- Email: [email protected]
The increase in tuberculosis in England and Wales 1987–1991
52
Tubercle and Lung Disease: Supplement
before being enrolled in NTP. Most of those cases were diagnosed without sputum examination and referred to NTP for free medicine. 25 % had visited a traditional healer, and it is more popular in rural, female and illiterate populations. However health posts were not well utilized for case-finding, as only 10 % had visited there for initial medical consultation. 50% (80%) of the patients had consulted a health post staff or a doctor within 1.5 month (3.9 m) after the onset of symptoms. However this period was significantly longer in rural area and illiterate people, and a little longer in female. In rural area, the delay of diagnosis after the first medical consultation was longer because of a lack of diagnostic facilities and the interruption of visiting due to the distance and/or poverty. Although NTP broadcasted an educational programme and campaign songs by radio, those were not recognized by illiterate people. The service oriented to rural, female and illiterate populations must be developed. Collaboration with doctors in private sectors and big hospitals is important for proper case-finding and treatment in NTP. And training to the traditional healers will shorten the patient delay in rural area. 1ss QUALITATIVE
ANALYSIS OF TUBERCULIN SKIN TEST IN THE DIAGNOSIS OF TUBERCULOSIS IN CHILDHOOD
Oliveira, H. M. V., Santhnna, C. C. and Braga, J. U.; Run Alice 150 sala I, Laranjeiras- CEP 22241-020 - Rio de Janeiro, Brasil
Tuberculin skin test with 2U PPD Rt 23 was given to 223 children: 101 had been immunized with BCG Id, and had no disease: 65 had pneumonia: 57 had clinical, radiological and epidemiological features suggesting tuberculosis, 33 of them had previously been immunized with BCG Id. We evaluated the efficacy of the test for diagnosis tuberculosis in children.
of
The results of findings from the tuberculin skin tests were submitted to a conventional quantitative analysis, that showed 85.9 % of sensitivity and 86.1% of specificity. We considered 10 mm as the limit value between reactors and non reactors. The qualitative analysis of the tuberculin skin test - Koch phenomena - indicated 77.2% of sensitivity and high specificity (98.0 %). We concluded that the qualitative interpretation of the tuberculin skin test played an important role in the diagnosis of tuberculosis in children with clinical and radiological features of this disease. 189 THE VALUE OF FINE-NEEDLE ASPIRATION
BIOPSY @‘NAB) IN THE DIAGNOSIS OF TUBERCULOUS LYMPHADENITIS IN HIVlSEROPOSITIVE AND HIV&SERONEGATIVE PATIENTS IN BRAZIL Conde-Junior, H. M.‘, Kritski, A. L.2, Carvalho, C. E. S.‘, DallaRosa, P.‘, Werneck-Barroso, E.‘, Vieira, M. A. M.‘, Carvalho, A. C. C.‘, Cardoso, A. P.2
1ITPAJFRJ; Objective:
* Service de Pneumologia
do HCFFIUFRJ,
To evaluate the fine-needle diagnosis of TB lymphadenitis.
Rio de Janeiro
(22-gauge) in the
Methods: 49 patients (32 HIVl-seropositive) presenting to one surgeon for diagnostic surgical biopsy of peripheral lymph node, after written consent, were evaluated during Sep, 1992-October, 1993. Fine-needle aspiration was routinely preceded open surgical biopsy. All the cases had Papanicolaou, Giemsa, Ziehl-Neelsen and metenamine silver stains and cultures for tuberculosis and fungi using the syringe washing with sterile saline. Results: The mean age of the patients was 30.2 SD f 8.8 yrs. The male/female ratio was 2.7:1. Thirty two out of 49 (65.3 %) patients had culture-proven TB lymphadenitis, of whom 23 out of 32 (71.8 %) HIVl-seropositive. Among HIVl-seropositive TB patients, the PPD skin test was > = 5 mm in 50 % (11122) and among HIVl-seronegative, PPD >= 10 mm in all cases. The diagnostic yield of FNAB (presence of granuloma and/or epithelioid cells) was 50.0% (16/32) and of surgical biopsy (presence of acid-fast bacilli-AFB or caseation and/or granulomas and giant cells) was 96.8% (31/32). In microscopic examination, if we include caseation in the aspirate as a diagnostic of TB, the final diagnostic yield of FNAB was 62.5 % (20/ 32) and false positive result was not found. Among patients with TB, regarding the FNAB and surgical biopsy, AFB were observed respectively in 7129 (24.2 %) and 12/32 (37.5%) (p=NS). The presence of AFB in surgical biopsy was significantly associated with HIVlseropositive patients (p=O.O4) but is was not in FNAB specimens. And, the absence of granulomatous process in surgical biopsy was not associated with the seropositivity for HIV1 (p=NS). Conclusions:
In primary health settings may be recommended that patients HIVl-seropositive or seronegative with suspected TB lymphadenitis, undergo fine-needle aspiration before surgical biopsy.
190 THE INCREASE
ENGLAND
IN TUBERCULOSIS AND WALES 1987-1991
IN
Doherty, M. J., Spence, D. P.S., Davies, P. D. 0.; Aintree Chest Centre and Tuberculosis Research Unit, Liverpool UK
Tuberculosis notifications have been rising in England and Wales since 1987. The number of notifications was at it’s lowest in 1987 at 5,085, rising to 5,436 in 1991 and just over 6,000 notifications in 1993. Little informations is available as to whether this rise is occuring in any particular group of subjects or whether it is a general increase. We have undertaken an analysis of notification rates divided by standard region, age and sex group and by site of disease for the period 1987-1991. 1991 is the last year for which data brokendown like this is available from the Office of Populations, Censuses and Surveys. The main findings were that the increase in notification rates occured in females (average annual percentage change + 2.5 [95 % confidence limits + 0.56 to + 4.71) rather than males -0.06 % (- 2.9 to +2.7). That the increase is in younger groups rather than the elderly, females aged 35-44 years show an increase of 3.2 % (+0.9 to +8.0) compared to females over 75 years who show a decrease of 1.4 % (- I2 to + 10). Analysis by region showed an increase in only three regions, Yorkshire and Humberside +3% (+0.89 to +7.75), the South East +2.76 (-0.37 to 13.63) and the West Midlands +4.85 % (-3.9 to + 13.6). Although the increase was significant only in Yorkshire and Humberside, if the data for region is broken down by
Tubercle and Lung Disease: Supplement sex, females from the South East show a significant rise +4.6% (+2.1 to +7.0). Data on site of disease shows the increase can be accounted for by an increase in disease at non-respiratory sites, non-respiratory + 7.13 % (+ 2.7 to + 11.5) compared with respiratory site -0.8% (-3.0 to + 1.3). In conclusion the increase in non-respiratory disease and the regions in which this increase has occured in suggest that immigration has played a large part in the increase in tuberculosis in England and Wales. The analysis also highlights areas for further research and areas where resources should be concentrated.
191 TRANSMISSION OF M. TUBERCULOSIS ASSOCIATED WITH AIR TRAVEL Driver, C., Valway, S., Morgan, M., Onorato, I., Castro, K.; Centers for Disease Control and Prevention, MS E-IO, 1600 Clifton Rd, Atlantu, GA, USA 30333
Background.
Eight of nine household contacts of a flight attendant (FA) with cavitary tuberculosis (TB) had positive tuberculin skin tests (TSTs), thus, transmission of Mycobacterium tuberculosis to coworkers was investigated. Methods.
Crew who flew with the FA during May October 1992, while she was symptomatic with cough were identified (contacts). Since baseline TST data were unavailable, comparison crew who did not fly with the FA was selected from volunteers attending required annual training. Demographic data, TST and TB exposure history were obtained and TSTs were applied to both groups. Registered frequent flyer passengers who flew with the FA were evaluated by TST. Dates and duration of flights with the FA were obtained for contacts and passengers. Results. Rates of positive TSTs were higher among foreign born persons in all study groups. Among US born comparisons and contacts, rates of positive TSTs did not differ between comparisons and contacts exposed May through July (5.3 % vs 5.9 %). However, contacts exposed August through October had significantly higher rates of positive TSTs than contacts exposed May through July (30% vs 5.8 %; p < 0.001); two had documented TST conversions between September 92 and February 93. The risk of infection increased with increasing hours of exposure to the FA. Four of 59 (6.7%) frequent flyers were TST positive. All flew in October. Conclusions.
Data support the conclusion that M. tuberculosis was transmitted from an infectious FA to crew on aircraft. Because of the clustering of TST-positive frequent flyers in October when the FA was most infectious, transmission of M. tuberculosis to passengers cannot be excluded.
192 TUBERCULOSIS CONTROL PROGRAM IN THE LACANDON JUNGLE REGION OF MEXICO (1982-1992) Emrich. .I., Heredia, J., Chiapas. Mexico 29960
Alfaro,
0.;
Apartado
219, Palenque,
The incidence of pulmonary tuberculosis in the communities studied in the Lacandon Jungle is higher than that reported at the national level. The disease was introduced to the area by the Tzeltal and Chol Mayan Indians who migrated from the mountainous region of the state in the 1950’s and ‘60’s and colonized the jungle.
53
Coordination of the health services provided by last year medical students working in the rural government health clinics of the Secretaria de Salud, along with the various programs of village health workers in the area, has resulted in the elaboration of a tuberculosis control program for the entire jurisdiction. We reviewed the 1167 cases of tuberculosis reported by the Secretaria de Salud in the health jurisdiction which includes the Lacandon Jungle, for the period 1982-1992. The program efficacy reached 73 % using the 6 month regimen of 2RHZ/4R2H2. Proposals for increasing the program efficacy are discussed. Treatment results of the relapse cases were greatly enhanced by the WHO recommended regimen of 2HRZE/HRZE/5R3H3E3. The majority of the 59 cases of extra-pulmonary tuberculosis were scrofula, predominating in the O-14 year age group. Computerization of the data has helped to trace patients who hop from one field clinic to another, where they sometimes mistakenly re-initiate treatment as new patients.
193 INTERNATIONAL TRAINING COURSE ON TUBERCULOSIS LABORATORY WORKS FOR TUBERCULOSIS CONTROL Fujiki, A. and Ishikawa, N.; International Cooperation Dept., The Research Institute of Tuberculosis (RIT). Japan Anti-Tuberculosis Association, Kiyose, Tokyo, Japan
International training course on TB laboratory works for TB Control has been held once a year since 1975 at RIT in order to train key personnels in TB laboratory works, especially of developing countries. Through our experience we made an assessment on the significance and the role of this training course in the international collaborations for TB Control. The curriculum of this course is composed of technical aspects of TB examination and managerial aspects of TB laboratory. Based on the fundamental policy of this course, we put the priority of the technical training on the improvement of quality of direct smear examination. However, many participants were eager to learn much more sophisticated techniques such as culture examination, identification tests, drug susceptibility tests etc. and less interested in managerial parts, such as situation analysis, evaluation on TB laboratory networks in national TB control programme. To minimize such discrepancy between the expectation of participants and purpose of the course, we have included into the curriculum various managerial subjects, such as supervision and evaluation method of TB laboratory and examination techniques, interpretation of TB examination results and teaching methods for training to develop manpower. To enable better commitment of TB laboratory to national TB control programme, 1) managerial aspect should be further emphasized and replenished in the curriculum, 2) the purpose of the course and the criteria to select the participants should be well understood by the responsible persons of respective countries, 3) there should be a definite plan beforehand how to utilize the participants after they return to their countries.
Tubercle and Lung Disease: Supplement
before being enrolled in NTP. Most of those cases were diagnosed without sputum examination and referred to NTP for free medicine. 25 % had visited a traditional healer, and it is more popular in rural, female and illiterate populations. However health posts were not well utilized for case-finding, as only 10 % had visited there for initial medical consultation. 50% (80%) of the patients had consulted a health post staff or a doctor within 1.5 month (3.9 m) after the onset of symptoms. However this period was significantly longer in rural area and illiterate people, and a little longer in female. In rural area, the delay of diagnosis after the first medical consultation was longer because of a lack of diagnostic facilities and the interruption of visiting due to the distance and/or poverty. Although NTP broadcasted an educational programme and campaign songs by radio, those were not recognized by illiterate people. The service oriented to rural, female and illiterate populations must be developed. Collaboration with doctors in private sectors and big hospitals is important for proper case-finding and treatment in NTP. And training to the traditional healers will shorten the patient delay in rural area. 1ss QUALITATIVE
ANALYSIS OF TUBERCULIN SKIN TEST IN THE DIAGNOSIS OF TUBERCULOSIS IN CHILDHOOD
Oliveira, H. M. V., Santhnna, C. C. and Braga, J. U.; Run Alice 150 sala I, Laranjeiras- CEP 22241-020 - Rio de Janeiro, Brasil
Tuberculin skin test with 2U PPD Rt 23 was given to 223 children: 101 had been immunized with BCG Id, and had no disease: 65 had pneumonia: 57 had clinical, radiological and epidemiological features suggesting tuberculosis, 33 of them had previously been immunized with BCG Id. We evaluated the efficacy of the test for diagnosis tuberculosis in children.
of
The results of findings from the tuberculin skin tests were submitted to a conventional quantitative analysis, that showed 85.9 % of sensitivity and 86.1% of specificity. We considered 10 mm as the limit value between reactors and non reactors. The qualitative analysis of the tuberculin skin test - Koch phenomena - indicated 77.2% of sensitivity and high specificity (98.0 %). We concluded that the qualitative interpretation of the tuberculin skin test played an important role in the diagnosis of tuberculosis in children with clinical and radiological features of this disease. 189 THE VALUE OF FINE-NEEDLE ASPIRATION
BIOPSY @‘NAB) IN THE DIAGNOSIS OF TUBERCULOUS LYMPHADENITIS IN HIVlSEROPOSITIVE AND HIV&SERONEGATIVE PATIENTS IN BRAZIL Conde-Junior, H. M.‘, Kritski, A. L.2, Carvalho, C. E. S.‘, DallaRosa, P.‘, Werneck-Barroso, E.‘, Vieira, M. A. M.‘, Carvalho, A. C. C.‘, Cardoso, A. P.2
1ITPAJFRJ; Objective:
* Service de Pneumologia
do HCFFIUFRJ,
To evaluate the fine-needle diagnosis of TB lymphadenitis.
Rio de Janeiro
(22-gauge) in the
Methods: 49 patients (32 HIVl-seropositive) presenting to one surgeon for diagnostic surgical biopsy of peripheral lymph node, after written consent, were evaluated during Sep, 1992-October, 1993. Fine-needle aspiration was routinely preceded open surgical biopsy. All the cases had Papanicolaou, Giemsa, Ziehl-Neelsen and metenamine silver stains and cultures for tuberculosis and fungi using the syringe washing with sterile saline. Results: The mean age of the patients was 30.2 SD f 8.8 yrs. The male/female ratio was 2.7:1. Thirty two out of 49 (65.3 %) patients had culture-proven TB lymphadenitis, of whom 23 out of 32 (71.8 %) HIVl-seropositive. Among HIVl-seropositive TB patients, the PPD skin test was > = 5 mm in 50 % (11122) and among HIVl-seronegative, PPD >= 10 mm in all cases. The diagnostic yield of FNAB (presence of granuloma and/or epithelioid cells) was 50.0% (16/32) and of surgical biopsy (presence of acid-fast bacilli-AFB or caseation and/or granulomas and giant cells) was 96.8% (31/32). In microscopic examination, if we include caseation in the aspirate as a diagnostic of TB, the final diagnostic yield of FNAB was 62.5 % (20/ 32) and false positive result was not found. Among patients with TB, regarding the FNAB and surgical biopsy, AFB were observed respectively in 7129 (24.2 %) and 12/32 (37.5%) (p=NS). The presence of AFB in surgical biopsy was significantly associated with HIVlseropositive patients (p=O.O4) but is was not in FNAB specimens. And, the absence of granulomatous process in surgical biopsy was not associated with the seropositivity for HIV1 (p=NS). Conclusions:
In primary health settings may be recommended that patients HIVl-seropositive or seronegative with suspected TB lymphadenitis, undergo fine-needle aspiration before surgical biopsy.
190 THE INCREASE
ENGLAND
IN TUBERCULOSIS AND WALES 1987-1991
IN
Doherty, M. J., Spence, D. P.S., Davies, P. D. 0.; Aintree Chest Centre and Tuberculosis Research Unit, Liverpool UK
Tuberculosis notifications have been rising in England and Wales since 1987. The number of notifications was at it’s lowest in 1987 at 5,085, rising to 5,436 in 1991 and just over 6,000 notifications in 1993. Little informations is available as to whether this rise is occuring in any particular group of subjects or whether it is a general increase. We have undertaken an analysis of notification rates divided by standard region, age and sex group and by site of disease for the period 1987-1991. 1991 is the last year for which data brokendown like this is available from the Office of Populations, Censuses and Surveys. The main findings were that the increase in notification rates occured in females (average annual percentage change + 2.5 [95 % confidence limits + 0.56 to + 4.71) rather than males -0.06 % (- 2.9 to +2.7). That the increase is in younger groups rather than the elderly, females aged 35-44 years show an increase of 3.2 % (+0.9 to +8.0) compared to females over 75 years who show a decrease of 1.4 % (- I2 to + 10). Analysis by region showed an increase in only three regions, Yorkshire and Humberside +3% (+0.89 to +7.75), the South East +2.76 (-0.37 to 13.63) and the West Midlands +4.85 % (-3.9 to + 13.6). Although the increase was significant only in Yorkshire and Humberside, if the data for region is broken down by
Tubercle and Lung Disease: Supplement sex, females from the South East show a significant rise +4.6% (+2.1 to +7.0). Data on site of disease shows the increase can be accounted for by an increase in disease at non-respiratory sites, non-respiratory + 7.13 % (+ 2.7 to + 11.5) compared with respiratory site -0.8% (-3.0 to + 1.3). In conclusion the increase in non-respiratory disease and the regions in which this increase has occured in suggest that immigration has played a large part in the increase in tuberculosis in England and Wales. The analysis also highlights areas for further research and areas where resources should be concentrated.
191 TRANSMISSION OF M. TUBERCULOSIS ASSOCIATED WITH AIR TRAVEL Driver, C., Valway, S., Morgan, M., Onorato, I., Castro, K.; Centers for Disease Control and Prevention, MS E-IO, 1600 Clifton Rd, Atlantu, GA, USA 30333
Background.
Eight of nine household contacts of a flight attendant (FA) with cavitary tuberculosis (TB) had positive tuberculin skin tests (TSTs), thus, transmission of Mycobacterium tuberculosis to coworkers was investigated. Methods.
Crew who flew with the FA during May October 1992, while she was symptomatic with cough were identified (contacts). Since baseline TST data were unavailable, comparison crew who did not fly with the FA was selected from volunteers attending required annual training. Demographic data, TST and TB exposure history were obtained and TSTs were applied to both groups. Registered frequent flyer passengers who flew with the FA were evaluated by TST. Dates and duration of flights with the FA were obtained for contacts and passengers. Results. Rates of positive TSTs were higher among foreign born persons in all study groups. Among US born comparisons and contacts, rates of positive TSTs did not differ between comparisons and contacts exposed May through July (5.3 % vs 5.9 %). However, contacts exposed August through October had significantly higher rates of positive TSTs than contacts exposed May through July (30% vs 5.8 %; p < 0.001); two had documented TST conversions between September 92 and February 93. The risk of infection increased with increasing hours of exposure to the FA. Four of 59 (6.7%) frequent flyers were TST positive. All flew in October. Conclusions.
Data support the conclusion that M. tuberculosis was transmitted from an infectious FA to crew on aircraft. Because of the clustering of TST-positive frequent flyers in October when the FA was most infectious, transmission of M. tuberculosis to passengers cannot be excluded.
192 TUBERCULOSIS CONTROL PROGRAM IN THE LACANDON JUNGLE REGION OF MEXICO (1982-1992) Emrich. .I., Heredia, J., Chiapas. Mexico 29960
Alfaro,
0.;
Apartado
219, Palenque,
The incidence of pulmonary tuberculosis in the communities studied in the Lacandon Jungle is higher than that reported at the national level. The disease was introduced to the area by the Tzeltal and Chol Mayan Indians who migrated from the mountainous region of the state in the 1950’s and ‘60’s and colonized the jungle.
53
Coordination of the health services provided by last year medical students working in the rural government health clinics of the Secretaria de Salud, along with the various programs of village health workers in the area, has resulted in the elaboration of a tuberculosis control program for the entire jurisdiction. We reviewed the 1167 cases of tuberculosis reported by the Secretaria de Salud in the health jurisdiction which includes the Lacandon Jungle, for the period 1982-1992. The program efficacy reached 73 % using the 6 month regimen of 2RHZ/4R2H2. Proposals for increasing the program efficacy are discussed. Treatment results of the relapse cases were greatly enhanced by the WHO recommended regimen of 2HRZE/HRZE/5R3H3E3. The majority of the 59 cases of extra-pulmonary tuberculosis were scrofula, predominating in the O-14 year age group. Computerization of the data has helped to trace patients who hop from one field clinic to another, where they sometimes mistakenly re-initiate treatment as new patients.
193 INTERNATIONAL TRAINING COURSE ON TUBERCULOSIS LABORATORY WORKS FOR TUBERCULOSIS CONTROL Fujiki, A. and Ishikawa, N.; International Cooperation Dept., The Research Institute of Tuberculosis (RIT). Japan Anti-Tuberculosis Association, Kiyose, Tokyo, Japan
International training course on TB laboratory works for TB Control has been held once a year since 1975 at RIT in order to train key personnels in TB laboratory works, especially of developing countries. Through our experience we made an assessment on the significance and the role of this training course in the international collaborations for TB Control. The curriculum of this course is composed of technical aspects of TB examination and managerial aspects of TB laboratory. Based on the fundamental policy of this course, we put the priority of the technical training on the improvement of quality of direct smear examination. However, many participants were eager to learn much more sophisticated techniques such as culture examination, identification tests, drug susceptibility tests etc. and less interested in managerial parts, such as situation analysis, evaluation on TB laboratory networks in national TB control programme. To minimize such discrepancy between the expectation of participants and purpose of the course, we have included into the curriculum various managerial subjects, such as supervision and evaluation method of TB laboratory and examination techniques, interpretation of TB examination results and teaching methods for training to develop manpower. To enable better commitment of TB laboratory to national TB control programme, 1) managerial aspect should be further emphasized and replenished in the curriculum, 2) the purpose of the course and the criteria to select the participants should be well understood by the responsible persons of respective countries, 3) there should be a definite plan beforehand how to utilize the participants after they return to their countries.