Unemployment in TB Patients – Ten-Year Observation at Regional Center of Pulmonology in Bydgoszcz, Poland

Background

Although Mycobacterium tuberculosis was discovered over 130 years ago and the first antituberculous drugs were discovered over 60 years ago, and despite the creation of disease prevention and control strategies, tuberculosis is still one of the leading infectious causes of death [1–6]. Despite efforts to eliminate TB, the world-wide epidemiological situation at the end of the 20th century was so serious that the World Health Organization (WHO) acknowledged that it was necessary to take immediate actions [7] and estimates that each year 9 million new TB cases occur and 1.7 million people die from this disease [3,7]. The prevalence of TB reaches 10/100 000 in Western Europe, over 150/100 000 in Asia, and more than 300/100 000 in Africa [3].

Over the past 50 years, the incidence of tuberculosis in Poland has decreased 10-fold. For instance, in 1957 over 82 000 new cases were registered, while in 2010 there were only 7509 cases. In 2010, Poland joined the group of countries with low tuberculosis incidence, but it was still higher than the incidence in many other European countries; the incidence rate was 19.7/100 000 [3].

The variable epidemiological situation of tuberculosis is associated with social risk factors, such as unemployment, which may favor the occurrence of this disease [8]. In many studies it is not presented directly, but lack of income can lead to impoverishment of the society and, as a result, to pathological problems associated with poor living conditions [9,10].

The aim of this study was to analyze unemployment as a factor that can influence the incidence and course of TB on the basis of clinical and epidemiological data of patients with tuberculosis, admitted to the Regional Center of Pulmonology, Poland.

Material and Methods

STATISTICAL ANALYSIS:

Statistical analysis was performed using Statistica PL software, version 10.0. Comparisons between categorical variables made using the chi-square test. In order to check the difference between 2 sample means, the unpaired t-test was used. Standard deviations (SD) are reported. The results were considered as significant for P value lower than 0.05. The sample size for analysis ranged from 1067 to 1130 because of missing or incomplete data.

The analysis protocol was acknowledged by Committee on Ethics of Nicolaus Copernicus University in March 2013 (KB 168/2013).

Results

The study sample comprised 1130 patients. Most (811) of them were male, 721 were over age 40 years. Six hundred and four (about 54%) were unemployed, and the others confirmed their employment. The average age of the patients was 42.9 years (SD 11.1 years).

Table 1 shows comparisons between the groups of employed and unemployed patients, referring to their socio-demographic characteristics and habits. Significant differences were observed for gender, age, place of residence, education, smoking status, and alcohol abuse. The proportions of men, homeless, unmarried, smokers, and alcoholics were significantly higher among the unemployed patients. They also appeared to be less educated. The mean value of age was significantly higher in the unemployed group – 43.9 years (10.8) vs. 41.7 years (11.2), P<0.001.

In the study group we had 142 (13%) patients with previously treated TB. The rate of patients suffering from TB adverse drug reaction during hospitalization was 36% and 1.4% of all patients had multi-drug-resistant tuberculosis (MDR-TB). Clinical characteristics of the study cases, with division into employed and unemployed groups, are shown in Table 2. There was no significant difference between the employed and unemployed groups in terms of re-activation, TB drug adverse reactions, or incidence of multi-drug-resistant tuberculosis MDR-TB. Radiological findings revealed bilateral and/or cavitary lesions for 799 cases. The proportion of patients with lesions was significantly higher among the unemployed group. Smear-positive pulmonary TB was diagnosed significantly less frequently in the employed group. The proportion with extra-pulmonary sites was significantly higher among the unemployed patients. We found that the unemployed group had more treatment interruptions. Finally, the risk of death in the course of hospitalization was also significantly higher in unemployed patients.

Discussion

The TB incidence rate is a vital population health parameter as regards the relationship with poverty. Pulmonary tuberculosis is a social disease in our country, which means that the incidence rate is high, and triggering factors make it necessary to employ social forces to eliminate them. The social determinants of tuberculosis in the study population are related to unemployment. Poverty undoubtedly contributes to the incidence of tuberculosis through increased progression from infection to disease due to poor diet or stress, and greater difficulties in using health services [21]. There were 2 083 100 unemployed persons registered at job centers in Poland at the end of September 2013. The unemployed registered at job centers at the end of September 2013 constituted 13.0% of professionally active persons. In the Kuyavian-Pomeranian region, the unemployment rate is high (17.5%), and is the second worst in the country after the Warmian-Mazurian region (20.4%) [22]. The above-mentioned parameters are high for the general population, but still significantly lower than in our study population of tuberculosis patients, in which, during the 10-year observation period, the percentage was as high as 31%.

In the 1980s and 1990s in Poland, most TB patients were employed [23, 24]. In 1992, Miller et al. recorded only 8.5% unemployment among all patients in Poland [25]. In the beginning of the 21st century, the unemployment rate was 23–37% of the patients [8, 26]. Jagodziński et al. reported that during the last 2 years the problem of unemployment was still rising, especially among men (57% unemployed) compared to women (25% unemployed [26,27]. In our study, only one-fourth of the patients had a permanent job. Among people from countries with varying degrees of TB cases, a several-fold increase in incidence of tuberculosis was noted among the unemployed compared to the employed [9,28–30].

Many studies have reported that unemployment is an important risk factor for TB. A 2006–2008 study from Croatia reported that 23% of unemployed people have TB [31]. In Russia, a 2001 study found that the TB infection rate varied from 6% to 11% [28]. Greenland has a high incidence of tuberculosis, and the risk of TB is more than 4 times higher among the unemployed [30]. Brazilian authors reported that unemployment was a risk factor for tuberculosis and that unemployed people had significantly delayed treatment [29].

A recently published meta-analysis evaluating the impact of the economic crisis on the transmission and control of TB contains 8 studies and reveals the effect of recession on TB [32]. The financial crisis may increase the size of the groups with a high risk of incidence of tuberculosis. An example is unemployment, where job insecurity seems to lead to behavior that increases the risk of tuberculosis, such as higher alcohol consumption. To make matters worse, the economic decline caused unemployment and an increase in the homeless population, both of which are risk factors for tuberculosis [30,33–35].

Nearly all homeless people in our study were unemployed. Only 1 patient with TB among the homeless had a job. The lack of employment as a symptom of impoverishment of the society is often connected with alcohol consumption and smoking. To sum up, it should be noted that unlike those obeying the hospital regimen, the patients who did not follow the regimen were statistically more frequently alcohol abusers, single, unemployed, and homeless. Risk of failure to complete therapy among alcoholics is seven7 times higher than among other patients [36,37]. According to the data cited in 1 of the studies, it appears that as many as 50% of patients in this group discontinue anti-TB treatment [38]. In our research, nearly 80% of those who stopped the treatment were unemployed.

The inappropriate treatment and the lack of mechanisms enabling more rigorous therapies cause the development of drug-resistant tuberculosis, including multi-drug resistant type TB (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). In our group of patients with these difficult and costly to treat forms of tuberculosis, more than 60% were unemployed. Statistically, employed people are more likely to have extrapulmonary TB. In the available literature there are no conclusive data regarding an association between pulmonary TB and unemployment, but if you combine other social factors with unemployment, there is more pulmonary TB in these social groups [39,40].

Among the unemployed patients, radiological changes were often characterized by a bilaterally abnormal radiogram with numerous cavities. Such results are confirmed by other studies [26,41]. This creates an erroneous therapeutic downward spiral. Since they do not want to be treated, the patients provoke the deepening TB changes, make the treatment harder, and have even more complications. It often entails long treatment and the use of more drugs. The low level of education and training, as well as unemployment, all are risk factors of poverty and social exclusion. This aspect is represented by our unemployed patients who tend to stop the treatment more often and who are indisciplined, which may result in an increased drug resistance, re-treatment, or disease reactivation [8].

Most people dying from TB live in developing countries. And yet, in order to compare it with Poland, one should recall regularities observed in economically developed societies. Sterling pointed out that, among many social and clinical causes, unemployment may be considered an independent risk factor of death for patients with TB [8,42]. In a Japanese review of 12 articles published in English language and 7 articles published in Japanese, unemployment is a risk factor for death due to TB, and research from China emphasizes an increased risk of death during TB therapy [43,44].

Our analysis confirms the conclusion drawn from the above-mentioned studies. Nearly 80% of patients who died during treatment were unemployed. The Kuyavian-Pomeranian region has one of the highest rates of unemployment [22]. Persistent unemployment increases poverty and its accompanying social pathologies, and keeps TB rates high. This can be prevented by accelerated economic growth and investment, which are required to reduce unemployment.

Conclusions

Employment creation is a key to eradicating poverty and reducing inequality. Unemployment among TB patients constitutes a serious problem. The anti-health behavior noted in this group of patients includes smoking, alcohol abuse, and homelessness. The problem of unemployment as an element impoverishing the society calls for more action from all government departments toward its reduction and elimination. Therefore, all programs, of both state and non-governmental organizations, by reducing unemployment on a national and global scale, contribute to the elimination of one of the oldest infectious diseases in the world, which is tuberculosis.