Impact of COVID-19 & Response Measures on HIV-HCV Prevention Services and Social Determinants in People Who Inject Drugs in 13 Sites with Recent HIV Outbreaks in Europe, North America and Israel

HIV/HCV prevention among people who inject drugs (PWID) is of key public health importance. We aimed to assess the impact of COVID-19 and associated response measures on HIV/HCV prevention services and socio-economic status of PWID in high-HIV-risk sites. Sites with recent (2011-2019) HIV outbreaks among PWID in Europe North America and Israel, that had been previously identified, were contacted early May 2020. Out of 17 sites invited to participate, 13 accepted. Semi-structured qualitative site reports were prepared covering data from March to May 2020, analyzed/coded and confirmed with a structured questionnaire, in which all sites explicitly responded to all 103 issues reported in the qualitative reports. Opioid maintenance treatment, needle/syringe programs and antiretroviral treatment /hepatitis C treatment continued, but with important reductions and operational changes. Increases in overdoses, widespread difficulties with food and hygiene needs, disruptions in drug supply, and increased homelessness were reported. Service programs rapidly reformed long established, and politically entrenched, restrictive service delivery policies. Future epidemic control measures should include mitigation of negative side-effects on service provision and socio-economic determinants in PWID.

Tuberculosis treatment outcomes of non-citizen migrants: Israel compared to other high-income countries

BACKGROUND

In TB low incidence countries, the outcome of TB treatment among non-citizen migrants from endemic countries affects ability to eliminate TB. This study compares TB treatment outcomes among non-citizen migrants in select pre-elimination country based on their policies for non-citizen migrant TB patients in order to determine how policy affects TB outcomes.

METHODS

A literature review was conducted via PUBMED, MEDLINE (2000-2017) on TB policy among non-citizen migrants and treatment outcome. Treatment outcome among migrants diagnosed in Israel during 2000-2014 was analysed.

RESULTS

In total, 18 publications met the inclusion criteria. All the countries reviewed except the United States offered free TB treatment to undocumented migrants. Successful TB treatment outcome for non-citizen migrants in Israel was 87%, the Netherlands was 90.7%, the UK was 82.1%, and outcomes in the US and Australia were not published.

CONCLUSIONS

There is a need to standardize results based on international definitions of migrants, asylum seekers, and refugees in order to determine status-specific barriers and to facilitate international comparisons. Policies insuring free access to TB care for non-citizen migrants are an important element for TB elimination in low incidence countries.

Cost utility analysis of HIV pre exposure prophylaxis among men who have sex with men in Israel

Background

Between 2011 and 2015, Men who have sex with men (MSM) accounted for nearly half of new HIV cases among men in Israel. This study carries out a cost-utility analysis of PrEP (HIV Pre Exposure Prophylaxis), an antiretroviral medication that can protect against the acquisition of HIV infection, whose incidence rate in Israel is around 1.74 per 1000 MSM.

Method

Epidemiological, demographic, health service utilisation and economic data were integrated into a spread-sheet model in order to calculate the cost per averted disability-adjusted life year (DALY) of the intervention from a societal perspective, in mid-2018 US$ using a 3% discount rate. Cost utility analyses were performed for both types of PrEP delivery (continuous regimen and on-demand), together with sensitivity analyses on numbers of condom users who take up PrEP (baseline 25%) and subsequently abandon condom use (baseline 75%), PrEP efficacy (baseline 86%), PrEP prices and monitoring costs.

Results

Around 21.3% of MSM are high risk (as defined by having unprotected anal intercourse). Offering PrEP to this group would have a ten year net cost of around 1563 million USD, preventing 493 persons from becoming HIV-positive, averting around 1616 DALYs at a cost per averted DALY of around 967,744 USD. This will render the intervention to be not cost-effective. PrEP drug prices would have to fall dramatically (by 90.7%) for the intervention to become cost-effective (i.e. having a cost per averted DALY less than thrice GNP per capita) in Israel. PrEP remains not cost-effective (at 475,673 USD per averted DALY) even if intervention costs were reduced by using an “on demand” instead of a daily schedule. Even if there were no changes in condom use, the resultant 411,694 USD cost-utility ratio is still not cost-effective.

Conclusions

Despite PrEPs high effectiveness against HIV, PrEP was found not to be cost-effective in the Israeli context because of a combination of relatively low HIV incidence, high PrEP costs, with a likelyhood that some low-risk MSM (ie: who use condoms) may well begin taking PrEP and as a consequence many of these will abandon condom use. Therefore, ways of minimizing these last two phenomena need to be found.

Continuum of HIV care of newly diagnosed individuals in Israel, 2011-2015: a population-based cohort study

Our aim was to assess the linkage to care (LTC) and treatment for people newly diagnosed with HIV in Israel during 2011–2015. The Ministry of Health estimated the annual prevalence of undiagnosed HIV; new diagnoses were identified by the Central Virology Laboratory. Only adult Israeli citizens were included. LTC at HIV centers within 90 days of diagnosis was assessed. Demographic and clinical data were collected from patient files. A total of 1538 individuals were diagnosed in 2011–2015. A moderate improvement over time was observed in the calculated proportions of undiagnosed individuals (23.1–17.3%) but no change occurred in LTC rates (82.6–81%). The proportion of diagnosed patients initiating treatment within six months increased from 54.7% in 2011 to 89.7% in 2015, with a parallel increase in the viral suppression rate from 30.5% in 2011 to 59.9% in 2015. Of 1159 patients with detailed records, 79.4% were men, median age 36 years (16–92), median CD4 cell count 342 cells/µl. Younger age, intravenous drug use, and imprisonment were independent risk factors for loss to follow-up. HIV is diagnosed late in Israel and LTC rates remain stagnated; higher awareness is still needed. Once in care, however, treatment and outcomes were in line with international standards.

HIV infection among men who have sex with men in Israel: a 35-year epidemiological and clinical overview, 1981-2015

BACKGROUND

This study is the first to describe major epidemiological trends and clinical characteristics among Israeli men who have sex with men (MSM), who are at a higher risk for HIV infection.

METHODS

This retrospective study includes all individuals reported to the Israeli Ministry of Health with HIV and self-identified as MSM between 1981 and 2015. The incidence rates of HIV infection and AIDS-defining diseases were analyzed and Kaplan-Meier survival estimates were calculated from time of HIV infection notification to AIDS diagnosis and death across three consecutive periods representing antiretroviral treatment availability.

RESULTS

The trend of increase in HIV incidence is similar to Western Europe, although Israeli rates are lower. Of 2052 HIV/AIDS Israeli MSM diagnosed during the follow-up, 296 (14.6%) developed AIDS. MSM constitute 28.4% of all HIV/AIDS cases and 41.5% of cases among men. Average times from HIV-notification until AIDS diagnosis were 15.5 [14.0-16.9], 16.0 [15.5-16.4], and 6.7 [6.7-6.8] years, within 1981-1996, 1997-2007, and 2008-2015, respectively. The HIV-incidence rate among Israeli MSM slightly declined from 2012, after peaking in 2011 at 6.2 per 100,000.

CONCLUSIONS

The recent reduction in HIV-incidence and in AIDS diagnoses among Israeli MSM is encouraging. Nevertheless, the disproportionate incidence of HIV among MSM requires sustained efforts to abate further infections.

Identification and characterization of HIV positive Ethiopian elite controllers in both Africa and Israel

OBJECTIVES

HIV elite controllers (ECs) are a unique subgroup of HIV-positive patients who are long-term virologically suppressed in the absence of antiretroviral treatment (ART). The prevalence of this subgroup is estimated to be < 1%. Various cohorts of ECs have been described in developed countries, most of which have been demographically heterogeneous. The aim of this study was to identify ECs in two large African cohorts and to estimate their prevalence in a relatively genetically homogenous population.

METHODS

We screened two cohorts of HIV-positive Ethiopian patients. The first cohort resided in Mekelle, Ethiopia. The second was comprised of HIV-positive Ethiopian immigrants in Israel. In the Mekelle cohort, ART-naïve subjects with stable CD4 counts were prospectively screened using two measurements of viral load 6 months apart. Subjects were defined as ECs when both measurements were undetectable. In the Israeli cohort, subjects with consistently undetectable viral loads (mean of 17 viral load measurements/patient) and stable CD4 count > 500 cells/μL were defined as ECs.

RESULTS

In the Mekelle cohort, 16 of 9515 patients (0.16%) fitted the definition of EC, whereas seven of 1160 (0.6%) in the Israeli cohort were identified as ECs (P = 0.011).

CONCLUSIONS

This is the first large-scale screening for HIV-positive ECs to be performed in entirely African cohorts. The overall prevalence of ECs is within the range of that previously described in developing countries. The significant difference in prevalence between the two cohorts of similar genetic background is probably a consequence of selection bias but warrants further investigation into possible environmental factors which may underlie the EC state.

Successful control of a large outbreak of HIV infection associated with injection of cathinone derivatives in Tel Aviv, Israel

OBJECTIVES

Outbreaks of HIV infection have been linked to injectable drug abuse, but specific triggers often remain obscure. We report on an outbreak of primary HIV infection among people who inject drugs (PWID) in Tel Aviv, associated with a local shift in drug-use practices.

METHODS

A cluster of primary HIV infection cases in PWID was detected in May 2012. Retrospective and prospective multi-hospital case finding was initiated. PWID were interviewed and risk factors for primary HIV infection were identified. Starting in December 2012, a multifaceted intervention was implemented, including educational activities, increasing syringe exchange supplies, active screening, early initiation of antiretroviral therapy, and referral to drug withdrawal programmes.

RESULTS

Forty-two PWID with primary HIV infection were detected between May 2012 and April 2013. Compared with the corresponding pre-outbreak period, the annual incidence of primary HIV infection in PWID increased from 0 to 20 cases/1000 population (p <0.0001). Sixty-nine per cent were hospitalized because of concomitant bacterial infections and sepsis. Phylogenetic analysis of HIV isolates from case patients showed tight clustering suggesting a single common source of infection. The outbreak was temporally related to a widespread shift from heroin to injectable cathinone-derivatives and buprenorphine, which entailed high-risk injection practices. Targeted intervention resulted in a dramatic and sustained reduction in HIV infection in the PWID population.

CONCLUSIONS

Injectable amphetamines are gaining momentum among PWID worldwide. Tracing of this outbreak to cathinone use and implementing a targeted intervention programme effectively terminated the outbreak.

Mortality after anti-tuberculosis treatment completion: results of long-term follow-up

BACKGROUND

Mycobacterium tuberculosis affects the lung parenchyma even after successful treatment.

OBJECTIVE

To assess long-term mortality in a cohort of individuals who had recovered from tuberculosis (TB), and to compare their mortality rate and causes of death with those of the general population.

METHODS

This retrospective cohort study of all Israeli citizens who recovered from tuberculosis between 2000 and 2010 included all patient files and death certificates and/or hospitalisation records of deceased individuals. Death rates were computed using standard mortality rates (SMR). Cox proportional hazard regression was conducted to identify risk factors for death, and causes of death were compared with those in the general Israeli population.

RESULTS

Over 11 years of follow-up, comprising 18,246 person-years, 389 (12.0%) Israeli citizens died after completion of anti-tuberculosis treatment, giving an SMR of 3.7. The SMR was strongly correlated with age, and was highest in males and individuals aged 25-44 years. Compared to the general population, among individuals who recovered from TB there were more deaths due to septicaemia and pneumonia, and fewer deaths due to cerebrovascular diseases, stroke and diabetes (P < 0.05).

CONCLUSIONS

Individuals who recover from TB are at higher risk of long-term mortality than the general population, and their causes of death are different. Periodical follow-up might be beneficial for individuals to facilitate early diagnosis.

Molecular epidemiology and mapping of tuberculosis in Israel: do migrants transmit the disease to locals?

SETTING

Israel receives migrants from various countries, some of which have high tuberculosis (TB) prevalence.

OBJECTIVE

To assess the predominant Mycobacterium tuberculosis strains in Israel isolated during 2008-2010 among Israeli-born and migrant patients, and to investigate possible transmission of TB from migrants to the local population.

METHODS

Molecular characterisation employed 43-spacer spoligotyping and 16-loci mycobacterial interspersed repetitive units-variable number of tandem repeats typing. All patients were classified according to those who were members of a cluster and those who were not.

RESULTS

Among 684 M. tuberculosis strains isolated from new patients genotyped and assigned to their specific cohort populations during the study period, major spoligotype families were Central Asian (CAS) (n = 140, 20%), Beijing (n = 101, 15%) and T (n = 160, 23%). Most Beijing strains (66%) were isolated from patients from the former Soviet Union (FSU), while CAS strains were mainly (74%) from Ethiopia, Eritrea and Sudan (EES). For the heterogeneous T-clade, patient countries of origin were 38% EES and 33% FSU.

CONCLUSIONS

Predominant M. tuberculosis genotypes in Israel in 2008-2010 were similar to genotypes endemic to the migrants' countries of origin. Epidemiological investigations did not demonstrate transmission between migrants and Israeli-born patients sharing the same cluster.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Mortality of tuberculosis patients during treatment in Israel, 2000-2010

SETTING

Tuberculosis (TB) epidemiology in Israel is similar to that reported from other industrialised countries where most patients are foreign-born.

OBJECTIVES

To assess TB case fatality rate (CFR) and mortality trends during treatment and to identify risk factors associated with mortality.

DESIGN

Retrospective cohort study of all TB patients in Israel diagnosed between 2000 and 2010. Cause of death was classified by TB-specific and non-TB-specific causes.

RESULTS

During the study period, 451 TB patients died during treatment, representing a CFR of 9.9%. Of these, 72.5% died due to TB-related causes, giving a TB-related CFR of 7.2%. Both the overall and TB-related CFR decreased over the study period. Risk factors for death included male sex, older age, human immunodeficiency virus coinfection, culture positivity and multidrug-resistant TB (MDR-TB). Patients aged ≥65 years comprised 70% of the TB-related deaths, and more than half of these (54.9%) were born in the former Soviet Union, Europe (excluding the former Soviet Union) or the USA.

CONCLUSION

Both the overall and TB-related CFR decreased over the study period. Physicians who treat older male TB patients with MDR-TB or HIV should increase the index of suspicion to include the possibility of a higher risk of mortality.

What do we need to learn for policy decision-making on sexually transmitted infections prevention and treatment in Israel?

The rising trend of sexually transmitted infections (STIs) reported in several western countries has also affected Israel. To review epidemiological trends and to address additional issues needed for a wider overview on STIs in Israel, we analysed notified data on infectious syphilis, gonorrhoea, Chlamydia trachomatis and HIV/AIDS during 1998–2007, by age groups, and each available publication on STIs in Israel. The trend of each disease had a unique pattern, probably influenced by different screening procedures, case definition, mix of populations and better access to care for high-risk populations. Higher rates were found among patients aged 25–34 years. Rates found in different peak years for gonorrhoea, HIV, chlamydia and infectious syphilis reached 43.6, 18.9, 10.8 and 8.1 cases per 100,000 population, respectively. We compare trends to those of countries from World Health Organization (WHO) European Region and discuss interventions for subpopulations on which additional data are needed for evidence-based policy-making. Incidence rates of syphilis, gonorrhoea, chlamydia and HIV/AIDS are still low in Israel. We propose additional components needed for a more comprehensive evidence-based policy on STIs.

Tuberculosis contact investigation in low prevalence countries: a European consensus

Contact investigation to identify individuals with tuberculosis and latent infection with Mycobacterium tuberculosis is an important component of tuberculosis control in low tuberculosis incidence countries. This document provides evidence-based and best-practice policy recommendations for contact tracing among high- and medium-priority contacts in a variety of settings. It provides a basis for national guidelines on contact investigation and tuberculosis outbreak management, and should support countries and tuberculosis control managers in evaluating and revising national policies. A review of existing guidelines, a literature search, several meetings and consultation with experts were used to formulate and grade recommendations for action during contact investigation. Available tests to identify individuals with latent infection with M. tuberculosis are designed to identify immune response against mycobacterial antigens and have variable predictive value for the likelihood to develop active tuberculosis in different populations. Contact investigation should therefore be limited to situations with a clear likelihood of transmission or to those with a higher probability of developing active tuberculosis, for instance, young children and immunocompromised persons. A risk assessment-based approach is recommended, where the need to screen contacts is prioritised on the basis of the infectiousness of the index case, intensity of exposure and susceptibility of contacts.

Pediatric tuberculosis immigration screening in high-immigration, low-incidence countries

BACKGROUND

Tuberculosis (TB) screening in migrant children, including immigrants, refugees and asylum seekers, is an ongoing challenge in low TB incidence countries. Many children from high TB incidence countries harbor latent TB infection (LTBI), and some have active TB disease at the point of immigration into host nations. Young children who harbor LTBI have a high risk of progression to TB disease and are at a higher risk than adults of developing disseminated severe forms of TB with significant morbidity and mortality. Many countries have developed immigration TB screening programs to suit the needs of adults, but have not focused much attention on migrant children.

OBJECTIVE

To compare the TB immigration medical examination requirements in children in selected countries with high immigration and low TB incidence rates.

DESIGN

Descriptive study of TB immigration screening programs for systematically selected countries.

RESULTS

Of 18 eligible countries, 16 responded to the written survey and telephone interview.

CONCLUSION

No two countries had the same approach to TB screening among migrant children. The optimal evidenced-based manner in which to screen migrant children requires further research.

Gay men who engage in substance use and sexual risk behaviour: a dual-risk group with unique characteristics

'Recreational' substances used among men having sex with men, and their association with risky unprotected anal intercourse (RUAI) were examined--for the first time in Israel--in an internet-based questionnaire assessing knowledge, practices and motivation. Between March and May 2005, 2873 participants completed the entire questionnaire. Of the total, 669 (23%) reported RUAI during the last six months, and 1319 (46%) used substances during sex. Use of substance was significantly higher among those performing RUAI than those who did not (31.5% versus 26.4%, P=0.03). Involvement in both substance use and RUAI was reported by 366 participants (13%). HIV rates were higher in this dual-risk group (P<0.01), and individuals reported more partners in the last six months than those not part of this dual risk (11.6 versus 8.2, P=0.02). In multivariate analyses, Tel-Aviv residency, lower education, performing receptive RUAI, misperception of HIV transmission and limited negotiation skills were positively associated with this dual-risk behaviour.

Epidemiology of HIV infection among Israeli Arabs

OBJECTIVE

Israeli Arab citizens comprise Israel's largest minority group (15.6% of Israelis>12 years old). The objectives of this study were to describe the epidemiology of human immunodeficiency virus (HIV) in this group for the first time at a national level, and to identify health promotion and treatment needs.

METHODS

All HIV/acquired immunodeficiency syndrome (AIDS) cases among Israeli Arab citizens that were notified to the Ministry of Health between 1985 and 2002 were analysed and compared with other Israelis (excluding immigrants from sub-Saharan Africa and their children).

RESULTS

Twenty-five AIDS cases and 51 HIV-positive cases were notified in adult/adolescent Israeli Arabs, (3.4% of all adult/adolescent cases). In addition, four child cases were reported. The cumulative rates for Arab and non-Arab Israelis were 10.1 and 37.8/100,000, respectively. The gender ratios (male/female) were 3.3 and 4.4 for AIDS cases and HIV cases, respectively. The median age was 31.5 years [interquartile range (IQR)=12] for AIDS cases and 30 (IQR=12) for HIV cases. Modes of transmission were heterosexual contact (34%), intravenous drug use (21%), male homosexual contact (19%), unknown (14%), haemophilia (6%), children of at-risk parents (4%) and blood (2%). The mean interval from HIV notification to AIDS diagnosis was 1.5 years until 1998 and 2.8 years thereafter. Knowledge, attitudes and practices studies on AIDS in Arabs are also discussed in this article.

CONCLUSION

HIV prevalence is lower in Arab Israelis than in non-Arab Israelis and Arabs residing in neighbouring countries. Nevertheless, the shorter interval from HIV notification to AIDS diagnosis in Arab Israelis suggests a lower rate of HIV testing and diagnosis at a later stage of infection. Patterns of transmission in Arab Israelis need further evaluation, including behavioural surveys.

Epidemiology of adult and adolescent HIV infection in Israel: a country of immigration

In Israel, the caseload and main modes of transmission have changed dramatically since 1991 after mass immigration from countries with generalized HIV epidemics. The previous annual average (of 60 new cases) has almost quadrupled, and 68% are among heterosexuals (compared with 11.6% before). We verified all HIV/AIDS cases ever documented, redefined (according to UNAIDS/WHO definitions) and analysed those aged 13+. Between 1980-2000, HIV and AIDS were diagnosed, respectively, in 2204 and 682 adults and adolescents (cumulative HIV infection rate = 61/100 000). Of these, 65.2% are male (mean age 35.0 years old; SD = 11.0), 31.5% female (mean age 31.4 years old; SD = 10.5) (and 3.3%, sex unknown). The main modes of HIV transmission were heterosexual (45%), MSM (16.9%) and IDUs (11.5%). Prevention measures must be strengthened, if the currently low-level of HIV epidemic among the Israeli general population is to be sustained.

Compulsory detention of recalcitrant tuberculosis patients in the context of a new tuberculosis control programme in Israel

OBJECTIVE

To analyse the use of compulsory detention in the context of a new national tuberculosis (TB) control programme launched in 1997.

METHODS

A retrospective review was made of the use of compulsory detention in the management of infectious TB before and after the initiation of a new TB control programme, using data from the central TB registry in the Ministry of Health and the charts of each patient.

RESULTS

Between 1994 and 2001, 13 recalcitrant patients out of 3056 (0.43%) cases of pulmonary TB were brought to trial. Eleven patients were detained. All were either hospitalized under a court order and, when failing to comply with the order, hospitalized in prison, or referred directly to a prison hospital. Twelve of 13 (92%) patients were new immigrants. After the new programme was launched, proportionately fewer patients were brought to trial [6/943 (0.64%) in 1994-1996 compared with 7/2113 (0.33%) in 1997-2001].

CONCLUSION

The reduction in the number of individuals detained could be viewed as an improvement in TB control due to the new TB control programme. It remains to be shown whether these individuals, most of whom had drug-resistant strains of TB, posed a sufficient threat to public health to justify detention.

Screening and management of tuberculosis in immigrants: the challenge beyond professional competence

SETTING

Right of entry may sometimes be denied to immigrants because of the threat of tuberculosis. During 1990-2000 some 1050000 immigrants, mostly from countries highly endemic for TB, arrived in Israel, a low prevalence country. Nevertheless, TB rates in Israel have remained low.

OBJECTIVE

To emphasise the challenge beyond technical competence for TB control for immigrants from the perspective of Israel's National Tuberculosis Programme (NTP).

MATERIALS AND METHODS

We defined criteria for an NTP geared to immigration, and analysed our implementation of the European Task Force recommendations on international migration and TB control. We interviewed immigrants and health care workers to identify barriers to diagnosis, prevention and treatment of TB among immigrants. We used classical epidemiology to evaluate the impact of immigration on TB rates in the host population.

RESULTS

Until now there has been no evidence of significant spread of TB from immigrants to the host population. Successful outcome of treatment has been noted in over 75%, although a sub-population of immigrant substance abusers is proving more difficult to treat.

CONCLUSIONS

The risk of TB for the host country is very low and it seems possible to enhance TB control in immigrants with measures designed to address their cultural needs.

The new National Tuberculosis Control Programme in Israel, a country of high immigration

SETTING

Israel has implemented a new tuberculosis (TB) control programme in response to the rise in the incidence of tuberculosis due to immigration in the last decade. It complies with World Health Organization guidelines, and also includes specific measures addressing the needs of immigrants. We describe the new programme and compare the outcome of treatment prior and after its realisation.

METHODS

Each component of the new strategy was scrutinised, aspects that did not function well were identified and how we contended with these issues is described. Analysis of outcome of treatment was according to WHO/IUATLD definitions.

RESULTS

Better and clearer organisation of TB treatment in all its aspects, including cultural sensitivity, has been obtained. Compliance improved from less than 27% for successful outcome before the new programme to more than 75% after. In addition to the improvement in completion rates, the universal use of directly observed treatment has ensured enhanced adherence.

CONCLUSION

Using legislative, administrative and budgetary measures, as well as clinical guidelines published by the Ministry of Health, the TB infrastructure in Israel has been successfully reorganised. The decision to do so was not only clinically and organisationally justifiable, it is also economically viable.

Genotypic variation of HIV-1 reverse transcriptase and protease: comparative analysis of clade C and clade B

OBJECTIVE

To compare drug-resistant variants from untreated (naive) and treated patients infected with clade B or C virus.

METHODS

Consecutive samples (165) from patients throughout Israel were analyzed. All those in the treated group were failing highly active antiretroviral therapy.

RESULTS

There were 87 clade B (14 naive) and 78 clade C (20 naive) [corrected] with significant differences in the prevalence of known drug-resistance mutations between the clades: in naive patients in the protease region M36I 7% and 95% (P < 0.0001), K20R 0% and 27% (P = 0.063), A71V 18% and 0% (P = 0.063), M46I 0% and 13%, and V77I 18% and 0% (P = 0.063), respectively, and in the reverse transcriptase region A98G/S 0% and 20% (P = 0.12), respectively. Most clade C viruses also showed significant differences from clade B consensus sequence at additional protease sites: R41K 100%, H69K/Q 85%, L89M 95% and I93L 80% (P < 0.0001). There were also significant differences (P < 0.03 to < 0.0001) in treated patients in clades B and C: in the protease region L10I 40% and 12%, M36I 26% and 95%, L63P 67% and 40%, A71I 38% and 7%, G73I and V77I 18% and 0%, I84V 16% and 3%, and L90M 40% and 12%, respectively; in the reverse transcriptase M41L 41% and 17%, D67N 41% and12%, K70R 30% and 7%, T215Y 48% and 29%, K219Q 21% and 7%, and A98G/S 3% and 24%, respectively.

CONCLUSION

Significantly differences between clade B and C viruses may be associated with development of differing resistance patterns during therapy and may affect drug utility in patients infected with clade C.

Epidemiological analysis of tuberculosis treatment outcome as a tool for changing TB control policy in Israel

BACKGROUND

Sensing an inadequacy of tuberculosis control due to an influx of TB associated with immigration, we analyzed TB treatment outcome in Israel by population groups.

OBJECTIVES

To provide an epidemiological basis necessary for any new national TB control policy, and to bring it to the attention of the medical profession in Israel and abroad since its results led to a change in Israel's TB control policy.

METHODS

We reviewed all TB cases notified during the period 1990 to September 1992. "New cases" (820 cases, 93.5%) and "re-treatment cases" (57 cases, 6.5%) were analyzed according to three mutually exclusive groups: "successful outcome," "death," and "potentially unsatisfactory outcome" (according to WHO/IUATLD definitions).

RESULTS

Of 820 "new cases," 26.6% had a "satisfactory outcome," 68.5% had a "potentially unsatisfactory outcome" and 4.9% died; compared to 47.4%, 45.6% and 7% among 57 "re-treatment cases," respectively. Using logistic regression analysis, outcome was associated with the district health office (P < 0.0001), the TB "experience" of the notifying clinic (P < 0.0001), and the form of TB (P = 0.02). No significant relationships were obtained for population groups, gender and age, interval between arrival in Israel and TB notification, and bacteriological results.

CONCLUSIONS

Non-supervised TB treatment resulted in poor outcomes regardless of population groups. Better outcomes occurred in the larger TB clinics. Therefore, in addition to measures such as adequate drug supplies, reorganization of TB laboratories and training of TB personnel, we recommend the "directly observed treatment short-course" for all cases as well as reducing the number of treatment centers thereby increasing their case load.

Molecular epidemiology of Mycobacterium tuberculosis infection in Israel

Restriction fragment length polymorphism analysis with IS6110 and DR-r probes was used to study 69 Mycobacterium tuberculosis isolates obtained from Israeli patients and new immigrants from the former Soviet Union and Ethiopia. DNA fingerprinting identified unique patterns for almost all isolates, indicating that most patients were infected with a unique strain imported from their country of origin and that their latent infection was reactivated in Israel.

Routine two-step skin testing for tuberculosis in the staff of a geriatric hospital in Israel: booster and conversion rates

The objective of this study was to determine the prevalence of positive skin tests amongst the staff of a 200 bed geriatric hospital in Haifa, Israel. By comparing the findings with those of a study performed five years previously, we hoped to ascertain the number of conversions which had occurred in the period studied. This was undertaken in order to assess a new policy from the Israel Ministry of Health regarding skin testing for health care workers. We also hoped to decide upon the frequency of skin testing required and to compare data from recent immigrants from countries with a high prevalence of TB. In 1997, we performed two-step skin testing (TSST) on 318 health care workers. We ascertained the number of positive reactions on the first and second testing and calculated the number of subjects who showed significant boosting. We also compared the results to those obtained in a study in 1992 and calculated the rate of conversion. We used multivariate analysis to examine the effects of age, gender, country of origin, years in Israel, previous BCG vaccination, previous exposure to contagious TB, work site and area of residence in the city, on the response to TSST. Between 1990 and 1996, 655 000 immigrants from the former USSR arrived; 'recent immigration' was defined from that date onward. The final number of positive reactions out of 282 subjects, who were either positive or negative on step 1 and presented for step 2, was 171 (60%). Booster effect was not significantly associated with any of the variables examined. The size of reaction in TSST was related to country of origin and recent immigration. The 83 recent immigrants from the former USSR had more frequent (61%) and larger reactions (mean (sd): 9.0 (6.46) mm) than the 114 native-born Israelis with 39% positive reactions (6.2 (5.89) P= 0.009). Comparison with 1992 revealed 26 (31%) of previous negatives as positive. Conversion was associated with age. All conversions save one were in individuals younger than 50 years (P= 0.07). In conclusion, TSST, performed to enable detection of recent infection after exposure to contagious TB, was relevant for 40% of health care workers (HCWs). Second step testing contributed an additional 23% positive reactions. New immigrants had larger initial reactions. Conversion occurred mostly in younger workers and could be either due to unrecognized TB in the hospital or to exposure in the community.

Prevention strategy of hepatitis B virus infection among the Ethiopian community in Israel

Between 1980 and 1985, over 16,000 immigrants from Ethiopia, a population at high risk for hepatitis B virus (HBV) infection, arrived in Israel. The present study was designed to provide epidemiological information necessary for developing prevention strategies against HBV infection. Among the 144 subjects studied in an absorption center in Israel, only 32% had no detectable HBV markers and were therefore susceptible to infection. The prevalence rate of HBsAg was 19% compared with 42% for anti-HBs and 7.6% for anti-HBc alone. The percentage of subjects with no HBV marker decreased sharply with age, and there was similarly an age-linked increase in anti-HBs, indicating the importance of horizontal transmission in HBV infection. The distribution of HBV markers was similar in both sexes. Evidence of mild liver disease was found in only three subjects. All newborns and new arrivals less than 2 years of age in the Ethiopian community are vaccinated against HBV infection to prevent vertical and early horizontal transmission. The data obtained in our study suggest that this means of prevention of HBV infection is insufficient. We suggest that the vaccination of all children aged 2-7 without prevaccination screening, and the vaccination of children aged 8-18 found to be susceptible on anti-HBc screening, would substantially lower HBV transmission in this community.

[Influence of the risk factors of atherosclerosis on the onset of early peri-operative complications in peripheral arterial surgery]

The influence of classical atherosclerosis risk factors (male sex, smoking, hypercholesterolemia, diabetes, overweight and hypertension on peri-hospital mortality and morbidity were studied in 83 patients (68 men and 15 women) aged 63 +/- 13 years and undergoing peripheral arterial surgery. None of these factors was statistically correlated with peri-operative complications with the exception of hypertension but the correlation was slight (0.5 less than p less than 0.10). In contrast, there was a powerful statistical (p less than 0.0003) link between age and morbidity and mortality associated with this type of surgery.