[Tuberculosis in Poland and the world at the beginning of the third millennium]. / Gruzlica w Polsce i w swiecie u progu trzeciego tysiaclecia.

BACKGROUND: Tuberculosis has been a major public health problem in Poland for many decades. OBJECTIVE: The aim of this investigation was to evaluated incidence, prevalence and mortality from TB in Poland in 1998 and to examine trends of TB incidence. METHODS: Individual date on tuberculosis cases reported to National TB Register and date of prevalence and mortality from TB were analysed. RESULTS: The paper presents the epidemiological situation of TB in Poland in 1998. The year of 1998 was the fifth consecutive year of decline at TB incidence after previous years (1991-1993) of increase. In 1998 there were 13,302 newly registered TB cases, of which 1,476 were relapses. The incidence was 34.4 per 100,000 population, (30.6 were the new cases and 3.8 relapses). Relapses represented 11.1% of all new registered cases. The incidence in 1998 was 4.7% lower than in 1997, but the rate of decline was smaller than in previous year (9.3%). Among the total number of newly registered cases there were 7,501 cases (19.4 per 100,000) bacteriologically confirmed, of which 4,090 cases were sputum smear positive. The proportion of bacteriologically culture positive cases was 56.4% and of sputum smear positive -30.7% which is rather low, but similar to previous years. In view of sufficient network of laboratory services this low proportion of bacteriological confirmation of diagnosis may indicate low quality of bacteriological examinations. In 96.2% of cases the diagnosis was respiratory tuberculosis. Low proportion (3.8%) of non respiratory tuberculosis, which continuous for many years, may indicate inadequacies in diagnosis and registration of this form of disease. The incidence of tuberculosis increases with age, from 1.5 in children up to 67.3 among 65 and older. The proportion of cases in the age group 20-44 years is still high (38.1%). The incidence in men (47.4) is two times higher than in women (22.1), and in rural population higher than in urban--35.6 and 33.7 respectively. The prevalence of tuberculosis at the end of 1998 was 39.5 (15,284 cases), of which 56.2% were bacteriologically confirmed cases (8,593 cases). In the latter group there were 256 cases bacteriologically positive for longer than one year, and 541 cases resistant to at least 1 drug. The proportion of resistant cases (6.3%) is similar to previous years and does not seem to influence the overall effectiveness of chemotherapy. CONCLUSIONS: In recent years incidence of TB in Poland decreased. The incidence of tuberculosis in Poland was about 2 times higher than the average for E.U. countries, but lower than in other Eastern European countries. The distance between Poland and countries with lowest incidence is estimated at 25-30 years.

[Tuberculosis in Poland in 1997]. / Gruzlica w Polsce w 1997 r.

The paper presents the epidemiological situation of TB in Poland in 1997--the fourth consecutive year of decline in TB incidence after three years (1991-1993) of increase. In 1997 there were 13,967 newly registered TB cases, of which 1,578 were relapses. The incidence was 36.1 per 100,000 population, of which 32.0 were the new cases and 4.1 relapses. Relapses represented 11.3% of all newly registered cases. The incidence in 1997 was 9.3% lower than in 1996. The rate of decline was 2 times higher than in previous two years (3.9% and 4.2% respectively). Between provinces the range in incidence was 20.1 to 58.2. Among the total number of newly registered cases there were 7,484 (19.4 per 100,000) bacteriologically confirmed, of which 4,117 cases were sputum smear positive. The proportion of bacteriologically culture positive cases was 53.6 and of sputum smear positive--29.5 which is rather low, but similar to previous years. 95.9% of TB cases the connected respiratory system. Low proportion (4.1%) of non respiratory TB, which continues for many years, may indicate inadequacies in diagnosis and registration of this form of disease. The incidence of TB increases with age, from 1.9 in children to 69.9 in those over 65 years of age. The proportion of cases in the age group 20-44 years is still high (38.6%). The incidence in men (49.8) is two times higher than in women (23.4), and in rural population higher than in urban--38.2 and 34.9 respectively. The prevalence of tuberculosis at the end of 1997 was 41.4 (16,023 cases) of which 52.4% were bacteriologically confirmed cases (8,397 cases). In the latter group there were 281 cases bacteriologically positive for longer than one year, and 469 cases resistant to at least 1 drug. The proportion of resistant cases (5.6%) is similar to previous years and does not seen to influence the overall effectiveness of chemotherapy.

[Adverse event after BCG vaccination in Poland in the years 1994-1997]. / Niepozadane odczyny po szczepieniach BCG w Polsce w latach 1994-1997.

On the basis of 865 registered cases of adverse effects after mass BCG vaccinations in Poland the frequency of these effects has been estimated at 0.2/1000 i.e. 2 cases per 10,000 vaccinated. Among the 865 such cases there were 465 cases (53.8%) of local adverse effects and 365 (43.6%) of lymphadenitis. Within the latter there were 0.04/1000 (i.e. 4 cases per 100,000 vaccinated) of cases with suppurative lymphadenitis. They were found mainly in newborns. No cases of disseminated adverse effects were found. Main errors in the diagnosis and follow-up of adverse effects were lack of data on the diameter of local changes and size of lymphnodes, as well as attempts to remove the lymphnodes. From the above data it can be concluded that BCG vaccinations very rarely produces adverse reaction and therefore may be considered as safe method of tuberculosis prevention.

[Treatment results of patients with bacteriologically confirmed tuberculosis registered in Poland in 1996]. / Wyniki leczenia chorych na gruzlice potwierdzona bakteriologicznie zarejestrowanych w Polsce w 1996 r.

Basing on the data from the Central Tuberculosis Register (existing since 1985), an analysis on the treatment regimens and outcomes was made in 7.919 (6.538 new cases and 1.010 recurrents) patients with active confirmed bacteriologically tuberculosis in 1996. After one year follow-up, among 7.919 patients: 371 were untreated (2.3%), 6.551 were cured (82.7%) (3 x 3 negative smears and culture examinations in the period of 6 months after last positive examination; and 386 were doubtful (4.9%)--i.e. patients in whom 1 x 3 or 2 x 3 negative smears and culture examinations were obtained after last positive examination. 676 patients (8.5%) died of which 418--(4.0%) due to TB; 121 patients--1.5% were still positive. In summary--87.6% of patients were cured or considered as completed treatment. In 1996 year 77.1% patients received four--drug regimens (INH, RMP, PZA, SM/EMB), 18.6% of patients received--3 drugs (in the majority INH, RMP, PZA) in the initial phase of the treatment. The treatment in this phase is, in the majority of cases, performed in hospital under supervision. In spite of the high efficacy of applied regimens, the duration of treatment was too long: 55.9% patients was treated longer than 6 months (32.8% > 9 months).

[Evaluation of diagnostic and therapeutic management in patients with bacteriologically negative pulmonary tuberculosis]. / Ocena postepowania diagnostycznego i leczniczego u chorych na czynna gruzlice ukladu oddechowego niepotwierdzona bakteriologicznie.

The study aimed at assessing the frequency and type of errors in the diagnosis and management of newly registered bacteriologically negative cases of pulmonary tuberculosis. Random sample of 560 out of 7272 such patients registered in 1993 was subject of detailed analysis of all available medical documentation. The analysis was performed by an independent team of three specialists: pulmonologist, radiologist and epidemiologist. The results of the analysis indicate insufficient utilization of modern available diagnostic methods. Apart from clinical assessment the main basis for diagnosis of tuberculosis was A-P radiography. Tomography examination was performed in 35.5% of patient only, bronchoscopic in 19.8% and cytologic examination of sputum in 15.9%. Bacteriological examinations during the first phase of diagnosis, usually in hospitals, were satisfactory. Error in diagnosis was found in 63 patients, i.e. 11.3% of cases. The treatment in patients considered as correctly diagnosed, was in the intensive phase correct, but in the continuation phase--too long.

[Analysis of diagnostic errors and recommendations of diagnostic procedures in bacteriologically negative pulmonary tuberculosis]. / Analiza blednych rozpoznan u chorych na gruzlice czynna niepotwierdzona bakteriologicznie. Zasady postepowania diagnostycznego.

The paper presents a detailed analysis of errors in the diagnosis of bacteriologically negative pulmonary tuberculosis in a random sample of 560 patients out of all such patients registered in 1993. The false diagnosis was found in 63 patients i.e. in 11.3% of the sample. Among the 63 patients with false diagnosis of tuberculosis there were 15 cases with lung cancer, 15 cases with pneumonia and/or pleuritis, 15 cases with disease of circulatory system with abnormal radiological of the lungs, 8 cases with old post-tuberculosis changes in the lung considered as relapses, 4 cases of bronchiolitis obliterans with organizing pneumonia, 3 cases of sarcoidosis and 1 case of aspergillosis in a post-tb cavity. The most serious errors were those related to failure in diagnosing (or of too late diagnosis) of lung cancer. These failures comprised 2.7% of patients in the sample. The chance to detect a lung cancer in the sample was 2900 cases in 100,000 men and 2200 cases in 100,000 women. This chance was much higher than in general population--29x for men and 100x for women. The main source of errors was false interpretation of radiological examinations and neglect to utilise other diagnostic procedures like bronchoscopy, cytology or tomography examinations. As an outcome of the analysis authors present their recommendations for diagnostic procedures in the diagnosis of bacteriologically negative pulmonary tuberculosis.

[Results of anti-tuberculosis treatment of patients with tuberculosis--children and adolescents treated in Poland in 1993]. / Wyniki leczenia przeciwpratkowego chorych na gruzlice dzieci i mlodziezy leczonych w Polsce w 1993 roku.

Treatment of 581 new cases tuberculosis in 215 children and 366 adolescents reported in 1993 were followed up for 12 months. The results show that 96.6% bacteriologically confirmed cases were cured (93.8% of children and 97.2% of adolescents). Among 409 bacteriologically negative cases (183 children and 222 adolescents) only in 7 (4 children and 3 adolescents) i.e. in 1.7% no radiological improvement was observed. 75.7% of cases BK+ received 4 drugs treatment regimen-85.4% adolescents and 40.6% children. Children with bacteriologically negative tuberculosis were treated with 2 drugs regimen -(53% of cases) and with 3 drugs regimen 43.2% of cases, while in adolescents majority of cases received 4 drugs (59.0%) or 3 drugs (33.8%). In almost all regiments there were INH and RMP. In spite of high efficacy of applied regimens, the duration of treatment was relatively long. In children BK+ , in 87.8% of cases it was longer than 6 months (in 43.8% of cases it was longer than 9 months). In adolescents BK+, in 81.2% of cases duration of treatment was longer than 6 months (in 34.7% it was longer than 9 months). Among cases BK(-), in 82.5% of children duration of treatment was longer than 6 months and 53.7% adolescents BK(-) were treated longer than 6 months.

[Is tuberculosis in children and adolescents in Poland an epidemiologic problem? Clinical?]. / Gruzlica dzieci i mlodziezy w Polsce problem epidemiologiczny? Kliniczyny?

The tuberculosis incidence and mortality in children and adolescents in Poland in the years 1970-1994 declined very substantially. In children (0-14 years) the incidence in 1970 was 14.3 per 100,000, and in 1989 it was 2.0 per 100,000, with slight increase to 2.3 per 100,000 in the years 1990-1994. In 1994 there were 203 cases of tuberculosis in children and 352 cases in adolescent. In adolescents during the whole period of 1970-1994 the incidence declined from 81.9 per 100,000 to 11.1 per 100,000, and in both of these age groups, i.e. 0-14 and 15-19 the level of decline was much higher than in older age groups. It was also noted that in both of these groups there were more cases among girls than boys. The very small number of cases with clinically severe forms of tuberculosis, i.e. miliary tuberculosis and meningitis is further evidence of improvement of the epidemiological situation of tuberculosis in the whole group of 0-19 years. In 1994, 60% of new cases among children had a close family contact, while in adolescent it was 15%, and in general population only 3%. Mortality from tuberculosis in children and adolescents was incidental only. In 1994 a death due to tuberculosis was reported in 1 child and 2 adolescents, while in 1950 there were 3056 deaths in children (11.6 per 100,000) and 1647 deaths in adolescents (68.2 per 100,000) of which 1500 were due to tuberculous meningitis.

[Effect of selected socio-economic factors on incidence and outcome of tuberculosis in Poland]. / Wplyw wybranych czynników socjalno-bytowych na wystepowanie i przebieg gruzlicy w Polsce.

The purpose of the paper was to verify the widely held opinion about the influence of socio-economic conditions on tuberculosis incidence and outcome. The analysis of the relationship between different socio-economic factors and tuberculosis shows that level of education seems to be the most important indicator. The level of education of tuberculosis patients in Poland is lower than the average. Together with the standard of living it differentiates patients with regard to clinical form of the disease-the lower the level of education and standard of living conditions, the more fibrocavernous forms. The analysis also indicated that the level of education and employment or unemployment did not influence the choice of treatment regiments but influenced the outcome of treatment.

[Drug resistance among patients with tuberculosis]. / Lekoopornosc wsród chorych na gruzlice.

Detailed questionnaire has been received from 365 patients with drug resistant tuberculosis. They represented 75% of all such patients in Poland. 360 of them had pulmonary tuberculosis. 76% were men. Among 365 analysed patients 55% were below the age of 50 (of whom 61% had initial drug resistance and 47% had acquired resistance). Among these patients 52% had initial and 48% acquired drug resistance. In 193 patients (i.e. 54%) resistance to one drug (in 97 patients to isoniazid-H, in 80 to streptomycin-S and in 5 to rifampicin-R was observed. Resistance to two drugs was observed in 25% of patients and among them a majority (57%) was resistant to H and S and 23% to H and R. In 11% of patients, resistance to three drugs was observed, in 8% to four drugs, and in 4% to five or more drugs. Multidrug resistance (at least H and R) was observed in 97 patients (25% of the total number) and in 76 patients resistance to other than H and R drugs was observed. Among the total number of analysed patients in 263 (72%) resistance to H was observed, in 208-to S, and in 102 to R. Among patients with initial drug resistance, the majority was resistant to one drug and among those with acquired resistance the majority was resistant to two or more drugs. On the basis of this analysis the estimated total initial drug resistance-2. 8% is 6-8 times lower than 30-40 years ago and have remained at this low level for at least 20 recent years. It is concluded therefore that drug resistance in Poland does not present any danger to the effectiveness of tuberculosis programme. Monitoring, however, should continue.

[Drug resistance in patients with tuberculosis in Poland in the years 1966-1992. A test for evaluating the scale of the problem]. / Lekoopornosc wsród chorych na gruzlice w Polsce w latach 1966-1992. Próba oceny skali problemu.

The study analysed the incidence of subjects with tuberculosis who were sputum positive and with at least one drug resistance of the bacilli was observed. The number of such cases in the total population of sputum positive cases in the years 1966-1992. In this period a marked decrease of patients with drug resistance was noticed, from 68/100,000 in 1966 to 1.1/100,000 in 1992. The rate of decline was observed to be decreasing in the last years. Patients with drug resistance comprised 32.5% of all sputum positive patients in 1966 and 4.4% in 1992. The decrease in the number and the percentage of drug resistant cases was observed parallelly to the general trend of better mass chemotherapy efficacy.

[Comparative study of BCG vaccines: Polish, Danish and Japanese]. / Badanie porównawcze szczepionek BCG produkcji polskiej, dunskiej i japonskiej.

In a group of 1111 school children aged 12 years from two selected town in Poland (Rzeszów and Ostroleka) a comparative study of three BCG vaccines was performed, the Polish, the Danish, and the Japanese. Tests for viability of the vaccines gave the following results: for the Polish vaccine 17680000 culturable particles in 1 mg; the Danish--12060000, and the Japanese--43540000 respectively Children eligible for vaccination were selected on the basis of prevaccination tuberculin testing with 2 TU tuberculin RT-23 with Tween 80. All the three vaccines gave high level of postvaccination tuberculin reactions measured after 10 weeks. In more than 30% of children these reactions were higher than 15 mm. The mean postvaccination reactions after the Polish vaccine was 14.2 mm (s.d.3.7), after the Danish--13.7 mm (s.d.3.9), and after the Japanese 14.9 mm(s.d.3.0). The difference between the Danish and the Japanese vaccines was statistically significant, but between the Polish and the other two vaccines was not. It was also formed that children with larger postvaccination tuberculin indurations had larger diameter of preview BCG scars.

[Verification of tuberculosis prognosis in Poland to the year 2000]. / Weryfikacja prognozy gruzlicy w Polsce do 2000 roku.

In 1978 year a tuberculosis prognosis in Poland up to 2000 year was prepared in the Institute of Tuberculosis and Lung Diseases in Warsaw, according to epidemiological and epidemiologic-metric model (efficacy of "diagnosis-therapy program" from 60 to 90% and efficacy of BCG vaccination to 60%). The aim of study was to compare epidemiological data for registered tuberculosis cases in 1980-1990 (incidence morbidity and mortality) with the same parameters presented in prognosis for 1980-1991). Efficacy of analyzed programme was similar to predicted values: for incidence of tuberculosis-64%, for morbidity-65% and for mortality-66%.

[Case finding program for tuberculosis with special reference to chest x-ray examination]. / Wykrywanie chorych na gruzlice pluc ze szczególnym uwzglednieniem badan radiofotograficznych.

An analysis of tuberculosis case-finding programme in Poland in 1966-1991 was performed. The main methods applied in practice were--case-finding according to "symptoms" and according to results of "chest x-ray examination". About 90% of new cases were detected by above mentioned methods. Case-finding according to "symptoms" was increasing parallel to age of patients and reached 74% in group over 60 years. On the other hand, the efficacy of chest x-ray examination was decreasing parallel to age of patients one was calculated as 19%. The case-finding method according to "symptoms" is suggested by authors as a basic and useful, especially in family doctor's practice. Chest x-ray examinations should be limited to high risk population.

[The role of radiophotography in tuberculosis control programs in Poland]. / Miejsce badan radiofotograficznych w programie zwalczania gruzlicy w Polsce.

The role of mass radiophotography in Poland in the years 1985-1898 is presented basing on routine data from Antituberculous Centers and Radiophotographic Units. Mass radiophotography detects approximately 30% of new registered pulmonary tuberculosis cases. In the analysed period the number of radiophotographic examinations systematically fell. Also the percentage of the population that was screened using this method decreased, as well as, although to a lesser state, the percentage of new detected cases of pulmonary tuberculosis. A significant decrease in usage of mass radiophotography equipment was also seen. The economical cost of such examination increased. The role and place of mass radiophotography in tuberculosis control programs in Poland is discussed by the authors. It seems that first contact physicians will have the most pronounced role in early diagnosis of pulmonary tuberculosis. Also more emphasis should be placed on bacteriological diagnosis of tuberculosis.

[Pulmonary tuberculosis convalescents (group IV D) at the outpatient tuberculosis and lung disease clinics in Poland 1967-1986]. / Ozdrowiency po gruzlicy pluc (grupa IV D) w poradniach gruzlicy i chorób pluc w Polsce w latach 1967-1986.

An analysis of risk rates of tuberculosis incidence in convalescents registered in tuberculosis dispensaries in Poland in the years 1967-1986 was made. In Poland they are registered in group IVD. Since 1978 this group is steadily decreasing although in 1986 it made up 1.27% of the whole country's population, and was the highest risk group. In 1986 the risk of a tuberculosis infection was six fold higher in this group, and eight fold higher confirmed bacteriologically. Out of this group 8.3% of new infections are derived, and 11.1% of freshly diagnosed cases of bacteriologically confirmed tuberculosis. Heterogeneity of this group suggests different proceedings.