[Tuberculosis infection in patients with inflammatory bowel diseases. Clinacal cases]

In most cases Tuberculosis (TB) affects the lungs, but 10-15% of patients have extrapulmonary TB localisations, that is difficult to diagnose. TB is more spread among patients having the human immunodeficiency virus and among those who receive immunosuppressive therapy, specifically in patients with inflammatory bowel disease requiring long-term treatment with immunosuppressants and/or biologics. The symptoms of intestinal TB are nonspecific and may include chronic diarrhea, weight loss, fever and ascites. Differential diagnosis includes Crohn's disease, malignant neoplasms, periappendiceal abscesses, yersiniosis, etc. The article presents cases showing similarity of the intestinal form of TB with Crohn's disease, complexity dealing, diagnosing and treating patients with inflammatory bowel disease also having latent tuberculosis infection.

Models of good practice to enhance infectious disease care cascades among people who inject drugs: a qualitative study of interventions implemented in European settings

BACKGROUND

People who inject drugs (PWID) in Europe are at an increased risk of HIV/AIDS, chronic viral hepatitis B (HBV) and C (HCV), and tuberculosis (TB). We aimed to complement the evidence base on interventions optimising their care cascade with evidence from models of good practice (MoGPs) implemented in the EU/EEA and countries from the Eastern European region.

METHODS

A model of good practice (MoGP) was defined as (a package of) interventions with proven effectiveness in certain settings that are likely to be replicable and sustainable in other settings or countries. Fifteen MoGPs, identified by the European Centre for Disease Prevention and Control (ECDC) and the European Monitoring Centre on Drugs and Drug Addiction (EMCDDA) following a call launched in 2020, have been analysed. For the 15 MoGPs, a qualitative content analysis was conducted of (i) intervention characteristics and (ii) enabling factors. Information was extracted and summarised for community-based testing, linkage to care and adherence to treatment.

RESULTS

MoGPs emerged from projects implemented in Belarus, Norway, Portugal, the Republic of Moldova, Spain, and the UK alongside the multi-country HepCare project (Ireland, Romania, Spain, the UK) targeting either HCV (6/15) or HIV/AIDS (4/15), alone or combined with HBV, and/or TB (5/15). All MoGPs used packages of interventions, with decentralisation of services (15/15), cooperation among service providers (14/15), integrated services (10/15), peer interventions (12/15), and case management (4/15) reported across all stages of the care cascade. The synthesis of enablers shows that when replicating interventions in other settings, consideration should be given to national (legal) frameworks, characteristics of and proximity between healthcare and service providers, and establishing relations of trust with PWID.

CONCLUSION

To improve the cascade of care for PWID in European settings, care structures and pathways should be simplified, based on cooperation and multidisciplinary. MoGPs can provide implementation-based evidence on interventions alongside evidence from peer-reviewed literature to optimise the care cascade among PWID.

Tuberculosis in the European Region

Purpose of Review

Tuberculosis (TB) remains a major public health concern worldwide. The COVID-19 pandemic and migration flow due to socioeconomic conditions, climate change, and geopolitical issues, such as the war, are important drivers influencing TB epidemiology in Europe. This article aims to review the data about TB in this area and the new findings about treatment and prevention strategies.

Recent Findings

During the COVID-19 pandemic, access to health facilities and retention in care were difficult for TB patients, with consequences on TB diagnosis and TB incidence. The ongoing conflict in Europe, in areas with high prevalence of TB and MDR-TB, has reduced the access to health services and the availability of anti-TB drugs and increased the migration of refugees. New data on short treatment regimens could change the length of therapy and adverse events.

Summary

TB control programs are facing emerging challenges that could change TB incidence in the near future. Novel antibiotic strategies and improved preventive policies could offer new opportunities to reduce the TB impact on public health.

Space-Time Distribution Characteristics of Tuberculosis and Its Socioeconomic Factors in Southern China from 2015 to 2019

Purpose

Guangxi is a high prevalence area of tuberculosis (TB) in China, urgent needing of further TB reduction. Our purpose is to analyze the epidemiological characteristics of TB in Guangxi and analyze the relationship between socioeconomic factors and TB from the dimensions of time and space to provide evidence to effectively prevent and control TB.

Patients and Methods

We performed a retrospective analysis of the epidemiology of TB. Moran’s index (I) was used for spatial autocorrelation analysis, and space-time scanning was used to detect temporal, space, and space-time clusters of TB. A Bayesian space-time model was used to analyze related factors of the TB epidemic at the county level in Guangxi.

Results

From 2015 to 2019, a total of 233,623 TB cases were reported in Guangxi. The majority of TB cases were in males; the reported incidence of TB was the highest in people aged ≥65 years. By occupation, farmers were the most frequently affected. The overall reported incidence of TB decreased by 4.95% during this period. Tuberculosis occurs all year round, but the annual reporting peak is usually from March to July. Spatial autocorrelation analysis showed that the reported incidence of TB in 2015–2019 was spatially clustered (Moran’s I > 0, P < 0.05); Kulldorff’s scan revealed that the space-time cluster (log-likelihood ratio = 2683.76, relative risk = 1.60, P < 0.001) was mainly concentrated in northern Guangxi. Using Bayesian space-time modeling, socioeconomic and healthcare factors are related to the high prevalence of TB.

Conclusion

The prevalence of TB is influenced by a space-time interaction effect and is associated with socioeconomic and healthcare status. It is necessary to improve the economic development and health service in areas with a high TB prevalence.

Tuberculosis burden in immigrants and natives, adults and children, in Tuscany between 2000-2018

BACKGROUND

Updated data on epidemiology of tuberculosis are needed in Italy. The aim of this study is to evaluate trends in incidence and associated lethality of tuberculosis in immigrants compared with Italians.

METHODS

All tuberculosis cases diagnosed from 2000 to 2018 in 31 Tuscan hospitals were retrospectively identified.

RESULTS

In 10,827 tuberculosis cases 6715 were males (62%), 4312 (60%) were Italian-born. Hospitalization rate was 15.37/100,000 population/year. The most common comorbidity were liver disease (832/10,827; 7.7%), COPD (675/10,827; 6.2%), cancer (614/10,827; 5.7%). HIV was more frequent in the immigrants (p < 0.001). Extra-pulmonary tuberculosis cases (EPTB) were mainly localized in pleura (740/3,894, 19%) and lymph nodes (449/3,894, 11,5%). HIV was associated with an increased risk of EPTB (OR 3.51 95% CI 2.92-4.23, p < 0.0001). EPTB risk was increased in South Asian-born patients (OR 1.77, 95% CI 1.46-2.15, p < 0.0001) as well in African-born patients (OR 1.13, 95% CI 1.03-1.24, p = 0.0091), who were at risk for gastroenteric tuberculosis (OR 3.74, 95% CI 2.69-5.22, p < 0.0001). Overall mortality rate was 0.006 per 1000. Most of death cases (89%) were Italians (p < 0.02) and mainly affected by pulmonary tuberculosis (PTB).

CONCLUSIONS

In Tuscany, tuberculosis is still a health concern in terms of both morbidity and mortality.

Migration and tuberculosis in Europe

Immigrants arriving from high-incidence tuberculosis (TB) countries may pose a threat to TB control in low-incidence European host countries. Besides the immediate morbidity and mortality from any resurgence of TB, there would also be the increased economic cost of treatment of cases, tracing and preventive treatment of contacts, as well as concern over the potential emergence of drug-resistant forms of TB. This study analysed the 28 countries of the European Union, plus Iceland and Norway (EU+2). A Pearson correlation analysis of each country and all countries combined during the years 2011-2017 was conducted in order to detect any potential correlation between the number of immigrants annually and the TB notification rates per 100,000 total population. The overall data showed a significant negative correlation between the number of immigrants and TB rate. A negative correlation was also found for 22 of the 30 EU countries. In three countries (Germany, Italy, and Norway), a significant positive correlation between TB notification rates and immigration numbers was observed. Overall, the study did not show a clear pattern between TB transmission and immigration. Continued surveillance of migration and TB rates is essential, and there is a need for harmonization of case definitions and reporting standards to optimize TB control programs within Europe.

The effectiveness and cost-effectiveness of screening for active tuberculosis among migrants in the EU/EEA: a systematic review

: The foreign-born population make up an increasing and large proportion of tuberculosis (TB) cases in European Union/European Economic Area (EU/EEA) low-incidence countries and challenge TB elimination efforts. Methods: We conducted a systematic review to determine effectiveness (yield and performance of chest radiography (CXR) to detect active TB, treatment outcomes and acceptance of screening) and a second systematic review on cost-effectiveness of screening for active TB among migrants living in the EU/EEA. Results: We identified six systematic reviews, one report and three individual studies that addressed our aims. CXR was highly sensitive (98%) but only moderately specific (75%). The yield of detecting active TB with CXR screening among migrants was 350 per 100,000 population overall but ranged widely by host country (110–2,340), migrant type (170–1,192), TB incidence in source country (19–336) and screening setting (220–1,720). The CXR yield was lower (19.6 vs 336/100,000) and the numbers needed to screen were higher (5,076 vs 298) among migrants from source countries with lower TB incidence (≤ 50 compared with ≥ 350/100,000). Cost-effectiveness was highest among migrants originating from high (> 120/100,000) TB incidence countries. The foreign-born had similar or better TB treatment outcomes than those born in the EU/EEA. Acceptance of CXR screening was high (85%) among migrants. Discussion: Screening programmes for active TB are most efficient when targeting migrants from higher TB incidence countries. The limited number of studies identified and the heterogeneous evidence highlight the need for further data to inform screening programmes for migrants in the EU/EEA.

The effectiveness and cost-effectiveness of screening for latent tuberculosis among migrants in the EU/EEA: a systematic review

Migrants account for a large and growing proportion of tuberculosis (TB) cases in low-incidence countries in the European Union/European Economic Area (EU/EEA) which are primarily due to reactivation of latent TB infection (LTBI). Addressing LTBI among migrants will be critical to achieve TB elimination. Methods: We conducted a systematic review to determine effectiveness (performance of diagnostic tests, efficacy of treatment, uptake and completion of screening and treatment) and a second systematic review on cost-effectiveness of LTBI screening programmes for migrants living in the EU/EEA. Results: We identified seven systematic reviews and 16 individual studies that addressed our aims. Tuberculin skin tests and interferon gamma release assays had high sensitivity (79%) but when positive, both tests poorly predicted the development of active TB (incidence rate ratio: 2.07 and 2.40, respectively). Different LTBI treatment regimens had low to moderate efficacy but were equivalent in preventing active TB. Rifampicin-based regimens may be preferred because of lower hepatotoxicity (risk ratio = 0.15) and higher completion rates (82% vs 69%) compared with isoniazid. Only 14.3% of migrants eligible for screening completed treatment because of losses along all steps of the LTBI care cascade. Limited economic analyses suggest that the most cost-effective approach may be targeting young migrants from high TB incidence countries. Discussion: The effectiveness of LTBI programmes is limited by the large pool of migrants with LTBI, poorly predictive tests, long treatments and a weak care cascade. Targeted LTBI programmes that ensure high screening uptake and treatment completion will have greatest individual and public health benefit.

Genetic Diversity of Mycobacterium tuberculosis Isolates in the Metropolitan Area of Rome

BACKGROUND

The presence in a geographic area of Mycobacterium tuberculosis (Mtb) strains belonging to different phylogeographic lineages and showing different drug susceptibility patterns may suggest recent transmission, with implications in terms of patient clinical management and disease control. The aim of this study was to carry out a preliminary epidemiological investigation of tuberculosis (TB) cases in Rome.

METHODS

A total of 232 Mtb isolates, collected from new or previously treated patients, admitted between 2008 and 2014 at 2 hospital settings in Rome with a diagnosis of TB, were analyzed by spoligotyping and analyzing 24 variable-number tandem repeats (VNTR) mycobacterial interspersed repetitive-unit (MIRU) loci. The SITVIT2 database and the MIRU-VNTRplus web applications were used to identify the strain genotypes and to generate phylogenetic trees.

RESULTS

Based on the position on the phylogenetic tree, 97.4% of the strains were associated with 1 of the 7 main lineages. The Euro-American lineage was the most commonly represented (81.9%) within both Italian and foreign-born populations, although all main lineages were present. The highest frequency of drug-resistant strains was found among the East-Asian lineage (Beijing genotype) isolated from foreign-born patients.

CONCLUSIONS

Dynamics of TB transmission in Rome indicate recent spread of Mtb strains belonging to phylogeographic lineages and clades usually found in countries and geographic areas with a high incidence of TB, similarly to what is observed in most metropolitan areas in Western Europe. Knowledge from molecular and classical epidemiology provides an important tool for disease control.

Incidence of psychiatric disorders among accompanied and unaccompanied asylum-seeking children in Denmark: a nation-wide register-based cohort study

One in four asylum applicants in Europe are children, and 23% of whom are unaccompanied and may be at increased risk of mental illness. This study contributes to the limited evidence base by comparing the incidence of psychiatric disorders among unaccompanied and accompanied refugee children. We linked a cohort of refugee children who obtained right of residency in Denmark between 01 January 1993 and 31 December 2010 to the Danish Psychiatric Central Register, and calculated incidence rates per 100,000 person years and incidence rate ratios of overall psychiatric disorder, psychotic disorders, affective disorders, and neurotic disorders for accompanied and unaccompanied minors using Poisson regression. We adjusted the analyses for sex, age at residency, and age at arrival (aIRR). Stratified analyses were conducted by nationality. Unaccompanied minors had significantly higher rates of any psychiatric disorder (aIRR: 1.38, 95% CI 1.14-1.68) and neurotic disorders (aIRR: 1.67, 95% CI 1.32-2.13) than accompanied minors. Among children from Afghanistan, unaccompanied minors had significantly higher rates of any psychiatric disorder (aIRR: 2.23, 95% CI 1.26-3.93) and neurotic disorders (aIRR: 3.50, 95% CI 1.72-7.11). Among children from Iraq, unaccompanied minors had higher rates of any psychiatric disorder (aIRR: 2.02, 95% CI 1.18-3.45), affective disorders (aIRR: 6.04, 95% CI 2.17-16.8), and neurotic disorders (aIRR: 3.04, 95% CI 1.62-5.70). Unaccompanied children were found to experience a higher incidence of any psychiatric disorder and neurotic disorders. Strategies are needed to address the specific mental health and social needs of unaccompanied minors.

HIV and tuberculosis co-infection among migrants in Europe: A systematic review on the prevalence, incidence and mortality

Background

International human migration has been rapidly growing. Migrants coming from low and middle income countries continue to be considerably vulnerable and at higher risk for infectious diseases, namely HIV (Human Immunodeficiency Virus) and tuberculosis (TB). In Europe, the number of patients with HIV-TB co-infection has been increasing and migration could be one of the potential driving forces.

Objective

This systematic review aims to improve the understanding on the burden of HIV-TB co-infection among migrants in Europe and to assess whether these populations are particularly vulnerable to this co-infection compared to nationals.

Design

MEDLINE^®, Web of Science^® and Scopus^® databases were searched from March to April 2016 using combinations of keywords. Titles and abstracts were screened and studies meeting the inclusion criteria proceeded for full-text revision. These articles were then selected for data extraction on the prevalence, incidence and mortality.

Results

The majority of HIV-TB prevalence data reported in the analysed studies, including extrapulmonary/disseminated TB forms, was higher among migrant vs. nationals, some of the studies even showing increasing trends over time. Additionally, while HIV-TB incidence rates have decreased among migrants and nationals, migrants are still at a higher risk for this co-infection. Migrants with HIV-TB co-infection were also more prone to unsuccessful treatment outcomes, death and drug resistant TB. However, contradicting results also showed lower mortality compared to nationals.

Conclusions

Overall, a disproportionate vulnerability of migrants to acquire the HIV-TB co-infection was observed across studies. Such vulnerability has been associated to low socioeconomic status, poor living conditions and limited access to healthcare. Adequate social support, early detection, appropriate treatment, and adequate access to healthcare are key improvements to tackle HIV-TB co-infection among these populations.

Multidrug-resistant tuberculosis and migration to Europe

Multidrug-resistant tuberculosis (MDR-TB) in low-incidence countries in Europe is more prevalent among migrants than the native population. The impact of the recent increase in migration to EU and EEA countries with a low incidence of TB (<20 cases per 100 000) on MDR-TB epidemiology is unclear. This narrative review synthesizes evidence on MDR-TB and migration identified through an expert panel and database search. A significant proportion of MDR-TB cases in migrants result from reactivation of latent infection. Refugees and asylum seekers may have a heightened risk of MDR-TB infection and worse outcomes. Although concerns have been raised around 'health tourists' migrating for MDR-TB treatment, numbers are probably small and data are lacking. Migrants experience significant barriers to testing and treatment for MDR-TB, exacerbated by increasingly restrictive health systems. Screening for latent MDR-TB is highly problematic because current tests cannot distinguish drug-resistant latent infection, and evidence-based guidance for treatment of latent infection in contacts of MDR patients is lacking. Although there is evidence that transmission of TB from migrants to the general population is low-it predominantly occurs within migrant communities-there is a human rights obligation to improve the diagnosis, treatment and prevention of MDR-TB in migrants. Further research is needed into MDR-TB and migration, the impact of screening on detection or prevention, and the potential consequences of failing to treat and prevent MDR-TB among migrants in Europe. An evidence-base is urgently needed to inform guidelines for effective approaches for MDR-TB management in migrant populations in Europe.