[Tuberculosis infection control - recommendations of the DZK]. / Infektionsprävention bei Tuberkulose - Empfehlungen des DZK.

The epidemiological situation of tuberculosis (TB) in Germany has improved considerably during the past few years. However, those in unprotected contact with infectious tuberculosis patients frequently and/or over longer periods of time and/or intensively continue to have a higher risk for TB infection. Rapid diagnosis, prompt initiation of effective treatment, and adequate infection control measures are of particular importance to prevent infection. The present recommendations depict the essentials of infection control as well as specific measures in the hospital (isolation, criteria for its duration and technical requirements, types of respiratory protection, disinfection measures, waste disposal). The specific requirements for outpatients (medical practice), at home, for ambulance services, and in congregate settings, including prisons, are also addressed. Compared with the previous recommendations the pattern of respiratory protection measures has been simplified. As a rule, hospital staff and those visiting infectious tuberculosis patients are advised to wear respiratory protection that satisfies the criteria of FFP2-masks (DIN EN 149), while patients should wear mouth-nose protectors (surgical masks) in the presence of others and outside the isolation room. A detailed depiction of criteria for isolation and its duration in smear positive and only culturally confirmed pulmonary tuberculosis has been added.

[Tuberculosis infection control--recommendations of the DZK]. / Infektionsprävention bei Tuberkulose--Empfehlungen des DZK.

The epidemiological situation of tuberculosis (TB) in Germany has improved considerably during the past few years. However, those in unprotected contact with infectious tuberculosis patients frequently and/or over longer periods of time and/or intensively continue to have a higher risk for TB infection. Rapid diagnosis, prompt initiation of effective treatment, and adequate infection control measures are of particular importance to prevent infection. The present recommendations depict the essentials of infection control as well as specific measures in the hospital (isolation, criteria for its duration and technical requirements, types of respiratory protection, disinfection measures, waste disposal). The specific requirements for outpatients (medical practice), at home, for ambulance services, and in congregate settings, including prisons, are also addressed. Compared with the previous recommendations the pattern of respiratory protection measures has been simplified. As a rule, hospital staff and those visiting infectious tuberculosis patients are advised to wear respiratory protection that satisfies the criteria of FFP2-masks (DIN EN 149), while patients should wear mouth-nose protectors (surgical masks) in the presence of others and outside the isolation room. A detailed depiction of criteria for isolation and its duration in smear positive and only culturally confirmed pulmonary tuberculosis has been added.

[Death due to tuberculosis requiring treatment or an accompanying disease? A contribution to the lethality and mortality of tuberculosis in Germany]. / Tod an behandlungsbedürftiger Tuberkulose oder an Begleitkrankheiten? Ein Beitrag zur Letalität und Mortalität der Tuberkulose in Deutschland.

BACKGROUND: Tuberculosis (TB) is a curable disease. Nevertheless, patients in Germany also die of TB. Although mortality is decreasing, there are indications for an increase in lethality. This observation provided the impetus for a detailed analysis that sought to investigate the validity of the statistics on deaths caused by TB. METHOD: The study population consists of the 926 fatal cases that were classified either as "death from TB" or as "death due to other causes" out of the 6044 TB patients in the DZK study. For the analysis, health authorities were asked to provide additional information and such documents as the death certificate, the autopsy protocol and the final medical report. In 778 cases, there was at least one additional piece of information available. Three teams of two experts each conducted independent evaluations of the documents. RESULTS: Based on the findings of the experts, every second death caused by TB in 1997 and 1998 was not recorded correctly during the post-mortem examination. Every third TB death was not diagnosed during the patient's lifetime. Patients who died due to TB were, on average, older and more likely to be born in Germany. This indicates that age-related comorbidity among the native German population plays a relevant role. Yet, the unicausal death registration did not acknowledge comorbidity as a contributing factor to the fatal outcome. Pulmonary TB with positive microscopy and culture, miliary TB and meningeal TB were more common among the deaths due to TB than among the general study population, and led more often to a fatal outcome than other organ manifestations. However, the two groups did not differ with regard to multi-drug resistant TB. Alcohol abuse was a leading risk factor for death caused by TB in patients under 65 years. Patient's delay ranged from six to 34 days, and doctor's delay from eight to 46 days. For example, alcohol abusers, on average, visited a physician much later, but were diagnosed more rapidly after the first visit than patients who were not alcohol-dependent. A period of 32 - 200 days elapsed between diagnosis and death caused by TB. CONCLUSIONS: The post-mortem examination often missed TB as the cause of death. Many native German TB patients showed age-related comorbidity. Pulmonary TB with positive microscopy, miliary TB and meningeal TB led more often to a fatal outcome than other organ manifestations. Alcohol abuse was a leading risk factor for TB deaths in patients younger the 65 years. The average period between the onset of symptoms and the diagnosis was significantly longer than the one month generally considered acceptable. The experts could not confirm an increase in lethality for the period under investigation.

[Tuberculosis in 22 Au-pairs in Germany and Austria - rapid diagnosis reduces risk of infection for host families]. / Tuberkulose bei 22 Au-pairs in Deutschland und Österreich - rasche Diagnose verringert Infektionsrisiko für Gastfamilien.

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate tuberculosis (TB) in au-pairs in Germany and Austria and to assess the risk of infection for the host families. METHODS: Reports from local health authorities were obtained between 2002 and 2010 (Bavaria, 12 cases) and from 2006 to 2010 (Baden-Wuerttemberg 6, North Rhine-Westphalia and Hesse, 1 each, additionally 2 from Austria). RESULTS: 22 cases of tuberculosis were reported to the local health authorities, all of them concerning young female au-pairs, age 19 - 27 years. Countries of origin were: Kenya (9), Georgia (4), Mongolia (3), Indonesia (2), Nepal, Russia, Romania, and Peru (1 each). In 17 au-pairs, sputum-smear positive pulmonary tuberculosis was diagnosed. Three au-pairs presented with extrapulmonary tuberculosis without or only with minor pulmonary involvement. In two asymptomatic cases, sputum-smear negative tuberculosis was diagnosed by screening. The time between entry and the beginning of symptoms was 7.5 ± 5.8 months (0 - 19.3). 10.0 ± 6.1 weeks (range 3 - 20 weeks) elapsed between the first symptoms and the diagnosis. No infection of the host families was caused by 5 au-pairs who had no or only minor pulmonary involvement. In 17 au-pairs with high mycobacterial burden, the infection rate increased with the duration of time between symptoms and diagnosis (1 - 11 infections per au-pair). A total of 46 contacts (21 children, 25 adults) were infected. 17 children received chemoprophylaxis with isoniazid (INH); none of them developed active disease. One child out of four who did not get INH was diagnosed with pulmonary TB. In addition, 5 out of 24 adults without chemoprevention developed active TB. 4 TB-strains were drug-resistant strains, one of them multidrug-resistant. CONCLUSIONS: In au-pairs from countries with high burden of tuberculosis, long lasting cough and weariness should prompt diagnostics for tuberculosis. By screening, the disease can be detected before it gets infectious. If infection has occurred, chemoprevention with INH for nine months can prevent overt tuberculosis.

[New recommendations for contact tracing in tuberculosis]. / Neue Empfehlungen für die Umgebungsuntersuchungen bei Tuberkulose*1.

In 2007, the German Central Committee against Tuberculosis (DZK) published recommendations for contact tracing that introduced the new interferon gamma release assays (IGRAs). Meanwhile, substantial progress has been made in documenting the utility of IGRAs. Because IGRAs are usually superior to the tuberculin skin test (TST) in detecting latent TB infection (LTBI) with respect to sensitivity and specificity in adult contact populations that are at least partially BCG vaccinated, it is now recommended that instead of two-step testing only IGRAs be used.[nl]As the literature does not yet provide sufficient data on the accuracy of IGRAs in children younger than 5 years, the TST remains the method of choice in that age group. To date, also, no clear body of data exists to substantiate better performance for IGRAs than for the TST in older children, thus in this age group using of either test is recommended. The new recommendations also underscore the importance of a diligent preselection of close contacts in order to achieve a high probability that positive test results represent recent infection and to thus increase the benefit of chemopreventive treatment for those identified as requiring it. In a third point of update, it is noted that re-testing of contacts individuals found positive for LTBI may produce a considerable number of false-negative results and should thus be avoided in case of documented exposure.

[New recommendations for contact tracing in tuberculosis. German Central Committee against Tuberculosis]. / Neue Empfehlungen für die Umgebungsuntersuchungen bei Tuberkulose. Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose.

In 2007, the German Central Committee against Tuberculosis (DZK) published recommendations for contact tracing that introduced the new interferon gamma release assays (IGRAs). Meanwhile, substantial progress has been made in documenting the utility of IGRAs. Because IGRAs are usually superior to the tuberculin skin test (TST) in detecting latent TB infection (LTBI) with respect to sensitivity and specificity in adult contact populations that are at least partially BCG vaccinated, it is now recommended that instead of two-step testing only IGRAs be used.[nl]As the literature does not yet provide sufficient data on the accuracy of IGRAs in children younger than 5 years, the TST remains the method of choice in that age group. To date, also, no clear body of data exists to substantiate better performance for IGRAs than for the TST in older children, thus in this age group using of either test is recommended. The new recommendations also underscore the importance of a diligent preselection of close contacts in order to achieve a high probability that positive test results represent recent infection and to thus increase the benefit of chemopreventive treatment for those identified as requiring it. In a third point of update, it is noted that re-testing of contacts individuals found positive for LTBI may produce a considerable number of false-negative results and should thus be avoided in case of documented exposure.

[Interferon-gamma release assays in tuberculosis diagnostics]. / Interferon-gamma-Release-Assays in der Tuberkulosediagnostik.

Two years ago, CE certified interferon-gamma release assays (IGRA) were launched on the German market (QuantiFERON-TB Gold In-Tube and T-SPOT-TB). Since this time, a multitude of studies have analysed these assays. Guidelines have been elaborated by national expert committees of England, the USA and Switzerland. However, standards of tuberculosis diagnostics and management may vary from country to country. This statement provides practice relevant recommendations for indications, pre-analytics and the interpretation of IGRA test results under different clinical conditions. The IGRA are integrated into existing guidelines for the management of tuberculosis.

[Christmas seals]. / Weihnachtssiegelmarken.

Christmas seals, i. e., special stamps used to decorate or seal Christmas and New Year's mail, were created by the Danish post office clerk E. Holboell. The proceeds from the sale of the stickers were meant to alleviate the suffering of children sick with tuberculosis. The first Christmas seal, showing a portrait of Queen Louise of Denmark, was issued on December 10, 1904. The demand at the post office was enormous. The funds raised exceeded all expectations and made it possible to finance the construction of a sanatorium for tuberculosis children. The idea of Christmas seals spread quickly around the world and ended up being copied in 130 countries. At the beginning of the 20 (th) century, the small stamp with the red double-barred cross became a banner for the crusade against tuberculosis. For many patients, it also represented a symbol of hope for recovery even though this hope, given the cure rates of a sanatorium treatment, only became a reality for a few. Worldwide, Christmas seals were and are colourful and imaginatively designed, mostly with Christmas symbols or motives relating to the fight against tuberculosis. The funds raised through the sale of the seals initially helped to build hospitals and were later also used to screen persons at risk for tuberculosis, to improve housing conditions of patients and for other measures of support. With the decrease of tuberculosis, some organisations discontinued fundraising through Christmas seals while others widened their intended purpose and supported, for example, the prevention of and research on lung diseases. In Germany, Christmas seals are closely connected with the German Central Committee against Tuberculosis. Today the "Kuratorium Tuberkulose in der Welt" is the only organisation in this country that still raises funds by this means. The funds are mostly used to assist developing countries with a high burden of tuberculosis.

[Interferon-gamma assays -- description and assessment of a new tool in the diagnosis of tuberculosis]. / Interferon-gamma-Tests in der Tuberkulose-Diagnostik -- Aktueller Stand.

Up to now the diagnosis of latent tuberculosis infection (LTBI) was based solely on the tuberculin skin test. However, this method offers neither 100 % sensitivity nor -- and this is in particular due to its cross-reactivity with BCG and environmental mycobacteria -- a 100 % specificity. The demand in Germany for a more reliable in vitro test is currently enhanced by the change from the multipuncture test to the intradermal (Mendel-Mantoux) test and by the uncertainty resulting from the ceased production of the tuberculin previously used in Germany. The manufacturers of immunologic test methods such as the QuantiFERON-TB Gold In-Tube (ELISA assay) and the T SPOT-TB Test (ELISPOT assay), which are based on the Interferon-gamma (IFN-gamma) production of sensitized T lymphocytes, offer their products as possible alternatives. This article explains the function of the IFN-gamma tests and gives an overview of the most recent data, possible indications and the open scientific questions to be investigated by future clinical studies. Although the new test methods have the potential to eventually prevail as an additional helpful diagnostic tool, the authors consider a complete replacement of the tuberculin skin test as premature. The IFN-gamma tests may, however, prove already now to be a useful additional diagnostic method.

[The Tuberculosis Rapid Assay from DiaVita - No Alternative to the Tuberculin Skin Test]. / Der Tuberkulose-Schnelltest von DiaVita - keine Alternative zum Tuberkulinhauttest.

New methods for diagnosing active tuberculosis (TB) and/or latent tuberculosis infection have been offered increasingly during recent years, also in Germany. The Tuberculosis Rapid Assay ('Tuberkulose Schnelltest [TB-ST]') from DiaVita is a serologic test method aiming to detect, within a few minutes, tuberculosis-specific antibodies in whole blood or serum of tuberculosis patients. Due to a lack of data, it is, however, hardly possible to assess this test on a scientific basis. With a relatively high specificity (according to DiaVita over 95 %) but inadequate sensitivity (approximately 60 - 80 %), particularly in paucibacillary types of TB, we consider this method of limited value for routine testing. If active TB is strongly suspected, a positive test result may corroborate the tentative diagnosis, whereas a negative test result is not helpful for differential diagnosis considering the great number of false-negative test results to be expected. The greatest value of the test seems to be in bacteriologically confirmed TB, in which however there may be no need for additional diagnostics. The test has not been evaluated, and in our opinion is probably unsuitable for detecting latent TB infection. Data is also lacking for a number of patient groups in urgent need of a reliable alternative to the tuberculin skin test (e. g., immunocompromised patients, children). It is not clear whether this method will find a place in routine TB diagnostics. We therefore cannot recommend this test as a routine diagnostic tool for TB at present.

[Latent tuberculosis infection: recommendations for preventive therapy in adults in Germany]. / Latente tuberkulöse Infektion: Empfehlungen zur präventiven Therapie bei Erwachsenen in Deutschland. Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose.

The immunologic mechanisms of latent tuberculosis (TB) infection are complex and hitherto not completely understood. The lifelong risk of an immunocompetent individual of developing active TB after infection with M. tuberculosis is 5-10 % and highest during the first two years after infection. Various factors may considerably increase the risk of developing active TB, e. g., immunosuppressive disease or immunosuppressive medication. However, the development of active TB may be avoided by preventive chemotherapy, the therapy of choice being isoniazid over a 9-month period. Alternative treatment regimens may be indicated in special cases, but it must be borne in mind that the efficacy of these regimens has not been studied sufficiently while they seem to be less well tolerated than isoniazid monotherapy. The tuberculin skin test is still the only sufficiently documented method to detect latent infection with M. tuberculosis which is also suitable for routine application. This test today should be performed exclusively as described by Mendel and Mantoux. Its sensitivity and specificity depend on the prevalence of tuberculosis infection. It should therefore be restricted to individuals at increased risk of latent TB infection. When interpreting the tuberculin skin test, it is necessary to know whether an individual belongs to one of the defined risk groups or has an elevated risk of developing active TB. Among the risk groups are individuals who may have been infected recently with M. tuberculosis (contacts of contagious TB patients) or in whom other factors increase their risk of developing active TB. The indication for chemotherapy for latent TB infection must be based on a careful individual risk-benefit analysis and, besides patient compliance, requires full information of the patient and careful monitoring during therapy. Before initiating treatment, active TB must always be excluded by the proven methods.

[Recommendations for personal respiratory protection in tuberculosis]. / Empfehlungen zur Anwendung von Atemschutzmasken bei Tuberkulose - Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose.

These recommendations of the German Central Committee against Tuberculosis give an overview of the current scientific knowledge on the tuberculosis risk of health service employees and on the risk of infection in individual areas of work. The efficacy of face masks and their benefit in tuberculosis control is discussed. There are no reliable data on the efficacy of face masks in preventing infection with M. tuberculosis, nor can such data be expected in the near future, due to the complex interaction of infection-preventing measures. As rapid case finding, isolation, and immediate, effective treatment of infected patients already greatly diminish the risk of transmission, we consider face masks to be of limited use in reducing this risk. However, they may be beneficial in certain areas of work and in certain situations, particularly in the presence of elevated aerosol concentrations. The benefit of face masks depends largely on their correct application. The choice of a particular type of mask requires knowledge of the current epidemiological situation, and a competent assessment of the risk in the area of work for which it is chosen, taking into account the closeness of contact with potentially infectious tuberculosis patients.

[Tuberculosis control in lower Franconia 1995 - 2001. Case-finding and treatment outcome]. / Tuberkulosebekämpfung in Unterfranken 1995 - 2001 - Fallfindung und Behandlungsergebnisse -

BACKGROUND: How useful is active case-finding for the controlling of tuberculosis (TB) in Lower Franconia? What treatment outcome is being achieved and which factors reduce this success? METHODS: All 867 TB cases reported to the public health departments in Lower Franconia between 1995 and 2001 were used as anonymous data for a prospective study. RESULTS: Average age, gender, country of origin and rates of bacterial resistance of the patients coincided to a large degree with the data of the DZK study. The percentage of resettlers from the former Soviet Union with TB was, however, almost double. Therapeutic success was reached in approx. 79 % of the contagious TB and thus surpassed the rates of published investigations slightly. A negative impact upon the treatment outcome was caused by the following circumstances: A number of asylum seekers disappeared into illegality before the treatment was completed; certain TB-patients stopped taking the medication after surgical removal of the focus; only half of the sick persons who died of the disease were diagnosed when still alive. CONCLUSION: Active TB case-finding is useful mainly among asylum seekers and resettlers. An improvement of the treatment outcome in Lower Franconia is desirable but appears to be only possible within strict limits.

Clinical efficiency of neobiphyllineR-studies on lung function and serum levels after rectal application of a combination of methyl-xanthines.

In a group of 12 patients suffering from reversible airways obstruction, lung function data and serum levels were studied before and after rectal application of a combination of methyl-xanthines (400 mh theophylline, 600 mg diprophylline, 600 mg proxyphylline). The follow-up over a period of 10 hours showed an immediate bronchodilator effect of the mixture within 30 minutes to 1 hour; bronchodilation was still detectable after an interval of 10 hours. The improvement in lung function correlated with the serum levels. No side effects were noted after rectal administration of the drugs.

[Comparison of the bronchodilatatory efficacy of oral methylxanthines (author's transl)]. / Vergleich der bronchodilatatorischen Wirksamkeit oraler Methylxanthine.

Two tablets of aminophylline (each 350 mg) or of a mixture (75 mg theophylline, 112,5 mg diprophylline, 112,5 mg proxyphylline per tablet) were given to 12 patients with reversible air-flow obstruction and their effects on lung function, blood pressure and pulse rate were surveyed for eight hours as an intra-individual randomized cross-over experiment. A three-day wash-out period was allowed between the studies on each patient. Statistical evaluation of the data shows that, on the average, the bronchodilator effects were comparable. Unwanted side-effects were seen in three patients after aminophylline. There were none after the mixture.