta and Suez from one side and Sohag from the other side. In addition, it could be also explained by the immunosuppressive effect of diabetes and increased susceptibility to TB infection. These results agreed with those of the other investigators [31].

As regards results of smear in sputum smear, it was positive in 1318 (89.3%) cases and negative in 158 (10.7%) cases; and there was significant increase of positive smear in Damietta when compared with Suez Governorates (92.1 vs. 86.2%, respectively). In their study Zidan et al. [19] reported that positive sputum test among pulmonary tuberculous patients was 62.2%. The possible explanation for this difference in positive smear can be attributed to the fact that they only included Bab-Elsheria Hospital; compared with all chest hospitals in both governorates in the present study.

Comparable results were obtained by Alwani [20] in El-Behira Governorate (1996–2010) who found that the percentage of smear-positive cases (60.8%) was significantly higher than the percentage of smear-negative cases (39.2%). Near results were obtained by George [17] in El-Minia Governorate (1997–2010) who found that the percentage of smear-positive cases (68.1%) was significantly higher than the percentage of smear-negative cases (39.18%) and that the results obtained by Alrashidy [22], in Port Said Governorate, found that the smear-positive cases percentage (73.8%) was significantly higher than the percentage of smear-negative cases (26.2%). The present study was supported by the results of Amornat et al. [32] who found that 63% of pulmonary cases were sputum smear positive and 37% were sputum smear negative.

As regards extrapulmonary lesion, the most common was pleural effusion (188 cases; 40.5%), then lymph node (19.4%) and the least was cold abscess (2.6%), then urinary (2.8%), and there was no significant difference between Damietta and Suez Governorates as regards extrapulmonary lesion. The present study matched with the results of Abdelghany [33] in Menoufia who found that the most common type of extrapulmonary TB was pleural TB. Alwani [20], in El Behira found that 62.8% were pleural TB, and 20% were tuberculous lymphadenitis. In addition, El-Zeheiry [16] in Dakahlia found that pleural cases (50.9%) represented the highest number of extrapulmonary cases and that the study obtained by Alrashidy [22], in Port Said Governorate, found that the pleural TB (45.4%) represented the highest percentage of extrapulmonary cases, followed by tuberculous lymphadenitis (30.2%). On the other hand, a study done in El-Minia Governorate (1997–2010) found that tuberculous lymphadenitis (40.45%) represented the most frequent types of extrapulmonary TB, followed by pleural TB (19.16%) [17]. In addition, Lowieke et al. [34] found in a study in the Netherlands from 1993 to 2001 that lymph node cases represented the most frequent type of extrapulmonary TB. The high percentage of lymph nodes among other extrapulmonary types could be explained by the fact that lymphatics represent the first station in facing tubercle bacilli after being inhaled and within 2 weeks they are transported through the lymphatics to establish secondary sites [35].

As regards the condition at discharge, improvement was reported in 85.5%, failure in 6.6%, relapse in 4.8%, and death in 3.1%, and there was no significant difference between Damietta and Suez Governorates. These results are comparable to those reported previously in the literature. It had been reported that treatment failure is a serious problem facing some national TB control programs. Significant risk factors for treatment failure in Egypt were irregularity of treatment, noncompliance to treatment, deficient health education to the patient, poor patient knowledge regarding the disease, and diabetes mellitus as a comorbid condition. In Egypt, treatment failure accounts for 3–5% of the treatment outcome of new smear-positive cases and 13–17% of retreated cases [36].

In Benha Chest Hospital (2002–2006), under DOTS strategy, the percentage of failed cases was 1.7%, percentage of defaulters was 3.1%, and the percentage of dead cases was 3.3% [21]. In a study done in Port Said Governorate (1996–2011), the default rate was 34.7% before DOTS and became 7.5% after DOTS; the treatment failure rate was 6.5% before DOTS and became 5.9% after DOTS; death rate was 6.1% before DOTS and became 3.2% after DOTS [22]. In El-Minia Governorate the treatment failure rate was 2.34% before DOTS and became 1.68% after DOTS; the death rate was 4.61% before DOTS and became 4.2% after DOTS; the default rate was 15.29% before DOTS and became 7.08% after DOTS [17].

In an Egyptian study that involved 17 Egyptian governorates from April 2001 to December 2002, Morsy et al. [37] found that the percentages of treatment failure under DOTS strategy were 5.1% in Assuit, 4.5% in Gharbia, 2.6% in Cairo, 2.5% in Quena, 2.2% in Qualiobia, 2.1% for each of Daqahlia, 2.0% for each of Alexandria and Sharqia, 1.8% for each of Sohag, Kafr Al-Sheikh and Beni-Suef, 1.6% for Giza, 1.5% for Suez, 1.4% for Port Said, 1.0% in Ismailia, and 0.9% in Fayoum.

Treatment failure may be due to poor compliance of the patient or due to practitioner error, for example, in cases where inadequate regimens and/or shortened periods of treatment are prescribed. Also drug resistance may be implicated. Unsuccessful treatment may result from irregularity in taking treatment and may loss to follow-up, which may be due to patients being transferred to another unit. Many patients stop treatment as soon as they feel better. Poor patient knowledge regarding TB may be a significant predictor of treatment failure, so strengthening health education in DOTS strategy is therefore recommended [36],[38].

Death during treatment of TB could be explained by the fact that tuberculous patient may suffer simultaneously from other diseases, such as diabetes which can affect both the development of TB and mortality. Nonadherence and defaulting which may result from alcohol and drug abuse may be implicated. Also death may be caused by drug-resistant TB. Possibly, TB fatality is increased if the disease duration has been sufficient for causing extensive disease.

 Conclusion



As regards theprevalence of TB in different cities, the old Damietta city had a prevalence of 63.3% of all reported cases: Kafr Saad (15%), El Shoara (5.2%), Kafr El Batiekh (4.4%), Faraskour (1.1%), Gamasa (0.8%), El Borg (4.8%), Shata (2.8%), El Zarka (0.4%), and New Damietta (1.0%) with no significant difference between different cities as the distribution of both pulmonary and extrapulmonary TB. However, the pulmonary type was higher in each city when compared with the extrapulmonary.

The differences in the total numbers of recorded tuberculosis cases in different localities in Demietta Governorate may be due to variations in hygienic and socioeconomic conditions, family income, overcrowding, badly ventilated houses, decreased sun exposure of the residence, ignorance and illiteracy, migration of farmers from their villages to the city where they live in low socioeconomic standards.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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