BACKGROUNDMycobacterium tuberculosis affects the lung parenchyma even after successful treatment.OBJECTIVETo 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.METHODSThis 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.RESULTSOver 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).CONCLUSIONSIndividuals 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.

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.

Non-national migrants have limited access to medical therapy. This study compares diagnostic delay and treatment outcomes of non-insured non-national migrants (NINNM) with insured Israeli citizens (IC) in the Tel Aviv tuberculosis (TB) clinic between 1998 and 2008. Patient delay was the time from symptoms onset to doctor's visit, while system delay was measured from doctor visit to anti-TB therapy administration. We randomly sampled 222 NINNM and 265 IC. NINNM were younger than IC, had lower male to female ratio and fewer smoked. They had less drug/alcohol abuse, more cavitations on chest radiography, longer patient and shorter system delay. Mean patient and system delays of all patients were 25 ± 14 and 79 ± 42 days, respectively. In multivariate analysis, being NINNM, asymptomatic or smoking predicted longer patient delay, while being asymptomatic or having additional co-morbidity predicted longer system delay. Treatment success in sputum smear-positive pulmonary TB NINNM was 81% and 95.7% in IC (p=0.01). Treatment success was not associated with patient or system delay. In multivariate analysis, work security and treatment adherence predicted treatment success. NINNM had longer patient delay and worse therapy outcome, while IC had longer system delay. Both delays should be reduced. NINNM should be informed that TB therapy is free and unlinked with deportation.

From the authors: The authors thank Bhuniya 1 for his interesting comments on our article published in the European Respiratory Journal ( ERJ ) 2. Tuberculosis (TB) screening policies are influenced by the structure of the national TB programme, the existing financial resources, the expertise of available professionals and the sense of apprehension expressed by the local population in the host country. The aim of our study was to evaluate the unique screening process performed in Ethiopian immigrants arriving in Israel, and to share our experience with the ERJ ’s readers. The tuberculin skin test (TST) is considered the preferred method for screening latent TB infection (LTBI) in immigrants originating from countries with high rates of TB 3–5. This method can potentially detect all patients with LTBI 6 in a simple, inexpensive and sensitive fashion. The merits of this instrument are increased when the physician considers the patients' age, previous TB exposure …

More than 75,000 displaced Ethiopians have moved to Israel. Tuberculosis (TB) incidence in Ethiopia is 44 times higher than in Israel (344 versus 8 cases per 100,000 inhabitants, respectively). The aims of the present retrospective cohort study were to evaluate the pre-immigration screening process initiated in 2001 on pulmonary TB (PTB) morbidity and to assess its cost-effectiveness. Ethiopian immigrants who were screened before departure (study group) were compared with those who were screened after arrival (comparison group). Between 1998 and 2005, 24,051 Ethiopian immigrants arrived in Israel. PTB was diagnosed in 332 (1.4%) immigrants, an incidence density of 325 patients per 100,000 person-yrs. PTB cumulative incidence was lower in the study group than in the comparison group: 711 compared with 1,746 patients per 100,000 immigrants, respectively (rate ratio 0.4). PTB was detected significantly earlier in the study group than in the comparison group: 193 versus 487 days after entry, respectively. Disease incidence declined significantly during the first 2 yrs following immigration. A 5-yr predictive model indicated that 98 individuals would be free of PTB, saving US$91,055 on annual treatment cost, due to screening. The pre-immigration screening process reduced pulmonary tuberculosis incidence in subsequent years following immigration. Pulmonary tuberculosis was diagnosed earlier in the screened group than in the comparison group and the process was found to be both cost-beneficial and cost-effective.

BACKGROUND:During the last decade, Israel, a country with low tuberculosis rates, absorbed some 900,000 new immigrants from TB-endemic countries.OBJECTIVES:To analyze the specific impact of our screening procedures on active TB among children in Israel.METHODS:We conducted a retrospective analysis of epidemiologic and clinical data of all children (aged 0-17) with TB notified to the Ministry of Health between 1990 and 1999.RESULTS:There were 479 children with TB (male/female ratio 1.36). Most cases (81.8%) were foreign born, predominantly (88.2%) immigrants from Ethiopia and, therefore, huge differences existed in TB incidence rates according to countries of origin. Some 80% were diagnosed within 3 years of arrival, mainly due to active case-finding. Pulmonary TB, with infiltrates on chest X-ray, was found in 49.5%. Extra-pulmonary TB sites were: intra-thoracic lymphadenitis (31.1%), extra-thoracic lymphadenitis (12.5%), bones (3.6%), pleura (1.3%), meninges (1%), and others (1%). Seventy percent had a tuberculin skin test reaction > or =10 mm in size. Two (non-immigrant) children died of TB meningitis.CONCLUSIONS:Most of the pediatric TB cases occurred in recent immigrants and were diagnosed within 3 years of immigration. These data support our policy of active case-finding among new immigrants from Ethiopia and extensive contact evaluation for all TB cases.

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.

SETTINGIsrael 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.METHODSEach 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.RESULTSBetter 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.CONCLUSIONUsing 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.

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.

In January 1994 mass antibiotic prophylaxis was undertaken in the contiguous villages of Deir el-Asad and B'ine in northern Israel (combined population of 11600) in response to a prolonged outbreak of serogroup B meningococcal infection with an overall annual rate of 37.4 cases of infection per 100000 residents. The average case fatality rate in the villages was 23% compared with 11% in Israel during the same period. Neisseria meningitidis group B was identified in 9 of 13 (69%) cases. Seven of these were subtype P1.7,16. The persistence of the outbreak with its accompanying public reaction prompted the establishment of an intervention programme that included antibiotic prophylaxis for the whole community with monitoring for pharyngeal carriage of meningococci in a stratified sample of the population. The objectives were to achieve a reduction of carriage of the outbreak strain and to reduce morbidity and mortality. A total of 1036 pharyngeal swabs were taken 1 day before and 6 weeks after treatment. Antibiotic prophylaxis was administered in one dose: children under 5-years-old received ceftriaxone i.m.; all others received oral ciprofloxacin. Overall, 96% of the population received treatment. The carriage rate was 8.3% prior to treatment (three serogroup B:14:P1.7,16), and 1.3% afterwards (one serogroup B:14:P1.7,16). The intervention failed to eradicate carriage of the putative outbreak strain, or to reduce the incidence and fatality rates in the villages. The outbreak finally terminated in late 1996. Public health professionals should bear this experience in mind when faced with prolonged, localized, nonexplosive outbreaks of meningococcal disease associated with low carriage rates of the outbreak strain.

Postoperative bladder distention, accompanied by serious difficulties in micturition, is not a rare occurrence in surgical patients. Two similar groups of patients undergoing surgical treatment were studied. In one group of 21 patients who received phenoxybenzamine prophylactically only one patient had urinary retention develop; nine of 22 patients in the control group who did not receive prophylactic phenoxybenzamine postoperatively had urinary retention develop. All of the latter patients who then received phenoxybenzamine were ultimately relieved of voiding difficulties. Phenoxybenzamine, an alpha adrenergic blocker, is recommended as an effective and safe drug in diminishing or abolishing obstructive urinary symptoms postoperatively.

The movement of the chest during breathing has been recorded in normal and asthmatic subjects by means of electronic transducers which measured changes in anteroposterior and lateral diameters. Preliminary studies showed that exercise-induced bronchoconstriction caused distortion of the movement of the diameters in relation to each other and to volume change recorded at the mouth. Because of the thoracic gas compression which occurs during breathing, volume change at the mouth does not represent the change in chest volume and further studies were therefore undertaken in a whole-body plethysmograph. These studies showed that the addition of a resistance to the airway of a normal subject distorted the movement of one diameter (usually the anteroposterior) in relation to the other and to volume. With exercise-induced asthma, the movement of both diameters was affected with the anteroposterior lagging behind the volume change. There was an approximate linear relationship between the degree of distortion and airways resistance in the asthmatic subjects and in one normal subject. The physical sign of costal margin paradox could be related to the severity of the obstruction.