The Influence of the COVID-19 Pandemic on Hospitalizations for Ambulatory Care-Sensitive Conditions in Split-Dalmatia County, Croatia.

Background and Objectives: We aimed to explore whether the COVID-19 pandemic influenced hospitalizations for ambulatory care-sensitive conditions (ACSCs) in Split-Dalmatia County, Croatia. Materials and Methods: We performed a cross-sectional comparative study using two different time periods, the pre-pandemic (from March 2019 to February 2020) and the pandemic period (from March 2020 to February 2021), to explore the possible influences that the COVID-19 pandemic had on hospitalizations for ACSCs. The ACSCs were classified into the categories of vaccine-preventable, chronic, and acute disease. The indicators were statistically analyzed. Results: During the pandemic, a decrease in the total number of hospitalizations and ACSC hospitalizations was recorded. The relative risk for having any ACSC hospitalization in the pandemic period compared to the pre-pandemic period was 0.67 (95% CI, 0.64-0.71; p = 0). The risk reduction was seen in all three categories of vaccine-preventable ACSCs, chronic disease, and acute disease. Large reductions were found in the relative risk of hospitalization for COPD and asthma. Considering the mode of discharge, there was a statistically significantly higher risk of ACSCs with fatal outcomes during the pandemic than in the pre-pandemic period (relative risk 1.31; 95% CI, 1.01-1.7; p = 0.0197). Conclusions: The results of this study show that the COVID-19 pandemic influenced the total number of hospitalizations as well as hospitalizations relating to ACSCs. Certainly, one of the reasons for these changes was due to organizational changes in the working of the entire health system due to the COVID-19 pandemic.

How Different Predominant SARS-CoV-2 Variants of Concern Affected Clinical Patterns and Performances of Infected Professional Players during Two Soccer Seasons: An Observational Study from Split, Croatia.

There are limited data describing clinical patterns and match running performance (MRP) among players with COVID-19 infection before and after infection, particularly related to different predominant SARS-CoV-2 variants, as well as in comparison to uninfected players. This observational study was conducted during two consecutive soccer seasons in one professional club in Split, Croatia. There were four clusters of mild, self-limited, or asymptomatic infection characterised by low adherence to preventive measures. Infected players had significantly more symptoms (t-test = 3.24; p = 0.002), a longer period of physical inactivity (χ2 = 10.000; p = 0.006) and a longer period of self-assessment for achieving full fitness (χ2 = 6.744; p = 0.034) in the 2020-2021 season (Wuhan wild strain and Alpha variant) than in the 2021-2022 season (Omicron variant). It was also found that, despite the milder clinical presentation of the infection in the 2021-2022 season, the players had significantly more abnormal laboratory findings (χ2 = 9.069240; p = 0.002), although without clinical significance at the time of the study. As for the MRP, player performance in the 2021-2022 season was not negatively affected by the Omicron variant, while there was an improvement in MRP in scores for a sample of all players. The RTP protocol was correctly applied because it helped the athletes to recover their pre-infection physical capacities relatively quickly. This study advances the understanding that an optimally and individually planned RTP protocol is crucial for the MRP of infected players. Future research needs to replicate the findings of abnormal laboratory results and extend the study focusing on their potential long-term clinical significance.

Body Mass Index Trends before and during the COVID-19 Pandemic in Primary School Students in Split-Dalmatia County, Croatia: A Retrospective Study.

Within the last decade, childhood obesity has become a serious problem, especially during the COVID-19 pandemic. This research paper aimed to examine whether body mass index (BMI) was higher during the pandemic (2020-2022) than in the pre-pandemic period (2012/2013-2019) using trends related to sex, urban-rural area, and physical activity (PA). This study included data from physical examinations of an entire population of primary school children from Split-Dalmatia County (Croatia) over a period of 10 years. There were 103,804 students from the first, fifth, and eighth grades who participated in the analysis. During the pandemic, the BMI of all the students increased, except for eighth-grade girls. Generations of eighth graders have had significantly different BMIs throughout the past decade. We found that first graders were overweight and obese in urban areas, while in rural areas, this problem was experienced by upper grades. Girls were more overweight and obese in the first and eighth grades, but boys experienced this more in the fifth grade. Reduced PA influenced an increase in BMI in both sexes, especially in girls. During the pandemic, this situation became worse. This study could be useful to experts for the creation of new policies for Split-Dalmatia County and surrounding regions that are similar economically and culturally.

Attitudes of Community Pharmacy Service Users towards Vaccination Programs in Pharmacy: A Cross-Sectional Survey-Based Study in Croatia.

BACKGROUND: The aim of this study was to explore community pharmacy service users' attitudes and opinions towards vaccination programs in pharmacy conducted by a doctor of medicine or a pharmacist. METHODS: The questionnaire used in this study comprised 40 items about demographics, sources of information, attitudes about vaccination, attitudes about vaccination in community pharmacies, and willingness to pay for such a service. RESULTS: A total of 385 people participated in this study. Injection was the preferred route of administration of vaccine for more than half of study participants (50.6%). Univariate analysis showed that those who had a healthcare worker as a family member and those familiar with the HPV vaccine had better attitudes; however, those results were no longer significant after factoring in other variables in multivariate analysis. More than half (59.2%) of the study population would consider vaccination service in community pharmacies only if it were free or covered by the national health insurance. CONCLUSIONS: More than half of the participants believed that providing vaccination services in community pharmacies would result in greater vaccination rates for seasonal illnesses. However, around half would prefer that it were conducted exclusively by a physician. Less than 10% of the study participants would pay out of their pocket for such a service.

Measles cases in Split-Dalmatia County (a Croatian tourist region), in May-July 2019: outbreak report and lessons learnt.

BACKGROUND: Measles elimination was accomplished in Croatia in 2016. Split-Dalmatia County, with population of ca. 425 000 inhabitants, is among the most important Croatian tourist areas with numerous seasonal workers coming during summer months. In both 2018 and 2019, more than 3 million tourists visited this county. In 2000-2018, there were no measles cases in this county, or their number was low (1-3 cases per year). METHODS: After measles was clinically suspected, all contacts were traced and contacted. Detection of specific IgM/IgG antibodies and real-time reverse transcription-polymerase chain reaction detection of viral RNA were used for laboratory confirmation. Sequencing and genotyping were performed for strains' molecular epidemiology analysis. RESULTS: Six epidemiologically unlinked measles virus occurrences happened in Split-Dalmatia County in 15 May-19 July 2019. Causative viral strains belonged to genotypes B3 and D8. Four were single imported cases. Ten patients belonged to two separate clusters within domicile population. Multiple individual and public health measures were implemented. In total, 483 contacts were identified, 64.2% within healthcare system where two persons contracted the disease. CONCLUSIONS: Besides the importance of timely vaccination of children, the lessons learned from this outbreak point to the need of stricter implementation of other aspects of Croatian measles prevention programme, such as checking of vaccination status in early adulthood. Despite the fact that measles elimination within domicile population in this tourist region has been accomplished and maintained for years, continuous public health workers' efforts are still necessary for identification and diminishment of populational pockets of susceptibility.

Influence of Metal Concentration and Plumbing Materials on Legionella Contamination.

Legionella colonization of water supply pipes is a significant public health problem. The objective of this work was to evaluate Legionella colonization in hotel hot water systems and to investigate the relationship between metal concentrations, piping materials (galvanized iron pipes and plastic pipes), and Legionella proliferation. Concentrations of calcium and magnesium ions and the presence of Legionella pneumophila were determined in a total of 108 water samples from the hot water systems of four hotels in Split-Dalmatia County over a 12-month period, and additional data on piping materials were collected. L. pneumophila was isolated in 23.1% of all samples-in 28.8% (15/52) of water samples from galvanized iron pipes and in 17.8% (10/56) of samples from plastic pipes. L. pneumophila serogroups 2-14 were isolated from all samples. This study found higher prevalence of L. pneumophila at higher concentrations of Ca and Mg ions (except for Mg and plastic pipes). The metal parts of the water supply may be important factors in Legionella contamination due to the possibility of lime scale or roughness of the pipes. Higher Ca and Mg ion concentrations increased the risk of Legionella colonization.

Evidencing the Influence of the COVID-19 Pandemic and Imposed Lockdown Measures on Fitness Status in Adolescents: A Preliminary Report.

It was established that the COVID-19 pandemic resulted in decreased physical activity levels, potentially leading to reduced physical fitness. The aim of this research was to investigate the impact of the COVID-19 lockdown on fitness indices in adolescents. We observed high school adolescents (33% girls; aged 15-17 years) divided into two cohorts. The first cohort (control; n = 48) included adolescents who were in school during the 2018/2019 year, while the second cohort (lockdown; n = 66) was observed during the school year 2019/2020 when COVID-19 lockdown measures were imposed. Variables included body height, body mass, BMI, sit-ups, and the 600 m dash. Both cohorts were tested at the beginning and at the end of the observed school years. A factorial analysis of variance for repeated measurements evidenced an improvement in sit-ups and the 600 m dash in the control, and a decrease of the same capacities in the lockdown cohort. In the lockdown cohort, a decrease in muscular fitness was more evident in boys than in girls. No differential changes between cohorts were evidenced in anthropometrics. Results suggest that the COVID-19 lockdown negatively influenced muscular fitness status in adolescents, especially in boys.

Evidencing the influence of pre-pandemic sports participation and substance misuse on physical activity during the COVID­19 lockdown: a prospective analysis among older adolescents.

OBJECTIVES: The physical activity level (PAL) has significantly decreased as a result of the social distancing and lockdown related to the COVID­19 pandemic, but there is a lack of knowledge on the correlates of PAL during the pandemic. The aim of this research was to examine the influence of pre-pandemic sports participation and substance use and misuse (SUM) on PAL during the COVID­19 pandemic. MATERIAL AND METHODS: The study included 661 high-school students from Bosnia and Herzegovina (aged 15-18 years, 292 females). The investigation included 2 testing waves: before the COVID­19 pandemic (baseline, January 2020) and during the COVID­19 lockdown (follow-up, April 2020). The variables included PAL as measured by the Physical Activity Questionnaire for Adolescents, sports factors, and SUM. RESULTS: Sports factors at baseline were positively correlated with PALs at both baseline and follow-up. Smoking tobacco negatively affected PALs at both baseline and follow-up. Alcohol consumption was positively correlated with PAL at baseline but had no effect on PAL at follow-up. CONCLUSIONS: This study confirmed the importance of sports participation in maintaining PAL during challenging situations, such as the COVID­19 lockdown. The substance-specific influence of SUM on PAL before and during the lockdown points to evident social and cultural aspects of SUM behaviors in adolescents. Further studies evidencing the cumulative effects of PAL decline during the lockdown are warranted. Int J Occup Med Environ Health. 2021;34(2):151-63.

Prospective Analysis of Prevalence, Trajectories of Change, and Correlates of Cannabis Misuse in Older Adolescents from Coastal Touristic Regions in Croatia.

The prevalence of illicit drug misuse, including cannabis, in Croatian touristic regions is alarming. This study aimed to identify the prevalence of cannabis consumption (CC), to identify associations between sociodemographic and sport factors and CC, and to evaluate the predictors of CC initiation in adolescents residing in touristic regions. This study enrolled 644 adolescents from two touristic regions in Croatia (Split-Dalmatia and Dubrovnik-Neretva County) who were tested at baseline (16 years of age) and follow-up (18 years of age). The study instrument consisted of questions focused on predictors (age, gender (male, female), place of residence (urban or rural environment), familial social status, and different sport-related factors) and CC outcome. The results indicated a high prevalence of cannabis consumption (>30% of adolescents consumed cannabis), with a higher prevalence in males, and adolescents from rural communities. The prevalence of CC increased by 10% during the study period, with no significant differences between genders in trajectories of changes. Quitting sports was a risk factor for CC at baseline and follow-up. Better sport competitive results (odds ratio (OR): 0.80, 95% confidence interval (CI): 0.65-0.96) and familial social status (socioeconomic status: OR: 0.66, 95% CI: 0.39-0.91; maternal education: OR: 0.65, 95% CI: 0.48-0.88) were associated with lower likelihood of CC at baseline. The adolescents who reported better sport competitive results were at increased risk for initiation of CC during the course of the study (OR: 1.40, 95% CI: 1.03-2.01). The protective effects of sports at baseline were most likely related to various factors that prevent the consumption of substances in youth athletes (i.e., commitment to results, adult supervision); with the end of active participation, adolescent athletes are at high risk for CC initiation.

Trace metals in the environment and population as possible long term consequence of war in Osijek-Baranja County, Croatia.

War in Croatia resulted with a significant release of contaminants into the environment as a result of the use of combat assets, mainly conventional, mostly aimed at civilian targets. The aim of the study was to investigate the concentration of metals and metalloids in the soils, water, plants (Taraxacum officinale), serum, urine and hair of the inhabitants in eastern Croatia. Overall results show minor abnormalities in presence of some trace metals in soil (As, Hg, Pb, Sb), water (As, Fe) and dandelion leaves (As) in some locations. Compared with soil samples from areas exposed to low intensity combat activity soil samples from areas exposed to heavy fighting had higher concentrations of As, Hg and Pb than allowed by national legislation for ecologic farming. Drinking water with the exceptions of the concentrations of Fe, As and Mn was in accordance with national legislation. Examinees from Dalj had mean hair Sb level 10-19x higher then examinees from any other location. However, when these data are correlated through methods of principal component analysis, presence of trace metals in some war affected areas can be followed from soil, through plants up to population proving that intense combat activities over small area leave metal presence that can be followed even 15 years after the war.

Bus water storage tank as a reservoir of Legionella pneumophila.

Health concerns associated with Legionnaires' disease have been identified as an area of the increasing public and professional interest. Any natural water or man-made water systems worldwide might be reservoirs of Legionellae. We presented a sporadic, community-acquired case of Legionnaires' disease caused by Legionellapneumophila serogroup 1 in a bus driver who used water for hand and face washing from a bus water storage tank. The history of any other usual place of exposure to Legionellae was negative. The water from the tank was dirty, filled with sediment and leaves, at the temperature of 22 degrees C. The water was heavily contaminated with Legionella pneumophila serogroup 1 isolated from each sample with the concentration of 66,000, 16,000, 42,000, 56,000 and 34,000 CFU/L. The disinfection of the bus water storage tank was made using hyperclorination with 50 mg/L of free residual chlorine. The control sampling one week after the disinfection yielded negative results. So far, there are no recommendations on regular management or disinfection of water in bus storage tanks, but it seems to be reasonable to assume that passengers as well as bus drivers may be exposed to Legionella and therefore at risk of acquiring the infection. These recommendations should include regular empting, rinsing and filling the tank with fresh tap water, at least once a week. Finally, we have to be aware that Legionella bacteria are ubiquitous and any potential mode of producing contaminated aerosol should not be overlooked during an epidemiological field investigation and proposed appropriate measures.

Sexual behaviour and condom use as a protection against sexually transmitted infections in student population.

The aim of the study was to determine the differences in sexual behaviour and condom use as a protection against sexually transmitted infections (STI) between the first-year and the last-year students. Data were collected by filling anonymous and consented questionnaire in June of 2011 at University of Josip Juraj Strossmayer in Osijek, Croatia. Out of 857 students in the planned sample, 462 (53.9%) filled out the questionnaire, and 353/462 (76.4%) were sexually active. Data from sexually active students were processed and statistically significant results between first-year and the last-year students were presented. Studied sample consisted of 192/353 (54.4%) first-year students and 161/353 (45.6%) last-year students. Average age of sexual initiation for the first-year students was 17.28 +/- 1.29 years, a for the last-year students 18.45 +/- 2.14 years, and the difference is significant (Man-Whitney test = 10335.00, p < 0.01). First-year students have lower number of sexual partners (chi2 = 28.005, p < 0.01), during relationship they had lower number of intercourses with the third person (2 = 17.947, p < 0.01), and feel that lower number of their friends were already sexually active at the time of their own sexual initiation (chi2 = 18.350, p < 0.01). First-year students more often inform their partners about existing or previous STI (chi2 = 14.476, p < 0.01) and curiosity significantly influenced their decision regarding sexual initiation (chi2 = 8.689, p < 0.05). First-year students more often used condom at their first sexual intercourse (chi2 = 7.275, p < 0.01), and more rarely used withdrawal (chi2 = 6.380, p < 0.05). At their last sexual intercourse, first-year students more often used any kind of protection (chi2 = 3.853, p < 0.05),more often used condom (chi2 = 11.110, p < 0.01) and withdrawal (chi2 = 5.156, p < 0.05), and more rarely used contraceptive pills (chi2 = 4.405, p < 0.05). First-year students more often use condom in a permanent relationship (chi2 = 13.384, p < 0.05), and also plan to use it during following intercourse in the permanent relationship (chi2 = 17.575, p < 0.01). Growing condom use and decreasing risky sexual behaviour among students, as well as other adolescents and young adults needs to be maintained. Youth should learn before sexual initiation that only correct condom use at every sexual intercourse protects them against STI and human immunodeficiency virus (HIV). Sexual education and STI/HIV prevention programmes, positive role of media (television) and civil organisations that communicate with the youth can help that. Such changes among adolescents and young adults should have to be seen in student population as well.

Bronchoalveolar pH and inflammatory biomarkers in newly diagnosed IPF and GERD patients: a case-control study.

BACKGROUND: Several studies have suggested that idiopathic pulmonary fibrosis (IPF) may be related to repeated aspiration of gastric contents over long periods of time. We aimed to investigate differences between pH measured directly in the lung, and biomarkers of acute inflammation in patients with newly diagnosed IPF and in patients with newly diagnosed GERD. MATERIAL AND METHODS: All subjects (N=61) underwent collection of medical history, physical examination, pulmonary function testing, bronchoscopy, endoscopy, arterial blood gas analyses, and biochemical testing. RESULTS: Previously diagnosed GERD was found in 56.7%, typical symptoms of reflux in 80%, and Helicobacter pylori in gastric biopsy specimens in 76.6% of the cases. pH in peripheral branches of bronchi in the cases was 5.32 ± 0.44 and was 6.27 ± 0.31 (p<0.001) in the control group. The average values of LDH, ALP, and CRP in bronchoalveolar aspirate and in serum, as well as TNF-alpha in bronchoalveolar aspirate, were significantly higher in IPF patients. CONCLUSIONS: The more acidic environment in the bronchoalveolar aspirate of the IPF subjects could contribute to the development or progression of IPF, possibly via changes in local metabolism or by damaging local cells and tissue. However, further studies with larger numbers of patients are required to clarify the role of gastric fluid aspiration in IPF pathogenesis. Our preliminary work has identified inflammatory biomarkers LDH, ALP, and TNF-alpha as potentially important in the pathologic processes in IPF. Further research is needed to determine their importance in clinical intervention and patient care.

Risk factors for pulmonary tuberculosis in Croatia: a matched case-control study.

BACKGROUND: Mycobacterium tuberculosis is a necessary, but not sufficient, cause of tuberculosis. A number of studies have addressed the issue of risk factors for tuberculosis development. Croatia is a European country with an incidence rate of 14/100 000 which is slowly decreasing. The aim of this study is to evaluate the potential demographic, socioeconomic, behavioural and biological risk factors for tuberculosis in Croatia in comparison to other high-income, low-incidence European countries. METHODS: A total of 300 tuberculosis patients were matched for age, sex and county of residence to 300 controls randomly selected from general practitioners' registers. They were interviewed and their medical records were evaluated for variables broadly described as potential risk factors. RESULTS: In multiple logistic regression, the following factors were significant: parents born in a particular neighbouring county (Bosnia and Herzegovina) (OR = 3.90, 95% CI 2.01-7.58), the lowest level of education (OR = 3.44, 95% CI 1.39-8.50), poor household equipment (OR = 4.72, 95% CI 1.51-14.76), unemployment (OR = 2.69, 95% CI 1.18-6.16), contact with tuberculosis (OR = 2.19, 95% CI 1.27-3.77), former (OR = 2.27, 95% CI 1.19-4.33) and current smoking habits (OR = 2.35, 95% CI 1.27-4.36), diabetes (OR = 2.38, 95% CI 1.05-5.38), a malignant disease (OR = 5.79, 95% CI 1.49-22.42), being underweight in the previous year (OR = 13.57, 95% CI 1.21-152.38). CONCLUSION: In our study, the identified risk groups for tuberculosis reflect a complex interaction between socioeconomic conditions, lifestyle and non-communicable diseases. Interventions focused on poverty will undoubtedly be useful, but not sufficient. Tuberculosis control would benefit from a combination of broad public health activities aimed at the prevention and control of risky lifestyles and non-communicable diseases, interventions outside the health sector, and efforts to constantly improve the Croatian national tuberculosis programme.

Health system delay in pulmonary tuberculosis treatment in a country with an intermediate burden of tuberculosis: a cross-sectional study.

BACKGROUND: Delayed diagnosis and treatment of tuberculosis increase both the severity of the disease and the duration of infectivity. A number of studies have addressed the issue of health system delays in the treatment of tuberculosis, but mostly in countries with a high or low incidence of the disease. Our understanding of delay is quite limited in settings with an intermediate burden of tuberculosis. We explore the duration and factors associated with delays in the Croatian health system which has free health care and a sufficient network of health services providing tuberculosis diagnosis and care. METHODS: A total of 241 consecutive adults with culture-confirmed pulmonary tuberculosis were interviewed in seven randomly selected Croatian counties and their medical records were evaluated. A health system delay was defined as the number of days from the first consultation with a physician to the initiation of anti-tuberculosis treatment. A long delay was defined as a period exceeding the median delay, while an extreme delay was considered to be above the 75th percentile delay. RESULTS: The median health system delay was 15 days while the 75th percentile was 42 days (the 5th and 95th percentile being 1 and 105 days respectively). Almost 30% of tuberculosis patients remained undiagnosed for more than 30 days after the initial health care visit. Female patients (p = 0.005), patients with a negative sputum smear (p = 0.002) and patients having symptoms other than the usual ones (0.027) were found to be in significant correlation with a long delay. In a multivariate model, a long delay remained associated with the same variables (p = 0.008, p = 0.003, and p = 0.037, respectively).A significant association was demonstrated between both the female gender (p = 0.042) and a negative sputum smear (p < 0.001) and extreme delay, while only a negative sputum smear (p < 0.001) remained significant in the multivariate analysis. CONCLUSIONS: Our findings suggest that some groups of tuberculosis patients experienced a health system delay. In such a setting where tuberculosis incidence is decreasing, which leads to a lack of physician experience and expertise, training in tuberculosis is required. Such measure may be useful in reducing the number of missed opportunities for tuberculosis diagnosis.

[Delays in diagnosing and treating tuberculosis in Croatia]. / Izgubljeno vrijeme u otkrivanju i pocetku lijecenja tuberkuloze: sto treba napraviti?

The aim of this study was to determine factors causing delay in tuberculosis diagnosis and treatment in Croatia. It included 240 adults with pulmonary tuberculosis, who were interviewed for demographics, socioeconomic, lifestyle, and personal health data. Total delay was defined as a number of days from the onset of symptoms to the initiation of therapy. The median and the 75th percentile of the total delay were 68 and 120 days, respectively: 16.7 % of the patients initiated treatment within the first month, 23.8 % within the second month, 23.3 % within the third month, 12.9 % within the fourth month, and 23.3 % more than four months after the symptoms appeared. Long delay (exceeding median delay) was strongly associated with drug abuse (p=0.021). Extreme delay (75th percentile of delay) was significantly associated with the lowest level of education (p=0.021), below minimal income (p=0.039), minimal to average income (p=0.020), current smoking (p=0.050), and co-morbidity (p=0.048). In the multivariate model, long delay remained associated with drug abuse, while extreme delay was associated with the lowest level of education (p=0.033) and current (p=0.017) and ex-smoking (p=0.045).In a setting with decreasing TB incidence, the reported delay can be reduced by increasing health education, not only about tuberculosis per se, but about health in general and attitudes towards prevention and early care. It is also important to increase tuberculosis knowledge among healthcare workers as well as their diagnostic skills.

The role of interferon-gamma release assay in tuberculosis control.

Tuberculosis is still one of the major global public health threats. Countries with low incidence must focus on exhausting the reservoir of future cases by preventing reactivation. Therefore, it is important to identify and effectively treat those individuals who have latent tuberculosis infection and who may develop active disease. The tuberculin skin test has been the standard for detection of immune response against M. tuberculosis since the beginning of the 20th century. The new millennium has brought advancement in the diagnosis of latent tuberculosis infection. The name of the new blood test is interferon-gamma release assay (IGRA). Croatia is a middle-incidence country with a long decreasing trend and developed tuberculosis control. To reach low incidence and finally eliminate tuberculosis, its tuberculosis programme needs a more aggressive approach that would include intensive contact investigation and treatment of persons with latent tuberculosis infection. This article discusses the current uses of IGRA and its role in tuberculosis control.

Health-care seeking behaviour for tuberculosis symptoms in Croatia.

BACKGROUND: Early detection and treatment of tuberculosis (TB) patients have been key principles of TB control. Therefore, it is important to understand the causes of delay and to estimate their magnitude in order to plan interventions that yield the maximum benefit. METHODS: A total of 240 subjects aged ≥ 15 year with pulmonary TB were interviewed. Patient delay was defined as the period (in days) from the appearance of any symptoms to the first visit to a medical provider. RESULTS: The median patient delay was 38 days. When using the median as a cut-off to define long patient delay, being an ex-smoker (P = 0.036), current smoker (P = 0.030), coughing (P = 0.021) and losing weight (P = 0.050) were found to be significant. Having high level of education (P = 0.014) was associated with short delay. Being an ex-smoker (P = 0.050, adjusted odds ratio (aOR) = 1.940, 95% CI 1.001-3.759), current smoker (P = 0.029, aOR = 2.077, 95% CI 1.076-4.012) and having a cough (P = 0.022, aOR = 2.032, 95% CI 1.108-3.727), were significant in multivariate logistic regression, while having high level of education remained associated with short delay (P = 0.016, aOR = 0.286, 95% CI 0.103-0.791). The most common reasons for delay were supposed influenza or symptoms improving over time (34.5%) and underestimated symptoms (32.9%). CONCLUSION: People with smoking habits and health-seeking behaviour that may favour advanced disease and prolonged infectiousness as well as people with the lowest level of education contributed to TB delay. To reduced patient delay, efforts should be made to increase TB knowledge, which has to be adjusted to the less-educated segments of the population.

Attitudes towards tuberculosis and sources of tuberculosis-related information: study on patients in outpatient settings in Split, Croatia.

Attitudes towards tuberculosis may have severe impact on individuals and their families as well as on the effectiveness of tuberculosis control programs. The purpose of this study was to describe these attitudes and explore the sources of tuberculosis information available to the general population in Croatia through a cross-sectional survey based on structured questionnaire using convenience sampling among 386 subjects aged 18 years and over. Data were stratified by sex, age groups, educational background, personal monthly income and contact with tuberculosis patient. Being near to a tuberculosis patient would be uncomfortable for 39.9% of respondents and 26.4% of subjects would avoid any contact. If they were sick of tuberculosis, 9.6% of respondents would keep it from the society. Less than 10% of study subjects would be ashamed of their own or potential tuberculosis in their family. Almost twice less subjects with high education would hide the disease (P=0.049), or be ashamed if sick in comparison with less educated respondents (P=0.036). The subjects who were not in contact were less likely to feel uncomfortable about being near to a tuberculosis patient (P=0.042). As the source of tuberculosis information, 61% of the subjects reported TV, radio and journals. Internet was the least used source (13.2%). The subjects in contact received information from the family or friends (P=0.025), while those without contact were informed through mass media (P<0.001). Study results revealed high stigma-generating attitudes towards tuberculosis. The strong potential of mass media capable of reaching different population groups should be used as part of the stigma-reduction strategies.

Epidemiological patterns of tuberculosis in Croatia in the period 1996-2005.

The last comprehensive publication on tuberculosis in Croatia and the earliest impact of war, besides the yearly routine reports, was done in 1996 in Croatian. We were, therefore, interested to explore incidence trends and to highlight the early post-war tuberculosis epidemiological patterns in the next ten years period (1996-2005). A retrospective analysis of epidemiological data on all registered tuberculosis cases in Croatia searching the databases of 21 Croatian Public Health Institutes and the National Tuberculosis Registry was made. During the study period, the total tuberculosis incidence rates in Croatia dropped from 45 to 25.8/100 000 inhabitants. The average highest age-specific rates were recorded in the age group > or = 65 years being in decrease in all age groups. Paediatric cases (0-14 years) represented 4.5% of all cases. Tuberculosis cases among males were recorded in 64% cases, and 83.6% were indigenous population. Tuberculosis was bacteriologically confirmed in 67.7% cases. A low proportion of drug resistance (3.3%) was recorded. During 1985-2005, 56 tuberculosis cases among 242 AIDS cases were reported. Tuberculosis mortality showed a decreasing trend (p < 0.001). However, tuberculosis has still had the highest mortality rates among infectious diseases in Croatia. Despite the War chain of events and tuberculosis programmatic changes, tuberculosis incidence rates in Croatia have been decreasing but they are still far away from national target, incidence rate of 10/100 000 declared in 1998 and much higher than in European Union and Western Europe. Tuberculosis among children, resistance to tuberculosis drugs and HIV prevalence, significant problems in many European countries, have not caused problems in tuberculosis control in Croatia. This favourable epidemiological situation must be kept and improved through strengthened tuberculosis control measures.