pt medici pneumoftiziologi

1. •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

2. 55,9
41,4
59,5
13,8
57,1
55,4
53,4
55,4
56,6
70,6
57,2
12,7
57,8
65,9
64,0
55,0
70,6
27,0
76,3
112,5
79,8
68,6
84,0
86,8
96,8
116,5
113,9
151,8
113,2
196,9
1378,6
117,3258,0
433,8
115,7
192,1
419,2
131,7
236,8
203,6
138,3
283,2
197,6
137,2
331,1
574,7
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.

3. Gypsies
5,8%
Non-
Gypsies
94,2%
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.

4. 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.

5. - 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. RESULTS
4.1. 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 general
population - Ciurea
7282 7081 7110 8033 8978
Mean rate of demographic change
(%)
-0,6 +0,08 +2,6 +2,4
Absolute number of the non-gypsy
population - Ciurea
6984 6733 6717 7578 8456
Mean rate of demographic change in
non-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 in
gypsies (%)
+3,4 +2,6 +3,2 +3
Share of gypsies in the general
population (%)
4,1 4,9 5,5 5,6 5,8

6. 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 ttoottaall
TTBB ppooppuullaattiioonn
1100..66%% 8899..44%%

7. 4.3. Incidence of new cases and relapses in
gypsies and non–gypsies
1378,6
196,9
433,8
258
419,2
191,2 203,6
236,8
197,6
283,2
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.

8. Gypsies
Children
45.7%
Adults
54.3%
Non-gypsies
Adults
94.5%
Children
5.5%
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%).

9. 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.

10. 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
DETECTION
Extrapulmonary 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)

11. 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

12. 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.

13. 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%
Gypsies12.2% Non-gypsies12.2%
Death Chronic Abandonedtreatment Failure Adequatetreatment
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.

14. 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.

15. 11. CONCLUSIONS AND DISCUSSIONS
1. 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

16. 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.