Decline of tuberculosis notification rate in different populations and regions in Portugal, 2010-2017.

BACKGROUND: Tuberculosis (TB) incidence declined in Portugal in recent decades, but trends differ between regions and population subgroups. We investigated these differences to inform prevention and control programmes. METHODS: We extracted TB notifications from the Portuguese National TB Surveillance System (SVIG-TB) in 2010-2017, disaggregated by region, age group, nationality and HIV status. We calculated notification rates using denominators from the Portuguese National Institute of Statistics and the Joint United Nations Programme on HIV/AIDS and performed stratified time series analysis. We estimated interannual decline percentages and 95% confidence intervals (CI) using Poisson and binomial negative regression models. RESULTS: The overall TB notification rate decreased from 25.7 to 17.5/100,000 population from 2010 to 2017 (5.2%/year) in Portugal. Interannual decline did not differ significantly between regions, but it was smaller amongst non-Portuguese nationals (-1.57% [CI: -4.79%, 1.75%] vs -5.85% [CI: -6.98%, -4.70%] in Portuguese nationals); children under five years of age (+1.77% [CI: -4.61%, 8.58%] vs -5.38% [CI: -6.33%, -4.42%] in other age groups); and HIV-negative people (-6.47% [CI: -9.10%, -3.77%] vs -11.29% [CI; -17.51%, -4.60%] in HIV-positive). CONCLUSIONS: The decline in TB notification rates in Portugal during the study period has been steady. However, the decline amongst non-Portuguese nationals, children under five years of age and non-infected-HIV patients was lower. No significant differences were observed between regions. Changes in TB epidemiology in specific risk groups and geographical areas should be closely monitored to achieve the objectives of the End TB Strategy. We recommend intensifying screening of TB in the subpopulations identified.

A new health care index predicts short term mortality for TB and HIV co-infected people.

BACKGROUND: Using 2004-2007 TB:HIV Study data from Europe and Latin America, we previously generated a health care index (HCI) for TB and HIV co-infected people. With improvements in diagnostic and management practices, we have now updated the HCI with new data.METHODS: We evaluated nine aspects of health care in Cox proportional hazards models on time from TB diagnosis to death. Kaplan-Meier methods were used to estimate the probability of death by HCI quartile.RESULTS: Of 1396 eligible individuals (72% male, 59% from Eastern Europe), 269 died within 12 months. Use of rifamycin/isoniazid/pyrazinamide-based treatment (HR 0.67, 95% CI 0.50-0.89), TB drug susceptibility testing (DST) and number of active TB drugs (DST + <3 drugs (HR 1.09, 95% CI 0.80-1.48), DST + ≥3 drugs (HR 0.49, 95% CI 0.35-0.70) vs. no DST), recent HIV-RNA measurement (HR 0.64, 95% CI 0.50-0.82) and combination antiretroviral therapy use (HR 0.72, 95% CI 0.53-0.97) were associated with mortality. These factors contributed respectively 5, -1, 8, 5 and 4 to the HCI. Lower HCI was associated with an increased probability of death; 30% (95% CI 26-35) vs. 9% (95% CI 6-13) in the lowest vs. the highest quartile.CONCLUSION: We found five potentially modifiable health care components that were associated with mortality among TB-HIV positive individuals. Validation of our HCI in other TB cohorts could enhance our findings.

[Contact tracing in patients infected with SARS-CoV-2. The fundamental role of Primary Health Care and Public Health]. / Estudio de contactos en infectados por SARS-CoV-2. El papel fundamental de la Atención Primaria y de la Salud Pública.

The aim of this study was to promote the rapid identification of the contacts of patients infected with SARS-CoV-2 and therefore the control of the pandemic. Different methodologies and recommendations on contact tracing for Primary Health Care (PHC) and Public Health Services (PHS), like articles in Pubmed about COVID-19 and contact tracing, official contact definitions, the classic contact tracing model in tuberculosis (TB), information about apps for contact tracing and the role of the diagnostic tests, were reviewed. To establish efficient prevention and control measures, it is always necessary to implement contact tracing based on clinical suspicion, early diagnosis and isolation of cases and contacts and their follow-up. The classic contact tracing model in TB can be applied to this new infection, but accelerating the process given its acute nature and its potential severity. Good coordination between PHC and PHS and having sufficient resources is essential.

Hospital-acquired influenza infections detected by a surveillance system over six seasons, from 2010/2011 to 2015/2016.

BACKGROUND: In addition to outbreaks of nosocomial influenza, sporadic nosocomial influenza infections also occur but are generally not reported in the literature. This study aimed to determine the epidemiologic characteristics of cases of nosocomial influenza compared with the remaining severe cases of severe influenza in acute hospitals in Catalonia (Spain) which were identified by surveillance. METHODS: An observational case-case epidemiological study was carried out in patients aged ≥18 years from Catalan 12 hospitals between 2010 and 2016. For each laboratory-confirmed influenza case (nosocomial or not) we collected demographic, virological and clinical characteristics. We defined patients with nosocomial influenza as those admitted to a hospital for a reason other than acute respiratory infection in whom ILI symptoms developed ≥48 h after admission and influenza virus infection was confirmed using RT-PCR. Mixed-effects regression was used to estimate the crude and adjusted OR. RESULTS: One thousand seven hundred twenty-two hospitalized patients with severe laboratory-confirmed influenza virus infection were included: 96 (5.6%) were classified as nosocomial influenza and more frequently had > 14 days of hospital stay (42.7% vs. 27.7%, P < .001) and higher mortality (18.8% vs. 12.6%, P < .02). The variables associated with nosocomial influenza cases in acute-care hospital settings were chronic renal disease (aOR 2.44 95% CI 1.44-4.15) and immunodeficiency (aOR 1.79 95% CI 1.04-3.06). CONCLUSIONS: Nosocomial infections are a recurring problem associated with high rates of chronic diseases and death. These findings underline the need for adherence to infection control guidelines.

Is it possible to eliminate hepatitis C from the prisons of Catalonia, Spain, in 2021?

AIM: Predict the elimination of chronic hepatitis C in Catalan prisons. MATERIAL AND METHOD: We analyzed the trend of the prevalence of HCV-RNA and anti-hepatitis C treatments prescribed in Catalonia in the period 2002-2016. Using linear exponential smoothing from the historical values in the time series, we estimate the time required to eliminate hepatitis C as a public health problem in prisons (prevalence of hepatitis C virus RNA<1%). RESULTS: A total of 1264 treatments were administered by 12/31/2016. The prevalence of hepatitis C virus RNA was 31.2% in 2002, decreasing to 8.81% in 2016. We estimate that prevalence will reach 0-0.5% in 5 years (second half 2021; 95% CI: 2019-2025). DISCUSSION: Appropriate actions can eliminate hepatitis C infection in prisoners. We estimate that by 2021 hepatitis C infection will no longer be a public health problem in Catalonia prisons.

Impact of socio-economic inequities on tuberculosis in a Southern European city: what is the effect of the recession?

INTRODUCTION: Economic crises affect a population's health, particularly among the most deprived. The increase in health inequalities in the latest recession may have influenced the incidence of tuberculosis (TB). We analysed the effect of socio-economic inequities and recession on TB incidence in Barcelona, Spain. METHODS: We conducted a population-based incidence study of TB cases in Barcelona of patients who started treatment between 2003 and 2015. A multilevel interrupted time-series analysis was performed to analyse differences in incidence trends between the pre-recession (until 2008) and recession periods. RESULTS: We found differences in TB incidence according to deprivation and immigration status. TB incidence among the most deprived neighbourhoods was 2.72 times higher than the least deprived neighbourhoods. Compared with native-born persons, incidence was nine times higher among those born in Africa, and six times higher among those born in Asia and Oceania. The previous decreasing trend in incidence (4%) was accentuated during the recession (7%). CONCLUSIONS: TB incidence decreased during the recession, probably due to a reduction in the number of new immigrants and the TB programme. However, incidence was highly unequal between districts with different levels of deprivation, and between foreign-born persons from different geographic regions. Social measures are important to reduce inequalities and TB incidence in Barcelona.

Capture-recapture and anti-tuberculosis drug prescriptions, Balearic Islands, Spain, 2010-2012.

SETTING: Tuberculosis (TB) control requires accurate knowledge of TB incidence, but few studies have been published on TB incidence using individual data from drug prescriptions. OBJECTIVE: To measure the estimated completeness of regional surveillance system data before and after adding data from anti-tuberculosis drug prescriptions. DESIGN: We compiled data on all individuals who received specific anti-tuberculosis drugs from three sources-the passive surveillance system, the active surveillance system and the anti-tuberculosis drug prescription database-in the Balearic Islands, Spain, between 2010 and 2012. We applied the capture-recapture method to measure completeness of data reporting. Statistical significance was set at P < 0.05, and 95% confidence intervals (CIs) were calculated. RESULTS: We detected 605 incident cases, compared with an estimated incidence of 719 cases (95%CI 646-793), representing 84.1% data completeness. We detected 480 of an estimated 559 pulmonary TB cases (95%CI 501-617; 85.9% data completeness) and 125 of an estimated 161 extra-pulmonary TB cases (95%CI 113-211; 77.6% data completeness). CONCLUSIONS: By adding a new source, we increased detection with respect to a previous study by 10.4% for all forms of TB, 9.7% for pulmonary TB and 13% for extra-pulmonary TB.

Effectiveness of antiviral treatment in preventing death in severe hospitalised influenza cases over six seasons.

We investigated the predictors of neuraminidase inhibitor (NAI) treatment in severe hospitalised influenza cases and the association between antiviral treatment and mortality. An observational epidemiological study was carried out in Catalonia (Spain) during 2010-2016 in patients aged ⩾18 years. Severe hospitalised cases of laboratory-confirmed influenza requiring hospitalisation were included. We collected demographic, virological and clinical characteristics. Mixed-effects logistic regression was used to estimate crude and adjusted odds ratio (aOR). We included 1727 hospitalised patients, of whom 1577 (91.3%) received NAI. Receiving NAI ⩽48 h after onset of clinical symptoms (aOR 0.37, 95% confidence interval (CI) 0.22-0.63), ⩽3 days (aOR 0.49, 95% CI 0.30-0.79) and ⩽5 days (aOR 0.50, 95% CI 0.32-0.79) was associated with a reduction in deaths. In patients admitted to the intensive care unit (ICU) (595; 34.5%), treatment ⩽48 h (aOR 0.32, 95% CI 0.14-0.74), ⩽3 days (aOR 0.44, 95% CI 0.20-0.97) and ⩽5 days (aOR 0.45, 95% CI 0.22-0.96) was associated with a reduction in deaths. Receiving treatment >5 days after onset of clinical symptoms was not associated with the reduction in deaths in hospitalised patients or those admitted to the ICU. NAI treatment of hospitalised patients with severe confirmed influenza was effective in avoiding death, mainly when administered ⩽48 h after symptom onset, but also when no more than 5 days had elapsed.

Management of MDR-TB in HIV co-infected patients in Eastern Europe: Results from the TB:HIV study.

OBJECTIVES: Mortality among HIV patients with tuberculosis (TB) remains high in Eastern Europe (EE), but details of TB and HIV management remain scarce. METHODS: In this prospective study, we describe the TB treatment regimens of patients with multi-drug resistant (MDR) TB and use of antiretroviral therapy (ART). RESULTS: A total of 105 HIV-positive patients had MDR-TB (including 33 with extensive drug resistance) and 130 pan-susceptible TB. Adequate initial TB treatment was provided for 8% of patients with MDR-TB compared with 80% of those with pan-susceptible TB. By twelve months, an estimated 57.3% (95%CI 41.5-74.1) of MDR-TB patients had started adequate treatment. While 67% received ART, HIV-RNA suppression was demonstrated in only 23%. CONCLUSIONS: Our results show that internationally recommended MDR-TB treatment regimens were infrequently used and that ART use and viral suppression was well below the target of 90%, reflecting the challenging patient population and the environment in which health care is provided. Urgent improvement of management of patients with TB/HIV in EE, in particular for those with MDR-TB, is needed and includes widespread access to rapid TB diagnostics, better access to and use of second-line TB drugs, timely ART initiation with viral load monitoring, and integration of TB/HIV care.

Tuberculosis in recipients of solid-organ transplants during 1995-2015 in Cali, Colombia.

SETTING: Tuberculosis (TB) in solid-organ transplants (SOTs) is an important opportunistic infection associated with mortality and graft loss. SOT recipients carry a higher risk of contracting active TB than the general population. Clinical and radiographic presentations are non-specific, and sputum smear and culture have low yields. TB patients with SOTs require standard anti-tuberculosis treatment. However, rifampicin (RMP) use is associated with a 30% rate of acute graft rejection (AGR) and a 20% rate of transplant loss. OBJECTIVE: To determine treatment outcomes in SOT recipients with active TB. DESIGN: A retrospective study of clinical and microbiological data and TB treatment outcomes. RESULTS: Among the 2349 transplants assessed, active TB was detected in 31 recipients; 55% had pulmonary TB and 40% were sputum smear-positive. In 32% of the patients, TB was diagnosed 30 days after symptom onset, 77% of the patients were cured and 10% died. AGR occurred in 13%. CONCLUSION: TB was diagnosed in <30 days. Anti-tuberculosis treatment without RMP (80% vs. 67%; P = 0.48, OR 0.5, 95%CI 0.07-3.55) and with moxifloxacin yielded higher treatment success rates and a lower risk of AGR.

Tuberculosis clinical units improve contact tracing.

INTRODUCTION: The Barcelona Tuberculosis Programme was established in 1987, and in 2007 five tuberculosis (TB) clinical units were created to improve the follow-up of cases and contacts. This included the designation of a nurse for case management. OBJECTIVE: To assess the impact of the TB clinical units on the screening programme for TB contacts. METHODS: Before-after population-based study before (2003-2007) and after (2008-2013) the creation of the clinical units. To determine which factors were related to contact tracing, we fitted a multivariate logistic regression model to estimate odds ratios (OR) with their 95% confidence intervals (CIs). RESULTS: Following the creation of the clinical units, the proportion of prescriptions for latent tuberculous infection among contacts in the clinical units increased from 40.7% to 57.4% (P < 0.001), and treatment adherence from 75.9% to 80.3% (P = 0.035). One factor associated with contact tracing was receiving care after the creation of the clinical units (2008-2013) (OR 1.2, 95%CI 1.0-1.3). During the second period, receiving care outside the clinical units reduced the probability of contact tracing (OR 0.7, 95%CI 0.5-0.9). CONCLUSION: The creation of the TB clinical units represents an organisational improvement for the study and management of contacts of patients with TB.

Factors associated with diabetes mellitus among adults with tuberculosis in a large European city, 2000-2013.

BACKGROUND: Diabetes mellitus (DM) can contribute to the development of tuberculosis (TB). OBJECTIVE: To analyse the prevalence of DM and its associated factors among adults with TB in a large city in an industrialised country. METHODS: This is a population-based study in adults diagnosed with TB between 2000 and 2013 in Barcelona. We studied potentially associated sociodemographic and clinical/epidemiological factors. Logistic regression was used to calculate odds ratios (ORs) and their 95% confidence intervals (CIs). RESULTS: Of 5849 TB patients, 349 (5.9%) had DM. The annual prevalence of DM ranged from 4.0% to 7.2%. Factors associated with DM were being Spanish-born (OR 1.46, 95%CI 1.11-1.96), age ⩾40 years (OR 6.08, 95%CI 4.36-8.66), cavitary patterns on chest X-ray (OR 1.42, 95%CI 1.08-1.86), experiencing more side effects due to anti-tuberculosis treatment (OR 1.86, 95%CI 1.28-2.64) and hospitalisation at the time of diagnosis (OR 1.8, 95%CI 1.40-2.31). Human immunodeficiency virus infection was associated with a lower probability of DM in both subjects with a history of injection drug use (OR 0.27, 95%CI 0.10-0.57) and those without (OR 0.04, 95%CI 0.002-0.19). CONCLUSIONS: DM prevalence among adults with TB in Barcelona is low and remained stable over the 14-year study period. However, TB patients with DM were potentially more infectious and their clinical management was more complicated.

Lymphogranuloma venereum in Barcelona, 2007-2012: the role of seroadaptation in men who have sex with men.

This study describes the incidence rate of reported lymphogranuloma venereum (LGV) in men who have sex with men (MSM) in Barcelona from 2007 to 2012. Epidemiological, clinical and sexual behaviour characteristics of LGV cases are described. Seroadaptive behaviours as a transmission risk factor were assessed by a telephone questionnaire during 2012. Data were handled on a strictly confidential basis. LGV annual rate ratios in MSM were compared with cases from 2007. Differences were statistically analysed with a Poisson test. The incidence rate of LGV in MSM aged 15-69 years ranged from 32·1/105 MSM per year in 2007 to 182·7/105 MSM per year in 2012. In 2012, 31/51 LGV cases (61%) answered the telephone questionnaire, of which 84% (26/31) were HIV positive, 39% (12/31) reported having sex according to their partners' serostatus and 7% (2/31) used strategic positioning. The incidence of LGV has increased since 2007 and mainly affects HIV-positive MSM. It is probable that seroadaptation has facilitated LGV transmission.

Screening for active tuberculosis in high-risk groups.

OBJECTIVE: To evaluate an active case-finding strategy among drug users (DUs), economically disadvantaged individuals and recent immigrants from hyperendemic countries, a population at high risk of developing tuberculosis (TB). METHODS: Retrospective, observational study carried out by the Tuberculosis Unit of the City of Barcelona from September 2009 to December 2012. All participants underwent chest X-ray and were screened for symptoms. RESULTS: Of 5982 participants screened, 30 TB cases were detected (total prevalence 0.5%): 26 were pulmonary, 8 were smear-positive and 2 were resistant to multiple drugs. Directly observed treatment was advised for 19 patients (63%). TB prevalence in the recent immigrants group was significantly greater (1.77%) than in all other groups studied: economically disadvantaged individuals 0.30% (RR 5.9, 95%CI 2.30-15.14); DUs 0.62% (RR 2.05, 95%CI 0.91-4.64), non-recent immigrants 0.41% (RR 4.31, 95%CI 1.68-11.4); and all native-born individuals 0.41% (RR 4.33, 95%CI 1.71-10.92). The rate was much greater than the estimated prevalence for the general population of the city (∼20 cases/100,000 population). CONCLUSIONS: In high-risk groups, active case finding can be used as a public health intervention to detect a large number of TB cases.

Epidemiology of tuberculosis in big cities of the European Union and European Economic Area countries.

This cross-sectional survey aimed to examine the epidemiology of tuberculosis (TB) in European Union (EU) and European Economic Area (EEA) cities with populations greater than 500,000. National TB programme managers were asked to provide data on big city population size, total number of notified TB cases in big cities and national notification rate for 2009. A rate ratio was calculated using the big city TB notification rate as a numerator and country TB notification rate, excluding big city TB cases and population, as a denominator. Twenty of the 30 EU/EEA countries had at least one big city. Pooled rate ratios were 2.5, 1.0, and 0.7 in low-, intermediate- and high-incidence countries respectively. In 15 big cities, all in low-incidence countries, rate ratios were twice the national notification rate. These data illustrate the TB epidemiology transition, a situation whereby TB disease concentrates in big cities as national incidence falls, most likely as a result of the higher concentration of risk groups found there. This situation requires targeted interventions and we recommend that big city TB data, including information about patients' risk factors, are collected and analysed systematically, and that successful interventions are shared.

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.

Monitoring changes in anti-tuberculosis treatment: associated factors determined at the time of diagnosis.

OBJECTIVES: To determine predictive factors for changes in standard anti-tuberculosis chemotherapy at the time of diagnosis. METHODS: A prospective study was performed among tuberculosis (TB) patients treated at specialised centres during 2008-2009. Treatment outcome was monitored per standard guidelines. Treatment was considered successful if the patient was cured or completed treatment. Factors associated with treatment modification were analysed at the bivariate and multivariate levels using logistic regression. RESULTS: A total of 427 patients were included in the study. The initial standard treatment regimen was retained for 249 patients (58.3%), extended to 9 months for 36 (8.4%) and changed for 142 (33.3%). Factors associated with a change of regimen at the multivariate level were female sex, age ≥ 50 years, human immunodeficiency virus infection, comorbidities, alcoholism, hospitalisation and culture-positive sputum. Drug resistance and toxicity were analysed independently. Treatment outcome was successful in 97.2% of cases without a regimen change and in 87.3% of those with a changed regimen (P < 0.001). CONCLUSION: Factors associated with changes in the initial anti-tuberculosis regimen should be considered for rigorous follow-up. Results obtained through individualised treatment provided by specialists were good despite the complexity of the cases treated.

Smoking in tuberculosis patients increases the risk of infection in their contacts.

OBJECTIVE: To determine the risk of latent tuberculous infection (LTBI) among contacts of smokers with tuberculosis (TB). METHODS: A study was conducted to determine the prevalence of LTBI among contacts of TB cases aged >14 years in Catalonia, Spain. A survey was carried out for each TB case and their contacts. LTBI was diagnosed using the tuberculin skin test (≥5 mm). The risk of LTBI associated with smoking was determined by multi-variate logistic regression analysis, with adjusted odds ratio (aOR) and their 95% confidence intervals (CI). RESULTS: The smoking prevalence among TB cases was 40.7% (439/1079). The prevalence of LTBI among their contacts was 29.7% (2281/7673). It was higher among contacts of smoking index cases (35.3%) than among those of non-smokers (25.7%). Smoking was independently associated with an increased risk of LTBI among contacts (aOR 1.5, 95%CI 1.3-1.7), and was estimated to be responsible for 12.8% of infections. CONCLUSIONS: Index case smoking increases the risk of LTBI and should be systematically investigated. A reduction in smoking could lower the risk of infection substantially.