[Contact Investigation in Active Tuberculosis and Management of Latent TB Infection: 5-year Analysis at a German City Health Authority]. / Kontaktuntersuchungen bei aktiver Tuberkulose und Management latenter Tuberkulose: 5 Jahres-Analyse an einem deutschen Großstadt Gesundheitsamt.

BACKGROUND: As part of the German TB control program, health authorities conduct investigations among contacts of patients with active tuberculosis based on the infection prevention legislation, to identify potential infections among these persons. The aim of this study was to analyze retrospectively procedures of the city health authority Cologne, in cases of newly diagnosed latent TB infection (LTBI) over a 5-year period. METHODS: Data from the Cologne City Health Authority on contact investigations of TB cases between July 1st 2012 und December 31st 2016 were analyzed. In the absence of signs for active TB and a positive result of the interferon gamma release assay (QFT), LTBI was diagnosed in contact persons. Those with positive test results aged 16 and above and registered in Cologne were included. RESULTS: Out of 3859 contact persons, 430 met the inclusion criteria: in 174/430 cases chemo-preventive therapy (CPT) was recommended and 65 (35.1 %) actually took the course of CPT; in 117 cases, no records of CPT were found in the files and 22/430 persons with LTBI developed active TB within the observation period. CONCLUSION: If the full potential of LTBI treatment on the basis of the recommendations of WHO's "End TB-Strategy" is to be realized, the present study reveals the need to continuously improve documentation and management of LTBI in this setting.

Health care provision for refugees in Germany - one-year evaluation of an outpatient clinic in an urban emergency accommodation.

BACKGROUND: In 2015, Germany recorded the highest rates of refugees since the early 1990s. Access to medical care is a legally regulated fundamental element of aid for refugees. In practice, there are several hurdles such as language barriers and legal regulations. In response to the massively increased need, special outpatient services for refugees were started in several German cities. In Cologne, an outpatient clinic (OPD) was established in the largest emergency accommodation centre for refugees supported by the Cologne municipality and operated by the German Red Cross and physicians from the Association of Statutory Health Insurance Physicians. This study reports experiences of the first year of the OPD regarding structure, processes and utilization. METHODS: Employing mixed methods, between May and December 2015 cross sectional pseudonymized data from patients' contacts were collected, coded in the International Classification of Primary Care (ICPC) and evaluated. Infrastructure, equipment, process organisation and function of the OPD were assessed during five participatory observations and triangulated with results of a self-administered questionnaire for staff and four qualitative interviews with key informants. RESULTS: During the observation period a total of 2205 persons (67% male) stayed in the emergency accommodation and 984 patient contacts (51% male) were registered, mainly by young persons from Western Balkan countries and Syria. Medical treatment was sought primarily for acute respiratory-, loco-motor-system- and skin symptoms followed by chronic physical diseases. Headache, back and neck pain and acute respiratory infection were the most frequent diagnoses. Questionnaires and interviews among staff revealed language barriers and psycho-trauma as the most frequently reported challenges. Equipment and staffing was adequate, but patient documentation was not systematic, leading to loss of information. CONCLUSION: To facilitate refugees' appropriate access to health care, the OPD was seen as functional for this refugee accommodation centre. Need was recognised for standardized, data protective documentation and a health passport for clients for medical information. Psychological support for refugees needs expansion taking legal circumstances and coverage of costs into consideration. To improve patient communication employees working with refugees should be offered an introduction to culturally sensitive understanding of health and illness.

Control measures following a case of imported Lassa fever from Togo, North Rhine Westphalia, Germany, 2016.

In a patient transferred from Togo to Cologne, Germany, Lassa fever was diagnosed 12 days post mortem. Sixty-two contacts in Cologne were categorised according to the level of exposure, and gradual infection control measures were applied. No clinical signs of Lassa virus infection or Lassa specific antibodies were observed in the 62 contacts. Thirty-three individuals had direct contact to blood, other body fluids or tissue of the patients. Notably, with standard precautions, no transmission occurred between the index patient and healthcare workers. However, one secondary infection occurred in an undertaker exposed to the corpse in Rhineland-Palatinate, who was treated on the isolation unit at the University Hospital of Frankfurt. After German authorities raised an alert regarding the imported Lassa fever case, an American healthcare worker who had cared for the index patient in Togo, and who presented with diarrhoea, vomiting and fever, was placed in isolation and medevacked to the United States. The event and the transmission of Lassa virus infection outside of Africa underlines the need for early diagnosis and use of adequate personal protection equipment (PPE), when highly contagious infections cannot be excluded. It also demonstrates that larger outbreaks can be prevented by infection control measures, including standard PPE.

Prevalence of latent TB infection among asylum seekers in emergency accommodation in Cologne, Germany.

∼12% of male asylum seekers from multiple countries were diagnosed with LTBI. Systematic documentation and reporting of LTBI, access to chemopreventive therapy, and early diagnosis of active TB are highly recommended for this vulnerable group. http://ow.ly/dVTp30onmaR.

Severe disseminated tuberculosis in HIV-negative refugees.

In high-income countries, the presentation of tuberculosis is changing, primarily because of migration, and understanding the specific health needs of susceptible populations is becoming increasingly important. Although disseminated tuberculosis is well documented in HIV-positive patients, the disease is poorly described and less expected in HIV-negative individuals. In this Grand Round, we report eight HIV-negative refugees, who presented with extensively disseminated tuberculosis. We discuss the multifactorial causes, such as deprivations during long journeys, precarious living conditions, and the experience of violence, which might add to nutritional factors and chronic disorders, eventually resulting in a state of predisposition to immune deficiency. We also show that disseminated tuberculosis is often difficult to diagnose when pulmonary symptoms are absent. Communication difficulties between refugees and health-care workers are another major hurdle, and every effort should be made to get a valid patient history. This medical history is crucial to guide imaging and other diagnostic procedures to establish a definite diagnosis, which should be confirmed by a positive tuberculosis culture. Because many of these patients are at risk for multidrug-resistant tuberculosis, drug susceptibility testing is imperative to guide therapy. In the absence of treatment guidelines for this entity, clinicians can determine treatment duration according to recommendations provided for extrapulmonary tuberculosis and affected organs. Paradoxical expansion of tuberculous lesions during therapy should be treated with corticosteroids. In many cases, treatment duration must be individualised and might even exceed 12 months.

Perfluorinated compounds in the vicinity of a fire training area--human biomonitoring among 10 persons drinking water from contaminated private wells in Cologne, Germany.

In Cologne, Germany, increased concentrations of perfluorinated compounds (PFC) have been observed in two private wells used for drinking water purposes. Both wells are located in the vicinity of a fire training area. Use of well water as a source of drinking water was prohibited by the Public Health Department of the City of Cologne. A human biomonitoring (HBM) survey was performed among all persons, who consumed water from these private wells (N=10). PFC concentrations in water of the private wells and in blood samples were analysed by tandem mass spectrometry with electrospray ionization (LC-ESI-MS/MS). Repeated water analyses (seven measurements between December 2009 and November 2010) indicated a decrease of PFOS from 8.35 to 1.60 µg/l, (PFHxS: 2.36-0.15 µg/l; PFOA: 0.16-0.03 µg/l) in one private well. Although situated close together, PFC-concentrations in the other private well were significantly lower. PFOS-concentrations in blood samples of private well water consumers ranged from 4.8 to 295 µg/l (PFHxS: 12.1-205 µg/l; PFOA: 4.0-18 µg/l). Although no data on the formulation of the firefighting foams applied on the fire training area is available, firefighting foams are supposed to be the most likely source of contamination. These findings give reason to track systematically the application of PFC-containing firefighting foams in order to identify contaminations of surface, ground and drinking waters.