Tuberculosis control in big cities and urban risk groups in the European Union: a consensus statement.

In low-incidence countries in the European Union (EU), tuberculosis (TB) is concentrated in big cities, especially among certain urban high-risk groups including immigrants from TB high-incidence countries, homeless people, and those with a history of drug and alcohol misuse. Elimination of TB in European big cities requires control measures focused on multiple layers of the urban population. The particular complexities of major EU metropolises, for example high population density and social structure, create specific opportunities for transmission, but also enable targeted TB control interventions, not efficient in the general population, to be effective or cost effective. Lessons can be learnt from across the EU and this consensus statement on TB control in big cities and urban risk groups was prepared by a working group representing various EU big cities, brought together on the initiative of the European Centre for Disease Prevention and Control. The consensus statement describes general and specific social, educational, operational, organisational, legal and monitoring TB control interventions in EU big cities, as well as providing recommendations for big city TB control, based upon a conceptual TB transmission and control model.

Management and treatment outcomes of tuberculous patients, eastern Paris, France, 2004.

BACKGROUND: France was one of the few European countries without a national tuberculosis (TB) treatment outcome monitoring system until 2007. OBJECTIVE: To examine TB management and treatment outcomes in the eastern Paris region, and to identify patient- and management-dependent factors affecting treatment outcome. METHODS: This retrospective study focused on all cases of microbiologically confirmed Mycobacterium tuberculosis cases diagnosed in 2004 in the eastern Paris region, one of the areas of France with the highest frequency of TB. RESULTS: Treatment outcomes of 629 identified cases (males 69.6%, median age 37 years, socio-economically disadvantaged 44%, foreign-born 78%) were as follows: treatment success 70.1% (95%CI 66.5-73.7), treatment interruption 4.9% (95%CI 3.2-6.6), loss to follow-up 15.0% (95%CI 12.2-17.8), death 5.7% (95%CI 3.9-7.9), transfers 4.3% (95%CI 3.5-5.1). Non-completion of treatment was associated with sputum smear positivity, injection drug use, non-adherence and irregular follow-up in univariate analysis, and with irregular follow-up and non-adherence in multivariate analysis. Duration of TB treatment and follow-up medical visits were not applied as recommended in more than a third of cases. CONCLUSION: The treatment success rate observed in this study (70.1%) is below the World Health Organization target of 85%, and requires the implementation and evaluation of interventions to increase treatment success rates.

[Tuberculosis in France: new challenges for practitioners]. / Tuberculose en France : nouveaux enjeux pour le praticien en 2008.

The need for a national tuberculosis control program was based on disparities of incidence by geographical area or by population group, and differences in tuberculosis control practice. This program was developed within the context of the 2004 public health act that prioritised tuberculosis control with the objective "to stabilise the tuberculosis incidence by reinforcing control strategies in groups and zones at risk". The tuberculosis control programme, launched in July 2007, aims to consolidate the decrease of the tuberculosis incidence and to reduce the inequalities. This implies, in particular, reaching the most exposed populations, to ensure an adequate management of cases with a good treatment observance. This also implies preventing transmission in health care settings, and maintaining the low level of multiresistance and must be done despite the loss of expertise due to a decrease in incidence. The six major objectives of the tuberculosis control program are to ensure an early diagnosis and an adequate treatment for all tuberculosis cases, to improve screening, to optimise the BCG policy, to maintain antituberculosis resistance at a low level, to improve the epidemiological surveillance and the knowledge of the determinants of tuberculosis and to improve the management of tuberculosis control activities.

[Follow-up with the assistance of TB-info software of 208 tuberculosis patients who were treated in 2004]. / Intérêt de l'utilisation du logiciel TB-info pour le suivi des patients mis sous traitement antituberculeux: analyse des 208 patients de la cohorte 2004.

INTRODUCTION: The impact of the TB-info software was assessed on the care of patients treated with antituberculosis regimen (ATT). METHODS: Cohort study of patients with tuberculosis who received an ATT in 2004 in two hospitals and five medical centres in Paris. Follow-up was implemented with the TB-info software. Data were compared to those of the 1999-2003 cohort. RESULTS: Two hundred and nine ATT were initiated in 2004, with a mean duration of 7.2 months. Demographic and clinical data reflected this population precariousness: 79% were foreign-born, 25% lived in institutions and half of them had no or unusual health insurance. Compared to the previous cohort, viral co-infections were tested in more than 80% cases and showed association with HIV, HBV or HCV in 11, 10 and 5% of the patients, respectively. Twenty-one patients were lost for follow-up (11%) and 76% of the smear-positive pulmonary tuberculosis therapies were declared successful but only 34% were declared cured with the WHO criteria. CONCLUSION: Analysis of the data obtained with TB-info software showed an improvement of tuberculosis patients care with more co-infection tested and less lost for follow-up. These results confirm the usefulness of this software for patients care and assessment of physicians practice in France.

Potentially preventable tuberculosis cases in children exposed to a contaminant case.

Early screening is recommended in children exposed to a contagious case of tuberculosis (TB), to prevent rapid progression to active TB. The aim of this study was to evaluate the percentage of potentially preventable cases of pediatric TB stemming from inadequate screening. The data gathered on children aged 0 to 10 years, who were evaluated by the Paris Center for TB Control (CLAT75) between January 2009 and December 2013, were extracted and retrospectively analyzed. French National Guidelines for screening were used as reference. During the study period, 1232 children 0-10 years were screened, because of a known exposure to an index case, including 124 (10%) with criteria for latent tuberculosis infection (LTBI) and 26 (2%) with active TB. Twelve additional cases of TB were reported, diagnosed based on symptoms or systematic exams. As a whole, 68% of pediatric TB cases were diagnosed at screening around an adult index case, highlighting the quality of the screening network. Among the 38 TB cases, 19 (50%) had a missed opportunity for potential prevention, due to the absence of screening despite a known contaminant (n=2) or to screening not in compliance with current recommendations (n=17). Delayed first evaluation was the most frequent error of the screening procedures. In conclusion, despite the quality of the screening network set up in Paris, half of the pediatric TB cases in this study did not undergo the recommended screening procedures. A significant reduction in the number of pediatric TB cases can be expected through the optimization of screening networks.

Tuberculosis in European cities: establishment of a patient monitoring system over 10 years in Paris, France.

BACKGROUND: Tuberculosis (TB) is a persistent public health problem in European cities. France has been unable to report on treatment outcomes until now, and it is not known whether the World Health Organization (WHO) target cure rate of 85% has been met. METHODS: All patients placed under treatment in four hospitals and five out-patient Social Medical Centres in Paris were followed up between 1996 and 2005. Patient monitoring and evaluation were performed using a new software programme, TB-INFO. RESULTS: In a cohort of 1127 patients, 76% had pulmonary TB, of whom 39% were smear-positive, 81% were foreign-born and 9.3% were human immunodeficiency virus positive. At the end of the follow-up, 16% were cured and 54% had completed treatment. Among the 1118 non-multidrug-resistant patients, these percentages were 17% and 46%, respectively, for smear-positive pulmonary patients. Some patients died (1.9%) or failed treatment (0.1%), but many more defaulted (20.5%) as they interrupted treatment (1.5%), were lost to follow-up (19.5%) or were transferred out (7.9%). CONCLUSIONS: This 10-year follow-up of TB patients, managed with TB-INFO software, shows that a patient monitoring system can be implemented in France, providing essential information. Treatment success in this cohort of patients was far below the WHO target.

Outbreak of tuberculosis in a migrants' shelter, Paris, France, 2002.

SETTING: An overcrowded 362-bed migrants' shelter in Paris, France. OBJECTIVES: To investigate an outbreak of tuberculosis (TB), to identify a common source of contamination and to prevent further transmission. METHODS: The outbreak was identified by radiographic screening and an active search for undeclared hospital treated cases, completed by strain phenotyping and a search for contact cases. RESULTS: Between October 2001 and October 2002, 56 cases of active TB were identified, 30 by radiological screening and 20 by contacting neighbouring hospitals. All cases involved men, with a median age of 30 years. Pulmonary involvement was present in 54% of cases, and nine patients were sputum smear-positive. Thirty-four of the 37 phenotyped strains clustered together. CONCLUSION: The grouping of the cases in time and place, the large number of cases with early-stage disease and the identical RFLP banding patterns of most of the isolates indicate that this outbreak results from transmission that occurred in France. This report underlines the need for public health departments in industrialised countries to maintain effective anti-tuberculosis control programmes.

[Tuberculosis control in France--evaluation of practice by a working group of the Société de Pneumologie de Langue Française]. / La lutte antituberculeuse en France: évaluation des pratiques par un groupe de travail de la SPLF auprès des services de lutte antituberculeuse.

INTRODUCTION: The management of tuberculosis has been the subject of renewed interest in France. Recently, the recommendations and the regulations concerning the disease have been updated. However, the resources that are actually available and the processes in place in different French departments are not clearly known. A national survey was thus carried out by a working group of the SPLF in charge of the recommendations concerning the medical, social and administrative management of the disease. METHODS: A questionnaire was sent to the 100 French departmental Antituberculous Services (SLAT). This explored the structures, activity, organisation involved, and difficulties encountered in Tuberculosis management. RESULTS: Ninety SLAT took part in the study. Their answers reveal: a discordance between a number of cases notified to the Department of Sanitation and Health (DDASS) and the number of cases known to the SLAT; a disparity between means involved in this study and the number of patients followed up as well as the choice of populations targeted for tracing); a willingness to deal with contact tracing although the investigations around individual cases and the definition of which subjects should be followed up were variable; a demand for protocols, networks and national recommendations. CONCLUSIONS: The SLAT are involved in the fight against tuberculosis with 20 years experience. The needs expressed in this survey point the way towards future prioritary actions to improve tuberculosis control nationally.

[Longitudinal follow-up of contact subjects of cases of tuberculosis in Paris]. / Suivi longitudinal des sujets contacts de cas de tuberculose à Paris.

AIM: To our knowledge, the proportion of active tuberculosis diagnosed after 12-18 months during a screening tuberculosis process in a specialized centre (centre de lutte antituberculeuse [CLAT]) has not been described in France. The majority of other countries do not have any recommendation to screen at this time. METHODS: We evaluated the number of treated or not treated latent tuberculosis infections (LTI) identified during tuberculosis screening. We identified the causes of ITL non-treatment, the number of active disease cases and the proportion of subjects lost to follow-up after 12-18 months. RESULTS: Among the 1066 contact subjects, 159 (15 %) had a positive QuantiFERON-TB-Gold In-Tube(®) test. A prophylactic treatment with Rifinah(®) was given to 97 (61 %) subjects, 7 (7.3 %) having developed side effects that led to treatment interruption. A high proportion (56 %) of contact subjects were lost of follow-up and the main reason for no prophylactic treatment (20/52, 38 %) was due to these losses. No active disease cases were identified among the 474 (44 %) contact subjects who had a chest X-ray after 12-18 months follow-up by the CLAT. The low level of positive QuantiFERON-TB-Gold In-Tube(®) tests (15 %) could be explained by the high specificity of this test and the strong proportion of occupational contacts, of whom a probably significant number were not exposed to active disease. CONCLUSION: The absence of active disease at 12-18 months and a majority (56 %) of contact subjects lost from follow-up at this period let us propose not to recall contact subjects at 12-18 months with the exception of those living under the same roof as the index case and/or those having a cumulative contact time of greater than 100 hours during the theoretical infectious period. This proposal remains to be confirmed by other studies, particularly including possible secondary cases diagnosed outside the screening periods by the CLAT.

[Aspects of pneumocystosis seen in a French pneumonology department in 1987-1988]. / Aspects des pneumocystoses observées dans un service de pneumologie français en 1987-1988.

Over a 2 years' period, 49 AIDS patients and 3 non AIDS patients were treated for pneumocystosis in our chest department. Forty-six were male and 6 were female. Pneumocystosis was the first opportunistic infection in 77 p 100 of patients. Fever above 38.5 degrees C was the major symptom in 92 p 100. Cough was present in 90 p 100 and dyspnoea in 94 p 100. Clinical symptoms had begun 21.7 +/- 15.7 days before diagnosis. Mean PaO2 value was 50.9 +/- 15.7 mmHg. Forty-eight patients were initially treated by daily intravenous administration of trimethoprim 960 mg and sulfamethoxazole 4,800 mg. Three patients received a pentamidine aerosol and one received DFMO. Treatment was effective in 39 patients; 11 patients died between the 5th and the 29th days of treatment; 2 had an early relapse. Fever disappeared after 9.8 +/- 6.6 days, and blood gases returned to normal within 10.8 +/- 7.7 days. All patients whose PaO2 was above 56 mmHg were cured. Thus, the trimethoprim-sulfamethoxazole combination proved active in the treatment of pneumocystosis. Other treatments are useful in case of side-effects or failure of the initial therapy. Failures can be suspected on the fourth day of treatment and in such cases CMV co-infection must be looked for and treated.

[Clinical management by the respiratory physician of patients with HIV infections]. / La prise en charge pratique par le pneumologue des malades atteints par le VIH.

The lung is directly affected by HIV virus early in the disease and is the site of a specific lymphocytic alveolitis. Neoplastic pulmonary disease linked to the virus occurs (Kaposi sarcoma, lymphoma and epidermoid tumour) but it is principally following opportunistic infections that patients with AIDS come under the care of a respiratory physician. Certain of the responsible infectious agents causing opportunistic pneumonia are probably present in a latent fashion before the disease presents and are reactivated by the immuno-depression. They may occur successively such as tuberculosis, toxoplasmosis (in this case pulmonary), infection to CMV and pneumocystis. Other infectious agents are transported by the environment and lead to recurrent bacterial infections, mycotic infections or infections with atypical mycobacteria. The clinical management of these different diseases has advanced greatly from a diagnostic therapeutic prophylactic and curative viewpoint.

[A trial comparing artificial noses and heat exchangers during assisted ventilation using tracheotomy at home. CARDIF. The Committee of the Organization of Respiratory Assistance of the Ile-de-France]. / Essai comparant nez artificiels et cascades chauffantes au cours de la ventilation assistée par trachéotomie à domicile. CARDIF. Comité d'Organisation de l'Assistance Respiratoire d'Ile-de-France.

Thirteen patients with a tracheostomy who were undergoing artificial ventilation at home were included in a study covering 62 episodes, during a month of treatment, which was undertaken with three different humidification systems: A Puritan Bennet Cascade humidifier (C), a Swedish nose Vygon-(V) (a hydroscopic condenser humidifier) and a Pall filter (P). Five patients abandoned the study because of discomfort with C (1), P (2), or V (2). The discomfort described by three patients was identical with the three systems used during ventilation. The two systems using the artificial heat humidification exchanger were considered more simple to use than the Cascade for the patients. Using the system for three years for a patient who was being ventilated for 12 hours out of 24 showed the increasing cost ranging from the Vygon nose, to the Cascade and finally to the Pall filter. The percentage of time spent on antibiotics was identical with the three systems (11% of the time). A bacteriological study showed that only the Pall filter permitted the respirator tubes to be kept sterile. The most polluted circuit from the bacteriological point of view was that used with the Cascade. In conclusion, when it was compared to the humidifier Cascade the two artificial noses appeared as simple to use and the Pall filter was the safest bacteriologically.

[Acquired rifampicin resistance during M. kansasii infection in a patient with AIDS]. / Résistance acquise à la rifampicine au cours d'une infection à M. kansasii chez un patient atteint de SIDA.

A man with AIDS and M. kansasii lung infection received rifampicin and isoniazid for 9 months, combined with ethambutol for four months. The treatment was effective with sputum culture negativation, but relapse occurred. The minimal inhibitory concentration of rifampicin for the M. kansasii strain was respectively 0.2 microgram/ml at the onset and 128 micrograms/ml after the treatment, giving evidence of acquired resistance. A new treatment was initiated but is was ineffective.

[Pentamidine aerosol in the preventive treatment of pneumocystosis in AIDS patients. Comparison of two salts and two nebulizers]. / Aérosol de pentamidine dans la prévention des pneumocystoses des malades atteints de SIDA. Comparaision de deux sels et de deux systèmes de nébulisation.

In a randomized trial conducted in AIDS patients requiring prophylaxis against pneumocystosis we compared two pentamidine salts, isethionate (I) and mesylate (M), and two nebulizers (a modified ultrasonic Ultraneb 99 Devilbiss nebulizer, and a disposable jet nebulizer). Patients were randomized to one or the other nebulizer and received alternatively, once every other week, the two pentamidine salts in the IMIM or MIMI order. Characteristics and the side effects of the two courses of each pentamidine salt, as well as drug delivery by each nebulizer during the first course, were studied in 48 patients. The ultrasonic nebulizer was more effective (nebulization time: 19.8 +/- 7.3 mn versus 30.7 +/- 11 mn) and produced less side-effects (FEV1 decrease: 186 +/- 677 versus 571 +/- 708 ml) than the jet nebulizer. The mesylate salt tended to produce more side-effects than the isethionate, but the difference was not significant (FEV1 decreases: 439 +/- 688 ml and 295 +/- 756 ml respectively). We concluded that the best therapeutic procedure is to use pentamidine isethionate delivered by the ultrasonic nebulizer.

[Epidemiologic followup of cases of tuberculosis in the medical-social centers of Paris for the year 1994]. / Suivi épidémiologique des cas de tuberculose dans les centres médico-sociaux de Paris pour l'année 1994.

This study was carried out in 280 patients in 1994 in five medico-social centres (CMS) in the city of Paris for the follow up of treatment tuberculous disease. The group represented approximately one fifth of the tuberculous patients in Paris. 90.7% of the subjects were of foreign origin, predominantly African. Amongst these 280 patients, 80% were unemployed and 64.6% without social security protection. Their tuberculous disease did not differ on clinical grounds from those of the general population but they were less often vaccinated with BCG. They are also less often co-infected with the HIV virus (4.4 vs 12-16%). The level of resistance to isoniazid and rifampicin was 1.4%. A cure was certainly achieved in 73.5% of the patients. For the remainder, the absence of information and the loss to follow up prevented us from having a definite answer. The patients lost to follow numbered 56 and represented 20% of the group.

[Recent latent tuberculous infection (LTBI) in different sub-groups of contacts]. / L'infection tuberculeuse latente (ITL) récente chez les sujets contact.

Screening for latent tuberculous infection (LTBI) in contacts of identified cases of tuberculosis should be based on intention to treat. We know that only LTBI that is attributable to a recent transmission requires preventive treatment in immunocompetent adults. There is no current test that allows accurate dating of LTBI. The objective of this retrospective study with QuantiFERON-TB-Gold In-Tube (QFT) is to estimate the probability of recent LTBI in various groups of contacts. Among 2424 subjects included, 407 (17%) tests were positive; 129 (28%) within the family circle, 69 (19%) within the social environment, 153 (14%) among professional acquaintances and 56 (10%) within the school environment (respectively: OR=0.69 and P=0.04; OR=0.49 and P<0.001; OR=0.51 and P<0.001). After comparison with a basal rate of LTBI, professional and family contacts less than 40 years old, born in a country of incidence lower than 20, had a rate of recent LTBI between 15 and 40% and between 68 and 80%, respectively. For those born in a country of incidence greater than 20, we estimate the rate of recent LTBI between 6 and 18% for professional contacts and between 43 and 50% for family contacts. These results, although approximate and specific to Paris, are important for the clinician who has to decide on preventive treatment and for the public health specialist who has to identify groups of contacts. Finally, to limit the differences in rates of recent LTBI, it would probably be necessary to specify thresholds of accumulated contact time, according to the type of contact, before considering an individual as a contact.

Impact of a 14-year screening programme on tuberculosis transmission among the homeless in Paris.

OBJECTIVE: To evaluate the impact of an active case-finding programme on tuberculosis (TB) transmission in homeless shelters in Paris, France. DESIGN: Between 1994 and 1997, an active case-finding programme was implemented in homeless shelters using a mobile radiological screening unit, and continued from 1997 to 2007. During these periods, the strains isolated from TB cases diagnosed in the homeless were genotyped by restriction fragment length polymorphism analysis using the insertion sequence IS6110 as a probe. RESULTS: Between 1994 and 2007, 313 new TB cases were diagnosed among the homeless population: 179 through the programme among shelter users, and 134 among homeless people not using shelters. Half of the strains were clustered in 35 distinct patterns (2-48 cases/cluster). The clustering of TB cases steadily decreased in shelters during the 13 years of the survey, from 14.3 to 2.7 related cases per year (P < 0.01) and from 75% to 30% of related cases among all TB cases (P < 0.01). In contrast, there was only a slight trend towards a decrease in homeless people not using shelters. CONCLUSION: Active case finding in homeless shelters resulted in a decrease in case clustering, mainly in shelter users. Genotyping contributed to confirming the positive impact of the intervention.