Tuberculosis outbreak in a nursing home involving undocumented migrants and Israeli citizens.

ABSTRACK: OBJECTIVES: Israel has absorbed > 60,000 migrant from the horn of Africa (MHOA) since 2006. No cross-transmission of Mycobacterium tuberculosis from MOHA to Israeli citizens has yet been reported. This study describes the results of contact investigation and laboratory work-out of a unique mixed cluster which included both MOHA and Israeli citizens. METHODS: Description of the results of epidemiological investigation including laboratory confirmation. RESULTS: This unique Mycobacterium tuberculosis strain included 29 patients: 26 were MOHA and three citizens who immigrated to Israel from the former Soviet Union. This is the first mixed cluster described in Israel, which has not been represented in the SITVIT international database of genotyping markers. The transmission from non-citizens to citizens occurred in a nursing institution, when MOHA infected three other contacts- two of whom were retarded residents, one of them died. The index case was screened before employment, and was permitted to return to wok although his chest X-ray demonstrated radiological findings compatible with tuberculosis. Epidemiological links were found in other 12 MOHA members of the cluster. CONCLUSION: This report describes cross-transmission of Mycobacterium tuberculosis from non-citizens MOHA to Israeli citizens who were residents of a nursing home, which may be the first sign for an epidemiological shift. Although cross-ethnical transmission is still rare in Israel, medical settings should employ efficient infection control measures to protect both patients and staff from Mycobacterium tuberculosis.

Tuberculosis diagnostic delay and therapy outcomes of non-national migrants in Tel Aviv, 1998-2008.

Non-national migrants have limited access to medical therapy. This study compares diagnostic delay and treatment outcomes of non-insured non-national migrants (NINNM) with insured Israeli citizens (IC) in the Tel Aviv tuberculosis (TB) clinic between 1998 and 2008. Patient delay was the time from symptoms onset to doctor's visit, while system delay was measured from doctor visit to anti-TB therapy administration. We randomly sampled 222 NINNM and 265 IC. NINNM were younger than IC, had lower male to female ratio and fewer smoked. They had less drug/alcohol abuse, more cavitations on chest radiography, longer patient and shorter system delay. Mean patient and system delays of all patients were 25 ± 14 and 79 ± 42 days, respectively. In multivariate analysis, being NINNM, asymptomatic or smoking predicted longer patient delay, while being asymptomatic or having additional co-morbidity predicted longer system delay. Treatment success in sputum smear-positive pulmonary TB NINNM was 81% and 95.7% in IC (p=0.01). Treatment success was not associated with patient or system delay. In multivariate analysis, work security and treatment adherence predicted treatment success. NINNM had longer patient delay and worse therapy outcome, while IC had longer system delay. Both delays should be reduced. NINNM should be informed that TB therapy is free and unlinked with deportation.

Epidemiology of extra-pulmonary tuberculosis in Israel, 1999-2010.

SETTING: The Israeli national tuberculosis (TB) surveillance system. OBJECTIVES: To describe the epidemiology of extra-pulmonary tuberculosis (EPTB) in Israel between 1999 and 2010 and identify more susceptible populations. DESIGN: Data were retrieved from the National Tuberculosis Registry and the Israeli Bureau of Statistics. RESULTS: During the study period, 995 EPTB patients were notified, corresponding to 19.6% of all TB cases. The average annual male:female ratio was 0.8, and the human immunodeficiency virus (HIV) infection rate was 5%. Most EPTB affected the lymph nodes (39.8%), pleura (16.9%) and urinary system (11.1%). Most EPTB patients (81.8%) were non-Israeli born. The estimated average annual incidence in Israeli-born citizens, non-Israeli-born citizens and migrant workers was respectively 0.23, 2.2 and 7.5 per 100,000 population. The ratio of non-Israeli-born migrant workers to non-Israeli-born citizens with EPTB decreased from 1:6.3 in 1999 to 1:0.78 in 2010. Culture results were obtained for 624 (62.9%) of all cases. Of these, 41 (6.6%) were resistant to at least one first-line anti-tuberculosis drug and 8 (1.3%) were multidrug-resistant. Treatment success was achieved in 86.5%. CONCLUSIONS: Physicians should be aware of the possibility of EPTB in older patients, especially in the non-Israeli-born. Innovative screening procedures should be implemented for migrants from high-burden countries.

Adult tuberculosis in Israel and migration: trends and challenges between 1999 and 2010.

BACKGROUND: Israel absorbs many migrants from countries with a high prevalence of tuberculosis (TB). OBJECTIVES: To describe the epidemiology of TB among adults in Israel between 1999 and 2010 and identify populations with a high TB burden. DESIGN: Data were retrieved from the National Tuberculosis Registry and the Israeli Bureau of Statistics. RESULTS: A total of 4652 adult TB patients were notified during the study period, with rates decreasing annually from 7.5 per 100,000 population in 1999 to 4.3 in 2010. Most (n = 3745, 80.5%) had pulmonary TB, the average female:male ratio was 1:1.4, and 227 (5.1%) were infected with the human immunodeficiency virus. Of all TB patients, 4079 (87.6%) were born outside Israel; of these, 3338 were citizens and 741 non-citizen migrant workers (MWs). The average annual rates of TB among Israeli-born citizens, foreign-born citizens and MWs were respectively 0.86, 11.9 and 27/100,000. The ratio of MWs to foreign-born citizens fell from 1:11.7 in 1999 to 1:1.5 in 2010. TB was diagnosed 13.9 ± 7.5 years following entry to Israel, mostly during the first year. Of 3551 isolates, 222 (4.5%) were multidrug-resistant; most (95.6%) were from foreign-born patients. The average treatment success rate for smear-positive pulmonary TB was 84.3%. CONCLUSION: TB rates have decreased, while the proportion of foreign-born subjects, particularly MWs, has increased. Adherence to preventive treatment can prevent TB in these cases.

Therapy with nifedipine in asthma: a randomized double-blind crossover trial.

A randomized double-blind crossover trial with nifedipine (10 mg orally four times a day for 2 weeks) was carried out in 11 asthmatic patients. The analysis of the differences between the periods of running-in, placebo and nifedipine administration showed a mild improvement in symptom scores during the nifedipine period (2.8 +/- 1.5, 2.8 +/- 1.8 and 2.1 +/- 1.6, respectively; P less than 0.05). Drug intake and peak expiratory flow rates remained unchanged. This suggests that the drug did not influence the baseline bronchial tone, but might have attenuated some superimposed exacerbations due to unavoidable exposure to cold, effort or allergens. We conclude that the benefit of orally administered nifedipine in low doses has little value in the treatment of asthma.

Salbutamol versus atropine. Site of bronchodilatation in asthmatic patients.

The site of bronchodilatation produced by inhaled salbutamol (0.045 mg/kg) versus atropine (0.035 mg/kg) was investigated in 14 asthmatic young patients. No significant difference was found between the effects of the drugs on any of the large- or small-airway tests in those patients in whom bronchodilatation originated mainly in the large airways or when all patients were considered together. In those patients, however, in whom the small airways made the major contribution to the total airways resistance, atropine produced a higher increase in specific conductance, in maximal flow at all lung volumes and in density dependence of flow, but only the specific conductance showed a significant difference between the effects of the two drugs (p less than 0.01). It was concluded that in these patients atropine produced more bronchodilatation than salbutamol in both central and peripheral airways. These findings do not confirm previous studies which suggested that in asthmatic patients, as in normal subjects, atropine produces mainly central bronchodilatation, while salbutamol produces mainly peripheral bronchodilatation. The difference in doses, route of administration, time response and in the pretreatment severity and site of bronchodilatation could account for the disagreement between previous studies and the present one.

The influence of endotoxin-induced pyrexia on the pharmacokinetics of gentamicin in the rabbit.

Endotoxin-induced pyrexia caused a 2-fold increase in the volume of distribution of intravenously administered gentamicin in the rabbit as compared to the basal state (0.13-0.23 and 0.31-0.65 l for the central and peripheral compartments, respectively). Elimination, half-life was prolonged (46 to 90 min control and pyrexia, respectively), total plasma clearance remaining unchanged (4.6 and 4.9 ml/min, respectively). Endotoxin-induced pyrexia caused a significant increase in the serum concentrations and area under the concentration-time curve of gentamicin administered intramuscularly (355 to 704 microgram . min/ml, control and pyrexia, respectively). The increase in gentamicin concentration area under the curve was positively correlated with the temperature load (P less than .01). As total plasma clearance was not affected by pyrexia, the increased serum concentrations after intramuscular injection may be explained by enhanced absorption from the site of administration.

Bacterial endocarditis on a prosthetic valve. Oral treatment with amoxicillin.

A patient with endocarditis due to Streptococcus faecalis on an aortic valvular prosthesis was successfully treated using large oral doses of amoxicillin concurrently with intramuscular administration of streptomycin. Oral therapy was employed because of a persistent reaction to intravenously administered antibiotics. Oral therapy for bacterial endocarditis occurring on an artificial valve may be attempted as a last resort when all other accepted therapeutic measures have failed.