The Challenges of Tuberculosis Management beyond Professional Competence: Insights from Tuberculosis Outbreaks among Ethiopian Immigrants in Israel.

Controlling tuberculosis (TB) among immigrants from high-incidence countries presents a public health concern as well as a medical challenge. In this article, we investigate a TB outbreak in a community of people of Jewish descent who emigrated from Ethiopia to Israel (Israeli Ethiopians) that started in June 2022. The index case was a 20-year-old female who had recently immigrated to Israel with her family. Her pre-immigration tuberculin skin test was positive. After excluding active TB, treatment with daily isoniazid for latent TB (LTB) was started shortly after her arrival. A year later, she was diagnosed with smear-positive, culture-positive, pulmonary TB. Investigation of 83 contacts revealed five additional patients with active TB, and three of whom were members were of her household. In this article, we report the current TB outbreak, review previously published TB outbreaks involving Israeli Ethiopians, analyze the factors that triggered each of these outbreaks, and discuss the challenges that face the Israeli TB control program in an era of declining TB incidence and diminishing resources available for TB control.

Latent Tuberculosis Treatment among Hard-to-Reach Ethiopian Immigrants: Nurse-Managed Directly Observed versus Self-Administered Isoniazid Therapy.

BACKGROUND: The treatment of latent tuberculosis infection (LTBI) among high-risk populations is an essential component of Tuberculosis (TB) elimination. However, non-compliance with LTBI treatment remains a major obstacle hindering TB elimination efforts. We have previously reported high treatment compliance with nurse-managed, twice-weekly, directly observed Isoniazid treatment (DOT) for LTBI among hard-to-reach Ethiopian immigrants (EI's). OBJECTIVES: to compare rate of completion of treatment, cost, and major adverse drug events with daily self-administered Isoniazid treatment (SAT) to nurse-managed Isoniazid DOT among hard-to-reach EIs. MATERIALS AND METHODS: We conducted a retrospective study and compared self-administered LTBI treatment outcomes among EIs housed in reception centers during 2008-2012 to EIs treated with DOT. RESULTS: Overall, 455 EIs were included (231 DOT, 224 SAT) in the study. We found no significant difference in treatment completion rates between the two groups (93.0% DOT vs. 87.9% SAT, p = 0.08). However, cases of grade III, drug-induced hepatitis were significantly fewer and treatment costs were significantly lower with the nurse-managed DOT compared with SAT (0% vs. 2.2%, p = 0.028, 363 vs. 521 United States Dollars, p < 0.001, respectively). CONCLUSIONS: Nurse-managed, twice-weekly DOT among hard-to-reach EIs housed in reception centers had less severe drug-related adverse events and reduced treatment cost compared with daily isoniazid SAT, yet we found no significant difference in treatment completion between the two strategies in this population.

An 80-year-old man with a right upper lobe opacity.

BACKGROUND AND AIMS: The differential diagnosis of a right upper lobe pulmonary opacity in an elderly afebrile patient includes infectious and malignant etiology. However, unilateral lung edema should also be included in the differential diagnosis. METHODS: Case report of an 80-year-old afebrile patient who presented with cough, dyspnea and blood-tinged sputum and had an isolated right upper lobe infiltrate on chest X-ray on whom a diagnostic work-up including computed tomography scan of the chest and echocardiography was performed. RESULTS: Bilateral alveolar opacities and pleural effusions, not apparent on the chest X-ray, and a flail posterior leaflet with severe mitral valve regurgitation were revealed. His symptoms and findings responded to diuretic treatment. CONCLUSION: Pulmonary edema should be considered in a patient with mitral valve regurgitation presenting with a unilateral lung infiltrate. Chest computed tomography scan findings consistent with heart failure and echocardiography demonstrating mitral valve regurgitation are the main clues to the diagnosis. Diuretic therapy should cause a rapid improvement of the radiologic and clinical findings.

Biometric monitoring in silicosis to detect early disease and monitor lung injury: not quite there.

Biometric monitoring in exposure to silica dust http://ow.ly/qRrB303lMDg.

Tuberculosis during Pregnancy in Northern Israel, 2002-2012: Epidemiology and Clinical Practices.

BACKGROUND: Atypical presentation of tuberculosis (TB) during pregnancy may cause diagnostic delay and adversely influence pregnancy outcome. OBJECTIVES: To examine the incidence and clinical and epidemiological features of TB during pregnancy and investigate infection control measures at delivery and during the postpartum period. METHODS: We retrospectively evaluated all reported cases of TB diagnosed during pregnancy to 6 months postpartum in Israel's Northern Health District (2002-2012). RESULTS: Active TB was detected in six patients; all were negative for human immunodeficiency virus (HIV). Two patients were diagnosed in the postpartum period, and four had pulmonary involvement. The average incidence during this period (3.9 per 100,000 pregnancies) was similar to that in the general population. Five patients were at high risk of contracting TB due to either recent immigration from a high-burden country or being in contact with another individual with active TB. Patients with pleuropulmonary involvement had prolonged cough and abnormal chest X-rays, without fever. Diagnosis was delayed for 3 to 7 months from symptom onset. Investigation of the newborn to rule out intrauterine infection was conducted in only one of four relevant cases. All patients were infected with organisms susceptible to all first-line drugs, and all were cured with standard therapy. CONCLUSIONS: There was a considerable delay in the diagnosis of TB among pregnant women, and investigation of the newborn upon delivery to rule out TB infection was routinely omitted. Effective management of TB during pregnancy and the postpartum period requires a multidisciplinary approach including an obstetrician, pediatrician, TB specialist, and public health physician.

Tuberculosis outbreak in an immigrant reception center in Israel: a clinical and epidemiologic perspective.

Tuberculosis (TB) outbreaks in congregate settings pose a public health concern and a clinical challenge. We report a TB outbreak involving 6 cases of active TB among 28 recent Ethiopian immigrants (EIs) in an immigrant reception center in Israel. The outbreak erupted several weeks after a meticulous pre-immigration TB screening of this group. All five culture-positive TB patients were infected with the CAS1_DELHI family, SIT 25 strain. Pulmonary involvement manifested as only a persistent cough without systemic symptoms. This outbreak occurred because of miscommunication among healthcare staff and between healthcare staff and the EI index case. It was fuelled by the staff ignorance of the social bonds within the group, and the sluggish once-monthly schedule of the on-site TB clinic operated at the reception center, which further lacked radiography facilities. This outbreak highlights the challenges of screening for active TB among immigrants and hard to reach groups.

[Accessibility and compliance of Ethiopian immigrants to latent tuberculosis infection treatment].

BACKGROUND: Since the incidence of TB has decreased in the developed countries, the diagnosis and treatment of latent TB infection (LTBI) has assumed increasing importance. It is estimated that 5-10% of persons with LTBI go on to develop TB; therefore, the crucial role of LTBI treatment in eliminating TB is well recognized. However, levels of adherence are found to be consistently low, and noncompliance constitutes the major barrier for achieving the full benefits of LTBI treatment. OBJECTIVE: 1. To estimate rates of treatment completion with an outreach - directly observed preventive treatment (DOPT), a program among Ethiopian immigrants (El) at absorption centers treated for LTBI. 2. To determine if follow-up visits by a physician at their place of residence, vs. management at a TB Clinic (TBC), would further enhance the patient's adherence. METHODOLOGY: Quasi experiment, retrospective cohort analysis of 495 medical records for all El at absorption centers in Zefat who had started DOPT for LTBI and were followed up at absorption centers (2005-2006, study group - SG), compared to patients followed up at a TBC (2008-2010, comparison group - CG). Free transportation to the TBC was provided for the CG. FINDINGS: Altogether 495 Els were included (263 in the SG and 232 in the CG group). Both groups had high completion rates (SG: 96.2% vs. CG: 93.1%, p=0.14). While demographic factors did not predict treatment completion, side effects were significantly associated with non-completion. CONCLUSION: High treatment completion rates among El were achieved when DOPT outreach and cultural case management strategies were combined. In these circumstances, the physician follow-up location had no significant impact on treatment completion rates.

Indolent pneumonia in a pregnant recent immigrant from Ethiopia: think TB.

Time delay to tuberculosis (TB) diagnosis remains a public health concern. In pregnancy, early TB diagnosis is challenging and acquires further significance due to the risk of infection of the newborn as well as others in the maternity setting. We report a delay of 12 weeks in the diagnosis of TB in a pregnant recent immigrant from Ethiopia to Israel. Contact investigation revealed pulmonary TB in her two daughters aged four and seven years. We discuss the reasons for this delay in diagnosis, how a more timely diagnosis might have been made, and the dilemma of initiating treatment in unconfirmed TB.

Chest radiography validity in screening pulmonary tuberculosis in immigrants from a high-burden country.

BACKGROUND: Chest x-ray (CXR) is widely used for diagnosing and screening pulmonary tuberculosis (PTB), yet its validity is debatable and its costs are relatively high. This study aimed to determine the validity of CXR screening in detecting radiological findings compatible with active PTB or with old healed tuberculosis (OHTB). METHODS: All Ethiopian immigrants to Israel between 2001 and 2005 were radiographed before emigration. Immigrants whose CXR demonstrated PTB or OHTB were evaluated, treated, and followed for one year after arrival. The end point of this historical cohort study was a diagnosis of active pulmonary disease within the study period. RESULTS: CXR was performed on 13,379 immigrants. Changes suggesting PTB were identified in 150 (1.1%) of those, and 46 were diagnosed with active PTB. Sensitivity, specificity, and positive predictive value of a CXR suggesting PTB were 80.1%, 99.2%, and 31%, respectively. As PTB prevalence in this cohort is 0.4%, post-test odds for CXR suggestive of PTB were 75.5. Changes suggesting OHTB were identified in 257 (1.9%) immigrants. Of those, 15 (5.8%) developed active PTB within one year following arrival. Sensitivity, specificity, and positive predictive value of CXR suggestive of OHTB were 17.2%, 98.2%, and 5.8%, respectively, when active PTB during the first year was the end point. In this study, 291 CXR were required to detect one active PTB patient, costing $5,802. CONCLUSIONS: CXR is a valid and cost-saving tool for screening active PTB in immigrants originating in high-burden countries, and is beneficial in detecting OHTB in immigrants who are at a higher risk for developing active PTB.

Sarcoidosis in residents of northern Israel of Arabic and Jewish origin: a comparative study.

BACKGROUND: This study describes the features of sarcoidosis among Arab patients and compares it to Jewish patients residing in northern Israel. METHODS: All new cases of biopsy-confirmed sarcoidosis diagnosed between 1980 and 1996 in northern Israel were divided into two groups according to their ethnic origin: Jewish (n = 72) and Arabic (n = 48). Disease parameters were recorded and compared. RESULTS: Arabs and Jews had similar incidence rates that increased from 0.2/10(5) in 1980 to 2/10(5) per year in 1996. The peak incidence was in the sixth and seventh decades and the female/male ratio was 2 and 1.4 for Arabic and Jewish patients, respectively. Jewish patients had higher proportion stage II-IV pulmonary disease (78% vs. 51.2%) while their Arabic counterparts had higher proportion of stage I disease (70.8% vs. 41.7%). The proportion of extra-thoracic organ involvement was similar. Different disease phenotype indicated differed diagnostic procedures; higher proportion of mediastinoscopy for stage I disease among Arabic patients (47.9% vs. 20.8%, P = 0.015) and trans-bronchial biopsy for stage II-IV pulmonary disease among Jewish patients (25% vs. 8.35%, P = 0.05). Corticosteroids were used in a non-significantly higher proportion of Jewish patients (56.9% vs. 43.8%, P > 0.05). Of six sarcoidosis-related deaths (5%), five occurred in Jewish patients. CONCLUSIONS: This study has documented different forms of presentation, clinical manifestation, severity and prognosis of sarcoidosis present among patients of Arabic and Jewish origin residing in the area of northern Israel.

Epidemiologic characteristics of pediatric active tuberculosis among immigrants from high to low tuberculosis-endemic countries: the Israeli experience.

BACKGROUND: During the last decade, Israel, a country with low tuberculosis rates, absorbed some 900,000 new immigrants from TB-endemic countries. OBJECTIVES: To analyze the specific impact of our screening procedures on active TB among children in Israel. METHODS: We conducted a retrospective analysis of epidemiologic and clinical data of all children (aged 0-17) with TB notified to the Ministry of Health between 1990 and 1999. RESULTS: There were 479 children with TB (male/female ratio 1.36). Most cases (81.8%) were foreign born, predominantly (88.2%) immigrants from Ethiopia and, therefore, huge differences existed in TB incidence rates according to countries of origin. Some 80% were diagnosed within 3 years of arrival, mainly due to active case-finding. Pulmonary TB, with infiltrates on chest X-ray, was found in 49.5%. Extra-pulmonary TB sites were: intra-thoracic lymphadenitis (31.1%), extra-thoracic lymphadenitis (12.5%), bones (3.6%), pleura (1.3%), meninges (1%), and others (1%). Seventy percent had a tuberculin skin test reaction > or =10 mm in size. Two (non-immigrant) children died of TB meningitis. CONCLUSIONS: Most of the pediatric TB cases occurred in recent immigrants and were diagnosed within 3 years of immigration. These data support our policy of active case-finding among new immigrants from Ethiopia and extensive contact evaluation for all TB cases.

Large lungs in divers: natural selection or a training effect?

BACKGROUND: Normal spirometry is required for medical clearance of professional divers in many countries. Divers frequently have unusually large lung volumes associated with a low ratio of FEV(1) to FVC (FEV(1)%), suggestive of obstructive airways disease. We retrospectively analyzed the records of divers in the Israeli Navy with a low FEV(1)% who fulfilled the criteria for large lungs, to determine whether this might be the effect of training or natural selection. We also investigated changes in pulmonary function in relation to diving experience. METHODS: A total of 171 divers with FEV(1)% < 80% on simple spirometry were evaluated. We conducted a retrospective analysis of lung function data for those subjects who met the criteria for large lungs. RESULTS: One hundred nine of 171 divers with low FEV(1)% met the criteria for large lungs and were included in the study. Their average age was 25 years (range, 18 to 44 years), and their mean diving experience was 7 years (range, 0 to 26 years). No difference was found in FVC values between experienced and inexperienced divers. The mean forced expiratory flow at 50% of vital capacity was significantly reduced in the most experienced group compared with the novice or less experienced divers. No difference was found in the diffusing capacity of the lung for carbon monoxide between experienced and inexperienced divers. CONCLUSIONS: We suggest that large lungs may represent part of the natural selection for diving, rather than a training effect. Prolonged diving experience may result in the development of small airways disease.

Swimming-induced pulmonary edema: clinical presentation and serial lung function.

BACKGROUND: Acute pulmonary edema has been noted in swimmers and divers, and has been termed swimming-induced pulmonary edema (SIPE). The mechanisms and consequences of SIPE are unknown, and there are currently no series of carefully evaluated patients with this condition. Herein we report the clinical presentation, incidence of recurrence, findings on physical examination, chest radiography, and oxygen saturation in 70 trainees with a diagnosis of SIPE. We also report the results of forced spirometry in a subgroup of 37 swimmers. METHODS: SIPE was diagnosed when severe shortness of breath and cough were reported during or after swimming, and were associated with evidence of pulmonary edema. During the years from 1998 to 2001, 70 cases of SIPE were documented in young healthy male subjects participating in a fitness-training program. Physical examination and pulse oximetry were performed immediately. Chest radiographs were obtained in all cases 12 to 18 h following onset of symptoms. In 37 swimmers, spirometry was performed at the time of chest radiography and again after 7 days. RESULTS: All subjects complained of severe shortness of breath. Sixty-seven of the 70 subjects (95.7%) had a prominent cough; in 63 subjects (90%), there was significant sputum production. Hemoptysis was observed in 39 subjects (55.7%). Mean arterial oxygen saturation after swimming was 88.4 +/- 6.6% breathing air, compared with 98 +/- 1.7% breathing air at rest before the start of the swimming trial (mean +/- SD) [p < 0.001]. Chest radiographs obtained 12 to 18 h after swimming were normal in all cases. Sixteen trainees (22.9%) had a recurrence of SIPE. Spirometry demonstrated restrictive lung function, which persisted for a week. CONCLUSIONS: In our trainee population, SIPE is a not uncommon, often recurrent phenomenon that significantly influences performance. It is not clear what predisposes to its occurrence or recurrence and what, if any, are its long-term effects.

Circumstances leading to the formulation and implementation of a new TB control program in Israel: a case study in public health and policy.

We describe how Israel effected new tuberculosis programs and policies beginning in the early 1990s. We explain how the epidemiology of the disease, particular events, and a small number of people influenced the creation of new policy. We believe that this story may be useful to other program managers and policymakers interested in changing course.

[Tuberculosis in Israel--main epidemiological aspects].

BACKGROUND: In the last decade, tuberculosis (TB) has re-emerged as a major worldwide disease and also as a significant disease in Israel, particularly in the context of public health. In 1993, TB was declared a "global emergency" by the World Health Organization and in 1996, it was declared a "dangerous infectious disease" by the Israeli Ministry of Health. AIM: This article aims to provide an epidemiological update on TB to the practicing physician in Israel. We present the perspective of the global situation together with relevant data on TB in Israel for use in clinical decision making. METHODS: All local data are from the ongoing epidemiological surveillance of TB conducted by the Department of Tuberculosis and AIDS in the Israeli Ministry of Health. Other data are cited from international sources. RESULTS: TB is greatly influenced by immigration (some 80-90% of TB cases are foreign-born and at least 65% are among new immigrants). Between 1989-1996 the incidence of TB by cohort analysis for year of immigration ranged from 38-172/100,000 (for new immigrants from the Former Soviet Union) to 500-3,000/100,000 (for new immigrants from Ethiopia). During this period incidence in the veteran population (Israeli-born and immigrants at least 5 years in the country) was, at the most. 4/100,000. Some 80% of TB cases were pulmonary. The rate of drug resistance is increasing some 20% of the isolated strains were resistant to at least one drug and some 8% were resistant to both Isoniazid and Rifampicin. (MDR, multi-drug-resistant). Tuberculosis associated with AIDS has increased in the last decade due to immigration from sub-Saharan Africa. Contrary to the belief existing in the general public, the number of TB cases among foreign workers was relatively low (7.6% of the cases reported in 1998). CONCLUSION: In the clinical context, a practicing physician is most likely to diagnose TB in a recent immigrant. Thus since the symptoms of early TB are non-specific, diagnostic efforts (which are labor intensive and expensive) should be guided by a high index of suspicion in that particular population group. Furthermore, this epidemiological data provided the rationale for determining TB control policy as described in the second article on this subject.

[The new national program for tuberculosis elimination in Israel].

BACKGROUND: The rise in the incidence of TB in Israel, mostly due to immigration from endemic areas, led to the establishment of a new TB control program which follows the guidelines of the World Health Organization (WHO). Reorganization of the TB infrastructure was enabled by specific legislative, administrative and budgetary measures initiated by the Ministry of Health (MOH) in conjunction with the Sick Funds. AIM: To present the theoretical and practical aspects of this new program to the physicians of Israel. PROGRAM OUTLINE: The essence of this program is the use of directly observed therapy (DOT) for all patients together with centralization of TB care in nine national centers, closely supervised by the MOH. This centralization allows a critical mass of patients to be seen in each clinic, thus enabling the labor-intensive task of modern TB treatment, including the supervision and/or the administration of DOT, to be performed in a cost-effective manner. Day to day treatment is conducted by general community clinics and supervised by District Health Offices. Hospitalization, a relatively rare necessity in the new program, is available in two dedicated centers with modern isolation facilities. Centralized laboratory services provide timely susceptibility testing. Billing is simplified according to disease categories, using a global assessment of costs negotiated with the Sick Funds. Management and quality control of the program are carried out on an ongoing basis by the Department of TB and AIDS at the MOH. PRELIMINARY OUTCOME: In the first two years that have elapsed since the inception of the program, almost 93% of cases have documented evidence of completion of treatment (under DOT), compared to 54% (without any treatment supervision) before the program came into effect.

Functional endoscopic sinus surgery in the treatment of massive polyposis in asthmatic patients.

The association between asthma and sinonasal disease has been known for years. Effective treatment of sinonasal disease, which is one of the factors that exacerbate asthma, may also improve and stabilize the asthmatic condition. This study examines the outcome of functional endoscopic sinus surgery (FESS) on asthmatic patients with massive nasal polyposis. Thirty-four asthmatic patients were included in the study. All were operated on in our department and were analysed for pre-operative data regarding their asthma and sinonasal disease. A questionnaire regarding subjective evaluation of asthma and sinonasal status was presented to the patients, and objective evaluations, including nasal endoscopy and spirometry, were performed. Follow-up endoscopy revealed satisfactory results in 88 per cent, with positive correlation to the patients' subjective assessment of nasal status. No such correlation was found with regard to subjective and objective assessment of asthma: a small group of patients had completely clean sinonasal cavities with no perceived improvement in their asthmatic condition. The use of prednisolone and bronchodilators was significantly reduced post-operatively. However, in a subgroup of 13 patients followed at the asthma clinic, who had adequate pre-operative and post-operative data, there was no difference in their pre- and post-operative asthma condition. Seven had minimal improvement and in six there was a definite worsening of their asthma; nevertheless, nasal breathing and quality of life improved in most patients. The mean follow-up was 2.1 years. Thus, we conclude that in this study FESS does not improve asthma, but does improve the quality of the life of the patient.

Compliance to treatment of latent tuberculosis infection in a region of Israel.

BACKGROUND: One of the measures adopted in Israel since 1959 as part of the tuberculosis control program was screening children aged 12-13 years old. The screening comprised single-step tuberculin skin testing using the Mantoux method. OBJECTIVES: To assess the efficacy of tuberculin skin screening for TB in schoolchildren in southwestern Israel as well as the compliance to treatment for latent tuberculosis infection. METHODS: We retrospectively reviewed the records of children in the Ashkelon region who underwent a tuberculin skin test during the period 1995-99. RESULTS: Of the 28,016 eligible children, 27,232 were tested. In 923 children, mostly from the former USSR and Ethiopia, an induration of 10 mm or more was found. Only 52 Israeli-born children tested positive. Tuberculosis was found in seven children with a positive test, five of whom were from Ethiopia. All children who tested positive were referred to the local TB clinic; only 266 children (28.8%) presented. Only 151 completed the recommended treatment of isoniazid for 6 months. Thus, although screening included most of the targeted children aged 13, only a third of them presented to a TB clinic, and of these only about half completed treatment for latent infection. CONCLUSIONS: Our results indicate that the current policy of screening for latent TB in our region is ineffective in terms of implementation of the recommended treatment. We suggest that only high risk groups be screened, and that a concerted effort be made to implement treatment.