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Vol. 56. Issue 8.
Pages 483-492 (August 2020)
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Vol. 56. Issue 8.
Pages 483-492 (August 2020)
Original Article
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Evaluation of the Integrated Tuberculosis Research Program Sponsored by the Spanish society of pulmonology and thoracic surgery: 11 years on
Evaluación del Programa Integrado de Investigación en Tuberculosis promovido por la Sociedad Española de Neumología y Cirugía Torácica tras 11 años de funcionamiento
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Teresa Rodrigoa,b,c,
Corresponding author
pii_tb_teresa_rodrigo@separ.es

Corresponding author.
, José-María García-Garcíad,a, José A. Camineroe,f,a, Juan Ruiz-Manzanog,a, Luis Anibarroh,a, Marta M. García-Clementei,a, José A. Gullónd,a, M. Ángeles Jiménez-Fuentesj,a, Juan F. Medinak,a, Isabel Mirl,a, Antón Penasm,a, Francisca Sánchezn,a, Maria Luiza De Souza-Galvãoj,a, Joan A. Caylàc,a, Grupo de Trabajo del Programa Integrado de Investigación en Tuberculosis (PII-TB) 1
a Fundación Respira, Programa Integrado de Investigación en Tuberculosis (PII-TB), Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain
b Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
c Fundación Unidad de Investigación en Tuberculosis (fuiTB), Barcelona, Spain
d Servicio de Neumología, Hospital Universitario San Agustín, Avilés, Asturias, Spain
e Servicio de Neumología, Hospital General Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
f International Union Against Tuberculosis and Lung Disease, París, France
g Servicio de Neumología, Hospital Universitario Germans Trials i Pujol, Badalona, Barcelona, Spain
h Unidad de Tuberculosis, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
i Servicio de Neumología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
j Unidad de Prevención y Control de Tuberculosis, Hospital Universitario Vall d’Hebrón, Barcelona, Spain
k Unidad de Tuberculosis, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain
l Servicio de Neumología, Hospital Son Llàtzer, Palma de Mallorca, Baleares, Spain
m Unidad de Tuberculosis, Hospital Universitario Lucus Augusti, Lugo, Spain
n Servicio de Medicina Interna, Hospital del Mar, Barcelona, Spain
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Tables (4)
Table 1. Case inclusion and exclusion criteria.
Table 2. Variables associated with tuberculous disease over the period 2006-2016.
Table 3. Significant trends in proportions of principal variables analyzed over the period 2006-2016.
Table 4. Description, annual variation and trends in PII-TB objective indicators (2006-2016).
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Abstract
Objective

The objective of the study was to determine the trend of variables related to tuberculosis (TB) from the Integrated Tuberculosis Research Program (PII-TB) registry of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR), and to evaluate the PII-TB according to indicators related to its scientific objectives.

Method

Cross-sectional, population-based, multicenter study of new TB cases prospectively registered in the PII-TB between 2006 and 2016. The time trend of quantitative variables was calculated using a lineal regression model, and qualitative variables using the χy test for lineal trend.

Results

A total of 6,892 cases with an annual median of 531 were analyzed. Overall, a significant down-ward trend was observed in women, immigrants, prisoners, and patients initially treated with 3 drugs. Significant upward trends were observed in patients aged 40−50 and >50 years, first visit conducted by a specialist, hospitalization, diagnostic delay, disseminated disease and single extrapulmonary location, culture(+), drug susceptibility testing performed, drug resistance, directly observed treatment, prolonged treatment, and death from another cause. The scientific objectives of the PII-TB that showed a significant upward trend were publications, which reached a maximum of 8 in 2016 with a total impact factor of 49.664, numbers of projects initiated annually, presentations at conferences, and theses.

Conclusions

PII-TB provides relevant information on TB and its associated factors in Spain. A large team of researchers has been created; some scientific aspects of the registry were positive, while others could have been improved.

Keywords:
Tuberculosis
Programs
Control
Research
Evaluation
Resumen
Objetivo

El objetivo del estudio fue conocer la tendencia de las variables relacionadas con la tuberculosis (TB) en España a partir del registro del Programa Integrado de Investigación en Tuberculosis (PII-TB) de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR) y evaluar el PII-TB mediante indicadores relacionados con sus objetivos científicos.

Método

Estudio transversal multicéntrico de base poblacional de casos nuevos de TB registrados prospectivamente por el PII-TB entre 2006 y 2016. La tendencia temporal de variables cuantitativas se realizó mediante un modelo de regresión lineal y las cualitativas mediante la prueba de χ2 de tendencia lineal.

Resultados

Se analizaron 6.892 casos de TB con una mediana anual de 531. La tendencia general fue significativamente decreciente en mujeres, inmigrantes, privados de libertad y en tratados inicialmente con 3 fármacos. Se incrementaron significativamente la tendencia de grupos de 40–50 años y > 50 años, primera atención por especialista de zona, hospitalización, retraso diagnóstico, localización diseminada y extrapulmonar única, cultivo (+), realización de antibiogramas, resistencia a fármacos, tratamiento directamente observado, prolongación del tratamiento y muerte por otra causa. Los objetivos científicos del PII-TB que incrementaron significativamente fueron las publicaciones alcanzando un máximo de 8 en 2016 y con un factor de impacto total de 49,664, y también mejoraron los proyectos iniciados anualmente, presentaciones en congresos y las tesis o tesinas.

Conclusiones

El PII-TB proporciona información relevante sobre la TB y sus factores asociados en España. Se ha formado un amplio equipo de investigadores y se han detectado aspectos científicos positivos y otros mejorables.

Palabras clave:
Tuberculosis
Programas
Control
Investigación
Evaluación
Full Text
Introduction

Tuberculosis (TB) is still one of the most important infectious diseases worldwide, and remains a major public health problem: in fact, in 1993 it was declared a global emergency by the World Health Organization (WHO).1

The incidence of TB in Spain in 1996 was 38.48 cases/100,000 inhabitants,2 varying widely among autonomous communities (AC).3 By 1999, it had fallen to 26.7 cases/100,000 inhabitants4 and by 2017, incidence was 9.43 cases/100,000 inhabitants.5 However, the real incidence is probably higher, since under-reporting is significant.6–8 A surge in immigration substantially altered the epidemiology of TB in Spain.9 In Barcelona between 1995 and 2001, for example, rates rose from 5% to 47%,7 and similar figures were observed in some CAs.10

In 2004, the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) created the Integrated Tuberculosis Research Program (PII-TB) with the aim of promoting and prioritizing multidisciplinary and multicenter research. Program objectives include facilitating TB research in Spain, incorporating evaluation into clinical practice, stimulating research training, coordinating TB research, and improving prevention and control.11

As early as 1978, the WHO published guidelines for evaluating health programs and adapting them to management processes,12 an initiative followed by agencies such as the International Union against Tuberculosis and Lung Disease (The Union).13 This approach was adopted in Spain with the Consensus on Prevention and Control Programs in TB14 and, more recently, the Spanish TB Prevention and Control Plan.15

The objectives of this study were to determine trends in TB prevention and control16 derived from the Spanish PII-TB registry and evaluate the scientific objectives of that program.11

MethodDesign

We performed a population-based, multicenter, cross-sectional study of all new TB cases reported prospectively between 2006 and 2016 by PII-TB investigators in 16 ACs and 1 autonomous city (Fig. 1). Previously defined inclusion and exclusion criteria17,18 are listed in Table 1.

Fig. 1.

Total and percentage distribution of tuberculosis cases contributed to the Integrated Tuberculosis Research Program by each autonomous community between 2006 and 2016.

(0.14MB).
Table 1.

Case inclusion and exclusion criteria.

Criteria  Inclusion  Exclusion 
Age 18 years or older   
Sputum smear (+) or sputum smear (–) with culture (+)   
EP-TB with granulomas in histology   
Suspected TB with TB treatment   
Informed consent   
< 18 years   
No confirmation of extrapulmonary tuberculosis   
Lack of informed consent   

A retrospective descriptive analysis of the main variables was performed for each year of the study period and a trend test was then conducted to determine significant, favorable or unfavorable variations in these variables. Similar analyses were performed with indicators of the PII-TB scientific objectives.

Variables and statistical analysis

  • 1

    Variables associated with tuberculosis

Number of cases (total and by age group), sex, country of origin, risk factors (tobacco, alcohol, drugs), associated diseases (human immunodeficiency virus, immunodepression), prior treatment, site, sputum smear, culture, drug susceptibility testing, type of treatment (combination of 3 drugs, isoniazid, rifampicin, pyrazinamide [HRZ], or 4 drugs with the addition of ethambutol [HRZE], or non-combined treatments), diagnostic delay, treatment adherence, directly observed treatment (DOT), and treatment outcome (cure, completed treatment, therapeutic failure, transfer, TB or another cause death, dropout, prolongation of treatment, lost-to-follow-up).

  • 2

    Scientific indicators of the Integrated Tuberculosis Research Program

Participating investigators and centers, publications, presentations at congresses, and theses/dissertations.

Qualitative and quantitative variables and frequency distribution were analyzed, and measures of central tendency, standard deviation, and 95% confidence intervals (CI) were calculated. Proportions were compared using the χ² test. Differences were considered significant at p < 0.05. Time trends among quantitative variables were investigated using a simple linear regression model, considering the variables described above as dependent and the period as the independent variable. For qualitative variables, the trend over time was analyzed using the χ² linear trend test. The mean annual decline was calculated by dividing the percentage reduction in incidence between the first and last years by the number of years considered.

SPSS 18 IBM and R freeware version 2.13 (http://cran.r-project.org) statistical packages were used.

Ethical aspects

Cases were included according to the requirements of the Declaration of Helsinki (Tokyo revision, October 2004) and the Spanish Organic Data Protection Act 15/1999. Each patient received detailed information and was asked to consent to the processing of their clinical data. Confidentiality was guaranteed because the surveys contain only the patient's initials, and access is restricted to the investigator and, if necessary, the pertinent Scientific Research Ethics Committee and the health authorities. No reference to patients’ identity was made in the publication of the results.

Results

  • 1

    Trend in variables of interest in tuberculosis: number of cases was 6892, with an annual median of 531 (Table 2) (Fig. 2), and a downward trend: y = 974.38−57.97x (Fig. 3).

    Table 2.

    Variables associated with tuberculous disease over the period 2006-2016.

      2006  2007  2008  2009  2010  2011  2012  2013  2014  2015  2016  Median 
      N (%)  N (%)  N (%)  N (%)  N (%)  N (%)  N (%)  N (%)  N (%)  N (%)  N (%)   
    Total cases (N):6,892  1390 (20.2)  779 (11.3)  528 (7.7)  559 (8.1)  497 (7.2)  737 (10.7)  643 (9.3)  462 (6.7)  398 (5.8)  368 (5.3)  531 (7.7)  531 
    Age                         
    < 30  465 (33.5)  246 (31.6)  171 (32.4)  173 (30.9)  149 (30.0)  214 (29.1)  167 (26.1)  103 (22.4)  96 (24.2)  88 (24.2)  111 (20.9)  167 
    31−39  294 (21.2)  171 (22.0)  112 (21.39)  118 (21.1)  109 (21.9)  167 (22.7)  138 (21.6)  115 (25.0)  82 (20.7)  84 (23.1)  82 (15.4)  115 
    40−50  252 (18.2)  151 (19.4)  115 (21.8)  101 (18.1)  95 (19.1)  139 (18.9)  123 (19.2)  97 (21.1)  87 (22.0)  72 (19.8)  126 (23.7)  115 
    > 50  375 (27.1)  210 (27.0)  129 (24.5)  167 (29.9)  144 (29.0)  216 (29.3)  211 (33.0)  145 (31.5)  131 (33.1)  120 (33.0)  212 (39.9)  167 
    Sex                         
    Men  877 (64.7)  483 (62.7)  335 (64.5)  342 (61.7)  305 (62.5)  473 (65.5)  396 (62.8)  273 (62.2)  249 (65.9)  247 (69.2)  391 (74.6)  342 
    Women  476 (35.1)  287 (37.3)  184 (35.5)  212 (38.3)  180 (36.9)  248 (34.3)  234 (37.1)  165 (37.6)  129 (34.1)  110 (30.8)  133 (25.4)  184 
    Not recorded  37 (2.7)  7 (1.2)  9 (1.7)  5 (0.9)  12 (2.4)  16 (2.8)  13 (2.0)  241 (5.2)  20 (5.0)  11 (3.0)  7 (1.3)  12 
    Country of origin                         
    Spain  998 (71.8)  500 (64.2)  339 (64.2)  371 (66.4)  315 (63.4)  503 (68.2)  418 (65.0)  284 (61.5)  276 (69.3)  242 (65.8)  342 (64.4)  342 
    Others  392 (28.2)  279 (35.8)  189 (35.8)  188 (33.6)  182 (36.6)  234 (31.8)  225 (35.0)  178 (38.5)  122 (30.7)  126 (34.2)  189 (35.6)  189 
    Living situation                         
    Confinement  27 (2.0)  12 (1.6)  2 (0.4)  3 (0.5)  7 (1.4)  12 (1.7)  9 (1.5)  5 (1.2)  6 (1.6)  8 (2.2)  3 (0.6) 
    Family  995 (73.1)  541 (70.5)  392 (76.6)  435 (78.5)  363 (74.7)  549 (77.9)  485 (79.1)  332 (77.6)  300 (77.9)  278 (76.2)  394 (74.9)  394 
    Group  172 (12.6)  112 (14.6)  58 (11.3)  57 (10.3)  59 (12.4)  69 (9.8)  59 (9.6)  42 (9.8)  47 (12.2)  27 (7.4)  45 (8.6)  58 
    No fixed abode  23 (1.7)  16 (2.1)  8 (1.6)  3 (0.5)  8 (1.6)  13 (1.8)  12 (2.0)  11 (2.6)  10 (2.6)  7 (1.9)  16 (3.0)  11 
    Lives alone  144 (10.6)  86 (11.2)  52 (10.2)  56 (10.1)  49 (10.1)  62 (8.8)  48 (7.8)  38 (8.9)  22 (5.7)  45 (12.3)  68 (12.9)  52 
    Place first seen                         
    Area specialist  200 (15.4)  128 (17.3)  91 (18.1)  104 (18.7)  83 (16.8)  107 (14.6)  81 (12.8)  51 (11.1)  73 (18.5)  60 (16.4)  108 (20.8)  91 
    Primary care physician  232 (17.8)  121 (16.4)  83 (16.5)  96 (17.2)  87 (17.6)  153 (20.9)  150 (23.6)  121 (26.3)  89 (22.5)  91 (24.9)  110 (21.2)  110 
    Hospital emergency department  651 (50.0)  382 (51.6)  252 (50.1)  286 (51.3)  278 (56.3)  384 (52.5)  328 (51.7)  232 50.4  195 (49.4)  180 (49.3)  258 (49.6)  278 
    Others  219 (16.8)  109 (14.7)  77 (15.3)  71 (12.7)  46 (9.3)  88 (12.0)  76 (12.0)  56 (12.2)  38 (9.6)  34 (9.3)  44 (8.5)  71 
    Prior treatment                         
    No  1237 (91.3)  703 (90.8)  484 (92.4)  510 (91.9)  459 (92.4)  679 (93.8)  587 (93.5)  401 (92.4)  352 (94.4)  340 (93.4)  491 (92.6)  491 
    Yes  118 (8.7)  71 (9.2)  40 (7.6)  45 (8.1)  38 (7.6)  45 (6.2)  41 (6.5)  33 (7.6)  21 (5.6)  24 (6.6)  39 (7.4)  40 
    HIV                         
    No  990 (71.00)  577 (74.5)  408 (77.7)  479 (85.8)  401 (80.8)  566 (77.9)  520 (81.6)  384 (84.6)  346 (87.6)  330 (89.9)  474 (89.6)  474 
    Not known  326 (23.7)  147 (19.0)  83 (15.8)  64 (11.5)  75 (15.1)  123 (16.9)  93 (14.6)  50 (11.0)  40 (10.1)  23 (6.3)  33 (6.2)  75 
    Yes  61 (4.4)  51 (6.6)  34 (6.5)  15 (2.7)  20 (4.0)  38 (5.2)  24 (3.8)  20 (4.4)  9 (2.3)  14 (3.8)  22 (4.2)  22 
    Site                         
    Pulmonary  1065 (76.6)  598 (76.8)  416 (78.8)  433 (77.5)  396 (79.7)  573 (77.7)  484 (75.3)  361 (78.1)  297 (74.6)  271 (73.6)  405 (76.3)  416 
    Pleural  185 (13.3)  112 (14.4)  68 (12.9)  77 (13.8)  52 (10.5)  102 13.8  76 (11.8)  55 (11.9)  55 (13.8)  50 (13.6)  63 (11.9)  68 
    Disseminated  56 (4.0)  37 (4.7)  28 (5.3)  22 (3.9)  17 (3.4)  39 (5.3)  37 (5.8)  34 (7.4)  24 (6.0)  18 (4.9)  39 (7.3)  34 
    Single location extrapulmonary  144 (10.4)  78 (10.0)  44 (8.3)  49 (8.8)  39 (7.8)  70 (9.5)  94 (14.6)  59 (12.8)  51 (12.8)  53 (14.4)  78 (14.7)  59 
    Sputum smear                         
    Positive  1313 (60.2)  421 (59.1)  296 (57.4)  272 (49.8)  243 (50.6)  368 (51.9)  309 (49.3)  246 (53.5)  200 (50.9)  179 (48.9)  254 (47.8)  272 
    Negative  523 (39.8)  290 (40.7)  220 (42.6)  274 (50.2)  237 (49.4)  336 (47.4)  279 (44.5)  194 (42.4)  164 (41.7)  168 (45.9)  262 (49.3)  262 
    Not done  0 (0.0)  1 (0.1)  0 (0.0)  0 (0.0)  0 (0.0)  5 (0.7)  39 (6.2)  19 (4.1)  29 (7.4)  19 (5.2)  15 (2.8) 
    Culture                         
    Positive  1027 (84.8)  520 (84.1)  413 (84.6)  435 (80.9)  382 (83.6)  550 (83.6)  462 (76.9)  340 (78.3)  294 (78.8)  296 (82.5)  457 (86.9)  437 
    Negative  184 (15.2)  96 (15.5)  75 (15.4)  103 (19.1)  74 (16.2)  103 (15.7)  120 (20.0)  78 (18.0)  55 (14.7)  47 (13.1)  56 (10.6)  78 
    Not done  0 (0.0)  2 (0.3)  0 (0.0)  0 (0.0)  1 (0.2)  5 (0.8)  19 (3.2)  16 (3.7)  24 (6.4)  16 (4.5)  13 (2.5) 
    Drug susceptibililty testing                         
    No  251 (20.6)  145 (22.0)  79 (17.6)  96 (19.2)  59 (16.3)  93 (17.0)  79 (14.9)  60 (15.9)  65 (20.3)  61 (18.1)  68 (13.1)  79 
    Yes  968 (79.4)  513 (78.0)  371 (82.4)  404 (80.8)  304 (83.7)  454 (83.0)  452 (85.1)  318 (84.1)  255 (79.7)  276 (81.9)  451 (86.9)  404 
    Drug resistance                         
    Yes  86 (6.2)  60 (7.7)  33 (6.3)  44 (8.0)  37 (7.4)  52 (7.1)  47 (7.3)  32 (7.0)  28 (7.1)  41 (11.3)  70 (13.3)  44 
    No  1304 (93.8)  719 (92.39)  494 (93.7)  507 (92.0)  460 (92.6)  684 (92.9)  593 (92.7)  428 (93.0)  368 (92.9)  321 (88.7)  457 (86.7)  494 
    DOT                         
    No  1154 (90.5)  593 (90.39)  402 (93.5)  459 (93.7)  375 (90.6)  588 (94.1)  481 (87.9)  330 (79.3)  292 (77.5)  265 (78.4)  337 (70.8)  402 
    Yes  121 (9.5)  64 (9.7)  28 (6.5)  31 (6.3)  39 (9.4)  37 (5.9)  66 (12.1)  86 (20.7)  85 (22.5)  73 (21.6)  139 (29.2)  66 
    Hospitalized                         
    No  917 (70.9)  525 (79.5)  309 (71.2)  369 (75.0)  318 (78.1)  385 (68.1)  339 (65.7)  257 (62.4)  194 (53.4)  205 (61.2)  293 (64.4)  318 
    Yes  377 (29.1)  135 (20.5)  125 (28.8)  123 (25.0)  89 (21.9)  180 (31.9)  177 (34.3)  155 (37.6)  169 (46.6)  130 (38.8)  162 (35.6)  155 
    Treatment outcome                         
    Cure  575 (41.7)  278 (36.2)  215 (41.6)  233 (42.0)  179 (36.3)  290 (40.2)  238 (37.7)  167 (36.7)  134 (34.2)  116 (32.0)  168 (31.8)  215 
    Treatment completed  430 (31.2)  246 (32.0)  150 (29.0)  151 (27.2)  146 (29.6)  200 (27.7)  168 (26.6)  115 (25.3)  129 (32.9)  98 (27.1)  141 (26.7)  150 
    Therapeutic failure  2 (0.1)  2 (0.3)  –  –  1 (0.2)  1 (0.1)  –  1 (0.2)  –  –  1 (0.2) 
    Death due to another cause  22 (1.6)  17 (2.2)  13 (2.5)  13 (2.3)  10 (2.0)  19 (2.6)  18 (2.9)  5 (1.1)  3 (0.8)  10 (2.8)  16 (3.0)  13 
    Death due to TB  4 (0.3)  4 (0.5)  5 (1.0)  3 (0.5)  5 (1.0)  15 (2.1)  11 (1.7)  9 (2.0)  7 (1.8)  4 (1.1)  8 (1.5) 
    Other + lost-to-follow-up + dropout  87 (6.3)  84 (10.8)  56 (10.6)  41 (7.3)  37 (7.4)  49 (6.6)  40 (6.2)  18 (3.9)  16 (4.0)  17 (4.6)  19 (3.6)  40 
    Prolongation of treatment  230 (16.7)  118 (15.4)  62 (12.0)  101 (18.2)  87 (17.6)  134 (18.6)  130 (20.6)  132 (29.0)  96 (24.5)  110 (30.4)  165 (31.2)  118 
    Transfer  28 (2.0)  19 (2.5)  16 (3.1)  13 (2.3)  28 (5.7)  13 (1.8)  26 (4.1)  8 (1.8)  7 (1.8)  7 (1.9)  11 (2.1)  13 
    Type of treatment                         
    4 drugs  425 (30.6)  373 (47.9)  306 (58.0)  367 (65.7)  251 (50.5)  342 (46.4)  241 (37.5)  335 (72.5)  284 (71.4)  290 (78.8)  433 (81.5)  335 
    3 drugs  846 (60.9)  352 (45.2)  202 (38.3)  169 (30.2)  214 (43.1)  319 (43.3)  311 (48.4)  100 (21.6)  94 (23.6)  58 (15.8)  49 (9.2)  202 
    Individual  298 (21.4)  110 (14.1)  25 (4.7)  40 (7.2)  108 (18.9)  180 (26.1)  178 (27.7)  39 (8.4)  13 (3.3)  34 (9.2)  82 (15.4)  82 
    Diagnostic delay                         
    ≤30 days  438 (32.8)  225 (31.6)  167 (33.4)  166 (31.1)  141 (30.7)  236 (33.9)  159 (26.0)  119 (27.8)  108 (29.3)  94 (26.5)  121 (24.7)  159 
    >30 days  896 (67.2)  488 (68.4)  333 (66.6)  367 (68.9)  319 (69.3)  461 (66.1)  452 (74.0)  309 (72.2)  261 (70.7)  261 (73.5)  369 (75.3)  367 

    DOT: directly observed treatment; HIV: human immunodeficiency virus; TB: tuberculosis.

    Fig. 2.

    Case numbers included annually (2006-2016).

    (0.09MB).
    Fig. 3.

    Trends in case numbers included in the period 2006-2016 and in the period 2007-2016.

    (0.06MB).

If the number of cases in 2006 is taken as an outlier, the number of cases recorded, without taking into account that year, also showed a downward, though less steep, trend: Y = 53654−26.4x (Fig. 3), with a mean annual decline of 5.61% between 2006 and 2016, and 3.18% between 2007 and 2016. Table 2, Figs. 2 and 3

Significant increases were observed among: age groups of 40−50 years and >50 years, first care administered by TB specialist, hospitalization, diagnostic delay of more than 30 days, disseminated TB and single extrapulmonary site, cultures (+), antimicrobial susceptibility, drug resistance, prolongation of treatment, and deaths due to non-TB causes. Significant reductions were observed in: women, immigrants, prisoners, and initial treatment with HRZ at fixed drug doses (Table 3).

  • 2

    Trends in indicators of scientific objectives

Table 3.

Significant trends in proportions of principal variables analyzed over the period 2006-2016.

Variable  Trend(+): growing(–): decreasing  OR (95% CI)  p value 
Age
40−50  y = −0.09 + 0.51x  1.400 (1.099–1.783)  0.006 
>50  y = −2.53 + 1.07x  1.792 (1.452–2.211)  <0.001 
Sex
Women  y = 9.13–1.84x  0.627 (0.500−0.786)  <0.001 
Country of origin
Others  y = 9.89−1.03x  0.711 (0.575−0.879)  0.002 
Living situation
Confined  y = 2075–1.69x  0.283 (0.086−0.938)  0.039 
Place first seen
Area specialist  y = −7.52 + 1.98x  1.444 (1.114–1.873)  0.006 
Hospitalization  y = 4.53 + 0.03x  1.345 (1.073–1.686)  0.010 
Diagnostic delay: >30 days  y = −0.03 + 0.20x  1.491 (1.179–1.886)  0.001 
Site
Disseminated  y = −12.17 + 2.85x  1.888 (1.239–2.879)  0.003 
Single extrapulmonary  y = −5.04 + 1.57x  1.490 (1.108–2.003)  0.008 
Microbiology
Culture (+)  y = −3.49 + 0.59x  1.462 (1.063–2.011)  0.017 
Drug susceptibility test  y = 0.05 + 0.14x  1.720 (1.286–2.299)  <0.001 
Drug resistance  y = −4.82 + 2.26x  2.323 (1.665–3.240)  <0.001 
Initial treatment
Combination of 3 drugs  y = 2.39−1.90x  0.065 (0.048−0.089)  <0.001 
Other  y = 16.09 + 1.88x  0.515 (0.370−0.715)  <0.001 
DOT  y = −10.83 + 4.65x  3.934 (2.996–5.165)  <0.001 
Treatment outcome
Cure  y = 0.05−0.36x  0.650 (0.526−0.804)  <0.001 
Prolongation of treatment  y = −31.75 + 5.14x  2.188 (1.660–2.883)  <0.001 
Death due to another cause  y = −20.15 + 6.78x  1.923 (1.002–3.691)  0.049 

CI: confidence interval; DOT: directly observed treatment; OR: odds ratio.

Investigators and participating centers showed a downward trend, but annual publications increased significantly to a maximum of 8 in 2016 (total impact factor: 49.664). The following also showed some improvement, although this was not significant: number of projects initiated annually, presentations at congresses, and theses/dissertations (Table 4; Fig. 4).

Table 4.

Description, annual variation and trends in PII-TB objective indicators (2006-2016).

Program objectives indicators/year  2006N  2007N(AV %)  2008N(AV %)  2009N(AV %)  2010N(AV %)  2011N(AV %)  2012N(AV %)  2013N(AV %)  2014N(AV %)  2015N(AV %)  2016N(AV %)  Trend  p value 
No. of investigators  54  41(−24.07)  33(−19.51)  33(0)  40(21.21)  44(10)  43(−2.27)  27(−37.21)  29(7.41)  39(34.48)  43(10.26)  y = 43.31−0.76x  0.224 
No. of participating centers  48  40(−16.67)  28(−30.00)  29(3.57)  34(17.24)  36(5.88)  36(0.00)  24(−33.33)  24(0.00)  32(33.33)  37(15.63)  y = 39.07−0.89x  0.154 
No. of studies started  0(−100)  1(–)  2(100)  2(0.00)  3(50.00)  3(0.00)  3(0.00)  4(33.33)  4(0.00)  2(-50.00)  y = 0.47 + 0.30x  0.346 
No. of publications  0(–)  2(–)  4(100)  1(−75.00)  1(0.00)  1(0.00)  1(0.00)  1(0.00)  2(100)  8(300)  y = 0.22 + 0.36x  0.006 
No. of communications at congresses  1(−50.00)  1(0.00)  4(300)  7(75.00)  2(−71.43)  1(−50.00)  3(200)  5(66.67)  5(0.00)  5(0.00)  y = −1.36 + 0.32x  0.426 
No. of theses/dissertations  0(–)  0(–)  0(–)  0(–)  0(–)  1(–)  0(−100)  0(–)  1(–)  3(200)  y = 0.64 + 0.18x  >0.999 

AV %: interannual variation: percentage change from previous year.

Fig. 4.

Trends in indicators related to the scientific objectives of the SEPAR Integrated Tuberculosis Research Program (2006-2016).

(0.13MB).
Discussion

In this study, we evaluated the first 11 years of the PII-TB registry, the first SEPAR integrated research program to be assessed. PII-TB data were used to evaluate the evolution of important variables related to TB in Spain and the scientific objectives of the program19.

Our findings highlight the downward trend in annual case numbers, suggesting that the disease is being positively controlled. Similar trends have been observed in other long-term active surveillance programs conducted in Barcelona and Galicia20,21 and by the Ministry of Health.22,23

The inclusion of cases varies widely and could be related to the degree of interest among pulmonologists in each CA (Fig. 1). The annual variability in the number of cases might be due to the existence or absence of funding for case finding, the interest in the different studies conducted, and the extent to which investigators remained motivated after so many years of voluntary participation. Indeed, the number of cases in 2006 could be considered as an outlier because in that year an incentive was paid per case included, a factor that could have boosted motivation, and with it the number of cases included. Excluding 2006 shows a flatter decline that is likely to be closer to reality (Fig. 3). The steepest decline in case numbers occurs among women, suggesting that socio-cultural issues may be at play.24

The downward trend in cases among immigrants could be related to the economic crisis that led to fewer immigrants coming to Spain25 and to limitations in access to healthcare imposed in recent years in various CAs.26 Mass immigration that occurred in some periods probably influenced the increase in drug resistance.27

The downward trend among younger individuals and the upward trend among older people would suggest that transmission is more controlled: recent transmission is increasing while endogenous reactivation is increasing.28

It is interesting to see that hospitalization rates are increasing, even though first-line management should be outpatient care. This could be due to the inclusion of cases from centers that see particularly complicated patients, but the growing diagnostic delay could also play a role, since it would mean that patients are seen when their TB is more advanced, and as such require admission and hospital stays longer than 15 days.29 Similarly, growing trends in disseminated and extrapulmonary TB have recently been observed.23

Two of the indicators for evaluating TB control programs are a diagnostic delay of less than 30 days and DOT in patients with factors associated with lack of compliance.30 This study shows that DOT increased in the years evaluated, but according to another PII-TB study, diagnostic delay also increased,31 which may lead to transmission and epidemic outbreaks.32–34

The latest WHO global report35 specifies drug susceptibility testing as one of the mainstays of TB control, and according to this study these procedures are being implemented more frequently, although the 100% target has never been reached.

Despite national36 and international37 recommendations for prescribing 4-drug combinations, a PII-TB study showed that until 2012 a high proportion of patients were treated with 3 drugs.38 Use of this regimen has now decreased significantly, possibly due to recommendations made since the publication of that particular working group study.

Some centers no longer participate in the project because the investigator has terminated his or her involvement (due to a change of hospital, retirement or illness), and it seems that project leaders have been unable to generate sufficient interest to ensure its continuity. The accreditation of TB units, promoted by SEPAR,39 may facilitate a more stable collaboration.

Indicators of scientific objectives have evolved favorably. The number of publications40 has increased significantly, and although the number of conference communications and thesis/dissertations has increased, particularly in the last year, there is room for improvement.

Retrospective analysis makes it easier to collect information, but disadvantages include difficulty in recovering missing data, the subjectivity of professionals in the interpretation of some activities, and the exclusive inclusion of cases diagnosed by registry participants. These limitations were minimized by constant monitoring of the database and close coordination with investigators.

In conclusion, this study shows that the SEPAR PII-TB registry provides important information on the evolution of TB in Spain. Some factors are positive: a downward trend in case numbers, greater numbers of cases first seen by area specialists, and the increasing use of DOT. However, others are negative: longer diagnostic delay and longer hospitalizations, drug resistance, and the need to prolong treatment. With regard to the PII-TB registry, we must encourage the participation of new collaborators, and continue evaluating this program, in order to improve monitoring and research into this old disease.

Funding

This study was funded by a SEPAR grant: 415/2017.

Authorship

TR: study conception, analysis of results, and preparation of the manuscript. JMGG, JAC, JRM, LA, MMG, JAG, MAJ, JFM, IM, AP, FS, MLS and JAC: analysis of results, critical reading, review of various versions, and final approval of the manuscript. PII-TB Working Group: data collection.

Conflict of interests

The authors state that they have no conflict of interests.

Appendix A
Integrated Tuberculosis Research Program Working Group

R. Agüero (Hospital Marqués de Valdecilla, Santander); J.L. Alcázar (Instituto Nacional de Silicosis, Oviedo); N. Altet (Unidad de Prevención y Control de la Tuberculosis, Barcelona); L. Altube (Hospital Galdakao, Galdakao); F. Álvarez Navascués (Hospital San Agustín, Avilés, Asturias); M. Barrón (Hospital San Millán-San Pedro, Logroño); P. Bermúdez (Hospital Universitario Carlos Haya, Malaga), R. Blanquer (Hospital Dr. Peset, Valencia); L. Borderías (Hospital San Jorge, Huesca); A. Bustamante (Hospital Sierrallana, Torrelavega); J.L. Calpe (Hospital La Marina Baixa, Villajoyosa); F. Cañas (Hospital Insular de Gran Canaria, Las Palmas de Gran Canaria); F. Casas (Hospital Clínico San Cecilio, Granada), X. Casas (Hospital de Sant Boi, Sant Boi de Llobregat), E. Cases (Hospital Universitario La Fe, Valencia); R. Castrodeza (Hospital El Bierzo Ponferrada-León, Ponferrada); J.J. Cebrián (Hospital Costa del Sol, Marbella); J.E. Ciruelos (Hospital de Cruces, Guetxo); A.E. Delgado (Hospital Santa Ana, Motril); D. Díaz (Complejo Hospitalario Juan Canalejo, Corunna); B. Fernández (Hospital de Navarra, Pamplona); A. Fernández (Hospital Río Carrión, Palencia); J. Gallardo (Hospital Universitario de Guadalajara, Guadalajara); M. Gallego (Corporación Sanitaria Parc Taulí, Sabadell); C. García (Hospital General Isla Fuerteventura, Puerto del Rosario); F.J. García (Hospital Universitario de la Princesa, Madrid); F.J. Garros (Hospital Santa Marina, Bilbao); C. Hidalgo (Hospital Universitario Virgen de las Nieves, Granada), M. Iglesias (Hospital Marqués de Valdecilla, Santander); G. Jiménez (Hospital de Jaén); J.M. Kindelan (Hospital Universitario Reina Sofía, Córdoba); J. Laparra (Hospital Donostia-San Sebastián, San Sebastian); R. Lera (Hospital Dr. Peset, Valencia), T. Lloret (Hospital General Universitario de Valencia, Valencia); M. Marín (Hospital General de Castellón, Castellón); J.T. Martínez (Hospital Mutua de Terrassa, Terrassa); E. Martínez (Hospital de Sagunto, Sagunto); A. Martínez (Hospital de La Marina Baixa, Villajoyosa); C. Melero (Hospital 12 de Octubre, Madrid); C. Milà (Unidad de Prevención y Control de la Tuberculosis, Barcelona); C. Morales (Hospital Universitario Virgen de las Nieves, Granada), M.A. Morales (Hospital Cruz Roja Inglesa, Ceuta); V. Moreno (Hospital Carlos III, Madrid); A. Muñoz (Hospital Universitario Carlos Haya, Malaga), L. Muñoz (Hospital Reina Sofía, Cordoba); C. Muñoz (Hospital Clínico Universitario de Valencia, Valencia); J.A. Muñoz (Hospital Universitario Central, Oviedo); I. Parra (Hospital Universitario Virgen de la Arrixaca, El Palmar); J.A. Pérez (Hospital Arnau de Vilanova, Valencia); P. Rivas (Hospital Virgen Blanca, Leon); J. Rodríguez (Hospital Universitario Virgen de las Nieves, Granada); J. Sala (Hospital Universitario Joan XXIII, Tarragona); M. Sánchez (Unidad de Tuberculosis Distrito Poniente, Almería); P. Sánchez (Hospital del Mar, Barcelona); F. Sanz (Hospital General Universitario de Valencia, Valencia); M. Somoza (Consorcio Sanitario de Tarrasa, Barcelona), E. Trujillo (Complejo Hospitalario de Ávila, Ávila); E. Valencia (Hospital Carlos III, Madrid); A. Vargas (Hospital Universitario Puerto Real, Cádiz); I. Vidal (Complejo Hospitalario Juan Canalejo, Corunna); R. Vidal (Hospital Vall d’Hebron, Barcelona); M.A. Villanueva (Hospital San Agustín, Avilés, Asturias); A. Villar (Hospital Vall d’Hebron, Barcelona); M. Vizcaya (Complejo Hospitalario Universitario de Albacete, Albacete); M. Zabaleta (Hospital de Laredo, Laredo); G. Zubillaga (Hospital Donostia-San Sebastián, San Sebastian).

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Please cite this article as: Rodrigo T, García-García J-M, Caminero JA, Ruiz-Manzano J, Anibarro L, García-Clemente MM, et al. Evaluación del Programa Integrado de Investigación en Tuberculosis promovido por la sociedad española de Neumología y Cirugía Torácica tras 11 años de funcionamiento. Arch Bronconeumol. 2020;56:483–492.

Members of the Integrated Tuberculosis Research Program (PII-TB) Working Group are listed in Appendix A.

Copyright © 2019. SEPAR
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