Survival And Associated Risk Factors Among Elder Patients With Smear Positive Pulmonary Tuberculosis In Shanghai, China

BackgroundChina is one of the twenty-three countries with high burden of tuberculosis and ranks second in terms of the total number of tuberculosis cases in the world. The incidence and mortality rate of pulmonary tuberculosis (PTB) cases in Shanghai decreased in recently years, lower than many other regions in China. But it is still a challenge to deal with the PTB among elder patient in such a metropolitan area with advancing proportion of elder people, for those elder people with PTB may have some difficulties in treatment and usually need special health care. About 30% reported TB patients in Shanghai were aged 60 or more in recent years. Elder PTB patients are usually reported to have worse prognosis. Thus, it is important for us to describe the survival of elder TB patients in Shanghai and to identify the risk factors associated with mortality and treatment outcomes among them so that effective measures and interventions could be used to decrease mortality rate especially for elder PTB patients.Research PurposeTo describe and analyze the prognosis for patients with PTB who were 60 or more at diagnosis from 2004 to 2006. To assess and identify potential demographic, clinical and treatment risk factors associated with their survival. To provide recommendations for TB control system and government. More vigorous management and prevention strategies based on these risk factors could reduce deaths among elder PTB patients.Research DesignThe current developmental study collected all PTB patients documented by the TB Registry at Shanghai Municipal Center for Disease Control & Prevention (SCDC). Surveillance and clinical data about treatment outcomes as well as demographic, clinical, treatment and drug-resistant of these patients during 2004-2006 were investigated and collected. The tuberculosis reference laboratory at SCDC tested and confirmed the samples for drug susceptibility. After exclusion,2133 elder patients remained in the study. Among them,1310 cases were tested for drug susceptibility. Multivariate logistic regression and Cox proportional hazards regression were performed to calculate the potential risk factors associated with mortality using SAS. Stratified analyses by age and co-morbidity status were also conducted.Results1.30.4% of registered PTB patients were aged 60 or older in Shanghai from year 2004 to 2006 and 81.8% of them were male. Elder patients had worse prognosis than young patients. The accumulative mortality rate for aged 60 or older registered patients was 12.89% during the study period and among them,56.7% cases died for cause other than TB.2. Among 1310 patients tested for drug susceptibility,212 (16.1%) cases were resistant to at least one of the four first-line anti-tuberculosis drugs used in Shanghai and 62 (4.7%) cases were multidrug-resistant tuberculosis (MDR-TB). Elder patients were more likely to be resistant to isoniazid (12.29%) and streptomycin (11.53%). Retreatment seemed to be significantly associated with drug-resistance (8.5% vs.3.2%, p<0.01). Furthermore, patients accepted standard chemotherapy (2.1% vs.2.6%, p<0.01) and hospitalized patients (1.8% vs.2.9%, p< 0.01) were observed to have lower drug resistance rate.3. Older age at time of diagnosis, male gender, sputum smear and co-morbidity were independently associated with increased risk of mortality for elder PTB patients in this study whether the patients were resistant to anti-tuberculosis drugs or not. Older age were positively related to worse prognosis. Subgroups of patients with different age varied in potential risk factors and prognosis. TB-specific mortality rate was 31.1% in the group of 60 to 69 years old,40.8% in the group of 70 to 79 years old and 52.0% in the group of patients aged 80 or more. Male patients and smear positive patients were observed to have worse outcomes. Those with chronic diseases such as mental disorder or neurological diseases (HR= 4.79, p< 0.01), other pulmonary disease (HR=1.64, p=0.03), cardiovascular or cerebrovascular diseases (HR=1.75, p=0.03) and cancer (HR= 3.61, p<0.01) had worst prognosis. Elder patients without history of TB and in rural or suburb district might have greater risk of death. None significant association between drug-resistance and survival were observed after univariate and multivariate analyses in this study.Recommendations1. Strengthen the TB control and manage model in Shanghai. TB control organizations such as SCDC, district CDCs, designated hospitals and community health centers should play better roles of planning, surveillance, diagnosis, treating as well as health education and health promotion especially for elder PTB patients.2. Elder PTB patients need special health care, so more attentions about health promotion, interventions for risk behavioral factors, mental counseling and personalized therapy should be paid to elder patients. TB control programs should interact with other public health programs to gain efficiency.3. Human-based management of DOTS should be performed in communities and families. Treatment facilities with more comfortable situations and better equipments should be created so that better compliance could be possible.4. An integrated TB information system is necessary to gather data on TB surveillance, personal health status and treatment management. Functions such as instant case report, tracing and verifying suspects, information storing and exchanging among TB control facilities as well as recording and reminding for anti-tuberculosis drugs can be conducted by such an information system. Data assessing and quality control could be more convenient.