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2.
BMJ ; 371: m2919, 2020 09 30.
Artigo em Inglês | MEDLINE | ID: mdl-32998910
3.
ERJ Open Res ; 5(4)2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31857993

RESUMO

Introduction: In the UK, several hundred patients notified with tuberculosis (TB) die every year. The aim of this article is to describe trends in deaths among notified TB patients, explore risk factors associated with death and compare all-cause mortality in TB patients with age-specific mortality rates in the general UK population. Methods: We used 2001-2014 data from UK national TB surveillance to explore trends and risk factors for death, and population mortality data to compare age-specific death rates among notified TB patients with annual death rates in the UK general population. Results: The proportion of TB patients in the UK who died each year declined steadily from 7.1% in 2002 to 5.5% in 2014. One in five patients (21.3%) was diagnosed with TB post-mortem. Where information was available, almost half of the deaths occurred within 2 months of starting treatment. Risk factors for death included demographic, disease-specific and social risk factors. Age had by far the largest effect, with patients aged ≥80 years having a 70 times increased risk of death compared with those aged <15 years. In contrast, excess mortality determined by incidence ratios comparing all-cause mortality among TB patients with that of the general population was highest among children and the working-age population (15-64 years old). Conclusions: Efforts to control TB and improve diagnosis and treatment outcomes in the UK need to be sustained. Control efforts need to focus on socially deprived and vulnerable groups. There is a need for further in-depth analysis of deaths of TB patients in the UK to identify potentially preventable factors.

4.
Emerg Infect Dis ; 25(12): 2284-2286, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31742516

RESUMO

Human infection with Mycobacterium bovis is reported infrequently in the United Kingdom. Most cases involve previous consumption of unpasteurized milk. We report a rare occurrence of 2 incidents of cat-to-human transmission of M. bovis during a cluster of infection in cats.


Assuntos
Mycobacterium bovis , Tuberculose/epidemiologia , Tuberculose/transmissão , Zoonoses/epidemiologia , Zoonoses/transmissão , Adolescente , Adulto , Animais , Gatos , Genoma Bacteriano , Genômica/métodos , Genótipo , Humanos , Mycobacterium bovis/classificação , Mycobacterium bovis/genética , Filogenia , Tuberculose/diagnóstico , Tuberculose/microbiologia , Adulto Jovem , Zoonoses/diagnóstico , Zoonoses/microbiologia
5.
Thorax ; 74(2): 185-193, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30121574

RESUMO

BACKGROUND: In January 2016, clinical TB guidance in the UK changed to no longer recommend screening contacts of non-pulmonary, non-laryngeal (ETB) index cases. However, no new evidence was cited for this change, and there is evidence that screening these contacts may be worthwhile. The objective of this study was to estimate the cost-effectiveness of screening contacts of adult ETB cases and adult pulmonary or laryngeal TB (PTB) cases in London, UK. METHODS: We carried out a cross-sectional analysis of data collected on TB index cases and contacts in the London TB register and an economic evaluation using a static model describing contact tracing outcomes. Incremental cost-effectiveness ratios (ICERs) were calculated using no screening as the baseline comparator. All adult TB cases (≥15 years old) in London from 2012 to 2015, and their contacts, were eligible (2465/5084 PTB and 2559/6090 ETB index cases were included). RESULTS: Assuming each contact with PTB infects one person/month, the ICER of screening contacts of ETB cases was £78 000/quality-adjusted life-years (QALY) (95% CI 39 000 to 140 000), and screening contacts of PTB cases was £30 000/QALY (95% CI 18 000 to 50 000). The ICER of screening contacts of ETB cases was £30 000/QALY if each contact with PTB infects 3.4 people/month. Limitations of this study include the use of self-reported symptomatic periods and lack of knowledge about onward transmission from PTB contacts. CONCLUSIONS: Screening contacts of ETB cases in London was almost certainly not cost-effective at any conventional willingness-to-pay threshold in England, supporting recent changes to National Institute for Health and Care Excellence national guidelines.


Assuntos
Busca de Comunicante/economia , Programas de Rastreamento/economia , Tuberculose Pulmonar/economia , Adulto , Análise Custo-Benefício , Estudos Transversais , Humanos , Londres , Guias de Prática Clínica como Assunto , Sensibilidade e Especificidade , Tuberculose Pulmonar/diagnóstico , Reino Unido
6.
Pediatr Infect Dis J ; 38(5): 470-475, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30256311

RESUMO

BACKGROUND: The epidemiology of tuberculosis (TB) is changing in the United Kingdom and globally. Childhood TB is a key indicator of recent transmission and provides a marker of wider TB control. We describe the recent epidemiology of childhood TB in the United Kingdom, how this compares to TB in adults, and document changes with time. METHODS: TB cases notified in the United Kingdom between 2000 and 2015 were categorized as children (<15 years of age) or adults (≥15 years of age). Descriptive analyses were carried out on demographic, clinical and microbiologic data. We carried out logistic regressions to identify risk factors associated with children having no microbiologic confirmation. RESULTS: In the study period, 6293 TB cases (5%) in the United Kingdom were notified in children. Childhood TB incidence declined from 487 cases in 2000 (3.4 per 100,000) to 232 cases (2.0 per 100,000) in 2015. The majority (68%) of children with TB were UK born, with a high proportion of Pakistani (24%) and Black-African (22%) ethnicity. Sixty-four percent of children had pulmonary disease. Culture confirmation was low (24%). Children who were younger, UK born and those with extrapulmonary disease were less likely to have microbiologically confirmed TB. A high proportion (87%) of children completed treatment at last-recorded outcome, with few deaths (39 cases; 0.7%). CONCLUSIONS: The incidence of TB in children in the United Kingdom has decreased in the past 16 years, with the majority of children completing TB treatment. Ongoing monitoring of childhood TB will provide a measure of the effectiveness of the national TB program.


Assuntos
Tuberculose/epidemiologia , Adolescente , Antituberculosos/uso terapêutico , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Fatores de Risco , Tuberculose/tratamento farmacológico , Tuberculose/microbiologia , Tuberculose/patologia , Reino Unido/epidemiologia
7.
Am J Epidemiol ; 187(10): 2233-2242, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-29878041

RESUMO

Genotyping provides the opportunity to better understand tuberculosis (TB) transmission. We utilized strain typing data to assess trends in the proportion of clustering and identify the characteristics of individuals and clusters associated with recent United Kingdom (UK) transmission. In this retrospective cohort analysis, we included all culture-confirmed strain-typed TB notifications from the UK between 2010 and 2015 to estimate the proportion of patients that clustered over time. We explored the characteristics of patients in a cluster using multivariable logistic regression. Overall, 58.5% of TB patients were concentrated in 2,701 clusters. The proportion of patients in a cluster decreased between 2010 (58.7%) and 2015 (55.3%) (P = 0.001). Being a clustered patient was associated with being male and UK-born, having pulmonary disease, having a previous TB diagnosis, and having a history of drug misuse or imprisonment. Our results suggest that TB transmission in the UK decreased between 2010 and 2015, during which time TB incidence also decreased. Targeted cluster investigation and extended contact tracing should be aimed at persons at risk of being in a transmission chain, including UK-born individuals with social risk factors in clusters with a high proportion of patients having pulmonary disease.


Assuntos
Tuberculose/epidemiologia , Tuberculose/genética , Adolescente , Adulto , Fatores Etários , Criança , Pré-Escolar , Emigrantes e Imigrantes/estatística & dados numéricos , Feminino , Genótipo , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Repetições Minissatélites , Epidemiologia Molecular , Mycobacterium tuberculosis/genética , Prisões/estatística & dados numéricos , Doenças Respiratórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/genética , Tuberculose Pulmonar/epidemiologia , Tuberculose Pulmonar/genética , Reino Unido/epidemiologia , Adulto Jovem
8.
Eur Respir J ; 51(6)2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29748309

RESUMO

We used whole-genome sequencing (WGS) to delineate transmission networks and investigate the benefits of WGS during cluster investigation.We included clustered cases of multidrug-resistant (MDR) tuberculosis (TB)/extensively drug-resistant (XDR) TB linked by mycobacterial interspersed repetitive unit variable tandem repeat (MIRU-VNTR) strain typing or epidemiological information in the national cluster B1006, notified between 2007 and 2013 in the UK. We excluded from further investigation cases whose isolates differed by greater than 12 single nucleotide polymorphisms (SNPs). Data relating to patients' social networks were collected.27 cases were investigated and 22 had WGS, eight of which (36%) were excluded as their isolates differed by more than 12 SNPs to other cases. 18 cases were ruled into the transmission network based on genomic and epidemiological information. Evidence of transmission was inconclusive in seven out of 18 cases (39%) in the transmission network following WGS and epidemiological investigation.This investigation of a drug-resistant TB cluster illustrates the opportunities and limitations of WGS in understanding transmission in a setting with a high proportion of migrant cases. The use of WGS should be combined with classical epidemiological methods. However, not every cluster will be solvable, regardless of the quality of genomic data.


Assuntos
Tuberculose Extensivamente Resistente a Medicamentos/epidemiologia , Polimorfismo de Nucleotídeo Único , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Sequenciamento Completo do Genoma , Técnicas de Tipagem Bacteriana , Análise por Conglomerados , Surtos de Doenças , Tuberculose Extensivamente Resistente a Medicamentos/transmissão , Humanos , Repetições Minissatélites , Mycobacterium tuberculosis/genética , Mycobacterium tuberculosis/isolamento & purificação , Tuberculose Resistente a Múltiplos Medicamentos/transmissão , Reino Unido/epidemiologia
9.
Thorax ; 73(8): 769-775, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29674389

RESUMO

BACKGROUND: Following nearly two decades of increasing tuberculosis in the UK, TB incidence decreased by 32% from 2011 to 2015. Explaining this reduction is crucial to informing ongoing TB control efforts. METHODS: We stratified TB cases notified in the UK and TB cases averted in the UK through pre-entry screening (PES) between 2011 and 2015 by country of birth and time since arrival. We used population estimates and migration data to establish denominators, and calculated incidence rate ratios (IRRs) between 2011 and 2015. We calculated the contribution of changing migrant population sizes, PES and changes in TB rates to the reduction in TB notifications. RESULTS: TB IRRs fell in all non-EU migrant and UK-born populations between 2011 and 2015 (0.61; 95% CI 0.59 to 0.64 and 0.78; 0.73 to 0.83 respectively), with the greatest decrease in recent non-EU migrants (0.54; 0.48 to 0.61). 61.9% of the reduction in TB notifications was attributable to decreases in TB rates, 33.4% to a fall in the number of recent/mid-term non-EU migrants and 11.4% to PES. A small increase in notifications in EU-born migrants offset the reduction by 6.6%. CONCLUSIONS: Large decreases in TB rates in almost all populations accounted for the majority of the reduction in TB notifications, providing evidence of the impact of recent interventions to improve UK TB control. The particularly large decrease in TB rates in recent non-EU migrants provides evidence of the effectiveness of screening interventions that target this population. These findings will inform ongoing improvements to TB control.


Assuntos
Tuberculose/epidemiologia , Emigrantes e Imigrantes/estatística & dados numéricos , Feminino , Humanos , Incidência , Masculino , Programas de Rastreamento , Vigilância da População , Reino Unido/epidemiologia
10.
Sci Rep ; 8(1): 6676, 2018 04 27.
Artigo em Inglês | MEDLINE | ID: mdl-29703981

RESUMO

Contact tracing is a key part of tuberculosis prevention and care, aiming to hasten diagnosis and prevent transmission. The proportion of case-contact pairs for which recent transmission occurred and the typical timespans between the index case and their contact accessing care are not known; we aimed to calculate these. We analysed individual-level TB contact tracing data, collected in London from 20/01/2011-31/12/2015, linked to tuberculosis surveillance and MIRU-VNTR 24-locus strain-typing information. Of pairs of index cases and contacts diagnosed with active tuberculosis, 85/314 (27%) had strain typing data available for both. Of these pairs, 79% (67/85) shared indistinguishable isolates, implying probable recent transmission. Of pairs in which both contact and the index case had a social risk factor, 11/11 (100%) shared indistinguishable isolates, compared to 55/75 (75%) of pairs in which neither had a social risk factor (P = 0.06). The median time interval between the index case and their contact accessing care was 42 days (IQR: 16, 96). As over 20% of pairs did probably not involve recent transmission between index case and contact, the effectiveness of contact tracing is not necessarily limited to those circumstances where the index case has transmitted disease to their close contacts.


Assuntos
Busca de Comunicante , Transmissão de Doença Infecciosa , Tuberculose/epidemiologia , Tuberculose/transmissão , Londres/epidemiologia , Repetições Minissatélites , Epidemiologia Molecular , Tipagem Molecular , Mycobacterium tuberculosis/classificação , Mycobacterium tuberculosis/genética , Mycobacterium tuberculosis/isolamento & purificação
11.
Emerg Infect Dis ; 24(3): 524-533, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29460735

RESUMO

Among tuberculosis (TB) patients, acquired resistance to anti-TB drugs represents a failure in the treatment pathway. To improve diagnosis and care for patients with drug-resistant TB, we examined the epidemiology and risk factors associated with acquired drug resistance during 2000-2015 among TB patients in England, Wales, and Northern Ireland. We found acquired resistance in 0.2% (158/67,710) of patients with culture-confirmed TB. Using multivariate logistic regression, we identified the following factors associated with acquired drug resistance: having pulmonary disease; initial resistance to isoniazid, rifampin, or both; a previous TB episode; and being born in China or South Africa. Treatment outcomes were worse for patients with than without acquired resistance. Although acquired resistance is rare in the study area, certain patient groups are at higher risk. Identifying these patients and ensuring that adequate resources are available for treatment may prevent acquisition of resistance, thereby limiting transmission of drug-resistant strains of mycobacteria.


Assuntos
Antituberculosos/farmacologia , Farmacorresistência Bacteriana/efeitos dos fármacos , Mycobacterium tuberculosis/efeitos dos fármacos , Tuberculose/epidemiologia , Adolescente , Adulto , Antituberculosos/uso terapêutico , Inglaterra/epidemiologia , Feminino , História do Século XXI , Humanos , Masculino , Irlanda do Norte/epidemiologia , Estudos Retrospectivos , Tuberculose/tratamento farmacológico , Tuberculose/história , Tuberculose/microbiologia , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/história , Tuberculose Resistente a Múltiplos Medicamentos/microbiologia , País de Gales/epidemiologia , Adulto Jovem
12.
AIDS ; 31(17): 2403-2413, 2017 11 13.
Artigo em Inglês | MEDLINE | ID: mdl-28857827

RESUMO

OBJECTIVES: Tuberculosis (TB) is common in people living with HIV, leading to worse clinical outcomes including increased mortality. We investigated risk factors for developing TB following HIV diagnosis. DESIGN: Adults aged at least 15 years first presenting to health services for HIV care in England, Wales or Northern Ireland from 2000 to 2014 were identified from national HIV surveillance data and linked to TB surveillance data. METHODS: We calculated incidence rates for TB occurring more than 91 days after HIV diagnosis and investigated risk factors using multivariable Poisson regression. RESULTS: A total of 95 003 adults diagnosed with HIV were followed for 635 591 person-years; overall incidence of TB was 344 per 100 000 person-years (95% confidence interval 330-359). TB incidence was high for people who acquired HIV through injecting drugs [PWID; men 876 (696-1104), women 605 (365-945)] and black Africans born in high TB incidence countries [644 (612-677)]. The adjusted incidence rate ratio for TB amongst PWID was 4.79 (3.35-6.85) for men and 6.18 (3.49-10.93) for women, compared with MSM. The adjusted incidence rate ratio for TB in black Africans from high-TB countries was 4.27 (3.42-5.33), compared with white UK-born individuals. Lower time-updated CD4 cell count was associated with increased rates of TB. CONCLUSION: PWID had the greatest risk of TB; incidence rates were comparable with those in black Africans from high TB incidence countries. Most TB cases in PWID were UK-born, and likely acquired TB through transmission within the United Kingdom. Earlier HIV diagnosis and quicker initiation of antiretroviral therapy should reduce TB incidence in these populations.


Assuntos
Infecções por HIV/complicações , Abuso de Substâncias por Via Intravenosa/complicações , Tuberculose/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Inglaterra/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Irlanda do Norte/epidemiologia , Fatores de Risco , País de Gales/epidemiologia , Adulto Jovem
13.
BMC Med ; 15(1): 105, 2017 06 13.
Artigo em Inglês | MEDLINE | ID: mdl-28606177

RESUMO

BACKGROUND: We estimate the proportion of tuberculosis (TB) in England due to recent household transmission, identify factors associated with being a household transmitter, and investigate the impact that identification of a case has on time to treatment of subsequent cases. METHODS: TB cases notified between 2010 and 2012 in England in the same household as another case were identified; 24 locus MIRU-VNTR strain typing (ST) was used to identify household cases with likely recent transmission. Treatment delay in index and subsequent cases was compared. Risk factors for being a household transmitter were identified in univariable and multivariable analyses. RESULTS: Overall, 7.7% (1849/24,060) of TB cases lived in a household with another case. We estimate that 3.9% were due to recent household transmission. ST data was unavailable for 67% (1242) of household pairs. For those with ST data, 64% (386) had confirmed, 11% probable (66) and 25% (155) refuted household transmission. The median treatment delay was 65 days for index cases and 37 days for subsequent asymptomatic cases. Risk factors for being a household transmitter included being under 25 years old, UK-born with Black African, Indian or Pakistani ethnicity, or born in Somalia or Romania. CONCLUSIONS: This study has a number of implications for household TB contact tracing in low incidence countries, including the potential to reduce the diagnostic delay for subsequent household cases and the benefit of using ST to identify when to conduct source contact tracing outside the household. As 25% of TB cases in households had discordant strains, households with multiple TB cases do not necessarily represent household transmission. The additional fact that 25% of index cases within households only had extra-pulmonary TB demonstrates that, if household contact tracing is limited to pulmonary TB cases (as recently recommended in UK guidelines), additional cases of active TB in households will be missed. Our finding that no lineage of TB was associated with recent household transmission and with no increased transmissibility in the Beijing lineage compared to others, suggests that the lineage need not impact contact tracing efforts. Improvements in contact tracing have the potential to reduce transmission of TB in low incidence countries.


Assuntos
Mycobacterium tuberculosis/genética , Tuberculose Pulmonar/diagnóstico , Adolescente , Adulto , Distribuição por Idade , Idoso , Criança , Pré-Escolar , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/microbiologia , Infecções Comunitárias Adquiridas/transmissão , Inglaterra/epidemiologia , Feminino , Genes Bacterianos , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Repetições Minissatélites , Técnicas de Diagnóstico Molecular , Tipagem Molecular , Análise Multivariada , Estudos Retrospectivos , Fatores de Risco , Análise de Sequência de DNA , Tuberculose Pulmonar/epidemiologia , Tuberculose Pulmonar/microbiologia , Tuberculose Pulmonar/transmissão , Adulto Jovem
14.
Thorax ; 72(8): 736-745, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28389598

RESUMO

BACKGROUND: Contact tracing is a key element in England's 2015 collaborative TB strategy, although proposed indicators of successful contact tracing remain undescribed. METHODS: We conducted descriptive and multivariable analyses of contact tracing of TB cases in London between 1 July 2012 and 31 December 2015 using cohort review data from London's TB Register, identifying characteristics associated with improved indicators and yield. RESULTS: Of the pulmonary TB cases notified, 60% (2716/4561) had sufficient information for inclusion. Of these, 91% (2481/2716) had at least 1 contact (median: 4/case (IQR: 2-6)) identified, with 86% (10 251/11 981) of these contacts evaluated. 4.1% (177/4328), 1.3% (45/3421) and 0.70% (51/7264) of evaluated contacts of pulmonary smear-positive, pulmonary smear-negative and non-pulmonary cases, respectively, had active disease. Cases who were former prisoners or male were less likely to have at least one contact identified than those never imprisoned or female, respectively. Cases diagnosed at clinics with more directly observed therapy or social workers were more likely to have one or more contacts identified. Contacts screened at a different clinic to their index case or of male index cases were less likely to be evaluated than those screened at the same clinic or of women, respectively; yield of active disease was similar by sex. 10% (490/4850) of evaluated child contacts had latent TB infection. CONCLUSIONS: These are the first London-wide estimates of TB contact tracing indicators which are important for monitoring the strategy's success and informing risk assessment of index cases. Understanding why differences in indicators occur between groups could improve contact tracing outcomes.


Assuntos
Busca de Comunicante/métodos , Tuberculose/diagnóstico , Adolescente , Adulto , Criança , Feminino , Humanos , Incidência , Londres/epidemiologia , Masculino , Sistema de Registros , Estudos Retrospectivos , Teste Tuberculínico , Tuberculose/epidemiologia , Tuberculose/transmissão , Adulto Jovem
15.
Emerg Infect Dis ; 23(3): 377-386, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-28220748

RESUMO

Despite control efforts, Mycobacterium bovis incidence among cattle remains high in parts of England, Wales, and Northern Ireland, attracting political and public health interest in potential spread from animals to humans. To determine incidence among humans and to identify associated factors, we conducted a retrospective cohort analysis of human M. bovis cases in England, Wales, and Northern Ireland during 2002-2014. We identified 357 cases and observed increased annual case numbers (from 17 to 35) and rates. Most patients were >65 years of age and born in the United Kingdom. The median age of UK-born patients decreased over time. For 74% of patients, exposure to risk factors accounting for M. bovis acquisition, most frequently consumption of unpasteurized milk, was known. Despite the small increase in case numbers and reduction in patient age, M. bovis infection of humans in England, Wales, and Northern Ireland remains rare.


Assuntos
Mycobacterium bovis , Tuberculose/epidemiologia , Tuberculose/microbiologia , Adolescente , Adulto , Idoso , Inglaterra/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Irlanda do Norte/epidemiologia , Estudos Retrospectivos , Fatores de Risco , País de Gales/epidemiologia , Adulto Jovem
16.
Thorax ; 72(7): 654-659, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-26888779

RESUMO

OBJECTIVES: To describe the burden of TB in healthcare workers (HCWs) in the UK and determine whether HCWs are at increased risk of TB due to occupational exposure. METHODS: Retrospective cohort analysis of national UK TB surveillance and genotyping data between 2009 and 2013. The rate of TB in HCWs compared with non-HCWs to calculate incidence rate ratios stratified by country of birth. RESULTS: 2320 cases of TB in HCWs were notified in the study period, 85% were born abroad. The TB rate in HCWs was 23.4 (95% CI 22.5 to 24.4) per 100 000 compared with 16.2 (95% CI 16.0 to 16.3) per 100 000 in non-HCWs. After stratifying by country of birth, there was not an increased TB incidence in HCWs for the majority of countries of birth, including in the UK-born. Using combined genotyping and epidemiological data, only 10 confirmed nosocomial transmission events involving HCWs were identified between 2010 and 2012. Of these, only two involved transmission to patients. CONCLUSIONS: The lack of an increased risk of TB after stratifying by country of birth, and the very few transmission events involving nosocomial transmission in the UK suggests that TB in HCWs in the UK is not generally acquired through UK occupational exposure. The majority of cases in foreign-born HCWs are likely to result from reactivation of latent TB infection (LTBI) acquired abroad, and is not likely to be prevented by BCG vaccination in the UK. Testing and treatment of LTBI in HCWs with exposure to high TB burden countries should be the focus of occupational health prevention activities.


Assuntos
Emigrantes e Imigrantes/estatística & dados numéricos , Pessoal de Saúde/estatística & dados numéricos , Exposição Ocupacional/efeitos adversos , Tuberculose Pulmonar/epidemiologia , Adolescente , Adulto , Infecção Hospitalar/epidemiologia , Feminino , Técnicas de Genotipagem , Humanos , Incidência , Transmissão de Doença Infecciosa do Paciente para o Profissional/estatística & dados numéricos , Transmissão de Doença Infecciosa do Profissional para o Paciente/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tuberculose Pulmonar/microbiologia , Reino Unido/epidemiologia , Adulto Jovem
17.
Lancet ; 388(10059): 2510-2518, 2016 11 19.
Artigo em Inglês | MEDLINE | ID: mdl-27742165

RESUMO

BACKGROUND: Tuberculosis elimination in countries with a low incidence of the disease necessitates multiple interventions, including innovations in migrant screening. We examined a cohort of migrants screened for tuberculosis before entry to England, Wales, and Northern Ireland and tracked the development of disease in this group after arrival. METHODS: As part of a pilot pre-entry screening programme for tuberculosis in 15 countries with a high incidence of the disease, the International Organization for Migration screened all applicants for UK visas aged 11 years or older who intended to stay for more than 6 months. Applicants underwent a chest radiograph, and any with results suggestive of tuberculosis underwent sputum testing and culture testing (when available). We tracked the development of tuberculosis in those who tested negative for the disease and subsequently migrated to England, Wales, and Northern Ireland with the Enhanced Tuberculosis Surveillance system. Primary outcomes were cases of all forms of tuberculosis (including clinically diagnosed cases), and bacteriologically confirmed pulmonary tuberculosis. FINDINGS: Our study cohort was 519 955 migrants who were screened for tuberculosis before entry to the UK between Jan 1, 2006, and Dec 31, 2012. Cases notified on the Enhanced Tuberculosis Surveillance system between Jan 1, 2006, and Dec 31, 2013, were included. 1873 incident cases of all forms of tuberculosis were identified, and, on the basis of data for England, Wales, and Northern Ireland, the estimated incidence of all forms of tuberculosis in migrants screened before entry was 147 per 100 000 person-years (95% CI 140-154). The estimated incidence of bacteriologically confirmed pulmonary tuberculosis in migrants screened before entry was 49 per 100 000 person-years (95% CI 45-53). Migrants whose chest radiographs were compatible with active tuberculosis but with negative pre-entry microbiological results were at increased risk of tuberculosis compared with those with no radiographic abnormalities (incidence rate ratio 3·2, 95% CI 2·8-3·7; p<0·0001). Incidence of tuberculosis after migration increased significantly with increasing WHO-estimated prevalence of tuberculosis in migrants' countries of origin. 35 of 318 983 pre-entry screened migrants included in a secondary analysis with typing data were assumed index cases. Estimates of the rate of assumed reactivation tuberculosis ranged from 46 (95% CI 42-52) to 91 (82-102) per 100 000 population. INTERPRETATION: Migrants from countries with a high incidence of tuberculosis screened before being granted entry to low-incidence countries pose a negligible risk of onward transmission but are at increased risk of tuberculosis, which could potentially be prevented through identification and treatment of latent infection in close collaboration with a pre-entry screening programme. FUNDING: Wellcome Trust, UK National Institute for Health Research, UK Medical Research Council, Public Health England, and Department of Health Policy Research Programme.


Assuntos
Migrantes , Tuberculose/epidemiologia , Estudos de Coortes , Inglaterra/epidemiologia , Humanos , Incidência , Irlanda do Norte , País de Gales/epidemiologia
18.
BMC Infect Dis ; 16: 195, 2016 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-27154015

RESUMO

BACKGROUND: The incidence of non-tuberculous mycobacteria (NTM) isolation from humans is increasing worldwide. In England, Wales and Northern Ireland (EW&NI) the reported rate of NTM more than doubled between 1996 and 2006. Although NTM infection has traditionally been associated with immunosuppressed individuals or those with severe underlying lung damage, pulmonary NTM infection and disease may occur in people with no overt immune deficiency. Here we report the incidence of NTM isolation in EW&NI between 2007 and 2012 from both pulmonary and extra-pulmonary samples obtained at a population level. METHODS: All individuals with culture positive NTM isolates between 2007 and 2012 reported to Public Health England by the five mycobacterial reference laboratories serving EW&NI were included. RESULTS: Between 2007 and 2012, 21,118 individuals had NTM culture positive isolates. Over the study period the incidence rose from 5.6/100,000 in 2007 to 7.6/100,000 in 2012 (p < 0.001). Of those with a known specimen type, 90 % were pulmonary, in whom incidence increased from 4.0/100,000 to 6.1/100,000 (p < 0.001). In extra-pulmonary specimens this fell from 0.6/100,000 to 0.4/100,000 (p < 0.001). The most frequently cultured organisms from individuals with pulmonary isolates were within the M. avium-intracellulare complex family (MAC). The incidence of pulmonary MAC increased from 1.3/100,000 to 2.2/100,000 (p < 0.001). The majority of these individuals were over 60 years old. CONCLUSION: Using a population-based approach, we find that the incidence of NTM has continued to rise since the last national analysis. Overall, this represents an almost ten-fold increase since 1995. Pulmonary MAC in older individuals is responsible for the majority of this change. We are limited to reporting NTM isolates and not clinical disease caused by these organisms. To determine whether the burden of NTM disease is genuinely increasing, a standardised approach to the collection of linked national microbiological and clinical data is required.


Assuntos
Complexo Mycobacterium avium/patogenicidade , Infecção por Mycobacterium avium-intracellulare/epidemiologia , Adulto , Idoso , Inglaterra , Feminino , Humanos , Síndromes de Imunodeficiência , Imunossupressores , Pneumopatias/epidemiologia , Pneumopatias/microbiologia , Masculino , Pessoa de Meia-Idade , Infecções por Mycobacterium não Tuberculosas/epidemiologia , Infecções por Mycobacterium não Tuberculosas/microbiologia , Infecção por Mycobacterium avium-intracellulare/microbiologia , Irlanda do Norte/epidemiologia , País de Gales/epidemiologia
19.
BMC Med ; 14: 52, 2016 Mar 23.
Artigo em Inglês | MEDLINE | ID: mdl-27004514

RESUMO

BACKGROUND: In low-incidence countries, clinical experience of tuberculosis is becoming more limited, with potential consequences for patient outcomes. In 2007, the Department of Health released a guidance 'toolkit' recommending that tuberculosis patients in England should not be solely managed by clinicians who see fewer than 10 cases per year. This caseload threshold was established to try to improve treatment outcomes and reduce transmission, but was not evidence based. We aimed to assess the association between clinician or hospital caseload and treatment outcomes, as well as the relative suitability of making recommendations using each caseload parameter. METHODS: Demographic and clinical data for tuberculosis cases in England notified to Public Health England's Enhanced Tuberculosis Surveillance system between 2003 and 2012 were extracted. Mean clinician and hospital caseload over the past 3 years were calculated and treatment outcomes grouped into good/neutral and unfavourable. Caseloads over time and their relationship with outcomes were described and analysed using random effects logistic regression, adjusted for clustering. RESULTS: In a fully adjusted multivariable model (34,707 cases)there was very strong evidence that management of tuberculosis by clinicians with fewer than 10 cases per year was associated with greater odds of an unfavourable outcome compared to clinicians who managed greater numbers of cases (cluster-specific odds ratio, 1.14; 95 % confidence interval, 1.05-1.25; P = 0.002). The relationship between hospital caseload and treatment outcomes was more complex and modified by a patient's place of birth and ethnicity. The clinician caseload association held after adjustment for hospital caseload and when the clinician caseload threshold was reduced down to one. CONCLUSIONS: Despite the relative ease of making recommendations at the hospital level and the greater reliability of recorded hospital versus named clinician, our results suggest that clinician caseload thresholds are more suitable for clinical guidance. The current recommended clinician caseload threshold is functional. Sensitivity analyses reducing the threshold indicated that clinical experience is pertinent even at very low average caseloads, which is encouraging for low burden settings.


Assuntos
Competência Clínica/normas , Infectologia/normas , Tuberculose/terapia , Adulto , Idoso , Estudos de Coortes , Inglaterra , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Resultado do Tratamento , Tuberculose/epidemiologia , Adulto Jovem
20.
Lancet HIV ; 2(6): e243-51, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26423197

RESUMO

BACKGROUND: Whether the incidence of tuberculosis in HIV-positive people receiving long-term antiretroviral therapy (ART) remains above background population rates is unclear. We compared tuberculosis incidence in people receiving ART with background rates in England, Wales, and Northern Ireland. METHODS: We analysed a national cohort of HIV-positive individuals linked to the national tuberculosis register. Tuberculosis incidence in the HIV-positive cohort (2007-11) was stratified by ethnic origin and time on ART and compared with background rates (2009). Ethnic groups were defined as follows: the black African group included all individuals of black African origin, including those born in the UK and overseas; the white ethnic group included all white individuals born in the UK and overseas; the south Asian group included those of Indian, Pakistani, and Bangladeshi origin, born in the UK and overseas; and the other ethnic group included all other ethnic origins, including black Afro-Caribbeans. FINDINGS: The HIV-positive cohort comprised 79 919 individuals, in whom there were 1550 incident cases in 231 664 person-years of observation (incidence 6·7 cases per 1000 person-years). Incidence of tuberculosis in the HIV-positive cohort was 13·6 per 1000 person-years in black Africans and 1·7 per 1000 person-years in white individuals. Incidence of tuberculosis during long-term ART (≥5 years) in black Africans with HIV was 2·4 per 1000 person-years, similar to background rates of 1·9 per 1000 person-years in this group (rate ratio 1·2, 95% CI 0·96-1·6; p=0·083); but in white individuals with HIV on long-term ART the incidence of 0·5 per 1000 person-years was higher than the background rate of 0·04 per 1000 person-years (rate ratio 14·5, 9·4-21·3; p<0·0001). The increased incidence relative to background in white HIV-positive individuals persisted when analysis was restricted to person-time accrued on ART with CD4 counts of at least 500 cells per µL and when white HIV-positive individuals born abroad were excluded. INTERPRETATION: Tuberculosis incidence is unacceptably high irrespective of HIV status in black Africans. In white individuals with HIV, tuberculosis incidence is significantly higher than background rates in white people despite long-term ART. Expanded testing and treatment for latent tuberculosis infection to all HIV-infected adults, irrespective of ART status and CD4 cell count, might be warranted. FUNDING: Public Health England.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Tuberculose/epidemiologia , Adulto , Contagem de Linfócito CD4 , Estudos de Coortes , Inglaterra/epidemiologia , Inglaterra/etnologia , Feminino , Infecções por HIV/sangue , Infecções por HIV/complicações , Infecções por HIV/etnologia , Humanos , Masculino , Pessoa de Meia-Idade , Irlanda do Norte/epidemiologia , Irlanda do Norte/etnologia , Tuberculose/etnologia , Tuberculose/etiologia , País de Gales/epidemiologia , País de Gales/etnologia
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