Correspondence
For the Public Health Services Directive 3/2008; update 11/12 see http://www.health.gov.il/ hozer/BZ11_2012.pdf
876
Number of tuberculosis patients
We would like to congratulate Robert Aldridge and colleagues1 for their systematic review and metaanalysis of pre-entry screening programmes for tuberculosis in migrants entering low-incidence countries, aimed to establish the yield of such a screening policy. To exemplify such an objective, we present our experience in Israel, a country of immigration, where since 1997, the National Tuberculosis Control Programme has provided diagnosis and treatment for both Israeli and non-Israeli patients with tuberculosis, free of charge.2 We compare the yield of the two screening methods used in Israel: a post-entryscreening, which has screened about 90% of the undocumented migrants from the Horn of Africa (according to the Public Health Services Directive 3/2008; update 11/12) versus a preentry screening for regular migrants from Ethiopia (who are eligible for Israeli citizenship3). During the period of 2007–12, 726 cases of tuberculosis were diagnosed among migrants from the Horn of Africa arriving in Israel; of these cases, 576 (79·3%) were diagnosed from among 53 820 undocumented migrants from the Horn of Africa (followed up for 205 057 personyears) and 150 (20·7%) were diagnosed from among 12 162 regular migrants from Ethiopia (followed up for 55 290 person-years). Of the undocumented migrants, 391 cases of tuberculosis (67·9%) originated from Eritrea, 165 (28·6%) from Sudan, and 20 (3·5%) from Ethiopia. Incidence of tuberculosis did not differ significantly between the two groups: 234 cases per 100 000 person-years in the undocumented migrants group versus 271 cases per 100 000 person-
200
Number of undocumented migrants from the Horn of Africa Number of regular migrants from Ethiopia
Number of undocumented migrants from the Horn of Africa Number of regular migrants from Ethiopia
2000
180
1800
160
1600
140
1400
120
1200
100
1000
80
800
60
600
40
400
20
200
Rate per 100 000
Tuberculosis screening programmes for migrants to lowincidence countries—the Israeli experience
0
0 2007
2008
2009
2010
2011
2012
Figure 1: Tuberculosis diagnosis by year of arrival in Israel and citizenship status, 2007–12
years in the Ethiopian group (twotailed χ² test; p=0·1; figure). Therefore, the Israeli experience in tuberculosis screening of migrants from high tuberculosis-incidence countries to a low tuberculosis-incidence country is in accordance with the recent action framework 4 to wards tuber culosiselimination in low-incidence countries, which recommends that some highrisk groups (eg, migrants) could be considered for systematic screening of active-tuberculosis on the basis of local tuberculosis epidemiology and an assessment of benefits, risks, and costs. We applied a similar approach in Israel for almost two decades, and raised the issue that tuberculosis screening was in fact challenging health professionals to develop and guarantee an efficient process for migrants—both regular and undocumented.5 In our experience, the pre-entry and post-entry tuberculosis screening programmes of migrants from high to low tuberculosis-incidence countries have achieved similar results, which is suggestive of an exhaustive tuberculosis screening programme and a close follow-up of patients, irrespective of their civil status.2 We declare no competing interests.
*Daniel Chemtob, Zohar Mor, Itamar Grotto [email protected] Department of Tuberculosis and AIDS, POB 1176, Jerusalem 944724, Israel (DC, ZM); and Public Health Services, Jerusalem, Israel (DC, ZM, IG)
1
2
3
4
5
Aldridge RW, Yates TA, Zenner D, White PJ, Abubakar I, Hayward AC. Pre-entry screening programmes for tuberculosis in migrants to low-incidence countries: a systematic review and meta-analysis. Lancet Infect Dis 2014; 14: 1240–49. Chemtob D, Leventhal A, Berlowitz Y, Weiler-Ravell D. The new National Tuberculosis Control Programme in Israel, a country of high immigration. Int J Tuberc Lung Dis 2003; 7: 828–36. Mor Z, Lerman Y, Leventhal A. Pre-immigration screening process and pulmonary tuberculosis among Ethiopian migrants in Israel. Eur Respir J 2008; 32: 413–18. Lönnroth K, Migliori GB, Abubakar I, et al. Towards tuberculosis elimination: an action framework for low-incidence countries. Eur Respir J 2015; published online March 18. DOI:10.1183/09031936.00214014. Chemtob D, Leventhal A, Weiler-Ravell D. Screening and management of tuberculosis in immigrants: the challenge beyond professional competence. Int J Tuberc Lung Dis 2003; 7: 959–66.
Urgent need for β-lactam-β-lactamase inhibitors The Review by Patrick Harris and colleagues1 emphasises the reasons for and against use of β-lactam-βlactamase inhibitors (BLBLIs) for infections caused by extended-spectrum β-lactamase (ESBL) producers.1 Here we draw attention to other important aspects overlooked by this Review. Harris and colleagues state that an important reason for the use and development of BLBLIs is to provide a carbapenem-sparing option to treat www.thelancet.com/infection Vol 15 August 2015
For the Public Health Services Directive 3/2008; update 11/12 see http://www.health.gov.il/ hozer/BZ11_2012.pdf
876
Number of tuberculosis patients
We would like to congratulate Robert Aldridge and colleagues1 for their systematic review and metaanalysis of pre-entry screening programmes for tuberculosis in migrants entering low-incidence countries, aimed to establish the yield of such a screening policy. To exemplify such an objective, we present our experience in Israel, a country of immigration, where since 1997, the National Tuberculosis Control Programme has provided diagnosis and treatment for both Israeli and non-Israeli patients with tuberculosis, free of charge.2 We compare the yield of the two screening methods used in Israel: a post-entryscreening, which has screened about 90% of the undocumented migrants from the Horn of Africa (according to the Public Health Services Directive 3/2008; update 11/12) versus a preentry screening for regular migrants from Ethiopia (who are eligible for Israeli citizenship3). During the period of 2007–12, 726 cases of tuberculosis were diagnosed among migrants from the Horn of Africa arriving in Israel; of these cases, 576 (79·3%) were diagnosed from among 53 820 undocumented migrants from the Horn of Africa (followed up for 205 057 personyears) and 150 (20·7%) were diagnosed from among 12 162 regular migrants from Ethiopia (followed up for 55 290 person-years). Of the undocumented migrants, 391 cases of tuberculosis (67·9%) originated from Eritrea, 165 (28·6%) from Sudan, and 20 (3·5%) from Ethiopia. Incidence of tuberculosis did not differ significantly between the two groups: 234 cases per 100 000 person-years in the undocumented migrants group versus 271 cases per 100 000 person-
200
Number of undocumented migrants from the Horn of Africa Number of regular migrants from Ethiopia
Number of undocumented migrants from the Horn of Africa Number of regular migrants from Ethiopia
2000
180
1800
160
1600
140
1400
120
1200
100
1000
80
800
60
600
40
400
20
200
Rate per 100 000
Tuberculosis screening programmes for migrants to lowincidence countries—the Israeli experience
0
0 2007
2008
2009
2010
2011
2012
Figure 1: Tuberculosis diagnosis by year of arrival in Israel and citizenship status, 2007–12
years in the Ethiopian group (twotailed χ² test; p=0·1; figure). Therefore, the Israeli experience in tuberculosis screening of migrants from high tuberculosis-incidence countries to a low tuberculosis-incidence country is in accordance with the recent action framework 4 to wards tuber culosiselimination in low-incidence countries, which recommends that some highrisk groups (eg, migrants) could be considered for systematic screening of active-tuberculosis on the basis of local tuberculosis epidemiology and an assessment of benefits, risks, and costs. We applied a similar approach in Israel for almost two decades, and raised the issue that tuberculosis screening was in fact challenging health professionals to develop and guarantee an efficient process for migrants—both regular and undocumented.5 In our experience, the pre-entry and post-entry tuberculosis screening programmes of migrants from high to low tuberculosis-incidence countries have achieved similar results, which is suggestive of an exhaustive tuberculosis screening programme and a close follow-up of patients, irrespective of their civil status.2 We declare no competing interests.
*Daniel Chemtob, Zohar Mor, Itamar Grotto [email protected] Department of Tuberculosis and AIDS, POB 1176, Jerusalem 944724, Israel (DC, ZM); and Public Health Services, Jerusalem, Israel (DC, ZM, IG)
1
2
3
4
5
Aldridge RW, Yates TA, Zenner D, White PJ, Abubakar I, Hayward AC. Pre-entry screening programmes for tuberculosis in migrants to low-incidence countries: a systematic review and meta-analysis. Lancet Infect Dis 2014; 14: 1240–49. Chemtob D, Leventhal A, Berlowitz Y, Weiler-Ravell D. The new National Tuberculosis Control Programme in Israel, a country of high immigration. Int J Tuberc Lung Dis 2003; 7: 828–36. Mor Z, Lerman Y, Leventhal A. Pre-immigration screening process and pulmonary tuberculosis among Ethiopian migrants in Israel. Eur Respir J 2008; 32: 413–18. Lönnroth K, Migliori GB, Abubakar I, et al. Towards tuberculosis elimination: an action framework for low-incidence countries. Eur Respir J 2015; published online March 18. DOI:10.1183/09031936.00214014. Chemtob D, Leventhal A, Weiler-Ravell D. Screening and management of tuberculosis in immigrants: the challenge beyond professional competence. Int J Tuberc Lung Dis 2003; 7: 959–66.
Urgent need for β-lactam-β-lactamase inhibitors The Review by Patrick Harris and colleagues1 emphasises the reasons for and against use of β-lactam-βlactamase inhibitors (BLBLIs) for infections caused by extended-spectrum β-lactamase (ESBL) producers.1 Here we draw attention to other important aspects overlooked by this Review. Harris and colleagues state that an important reason for the use and development of BLBLIs is to provide a carbapenem-sparing option to treat www.thelancet.com/infection Vol 15 August 2015
