The Survial Analysis And Strategies To Reduce The Mortality Of Urban Tuberculosis Patients In Pudong District,Shanghai

Background:Tuberculosis is a kind of chronic respiratory infection which severely harms people’s health. China is one of the22countries which suffered from tuberculosis most severely, and the number of tuberculosis patients ranks the2nd worldwide. There are many deaths of TB. High mortality is one of the features of tuberculosis in our country. With the successful implementation of modern TB control strategy, Morbidity and mortality of tuberculosis in China nowadays has declined compared with its of tuberculosis20years ago. However, due to the prevalence of multidrug-resistant tuberculosis, the urban population aging and increasing floating population, Chinese TB’s prevention and control are also facing a severe situation. According to the statistical report, Shanghai has an average mortality in the time when tuberculosis patients receiving medical treatment. Pudong district is the largest one in Shanghai. The number of its tuberculosis patients and deaths is far more than the other districts. So, It’s necessary for us to carry out an in-depth study to learn that why there are still so many deaths nowadays with efficient chemotherapy for TB. On the other hand, in order to improve the living conditions and reduce mortality rate of tuberculosis patients, we need to analyze the risk factors closely associated with the TB death. By our research, we can develop the targeted countermeasures to improve people’s health.Research objectivities:1. To get mortality rate of tuberculosis by analyzing the data of the living conditions of urban patients during and after the period of medical treatment in Pudong New Area from2004to2008.2. To investigate the causes of the tuberculosis patients’death and develop classification analysis of death causes to obtain the risk factors of affecting their living conditions in Pudong New Area. 3. To give some appropriate recommendations for reducing the mortality rate of tuberculosis in Pudong district according to the analysis of the risk factors.Research contents and methods:According to registration database of tuberculosis case in Pudong New Area, select active tuberculosis cases of urban population as the research subjects (Expo demolition area cases excepted) from the year2004to2008. Collect information about basic conditions, tuberculosis registration, clinical diagnosis, treatment and complication by filtering tuberculosis database and excerpting case history according to the questionnaire designed ahead. Doctors at Community Hospital were trained to get information about the current living condition and living time of subjects by face to face investigation at home or follow-up on the telephone. The death time and death reason of all dead subjects were recorded by looking up information in death registration information system of Shanghai center for disease control and prevention. SPSS16.0was used to manage and analyze data, Descriptive analysis, Chi-square test and Cox regression model were adopted to select risky factors of tuberculosis death.Main results:1. Distribution of demographic characteristics, tuberculosis registration and clinical information.1570tuberculosis patients were selected as eligible subjects after screening, and all the wrongly diagnosed and failure of follow-up ones were excepted. Active tuberculosis are mainly middle-aged and old patients in Pudong urban area from2004to2008,age between40and59account for41.21%and age over60account for35.35%. Male patients account for73.31%and are obviously more than female patients.84%of the patients received a medical treatment for the first time, most of the them were certified as secondary tuberculosis (typeⅢ) while type I primary tuberculosis and type Ⅱ Hematogenous disseminated pulmonary tuberculosis are less seen. The proportion of Hemoptysis is relatively small, accounting for15.7%; The proportion of cavitary pulmonary tuberculosis is higher, accounting for31%; First sputum smear positive ones accounting for44.1%, and the rest are negative or not tested; Severe lesions were found among38.7%patients; Delay for receiving medical services is very serious in Pudong urban area, examination delay, diagnosis delay and found delay accounted for38.3%,33.6%and52.9%respectively; Total drug resistance rate was22.1%and multidrug-resistant rate was4.1%.High proportion of complicated diseases was found among tuberculosis patients in Pudong urban area, especially for diabetes mellitus, chronic bronchitis with infection and cardiovascular disease and other chronic diseases.2. Analysis of the patient’s death inquiry, demographic, and tuberculosis clinical informationAfter2-6years follow-up studies,236people died of1570cases, the main causes of death were pulmonary tuberculosis (30.1%), other respiratory diseases (29.2%), cancer (20.8%) and cardiovascular diseases (9.7%). The overall cases fatality rate in Pudong New Area was15%and4.5%of the death were attributed to causes of pulmonary tuberculosis. The significant independent risk factors for the overall cases fatality were advancing age especially in over70years group. The trend of died from tuberculosis is also increased with age. But the fatality rate in40-59group was significantly higher than that of60-69, should pay more attention. Male sex was significantly associated with mortality compared with female in our study (X2=29.436, P<0.01). The new-to-retreatment ratio in death cases is significantly higher than the survival cases (X2=21.583, P<0.01). Hematogenous disseminated pulmonary tuberculosis deaths accounted for the highest proportion in the same type of pulmonary tuberculosis. But the general case is less, only5cases. There were no significant differences of hemoptysis and void between the death and survival cases. The association between first sputum smear positivity and treatment mortality is significantly higher than the surviving patients (X2=58.951, P<0.01). The severity of lesion range in death case was much higher than the survival (X2=46.567, P<0.01) The diagnosis delay, patient delay and finding delays were all slightly higher in death than survival patients. The proportion of MDR was higher in death patients than the survival patients. The most common diseases that were listed with TB as the cause of death included chronic windpipeitis infection, cardiovascular disease and diabetes. The cause of death patients of overall cases with tumor and two or more comorbidities significant higher than the death were attributed to causes of pulmonary tuberculosis. We also found48.7%of patients were died during the first year after diagnosis and death rate were in a declining trend in the following years. This situation is more obvious in the death cases were attributed to causes of pulmonary tuberculosis.71.8%were died in the first year, should pay more attention in the patients.3. Survival analysis in patients with pulmonary tuberculosis Based on the Cox model analysis, the characteristics of the TB patients associated with overall cases fatality were elderly patients, male sex, first sputum smear positivity, treatment delaying, lesions range equal to or more than3lung fields, multiple drug resistant pulmonary tuberculosis, and chronic windpipeitis infection. Risk factors for the death due to tuberculosis were elderly patients, first sputum smear positivity, treatment delaying, and lesion ranges equal to or more than3lung fields. Single factor analysis shows that, regardless of death due to tuberculosis or other diseases, retreatment patients were at higher risk of mortality.Recommendations1、To strengthen the TB managements and health improvements for the elderly tuberculosis patients. Elderly TB patients with complications need hospitalization and more attention should be paid to improve resistance and give the necessary nutrition support. Individualized treatment based on the actual situation should be used to improve the cure rate for the patients. Furthermore, we should strengthen the management and appropriately extend the course of treatment for patients with smear positivity. Sputum smear and culture should also be reexamined in the key months. TB drug susceptibility test should be undertaken in the course of two months after the smear and culture of non-negative patients. According to the results of test, we could adjust the treatment program, improve the cure rate of tuberculosis patients and reduce the risk of mortality.2、To adopt the integrated intervention measures for reducing the delay of tuberculosis patients. TB health promotion should be increased to improve awareness rate of tuberculosis knowledge among public. Furthermore, to strengthen the screening of TB suspects can reduce the risk of mortality because of the patient delay. To strengthen the construction of network on tuberculosis’early detection, and to reinforce TB-related training program of medical personnel can reduce the medical delay in general hospital.3、To attach importance to chemotherapy of tuberculosis management in order to prevent and control multidrug-resistant tuberculosis. Pulmonary tuberculosis cases by irregular treatment are major objects of tuberculosis management, the centers for disease control and prevention should establish related system and measures. On the model of trinity tuberculosis prevention in Shanghai, community hospital、district CDC and TB specialized hospital closely cooperate with each other for improving compliance of patients, then to cure them and reduce the occurrence of re-treatment pulmonary tuberculosis and drug-resistant tuberculosis. To improve the success rate of treatment, tuberculosis prevention institutes should establish and perfect the system of discussing chest radiograph by experts, especially in pulmonary tuberculosis patients of irregular treatment and smear positive. In addition, it can reduce the epidemic of MDR-TB and the incidence of the initial treating MDR-TB by increasing investment on prevention and medication of TB.4、To cure tuberculosis patients complications by combining other clinical departments. We should pay attention to diagnosis and differential diagnosis between chronic bronchitis and pulmonary tuberculosis to prevent missed diagnosis of pulmonary tuberculosis. Furthermore, we should attach importance to treatment of cancer and cardiovascular disease. Patients with the two kinds of complications should be transported to the tuberculosis hospital after the complication symptoms being controlled in general hospital.5、It is necessary to call for psychological support in the management of tuberculosis patients. The social support of re-treatment and MDR-TB patients is very weak. So, they should gain more hygienic knowledge and psychological support, and we should help them establish the confidence of conquering disease and improve psychological health of the patients in the care of the members of the society.