| Abstract | Cilj istraživanja: Preglednom studijom istražiti pojavnost tuberkuloze u Hrvatskoj, analizirati sheme BCG-cijepljenja u europskoj regiji SZO-a te razmotriti zadovoljavamo li preporuke SZO-a vezane za ukidanje univerzalnog cijepljenja BCG-cjepivom.
Materijali i metode: U radu su korišteni podatci Registra za tuberkulozu Hrvatskog zavoda za javno zdravstvo i Registra nuspojava cjepiva Hrvatskog zavoda za javno zdravstvo te godišnja izdanja World Health Organization: Global Tuberculosis Report i European Centre for Disease Prevention and Control: Tuberculosis Surveillance in Europe. Podatci Registra nuspojava cijepljenja koji se odnose na BCG cjepivo dobiveni su ljubaznošću prim.dr.sc. Bernarda Kaića, voditelja Službe za epidemiologiju zaraznih bolesti Hrvatskog zavoda za javno zdravstvo.
Rezultati: U Hrvatskoj se prakticira univerzalna primovakcinacija BCG-om u novorođenačkoj dobi. U periodu od 2006. do 2015. godine 98,2% ciljane populacije se propisno cijepilo prema redovitim izvješćima epidemiološkoj službi, što cjepni obuhvat čini vrlo visokim. Incidencija tuberkuloze u Hrvatskoj je u laganom, ali kontinuiranom padu. Posljednji podatci za 2015. godinu govore u prilog tome, a sa stopom od 10/100 000 ulazimo u skupinu zemalja s niskom incidencijom. Najviša stopa je primjećena u Sisačko-moslavačkoj županiji, 23,2/100 000, a najniža u Dubrovačko-neretvanskoj županiji sa svega 4/100 000 stanovnika. Prateći incidenciju tuberkuloze po dobnim skupinama u radoblju od 2001. do 2015. godine uočava se da incidencija raste sa dobi. 2015. godina tome svjedoči pa u skladu s tim osobe dobi 70 i više godina imaju najveću incidenciju oboljevanja od tuberkuloze, 26,8/100 000, dok u najmlađoj dobnoj skupini nije bilo niti jednog oboljelog djeteta. 61 % oboljelih od tuberkuloze su bile osobe muškog spola, a 39% ženskog spola. Najčešće sijelo tuberkuloze su pluća i na njih otpada 91% dijagnosticiranih slučajeva (79% mikrobiološki potvrđena). Na izvanplućne oblike tuberkuloze otpada 9% slučajeva u 2015. godini. Prijavljene nuspojave su rijetke, 77 u razdoblju od 1993. do 2015. godine od čega 34 otpada na limfadenitis, dok su ozbiljnije nuspojave rijetkost. Prema preporukama SZO-a, za prelazak sa univerzalnog na selektivno cijepljenje, zemlje niske incidencije mogu ograničiti cijepljenje novorođenčadi i dojenčadi na prepoznate rizične skupine ili na tuberkulin negativnu stariju djecu. Promatrajući postavljene preduvjete i kriterije Hrvatska preduvjet ispunjava još od 1998. godine, uvodeći dvojni sustav prijavljivanja tuberkuloze, a dodatni uvjet koji ispunjava je da je prosječna godišnja stopa tuberkuloznih meningitisa u djece mlađe od 5 godina manja od 1/10 milijuna stanovnika tijekom prethodnih 5 godina. Naime u Hrvatskoj je zadnji slučaj tuberkuloznog meningitisa kod djece mlađe od 5 godina zabilježen 2001. godine.
Zaključak: S obzirom na stav Svjetske zdravstvene organizacije iz 2004. godine i postavljene kriterije, iz ovog rada je vidljivo da Hrvatska zadovoljava preporuke SZO za ukidanje univerzalnog BCG-iranja. Naime Republika Hrvatska ispunjava osnovni preduvjet, a to je učinkovit sustav prijavljivanja te nema ni jedan prijavljeni slučaj tuberkuloznog meningitisa djece mlađe od 5 godina u posljednjih 14 godina. Međutim, ukidanje univerzalne imunizacije nužno zahtjeva široku stručnu raspravu, uz analizu prednosti i mana promjene sheme BCG-iranja i kvalitetnu organizacijsku pripremu eventualnog selektivnog cijepljenja. |
| Abstract (english) | Objective: systematic review to investigate the incidence of tuberculosis in Croatia, analyze schemes of BCG vaccination in the European Region of the WHO, and to consider whether we meet the recommendations of the WHO regarding the abolition of universal vaccination of BCG vaccine.
Design: Systematic review.
Materials and Methods: The data were gathered from the Register of tuberculosis of the Croatian Institute for Public Health and the Registry of the side effects of vaccines of the Croatian Institute for Public Health and the annual edition of the World Health Organization: Global Tuberculosis Report and The European Centre for Disease Prevention and Control: Tuberculosis Surveillance in Europe. Data from The Registry of side effects related to the BCG vaccine were obtained by the courtesy of prim.dr.sc. Bernard Kaića, head of the Department for Infectious Disease Epidemiology of the Croatian Institute for Public Health.
Results: In Croatia, according to the Childhood Vaccination Program (CVP) active immunization against TB is mandatory. The practiced scheme is universal primary BCG immunization in the neonatal period. In the period from 2006 to 2015, 98.2% of the target population is vaccinated properly according to regular reports of the epidemiological service, which makes the vaccination rate very high. The incidence of tuberculosis in Croatia is in a slight but continuous decline. Recent data for 2015 are in favor of it, and with a rate of 10/100 000 Croatia belongs to the group of countries with a low incidence of TB. The highest rate was observed in Sisačko-moslavačka county with rate of 23.2/100 000, and the lowest in the Dubrovačko-neretvanska county with rate of only 4/100 000 inhabitants. Tracking the incidence of tuberculosis by age group, from 2001 to 2015 it can be seen that incidence increases with age. 2015 corresponds with that. Accordingly to the newest data persons aged 70 years and older have the highest incidence of tuberculosis, 26.8/100 000, while in the youngest age group there wasn't a single case of tuberculosis reported. 61% of tuberculosis patients were male and 39% female gender. The most common seat of the disease are the lungs and they account for 91% of all diagnosed cases (79% microbiologically confirmed). Extrapulmonary forms of tuberculosis account 9% of all cases in 2015. Reported side effects are rare, 77 in the period from 1993 to 2015, of which 34 were lymphadenitis, while serious side effects were uncommon. According to the recommendations of the WHO, the shift from universal to selective vaccination scheme in the low-burden countries of TB may be limited on the vaccination of the newborns and infants of recognized high-risk groups for TB or to tuberculin-negative older children. In some countries with low TB prevalence, BCG vaccination is largely replaced by intensified case detection and supervised early treatment. Observing the set of conditions and criteria, Croatia meets the prerequisite since 1998 by introducing an efficient notification system: dual system tuberculosis report. The additional requirement that Croatia fulfills is that an average annual notification rate of tuberculous meningitis in children aged under five years is below 1 per 10 million population during the previous five years. Namely in Croatia the last case of tuberculous meningitis in children aged under five years was reported in 2001.
Conclusion: In view of the attitude of the World Health Organization in 2004 and set of the criteria from this study, it shows that Croatia meets the WHO recommendations for the abolition of universal BCG vaccination. The Republic of Croatia fulfills the basic requirement, an efficient notification system, and has no case of tuberculous meningitis in children aged under five years reported in the last 14 years. However, the abolition of universal immunization necessarily requires extensive expert discussion and analysis of the advantages and disadvantages of schema changes of BCG vaccination and high-quality organizational preparation of the potential selective vaccination. |
