Rapid TB diagnostic service and community action to FIND.TREAT.ALL#EndTB, Maputo, Mozambique, 2013-2018.

Finding and treating all tuberculosis (TB) patients is crucial for ending TB. We investigated whether rapid diagnostic turnaround time (TAT) and patient tracking could increase TB treatment initiation in Maputo, Mozambique. Among 3329 TB patients newly diagnosed by the University Eduardo Mondlane-Anti-Persoonsmijnen Ontmijnende Product Ontwikkeling/Anti-Personnel Landmines Detection Product Development (APOPO) Laboratory between 2013 and 2018, on average 61% were verifiably linked to care. This proportion increased from 54% (first half 2013) to 79% (second half 2018) after introducing a 24-hour TAT in 2015 and patient tracking conducted by a community-based partner, Associação Kenguelekezé, in 2017. Rapid, well-connected TB diagnostic services can reduce pre-treatment loss to follow-up and support the joint initiative of WHO, Stop TB and Global Fund to 'FIND.TREAT.ALL.#EndTB'.

Identifier et traiter tous les patients atteints de tuberculose (TB) est crucial pour mettre fin à la TB. Nous avons vérifié si un délai plus court de diagnostic (TAT) et un système de recherche des patients augmentait la mise en œuvre du traitement de la TB à Maputo, Mozambique. Parmi 3329 patients TB nouvellement diagnostiqués par le laboratoire UEM-APOPO (2013­2018), en moyenne 61% ont été réellement connectés à la prise en charge. Le pourcentage a augmenté de 54% (première moitié de 2013) à 79% (deuxième moitié de 2018) après l'introduction du TAT en 24h en 2015 et la surveillance des patients effectuée par notre partenaire l'association à base communautaire Kenguelekezé en 2017. Notre expérience suggère que des services de diagnostic de TB rapides, bien connectés peuvent réduire les abandons avant le traitement et soutenir les tentatives mondiales « FIND.TREAT.ALL.#EndTB ¼.

La búsqueda y el tratamiento de todos los pacientes con tuberculosis (TB) son primordiales para poner fin a esta enfermedad. Se investigó si con un lapso corto de obtención del diagnóstico y el seguimiento de los pacientes aumentaría el inicio del tratamiento antituberculoso en Maputo, Mozambique. En promedio, en 61% de los 3329 casos nuevos de TB diagnosticados en el laboratorio UEM-APOPO (2013­2018) se confirmó la vinculación de los pacientes con los servicios de atención. El porcentaje aumentó de 54% (primer semestre del 2013) a 79% (segundo semestre del 2018), después de haber introducido un plazo de obtención del diagnóstico de 24 horas en el 2015 y la localización de los pacientes por parte de la asociación comunitaria Kenguelekezé en el 2017. Esta experiencia indica que los servicios diagnósticos de la TB que son rápidos y mantienen vínculos adecuados disminuyen la pérdida durante el seguimiento antes de comenzar el tratamiento y fortalecen los esfuerzos de la iniciativa 'FIND.TREAT.ALL.#EndTB'.

Tuberculosis and latent tuberculous infection screening of migrants in Europe: comparative analysis of policies, surveillance systems and results.

Migration patterns into and within Europe have changed over the last decade. In 2015, European Union (EU) countries received over 1.2 million asylum requests, more than double the number registered in the previous year. This review compares the published literature on policies for tuberculosis (TB) and latent tuberculous infection (LTBI) screening in EU and European Free Trade Association (EFTA) countries with the existing TB/LTBI screening programmes for migrants in 11 EU/EFTA countries based on a survey of policy and surveillance systems. In addition, we provide a systematic review of the literature on the yield of screening migrants for active TB and LTBI in Europe. Published studies provide limited information about screening coverage and the yield of screening evaluations in EU/EFTA countries. Furthermore, countries use different screening strategies and settings, and different definitions for coverage and yield of screening for active TB and LTBI. We recommend harmonising case definitions, reporting standards and policies for TB/LTBI screening. To achieve TB elimination targets, a European platform for multi-country data collection and analysis, sharing of countries' policies and practices, and harmonisation of migrant screening strategies is needed.

[Current epidemiology of tuberculosis in Germany]. / Aktuelle Epidemiologie der Tuberkulose in Deutschland.

BACKGROUND: In addition to malaria and HIV/AIDS, tuberculosis (TB) is one of the world's most important infectious diseases. Also in Germany tuberculosis still remains a relevant public health problem that needs special attention. OBJECTIVES: This article provides an overview of the tuberculosis epidemiology in Germany with emphasis on drug resistance and population groups that are predominantly affected. METHODS: Based on surveillance data provided in the notification system, the TB-situation in Germany is presented-particularly with respect to drug resistance, origin of patients (country of birth and nationality) and treatment outcome. RESULTS: Since 2009, the continuous decline in case numbers has slowed down and is now stagnating as observed in several other industrialized nations. Since 2007, the proportion of foreign-born patients has continuously increased and accounts for over half of all cases registered in Germany. Special attention deserves the current drug resistance situation: With a proportion of 3.4% in 2013, multidrug-resistant tuberculosis (MDR-TB) has increased significantly compared to the previous year (2.1%) and the rate is therefore higher than in many other European low-incidence countries. Particularly high levels of MDR-TB were observed among foreign-born patients originating from a former Soviet Union country. On average, treatment success was observed in 79% of the cases. Thus, Germany does not reach the WHO target of 85% treatment success. Stagnating case numbers together with the observed drug resistance trend clearly indicate the need for continued efforts in tuberculosis control in Germany including focused strategies for the most affected population groups.

Bacteriological confirmation of pulmonary tuberculosis in children with gastric aspirates in Germany, 2002-2010.

OBJECTIVE: To assess bacteriological confirmation of pulmonary tuberculosis (TB) in children using nucleic acid amplification tests (NAAT) and culture of gastric aspirates in Germany. DESIGN: We analysed 2002-2010 TB notification data to determine the use of gastric aspirates, NAAT and culture performance, including test agreement among pulmonary TB patients aged <15 years (grouped into <1, 1-4, 5-9 and 10-14 years). RESULTS: Gastric aspirates were used among 59% (769/1307) of the patients with available diagnostic information. For 454 patients, gastric aspirates were the only reported specimen, and both NAAT and culture were performed. Among these, culture was positive in 53% (95%CI 48-58), NAAT in 48% (95%CI 44-53) and either test in 63% (95%CI 59-68), with an overall test agreement of 74% (95%CI 70-78). Infants < 1 year had the highest positivity rate (79%, 95%CI 68-88, either test). Test agreement was the highest among 10-14 year olds (79%, 95%CI 67-89). CONCLUSIONS: Routine notification data document a wide use of gastric aspirates and high yield of both NAAT and culture for bacteriological confirmation of TB with gastric aspirates, particularly in infants. Imperfect test agreement supports the combined use of molecular assays and culture-whenever available-in the diagnosis of childhood TB.

Laboratory diagnosis of paediatric tuberculosis in the European Union/European Economic Area: analysis of routine laboratory data, 2007 to 2011.

Laboratory confirmation of paediatric tuberculosis (TB) is frequently lacking. We reviewed the range of routine laboratory tests and their performance in different biological samples used to diagnose active TB in children. A questionnaire-based survey was conducted among the European Reference Laboratory Network for TB followed by collection of routine laboratory data on 10,549 paediatric samples tested in 2007 to 2011 at six reference laboratories (in Croatia, Germany, Italy, Latvia, Lithuania and the United Kingdom (UK)). The questionnaire showed that all laboratories used rapid assays. Non-respiratory samples were collected more often in Germany (135/275, 49.1%) and the UK (490/2,140, 22.9%) compared with Croatia (138/2,792, 4.9%), Latvia (222/2,401, 9.2%) and Lithuania (76/1,549, 4.9%). Overall laboratory positivity rates (isolation of Mycobacterium tuberculosis complex and/or identification of its nucleic acids in a sample) were higher in lymph node and gastric aspirate samples (14/203 (6.9%) and 43/1,231 (3.5%)) than in sputum samples (89/4,684 (1.9%)). Pooled sensitivity, specificity, positive and negative predictive values and accuracy of molecular assays assessed against solid or liquid culture were 79.2%, 93.6%, 67.1%, 96.5% and 91.6%, respectively. A more intensive approach in obtaining gastric aspirate and non-respiratory samples may increase laboratory confirmation of paediatric TB. Major effort is needed in optimisation and validation of molecular tests in these samples.

The burden of extrapulmonary and meningitis tuberculosis: an investigation of national surveillance data, Germany, 2002 to 2009.

Tuberculosis (TB) surveillance commonly focuses on pulmonary (PTB) where the main organ affected is the lung. This might lead to underestimate extrapulmonary TB (EPTB) forms, where in addition to the lung other sites are affected by TB. In Germany, TB notification data provide the main site and the secondary site of disease. To gain an overview of all the different EPTB forms, we analysed German TB notification data between 2002 and 2009 using information on both main and secondary disease site to describe all individual EPTB forms. Further, we assessed factors associated with meningitis using multivariable logistic regression. Solely analysing the main site of disease, lead to one third of EPTB manifestations being overlooked. Case characteristics varied substantially across individual extrapulmonary forms. Of 46,349 TB patients, 422 (0.9%) had meningitis as main or secondary site. Of those, 105 (25%) of the 415 with available information had died. Multivariable analysis showed that meningitis was more likely in children younger than five years and between five and nine years-old (odds ratio (OR): 4.90; 95% confidence interval (CI): 3.40­7.07 and OR: 2.65; 95% CI: 1.40­5.00), in females (OR: 1.42; 95% CI: 1.17­1.73), and in those born in the World Health Organization (WHO) regions of south-east Asia (OR: 2.38; 95% CI: 1.66­3.43) and eastern Mediterranean (OR: 1.51; 95% CI: 1.02­2.23). Overall, EPTB manifestations, including meningitis, which is often fatal, were underestimated by routine analysis. We thus recommend using all information on disease manifestation generated by surveillance to monitor severe forms and to transfer the gained knowledge to TB case management where awareness of EPTB is most important.

Tuberculosis surveillance and control in Germany - An application of the Berlin Declaration Monitoring and Evaluation Framework.

BACKGROUND: In 2007, the 'Berlin Declaration on Tuberculosis' (BD) was signed by the Ministers of the WHO European Region Member States (MS) to address the re-emerging threat of tuberculosis (TB) by fully implementing the Stop TB strategy. WHO Euro developed a Monitoring and Evaluation (M&E) Framework using programmatic and epidemiological indicators to follow-up the BD from 2013 onwards. Ahead of this, we explored the Framework performance for Germany, a low TB incidence country. METHODS: We selected from a surveillance perspective on five country-specific indicators asked for all MS. Information sources included guidelines, notification data and laboratory quality assurance results. RESULTS: As to national TB guidelines (indicator 1.1.1), up-to-date guidance documents are available. Regarding external quality assurance (3.2) proficiency testing confirms high quality of culture and drug-susceptibility testing. M/XDR-TB prevention and control is reflected by a 1.7% MDR-TB rate in 2010 with decreasing tendency (4.1.2). As to treatment success (5), the WHO target of 85% is reached for all age groups except the elderly ≥60 years. Germany disposes of an electronic case-based surveillance providing evidence for TB policy and practices (5.2.2). CONCLUSIONS: The selected M&E Framework indicators proved well applicable to a low-incidence country. The results show no specific gaps in TB surveillance and control in Germany.

Avian influenza A(H5N1) in humans: new insights from a line list of World Health Organization confirmed cases, September 2006 to August 2010.

The threat of avian influenza (AI) viruses to humans in Europe in 2005 prompted the Robert Koch Institute to establish a routine monitoring instrument condensing information on all human AI cases worldwide reported from the World Health Organization (WHO) and other sources into a line list for further analysis. The 235 confirmed AI cases captured from September 2006 to August 2010 had a case fatality rate of 56% (132/235), ranging from 28% (27/98) in Egypt to 87% (71/82) in Indonesia. In a multivariable analysis, odds of dying increased by 33% with each day that passed from symptom onset until hospitalisation (OR: 1.33, p=0.002). In relation to children of 0­9 years, odds of fatal outcome were more than six times higher in 10­19 year-olds and 20­29 year-olds (OR: 6.06, 95% CI: 1.89­19.48, p=0.002 and OR: 6.16, 95% CI: 2.05­ 18.53, p=0.001, respectively), and nearly five times higher in patients of 30 years and older (OR: 4.71, 95% CI: 1.56­14.27, p=0.006) irrespective of the country, which had notified WHO of the cases. The situation in Egypt was special in that case number and incidence in children were more than twice as high as in any other age group or country. With this study, we show that data from the public domain yield important epidemiological information on the global AI situation. This approach to establish a line list is time-consuming but a line list is a prerequisite to such evaluations. We thus would like to encourage the placing of a publicly accessible line list of anonymised human AI cases, e.g. directly by WHO. This might enhance our understanding of AI in humans and permit the rapid detection of changes in its epidemiology with implications for human health.

Disease awareness of the poultry keepers in Switzerland and their access to information concerning highly pathogenic avian influenza.

The passive surveillance of highly pathogenic avian influenza (HPAI) in domestic poultry is based essentially on the reporting of suspicious clinical cases by the poultry keepers to the veterinary services. As little was known about HPAI disease awareness among Swiss poultry keepers, a cross-sectional study was conducted among poultry keepers in Switzerland in 2007. For data triangulation and complementary information, interviews have been conducted with experts of poultry marketing organizations. The main information source used by the poultry keepers was mass media. Having a non-commercial poultry husbandry was significantly associated with lower knowledge scores. Non-commercial poultry keepers felt neglected by the veterinary authorities. Risks perceived by the poultry keepers reflected well the officially communicated risks for HPAI introduction. By highlighting the needs and the knowledge level of the poultry keepers, we make recommendations with regard to more efficient information exchange between poultry keepers and veterinary authorities. The main challenge will be to consistently integrate non-commercial poultry keepers in the formal information channels.