Tuberculosis during Pregnancy in Northern Israel, 2002-2012: Epidemiology and Clinical Practices.

BACKGROUND: Atypical presentation of tuberculosis (TB) during pregnancy may cause diagnostic delay and adversely influence pregnancy outcome. OBJECTIVES: To examine the incidence and clinical and epidemiological features of TB during pregnancy and investigate infection control measures at delivery and during the postpartum period. METHODS: We retrospectively evaluated all reported cases of TB diagnosed during pregnancy to 6 months postpartum in Israel's Northern Health District (2002-2012). RESULTS: Active TB was detected in six patients; all were negative for human immunodeficiency virus (HIV). Two patients were diagnosed in the postpartum period, and four had pulmonary involvement. The average incidence during this period (3.9 per 100,000 pregnancies) was similar to that in the general population. Five patients were at high risk of contracting TB due to either recent immigration from a high-burden country or being in contact with another individual with active TB. Patients with pleuropulmonary involvement had prolonged cough and abnormal chest X-rays, without fever. Diagnosis was delayed for 3 to 7 months from symptom onset. Investigation of the newborn to rule out intrauterine infection was conducted in only one of four relevant cases. All patients were infected with organisms susceptible to all first-line drugs, and all were cured with standard therapy. CONCLUSIONS: There was a considerable delay in the diagnosis of TB among pregnant women, and investigation of the newborn upon delivery to rule out TB infection was routinely omitted. Effective management of TB during pregnancy and the postpartum period requires a multidisciplinary approach including an obstetrician, pediatrician, TB specialist, and public health physician.

[Accessibility and compliance of Ethiopian immigrants to latent tuberculosis infection treatment].

BACKGROUND: Since the incidence of TB has decreased in the developed countries, the diagnosis and treatment of latent TB infection (LTBI) has assumed increasing importance. It is estimated that 5-10% of persons with LTBI go on to develop TB; therefore, the crucial role of LTBI treatment in eliminating TB is well recognized. However, levels of adherence are found to be consistently low, and noncompliance constitutes the major barrier for achieving the full benefits of LTBI treatment. OBJECTIVE: 1. To estimate rates of treatment completion with an outreach - directly observed preventive treatment (DOPT), a program among Ethiopian immigrants (El) at absorption centers treated for LTBI. 2. To determine if follow-up visits by a physician at their place of residence, vs. management at a TB Clinic (TBC), would further enhance the patient's adherence. METHODOLOGY: Quasi experiment, retrospective cohort analysis of 495 medical records for all El at absorption centers in Zefat who had started DOPT for LTBI and were followed up at absorption centers (2005-2006, study group - SG), compared to patients followed up at a TBC (2008-2010, comparison group - CG). Free transportation to the TBC was provided for the CG. FINDINGS: Altogether 495 Els were included (263 in the SG and 232 in the CG group). Both groups had high completion rates (SG: 96.2% vs. CG: 93.1%, p=0.14). While demographic factors did not predict treatment completion, side effects were significantly associated with non-completion. CONCLUSION: High treatment completion rates among El were achieved when DOPT outreach and cultural case management strategies were combined. In these circumstances, the physician follow-up location had no significant impact on treatment completion rates.

Indolent pneumonia in a pregnant recent immigrant from Ethiopia: think TB.

Time delay to tuberculosis (TB) diagnosis remains a public health concern. In pregnancy, early TB diagnosis is challenging and acquires further significance due to the risk of infection of the newborn as well as others in the maternity setting. We report a delay of 12 weeks in the diagnosis of TB in a pregnant recent immigrant from Ethiopia to Israel. Contact investigation revealed pulmonary TB in her two daughters aged four and seven years. We discuss the reasons for this delay in diagnosis, how a more timely diagnosis might have been made, and the dilemma of initiating treatment in unconfirmed TB.

[Tuberculosis in pregnancy and puerperium].

According to the World HeaLth Organization, tuberculosis (TB) is the third leading cause of death worldwide among women at child bearing age. However, in Israel, a low TB prevalence country, TB in pregnant women is infrequent and infectious pulmonary TB at puerperium is rare. Early diagnosis of TB in pregnancy is challenging because the non-specific symptoms of early TB such as weakness, excess perspiration and tachycardia will usually be attributed to pregnancy. Furthermore, since health care givers attempt to avoid superfluous exposure of the fetus to radiation, and pregnant women are reluctant to be X-rayed, the diagnosis of active TB may be further delayed, especially if the woman is not in a risk group for TB. However, delaying treatment of TB in a pregnant woman, especially in advanced pregnancy may lead to TB in the fetus, TB infection of the new born transmitted from the mother who may also infect other mothers and their infants in the maternity ward. We report a case of highly infectious active TB diagnosed in a pregnant woman one week before delivery. The woman, a native Israeli, had no risk factor for TB except her recent stay in a high burden TB country. We present the diagnostic workup and therapeutic approach to the pregnant patient, the newborn infant and the measures applied to control infection. Awareness of risk factors for TB, the elusive symptoms of the disease during pregnancy, and implementing the necessary diagnostic workup at delivery is vital to minimize pregnancy related TB morbidity.

Geographic and epidemiologic analysis of the cutaneous Leishmaniasis outbreak in northern Israel, 2000-2003.

BACKGROUND: The incidence of cutaneous leishmaniasis in northern Israel began to rise in 2000, peaking at 41.0 per 100,000 in the Kinneret subdistrict during the first half of 2003. OBJECTIVES: To examine the morbidity rates of CL in northern Israel during the period 1999-2003, which would indicate whether new endemic areas were emerging in this district, and to identify suspicious hosts. METHODS: The demographic and epidemiologic data for the reported cases (n=93) were analyzed using the GIS and SPSS software, including mapping habitats of suspicious hosts and localizing sites of infected sand flies. RESULTS: The maximal incidence rate in the district was found in the city Tiberias in 2003: 62.5/100,000 compared to 0-1.5/100,000 in other towns. The cases in Tiberias were concentrated on the peripheral line of two neighborhoods, close to the habitats of the rock hyraxes. Sand flies infected with Leishmania tropica were captured around the residence of those affected. Results of polymerase chain reaction were positive for Leishmania tropica in 14 of 15 tested patients. CONCLUSIONS: A new endemic CL area has emerged in Tiberias. The most suspicious reservoir of the disease is the rock hyrax.