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Vol. 55. Núm. 2.
Páginas 113-115 (Febrero 2019)
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Vol. 55. Núm. 2.
Páginas 113-115 (Febrero 2019)
Scientific Letter
DOI: 10.1016/j.arbres.2018.06.019
Acceso a texto completo
Burden of Tuberculosis Hospitalizations in Portugal From 2000 to 2015
Hospitalizaciones por tuberculosis en Portugal entre 2000 y 2015
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Flávia Fonseca Duartea,
Autor para correspondencia
mimed12249@med.up.pt

Corresponding author.
, João Santosb,c, Raquel Duarted,e,f, Alberto Freitasb,c
a Faculty of Medicine, University of Porto, Porto, Portugal
b Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
c Center for Health Technology and Services Research, Porto, Portugal
d Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
e ISPUP-EPIUnit, Universidade do Porto, Porto, Portugal
f CISPFEM, Department of Public Health and Forensic Science and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
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Tablas (1)
Table 1. Clinical and demographic characteristics of TB hospitalizations in Portugal, between 2000 and 2015.
Texto completo
Dear Editor,

Tuberculosis (TB) is a major public health problem caused by infection with Mycobacterium tuberculosis, or rarely with certain other species of Mycobacterium.1 Worldwide, TB causes more deaths than any other infectious disease and World Health Organization (WHO) TB data for 2015 indicated there were 10.4 million new cases and 1.8 million deaths.2

In Europe, the incidence of TB has decreased at an average rate of 5.0% per year since 2001, and Europe has the lower TB burden comparing to other continents.3,4 The same has happened in Portugal with a steady decrease of the incidence in the last years. However, Portugal had the highest incidence rate and prevalence among western European countries in 2015.5

Despite abundant epidemiological data, no studies, to the best of our knowledge, have yet examined the clinical, geographic, and epidemiologic burden of TB hospitalizations in Portugal and their changes over time, instead other European countries, like Spain,6 France and Italy.7 Our purpose was to identify the characteristics of patients hospitalized with TB in the public hospitals of mainland Portugal between 2000 and 2015.

This retrospective observational study used data from the nation-wide hospitalization database of Portugal, provided by the Central Administration of Health System of the Portuguese Ministry of Health (ACSS, IP). These data include administrative and clinical data of hospitalization episodes in mainland Portuguese public hospitals over a period of sixteen years (discharges between 2000 and 2015). Data from private hospitals is not part of this database. The records of all inpatients with a principal or secondary diagnosis of TB (coded as 010.xx – 018.xx) were examined. Principal diagnosis represents the clinical condition responsible for the hospitalization and secondary diagnosis describes those conditions that coexists at the time of admission, or develops subsequently, and that affect the patient care for the current episode. Each hospitalization and readmission was considered an independent episode. The anonymity of all patients was maintained during the analysis of the database.

For each hospitalization episode, the following variables were analyzed: sex, birth date, comorbidities (e.g. HIV co-infection), length of stay (LoS), patient residence, and discharge status. There were no age restrictions, and patients were divided into 6 age groups (≤5 years; 6–15 years; 16–25 years; 26–45 years; 46–65 years, and >65 years). Birth date was unavailable for one episode. TB hospitalization rate per 100,000 people and mortality indicators [in-hospital death and in-hospital premature death, in-hospital mortality rate and Potential Years of Life Lost (PYLL)] were calculated.

There were 47,997 hospitalizations for TB in the public hospitals of mainland Portugal from 2000 to 2015 (Table 1), with 58.7% (n=28,171) for principal TB episodes and the other 41.3% for secondary diagnosis. HIV infection (n=48.3%), pneumonia (except that caused by tuberculosis or sexually transmitted disease) (n=5.5%) and chronic obstructive pulmonary disease and bronchiectasis (n=2.1%) are the most common secondary diagnosis for TB hospitalization.

Table 1.

Clinical and demographic characteristics of TB hospitalizations in Portugal, between 2000 and 2015.

  Total  HIV  Non-HIV  2000  2005  2010  2015 
Total Hospitalizations  47,997  12,911  35,086  4199  3452  2307  1728 
Hospitalization Rate (hospitalization/100,000inhabitants)  30.1  –  –  42.7  34.5  22.9  17.6 
Gender (Male)  34,396  10,158  24,238  3056  2552  1636  1217 
Hospitalization Rate (hospitalization/100,000inhabitants)  45.0  –  –  64.3  53.0  34.0  26.1 
HIV  12,911  –  –  1316  1066  535  292 
LOS, median (days)  16  19  15  16  16  16  15 
Mean Age (SD)  46.9 (19.3)  38.5 (10.3)  50.0 (20.9)  43.9 (19.5)  45.3 (18.6)  48.7 (19.5)  52.5 (20.1) 
Age Group (years)               
≤5 years  713  20  693  86  73  22  24 
Hospitalization Rate (hospitalization/100,000inhabitants)  7.6  –  –  13.9  11.6  3.8  4.7 
6–15 years  837  12  825  57  73  48  20 
Hospitalization Rate (hospitalization/100,000inhabitants)  5.0  –  –  5.3  6.9  4.6  2.0 
16–25 years  3737  730  3007  442  247  163  131 
Hospitalization Rate (hospitalization/100,000inhabitants)  19.7  –  –  30.6  20.1  14.9  12.8 
26–45 years  20,348  9508  10,840  1988  1588  889  476 
Hospitalization Rate (hospitalization/100,000inhabitants)  43.8  –  –  69.0  52.9  30.4  17.9 
46–65 years  12,454  2374  10,080  855  868  675  587 
Hospitalization Rate (hospitalization/100,000inhabitants)  30.8  –  –  37.0  35.6  25.6  21.7 
>65 years  9907  266  9641  771  603  510  490 
Hospitalization Rate (hospitalization/100,000inhabitants)  35.9  –  –  50.9  36.4  28.5  25.1 
Types of Tuberculosis               
010.x Primary Tuberculous infection  870  79  791  79  67  41  55 
011.x Pulmonary tuberculosis  31,854  7686  24,168  2777  2310  1526  1096 
012.x Other respiratory tuberculosis  5947  918  5029  563  424  290  210 
013.x Tuberculosis of meninges and central nervous system  1741  868  873  164  143  81  67 
014.x Tuberculosis of intestines peritoneum and mesenteric glands  1089  266  823  73  70  51  52 
015.x Tuberculosis of bones and joints  1788  212  1576  186  110  107  83 
016.x Tuberculosis of genitourinary system  1063  130  933  76  87  59  49 
017.x Tuberculosis of other organs  3771  1533  2238  295  241  198  147 
018.x Miliary tuberculosis  3819  2783  1036  304  306  172  129 
In-hospital mortality               
10.7  16.1  8.7  12.0  11.5  10.7  9.7 
N  5148  2078  3070  502  398  246  167 
In-hospital premature deaths  4086  2052  2034  418  332  179  111 
Total PYLL  110,960  72,837  28,122  –  –  –  – 
Age-adjusted PYLL Rate  64.2  47.3  22.0  –  –  –  – 
Unplanned Admissions (%)  82.1  81.8  82.2  86.5  80.5  82.2  82.6 
Discharges to               
Home  37,171  8890  28,281  3141  2609  1826  1421 
Another institution with hospitalization  4245  1260  2985  413  343  168  84 
Domiciliary Service  146  17  129  15  11  18 
Without authorized medical opinion  1146  632  514  128  91  49  27 
NUTS II               
North  17,116  3753  13,363  1554  1268  751  579 
Hospitalization Rate (hospitalization/100,000inhabitants)  29.0  –  –  42.2  34.1  20.3  16.1 
Center  6893  918  5975  526  500  367  292 
Hospitalization Rate (hospitalization/100,000inhabitants)  18.5  –  –  22.4  21.3  15.7  12.9 
Lisbon  19,094  7067  12,027  1710  1348  939  669 
Hospitalization Rate (hospitalization/100,000inhabitants)  43.1  –  –  64.5  49.1  33.3  23.8 
Alentejo  2179  323  1856  159  169  125  94 
Hospitalization Rate (hospitalization/100,000inhabitants)  17.9  –  –  20.5  21.9  16.5  13.0 
Algarve  1924  543  1381  180  119  92  80 
Hospitalization Rate (hospitalization/100,000inhabitants)  28.0  –  –  45.8  28.1  20.4  18.1 

The overall hospitalization rate during this time was 30.1/100,000/year, and this number decreased by 58.8% during the study period (2000: 42.7/100,000; 2015: 17.6/100,000).

Individuals 26–45 years old had the highest overall hospitalization rate (43.8/100,000/year; Table 1), and the hospitalization rate in this group decreased by 74.1% during the study period (2000: 69.0/100,000; 2015: 17.9/100,000). The overall hospitalization rate was greater for males (45.0/100,000/year) than females (16.4/100,000/year). Moreover, the hospitalization rates declined over time for both sexes (males: 64.3/100,000 in 2000 to 26.1/100,000 in 2015; females: 22.4/100,000 in 2000 to 9.9/100,000 in 2015) (Table 1).

Pulmonary TB (011.x) was the most common type of TB (66.4%), followed by other respiratory TB (012.x) (12.5%). Primary TB infection (010.x) accounted for only 1.8% of all admissions (Table 1).

A total of 12,911 TB patients were HIV co-infected (26.9% of all TB hospitalizations) (Table 1). In males, simultaneous HIV and TB accounted for 78.7% of all TB admissions.

The in-hospital mortality rate was 10.7%, corresponding to 5148 in-hospital deaths (Table 1). A total of 38.7% of these cases (1991 episodes) presented with TB as the main diagnosis and 78.6% were males (4,046 episodes). The in-hospital mortality rate was higher in the elderly (>65 years old).

We also examined the geographic distribution of TB hospitalizations using the NUTS II classification (Table 1). Lisbon had the highest rate of TB hospitalizations, followed by the North. Lisbon and Porto had the highest age-standardized TB hospitalization rates, 46.0/100,000 and 38.4/100,000, respectively. Moreover, during the 16 year study period, all districts had declining hospitalization rates, except for Castelo Branco, which had an increase of 20% between 2000 and 2015 (2000: 36.8/100,000; 2015: 41.3/100,000). Castelo Branco had the highest TB hospitalization age-standardized rate in Portugal in 2015.

Interestingly, we also found a trend for decreasing TB hospitalizations over time. Up until 2007, the TB hospitalization rate was close to or a bit higher than the TB notification rate, and clearly higher than the TB incidence rate. However, after 2007, the TB hospitalization rate decreased more rapidly than the notification and incidence rates. This suggests a change in the criteria used for TB hospitalization.

These results highlight that TB continues to be a major public health problem in Portugal that requires more attention. Further studies should focus on the criteria used for TB hospitalization and its impact on outcome, and the reason for the high TB hospitalization rate in Castelo Branco.

Acknowledgements

The authors would like to thank the Portuguese Ministry of Health's Authority for Health Services (Administração Central do Sistema de Saúde I.P. – ACSS) for providing access to national hospitalizations data.

We would also like to thank H. Gonçalves, for the elaboration of the maps.

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[3]
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[5]
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[6]
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[7]
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