Epidemiological evolution and economic impact of the COVID-19 pandemic in the European Union and worldwide and effects of control strategies on them: An ecological study.

OBJECTIVE: To evaluate the epidemiological evolution and economic impact of COVID-19 pandemic in the European Union (EU) and worldwide, and the effects of control strategies on them. MATERIAL AND METHODS: We collected incidence, mortality, and gross domestic product (GDP) data between the first quarter of 2020 and of 2023. Then, we reviewed the effectiveness of the mitigation and zero-COVID control strategies. The statistical analysis was done calculating the incidence rate ratio (IRR) of two rates and its 95% confidence interval (CI). RESULTS: In the EU, COVID-19 presented six epidemic waves. The sixth one at the beginning of 2022 was the biggest. Globally, the biggest wave occurred at the beginning of 2023. Highest mortality rates were observed in the EU during 2020-2021 and globally at the beginning of 2021. In mitigation countries, mortality was much higher than in zero-COVID countries (IRR=6.82 [95% CI: 6.14-7.60]; p<0.001). A GDP reduction was observed worldwide, except in Asia. None of the eight zero-COVID countries presented a GDP growth percentage lower than the EU percentage in 2020, and 3/8 in 2022 (p=0.054). COVID-19 pandemic caused epidemic waves with high mortality rates and a negative impact on GDP. CONCLUSION: The zero-COVID strategy was more effective in avoiding mortality and potentially had a lower impact on GDP in the first pandemic year.

Social and cultural factors behind community resistance during an Ebola outbreak in a village of the Guinean Forest region, February 2015: a field experience.

BACKGROUND: During the Ebola outbreak in Guinea, community resistance obstructed case investigation and response. We investigated a cluster of Ebola cases that were hiding in the forest, refusing external help, to identify sociocultural determinants related to community resistance. METHODS: Participant observation, interviews and focus group discussions were carried out. RESULTS: Most villagers feared the Ebola treatment centre (ETC) as there was the belief that people were killed in ETCs for organ trade. Four survivors accompanied back to the village from the ETC shared their experiences and reassured their neighbours. Subsequently, community compliance with contact tracing improved, leading to the timely detection of cases. CONCLUSIONS: Engaging Ebola virus disease survivors improved community compliance. Understanding the sociocultural context and community perceptions may improve community engagement and prevent Ebola virus transmission.

First secondary case of Ebola outside Africa: epidemiological characteristics and contact monitoring, Spain, September to November 2014.

On 6 October 2014, a case of Ebola virus disease (EVD) acquired outside Africa was detected in Madrid in a healthcare worker who had attended to a repatriated Spanish missionary and used proper personal protective equipment. The patient presented with fever <38.6 °C without other EVD-compatible symptoms in the days before diagnosis. No case of EVD was identified in the 232 contacts investigated. The experience has led to the modification of national protocols.

New times for migrants' health in Europe.

Patterns of migration can change greatly over time, with the size and composition of migrant populations reflecting both, current and historical patterns of migration flows. The recent economic crisis has caused a decrease on migration flows towards the most affected areas, as well as cut offs in health interventions addressed to migrants. The objective of this paper is to review available data about interventions on migrants' health in Europe, and to describe changes in migrant health policies across Europe after the economic crisis, that can have a negative effect in their health status. Although migrants have the right to health care under legal settlements issued by the EU, there is no a standard European approach to offer health care to migrants, since; policies in each EU Member State are developed according to specific migrant experience, political climate, and attitudes towards migration. Migrants use to face greater health problems and major health care access barriers, compared with their counterparts from the EU. Therefore, migrant health policies should focus in protects this vulnerable group, especially during economic hardship, taking into account economic and socio-demographic risk factors. There is an especial need for research in the cost-effectiveness of investing in the health care of the migrant population, demonstrating the benefit of such, even in the health of the European native population, and the need for constant intervention despite of resource constraints.

Chagas disease in European countries: the challenge of a surveillance system.

A study of aggregate data collected from the literature and official sources was undertaken to estimate expected and observed prevalence of Trypanosoma cruzi infection, annual incidence of congenital transmission and rate of underdiagnosis of Chagas disease among Latin American migrants in the nine European countries with the highest prevalence of Chagas disease. Formal and informal data sources were used to estimate the population from endemic countries resident in Europe in 2009, diagnosed cases of Chagas disease and births from mothers originating from endemic countries. By 2009, 4,290 cases had been diagnosed in Europe, compared with an estimated 68,000 to 122,000 expected cases. The expected prevalence was very high in undocumented migrants (on average 45% of total expected cases) while the observed prevalence rate was 1.3 cases per 1,000 resident migrants from endemic countries. An estimated 20 to 183 babies with congenital Chagas disease are born annually in the study countries. The annual incidence rate of congenital transmission per 1,000 pregnancies in women from endemic countries was between none and three cases. The index of under diagnosis of T. cruzi infection was between 94% and 96%. Chagas disease is a public health challenge in the studied European countries. Urgent measures need to be taken to detect new cases of congenital transmission and take care of the existing cases with a focus on migrants without legal residency permit and potential difficulty accessing care.

Utility of clinical-epidemiological profiles in outbreaks of foodborne disease, Catalonia, 2002 through 2006.

The objective of this study was to evaluate the use of clinical-epidemiological profiles for classifying non-laboratory-confirmed outbreaks of foodborne disease (FBD) in Catalonia between 2002 and 2006 and for elucidating associations among factors contributing to these outbreaks. A total of 275 nonfamily outbreaks were studied, of which 190 (69.1%) were laboratory confirmed and 85 (30.9%) were not. In 176 (92.6%) of laboratory-confirmed outbreaks and 69 (81.2%) of non-laboratory-confirmed outbreaks, information was obtained on contributing factors (P = 0.009). In 72% of non-laboratory-confirmed outbreaks, the etiology was assigned by using clinical-epidemiological profiles; thus, 93% of outbreaks eventually were associated with an etiology. In laboratory-confirmed outbreaks, poor personal hygiene was positively associated with norovirus (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.47 to 4.89; P = 0.0007) and negatively associated with Salmonella and Campylobacter (OR, 0.54; 95% CI, 0.33 to 0.89; P = 0.01), and an unsafe source was positively associated with Salmonella and Campylobacter (OR, 4.07; 95% CI, 1.72 to 10.09; P = 0.001) and negatively associated with norovirus (OR, 0.14; 95% CI, 0.04 to 0.58; P = 0.001). No differences were found among contributing factors associated with outbreaks with a laboratory-confirmed etiology and those associated with outbreaks with an etiology assigned according to the clinical-epidemiological profiles. Clinical-epidemiological profiles are useful for determining what prevention and control strategies are appropriate to the agents involved in each community and for designing outbreak investigations.

Usefulness of simulated cases for assessing pandemic influenza preparedness plans.

To evaluate compliance with preparedness plans, actors simulating avian influenza attended various hospital emergency departments and public health centres during the last quarter of 2007. Most centres (89%) did not respond correctly. The useful information obtained was sent to the medical and administrative staff who were responsible for the preparedness plans. Awareness of these errors and their rectification can lead to improvements in the response to any case of influenza with pandemic potential and in the capacity to combat any other emergent or re-emergent community infection.

Tuberculosis transmission patterns among Spanish-born and foreign-born populations in the city of Barcelona.

During a 2-year period (2003-2004), tuberculosis (TB) transmission in Barcelona and the factors related to transmission among the Spanish- and foreign-born populations were studied by molecular epidemiology. Data were obtained from TB cases and Conventional Contact Tracing registries and genotyping was performed using restriction fragment length polymorphism (RFLP)-IS6110 and MIRU12 as a secondary typing method. Of the 892 TB cases reported, 583 (65.3%) corresponded to Spanish-born and 309 (34.6%) to foreign-born. Six hundred and eighty-seven cases (77%) were confirmed by culture. RFLP typing of 463/687 (67.4%) isolates was performed, revealing 280 (60.5%) unique and 183 (39.5%) shared patterns, which were grouped into 65 clusters. Spanish-born individuals were significantly more clustered than foreign-born individuals (44.6% vs. 28.8%; p 0.016). Clustering in foreign-born individuals was associated with HIV (p 0.051, odds ratio = 3.1, 95% confidence interval 1-10.9) and alcohol abuse (p 0.022), whereas, in the Spanish-born individuals, clustering was associated with age in the range 21-50 years, (p 0.024). Of the total clusters, 36/65 (55.3%) included only Spanish-born patients, whereas 22/65 (33.8%) included individuals from both populations. In mixed clusters, the index case was Spanish-born in 53% and foreign-born in 47%. Among the foreign-born, 2.8% were ill on arrival, 30% developed TB within the first year and 50.3% developed TB within the first 2 years; 58.3% were from South America. In conclusion, half of the foreign-born TB patients developed the disease during the first 2 years after arrival, which, in most cases, was the result of endogenous reactivation. Recent TB transmission among Spanish-born and foreign-born populations, as well as bidirectional transmission between communities, contributed significantly to the burden of TB in Barcelona, suggesting the need to improve Public Health interventions in both populations.

Differential features of foodborne gastroenteritis outbreaks of known and unknown etiology.

Foodborne diseases (FBD) are a major cause of disease and death, but their etiologies are not always known. Factors associated with determination of the etiologic agent of FBD outbreaks reported to the Department of Health in Catalonia (Spain) during 2002 to 2005 were studied. For each outbreak, the year, number of persons affected, hospitalization, and availability of samples from patients, food handlers, and foods were collected. The delay between the date of onset of symptoms of the second case and the report to the surveillance unit was calculated. The relationship between explanatory variables and determination of the cause of each outbreak was studied by logistic regression. The causal agent was identified in 242 (73.3%) of 330 outbreaks. Factors associated with determining the etiologic agent of the outbreak in the univariate analysis were availability of samples from cases (odd ratio [OR] of 6.0, 95% confidence interval [CI] of 3.2 to 11.1), hospitalization (OR of 5.1, 95% CI of 2.6 to 11.1), availability of samples from food handlers (OR of 2.7, 95% CI of 1.6 to 4.5), size > or = 10 cases (OR of 2.2, 95% CI of 1.3 to 3.2), availability of samples from food (OR of 1.8, 95% CI of 1.1 to 3.0), and the last year (2005) of the study period (OR of 1.9, 95% CI of 1.0 to 3.6). In the multivariate analysis, hospitalization (adjusted OR of 5.1, 95% CI of 2.4 to 11.2), size > or = 10 cases (adjusted OR of 2.1, 95% CI of 1.2 to 3.7), and the year 2005 (OR of 2.1, 95% CI of 1.1 to 4.0) remained associated. Collection and processing of clinical samples from cases and appropriate laboratory diagnoses of all possible etiologies of FBD, including viruses, are very important. Efforts by physicians and public health services to coordinate and improve their activity in these areas may help provide more accurate knowledge concerning the etiologies of FBD outbreaks and lead to more effective preventive procedures.

Epidemiology of hepatitis A before and after the introduction of a universal vaccination programme in Catalonia, Spain.

A universal vaccination program for preadolescents, aged 12 years, with the hepatitis A + B vaccine was introduced in 1998 in Catalonia (Spain) with the aim of protecting the whole population against hepatitis A. The hepatitis A + B vaccine program replaced the hepatitis B vaccination program for preadolescent started in 1991. The impact of the hepatitis A + B vaccination program was studied by assessment of the trend of reported cases of hepatitis A. All cases of viral hepatitis reported from 1992 to 2006 were included in the study. To evaluate changes in the epidemiology of hepatitis A, two periods were considered: a prevaccination period (1992-1998) and a post-vaccination period (2001-2006). The ratios of the rates were calculated according to age and sex. The comparison of rates and proportions was made by calculation of the normal z statistic. A total of 7536 cases of viral hepatitis were reported, of which 4109 (54.52%) were hepatitis A. The incidence rate of hepatitis A fell from 5.44 per 100 000 person-years in the prevaccination period to 3.02 in the post-vaccination period. In males, the rate fell from 6.85 to 3.89 and in females from 4.10 to 2.18. The male-female ratio of incidence rates was lower in the post-vaccination period. In males the global decline of incidence rate was 43.26% and in females 46.96%. The greatest decline occurred in the 15 to 19 years age group in both sexes (79.1% in men and 78.34% in women) but declines in the 10-14 years age group were also very important (69.21% and 67.88%, respectively). In conclusion, hepatitis A incidence fell in Catalonia in the post-vaccination period in vaccinated adolescents and also in other unvaccinated groups who have benefited from the indirect effects of the vaccination program.

[Excess mortality due to tuberculosis and factors associated to death in and annual cohort of patients diagnosed of tuberculosis]. / Exceso de mortalidad por tuberculosis y factores asociados a la defunción en una cohorte anual de enfermos diagnosticados de tuberculosis.

OBJECTIVE: To calculate excess mortality in an annual cohort of tuberculosis patients and study the factors associated with death. MATERIAL AND METHOD: Cases of tuberculosis reported in Catalonia (May 1996-April 1997). Patients were classified as completed treatment/cured (compliant), non-compliant, failures, transfers out and deaths. Excess mortality was defined as the ratio actual deaths/expected deaths (according to general mortality figures for Catalonia, May 1996-April 1997). Factors associated with death were determined by a comparative study of variables (demographic, substance abuse, comorbidity, tuberculosis-related disease) in deaths after diagnosis and survivors. Time from diagnosis to death was recorded. RESULTS: Patients included: 2,085. Patients classified as: completed treatment/cured (compliant), 1,406 (67.43 %); noncompliant, 165 (7, 91%); failures, 5 (0.24%); transfers out, 25 (1.21%); deaths, 133 (6.38%), 28 of which occurred before diagnosis and 105 after diagnosis. Insufficient data in medical record for classification, 351 (16.83%) patients. Excess mortality: 5.98 (95% CI: 4.96-7.0). Factors associated with death: treatment with non-standardized guidelines, 46%; OR: 10.3 (6.2-17.4); HIV infection, 40%; OR: 13.0 (6.6-25.8); age greater than 64 years, 40%; OR: 14.6 (3.0-69.8); alcoholism, 25%; OR: 2.0 (1.1-3.6); neoplasm, 16%; OR: 3.9 (1.8-8.6; renal failure, 8%; OR: 10.1 (3.1-32.3). The shortest time from diagnosis to death was in patients with only one risk factor, except for HIV infection, where the time passed was the longest observed. CONCLUSIONS: We found substantial excess mortality in tuberculosis patients. Death was associated with the efficacy of treatment, HIV coinfection, advanced age, alcoholism and the coexistence of neoplasms or renal failure.

[Proteinuria and chronic renal failure in the coast of El Salvador: detection with low cost methods and associated factors]. / Proteinuria e insuficiencia renal crónica en la costa de El Salvador: detección con métodos de bajo costo y factores asociados.

OBJECTIVES: El Salvador has high mortality rates from chronic kidney disease (CKD). The actual prevalence and causes remain unknown and local resources are scarce. Previous studies have suggested very high prevalence in specific populations: adult male farmers living in the coastlands, with high frequency of pesticides exposure and alcohol consumption. This population has low incomes and poor healthcare accessibility. Our aim was to detect CKD cases in this population using proteinuria as an inexpensive initial screening, investigating associations with those characteristics and comparing them with another population from the midlands. METHODS: We performed a transversal study on volunteer men from both regions, taking into consideration the variables: age, farmer living, pesticides, exposure, alcohol consumption, medical past history, blood pressure level, glycemia and proteinuria in a random urine sample. Coastland men with proteinuria were additionally screened for CKD measuring hemoglobin and serum creatinine levels. Finally, we employed a logistic regression model, and Perason's Chi2 to investigate associations between those variables and the presence of proteinuria or CKD. RESULTS: We included 291 men from the coastlands and 62 from the midlands: 35 and 16% off the total male population from their respective communities. Proteinuria (table I) was found in 133 (45.7%) and 8 cases (12.9%). CKD was diagnosed in 37 (12.7%) coastland men (table III), with mean creatinine 2.64 +/- 2.5 mg/dl, hemoglobin 12.32 +/- 1.9 g/dl and 81.1% with proteinuria 15-30 mg/l. Only 14 (37.8%) out of those 37 CKD patients featured diabetes or hypertension, while the remaining (62.2%) did not appear to have a clear-cut cause for CKD. Only one of them was formerly diagnosed with CKD. Farmer living, pesticides exposure and alcohol consumption were found to be very common characteristics in both populations, and were not associated to the presence of proteinuria or CKD (table II and III) DISCUSSION: The prevalence of CKD within the adult male farmers from the Salvadoran coastlands is remarkably high: at least 12.7%. There is a large number of undiagnosed cases, but they can be easily detected with inexpensive methods. This high prevalence is not completely explained by usual CKD causes like diabetes or hypertension. In addition, pesticides exposure and alcohol consumption may not be related, too. The disease is moderate, non symptomatic and has fairly mild proteinuria, possibly from interstitial origin. Further research is required to investigate environmental, occupational and hereditary factors, and to determine the real extent of the problem.

Characteristics of tuberculosis patients with positive sputum smear in Catalonia, Spain.

BACKGROUND: Patients with positive sputum smears are those with the capacity to spread infection. The objective of this study was to describe the incidence of tuberculosis in Catalonia (an autonomous community in the northeast of Spain which includes Barcelona) and to determine risk factors associated to patients with positive sputum smear test. METHODS: New cases of tuberculosis detected by active surveillance between May 1996 and April 1997 were studied. The study was analysed as a coincident cases and controls study. The rate of incidence was calculated per 100,000 persons-year. The association of the dependent variable--case of tuberculosis with positive sputum smear--with the remainder of independent variables was determined by odds ratio (OR) with a 95% confidence interval (CI). RESULTS: A total of 2508 cases of tuberculosis were detected. The rate of incidence was 41.4 per 100,000 persons-year. Of these 19.4% (487/2508) were coinfected with HIV and 35.6% (893/2508) presented a positive sputum smear, which implies a rate of 14.7 per 100,000 persons-year. In an adjusted multivariate analysis, cases with positive smears were positively associated with the 15-24 (OR=1.9; 95% CI: 1.4-2.4), 25-34 (OR=2.1; 95% CI: 1.7-2.7) and 35-44 years (OR=1.7; 95% CI: 1.3-2.2) age compared with persons 45 years old and above; with males (OR=1.8; 95% CI: 1.5-2.2) and consumers of alcohol (OR=2.1; 95% CI: 1.7-2.7) and negatively with those under 15 years of age (OR=0.1; 95% CI: 0.1-0.2) and coinfection with HIV (OR=0.5; 95% CI: 0.3-0.7). CONCLUSIONS: Measures to control tuberculosis transmission (prompt diagnosis, study of contacts and directly observed treatments) should be reinforced for male adults with excessive consumption of alcohol.

Tuberculosis screening among immigrants holding a hunger strike in churches.

SETTING: In January 2001, approximately 600 immigrants held a sit-down and hunger strike in several churches in Barcelona to force the Spanish government to comply with demands to regulate their immigration status. Following the diagnosis of a case of smear-positive pulmonary tuberculosis (TB) in one of the immigrants, we performed a large contact investigation. OBJECTIVES: To describe contact investigation procedures used in this setting and to evaluate contact investigation results. METHODS: Demographic variables were collected, and tuberculin skin tests (TST) and chest radiograph examinations were performed. Odds ratios (OR) with 95% confidence intervals (CI) were calculated and logistic regression was used for multivariate analyses. RESULTS: A total of 541 TSTs were performed. Of these, 86% were read and 40.5% yielded a positive reaction with an induration >14 mm. In a multivariate analysis, the risk of presenting a TST induration >14 mm was found to be three times higher among those aged >35 years compared to those <24 years (OR 3.40; 95%CI 1.76-6.59), and for immigrants from Bangladesh (OR 3.14; 95%CI 1.16-6.10) and Pakistan (OR 2.04; 95%CI 1.11-3.73) compared to those from India. A total of 314 chest radiographs examinations were performed and three additional cases of TB were identified, yielding a TB prevalence of 0.7%. CONCLUSIONS: By focusing efforts and conducting targeted TB screening in this high-risk population, it was possible to complete the intervention in only 3 days. A high prevalence of TB infection and TB disease was found.

An outbreak of Legionnaires' disease in an inner city district: importance of the first 24 hours in the investigation.

OBJECTIVE: To present the main results of the investigation of an outbreak of Legionnaire's disease that occurred in an inner city district of Barcelona between 15 October and 15 November 2000. METHODS: Epidemiological surveys of patients and environmental investigations were initiated on the day the first five cases were notified. Water samples and smears from cooling tower trays were taken for microbiological analysis. Maps of the distribution of cases and possible contamination foci were elaborated. Incidences were calculated for each census tract. RESULTS: A total of 54 patients related to the outbreak were identified, with a case fatality rate of 5.5%. Incidence rate in the area closest to the cooling tower (6.40/1000) was significantly higher than that of the rest of the neighbourhood (2.23/1.000, RR 2.87, 95%CI 1.37-6.12, P = 0.0035). Cultures positive for Legionella pneumophila serogroup 1, subtypes Pontiac, Philadelphia or Allentown, were obtained from eight patients. On the 39th day of the investigation it was found that the strain isolated in one of the cooling towers coincided with the serogroup, subtype and molecular profiles identified in clinical samples. CONCLUSIONS: Rapid coordination of clinicians, microbiologists, epidemiologists and environmentalists permitted the source of infection and the affected cases to be correlated within a few days.

[Tuberculin test responses of tuberculosis patients]. / La respuesta a la prueba de la tuberculina en enfermos tuberculosos.

OBJECTIVE: To determine the response of tuberculosis patients to tuberculin skin tests. METHOD: The results of skin tests used for initial assessment of tuberculosis patients in Catalonia were reviewed (Multicenter Tuberculosis Research Project). Negative skin tests were those with indurations < 5 mm; positive tests were those with indurations measuring > or = 5 mm. Individuals were classed as having or not having risk factors for developing tuberculosis and those without risk factors were classified by age, location and extension of tuberculosis. RESULTS: Negative skin tests were seen in 1,566 patients (23%). Negative tests were more common in patients with risk factors, significantly so in those undergoing immunosuppressant therapy (50%) or with HIV infection (61%). Negative tests were less prevalent in patients with no risk factors (13%) and, among them, in children (1%), in patients between 15 and 29 years of age (10%) or in those with non-pulmonary forms (10%). Negative tests were significantly more prevalent among patients 60 to 74 years of age (27%), those over 74 (44%), and those whose disease was pulmonary and extrapulmonary (26%) or disseminated (64%). No significant differences in induration size of positive skin tests were observed for patients with and without risk factors (including HIV infection or non-infection). A normal distribution of induration size was observed in all groups. CONCLUSIONS: A negative tuberculin skin test for initial assessment should be interpreted in function of the presence or absence of risk factors, age, location or extension of tuberculosis. When a skin test is positive, the response will be similar whether or not an immunodepressant factor is present.

Influence of highly active anti-retroviral therapy (HAART) on the natural history of extra-pulmonary tuberculosis in HIV patients.

OBJECTIVE: To determine factors related to survival in acquired immune-deficiency syndrome (AIDS) patients with extra-pulmonary tuberculosis (EPTB), when this condition is the first AIDS-defining disease. DESIGN: A retrospective cohort-study of 549 AIDS patients with EPTB as the first AIDS-defining disease. Potential candidates to predict survival were sex, human immunodeficiency virus (HIV) exposure, the coexistence of pulmonary and EPTB at diagnosis, tuberculin skin test, directly observed therapy for tuberculosis (DOT), and highly active anti-retroviral therapy (HAART). The Kaplan-Meier method and Cox regression models were used to assess factors associated with survival. RESULTS: Estimated 3-year survival was 47.0% for those diagnosed before 1993, 72.6% for patients with first AIDS diagnosis during 1995-1996 and 84.6% for those diagnosed after 1996. A negative tuberculin test (hazard ratio [HR] = 1.6, 95% CI 1.1-2.3), not being on DOT (HR 2.2; 95% CI 1.3-3.7) and having pulmonary tuberculosis involvement also (HR 1.3; 95% CI 1.1-1.7) were independently associated with poorer survival. The survival of patients significantly improved after the introduction of HAART (HR 0.4; 95% CI 0.2-0.6). CONCLUSION: The survival of HIV patients with EPTB as their first AIDS-defining disease has substantially improved during the last decade. A negative tuberculin skin test and not receiving DOT are associated with poorer survival among HIV-infected patients whose first AIDS-defining disease is EPTB.

Effectiveness of tuberculosis control programmes in prisons, Barcelona 1987-2000.

SETTING: Different bodies have emphasised the need for prisons to implement and evaluate their own tuberculosis prevention and control programmes (TPCP), with the aims of evaluating TPCP in Barcelona prisons and obtaining conclusions that would allow any necessary modifications to be introduced to improve their effectiveness. METHODS: An assessment was carried out for the period 1987-2000, using the exhaustive retrospective method. The quantitative indicators used were defined in the same way as those employed by the Barcelona TPCP, which were taken as the gold standard. The assessment studied trends in the indicators and evaluated the impact by comparing the results with the gold standard. RESULTS: Statistically significant trends (P < 0.0001) were found for incidence rates, infection prevalence, treatment adherence rates among smear-positive cases and percentage of cases on directly observed treatment (DOT). When impact was assessed, only the decline in the average annual incidence rate (25.2%) and desired rates of adherence among smear-positives (> or = 95% since 1993) achieved the proposed objectives. CONCLUSIONS: The observed decline in incidence shows that when programmes are based on reducing diagnostic delay, controlling adherence using DOT and tracing contacts, tuberculosis control among the prisons is effective.