Tuberculosis is a classic example of an infectious disease linked with social determinants of the health. The survey includes information about the risk factors, socio-economical status pulmonary tuberculosis patients from a high tuberculosis burden trans-border region: Chisinau and Balti city and Western Ukraine Chernivtsi region

Ieremenchuk, I.V.

Lesnic, E.

Niguleanu, A.

Pidverbetska, О.

Semianiv, I.

Todoriko, L.

Цифровий Репозиторій - Інтелектуальні Фонди Буковинського державного медичного університету

 109 Буковинський медичний вісник        Том 20, № 4 (80), 2016  © E. Lesnic1, L. Todoriko2, A. Niguleanu1, I. Ieremenchuk2,  I. Semianiv2, О. Pidverbetska2, 2016 CZU 616-002 E. Lesnic1, L. Todoriko2, A. Niguleanu1, I. Ieremenchuk2,  I. Semianiv2, О. Pidverbetska2 THE SOCIO-ECONOMIC RISK FACTORS OF TUBERCULOSIS IN  CONDITIONS OF A HIGH MIGRATION IN TRANS-BORDER REGION State Medicine and Pharmacy University Nicolae Testemicanu, Chisinau, Republic of Moldova1 HSEI of Ukraine «Bukovinian State Medical University», Chernivtsi, Ukraine2 Abstract. Tuberculosis is a classic example of an infectious disease linked with social determinants of the health. The survey includes information about the risk fac-tors, socio-economical status pulmonary tuberculosis pa-tients from a high tuberculosis burden trans-border region: Chisinau and Balti city and Western Ukraine Chernivtsi region.  Key words: tuberculosis, risk factors, socio-economic status. Background. Tuberculosis (TB) represents a major global health problem, that is well recognized in the Republic of Moldova as well as in Ukraine [2, 4, 5]. It was established that the decline of TB epide-miological indices is attributed to the improving of social and economic conditions, rather than to the clinical advances [1, 3]. In 90 % of cases at least three different factors are associated, the most preva-lent being social factors. The major social factors are overcrowding, poor indoor ventilation, close contact with an infectious source, medical conditions that diminish the immune host defenses against micobac-terial infection, such as malnutrition, tobacco smoke, indoor air pollution, alcoholism, and comorbid con-ditions (HIV infection, diabetes, gastro-intestinal diseases, chronic respiratory diseases, silicosis, ma-lignancies and immunosuppressive treatment). Objective: comparative assessment of demo-graphic and TB epidemiological indices in two Moldovan overburden regions (Chisinau and Balti cities in comparison with national data) and Western Ukraine Region (Chernivtsi region). Material and methods. We have conducted a retrospective, randomized, selective, descriptive study targeting TB risk factors and socio-economical peculiarities of 228 new pulmonary TB cases from two Moldovan cities Chisinau and Balti and 271 new pulmonary TB cases from Chernivtsi region of Ukraine. First Moldovan sample included 185 pa-tients selected as being diagnosed and therapeutically managed in the frame of medical specialized organi-zations of Chisinau city (Chisinau group – CG), the second Moldovan sample included 43 patients from Balti city (Balti group – BG) and the third group, Ukrainian sample included 271 patients of Chernivtsi region (Chernivtsi group – ChG) registered in the period of 01.01.2015-31.12.2015.  Results and discussion. The study was de-signed to incorporate health-related issues of TB morbidity into demographic measures. According to the National Statistical Bureau the stable population of the RM is continuously decreasing. Between 2013 to 2015 the total number of the Moldovan population decreased by 4278 people from 3 559 497 in 2013 to 3 555 159 citizens in 2015. In 65 Moldovan towns, considered as the major infectious cluster were resid-ing 1 492 165 Moldovan citizens (40,67 % of the total population) in 2013, 1 502 996 (42,24 % of the total population) in 2014 and 1 507 265 citizens (42,39 % of the total population) in 2015. Therefore, the population in the urban area increased between 2013 to 2015 by 10 831 people, by on the other hand the rural population of the RM decreased by 19 428 people in the same period. To compare, between 2013 and 2015, the population of Chisinau city in-creased by 9600 people and the population of Baltsi by 491 citizens.  In the global epidemiological context the major epidemiological indices describing the spread of TB disease in the general population are: global inci-dence (number of new cases and relapses reported in 100 000 people), incidence of new case, prevalence and mortality. According to the published data by the Moldovan National Centre for the Management in Health during the period 2013-2015 it was registered an important decline of all TB indices. According to the table 1 the global incidence in RM decreased between 2013 and 2015 by – 22 %, in Chisinau city by – 22,4 % and in Balti by – 24,2 %. A similar vec-tor was established regarding the prevalence (the total number of TB patients) which decreased be-tween 2013-2015 in RM by – 23,3 %, in Chisinau by – 25,5 %, in Balti by 28,3 %. Multiple causes are involved in this rapid decline of registered values: low rate of high risks groups investigated in the frame of active way of screening (annual chest radio-logical examination), high rate of migration popula-tion inaccessible for screening procedures (according to mass-media data 1 million Moldovan citizen are migrants), low health care seeking behavior of the population, high rate of citizens with lack of insur-ance policy and low accessibility to health care ser-vices. Mortality due to the progression of tuberculo-sis is very high, despite of decreasing trend of indi-ces. During the period 2013-2015 mortality de-creased twice from 16,1 to 8,8 at 100 000 population in RM, as well as from 10,8 to 6,9 at 100 000 popu-lation in Chisinau. On the other hand the mortality increased in Balti during the same period of time from 9,3 to 16 of 100 000 population. Буковинський медичний вісник        Том 20, № 4 (80), 2016 110  Table 1 Demographic indices of three high TB burden trans-border regions Index 2013 2014 2015 abs. % abs. % abs. % Population of RM1 3 559 437 - 3 557 634 - 3 555 200 - Urban population1 (rate/RM) 1 492 165 40,67 1 502 996 42,24 1 507 265 42,39 Population of Chisinau1 (rate/RM) 800 601 22,49 804 476 22,61 809 600 22,77 Population of Balti1 (rate/RM) 149 709 4,2 149 784 4,2 150 200 4,2 Population of Ua2 44 629 813 - 42 903 211 - 42 929 298 - Population of Kiev2 (rate/UA) 1 722 100 3,85 2 827 395 6,6 2 829 000 6,3 Population of Chernivtsi2 (rate/UA) 907 139 2,03 905 443 2,06 906 828 1,87 Note. 1. Statistic of Moldova. Demographic situation of Moldova; 2. Medstat.gov.ua/ukr  Table 2 Distribution of patients according to the risk Risk groups Chisinau group Balti group Chernivtsi group N=185 (M±m %) N=43 (M±m %) N=271 (M±m %) Social groups Uninsuranced 139 (75,13±3,17) 23(53,49±7,61*) n/a Unemployed 124 (67,03±3,46) 23 (53,49±7,61*) 191 (70,48±2,71) Young persons 112 (60,5±3,59%) 26 (60,46±7,46) 154 (56,83±3,01) Poor persons 106 (57,29±3,64) 33 (76,74±6,44*) 182 (67,16±4,42) Extreme poverty 29 (15,68±2,67) 3 (6,96±3,89) 11 (4,06±1,19) Co-morbid groups Comorbid cases 50 (27,03±3,26) 23 (53,49±7,61*) 63 (23,24±2,56*) HIV positive 11 (5,94±1,74) 6 (13,95±5,28) 34 (12,54±2,21) Chronic alcoholism 13 (7,03±1,88) 12 (27,91±6,84*) 31 (11,44±1,93) IDU 3 (1,62±0,93) 1 (2,32±2,29) 6 (2,21±0,89) Psychic diseases 4 (2,16±1,07) 3 (6,98±3,88) 9 (3,32±1,09) Epidemiological risk group TB contacts 15 (8,11±2,01) 8 (18,61±5,93) 16 (5,91±1,42) High risk group Migrants 24 (12,97±2,47) 7 (16,28±5,63*) 3 (1,11±0,63) Former detained 9 (4,86±1,58) 2 (4,65±3,21) 11 (4,06±1,19) Note. * - statistical difference, n/a – no available situation, IDU - injection drug using, former detained– patient with history of detention Distributing patients according to the sex we established the predominance of men 138 (74,6±3,20 %) in comparison with women 47 (25,4±3,20 %), with a male/female ratio=2,93/1 in Chisinau group (CG), 31 (72,09±6,84 %) men vs 12 (27,90±6,84 %) women in Balti group (BG), with male/female ra-tio=2,58/1 and 204 (75,27±2,62 %) men and 67 (24,72±2,62 %) women, with male/female ra-tio=3,04/1 in Chernivtsi region group (ChG). Repar-tition of patients in age groups according to the WHO recommendations, identified a same distribu-tion of patients in all three groups, so the biggest one was 35-44 years age group: 52 (28,1±3,30 %) pa-tients in CG, 14 (32,56±7,15 %) patients in BG and 76 (28,04±2,73 %) patients in ChG. Redistributing patients in two age groups (15-44 years old and >45 years) we established the predominance of young patients in CG 112 (60,5±3,59 %) compared to those aged more than 45 years old 73 (39,5±3,59 %). In BG and ChG was established a similar proportion 26 (60,46±7,46 %) compared to 17 (39,53±7,46 %) cases in BG, and 154 (56,83±3,01 %) compared to 117 (43,17±3,01 %) cases in ChG. So, distributing patients according to the biological characteristics we demonstrated that men and young individuals must be targeted by the screening methods and risk reduction measures. Hierarchy of risk groups identified that the big-gest impact on the risk of developing active pulmo-nary tuberculosis in Chisinau city determines: inac-cessible healthcare due to the lack of health insur-ance associated with unemployment (two third of patients), living in poor conditions and young age of patients (one half of patients). Comparing with Ukrainian group were only few migrants (3 (1,11±0,63) cases) were diagnosed with tuberculosis. Comorbid patients were one third of CG and ChG cases and one half of BG, among them HIV- 111 Буковинський медичний вісник        Том 20, № 4 (80), 2016  © E. Lesnic1, L. Todoriko2, A. Niguleanu1, I. Ieremenchuk2,  I. Semianiv2, О. Pidverbetska2, 2016 infected being the fifth part of BG and ChG. In this context Balti and Chernivtsi are two regions endemic for HIV and TB co-infection. Diagnosed with chronic alcoholism were the tenth part of CG and ChG, and the third part of BG. Drug users and pa-tients with psychic diseases are the minor part of all samples. Former detained patients were in a similar proportion in all three groups. Conclusions Republic of Moldova shows a continuously decrease of its entire population and an increase of urban population that contributes to the polarization of health care services, which became much more accessible in urban area. Ukraine is experiencing an increase in its population due to territorial redistribu-tion, despite this, the population of Chernivtsi region is decreasing as being reported to the entire Ukraine population. Moldovan health care system is based on the health insurance mechanisms, but one third of Moldovan population is uninsured, as consequence, active screening of all high risk groups is unafford-able. Although we established a decreasing vector of main tuberculosis epidemiological indices in urban areas of the Republic of Moldova and in Chisinau city, their increase in rural regions demonstrated that epidemiological situation remains tense. References 1. Centrul National de Management in Sanatate [Електронный ресурс]: за даными Национального центра управления здравоохранением министерство здравоохранения Республики Молдова / Nicolae Jelam-schi, Svetlana Nichita, Oleg Barba, Elena Boboc // Poten-cialul uman din sistemul sanatatii implicat in acordarea asistencei medicale ftiziopneumologice. – 2015. – C. 61. – Режим доступа : http://www.cnms.md/ro/rapoarte. 2. Global tuberculosis report 2012: WHO [Електронний ресурс]. – Режим доступу : http://www.who.int/tb/publications/global_report/en/.  3. United Nations [Електронный ресурс] / Report on Mille-nium Development Goals. Republic of Moldova. – Chisi-nau. – 2013. – C. 48. – Режим доступа: http://md.one.un.org/content/dam/unct/moldova/docs/pub/strateg/UNPF_poregss_report_2013.pdf. 4. Медична статистика [Електронный ресурс] / http://medstat.gov.ua/ukr /news.html?id=203. 5. Национальное бюро статистики республики Молдова [Електронный ресурс] / http://statbank.statistica.md. СОЦИАЛЬНО-ЭКОНОМИЧЕСКИЕ ФАКТОРЫ РИСКА РАЗВИТИЯ ТУБЕРКУЛЕЗА  В УСЛОВИЯХ ВЫСОКОЙ МИГРАЦИИ В ПРИГРАНИЧНОМ РЕГИОНЕ E. Лесник1, Л. Тодорико2, A. Нигулену1, И. Еременчук2, И. Семьянив2, Е. Подвербецкая2 Резюме. Туберкулез является классическим примером инфекционного заболевания, связанный с социальными детерминантами здоровья. Исследование включает в себя информацию о факторах риска, социально-экономический статус больных туберкулезом легких с высоким бременем туберкулеза трансграничного региона: Кишинев и город Бельцы и Западная Украина, Черновицкая область. Ключевые слова: туберкулез, факторы риска, социально-экономический статус. СОЦІАЛЬНО-ЕКОНОМІЧНІ ФАКТОРИ РИЗИКУ РОЗВИТКУ ТУБЕРКУЛЬОЗУ  В УМОВАХ ВИСОКОЇ МІГРАЦІЇ В ТРАНСКОРДОННОМУ РЕГІОНІ E. Лесник1, Л. Тодоріко2, A. Нігулену1, I. Єременчук2, I. Сем’янів2, О. Підвербецька2 Резюме. Туберкульоз є класичним прикладом інфекційного захворювання, пов'язаний із соціальними детермі-нантами здоров'я. Дослідження включає в себе інформацію про фактори ризику, соціально-економічний статус хворих на туберкульоз легень із високим тягарем туберкульозу транскордонного регіону: Кишинів і місто Бєльци і Західна Україна, Чернівецька область. Ключові слова: туберкульоз, фактори ризику, соціально-економічний статус. Державний медичний університет медицини і фармації Ніколае Тестеміцану (Кишинів, Республіка Молдова)1 Вищий державний навчальний заклад України «Буковинський державний медичний університет» (Чернівці)2 Рецензент – проф. Л.П. Сидорчук                                  Buk. Med. Herald. – 2016. – Vol. 20, № 4 (80). – P. 109-111 Надійшла до редакції 29.09.2016 року  

The socio-economic risk factors of tuberculosis in conditions of a high migration in trans-border region

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Цифровий Репозиторій - Інтелектуальні Фонди Буковинського державного медичного університету