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Pulmonary tuberculosis in a hospital setting: Gender differences
Public Health (2006) 120, 441–443
SHORT COMMUNICATION
Pulmonary tuberculosis in a hospital setting: Gender differences V. Nissapatorna,*, I. Kuppusamyb, B.L.H. Simc, Q. Kia Fattd, A. Khairul Anuara a
Department of Parasitology, University of Malaya Medical Centre, 50603 Kuala Lumpur, Malaysia National Tuberculosis Centre, Kuala Lumpur, Malaysia c Department of Medicine, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia d Department of Social and Preventive Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia b
Received 5 July 2004; received in revised form 27 May 2005; accepted 25 November 2005
KEYWORDS Pulmonary tuberculosis; Non-HIV-infected patients; Gender; Malaysia
Introduction Tuberculosis (TB) continues to be a major public health problem and challenge despite control programmes being implemented worldwide. The global resurgence of TB has been accompanied by an increased frequency of multi-drug-resistant Mycobacterium tuberculosis (MDR-TB).1 In Malaysia, TB is among the top five communicable diseases reported, with 15,643, 14,820 and 14,389 cases reported in 2000, 2001 and 2002, respectively, and a mean mortality rate of 6.2/100,000 population.2 TB is a disease of major impact in Malaysia, and few
* Corresponding author. Tel.: C603 79676618; fax: C603 79674754. E-mail address: [email protected] (V. Nissapatorn).
data are available on gender differences of pulmonary tuberculosis (PTB) in non-HIV-infected patients. The aim of this study was to improve understanding and management of this resurgent but curable disease.
Results Using data from the National Tuberculosis Centre from January 2001 to December 2002, 1456 nonHIV-infected patients were identified, the majority of whom were newly diagnosed TB cases (1345; 92.4%). The age range was 14–95 years (median 37 years), and 68% were male. The significant finding of PTB was observed in active young people (%34 years) and older people (R55 years) of both sexes. Interestingly, PTB was more remarkably seen in
0033-3506/$ - see front matter Q 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2005.11.005
442
V. Nissapatorn et al.
women of childbearing age (15–44 years; 69.3%). The majority of cases (male vs. female) were Malays (47.5 vs. 51.2%), married (57 vs. 66.5%) and unemployed (43.7 vs. 63%). Men were significantly more likely to be smokers, drinkers and intravenous drug users than women (P!0.05), and women were significantly more likely to have had contact with TB patients than men (P!0.05), as illustrated in Table 1. At the time of diagnosis, the four main respiratory presentations were significantly higher in men than women (P!0.05): cough (90 vs. 88%), loss of appetite and/or weight (73 vs. 66%), sputum production (62 vs. 58%) and haemoptysis (34 vs. 28%). Lymph node enlargement and positive tuberculin skin test were the most common clinical Table 1
Sociodemographic characteristics of 1456 tuberculosis patients.
Age range (years) MeanGSD Age group (years) 15–24 25–34 35–44 45–54 R55 Race Malay Chinese Indian Otherb Marital status Single Married Occupation Labourer Non-labourer Unemployed Determining factors Smoking and/or alcohol Yes No Intravenous drug user Yes No Concomitant illness: diabetes mellitus Yes No History of contact with tuberculosis patients Yes No a b
signs, and were significantly more common in women (P!0.05). Upper lobe opacity on chest radiographs was the most common abnormal sign consistent with TB. This was found in 83% of men and 79% of women. Positive results for sputum smear (51 vs. 43.7%) and culture (61.4 vs. 60%) for M. tuberculosis were similar in men and women. PTB occurred more often in men, and lymph node involvement was the most frequent dissemination of PTB in women. EHRZCRH2 (85%) was the most common antitubercular regimen used. More women (75.4%) completed treatment of R6, 9 or 12 months duration than men (69%), and fewer women (15.8%) showed non-compliance with treatment compared with men (25.2%). Sixty-one patients had adverse reactions to the antitubercular drugs, and another
P valuea
Male (nZ987) n (%)
Female (nZ469) n (%)
15–95 40.5G15.9
15–83 37.8G15.9
176 241 187 185 198
(17.8) (24) (19) (18.7) (20)
105 (22.3) 136 (29) 84 (18) 61 (13) 83 (17.7)
0.020
467 247 121 152
(47.3) (25) (12.3) (15.4)
240 (51.2) 105 (22.4) 36 (7.7) 88 (19)
0.016
424 (43) 563 (57)
157 (33.5) 312 (66.5)
0.001
275 (28) 281 (28.5) 431 (43.7)
61 (13) 112 (24) 296 (63)
0.000
505 (51.2) 482 (48.8)
28 (6) 441 (94)
0.000
51 (5.2) 936 (94.8)
0 (0) 469 (100)
0.000
0.46 149 (15) 838 (85)
64 (13.6) 405 (86.4) 0.004
183 (18.5) 804 (81.5)
118 (25.2) 351 (74.8)
P!0.05 for statistical significance by chi-square test. OtherZpeople with foreign nationality and people with first and/or family names that were clearly not Malaysian.
Pulmonary TB in a hospital setting: gender differences nine patients had drug resistance to isoniazid (four cases), and to both rifampicin and isoniazid (MDRTB; five cases).
Discussion The predominance of men with PTB has been reported previously,3,4 but there are no definite explanations for this finding. This study showed that PTB was more significant among women of reproductive age. TB is the leading cause of preventable suffering and death in this age group, and it is possible that cases of TB are being under-reported, particularly in developing countries.5 Screening with tuberculin skin test6 is recommended to measure the risk of M. tuberculosis infection in women, as there may be serious repercussions for the families and households of those affected. In addition, tissue examination should be considered as a useful tool in women with lymph node enlargement to indicate either the prime location of TB origin or other diseases. Regardless of their level of education, women should be aware of this disease, particularly in terms of the importance of BCG immunization towards the prevention of TB and disease transmission to their children or family members. This study showed that PTB was more common among the Malays. This group is the main ethnic group in this region, with many still living in unfavourable socio-economic conditions. PTB was also more significant among couples. This would be expected for TB, as it is an airborne disease that can be directly transmitted between close contacts or in an overcrowded environment with poor sanitation and ventilation. A significantly lower percentage of women were smokers and drinkers. This was expected given that, generally, women in Malaysia conform to conservative cultural practices, and drinking and smoking are prohibited. At clinical presentation, the presence or suspicion of PTB should be further investigated in patients with prolonged respiratory symptoms of unknown cause; these symptoms were seen consistently in patients of both sexes in this study. This study found that men showed less compliance with treatment; being unemployed and the side-effects of antitubercular drugs, particularly hepatitis, could be the main reasons for nonadherence in these patients. Modifying existing antitubercular drugs into a combination form
443 should give a better outcome in terms of easier access, fewer side effects, cost-effectiveness and tolerability. Drug susceptibility should be screened routinely in all newly diagnosed TB patients. The Directly Observed Treatment (DOT) programme should also be utilized extensively in patients displaying side effects to antitubercular drugs or patients with a history of defaulting treatment. These could contribute to reduce the incidence of drug resistance in the future. PTB, the primary tuberculosis infection, is commonly found in these patients, and co-existing factors play important roles in the course of the disease. Health personnel or mobile clinic services should provide basic TB screening. In addition, TB information needs to be disseminated constantly by distributing pamphlets, posters, campaigning, giving health talks or via the mass media such as newspaper, radio and television. This would help to reduce misconceptions and prejudice about this contagious disease.
Conclusion Overall, there are differences in gender-specific rates in the course of PTB in this region. Further studies are recommended to highlight the incidence of TB between genders, to identify reasons for nonadherence to treatment in men, and to investigate notification of confirmed TB cases in women, particularly women of childbearing age, in Malaysia.
References 1. Frieden TR, Sterling T, Pablos-Mendez A, Kilburn JO, Cauthen GM, Dooley SW. The emergence of drug-resistant tuberculosis in New York city. N Engl J Med 1993;328:521–6. 2. Aziah AM. Tuberculosis in Malaysia: combating the old nemesis. Med J Malaysia 2004;59:1–3. 3. Howell F, Kelly P, Clancy L. Pulmonary tuberculosis in the republic of Ireland: an epidemiological profile from a single unit. Respir Med 1990;84:111–7. 4. Ismail Y. Pulmonary tuberculosis—review of clinical features and diagnosis in 232 cases. Med J Malaysia 2004;59:56–64. 5. Holmes CB, Hausler H, Nunn P. A review of sex differences in the epidemiology of tuberculosis. Int J Tuberc Lung Dis 1998; 2:96–104. 6. Hudelson P. Gender differentials in tuberculosis: the role of socio-economic and cultural factors. Tuberc Lung Dis 1996; 77:391–400.
SHORT COMMUNICATION
Pulmonary tuberculosis in a hospital setting: Gender differences V. Nissapatorna,*, I. Kuppusamyb, B.L.H. Simc, Q. Kia Fattd, A. Khairul Anuara a
Department of Parasitology, University of Malaya Medical Centre, 50603 Kuala Lumpur, Malaysia National Tuberculosis Centre, Kuala Lumpur, Malaysia c Department of Medicine, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia d Department of Social and Preventive Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia b
Received 5 July 2004; received in revised form 27 May 2005; accepted 25 November 2005
KEYWORDS Pulmonary tuberculosis; Non-HIV-infected patients; Gender; Malaysia
Introduction Tuberculosis (TB) continues to be a major public health problem and challenge despite control programmes being implemented worldwide. The global resurgence of TB has been accompanied by an increased frequency of multi-drug-resistant Mycobacterium tuberculosis (MDR-TB).1 In Malaysia, TB is among the top five communicable diseases reported, with 15,643, 14,820 and 14,389 cases reported in 2000, 2001 and 2002, respectively, and a mean mortality rate of 6.2/100,000 population.2 TB is a disease of major impact in Malaysia, and few
* Corresponding author. Tel.: C603 79676618; fax: C603 79674754. E-mail address: [email protected] (V. Nissapatorn).
data are available on gender differences of pulmonary tuberculosis (PTB) in non-HIV-infected patients. The aim of this study was to improve understanding and management of this resurgent but curable disease.
Results Using data from the National Tuberculosis Centre from January 2001 to December 2002, 1456 nonHIV-infected patients were identified, the majority of whom were newly diagnosed TB cases (1345; 92.4%). The age range was 14–95 years (median 37 years), and 68% were male. The significant finding of PTB was observed in active young people (%34 years) and older people (R55 years) of both sexes. Interestingly, PTB was more remarkably seen in
0033-3506/$ - see front matter Q 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2005.11.005
442
V. Nissapatorn et al.
women of childbearing age (15–44 years; 69.3%). The majority of cases (male vs. female) were Malays (47.5 vs. 51.2%), married (57 vs. 66.5%) and unemployed (43.7 vs. 63%). Men were significantly more likely to be smokers, drinkers and intravenous drug users than women (P!0.05), and women were significantly more likely to have had contact with TB patients than men (P!0.05), as illustrated in Table 1. At the time of diagnosis, the four main respiratory presentations were significantly higher in men than women (P!0.05): cough (90 vs. 88%), loss of appetite and/or weight (73 vs. 66%), sputum production (62 vs. 58%) and haemoptysis (34 vs. 28%). Lymph node enlargement and positive tuberculin skin test were the most common clinical Table 1
Sociodemographic characteristics of 1456 tuberculosis patients.
Age range (years) MeanGSD Age group (years) 15–24 25–34 35–44 45–54 R55 Race Malay Chinese Indian Otherb Marital status Single Married Occupation Labourer Non-labourer Unemployed Determining factors Smoking and/or alcohol Yes No Intravenous drug user Yes No Concomitant illness: diabetes mellitus Yes No History of contact with tuberculosis patients Yes No a b
signs, and were significantly more common in women (P!0.05). Upper lobe opacity on chest radiographs was the most common abnormal sign consistent with TB. This was found in 83% of men and 79% of women. Positive results for sputum smear (51 vs. 43.7%) and culture (61.4 vs. 60%) for M. tuberculosis were similar in men and women. PTB occurred more often in men, and lymph node involvement was the most frequent dissemination of PTB in women. EHRZCRH2 (85%) was the most common antitubercular regimen used. More women (75.4%) completed treatment of R6, 9 or 12 months duration than men (69%), and fewer women (15.8%) showed non-compliance with treatment compared with men (25.2%). Sixty-one patients had adverse reactions to the antitubercular drugs, and another
P valuea
Male (nZ987) n (%)
Female (nZ469) n (%)
15–95 40.5G15.9
15–83 37.8G15.9
176 241 187 185 198
(17.8) (24) (19) (18.7) (20)
105 (22.3) 136 (29) 84 (18) 61 (13) 83 (17.7)
0.020
467 247 121 152
(47.3) (25) (12.3) (15.4)
240 (51.2) 105 (22.4) 36 (7.7) 88 (19)
0.016
424 (43) 563 (57)
157 (33.5) 312 (66.5)
0.001
275 (28) 281 (28.5) 431 (43.7)
61 (13) 112 (24) 296 (63)
0.000
505 (51.2) 482 (48.8)
28 (6) 441 (94)
0.000
51 (5.2) 936 (94.8)
0 (0) 469 (100)
0.000
0.46 149 (15) 838 (85)
64 (13.6) 405 (86.4) 0.004
183 (18.5) 804 (81.5)
118 (25.2) 351 (74.8)
P!0.05 for statistical significance by chi-square test. OtherZpeople with foreign nationality and people with first and/or family names that were clearly not Malaysian.
Pulmonary TB in a hospital setting: gender differences nine patients had drug resistance to isoniazid (four cases), and to both rifampicin and isoniazid (MDRTB; five cases).
Discussion The predominance of men with PTB has been reported previously,3,4 but there are no definite explanations for this finding. This study showed that PTB was more significant among women of reproductive age. TB is the leading cause of preventable suffering and death in this age group, and it is possible that cases of TB are being under-reported, particularly in developing countries.5 Screening with tuberculin skin test6 is recommended to measure the risk of M. tuberculosis infection in women, as there may be serious repercussions for the families and households of those affected. In addition, tissue examination should be considered as a useful tool in women with lymph node enlargement to indicate either the prime location of TB origin or other diseases. Regardless of their level of education, women should be aware of this disease, particularly in terms of the importance of BCG immunization towards the prevention of TB and disease transmission to their children or family members. This study showed that PTB was more common among the Malays. This group is the main ethnic group in this region, with many still living in unfavourable socio-economic conditions. PTB was also more significant among couples. This would be expected for TB, as it is an airborne disease that can be directly transmitted between close contacts or in an overcrowded environment with poor sanitation and ventilation. A significantly lower percentage of women were smokers and drinkers. This was expected given that, generally, women in Malaysia conform to conservative cultural practices, and drinking and smoking are prohibited. At clinical presentation, the presence or suspicion of PTB should be further investigated in patients with prolonged respiratory symptoms of unknown cause; these symptoms were seen consistently in patients of both sexes in this study. This study found that men showed less compliance with treatment; being unemployed and the side-effects of antitubercular drugs, particularly hepatitis, could be the main reasons for nonadherence in these patients. Modifying existing antitubercular drugs into a combination form
443 should give a better outcome in terms of easier access, fewer side effects, cost-effectiveness and tolerability. Drug susceptibility should be screened routinely in all newly diagnosed TB patients. The Directly Observed Treatment (DOT) programme should also be utilized extensively in patients displaying side effects to antitubercular drugs or patients with a history of defaulting treatment. These could contribute to reduce the incidence of drug resistance in the future. PTB, the primary tuberculosis infection, is commonly found in these patients, and co-existing factors play important roles in the course of the disease. Health personnel or mobile clinic services should provide basic TB screening. In addition, TB information needs to be disseminated constantly by distributing pamphlets, posters, campaigning, giving health talks or via the mass media such as newspaper, radio and television. This would help to reduce misconceptions and prejudice about this contagious disease.
Conclusion Overall, there are differences in gender-specific rates in the course of PTB in this region. Further studies are recommended to highlight the incidence of TB between genders, to identify reasons for nonadherence to treatment in men, and to investigate notification of confirmed TB cases in women, particularly women of childbearing age, in Malaysia.
References 1. Frieden TR, Sterling T, Pablos-Mendez A, Kilburn JO, Cauthen GM, Dooley SW. The emergence of drug-resistant tuberculosis in New York city. N Engl J Med 1993;328:521–6. 2. Aziah AM. Tuberculosis in Malaysia: combating the old nemesis. Med J Malaysia 2004;59:1–3. 3. Howell F, Kelly P, Clancy L. Pulmonary tuberculosis in the republic of Ireland: an epidemiological profile from a single unit. Respir Med 1990;84:111–7. 4. Ismail Y. Pulmonary tuberculosis—review of clinical features and diagnosis in 232 cases. Med J Malaysia 2004;59:56–64. 5. Holmes CB, Hausler H, Nunn P. A review of sex differences in the epidemiology of tuberculosis. Int J Tuberc Lung Dis 1998; 2:96–104. 6. Hudelson P. Gender differentials in tuberculosis: the role of socio-economic and cultural factors. Tuberc Lung Dis 1996; 77:391–400.