smpp tuberculosis janssens

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Published on October 15, 2007

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Epidemiological and social aspects of tuberculosis in Switzerland:  Epidemiological and social aspects of tuberculosis in Switzerland JP Janssens; Lugano, 2007 Incidence of active TB among foreign-born populations:  Incidence of active TB among foreign-born populations In most low-incidence countries: 35-70% of cases of reported TB are foreign-born Over-all public health impact of TB among foreign-born considered as modest Incidence of TB in the UK (1998): Native-born: 4.4 /105 Foreign-born (mainly India and Pakistan): 120 – 210 /105 Tuberculosis in Switzerland 2001-2004:  Tuberculosis in Switzerland 2001-2004 593 cases in 2004: 8 / 10E5 inhabitants 212 cases among the Swiss born population: 3.6 / 10E5 inhabitants Foreign born subjects: 59% in 2001  64% in 2004 80% S+/C+ or S-/C+ Mean age of Swiss subjects: 65 years Mean age of foreign subjects: 31 years Tuberculosis in Switzerland 2001-2004 (2):  Tuberculosis in Switzerland 2001-2004 (2) AIDS and TB: 4% of cases (4.5% of foreigners, 2.6% of Swiss nationals)  minor role in epidemiology of TB in Switzerland 58% M (69% among foreigners) 24% of all TB cases are asylum-seekers (« du domaine de l’asile ») Epidemiology of tuberculosis in Geneva:  Epidemiology of tuberculosis in Geneva Slide10:  0% 5% 10% 15% 20% 25% 30% 35% 40% Suisse Origin of patients with TB in Geneva: 2005-6 80 cases /year More than 80% of subjects with TB are foreigners Slide11:  0% 5% 10% 15% 20% 25% 30% Suisses Permis B Permis C Social status of patients with TB in Geneva: 2005-6 26-35% of TB cases occur in foreign subjects in an unstable social situation Tuberculosis in the illegal immigrant population of Geneva 1994-2003:  Tuberculosis in the illegal immigrant population of Geneva 1994-2003 World wide dimension of migration:  World wide dimension of migration Asylum seekers in industrialised countries 5 Mio Irregular migrants in Europe 3 Mio Irregular migrants in Switzerland 1-200’000 Irregular migrants in Geneva 10’000 Migrants without legal status: potential causes of concern:  Migrants without legal status: potential causes of concern Fear of local authorities/services Reduced access to health care Delay in seeking care Increased risk of transmission to local population Decreased compliance, geographic instability Multidrug resistance: higher prevalence? Slide15:  Migrants in an irregular situation with active TB: Geneva: 1994-1998 Perone SA et al Emerg Infect Dis. 2005 Feb;11(2):351-2 Slide16:  19F/2 M (90% F), M age: 32 yrs (range: 19-48 yrs) 66% originated from South America; 24% from Africa 66% gainfully employed Pulmonary TB: 13 cases (62%); Extra-pulmonary TB: 15 cases (71%); Pulmonary and extra-pulmonary TB: 7 cases (33%) No MDR-TB; 19%: resistance to 1 drug 4 DOT 13/21 (62%): treatment completed, good compliance 8 patients left Switzerland (after a median of 3.7 months of tt) 82%: good compliance while treated Data from Geneva: 1994-1998 Slide17:  Data from Geneva: 1999-2003 23F/9 M (72% F); M age: 38 (17-55 years) Pulmonary TB: 69% Extra-pulmonary TB: 46% Pulmonary and extra-pulmonary TB: 14% 62% originated from South America; 12% from Africa; 9% from Kosovo & Macedonia 81% compliance rate while treated (monthly urinary INH dosage) 28% lost to follow-up 1 case of MDR-TB; 2 patients HIV+ JP Janssens, S Sauthier Costs: Geneva 1999-2003:  Costs: Geneva 1999-2003 Estimation of costs related to contact tracing and treatment for TB in illegal migrants in Geneva (based on costs billed to the Department of Medicine, Geneva University Hospital) Data for 24 patients 175 subjects screened Average of 7 subjects screened per TB case Total cost for 24 patients: 33 ’800 CHF Average cost per TB case: 1 ’410.00 CHF Social and economic aspects: data from the 1994-98 study:  Social and economic aspects: data from the 1994-98 study 66% (8/12) lost their job 82% (18/22) did not have any health insurance Debt contracted due to hospitalisation at beginning of treatment Patients have to pay for their drugs, but medical follow-up is free of charge Tuberculosis and irregular migration: important goals:  Tuberculosis and irregular migration: important goals Facilitate access to health care Free treatment or financial support Explore innovative approaches for early detection of TB Find new channels of information on TB reaching irregular migrants Delay sending back subjects to their country of origin to allow completion of treatment Comments on TB in illegal migrants in Geneva:  Comments on TB in illegal migrants in Geneva The majority of irregular migrants with active TB in Geneva over the last 10 years are women from South America or Africa High rates of extra-pulmonary TB were documented, probably for ethnic reasons; this may increase delay before seeking care Compliance was excellent but pressure from the authorities and expulsion from Switzerland jeopardizes completion of treatment In this group, there was a low rate of MDR-TB, and HIV/TB co-infection Resistance to anti-TB drugs: a concern in Switzerland?:  Resistance to anti-TB drugs: a concern in Switzerland? Gamma-interferon assays for detecting latent tuberculosis infection (LTBI):  Gamma-interferon assays for detecting latent tuberculosis infection (LTBI) Slide26:  -IFN assays for detecting LTBI Antigens highly specific for the M TB complex: ESAT-6 (Early secreted antigenic target) & CFP-10 (culture filtrate protein) ESAT-6 and CFP-10 are not present on the BCG Circulating lymphocytes (CD4) of a subject infected by M. tuberculosis produce  -IFN when they are cultivated in presence of these antigens 2 tests available: T-SPOT.TB (ELISPOT) & QuantiFERON-TB (ELISA) Slide27:  Centrifugation Overnight culture in presence of ESAT-6 or CFP-10 And anti- IFN- antibodies; + and - Controls Optic reading PBMC T-SPOT.TB JPJ/5.05 Slide28:  If > 6 spots difference between Panel A or B and negative control: Test + If < 20 spots in + control: indeterminate Slide29:  T-SPOT.TB: specifics Sample must reach a competent laboratory within 8 hours Laboratory must be familiar with extraction of white cells from peripheral blood and cell culture Qualitative result : +/-/? False +: M. Kansasii; M szulgai; M marinum: Se (Active TB, normal immunity) 96%; Sp: 98-99% JPJ/5.06 Slide31:  QuantiFERON-Gold: specifics Sample must reach a competent laboratory within 12 hours Elisa performed in peripheral blood: no cell extraction Influence of background -IFN (cells are not washed)? Indeterminate results more frequent (ad 21%) Qualitative results Se (Active TB, normal immunity) 85%; Sp: 98-99% Slide32:  Lancet, 2001: 357: 2017 JPJ/11.05 Slide33:  Lancet, 2001: 357: 2017 JPJ/11.05 Slide34:  91 subjects, mean age 46 years, exposed to an index case. Contact screening: T-SPOT.TB et TST 78 (86%): BCG vaccinated… Slide36:  -IFN assays for detecting LTBI Specificity very attractive Quantiferon-Gold FDA approved and recommended by CDC Two-step procedure (TST then -IFN assay) recommended by « NICE » guidelines (UK) -IFN assays do not distinguish active from latent disease Slide37:  The clinical contribution of T-SPOT.TB and QuantiIFERON-GOLD rests only on circumstantial evidence….. Slide38:  Conclusions *:OFSP Bulletin 2006; 22: 428 Over the past 5 years, TB in Switzerland has stopped decreasing TB is increasingly a disease of younger foreign-born adults Immigrants carry with them the risk of TB of their home country One quarter of active cases are related to the process of asylum* In illegal immigrants, compliance to treatment is quite acceptable In unstable populations, screening for LTBI and treatment for LTBI are of questionnable value In illegal migrants, treatment completion must be guaranteed by migration authorities Figures for discussing screening against TB:  Figures for discussing screening against TB Chest X-Ray screening for TB in high-risk populations:  Chest X-Ray screening for TB in high-risk populations Eur Respir J 2005; 25: 1107 1 cas de TB active détecté pour 125 – 2500 Rx Slide41:  Risk of reactivation in subjects with LTBI Eur Respir J 2005; 25: 1107 0.1% / yr with normal X-ray 0.2% /yr with « granulomas » 0.6% / yr with apical fibro-nodular disease Slide42:  General comments on X-ray screening for TB Eur Respir J 2005; 25: 1107 Se: 59-82% Sp: 52-63% Less sensitive and specific in HIV + subjects If prevalence of 1%: PPV  1.7%; NPV  99.5%

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