The epidemiology of Tuberculosis in Jahrom (2005-2014)

Abstract

bstrac
t

Introduction:

Tuberculosis is a chronic infectious and communicable disease, ranking seventh according to DALY,
and predicted to remain so by 2020. The present study was conducted to evaluate the epidemiology of
tuberculosis.

Materials and methods:

In this descriptive
-analytical study, records of all patients with TB during 2005-
2014 were examined.
Data were analyzed in SPSS 22 using descriptive statistics, Chi
-square test and t
-student at
significance level P<0.05.

Results:

Out of 114 TB patients, 67.5% were male, 69.3% were infected with pulmonary TB and 6.1% were
infected with HIV. Furthermore, the patients were Afghan, 31.6% and 64% of the patients were city
dwellers. The highest prevalence of TB (pulmonary and extra-
pulmonary) was observed those
younger than 40 years old (44.7%). There were no significant differences in types of TB (pulmonary
and extra
-pulmonary) based on sex, nationality, residing place, age groups and occupations (P>0.05).
Meanwhile, a significant differ
ence was observed in terms of exposure to TB cases (P=0.02). No
significant differences were observed between patients with pulmonary and extra-
pulmonary TB in
terms of mean age at diagnosis of TB (P=0.652), whereas significant differences were observed
between the results of all TB cases and those using DOTS (P<0.001).

Conclusion:

Given the young age of people with TB, it appears necessary that the barriers to treatment and control
programs be addressed, measures be taken to screen and train the high risk
population in Jahrom in
order to achieve the goals of preventing and controlling TB.

(PDF) The epidemiology of Tuberculosis in Jahrom (2005-2014). Available from: https://www.researchgate.net/publication/323853117_The_epidemiology_of_Tuberculosis_in_Jahrom_2005-2014 [accessed Oct 20 2019].

Full text

* Corresponding author, Address: Research Center for social determinants of health, Jahrom University of
Medical Sciences, Jahrom, Iran
Tel: +989175985204 Email: rahmaniank@yahoo.com
16
Epidemiology of Tuberculosis in Jahrom in 2005-2014
Vahid Rahmanian 1, 2, Karamatollah Rahmanian*1, Alireza Safari1, Elham Mansoorian1
Mohammad Ali Rastgoofard1
Received: 2016/15/08 Revised: 2017/3/01 Accepted: 2017/11/02
1. Research Center for social determinants of health, Jahrom University of Medical Sciences, Jahrom, Iran
2. Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
Pars Journal of Medical Sciences, Vol. 14, No.4, Winter 2017
Abstract
Introduction:
Tuberculosis is a chronic infectious and communicable disease, ranking seventh according to DALY,
and predicted to remain so by 2020. The present study was conducted to evaluate the epidemiology of
tuberculosis.
Materials and methods:
In this descriptive-analytical study, records of all patients with TB during 2005-2014 were examined.
Data were analyzed in SPSS 22 using descriptive statistics, Chi-square test and t-student at
significance level P<0.05.
Results:
Out of 114 TB patients, 67.5% were male, 69.3% were infected with pulmonary TB and 6.1% were
infected with HIV. Furthermore, the patients were Afghan, 31.6% and 64% of the patients were city
dwellers. The highest prevalence of TB (pulmonary and extra-pulmonary) was observed those
younger than 40 years old (44.7%). There were no significant differences in types of TB (pulmonary
and extra-pulmonary) based on sex, nationality, residing place, age groups and occupations (P>0.05).
Meanwhile, a significant difference was observed in terms of exposure to TB cases (P=0.02). No
significant differences were observed between patients with pulmonary and extra-pulmonary TB in
terms of mean age at diagnosis of TB (P=0.652), whereas significant differences were observed
between the results of all TB cases and those using DOTS (P<0.001).
Conclusion:
Given the young age of people with TB, it appears necessary that the barriers to treatment and control
programs be addressed, measures be taken to screen and train the high risk population in Jahrom in
order to achieve the goals of preventing and controlling TB.
Keywords: Tuberculosis, Pulmonary, Epidemiology, Extra-pulmonary, Jahrom
Introduction
Tuberculosis (TB), an infectious and life-
threatening disease with a wide range of
clinical presentations, is mostly caused by
Mycobacterium tuberculosis, 85% of
which present as pulmonary and the rest as
extra-pulmonary tuberculosis (1, 2). TB
usually engages the apical, posterior and
upper lobe of the lung. Clinical signs are
Pars J Med Sci 2017; 14(4):16-24

Epidemiology of Tuberculosis in Jahrom in Vahid Rahmanian et al
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017 17
often specific and include fever, night
sweats, weight loss, appetite loss and
general malaise. More than 90% of the
cases result in coughs that are initially dry
in the morning continuing with
suppurative coughs and hemoptysis (3).
According to global statistics, every
second one person is infected with TB
bacilli, every 4 seconds one person catches
TB, and every 10 seconds one person dies
of TB (4).
TB is the deadliest infectious disease
among women of reproductive age and
most disease-induced orphans have lost
their parents to TB (5).
The accepted approach in controlling TB
is Directed Observed Treatment Short term
(DOTS), which is the correct treatment of
the disease preventing the occurrence of
new cases of drug resistance (1).
Drug-resistant tuberculosis including
multidrug-resistant tuberculosis (MDR-
TB) and extensively drug-resistant
tuberculosis (XDR-TB) are becoming a
major health problem in Iran. In addition,
recent reports suggest the development of
totally drug-resistant tuberculosis (TDR-
TB) in Iran, too (6).
More than 80% of TB patients live in 22
Asian and African countries, including
Afghanistan and Pakistan, the eastern
neighbors of Iran. Furthermore, the
incidence of TB in Iraq, the western
neighbor of Iran, is on the rise in recent
years due to political events and regime
change (7).
Currently, positive smear is the main
indicator of incidence of pulmonary TB in
Iran (8).
The incidence of TB in Iran is not the
uniform throughout Iran, as it is more
prevalent in the borderlines such as Sistan-
Baluchestan, Khorasan, Gorgan, East
Azerbaijan, Khuzestan, and southern
shores, but less prevalent in central
provinces. According to the Bureau of
Tuberculosis and Leprosy of the Center for
Disease Control of the Ministry of Health,
14.4 per 100,000 people catch TB in Iran
annually (7).
Fars Province has a moderate prevalence
of TB, which may be attributed to the
anthropological conditions, population and
high rate of migration into the province.
Also, in terms of screening, diagnosis, and
treatment of TB, Fars is a successful
province and the second center for treating
resistant TB in Iran (9).
Estimates of health and well-being of
society based on the available information
are necessary to determine health priorities
and interventions and the lack of
epidemiological data is a limiting factor in
the control and prevention of diseases (10).
In this regard, since no studies have been
conducted on the epidemiological situation
of TB in Jahrom (Fars, Iran), the present
study was conducted to assess the
epidemiology of TB from 2005 to 2014 in
Jahrom.
Materials and methods
This descriptive study is a subgroup of
secondary analysis studies. All patients
diagnosed with TB that presented to or
were referred to the CDC department of
Health Deputy of the university for
treatment were selected by convenience
sampling. A questionnaire designed based
on research objectives was used to collect
the information. The information in
patients’ files such as age, gender,
nationality, place of residence, affected
organ, type of the disease, time of
incidence, etc. was recorded in information
forms. The obtained data was analyzed by
SPSS software version 16 using
descriptive statistics, Chi-square and t-test

Epidemiology of Tuberculosis in Jahrom in Vahid Rahmanian et al
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017 18
at a significance level of p<0.05. All cases
of extrapulmonary tuberculosis (EPTB)
were diagnosed by pathology and 64% of
patients with pulmonary tuberculosis
(PTB) were diagnosed by direct
examination or sputum culture. The 36%
of pulmonary patients without pathological
findings or smear-positive sputum were
diagnosed and treated as TB patients
according to symptoms and observing
chest X-ray and consulting with specialists
in infectious or internal diseases.
According to the instructions, patients
diagnosed more than two weeks after the
onset of their symptoms were recorded as
delays in diagnosis in their files.
The present study was approved by the
Ethics Committee of the Jahrom
University of Medical Sciences
(IR.jums.REC.1394.147).
Results
Of the 114 registered patients, 67.5% were
male, 35.1% were non-Iranian (31.6%
Afghans and 3.5% Iraqis) and 64% were
urban dwellers. Among the patients, 74
(64%) were diagnosed with positive
smear, of whom 45.94% had 3+ intensity;
11.4% were smokers, 9.6% used drugs
through inhalation or injection; 10.5%
were diagnosed with diabetes, and 6.1%
were HIV positive (7 patients) and 15.8
had an uncertain situation. As national TB
program has been integrated in Iran's
health network, 81.6% of patients
diagnosed in the last decade by health
centers under the health service system
and 18.4% by non-health care network
systems such as private offices, prison, etc.
were referred to the Tuberculosis
Treatment Center for diagnosis and
treatment. In this study, 94.7% of patients
had a delay in diagnosis. In terms of the
type of TB, 69.3% had PTB and only 0.9%
had simultaneous PTB and EPTB. The
most organs involved in EPTB were
lymph nodes (54.88%) and pleura
(22.85%), respectively. In terms of
treatment results based on all TB cases,
51.8% recovered and 5.3% failed. The
highest prevalence of TB (pulmonary and
extrapulmonary) was in the under-40-year-
old age group (44.7%). The prevalence of
PTB and EPTB in men was 67.1% and
68.6%, and 32.9% and 31.4% in women,
respectively. Tables 1 and 2 and Figures 1
and 2 show the frequency distribution of
TB and TB incidence during the studied
years. The incidence of TB in the past ten
years did not have a steady trend. It had an
upward trend from 2005 to 2008, a decline
from 2009 to 2012, and again a rise from
2013 onward.
Table 3 shows the frequency distribution
of smear-positive PTB and its incidence
rate during the studied years. The
incidence rate of smear-positive PTB did
not have a steady course in the past ten
years, either. The incidence of PTB was
rising until 2009 and it had a steady course
since then, despite the fact that the
incidence of EPTB was relatively stable
(Figure 3).
The average weight of patients at baseline
was 14.14±55.64, and 36% of patients
weighed equal to or less than 50 kg and
64% were over 50 kg.
The mean age at the time of diagnosis was
44.84±20.61 and 51.11±23.14 years,
respectively for men and women. The
mean age of patients with PTB and EPTB
was 48.14±21.60 and 43.12±21.13 years,
respectively. The difference was not
significant (P=0.652).
In this study, there was no significant
difference between PTB and EPTB in
terms of gender, nationality, place of
residence and job (p˃0.05). While the

Epidemiology of Tuberculosis in Jahrom in Vahid Rahmanian et al
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017 19
difference was significant in terms of
exposure to TB cases, weight, DOTS and
the result of treatment (p<0.05). There was
also a significant difference between
treatment outcome of all TB cases and
DOTS (P<0.001) (Table 1).
Table 1: Frequency distribution of TB cases in terms of the studied variables
P-
value
All TB cases
Extrapulmonary
tuberculosis
Pulmonary
tuberculosis
Variable
Percent
Number
Percent
Number
Percent
Number
0.486
45.6
52
37.1
13
49.4
39
Simple worker
Occupation
20.2
23
20
7
20.3
16
Employee
22.8
26
28.6
10
20.3
16
Housewife
11.4
13
14.3
5
10.1
8
Other
100
114
100
35
100
79
Total
0.02
21.9
28
11.4
4
26.6
21
Yes
History of
contact
78.1
89
88.6
31
73.4
58
No
100
100
35
100
79
Total
0.001
77.2
88
42.9
15
92.4
73
Yes
DOTS
22.8
26
57.1
20
7.6
6
No
0.001
51.8
59
2.9
1
73.4
58
Recorded
Treatment
Outcome
36.8
42
91.4
32
12.7
10
Completion of the
treatment course
5.3
6
2.9
1
6.3
5
Treatment failure
1.8
2
0
0
2.5
2
Absence from
treatment
3.5
4
2.9
1
3.8
3
Death
0.9
1
0
0
1.3
1
Transferred
0.001
36
41
11.4
4
46.8
37
< 50 (kg)
Weight
64
73
88.6
31
53.2
42
> 50 (kg)
0.328
67.5
77
68.6
24
67.1
53
Male
Gender
32.5
37
31.4
11
32.9
26
Female
0.640
64
73
68.6
24
62
49
Urban
Place of
residence
36
41
31.4
11
38
30
Rural
0.067
64.9
74
80
28
58.2
46
Iranian
Nationality
3.5
4
0
0
5.1
4
Iraqi
31.6
36
20
7
36.7
29
Afghan
Table 2: Frequency distribution of EPTB cases from 2005 to 2014 in Jahrom
Percent
Frequency
Type of extrapulmonary tuberculosis
54.31%
19
Lymph nodes
22.85%
8
Pleura
14.28%
5
Bone
5.71%
2
Skin
2.85%
1
Meninges
100%
35
Total

Epidemiology of Tuberculosis in Jahrom in Vahid Rahmanian et al
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017 20
Figure 1: Prevalence of TB from 2005 to 2014 in Jahrom
Figure 2: The incidence rate of TB from 2005 to 2014 in Jahrom
12 12
13
16
14
8
11
5
12
11
0
2
4
6
8
10
12
14
16
18
84 85 86 87 88 89 90 91 92 93
Frequency
Year
5.34 5.33
5.74
7.09
6.19
3.52
4.82
2.19
5.26
4.85
0
1
2
3
4
5
6
7
8
84 85 86 87 88 89 90 91 92 93
Incidence per 100,000 people
Year

Epidemiology of Tuberculosis in Jahrom in Vahid Rahmanian et al
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017 21
Figure 3: The incidence rate of PTB and EPTB from 2005 to 2014 in Jahrom
Table 3: Prevalence and incidence rate of smear-positive PTB from 2005 to 2014 in Jahrom
incidence in 100,000 people Population
Frequency
Relative (percentage) Frequency Year
3.11
224551
9.7
7
84
3.99
225051
12.5
9
85
3.97
226170
12.5
9
86
3.99
225543
12.5
9
87
3.98
226051
11.1
8
88
2.20
226772
4.2
3
89
3.51
227800
11.1
8
90
0.87
227800
2.8
2
91
4.38
227800
13.9
10
92
3.09
226350
9.7
7
93
-
-
100
72
Total
Discussion
The results of this study indicated that the
incidence of TB per 100,000 people did
not have a steady course in the last decade.
The highest incidence of all TB cases
(pulmonary and extrapulmonary) in the
last ten years was in 2008 and 2009 with
an incidence rate of 7.09 and 6.19 cases
per 100,000 people and the lowest rate was
in 2012 with 2.19 cases per 100,000
people. The highest and lowest rate of
positive- smear TB incidence were in 2013
and 2012 with 4.38 and 0.78 cases per
100,000 people, respectively. In a study
conducted in Birjand in Iran during 1998
to 2006, the incidence rate of TB was 14.6,
21.8, 40.6, 32.2, 34.4, 31.5, 24.7, 15.8,
17.9, 23.3, respectively (11) which was
greater than the incidence rate in the
present study. In a 9-year survey in
Kurdistan in Iran, the highest and lowest
incidence rate of pulmonary smear positive
TB were 7 and 3.7 cases per 100,000
0
2
4
6
8
10
12
84 85 86 87 88 89 90 91 92 93
Frequency
Year
یﻮﯾر یﻮﯾر جرﺎﺧ

Epidemiology of Tuberculosis in Jahrom in Vahid Rahmanian et al
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017 22
people (12). In a study conducted in
Mazandaran in Iran from 2004 to 2006, the
incidence rate of TB was 9.08, 9.84 and
8.84; and the incidence rate of smear-
positive TB was 4.29, 4.35 and 4.03 cases
per 100,000 people, respectively (13).
Another study in Ardebil in Iran showed
that the incidence rate of TB was 8.54
cases per 100,000 people during 5 years
(8). The incidence of TB in Afghanistan
and Pakistan, which are among the 22
most polluted countries of the world, was
over 100 cases per 100,000 people (11,
14). The incidence of TB is not the same
everywhere in Iran. According to the
Bureau of Tuberculosis and Leprosy of the
Center for Disease Control of the Ministry
of Health, the incidence rate of all TB
cases is 14.4 cases per 100,000 people in
Iran(7).
Thus, based on these statistics, although
the rate of TB in Jahrom is not high
relative to the other provinces, the
incidence of smear-positive PTB is
somewhat high. Poor economy, culture,
and health, small living spaces with a high
number of dwelling people, the presence
of foreigners in the gardens and the central
part of the city might be the cause of TB
incidence in Jahrom.
In the present study, 69.3% of all cases
were PTB and 8.29% were EPTB which
was consistent with the result of Biranvand
et al. in southwestern Iran (1), Azni et al.
in Damghan (15) Ebrahimzadeh et al. in
Birjand (11), Culqui et al. in Spain (16)
and Taj al-Din et al. in Sudan (17).
A study by Ministry of Health in 2006
indicated that the most involved organs in
EPTB cases were lymph nodes (26.8%),
pleura (20.8%) and spine (17.7%). The
prevalence of EPTB cases in Iran is higher
than the World Health Organization report
(18), which might be due to increased HIV
infection or wrong diagnosis of EPTB and
exaggeration in diagnosis.
The results of treatment in 51.8% of
studied patients was full recovery, 36.8%
completion of the course of treatment,
5.3% treatment failure, 1.8% absence for
treatment, 3.3% death due to TB, and 0.9%
referring to other cities to continue
treatment. However, since recovered cases
are only considered in smear-positive
PTB, and since based on the national
guidelines all cases of smear-negative and
EPTB cases should be recorded as
completion of the treatment course, 80.8%
of smear-positive patients recovered, 4.1%
completed the course of treatment (smear-
positive cases should be recorded as
completion of treatment course if samples
cannot be taken from them for justifiable
reasons at the end of the treatment), 6.8%
had treatment failure, 2.7% were absent
for treatment, 1.4% were transferred to
other centers and cities to continue
treatment, and 4.1% died because of TB.
These statistics were close to the goals of
WHO (diagnosis of 75% of TB cases and
recovery of 85% of TB patients). The
study of Ebrahimzadeh et al. in Birjand in
Iran reported 81.7% full recovery, 2.9%
death because of disease, 3.3% treatment
failure, 4.4% referring to other centers to
continue treatment, 1.2% absence for
treatment, and 3.3% unknown results (11).
Also, a study on 58 patients in Sari in Iran,
reported 4.5% treatment failure and 18%
completion of the treatment course (19).
The frequency of treatment failure and
death due to tuberculosis in the present
study, both in all cases of TB and in
smear-positive PTB was very high.
The mean age at the time of diagnosis was
44.84±20.61 and 51.11±23.14 years for
men and women, respectively, which

Epidemiology of Tuberculosis in Jahrom in Vahid Rahmanian et al
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017 23
mainly include the active age group of the
society.
Based on national guidelines, patients who
are diagnosed within 14 or fewer days
from the onset of their symptoms are
recorded as no delays in diagnosis (7). In
this study, 94.7% of patients had a delay in
diagnosis and only 5.3% did not. These
results indicate the need for refresher
courses for physicians working in health
centers and hospitals regarding TB and
more attention to chronic coughs in the
differential diagnosis. The delay in
diagnosing TB, in addition to making
treatment harder (secondary prevention),
will also increase the risk of disease
transmission to other people in the society
(primary prevention).
In this study, there was no significant
difference between PTB and EPTB in
terms of gender, nationality, place of
residence and occupation (p˃0. 05), which
is consistent with the results of
Ebrahimzadeh et al. in Birjand (11),
Taghipoor et al. in Qom (10) and Khazaei
et al. in Hamadan, (20), while it was
inconsistent with the results of Yazdani et
al. in Lorestan (5).
There was a significant difference between
TB and history of contact with TB
patients, weight and DOTS (p<0.05).
There was also a statistically significant
difference between treatment outcome of
all TB cases and DOTS (P<0.001).
The mean age of patients with PTB and
EPTB was 48.14±21.60 and 43.12±21.13,
respectively. The difference was not
significant (P=0.62). These were not
consistent with the results of
Ebrahimzadeh et al. in Birjand (11).
Conclusion
Due to the high rate of smear-positive PTB
in relation to smear-negative and EPTB in
this study, early detection of new cases of
smear-positive PTB and treatment start
after diagnosis requires more precision.
Also, due to the high rate of treatment
failure in Jahrom compared to other
provinces and the entire country, more
work is necessary to achieve the goals set
by WHO in early detection of the disease
as well as the implementation of more
effective treatment. Furthermore, due to
the young age of people with TB in the
present study, it appears that in order to
reach the goals and success in the fight
against TB, more attention should be paid
to the obstacles to the implementation of
TB control and treatment programs and the
screening and education of these
population groups need to be arranged in
priority programs of Jahrom health center.
Acknowledgments
This study was sponsored by the Research
Deputy of Jahrom University of Medical
Sciences. The personnel of a disease-
fighting unit of the health department of
the university are hereby thanked.
Conflict of Interest
There is no conflict of interest
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