Community strategies to tackle tuberculosis according to the WHO region of origin of immigrant communities.

Setting: Tuberculosis (TB) control requires the proper identification and treatment of affected patients and investigation of their contacts. In certain vulnerable immigrant groups, however, these tasks may be hindered due to their ethnic and sociocultural characteristics. Objective: To analyse the results of a community programme designed to locate hard-to-reach immigrants with TB. Design: Descriptive study of all cases diagnosed with confirmed TB referred to the Public and Community Health team of the Drassanes International Health Unit in Barcelona during 2012-2014 due to difficulties in tracing these patients. Both cases and contacts were categorised based on their World Health Organization region of origin. The sociodemographic characteristics of each group and the community interventions carried out during the tracing period are described. Results: A total of 122 cases and 316 contacts were detected. As a result of community-based strategies, 73% of the initial cases completed treatment; 3.8% of the contacts were diagnosed with TB, 91.7% of whom were treated appropriately; 17.1% contacts had latent infection, 79.3% of whom completed chemoprophylaxis. Conclusions: Intervention strategies with a community approach for follow-up and control of TB in certain immigrant communities seem to be effective.

Contexte : La lutte contre la tuberculose (TB) requiert l'identification et le traitement appropriés des patients affectés et l'examen de leurs contacts. Ces tâches peuvent néanmoins être entravées dans certains groupes vulnérables d'immigrants en raison de leurs spécificités ethniques et socioculturelles.Objectif : Analyser les résultats d'un programme communautaire conçu pour localiser les immigrants atteints de TB dont le suivi s'avère difficile.Schéma : Etude descriptive de tous les cas ayant un diagnostic de TB confirmé référés à l'équipe de santé publique et communautaire dans l'unité de santé internationale Drassanes de Barcelone en 2012­2014 en raison des difficultés à les localiser. A la fois les cas et les contacts ont été classés en se basant sur leur région Organisation Mondiale de la Santé d'origine. Les caractéristiques sociodémographiques de chaque groupe et les interventions communautaires réalisées pendant leur recherche sont décrites.Résultats : Ont été détectés 122 cas et 316 contacts. Grâce aux stratégies communautaires, 73% des cas initiaux ont achevé leur traitement, 3,8% des contacts ont eu un diagnostic de TB, dont 91,7% ont été traités correctement ; 17,1% des contacts avaient une infection latente, dont 79,3% ont achevé la chimioprophylaxie.Conclusions: Les stratégies d'intervention par approche communautaire du suivi et de la lutte contre la TB dans certaines communautés d'immigrants semblent efficaces.

Marco de Referencia: El control de la tuberculosis (TB) requiere identificar y tratar adecuadamente a los pacientes afectados y realizar el seguimiento de sus contactos. Sin embargo, la realización de estas tareas puede ser complicada de llevar a cabo en ciertos colectivos de inmigrantes vulnerables debido a sus peculiaridades étnicas y socioculturales.Objetivo: Analizar los resultados de un programa comunitario diseñado para realizar el seguimiento de inmigrantes afectados de TB.Diseño: Estudio descriptivo de todos los casos con diagnóstico confirmado de TB remitidos al equipo de Salud Pública y Salud Comunitaria de la Unidad de Salud Internacional de Drassanes de Barcelona debido a las dificultades para realizar su seguimiento, durante el período 2012­2014. Se describen las características sociodemográficas tanto de los casos como de los contactos categorizados según su región de origen como intervenciones comunitarias llevadas a cabo durante su seguimiento.Resultados: Se detectaron 122 casos y 316 contactos. Como resultado de las estrategias comunitarias el 73% de los casos iniciales completaron el tratamiento. Un 3,8% de los contactos fueron diagnosticados de TB, de los cuales el 91,7% fueron tratados correctamente. El 17,1% de los contactos tenían una infección tuberculosa latente, de los cuales el 79,3% completaron la quimioprofilaxis.Conclusiones: Las estrategias de intervención comunitarias para el seguimiento y control de la TB en ciertos colectivos inmigrantes parecen ser efectivas.

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.

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.

Human immunodeficiency virus testing uptake and risk behaviours in Spain.

BACKGROUND: The purpose of this study was to estimate the prevalence of human immunodeficiency (HIV) testing in the general population; to analyse factors related to voluntary testing; and to describe the main reasons for testing, the kinds of health services where testing takes place and the relations between self-risk perception and HIV testing. METHODS: A probability sample survey of health and sexual behaviour in men and women aged 18-49 years and resident in Spain in 2003 (n = 10 980) was used. A combination of face-to-face and computer-assisted self-interview was used, and bivariate and multivariate logistic regression analyses were performed. RESULTS: Some 39.4% (40.2% in men and 38.5% in women) had ever been tested, blood donation being the main reason for men and pregnancy for women. In the multivariate analysis, HIV testing was associated with foreign nationality, high educational level, having injected drugs and having a large number of sexual partners. In men, it was also associated with age 30-39 years, having had sex with other men and having paid for sex. About 29.3% of men and 32.8% of women had their last voluntary HIV test in primary healthcare centres, whereas only 3.4% of men and 3.6% of women had last been tested in sexually transmitted infection/HIV diagnostic centres. About 20.2% of men and 5.5% of women with risk behaviours had never been tested. CONCLUSION: The proportion of men with risk behaviours who have never had an HIV test is unacceptably high in Spain. Scaling up access to HIV testing in this population group remains a challenge for health policies and research.

Lessons from the history of the human immunodeficiency virus/acquired immunodeficiency syndrome epidemic among Spanish drug injectors.

In Spain, approximately 10 years passed between the time when human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) harm-reduction programs should have been developed with sufficient coverage to have an optimum impact on public health (before the HIV/AIDS epidemic's explosion in 1984) and the date of their actual implementation. This delay yielded an enormous cost for the country. The introduction of the virus in drug injector networks during a period of widespread diffusion of heroin injection and the lack of political awareness of the growing problem were 2 important factors that contributed to the important diffusion of the HIV infection among Spanish injection drug users. Lessons can be learned that may be of great interest in countries or territories facing similar challenges now and in the future.

Monitoring HIV prevalence and behaviour of men who have sex with men in Barcelona, Spain.

Recently, different studies among men who have sex with men (MSMs) have reported an increase in HIV incidence and sexually transmitted infections, and an increase in sexual risk behaviour. But the optimism regarding anti-retroviral treatments may lead to a greater relaxation in protective measures in the near future.

[Community collection of syringes by parenteral drug users complementary to syringe exchange programs]. / RECOJE: recogida comunitaria de jeringas por usuarios de drogas por vía parenteral como complemento a los programas de intercambio.

OBJECTIVES: To contribute to harm reduction in injecting drug users (IDUs) by the implementation of a programme to withdraw abandoned syringes from public places, as well as to collaborate on the social reinsertion of IDUs. METHODS: Descriptive study of the Syringe Withdrawal Community (RECOJE in Spanish), carried out from 1997 to 1999 by IDUs, the We Are Helpful Association (ASUT in Spanish) and the Social and Health Prevention and Attention Service (SAPS in Spanish) of the Red Cross, in Ciutat Vella (Barcelona, Spain). RESULTS: 4,332 syringes were withdrawn, 849 in 1997, 1,324 in 1998 and 2,159 in 1999. The mean number of syringes withdrawn each time was 57 33. 45 different IDUs worked in RECOJE. 74.2% of the abandoned syringes were found in parks, gardens, car parks and open spaces. CONCLUSIONS: RECOJE can be a valid programme for harm reduction complementary to the exchange syringe programmes. It could improve the self-esteem, external image and organization of IDUs, contributing to their social reinsertion.

Evolución de la epidemia de la infección por el VIH en el siglo XXI

La infección por el VIH, debido a su impacto devastador, tanto social, económica como demográficamente en amplias zonas del planeta, está teniendo consecuencias sin precedentes a nivel mundial. El Programa de Sida de las Naciones Unidas (UNAIDS) estima que en el mes de diciembre de 1999 el número total de infecciones acumuladas por el VIH/sida era de más de 53 millones. Unos 34 millones de adultos y niños afectados estarían actualmente vivos, siendo el 41 por ciento mujeres. Menos de un 5 por ciento de todos estos casos corresponden a pacientes que viven en los países desarrollados en Europa Occidental y Norteamérica, únicas zonas donde se puede administrar de forma generalizada el tratamiento antirretroviral adecuado. El impacto internacional de esta epidemia queda demostrado por el hecho de que hasta esta fecha se habrían producido casi 19 millones de muertes directamente atribuibles a esta infección, de las cuales unos 4 millones sucedieron en niños. Se estima que sólo durante el año 1999 se habrían infectado unos 5 millones de personas (más de 14.000 casos diarios). En todo el mundo, entre el 75 y el 80 por ciento de las infecciones se han producido por una relación sexual no protegida, y más del 75 por ciento de ellas corresponde a una relación heterosexual. La adquisición del virus por el uso compartido de material de inyección entre los usuarios de drogas por vía parenteral (UDVP) supone sólo entre el 5 y el 10 por ciento del conjunto de infecciones. Entre los niños, más del 90 por ciento de los infectados son hijos de madres VIH positivas y contrajeron el virus en el momento del parto o durante la lactancia. De los 620.000 niños, que se infectaron durante este pasado año, más del 80 por ciento de los casos correspondieron al África Subsahariana.En este capítulo se revisa la evolución de la epidemia en el ámbito mundial, concretamente en España y en Cataluña. Se calcula que en España hay unas 150.000 personas infectadas.Finalmente, se analiza el impacto sanitario que puede tener la infección por el VIH/sida en el siglo XXI (AU)

RECOJE: recogida comunitaria de jeringas por usuarios dedrogas por vía parenteral como complemento a los programasde intercambio / Community collection of syringes by parenteral drug users complementary to syringe exchange programs

Objetivo: Reducir riesgos para los usuarios de drogas por vía parenteral (UDVP) y la comunidad a través de un programa de recogida de jeringas abandonadas en lugares públicos y contribuir a la reinserción social de los UDVP. Método: Estudio descriptivo de la recogida comunitaria de jeringas (RECOJE) abandonadas, realizada entre 1997 y 1999por UDVP, la asociación somos útiles (ASUT) y el servicio de atención y prevención sociosanitaria (SAPS) de la Cruz Roja,en la Ciutat Vella de Barcelona. Resultados: Se recogieron 4.332 jeringas; 849 en 1997, 1.324en 1998 y 2.159 en 1999. La media de jeringas recogidas por salida fue de 57 ± 33. Un total de 45 UDVP realizaron RECOJE. La mayoría de jeringas (74,2%) se localizaron en parques, jardines, aparcamientos y descampados. Conclusiones: La recogida comunitaria de jeringas es un programa válido para la reducción de riesgos, complementario al intercambio de jeringas. Mejora la autoestima, imagen externa y organización de los UDVP y contribuye a su reinserción social (AU)

Objectives: To contribute to harm reduction in injecting drug users (IDUs) by the implementation of a programme to withdraw abandoned syringes from public places, as well as to collaborate on the social reinsertion of IDUs. Methods: Descriptive study of the Syringe Withdrawal Community(RECOJE in Spanish), carried out from 1997 to 1999by IDUs, the We Are Helpful Association (ASUT in Spanish)and the Social and Health Prevention and Attention Service(SAPS in Spanish) of the Red Cross, in Ciutat Vella (Barcelona,Spain).Results: 4,332 syringes were withdrawn, 849 in 1997,1,324 in 1998 and 2,159 in 1999. The mean number of syringes withdrawn each time was 57 ± 33. 45 different IDUs worked in RECOJE. 74.2% of the abandoned syringes were found in parks, gardens, car parks and open spaces. Conclusions: RECOJE can be a valid programme for harm reduction complementary to the exchange syringe programmes. It could improve the self-esteem, external image and organization of IDUs, contributing to their social reinsertion (AU)

[Prevalence of human immunodeficiency virus infection and behaviors associated with its transmission among parenteral drug users selected on the street]. / Prevalencia de infección por el virus de la inmunodeficiencia humana y de los comportamientos asociados a su transmisión entre usuarios de drogas por vía parenteral seleccionados en la calle.

BACKGROUND: To estimate the prevalence of HIV infection and the associated risk behaviours among intravenous drug users not receiving treatment for their drug dependence. PATIENTS AND METHODS: A cross-sectional study of 200 intravenous drug users recruited from the streets of Barcelona in 1993. Information about the socio-demographic aspects and behaviours was obtained through a personal interview using a standardised questionnaire which was carried out by three ex-drug users. Saliva samples were used to determine anti HIV antibodies. RESULTS: The prevalence of HIV infection was 51%. 57% borrowed used syringes, 65% lended their syringes, and 41% practised back of frontloading. 85% if those who shared syringes always cleaned them, however 59% only used water. 78% had heterosexual relations, in 33% of the cases with a non-injecting sexual partner. 65% always used condoms with sexual clients although only 26% always used them with stable sexual partners and 36% with casual sexual partners. 78% had performed the HIV test and among those who knew they were seropositive, 40% had received some kind of health control in the last 6 months. Not having a legal income, injecting speedball or barbiturates, unknowing self HIV negative status and practicing forms of indirect sharing were found to be independently associated with syringe sharing. CONCLUSIONS: The high prevalence of HIV infection and associated risk behaviours highlights the need to increase and adapt the prevention efforts and investigation to this group. Social marginalization and poliuse of drugs should be addressed in HIV prevention programs.

[Risk behaviors related with infection by human immunodeficiency virus among adolescent students in Catalonia]. / Conductas de riesgo relacionadas con la infección por el virus de la inmunodeficiencia humana en los adolescentes escolarizados en Cataluña.

OBJECTIVE: To determine the prevalence of HIV-risk behaviours among high-school adolescents, and the association with HIV-related knowledge, attitudes and risk perception. SUBJECTS AND METHODS: In 1992-93 a questionnaire was administered to the students of a convenience sample of 30 classes, previously to an AIDS education intervention. RESULTS: 1,213 questionnaires corresponding to 12 to 21 years-old respondents were analyzed. The mean age of the sample was 16 years and 61.6% were females. The use of drugs inhibiting the capacity to avoid risk situations was frequent (alcohol: 61.7% and hashish: 11.6%). 18.5% of the respondents were sexually active, of whom 18.1% reported at least one unknown sexual partner during the former year. 3.7% and 9.8% of the sexually active males reported a sexual intercourse with a male or with a prostitute, respectively. Condoms were consistently used by 51.3% of the sexually active students. Knowledge and risk perception were not related to risk behaviours, whereas less positive attitudes towards AIDS information and the HIV-infected were associated with having had intercourse with a high risk partner, and a positive attitude towards condoms was related to consistent use. CONCLUSIONS: Nearly 20% of school teenagers are sexually active and only half of these always use condoms. This places heterosexual activity as the main potential route for HIV-transmission in this group.

HIV testing history among gay/bisexual men recruited in Barcelona: evidence of high levels of risk behavior among self-reported HIV + men.

As part of the first quantitative study of men who have sex with men (MSM) and HIV/ AIDS in Spain, anonymous, self-administered questionnaires were distributed via gay/lesbian organization mailings, bathhouses, and sex shops in Barcelona. We analyzed 547 gay/bisexual men along self-reported HIV testing history-i.e. untested, previously tested HIV-, and previously tested HIV +. Eleven variables discriminated significantly between the three groups in multivariable analysis. HIV- men were over-represented in the mailing subsample. While untested men exhibited potentially protective behaviors (e.g. least likely to have had stable and casual sex partners with HIV/AIDS and to practice anal intercourse), they were also least likely to be out with their homosexuality and most likely to never use condoms when they practiced anal intercourse. HIV + men were most likely to report insertive and receptive anal intercourse with a condom and least likely to practice insertive anal intercourse without a condom in the past month, yet they were also most likely to report the highest interpersonal barriers to safer sex, recent cocaine use with sex, meeting sex partners in public restrooms, and recent episodes of STD. A potentially volatile combination of higher sexual activity (e.g. more sex partners and casual sex activity) coupled with the presence of safer sex barriers (e.g. poor scores on indices measuring safer sex disposition, elevated drug use accompanying sex) was evidenced among HIV + men. There were no statistically significant differences between the three groups for anal intercourse without a condom, but with 37.5% of this collective reporting one such episode in the past month, all groups can be considered equally risky. Against the backdrop of a 20.5% self-reported HIV prevalence, there is considerable need for enhanced prevention efforts among gay/bisexual men in general and targeted strategies among HIV + men in particular.

[Transverse study on sex behavior associated with HIV transmission among homosexual men in Catalonia]. / Estudio transversal sobre conductas sexuales asociadas a la transmisión del VIH entre hombres homosexuales de Cataluña.

In 1993, a cross sectional study was carried out on the sexual behaviour of a sample of homosexual men recruited in saunas, sex shops and a gay community-beased organisation of Catalonia. A total of 551 men with an average age of 34 years and a high educational level sent in an anonymous questionnaire. In the previous 6 months the mean number of male sexual partners was 6 and for penetrative partners 3. In the previous month, 94% had had oral sex (22% with ejaculation) and 76% anal intercourse (38% without a condom and 21% with ejaculation). During sex, 51% used alcohol, 34% nitrite inhalants, 20% hashish and 10% cocaine, 61% had had the HIV test, with a self-reported HIV prevalence of 21%. 86% stated that they knew of one or more people infected by HIV or with AIDS. The high percentage of men who had unprotected anal intercourse and the high self-reported HIV prevalence highlights the need to increase efforts in AIDS prevention and research in this group. Monitoring HIV associated sexual behaviours provides valuable indicators of the evolution of the epidemic, useful for designing and evaluating preventive interventions.

[Evaluation of an informative leaflet on AIDS/HIV infection aimed at primary health care professionals in Catalonia]. / Evaluación de una hoja informativa sobre la infección por VIH/sida dirigida a los profesionales de atención primaria de Cataluña.

OBJECTIVE: To assess primary care professionals' understanding and acceptance of a periodic information leaflet on HIV/AIDS. DESIGN: Crossover. SETTING: Primary care teams from the Institut Català de la Salut. PARTICIPANTS: A random sample of 300 doctors, qualified nurses and social workers. INTERVENTION: A self-administered, anonymous questionnaire returned by normal post. MEASUREMENTS AND MAIN RESULTS: Questions covered the following thematic areas: clinical care of people infected by HIV/AIDS and requests for diagnostic tests for infection, perception of skills in the promotion of changes in patients' sexual behaviour and drug use, providing psychological support and guidelines for integrating HIV+ children in schools and information on social resources. 60% knew the publication. Thematic areas which aroused most interest were: psychological support for people affected, prevention of HIV infection in the health environment, clinical advice and diagnosis. 77% had received requests for diagnostic tests and 88% had attended infected people. CONCLUSIONS: In spite of the low reply rate (50%) and relative variability among the professionals and the health regions they came from, this first assessment enabled us to identify specific educational needs in the care and prevention of HIV/AIDS infection in the primary care framework and also to improve the distribution methods we used.

The impact of HIV infection in a rural hospital in Haiti.

To assess the impact of the human immunodeficiency virus type 1 (HIV) infection on the patients treated at the Medicine Department of the Hôpital Albert Schweitzer (HAS) in Haiti and the economic costs to this institution that their medical care caused, a group of HIV infected patients was followed and compared to a control group of non-infected patients. Infected patients had a significantly higher number of diagnoses suggestive of HIV infection and of sexually transmitted diseases (STDs) and also had a higher rate of mortality during the follow-up period. Infected patients attended the out-patient Medicine Clinic and were hospitalized more frequently than non-infected patients. The yearly cost of treating an HIV patient was estimated to be about US $860. We suggest that a wider use of HIV testing might be beneficial among patients such as ours for providing adequate care for them if the necessary resources are made available.

Prevalence of HIV-1 infection in a rural medical clinic in Haiti.

To estimate the prevalence of the human immunodeficiency virus type 1 (HIV-1) among the patients attending the out-patient Medicine Clinic of the Hôpital Albert Schweitzer in Haiti, the serum samples of 535 consecutive patients were examined for HIV-1 antibodies by enzyme immunoassay. One hundred and twelve sera (20.9%) tested positive (19.3% of the in-district patients and 27.6% of the out-district patients). We concluded that HIV-1 infection has already spread to rural areas in Haiti and that we should prepare ourselves for the impact that the increasing number of infected patients will have.

[Evaluation of the demand for tests for the detection of anti-human immunodeficiency virus antibodies in Catalonia]. / Evaluación de la demanda de pruebas para la detección de anticuerpos antivirus de la inmunodeficiencia humana en Cataluña.

BACKGROUND: Most programs for the control of the acquired immunodeficiency syndrome (AIDS) contemplate the registry of cases as the principal source of information. Despite the fact that these data have permitted important epidemiologic and clinical aspects of the disease to become known epidemiologic surveillance systems should be developed based on the detection of infection by the human immunodeficiency virus (HIV). METHODS: The prevalence and the epidemiologic profile of patients who underwent an anti-HIV test were studied in 17 hospitals in Catalonia in 1989. In addition, a questionnaire concerning demographic and epidemiologic variables was completed by all the patients in whom an ELISA test had been carried out during 4 periods of 15 days. RESULTS: During this period 33,012 serologic tests were performed in 17 centers with a global prevalence of positive results of 20.7% (IC 95% = 20.2%-21.1%). The greatest number of positive serologies corresponded to the collective of intravenous drug users (IVDU), consisting of 68% of all the positive tests with a prevalence of infection of 76.4%. Prevalence was considered as constant throughout the year despite the differences between the prevalence observed in some periods. CONCLUSIONS: The fact that the collective of intravenous drug users is most prevalent among the patient with positive results in the serologic detection of the human immunodeficiency virus (HIV) confirms that this is the principal group of transmission in Catalonia. This type of study may provide information on the rate of infection by HIV complementing other surveillance methods of the epidemic. However, the basic function of these tests stems from the study of the demand and use of detection tests.

Recruitment methods and differences in early, late and non-respondents in the first MONICA-Catalonia population survey.

The early response rate in the first MONICA-Catalonia population survey was 52.7% and the final response rate was 73.8%. The intensity of recruitment effort in this survey led to a considerable increase in response rate (20%), with the extra cost per late respondent being relatively low ($13.9). Added recruitment effort was most effective in the youngest age group, 25-34 years. It was also more effective among women living in urban areas than among those from rural areas. In men, early respondents had a higher proportion of smokers than late respondents, and in women, early respondents had higher systolic and diastolic blood pressure levels and were more aware of their history of high blood pressure than late respondents. Non-respondents were less educated than respondents in both sexes, and this was more marked in women. No differences were found in the proportion of smokers between respondents and non-respondents. Respondents were more aware of their high blood pressure history than non-respondents. The recruitment costs and distribution of non-response components are given.