•Maria Ionita - Medical Center Ciurea •Margareta Nastase - Clinic of Pulmonary Diseases Iasi•Traian Mihaescu - Clinic of Pulmonary Diseases Iasi

TUBERCULOSIS IN A GYPSY RURAL COMMUNITY IN ROMANIA

55

,94

1,4

59

,51

3,8 57

,15

5,4

53

,45

5,4

56

,67

0,6

57

,21

2,7 57

,86

5,9

64

,05

5,0

70

,62

7,0 76

,3 11

2,5

79

,86

8,6

84

,08

6,8

96

,81

16

,5

11

3,9

15

1,8

11

3,2 1

96

,91

37

8,6

11

7,3

25

8,0

43

3,8

11

5,7 19

2,1

41

9,2

13

1,7

23

6,8

20

3,6

13

8,3

28

3,2

19

7,6

13

7,2

33

1,1

57

4,7

0

200

400

600

800

1000

1200

1400

1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Iasi County Ciurea Gypsies from Zanea

1. PREMISE OF THIS STUDY

•The incidence of tuberculosis in Ciurea was situated around the mean incidence for Iasi county for 15 years (1981-1995);•The morbidity peak recorded in 1995 was again reached in 2000;•The increase in case numbers was prevalently among the gypsies from Zanea village.

Gypsies5,8%

Non-Gypsies94,2%

2. GENERAL DATA

Ciurea rural community, situated at 4 km from Iasi town, has a surface of 13 km2, a population of 8978 inhabitants in 2000. The village is spread across 7 villages from which Zanea has a compact population consisting exclusively in 154 families of gypsies.

The gypsies from Zanea village represented in year 2000 approximately 1/6 of the inhabitants of Ciurea rural community.

3.MATERIAL AND METHOD3.MATERIAL AND METHOD

- The data on the number and dynamics of the general population and gypsies were obtained from Ciurea mayor’ office, statistics of Iasi Health Department and Iasi County Statistics Department.- Information on morbidity from tuberculosis was obtained from the analysis of patient - TB focus records of the Iasi Pneumophtisiology Outpatient Unit.

- After 1985, and especially after 1995, the general population of Ciurea rural community increased from 7282 to 8978 inhabitants.- The increase was exclusively due to the gypsy minority, with values of +3,4 %, +2,6%, +3,2%, and +3,0%.

4. RESULTS4.1. Dynamics of gypsy and non-gypsy population, between 1981-2000.

Number and dynamics of general and gypsy population between 1981-2000 (Table 2)

Year 1981 1985 1990 1995 2000

Absolute number of generalpopulation - Ciurea

7282 7081 7110 8033 8978

Mean rate of demographic change(%)

-0,6 +0,08 +2,6 +2,4

Absolute number of the non-gypsypopulation - Ciurea

6984 6733 6717 7578 8456

Mean rate of demographic change innon-gypsies %

-0,72 -0,08 -2,56 -2,3

Absolute number of gypsy population- Zanea

298 348 393 455 522

Mean rate of demographic change ingypsies (%)

+3,4 +2,6 +3,2 +3

Share of gypsies in the generalpopulation (%)

4,1 4,9 5,5 5,6 5,8

Gypsies represented about 5,8 % of the general population (table 2), but 10,6% of those who developed tuberculosis.

4.2. Comparative analysis of the incidence of tuberculosis in gypsies and non-gypsies population, between 1995-2000.

The number of persons suffering from tuberculosis, recorded between 1995-2000 (Table 3)

GGyyppssiieess NNoonn --ggyyppssiieess

NNuummbbeerr 1155 112266%% ffrroomm tthhee ttoottaallTTBB ppooppuullaattiioonn

1100..66%% 8899..44%%

4.3. Incidence of new cases and relapses in gypsies and non–gypsies

1378,6

196,9

433,8

258

419,2

191,2 203,6236,8

197,6283,2

574,7

331,1

0

200

400

600

800

1000

1200

1400

1995 1996 1997 1998 1999 2000

Gypsies Non-gypsies

- values over 7 - 2,3 times higher in gypsies than non-gypsies;- the incidence declined between 1996-1997, but still remained higher than that recorded in non-gypsy population;- resumption of the increase in incidence in year 2000.

Gypsies

Children45.7%

Adults54.3%

Non-gypsies

Adults94.5%

Children5.5%

5. DISTRIBUTION OF CASES

Age distribution of cases

Almost half (45,7%) of the TB cases in gypsies were children, contrary to the situation in non–gypsy population (5,5%).

Sex distribution of cases

70%

30%

76,2%

23,8%

0%

20%

40%

60%

80%

100%

Gypsies Non-gypsies

Females

Males

No difference were found in the sex distribution of cases between gypsies and non-gypsies, except for a slightly higher receptivity of gypsy women. It has to be mentioned that women represent 47.6% of the gypsy population as compared to 51% in the general population.

37,5%

62,5%

78,5%

21,5%

0%

20%

40%

60%

80%

100%

Gypsies Non-gypsies

Extrapulmonary

Pulmonary

6. LOCALIZATION OF THE DISEASE AT THE TIME OF DETECTIONExtrapulmonary tuberculosis was prevalent (62.5%) in gypsies, while in non-gypsies the pulmonary localization was most frequent.

Localization of the disease at the time of detection (Fig.6)

7. RADIOLOGICAL AND CLINICAL FORMS AT DETECTION (Fig.7)

31,2% 4,3%11,8% 0,8%12,5%

18,8% 24,1%12,5% 38,8%

10,3%6,6%6,6%

6,4%9,4%

4,3%0,8%0,8%

0% 10% 20% 30% 40% 50% 60%

S&C AH

AH+pleurisy

Meningitis

Infiltrative

Cavitary

Pleurisy

Pericardium

Peritoneum

Caseous

Lymphatic

Peripheral node

Bone

Meningitis

Gypsies

Non-gypsies

Gypsies

Non-gypsies Primary TBCPrimary TBC

Secondary TBCSecondary TBC

8. KOCH BACILLUS AT THE TIME OF PULMONARY TUBECULOSIS DETECTION

Bacteriologic findings at the time of pulmonary tuberculosis detection (Fig.8)

14,

3%

57,

1%

28,

6%

63%

25%

12%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

Gypsies Non-gypsies

Positive microscopy

Positive culture

Negative

Most cases were relatively incipient, with positive cultures in 57.1% of the gypsies while positive microscopy was 4 times more common in non-gypsies.

9. POSTTREATMENT OUTCOME (Fig.9)

6,6% 6,6%

66,6%

20,0%

1,5% 3,9% 2,3% 1,5%

82,0%

0,0%

20,0%

40,0%

60,0%

80,0%

100,0%

Gypsies 12.2% Non-gypsies 12.2%

Death Chronic Abandoned treatment Failure Adequate treatment

There was but a slight difference in the therapeutic failure rate between gypsies and non-gypsies (12.2% and 9.25%, respectively) although gypsies systematically refused outpatient treatment.

10. DISTRIBUTION OF CASES IN

THE TERRITORY (Fig.9)

With one exception, the cases were scattered. Even the epidemiological surveys did not manage to detect active sources of infection within families.

11. CONCLUSIONS AND DISCUSSIONS1. Between 1995 - 2000 tuberculosis reached levels of about 7

- 2.3 higher in Zanea gypsies than in Ciurea non-gypsies, and 10 - 15 times higher than in Iasi county.

2. The features of tuberculosis in gypsies were:- most cases belonged to the age group 0 - 14 years and to the

female gender;- prevalence of extrapulmonary localization;- marked high frequency of primary tuberculosis;- all young cases received BCG vaccination at birth;- therapeutic success rate similar with that in non-gypsies

despite the refusal of outpatient treatment;- cases occurring in scattered foci (with one exception), not

related to a previous case;- not accounted for by poverty (over 80% of Zanea gypsies

own houses of 100 - 1500 m2 and eat well);- thus, the only possible explanation would be related to

precarious social and immunity factors. One supposition would be that as gypsies do no longer live in close communities but travel a lot, they are faced with an increased risk for exogenous suprainfections.

3. The presence in Romania of a large gypsy minority, estimated at 1,200,000 - 2,500,000 people, together with their demographic growth and increased morbidity, require a careful and permanent TB surveillance, the more so as in Zanea the incidence of tuberculosis started again to increase in 2000.

4. Firm actions are also needed in view of the social integration of gypsies. Most of them have not identity cards, do not go to school and refuse to obey the laws and rules of the country.