Comparison of the Clinical and Socio- Demographical factors in Pulmonary and Extra Pulmonary Tuberculosis patients in YemenCorrespondence Address :
Dr. Gamil Qasem Othman, MSc, School of Pharmaceutical Sciences,
Universiti Sains Malaysia, 11800 Penang, Malaysia.
E- mail: firstname.lastname@example.org
This study aimed to assess the clinical and socio-demographic factors which were associated with pulmonary and extra pulmonary tuberculosis in Yemen.
A cross-sectional study was carried out among 160 Pulmonary Tuberculosis (PTB) and 160 Extra Pulmonary Tuberculosis (EPTB) patients who were diagnosed and treated in TB centres in Sana’a, the capital city of Yemen. Socio demographical, clinical and laboratory data and types of drug regimens which were used for treatment were collected from TB patients and from the medical records from the TB centres. The risk factors for the EPTB patients and the PTB patients were identified through a structured questionnaire.
The female to male ratio was 1.2 and 1.6 for PTB and EPTB, respectively. The median age for the PTB patients was 29 and it was 30 for the EPTB patients. It was also found that TB patientswith a low educational level amounted to 52% and 48% in the PTB and EPTB groups, respectively. This study illustrated that the majority of smokers were males (64% for PTB and 58% for EPTB), whose ages ranged between 15-54 years in both the PTB and the EPTB groups. This study found that more numbers of extra pulmonary tuberculosis patients were diagnosed in private hospital and clinics (41%) than the pulmonary tuberculosis patients (26%).
More numbers of females and younger patients were seen in both the EPTB and PTB groups. More numbers of extra pulmonary tuberculosis patients were diagnosed in private hospital and clinics than the pulmonary tuberculosis patients. The extra pulmonary patients had less monthly income than the pulmonary TB patients.
clinical, extra pulmonary tuberculosis, pulmonary tuberculosis, socio-demographical, Yemen
GAMIL QASEM OTHMAN, MOHAMED IZHAM M IBRAHIM, YAHIA AHMED RAJA A. COMPARISON OF THE CLINICAL AND SOCIO-
DEMOGRAPHICAL FACTORS IN PULMONARY
AND EXTRA PULMONARY TUBERCULOSIS
PATIENTS IN YEMEN. Journal of Clinical and Diagnostic Research [serial online] 2011 April [cited: 2019 Feb 21 ]; 5:191-195. Available from
Mycobacterium tuberculosis (TB) is an infectious communicable disease that continues to remain as a major cause of death in the world (1).
There are two principle kinds of TB: pulmonary tuberculosis (PTB), which usually attacks the lungs, and extra-pulmonary tuberculosis (EPTB), which attacks any part of the body, such as: the lymphatic, pleural, bone and/or joint, genitourinary and the peritoneal systems, the meninges and/or the central nervous system (CNS) and all other sites combined. Pulmonary TB sometimes combines with extra pulmonary tuberculosis (2), (3).
Tuberculosis spreads through droplets from infected patients through coughing, sneezing, or during talking. In addition, closer contact with infected patients; prolonged, repeated, or intense contacts are considered as the major routes of infection for TB. Furthermore, there are other predisposing factors for TB that include: residents and employees living in congregate areas, health care workers who work with severely infected patients, low-income population, racial or ethnic minority population, children in contact with severely infected adults, and finally, persons who inject illicit drugs (2).
Extra pulmonary TB occurs outside the lungs and may spread through lymphatic or haematogenous dissemination. The TB bacteria may remain dormant for years at a particular site before causing the disease. Nearly all organs of the body can be infected by EPTB. It can also have a wide variety of clinical manifestations, thus leading to difficulty and delay in its diagnosis (4).
EPTB is reported to be more often diagnosed in females and in young patients (4), (5).
Tuberculosis is still one of the major public health problems in Yemen. A majority of tuberculosis patients in Yemen are in the age group of 15-54 years (6).
Almost one-third of the tuberculosis cases in Yemen are extrapulmonary (28%); most of them (24%) reside in Sana’a city (22 provinces in Yemen). The pulmonary tuberculosis represented 72% of all the TB cases (6).
The most recent estimates of tuberculosis in Yemen by the National Tuberculosis Control Program (NTCP) (6) showed that the annual incidence of new smear-positive TB cases was 37 per 100,000 population, and that for all forms of TB cases, it was 82 per 100, 000 population, while the prevalence was 136 per 100,000 population. The purpose of this study was to assess the clinical and socio- demographical factors which were associated with EPTB and PTB.
This descriptive study was designed to compare the pulmonary and extra pulmonary tuberculosis cases in TB centres and governmental health facilities in the capital city of Sana’a, Yemen.
This study was conducted during March 2008–August 2009 at TB centres and health facilities in the capital city of Yemen, Sana’a. These centres were selected for their high patient attendance. Ascompared to other cities, Sana’a is characterized as having large and rich medical TB centres with large caseloads, data availability, consultants, and with good recording and reporting systems.
A total of 320 patients (160 EPTB and 160 PTB) were compared by their ages, genders, education, residential areas, employment status, marital status, smoking, and the place of diagnosis, symptoms, vaccination and treatment.
The study populations consisted of all tuberculosis patients who started a new course of tuberculosis treatment at the TB centres in Sana’a. The study included all patients with suspected or confirmed pulmonary and extra pulmonary tuberculosis; who were investigated and recorded in the medical records during March 2008 until August 2009. The patients who had defaulted, who were transferred or those who had died were excluded.
Clinical data and demographical and socioeconomic factors were collected by a direct interview by using a structured questionnaire. This questionnaire included data like patient’s name, gender, BCG vaccination status, full address, telephone number, the medical history of the patient’s family, social status (smoking and working) and the patient’s past medical history. According to the guidelines from the WHO and the Yemen Control Programme, several anti-tuberculosis regimens were used for treating TB.
The Statistical package for the Social Sciences (SPSS), version 12, was employed for data analysis. The Chi Square test was used to compare the socio economic status in the pulmonary and extra pulmonary patients. A statistical significance level of 0.05 was used in all analyses.
A total of 320 patients were included in the study. The demographical details of the patients who visited the TB centres are listed in (Table/Fig 1).
Note: Chi Square test at alpha level of 0.05 Pulmonary versus extra pulmonary tuberculosis in terms of the demographical profile: The analysis elucidates that there was no marked differences between the pulmonary and the extra pulmonary TB cases in terms of gender, age group, residential area and the level of education. On the other hand, a significant difference was shown in terms of monthly income (P=0.002) and the place of diagnosis (P=0.009), as shown in (Table/Fig 1).
Pulmonary and extra pulmonary tuberculosis in terms of clinical profile: This study illustrated no differences between the type of disease and the vaccination status. There was a significant difference between the type of disease and the symptoms (P< 0.0001), as shown in (Table/Fig 2).
Pulmonary and extra pulmonary tuberculosis in terms of treatment: In terms of treatment, the study showed that there was no difference between the types of disease and the drug regimen which was given. It was noted that the patients of PTB paid twice the number of visits to the centres as was paid by the EPTB patients. Further details are presented in (Table/Fig 3).
The study included three hundred and twenty patients. Of these patients, only 4.7% were transferred to other health facilities, 7.5% patients defaulted and 2.5% patients died. The above mentioned study had a lower number of defaulters and deaths as compared to a study from Pakistan, which found that 27% of the patients were defaulters and that 3.5% died (7).
Similarly, a study from India indicated that 20% of the patients were defaulters, 2.6% had failed to be treated and that 7.6% had died (8). In Malaysia, on the other hand, only 3.4% of the patients were defaulters, 2.2% had died and 13.4% were transferred patients (9).
This study showed that females constituted the majority of the patients, whether with pulmonary tuberculosis (54%) or with extra pulmonary tuberculosis (62%); this result was consistent with the findings made by other studies (10), (3); they reported that females occupied the first place as far as extra pulmonary tuberculosis was concerned. The findings of this study were however different from those reported from studies which were conducted in Netherlands (11) and in Malaysia (9), who indicated that the majority of the patients were males, figuring out 63% and 74.2%, respectively. The majority of our patients were females because women often face some obstacles such as high females illiteracy, childcare, housework and economic dependency, which allow them only little access to health care. Other possible factors might be biological sex differences and socio-cultural risk factors which are related to gender roles, which may be the main reasons that made women more susceptible to the disease. Moreover, some mothers feed their children on the expense of their own nutrition. This differential access to food by the females may be an additional factor that may relatively lead them to be more malnutritious than the males. The immunity of the females to tuberculosis may be weakened due to early marriages, pregnancy, multi-pregnancy, births, abortion and lactation, with a lesser time interval between successive pregnancies and lactational stress. The infection with extra pulmonary tuberculosis was usually found to occur in females of the reproductive age group, whose ages ranged between 15–45 years. All the above causes were found to be consistent with the findings made by other studies (3), (12).
The present study noticed that there was a strong association between pulmonary tuberculosis and extra pulmonary tuberculosisand young age. The median age of the extra pulmonary tuberculosis patients was 30 years; while in pulmonary tuberculosis, it was 29 years. The findings of the present study were consistent with those of a study which was conducted in Nepal, with regards to extra pulmonary tuberculosis patients (aged 28.5 years) and they were not consistent with the findings on pulmonary tuberculosis patients (aged 47 years) (3).
A study which was conducted in the United States found no connection between the extra pulmonary tuberculosis cases and young age (10).
The pulmonary TB cases in this age group were found to increase due to the exposure to infected people in crowded places such as markets and public transports and unhealthy working conditions. These may play an important role in the transmission of both pulmonary and extra pulmonary tuberculosis. Mario et al. (13) reported that age is an important determinant of the risk of disease after infection. Among infected persons, the incidence of tuberculosis was highest during late adolescence and early adulthood; the reasons are unclear.
In terms of age distribution, this study found that the majority of tuberculosis patients were within the economically productive age group whose ages ranged between 15-54 years old (14), who registered a percentage as high as 90% in pulmonary tuberculosis, whereas it was 93% for extra pulmonary tuberculosis. This was similar to that which was reported by other studies (15), (7) which revealed that tuberculosis patients within this age group were 85.9% and 85.2% in the pulmonary and the extra pulmonary groups, respectively. On the other hand, another study (12), (9) revealed a lower proportion of patients falling within this age group, figuring out at 70% and 66.2% of the pulmonary and the extra pulmonary cases, respectively.
A matter that was proved by the current study was that smoking was associated with pulmonary tuberculosis, a finding that was inconsistent with the findings from other studies (3), (16).
The current study reported that male smokers constituted a majority of the pulmonary and the extra pulmonary tuberculosis patients, as indicated by the following percentages: 64% and 58%, respectively. This finding was inconsistent with those of the studies which were carried out in Turkey, which found that male smokers accounted for 64.9% of both types of TB cases (17).
On the other hand, a study which was carried out in Hong Kong reported that the smoking rate was 56% in tuberculosis patients and that the incidence of extra pulmonary tuberculosis was higher among non-smokers (18).
A study from India, added that the smoking was found to increase the percentage of mortality in tuberculosis patients (19).
Another study from India proved that there was a relationship between smoking and pulmonary tuberculosis among the Indian males, the percentage being 75% in pulmonary tuberculosis cases (20).
Despite all studies which were conducted to assess the association between smoking and TB, the exact mechanism is not known, and it may be attributed to the nicotine content in tobacco, which might be interfering with the immunity of the patients. The situation in Yemen is still worse; there are less opportunities for health education, neither is there any application of laws to control the sale of cigarettes; a matter that has popularized such an important public health problem.
This study found that 85% of the patients were not employed,
a result that was inconsistent with the findings of studies from
Malaysia (9) and South Africa (21), which found that tuberculosis
patients who were not employed constituted 53% and 62% of all the TB cases, respectively. This high percentage of unemployment was attributed to a high percentage of illiteracy and a low education status, which were the main reasons that made Yemen to be considered as the poorest country.
As far as the educational status of the patients was concerned, they were classified into three different categories: low educational level, which referred to the primary and secondary school level; high educational level, i.e., patients at the university level; and no educational level, which denoted the patients who did not have any type of formal education.
This study indicated that the tuberculosis patients with low educational levels accounted to 52% and 48% cases in the pulmonary tuberculosis and the extra pulmonary tuberculosis groups, respectively. Furthermore, highly educated TB patients accounted for 11% cases in the pulmonary tuberculosis and 10% cases in the extra pulmonary tuberculosis groups, while the uneducated TB patientsaccounted for 37% and 42% cases in the pulmonary tuberculosis and the extra pulmonary tuberculosis groups, respectively. The percentage of uneducated and low educated patients in the two types of TB groups was 85%, which equalled the percentage of the no income patients. Therefore, the findings of this study were consistent with the reports from the WHO (14), which confirmed that tuberculosis patients were from vulnerable groups and were unemployed.
In terms of monthly income, this study found the extra pulmonary tuberculosis patients had less monthly income than the pulmonary tuberculosis patients. This finding can be attributed to the fact that tuberculosis was associated with poverty and that most of the extra pulmonary tuberculosis patients came from rural areas; most of the people in the rural areas drank non pasteurized milk, which was considered to be one of the most important methods for the transmission of tuberculosis. Dankner et al. (22) reported that outbreaks of the infection with M. bovis were still an important public health problem among children and adults in developing countries in which non pasteurized milk was consumed.
In terms of the place of diagnosis, this study found that more numbers of extra pulmonary tuberculosis patients were diagnosed in private hospitals and clinics than the pulmonary tuberculosis patients. This finding can be attributed to the fact that extra pulmonary tuberculosis presents more diagnostic and therapeutic problems than pulmonary tuberculosis which are less familiar to most of the clinicians (4), (23).
In addition, the clinical signs are not specific and so they arouse a high amount of suspicion on the part of the physicians (24).
In other words, the signs and symptoms of pulmonary TB are typical and known (cough and sputum), whereas extra pulmonary TB is difficult to be identified not only by the population, but also by the clinicians themselves. Therefore, patients who are suspected to have pulmonary TB, seek medical care in public hospitals in order to get free medication. On the other hand, extra pulmonary TB patients usually consult the nearest clinic or private hospital for their unknown illness.
Our study had a few limitations. Firstly, the study was conducted only in the urban centres in Sana’a and hence, the findings of this study cannot be generalized to the entire population of Yemen. Secondly, this study only compared the two categories of TB. Finally, our study did not take into consideration the different kinds of extra pulmonary TB.
In conclusion, females constituted the majority of the patients, whether with pulmonary tuberculosis (54%) or with extra pulmonary tuberculosis (62%). A strong association was noticed between PTB and EPTB with age; the median age of the extra pulmonary tu-berculosis patients was 30 years, while in pulmonary tuberculosis, it was 29 years. In terms of age distribution, this study found that the majority of tuberculosis patients were within the economically productive age group that ranged between 15-54 years. Finally, this study found that more numbers of extra pulmonary tuberculosis patients were diagnosed at private hospitals and clinics than the pulmonary tuberculosis patients.
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