Reversing the tuberculosis upwards trend: a success story in Romania.

At present, no published evidence is available on the effectiveness of the DOTS (directly observed treatment, short-course) strategy in reducing the incidence of tuberculosis (TB) within a country in the European "hot spots". The present study aimed to demonstrate the effectiveness of the strategy implementation in reversing the epidemiological TB trend in Romania based on programmatic data analysis. Key programme indicators were analysed from 1998 to 2007, and included DOTS coverage, case-detection rate, treatment success and overall incidence of notified cases. Internationally agreed definitions were used. The key programme indicators began declining and the World Health Assembly targets were reached (79% case-detection of new sputum-smear positive cases and 85.5% success rate in new culture-positive TB cases), 7 yrs after initiation of the DOTS expansion. The success story in Romania suggests that other middle-income, high-incidence countries (i.e. those belonging to the former Soviet Union) might be able to reach the World Health Assembly Targets and curb the burden of tuberculosis.

[Evolution of endemic tuberculosis in Olt county, Romania, between 1990 and 2008]. / Caracteristici ale evolutiei endemiei de tuberculoza în judetul Olt, în perioada 1990-2008.

A world-wide recrudescence of tuberculosis has been seen, due to the deterioration of the health state of the population from many areas of the world, because of increasing number of homeless persons, and also the immigrants from countries with TB epidemic. The present epidemiological context draw attention to the necessity of early detection of the disease and the beginning of early directly observed treatment, preferably ambulatory, if the sick person doesn't have other complications, isn't infected with multidrog resistant bacili and lives in a properly social environment for his support. For the evaluation of tuberculosis epidemic in Olt county, the authors realised a retrospective study on a period of over 15 years (1990-2008), based on the analysis of the main epidemiological indices of TB epidemic in this county compared with Romania: global incidence both in adults and children, for new cases nd relapses apart, incidence of MDR-TB (multidrug resistant-tuberculosis) cases, mortality through tuberculosis. Global incidence of TB in Olt county almost doubled between 1990-2008, reaching 147, 4 per hundred thousand, with much higher values compared with the national ones. Olt county presents constant values over the national ones between 1995-2008, due to the global incidence and also to the new cases and relapses. The incidence of new cases in children in 2008 (20,4 per hundred thousand) was below the national level (28 per hundred thousand). The risk of illness for the 0-14 years old children from Olt county was significantly lower in 2008 compared with the previous year, which, toghether with a number of MDR-TB cases under 15, signifies a regress of the epidemic.

[Tuberculosis of the spleen--very rare site of extrapulmonary TB]. / Tuberculoza splenica--localizare extrarespiratorie foarte rara a bolii.

The extrapulmonary tuberculosis (TB) includes all the sites excepting lung, its origin being in the hematogenous disseminating foci within the main infection. The case of a woman, aged 36, is presented suffering of second degree obesity and type II diabetes mellitus under diet. She was admitted in the Surgery Clinics I of Emergency "Floreasca" Hospital (October 21, 2008) for discontinuous pains, relatively strong in the left hypocondrium, vesperal fever, perspirations, symptoms being present for 5 months. The investigations carried out before and after the admission show the presence of a splenomegaly (stage I-WHO), the absence of hypersplenism, portal hypertension, or other objective elements--excepting those mentioned at admittance--as well as the imaging changes (thoracic abdominal CT: spleen with an axis of 17 cm length, multiple solid hypodense lesions with a diameter of 5 cm). The surgical intervention is undergone (laparoscopic splenectomy). The morphological-pathological diagnosis was tuberculosis of the spleen. Considerations are made on this TB rare site.

[BOOP--a rare diagnosis in clinical practice]. / BOOP--un diagnostic rar în practica pneumologica.

The authors present the case of a patient diagnosed in the first place as an idiopathic pulmonary fibrosis with unfavorable evolution (clinical and functional decline under corticosteroid and immunosuppressive treatment). Lung biopsy established the diagnosis of bronchiolitis obliterans with organizing pneumonia (BOOP).

[Post-tuberculosis syndromes appearing in cases undergoing initial chemotherapy]. / Sindroamele posttuberculoase instalate la cazurile supuse chimioterapiei initiale.

The study of frequency and of the nature of post-tuberculous syndromes in a group including 1351 patients with pulmonary tuberculosis at their first treatment, investigated between 1974 and 1977, has demonstrated that in the present stage of initial chemotherapy with standardized drug regimens, the post-tuberculous syndromes are decreasing in most of the cases, developing in those of the patients that presented with advanced froms of the disease at the start of the the therapy (2,8% in our study). At the same time one should note the prevalence of patients that have benefited from initial courses of chemotherapy with classical and relay drugs, such patients usually having less severe anatomic and radiologic lesions. The study of types of post-tuberculous syndromes has revealed the increased frequency of the bronchitic syndrome.

[Economic and social implications of post-tuberculosis syndromes]. / Implicatii economico-sociale ale sindroamelor posttuberculoase.

The fact that 30.5% of patients with post-tuberculous syndromes belonging to a category of active population have been pensioned off for health reasons is a demonstration that these syndromes may play a significant role in determining the incapacity for work. The practical conclusion is that the prophylaxis of post-tuberculous syndromes--early diagnosis, chemotherapy with new drugs, and kinesitherapy--in all cases of tuberculosis at their first treatment may determine a deceased incidence of these syndromes. The reduction of the percentage of post-tuberculous syndromes recorded for 100 cases of tuberculosis treated with modern therapeutic regimens will result in a collective benefit consisting in a lower pressure on the general and specialized sanitary network with regard to the number of procedures provided. The health network potentialities could this be used for the solving of other problems of public health. At the same time by reducing the percentage of post-tuberculous syndromes, important funds can be spared, which are used for treatment, sick-leave pay, and invalidity pensions. The continuous improvement of the organizational frame of health protection in our country should consider also the official regulatory of the medico-social status of patients with post-tuberculous syndromes.

[The tuberculosis endemic and its control in the city of Bucharest in 1996]. / Endemia de tuberculoza si combaterea ei în Municipiul Bucuresti în anul 1996.

Tuberculosis is one of the main problems of public health and the population has to face it in one of the biggest crowded town in Romania, Bucharest. It is also the capital of the country. An increasing tendency has appeared in the number of cases and deaths due to tuberculosis. The overall incidence of tuberculosis has increased by 5% in 1996, attaining finally the level of 128.6/100,000. The level is exceeded only by a few towns in Romania. The increase is due almost exclusively to the new cases of disease. The program of chemotherapy is facing a more reduced rate of cure and, implicitly, a high rate of failure by treatment. The periodical prevalence of the bacilliferous patients has attained 129.0/100,000 inhabitants. The deaths by tuberculosis have been increasing for a few years; the mortality was of 13.6/100,000 inhabitants in 1995 more than double as that in 1995 (6.5/100,000).

[Notes on 2 cases of pneumonia caused by Klebsiella pneumoniae]. / Consideratii pe marginea a doua cazuri de pneumonie cu klebsiella peumoniae.

In two cases of bacterial pneumonia occurring in adults which were due to Klebsiella pneumoniae germs. The evolution became chronic with extensive invasion of the pulmonary tissues and destruction of the parenchyma. There was also multiple resistance of the germs to antibiotics as evidenced by sensitivity tests. The severe pleural complications have determined serious difficulties in the performance of the treatment. Confronted with such a condition the only therapeutical attitude consisted in testing the known antibiotics with efficiency in Klebsiella infections.

[Diagnosis and treatment of a case of obstructive sleep apnea syndrome with AutoSet]. / Diagnosticul si tratamentul unui caz de sindrom de apnee în somn de tip obstructiv (SASO) cu AutoSet.

The author presents the case of a male patient with obstructive sleep apnoea syndrome, in which the use of classic CPAP therapy after performing an uvulo-pharyngoplasty (UVPP) led to very good results. The pressure levels determined initially after a polysomnography with Apnoe Check were compared with the results of the measurements with another device, AutoSet, used for the first time in our country. This allowed the tapering of pressure levels for CPAP and also revealed other advantages of the device, reviewed here.

[Risk factors in chronic posttubercular cor pulmonale in the elderly]. / Factorii de risc în cordul pulmonar cronic posttuberculos la vîrstnici.

From the analysis of 866 aged patients with post tuberculosis sequels admitted to the Tuberculosis Hospital at Constanta in the interval 1979-1988, a high percentage of the post-tuberculosis respiratory syndromes (41.8%) was recorded. Post-tuberculosis chronic cor pulmonale was in 62 patients (17%). The recent onset or reactivation of the bacillary process seem to represent important risk factors for such patients. The old age and other associated diseases usually restrict the therapeutical possibilities and, consequently, delay the cure.

[The epidemiological aspects of respiratory tuberculosis recorded in the last 12 years in those over 60]. / Aspecte epidemiologice ale tuberculozei aparatului respirator consemnate în ultimii 12 ani la vîrstele peste 60 ani.

As the elements of geriatric epidemiology, pathology and sociology are more and more studied nowadays, the paper reports on several epidemiologic aspects resulting from the evolution of the tuberculous endemic, at the ages over 60, in the last 12 years (1976-1987) in the Constanta County. The data presented show, in the 12 years of our study, important decreases of the incidence of the tuberculosis of the respiratory system at ages over 60, to values below 20% in the last years, with characteristics and evolution tendencies, generally superimposable, over the data recorded for the same time interval on a national scale. The paper insists on the epidemiologic impact, on a mass scale, of the patients with tuberculosis over 60 years old, dispersed among the whole population and having the most various possibilities of contact and transmittance of the infection and disease towards the receptive population mainly children and youngsters.

[The prevalence of smoking in physicians in Romania]. / Prevalenta fumatului la medici în România.

An inquiry upon the prevalence of the habit of smoking in doctors in Romania, performed in a group of 1136 doctors (p = 0.05) revealed a prevalence of 43.2%, 50.1% in men and 38.6% in women. Smoking is more frequent in group age 30-49 (47.2%). More than half of the smoking doctors smoke between 10 and 20 cigarettes a day. 45.7% of the resident doctors are smokers. Taking into account the large interface with the public, the medical staff can play an important part in the activity of reducing or stopping smoking.

[Marketing and mortality with tobacco in front line]. / Marketing si mortalitate cu tutunul in prim plan.

Tobacco is an economical force. To make some people rich, by mankind paying the price, which--for years--count hundreds and hundreds of billions of dollars and millions of human lives. After 1990, in Romania tobacco plantation was not profitable anymore and as a consequence, we registered a diminution of tobacco cultivated surfaces, that reached 0.1% of total arable surface (in 1997 the lowest among similar surfaces in South-Eastern European countries). The original production of fermented tobacco decreased at the same rate. Cigarette consumption at the country level remains the same, the "supply" of cigarettes being assured by massive imports, under licensed production and smuggling. The mortality by different diseases due to smoking, is increasing progressively in the interval 1997-2002. The increase rate of mortality by broncho-pulmonary neoplasm was 127% in men and 95.7% in women. In cerebrovascular diseases case the same indicator between 1998-2002 has values of 2.1% in men and 3.9% in women. The presentation of those gravity elements base the purpose of touching all the factors who complete in present to the application of individual and global strategies of smoking control in our country.

[Tuberculosis in the city of Bucharest in 1989-1993]. / Tuberculoza în Municipiul Bucuresti în anii 1989-1993.

The global incidence of tuberculosis increased during the last 5 years in the city of Bucharest by 37.8%, from 84.2%000 in 1989 to 116.0%000 in 1993. The risk of disease was permanently higher in the rural area of the Ilfov Agricultural Sector (148.5%000 in 1993). During 1993 almost 55% of new cases of pulmonary tuberculosis registered in the city of Bucharest presented advanced lesions on case-finding; 71% of these cases were tb bacilli eliminators. In the epidemiological conditions induced by a marked increase of contamination sources (periodic prevalence of tb bacilli eliminators reached 111.6%000 in 1993) the disease risk in children increased as well in Bucharest from 19.6%000 in 1989 to 38.3%000 in 1993. Tuberculosis control in Bucharest benefits from a rather complex material basis which should be improved according to the present day epidemiological conditions.

[The clinico-epidemiological aspects of tuberculosis occurring in medical personnel in pneumophthisiology units in Bucharest (1992-1996)]. / Aspecte clinico-epidemiologice ale tuberculozei survenite la personalul medical din unitatile de pneumoftiziologie din Bucuresti (1992-1996).

The authors studied 38 TB cases diagnosed between 1992 and 1996 among the 1092 employees (medical and nonmedical) of the pneumophthisiology departments in Bucharest (hospitals and ambulatory units). Most cases had pulmonary involvement (76.3%), 85.7% were bacteriologically tested for bK. Among them, 66.7% were confirmed. The therapeutic results evaluated after 1 year, showed just 1 failure. The medium annual risk of tuberculosis at the PF personnel is corresponding to an incidence of 700/100,000 (6.36 times higher than TB incidence in general population). This conclusions calls for emergency measures for protecting and compensating this personnel.

[The epidemiological profile and current evolutionary trends in tuberculosis in adolescents (15-19 years old) in the capital]. / Studiu asupra profilului epidemiologic si tendintelor actuale ale evolutiei tuberculozei la adolescenti (15-19 ani) în Capitala.

In Bucharest, the increasing TB incidence in the age group of 15 to 19 years till 100.11/100000 in 1996 has to become a concerning matter. The study of 585 cases aged 15 to 19 registered in Bucharest between 1991 and 1995 (more than 2/3 of all the cases in that period) revealed the important proportion of secondary TB (67.4%), as well as the frequency of pleural involvement (25.6%). The main discovering methods remain the examination of symptomatic cases (78.6%) and epidemiological inquiry (10%). The fact that 85% of the bacteriological confirmed cases had positive sputum specimens in microscopy confirms the idea of discovering the patients in advanced stages of disease, as well as epidemiological signification. Almost 50% of the ill teen-agers belong to families with low living status. At this age group we found an important degree of recovery after chemotherapy (82% rate of healing in the first year).

[The epidemiological aspects of tuberculous pleurisy in Romania]. / Aspecte epidemiologice ale pleureziilor tuberculoase în România.

The re-organization of the Tb network in Romania, which took place after 1948, made possible a gradual accumulation of a number of data on the epidemiological surveillance of the territory, including the tuberculous pleurisies. The incidence of tuberculous pleurisies showed a decrease from 30.7/100,000 to 4.2/100,000 between 1958 and 1985, followed by a "stagnation" at 4.3/100,000 for 1986-1989. In 1990, the incidence of Tb pleurisy reached 6.8/100,000. The weight of pleural localization among the respiratory ones was maintained 15%-13% for 1960-1980, with a subsequent diminution up to 7.9% in 1989. By age-groups, the incidence of Tb pleurisy was at its highest level (19.1/100,000) at the age of 20-24 years in 1990 (as well as in 1972, 1980 and 1985). The present time imperative is the improving of the etiological diagnosis of pleurisies by a larger accessibility to the histological (pleural biopsy puncture) and bacteriological investigations.

[A study of the risk factors for relapse in pulmonary tuberculosis patients and the results of the re-treatment]. / Studiul factorilor de risc de recidiva la bolnavii cu tuberculoza pulmonara si rezultatele retratamentului acestora.

The percentage of relapses among the global TB incidence in Romania increased from 7.7% in 1990 to 13.1% in 1999. The study group included 648 cases with relapsing lung tuberculosis, registered in the second semester, 1997. In more than half of the cases (54.9%) the relapse occurred in the 5 years following the healing of the previous episode. The percentage of 65.5% smear positives represents an increase compared to the first episode (61.7%) and illustrates the severity of these cases. From the first to the second episode, there was an increase of the percentage of "unemployed" and "retreated". Associated diseases were: COPD (10.6%), peptic ulcer (10%) and chronic hepatitis (9.6%). We found high percentages for drinking habits (46.9%) and smoking (41.5%). The re-treatment resulted in only 49% healing, compared to 75.7% at the first episode. This calls for an improvement of initial chemotherapy as well as re-treatment (introducing DOTS).

[An evaluation of the possibilities for a paraclinical study in outpatient pneumophthisiology care and proposals for its improvement]. / Evaluarea posibilitatilor de investigare paraclinica în asistenta de pneumoftiziologie ambulatorie si propuneri de optimizare a acesteia.

An attempt was made to make an estimation of equipment and accessibility of pneumophthisiology ambulatory units for diagnosis and treatment of patients newly discovered and the already registered ones. A number of 172 (97% of total number) pneumophthisiology units have been taken into the study showing a certain progress regarding the lb diagnosis. As for other chronic lung diseases, the specific equipment is not available in all units: 73 have not spirometer, bronchoscopy is performed in other places, a.s.o. The situation requires urgent providing the pneumophthisiology network units with new techniques equipment for diagnosis and replacing the present one which is outdated and worn-out.

[Effectiveness of the routine treatment of workers employed in the region of the Tuberculosis center, Constanta]. / Eficacitatea tratamentului de rutina in teritoriul cabinetului de ftiziologie, Constanta, la bolnavii încadrati în cîmpul muncii.

The present work demonstrates the high overall efficiency of the present regimes in the treatment of tuberculosis (97%), provided the rules and indications are strictly complied with. The duration of the medical sick leave influences the regularity with which the treatment is applied. Many of the younger patients frequently accept to resume work at an earlier date. Earlier work resumption under present conditions should be had in view since it obviates the major drawbacks in the treatment of tuberculosis--socio-occupational disadaptation of the patients.