Health system factors influencing management of multidrug-resistant tuberculosis in four European Union countries - learning from country experiences.

BACKGROUND: In the European Union and European Economic Area only 38% of multidrug-resistant tuberculosis patients notified in 2011 completed treatment successfully at 24 months' evaluation. Socio-economic factors and patient factors such as demographic characteristics, behaviour and attitudes are associated with treatment outcomes. Characteristics of healthcare systems also affect health outcomes. This study was conducted to identify and better understand the contribution of health system components to successful treatment of multidrug-resistant tuberculosis. METHODS: We selected four European Union countries to provide for a broad range of geographical locations and levels of treatment success rates of the multidrug-resistant tuberculosis cohort in 2009. We conducted semi-structured interviews following a conceptual framework with representatives from policy and planning authorities, healthcare providers and civil society organisations. Responses were organised according to the six building blocks of the World Health Organization health systems framework. RESULTS: In the four included countries, Austria, Bulgaria, Spain, and the United Kingdom, the following healthcare system factors were perceived as key to achieving good treatment results for patients with multidrug-resistant tuberculosis: timely diagnosis of drug-resistant tuberculosis; financial systems that ensure access to a full course of treatment and support for multidrug-resistant tuberculosis patients; patient-centred approaches with strong intersectoral collaboration that address patients' emotional and social needs; motivated and dedicated healthcare workers with sufficient mandate and means to support patients; and cross-border management of multidrug-resistant tuberculosis to secure continuum of care between countries. CONCLUSION: We suggest that the following actions may improve the success of treatment for multidrug-resistant tuberculosis patients: deployment of rapid molecular diagnostic tests; development of context-specific treatment guidance and criteria for hospital admission and discharge in the European context; strengthening patient-centred approaches; development of collaborative mechanisms to ensure cross-border care, and development of long-term sustainable financing strategies.

Implementation of the national tuberculosis guidelines on culture and drug sensitivity testing in Guatemala, 2013.

Objective To assess whether the National Tuberculosis Program (NTP) guidelines for culture and drug sensitivity testing (DST) in Guatemala were successfully implemented, particularly in cases of smear-negative pulmonary tuberculosis (TB) or previously treated TB, by documenting notification rates by department (geographic area), disease type and category, and culture and DST results. Methods This was a cross-sectional, operational research study that merged and linked all patients registered by the NTP and the National Reference Laboratory in 2013, eliminating duplicates. The proportions with culture (for new smear negative pulmonary cases) and culture combined with DST (for previously treated patients) were estimated and analyzed by department. Data were analyzed using EpiData Analysis version 2.2. Results There were 3 074 patients registered with TB (all forms), for a case notification rate of 20/100 000 population. Of these, 2 842 had new TB, of which 2 167 (76%) were smear-positive pulmonary TB (PTB), 385 (14%) were smear-negative PTB, and 290 (10%) were extrapulmonary TB. There were 232 (8%) previously treated cases. Case notification rates (all forms) varied by department from 2-68 per 100 000 population, with the highest rates seen in the southwest and northeast part of Guatemala. Of new TB patients, 136 had a culture performed and 55 had DST of which the results were 33 fully sensitive, 9 monoresistant, 3 polyresistant, and 10 multidrug resistant TB (MDR-TB). Only 21 (5%) of new smear-negative PTB patients had cultures. Of 232 previously treated patients, 54 (23%) had a culture and 47 (20%) had DST, of which 29 were fully sensitive, 7 monoresistant, 2 polyresistant, and 9 MDR-TB. Of 22 departments (including the capital), culture and DST was performed in new smear-negative PTB in 7 departments (32%) and in previously treated TB in 13 departments (59%). Conclusions Despite national guidelines, only 5% of smear-negative PTB cases had a culture and only 20% of previously treated TB had a culture and DST. Several departments did not perform culture or DST. These short comings must be improved if Guatemala is to curtail the spread of drug resistant forms of TB, while striving to eliminate all TB.

Contrasting trends of tuberculosis in the cities of San Pedro Sula and Tegucigalpa, Honduras, 2005-2014.

Objective To 1) describe and compare the trends of tuberculosis (TB) case notification rates (CNRs) and treatment outcomes in the two largest cities in Honduras (San Pedro Sula and Tegucigalpa) for the period 2005-2014 and 2) identify possible related socioeconomic and health sector factors. Methods This retrospective ecological operational research study used aggregated data from the National TB Program (socioeconomic and health sector information and individual data from the 2014 TB case notification report). Results TB CNRs declined steadily over the study period in Tegucigalpa (from 46 to 28 per 100 000 inhabitants) but remained high in San Pedro Sula (decreasing from 89 to 78 per 100 000 inhabitants). Similar trends were observed for smear-positive TB. While presumptive TB cases examined were similar for both cities, in San Pedro Sula the proportions of presumptive cases with a positive smear; (7.7% versus 3.6%) relapses (8.9% versus 4.2%); and patients lost to follow-up (10.9% versus 2.7%) were significantly higher, and the treatment success lower (75.7% versus 87.0%). San Pedro Sula had lower annual income per capita, fewer public sector health workers and facilities, and a higher and increasing homicide index. The 2014 TB case data from San Pedro Sula showed a significantly lower median age and a higher proportion of assembly plant workers, prisoners, drug abusers, and diabetes. Conclusions The TB rate was higher and treatment success lower, and health care resources and socio-demographic indicators less favorable, in San Pedro Sula versus Tegucigalpa. City authorities, the NTP, and the health sector overall should strengthen early case detection, treatment, and infection control, involving both public and private health sectors.

Quality of tuberculosis care at different levels of health care in Brazil in 2013.

Objective To assess 1) the burden and socio-demographic and clinical characteristics of tuberculosis (TB) cases, and 2) the quality of TB care provided to patients who entered and remained within each health care service level (primary, secondary, or tertiary) and those who moved from one level to another, using process and results indicators. Methods This cross-sectional operational research study assessed new smear-positive pulmonary TB cases diagnosed in Brazilian state capitals in 2013 using TB program records and the TB surveillance system. Quality of care was assessed based on process and results indicators including HIV screening, TB contact screening, Directly Observed Treatment (DOT), sputum smear microscopy monitoring, and treatment outcomes. Results There were 12 977 new smear-positive TB cases reported. Of these, 7 964 (61.4%) cases were diagnosed and treated at the primary care level, 1 195 (9.2%) at the secondary level, 1 521 (11.7%) at the tertiary level, and 2 296 (17.7%) at more than one level, with 65% of the latter group moved from the tertiary level to the primary level. The proportion of cases tested for HIV was significantly higher in patients receiving care at the primary level compared to those receiving care at the secondary level (prevalence ratio (PR): 1.17; 95% confidence interval (CI): 1.07-1.28) and those attending more than one service level. Patients attending the tertiary health care level had a 122% higher PR for not doing DOT ("DOT not done") compared to patients at the primary level (PR: 2.22; CI: 2.12-2.32). When the two levels were compared, the prevalence for an unfavorable outcome (lost to follow-up, death from TB, death with TB, transferred out, or not evaluated) was higher at the tertiary health care level. Conclusions Primary health services are successfully incorporating the management of new smear-positive TB cases. Primary health care obtained better operational indicators than secondary or tertiary levels.

Tuberculin responses after BCG vaccination predict amyotrophic lateral sclerosis risk.

Background: T cell infiltration around dying motor neurons is a hallmark of amyotrophic lateral sclerosis (ALS). It is not known if this immune response represents a cause or a consequence of the disease. We aimed to establish whether individual variation in regulation of a T cell driven immune response is associated with long-term ALS risk. Methods: Tuberculin skin test (TST) following BCG vaccination represents a standardized measure of a secondary T cell driven immune response. During a Norwegian tuberculosis screening program (1963-1975) Norwegian citizens born from 1910 to 1955 underwent TST. In those previously BCG vaccinated (median 7 years prior to TST), we related tuberculin skin tests to later ALS disease identified through validated Norwegian health registers. We fitted Cox proportional hazard models to investigate the association between tuberculin reactivity and ALS risk. Results: Among 324,629 participants (52 % women) with median age 22 (IQR 10) years at tuberculosis screening, 496 (50 % women) later developed ALS. Hazard ratio for ALS was 0.74 (95% CI 0.57-0.95) for those who remained TST negative compared to those who mounted a positive TST. The association was strongest when time between BCG immunization and TST was short. The associations observed persisted for more than four decades after TST measurement. Conclusions: Negative TST responses after BCG vaccination is associated with decreased long-term risk for ALS development, supporting a primary role for adaptive immunity in ALS development.

Prevalence and incidence of symptomatic pulmonary tuberculosis based on repeated population screening in a district in Ethiopia: a prospective cohort study.

OBJECTIVE: In Ethiopia, one-third of the estimated tuberculosis cases are not detected or reported. Incidence estimates are inaccurate and rarely measured directly. Assessing the 'real' incidence under programme conditions is useful to understand the situation. This study aimed to measure the prevalence and incidence of symptomatic pulmonary tuberculosis (PTB) during 1 year in the adult population of Dale in Ethiopia. DESIGN: A prospective population-based cohort study. SETTING: Every household in Dale was visited three times at 4-month intervals. PARTICIPANTS: Individuals aged ≥15 years. OUTCOME MEASURES: Microscopy smear positive PTB (PTB s+), bacteriologically confirmed PTB (PTB b+) by microscopy, GeneXpert, or culture and clinically diagnosed PTB (PTB c+). RESULTS: Among 136 181 individuals, 2052 had presumptive TB (persistent cough for 14 days or more with or without haemoptysis, weight loss, fever, night sweats, chest pain or difficulty breathing), in the first round of household visits including 93 with PTB s+, 98 with PTB b+ and 24 with PTB c+; adding those with PTB who were already on treatment, the total number of PTB was 201, and the prevalence was 147 (95% CI: 127 to 168)/100 000 population. Out of all patients with PTB, the proportion detected by symptom screening was in PTB s+ 65%, PTB b+ 67% and PTB c+44%. During 96 388 person-years follow-up, 1909 had presumptive TB, 320 had PTB and the total incidence of PTB was 332 (95% CI: 297 to 370)/100 000 person-years, while the incidence of PTB s+, PTB b+ and PTB c+ was 230 (95% CI: 201 to 262), 263 (95% CI: 232 to 297) and 68 (95% CI: 53 to 86)/100 000 person-years, respectively. CONCLUSION: The prevalence of symptomatic sputum smear-positive TB was still high, only one-third of prevalent PTB cases notified and the incidence rate highest in the age group 25-34 years, indicating ongoing transmission. Finding missing people with TB through repeated symptom screening can contribute to reducing transmission.

Prevention of bronchial fistulas after pneumonectomies for selected cavitary drug resistant lung tuberculosis.

Background: The World Health Organization guidelines for management drug resistant tuberculosis include surgery as an additional method in selected cases. Pneumonectomies have higher risk of morbidity such as bronchial fistulas which may be prevented by bronchial stump covering. We compare two methods of bronchial stump reinforcement. Methods and materials: A retrospective single center follow-up study was done in 52 patients who underwent pneumonectomy for drug resistant pulmonary tuberculosis. Between 2000 and 2017 we performed pneumonectomies with pericardial fat reinforcement of bronchial stump in group 1 (n = 42), and between 2017 and 2021 in group 2 with pedicled muscle flap reinforcement group 2 (n = 10). Results: Bronchial fistulas occurred in 17/42 (41%) of patients group 1 and there was no fistula in group 2, and this was statistically different (Fisher's test p = 0.02). Post-operative complications were seen in 24/42 (57%) of the patients in Group 1, and 4/10 (40%) patients in Group 2 (Fischer's test p = 0.53). In group 1 positive bacteriology decreased from 74% to 24% just after surgery, and in group 2 it decreased from 90% to 10%, but this was not statistically different (Fisher's test p = 0.63). In group 1 no-one died the first month, but 8/42 (19%) died within a year; in group 2 one died within a month, and only this death (10%) within a year. This difference in case fatality was not statistically significant. Conclusions: The use of pedicle muscle flap for bronchial stump coverage during the pneumonectomies for destructive drug resistant tuberculosis can prevent severe postoperative fistulas and improve postoperative life.

Minimum package for cross-border TB control and care in the WHO European region: a Wolfheze consensus statement.

The World Health Organization (WHO) European region estimates that more than 400,000 tuberculosis (TB) cases occur in Europe, a large proportion of them among migrants. A coordinated public health mechanism to guarantee TB prevention, diagnosis, treatment and care across borders is not in place. A consensus paper describing the minimum package of cross-border TB control and care was prepared by a task force following a literature review, and with input from the national TB control programme managers of the WHO European region and the Wolfheze 2011 conference. A literature review focused on the subject of TB in migrants was carried out, selecting documents published during the 11-yr period 2001-2011. Several issues were identified in cross-border TB control and care, varying from the limited access to early TB diagnosis, to the lack of continuity of care and information during migration, and the availability of, and access to, health services in the new country. The recommended minimum package addresses the current shortcomings and intends to improve the situation by covering several areas: political commitment (including the implementation of a legal framework for TB cross-border collaboration), financial mechanisms and adequate health service delivery (prevention, infection control, contact management, diagnosis and treatment, and psychosocial support).

Strong tuberculin response after BCG vaccination is associated with low multiple sclerosis risk: a population-based cohort study.

BACKGROUND: Multiple sclerosis (MS) is characterized by inflammatory lesions in the central nervous system involving pro-inflammatory T-cells. Immune dysregulation is well described in prevalent disease, but it is not known whether this precedes disease development. Bacillus Calmette-Guérin (BCG) vaccination ameliorates MS-like disease in mice. In people vaccinated with BCG, the tuberculin skin test (TST) offers a standardized measure of a T-cell-mediated immune response. We therefore hypothesized that the strength of the TST response after BCG vaccination is associated with subsequent MS risk. METHODS: Using data from a Norwegian tuberculosis screening programme (1963-1975), we designed a population-based cohort study and related the size of TST reactions in individuals previously vaccinated with BCG to later MS disease identified through the Norwegian MS registry. We fitted Cox proportional hazard models and flexible parametric survival models to investigate the association between TST reactivity, MS risk and its temporal relationship. RESULTS: Among 279 891 participants (52% females), 679 (69% females) later developed MS. Larger TST reactivity was associated with decreased MS risk. The hazard ratio for MS per every 4-mm increase in skin induration size was 0.86 (95% confidence interval 0.76-0.96) and similar between sexes. The strength of the association persisted for >30 years after the TST. CONCLUSION: A strong in vivo vaccine response to BCG is associated with reduced MS risk >30 years later. The immunological mechanisms determining TST reactivity suggest that skewed T-cell-mediated immunity precedes MS onset by many decades.

How many of persistent coughers have pulmonary tuberculosis? Population-based cohort study in Ethiopia.

OBJECTIVE: Many individuals with persistent cough and smear microscopy-negative sputum test for tuberculosis (TB) remain at risk of developing the disease. This study estimates the incidence of pulmonary TB (PTB) among initially smear-negative persistent coughers and its risk factors. DESIGN: A prospective population-based follow-up study. SETTING: Health extension workers visited all households in Dale woreda three times at 4-month intervals in 2016-2017 to identify individuals with symptoms compatible with TB (presumptive TB) using pretested and semistructured questionnaires. PARTICIPANTS: We followed 3484 presumptive TB cases (≥15 years) with an initial smear-negative TB (PTB) test. OUTCOME MEASURES: Bacteriologically confirmed PTB (PTB b+) and clinically diagnosed PTB (PTB c+). RESULTS: 3484 persons with initially smear-negative presumptive PTB were followed for 2155 person-years (median 0.8 years); 90 individuals had PTB b+ and 90 had PTB c+. The incidence rates for PTB b+ and PTB c+ were both 4176 (95% CI 3378 to 5109) per 100 000 person-years. We used penalised (lasso) and non-penalised proportional hazards Cox regression models containing all exposures and outcomes to explore associations between exposures and outcomes. In lasso regression, the risk of development of PTB b+ was 63% (HR 0.37) lower for people aged 35-64 years and 77% (HR 0.23) lower for those aged ≥65 years compared with 15-34 year-olds. Men had a 62% (HR 1.62) greater risk of PTB b+ development than women. The risk of PTB c+ was 39% (HR 0.61) lower for people aged 35-54 years than for those aged 15-34 years. Men had a 56% (HR 1.56) greater risk of PTB c+ development than women. CONCLUSIONS: PTB incidence rate among persistent coughers was high, especially among men and young adults, the latter signifying sustained transmission. Awareness about this among healthcare workers may improve identification of more new TB cases.

Extending contact screening within a 50-m radius of an index tuberculosis patient using Xpert MTB/RIF in urban Pakistan: Did it impact treatment outcomes?

BACKGROUND: Pakistan implemented initiatives to detect tuberculosis (TB) patients through extended contact screening (ECS); it improved case detection but treatment outcomes need assessment. OBJECTIVES: To compare treatment outcomes of pulmonary TB (PTB) patients detected by ECS with those detected by routine passive case finding (PCF). METHODS: A cohort study using secondary program data conducted in Lahore, Faisalabad and Rawalpindi districts and Islamabad in 2013-15. We used log binomial regression models to assess if ECS was associated with unfavorable treatment outcomes (death, loss-to-follow-up, failure, not evaluated) after adjusting for potential confounders. RESULTS: We included 79,431 people with PTB; 4604 (5.8%) were detected by ECS with 4052 (88%) bacteriologically confirmed. In all PTB patients the proportion with unfavorable outcomes was not significantly different in ECS group (9.6%) compared to PCF (9.9%), however, among bacteriologically confirmed patients unfavorable outcomes were significantly lower in ECS (9.9%) than PCF group (11.6%, P = 0.001). ECS was associated with a lower risk of unfavorable outcomes (adjusted relative risk (aRR) 0.90; 95% CI 0.82-0.99) among 'all PTB' patients and bacteriologically confirmed PTB patients (aRR 0.91; 95% CI 0.82-1.00). CONCLUSION: In PTB patients detected by ECS the treatment outcomes were not inferior to those detected by PCF.

Screening and treatment of latent tuberculosis in a cohort of asylum seekers in Norway.

AIMS: Asylum seekers are screened for tuberculosis at entry to Norway. We aimed to assess follow-up of screening results at different healthcare levels in relation to demographics, screening results and organizational factors, and how this influenced treatment of latent tuberculosis. METHODS: All asylum seekers >or=18 years with a Mantoux test >or=6 mm or positive x-ray findings who arrived at the National Reception Centre from January 2005 to June 2006, were included. Data were collected from public health authorities in the municipality where the asylum seekers had moved, and from internists in case they had been referred to a specialist. Specialists are responsible for treating latent tuberculosis. Individual subjects were matched with the National Tuberculosis Register to which everybody who had started treatment for latent tuberculosis was reported. RESULTS: Of 4,643 asylum seekers, 2,237 fulfilled the inclusion criteria. By May 2008, 30 persons had started treatment for latent TB, a median of 17 months (range 3-36) after arrival. A Mantoux test >or=15 mm on arrival was significantly associated with treatment. Demographic factors influenced follow-up in primary healthcare while screening results did not. Referral to specialist was related to screening results. Several specialists were reluctant to diagnose and treat latent tuberculosis and to treat persons without a permanent visa in particular. CONCLUSIONS: Just 1% of the study group received treatment for latent tuberculosis and with a long time delay. The reason for this may be organizational factors affecting follow-up and referral and specialists not following current guidelines.

The role of entry screening in case finding of tuberculosis among asylum seekers in Norway.

BACKGROUND: Most new cases of active tuberculosis in Norway are presently caused by imported strains and not transmission within the country. Screening for tuberculosis with a Mantoux test of everybody and a chest X-ray of those above 15 years of age is compulsory on arrival for asylum seekers.We aimed to assess the effectiveness of entry screening of a cohort of asylum seekers. Cases detected by screening were compared with cases detected later. Further we have characterized cases with active tuberculosis. METHODS: All asylum seekers who arrived at the National Reception Centre between January 2005--June 2006 with an abnormal chest X-ray or a Mantoux test ≥ 6 mm were included in the study and followed through the health care system. They were matched with the National Tuberculosis Register by the end of May 2008.Cases reported within two months after arrival were defined as being detected by screening. RESULTS: Of 4643 eligible asylum seekers, 2237 were included in the study. Altogether 2077 persons had a Mantoux ≥ 6 mm and 314 had an abnormal chest X-ray. Of 28 cases with tuberculosis, 15 were detected by screening, and 13 at 4-27 months after arrival. Abnormal X-rays on arrival were more prevalent among those detected by screening. Female gender and Somalian origin increased the risk for active TB. CONCLUSION: In spite of an imperfect follow-up of screening results, a reasonable number of TB cases was identified by the programme, with a predominance of pulmonary TB.

Individual Variation in Adaptive Immune Responses and Risk of Hip Fracture-A NOREPOS Population-Based Cohort Study.

Immune-mediated bone loss significantly impacts fracture risk in patients with autoimmune disease, but to what extent individual variations in immune responses affect fracture risk on a population level is unknown. To examine how immune responses relate to risk of hip fracture, we looked at the individual variation in a post-vaccination skin test response that involves some of the immune pathways that also drive bone loss. From 1963 to 1975, the vast majority of the Norwegian adult population was examined as part of the compulsory nationwide Norwegian mass tuberculosis screening. These examinations included standardized tuberculin skin tests (TSTs). Our study population included young individuals (born 1940 to 1960 and aged 14 to 30 years at examination) who had all received Bacille Calmette-Guerin (BCG) vaccination after a negative TST at least 1 year prior and had no signs of tuberculosis upon clinical examination. The study population ultimately included 244,607 individuals, whose data were linked with a national database of all hospitalized hip fractures in Norway from 1994 to 2013. There were 3517 incident hip fractures during follow-up. Using a predefined Cox model, we found that men with a positive or a strong positive TST result had a 20% (hazard ratio [HR] = 1.20, 95% confidence interval [CI] 1.01-1.44) and 24% (HR = 1.24, 95% CI 1.03-1.49) increased risk of hip fracture, respectively, compared with men with a negative TST. This association was strengthened in sensitivity analyses. Total hip bone mineral density (BMD) was available for a limited subsample and similarly revealed a non-significantly reduced BMD among men with a positive TST. Interestingly, no such clear association was observed in women. An increased immune response after vaccination is associated with an increased risk of hip fracture decades later among men, possibly because of increased immune-mediated bone loss. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Tuberculosis screening and follow-up of asylum seekers in Norway: a cohort study.

BACKGROUND: About 80% of new tuberculosis cases in Norway occur among immigrants from high incidence countries. On arrival to the country all asylum seekers are screened with Mantoux test and chest x-ray aimed to identify cases of active tuberculosis and, in the case of latent tuberculosis, to offer follow-up or prophylactic treatment.We assessed a national programme for screening, treatment and follow-up of tuberculosis infection and disease in a cohort of asylum seekers. METHODS: Asylum seekers >or= 18 years who arrived at the National Reception Centre from January 2005 to June 2006, were included as the total cohort. Those with a Mantoux test >or= 6 mm or positive x-ray findings were included in a study group for follow-up.Data were collected from public health authorities in the municipality to where the asylum seekers had moved, and from hospital based internists in case they had been referred to specialist care.Individual subjects included in the study group were matched with the Norwegian National Tuberculosis Register which receive reports of everybody diagnosed with active tuberculosis, or who had started treatment for latent tuberculosis. RESULTS: The total cohort included 4643 adult asylum seekers and 97.5% had a valid Mantoux test. At least one inclusion criterion was fulfilled by 2237 persons. By end 2007 municipal public health authorities had assessed 758 (34%) of them. Altogether 328 persons had been seen by an internist. Of 314 individuals with positive x-rays, 194 (62%) had seen an internist, while 86 of 568 with Mantoux >or= 15, but negative x-rays (16%) were also seen by an internist. By December 31st 2006, 23 patients were diagnosed with tuberculosis (prevalence 1028/100 000) and another 11 were treated for latent infection. CONCLUSION: The coverage of screening was satisfactory, but fewer subjects than could have been expected from the national guidelines were followed up in the community and referred to an internist. To improve follow-up of screening results, a simplification of organisation and guidelines, introduction of quality assurance systems, and better coordination between authorities and between different levels of health care are all required.

Diagnosis and treatment of patients with pulmonary nontuberculous mycobacterial diseases in Arkhangelsk, Russia.

BACKGROUND: Nontuberculous mycobacteria (NTM) are acid-fast bacilli (AFB) that can cause disease in human. Patients with NTM pulmonary disease can be falsely diagnosed with pulmonary tuberculosis (TB) due detection of AFB in sputum and similar clinical and chest X-ray picture. Laboratory detection of NTM is complicated and does not always mean presence of the disease, but can be attributed to colonization or sample contamination. Molecular tests, such as Genotype Mycobacterium CM/AS, allow quick and reliable detection of NTM. OBJECTIVE: To assess the NTM identification rate, to estimate the incidence of pulmonary NTM disease and to report the treatment outcomes among patients with NTM disease. DESIGN: Retrospective cohort design. RESULTS: NTM were detected among 92 (0.98 per 100,000 population) presumptive pulmonary TB patients in Arkhangelsk region in 2010-2017 among who 39 (0.42 per 100,000 population) patients were diagnosed with NTM disease. The most prevalent species found in our study were M. avium (33%) and M.intracellulare (11%). 69% of patients with NTM disease completed their treatment, 15% died, 13% were lost to follow up and 3% failed treatment. CONCLUSION: A system of diagnostics and treatment for NTM disease was set up in the Arkhangelsk region in Russia. Average NTM identification rate and incidence of pulmonary NTM disease were 0.98 per 100,000 and 0.42 per 100,000 population accordingly and were lower than reported in other studies. Treatment success rate in our study was 69% encouraging further improvements in diagnostics and treatment of patients with NTM.

Immigrant screening for latent tuberculosis infection: numbers needed to test and treat, a Norwegian population-based cohort study.

OBJECTIVES: To estimate the number needed to screen (NNS) and the number needed to treat (NNT) to prevent one tuberculosis (TB) case in the Norwegian immigrant latent tuberculosis infection (LTBI) screening programme and to explore the effect of delay of LTBI treatment initiation. DESIGN: Population-based, prospective cohort study. PARTICIPANTS: Immigrants to Norway. OUTCOME: Incident TB. METHODS: We obtained aggregated data on immigration to Norway in 2008-2011 and used data from the Norwegian Surveillance System for Infectious Diseases to assess the number of TB cases arising in this cohort within 5 years after arrival. We calculated the average NNS and NNT for immigrants from the top 10 source countries for TB in Norway and by estimated TB incidence rates in source countries. We explored the sensitivity of these estimates with regard to test performance, treatment efficacy and treatment adherence using an extreme value approach, and assessed the effects of emigration, time to TB diagnosis (to define incident TB) and intervention timing. RESULTS: NNS and NNT were overall high, with substantial variation. NNT showed numerically stronger negative correlation with TB notification rate in Norway (-0.75 [95% CI -1.00 to -0.44]) than with the WHO incidence rate (IR) (-0.32 [95% CI -0.93 to 0.29]). NNT was affected substantially by emigration and the definition of incident TB. Estimates were lowest for Somali (NNS 99 [70-150], NNT 27 [19-41]) and highest for Thai immigrants (NNS 585 [413-887], NNT 111 [79-116]). Implementing LTBI treatment in immigrants sooner after arrival may improve the effectiveness of the programme. CONCLUSION: Using TB notifications in Norway, rather than IR in source countries, would improve targeting of immigrants for LTBI management. However, the overall high NNT is a concern and challenges the scale-up of preventive LTBI treatment for significant public health impact. Better data are urgently needed to monitor and evaluate NNS and NNT in countries implementing LTBI screening.