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Background In 2006, the Swiss Federal Office of Public Health (FOPH) decided recommending a prolongation of vaccine booster intervals after the third dose for the prevention of tick-borne encephalitis (TBE) from 3 to 10 years. Methods To ascertain whether this amendment resulted in an increased rate of vaccine breakthroughs, we conducted a retrospective analysis of surveillance data collected 2000–19 by mandatory reporting to the Swiss FOPH. Fractions of breakthroughs [with 95% confidence intervals (CIs)]—0–3 years vs >3–10 years after the third vaccination dose—were compared across time periods and age groups. Results Among 3205 notified TBE cases, known vaccination status was reported in 2562 (79.9%), including 103 patients with ≥3 vaccine doses (4.0%). Among those, there were 39 patients who had received the last dose within 3 years and 48 patients in the >3–10 years group. During the 2010–19 period in which the new booster strategy was implemented there were 23 and 38 breakthroughs, respectively, and the annual breakthrough rate was 7.7 (95% CI 5.0–11.7) cases during the first 3 years after the last dose, and 5.4 (95% CI 3.9–7.5) cases in following 7 years. We observed no significant trend of TBE breakthroughs with increasing age. Increasing numbers of TBE and of vaccine breakthroughs over time have been associated with spreading endemicity and higher vaccination coverage in Switzerland. Conclusions There is no indication that extended booster intervals resulted in an increased rate of breakthroughs, but there was a marked public health benefit with respect to increased acceptability of TBE immunization in the general population.

ObjectivesThere is no estimate of the current number of men who have sex with men (MSM) in Switzerland, or of their geographical distribution. We aimed to (1) estimate MSM concentration factors and population sizes for 83 Swiss postal code areas (PCA), including the nine largest Swiss cities, and (2) calculate MSM-specific local HIV prevalence and yearly rates of diagnosed HIV, hepatitis C virus (HCV), syphilis and gonorrhoea.MethodsWe triangulated data from general population estimates, MSM online surveys, published data on HIV prevalence and Swiss notification data for HIV and STDs. We compared two different formulae for the estimation of local MSM populations and calculated Bayesian 95%-credible-intervals (CrI) for each PCA.ResultsAcross Switzerland, we estimate the MSM population aged 15–64 at roughly 80 000 men (95% CrI 64 000–96 000). (1) MSM in Switzerland were most concentrated in the five largest cities of Zurich, Geneva, Lausanne, Bern and Basel. (2) We estimate that in 2012, 6300 MSM, or 8.0%, were living with HIV, both diagnosed and undiagnosed and 1700 MSM, or 2.2%, had non-suppressed HIV infection. Between 2010 and 2013, average yearly rates of diagnosed HIV, HCV, syphilis and gonorrhoea were 0.3%, 0.02%, 0.4 % and 0.4 %, respectively.ConclusionsCombining general population data, MSM online surveys and notification data allows the calculation of realistic estimates of local MSM populations and thus proportions of MSM with diagnosed HIV and other STIs, with implications for prevention planning, commissioning of health services and counselling MSM on HIV/STI risk. Our methodology for Switzerland is transferable to other countries with similar data sources.

OBJECTIVE: To describe the epidemiology of tuberculosis in Switzerland from 2009 to 2019. METHODS: Analysis of Swiss notification data. RESULTS: Tuberculosis cases declined from 553 (7.1/100,000) in 2009 to 437 (5.1/100,000) in 2019. The male-to-female ratio was 3:2. Although the number of tuberculosis cases of Swiss origin has steadily declined, the number of tuberculosis cases of foreign origin was rather stable but peaked in 2016. Overall, three quarters of tuberculosis cases were among people of foreign origin; of these, around half were from East Africa, Southern East Europe, and Southern Asia. Forty-nine percent had extrapulmonary manifestations. Every year, with little variation, 7–16 cases with rifampicin resistance were reported (2.9% overall). Independent risk factors for rifampicin resistance were prior anti-tuberculosis treatment, with an adjusted odds ratio (aOR) of 5.5 and a 95% confidence interval (CI) from 3.7 to 8.1, and foreign origin (aOR 3.6, 95% CI 2.0–7.0), particularly Georgia (aOR 10.0, 95% CI 4.0–23.1), Ethiopia (aOR 9.4, 95% CI 3.5–24.2), Tibet (aOR 6.9; 95% CI 2.9–16.6) and Somalia (aOR 8.1, 95% CI 4.0–17.2), together with Eritrea (aOR 2.6, 95% CI 1.1–5.9), accounting for more than half of all 134 cases . From 2016 to 2018, applying the World Health Organization definitions, overall treatment success in culture-confirmed pulmonary cases was 78%, and thus below the target of 85%. Since most cases with unsuccessful outcome are due to missing information, the proportion of unsuccessful outcome are overestimated. CONCLUSION: Autochthonous tuberculosis has become rare in Switzerland and the new diagnoses are increasingly attributable to immigration. Rifampicin resistance remains rare. Switzerland currently fails to achieve international targets for treatment success.

Immigrants from regions with a high incidence of tuberculosis (TB) are a risk group for TB in low-incidence countries such as Switzerland. In a previous analysis of a nationwide collection of 520 Mycobacterium tuberculosis isolates from 2000 to 2008, we identified 35 clusters comprising 90 patients based on standard genotyping (24-locus mycobacterial interspersed repetitive-unit–variable-number tandem-repeat [MIRU-VNTR] typing and spoligotyping). Here, we used whole-genome sequencing (WGS) to revisit these transmission clusters. Genome-based transmission clusters were defined as isolate pairs separated by ≤12 single nucleotide polymorphisms (SNPs). WGS confirmed 17/35 (49%) MIRU-VNTR typing clusters; the other 18 clusters contained pairs separated by >12 SNPs. Most transmission clusters (3/4) of Swiss-born patients were confirmed by WGS, as opposed to 25% (4/16) of the clusters involving only foreign-born patients. The overall clustering proportion was 17% (90 patients; 95% confidence interval [CI], 14 to 21%) by standard genotyping but only 8% (43 patients; 95% CI, 6 to 11%) by WGS. The clustering proportion was 17% (67/401; 95% CI, 13 to 21%) by standard genotyping and 7% (26/401; 95% CI, 4 to 9%) by WGS among foreign-born patients and 19% (23/119; 95% CI, 13 to 28%) and 14% (17/119; 95% CI, 9 to 22%), respectively, among Swiss-born patients. Using weighted logistic regression, we found weak evidence of an association between birth origin and transmission (adjusted odds ratio of 2.2 and 95% CI of 0.9 to 5.5 comparing Swiss-born patients to others). In conclusion, standard genotyping overestimated recent TB transmission in Switzerland compared to WGS, particularly among immigrants from regions with a high TB incidence, where genetically closely related strains often predominate. We recommend the use of WGS to identify transmission clusters in settings with a low incidence of TB.

Ein bisher selbstandiger 79-jahriger Patient wurde auf die Notfallstation zugewiesen bei seit drei Tagen bestehendem Fieber mit trockenem Husten sowie intermittierenden Abdominalschmerzen und Diarrhoe.

Objectives The objectives were to measure uptake of and factors associated with human papillomavirus (HPV) vaccination initiation and to determine whether HPV vaccination reduced the uptake of cervical cancer screening. Methods We conducted a cross-sectional survey in a random sample of Swiss women aged 18–49 years in 2014 (N = 3588). Results Vaccination initiation was 69.3% and full coverage (three doses) 54.1% for 18–20-year olds, respectively, 42.4% and 33.9% for 21–24-year olds. Women with ≥ 10 lifetime sexual partners were less likely to have received any HPV vaccination than women with ≤ 2 partners (18–20 years OR 0.2, 21–24 years OR 0.5). Amongst 1000 unvaccinated women (18–24 years), reasons for not having initiated vaccination were lack of information (22.5%) and fear of vaccine side effects (18.1%). Vaccination status was not associated with adherence to cervical cancer screening recommendations (OR 1.3). 95.4% of all vaccinated participants knew about the continued need for screening. Conclusions Our data suggest that HPV vaccination is not associated with reduced uptake of cervical cancer screening. This study provides information that can be used to improve HPV vaccination uptake in Switzerland. Electronic supplementary material The online version of this article (doi:10.1007/s00038-017-1050-x) contains supplementary material, which is available to authorized users.

Aim To compare acute flaccid paralysis (AFP) surveillance systems used by members of the International Network of Paediatric Surveillance Units (INoPSU) across the five AFP surveillance performance indicators recommended by the World Health Organization (WHO) for the maintenance of polio-free certification. Methods A survey was administered to AFP surveillance co-ordinators in five INoPSU member countries (Australia, Belgium, Canada, New Zealand and Switzerland). Data collected included information on surveillance system processes, WHO-recommended performance indicators, investigative practices and final diagnoses of cases from 2006 to 2010. Results All countries contacted completed the survey. Each country used similar case definitions and processes for collecting AFP data. All countries used at least one of the WHO indicators for surveillance. No country consistently met the performance indicator for incidence or stool sampling. In all countries, at least one form of neurological testing was used to diagnose cases of AFP. Guillain-Barre syndrome was the most common final diagnosis in all countries for all years examined. Conclusions Industrialised countries surveyed do not consistently meet the WHO-recommended AFP surveillance performance indicators. An opportunity exists for INoPSU to suggest a standard way for member countries to collect AFP data in order to examine the potential for strengthening the current systems or introducing additional enterovirus surveillance or alternative/complementary neurological performance measures suitable for countries that have eliminated polio. INoPSU member countries are evaluating these possibilities.

Adolescents with an immigrant background who are from tuberculosis high-incidence regions were at highest risk to develop adult-type tuberculosis disease in a low-incidence region during a 20-year period. If diagnosis and treatment were delayed up to 6 months, latent tuberculosis infection was detected in almost half of the affected individuals' school contacts.

Approximately 9 million cases of tuberculosis (TB) are reported annually and half a million occur in children

Da Hausarzte bei der Erkennung von an Tuberkulose Erkrankten eine entscheidende Rolle spielen, hat das Bundesamt fur Gesundheit (BAG) das Schweizerische Tropen- und Public Health-Institut mit der Durchfuhrung einer Tuberkulose-Wissensstudie bei Hausarzten beauftragt.

To assess feasibility and yield of diagnostic procedures after active case finding for tuberculosis with radiologic screening at the three main entry points for asylum seekers to Switzerland.Prospective multicenter study on the value of symptoms, spontaneous and induced sputum, and bronchoscopy for the confirmation of tuberculosis in radiologically selected cases.Among 101 asylum seekers examined, spontaneous sputum was collected "on the spot" in 83 and yielded 7 (54%) of 13 smear-positive and 13 (39%) of 33 culture-positive cases. Morning sputum, collected in 84, yielded 8 (62%) and 16 (49%), and the two spontaneous sputa combined 9 (69%) and 20 (61%), respectively. Two additional induced sputa, collected in 91 persons, yielded no additional smear-positive, but yielded seven culture-positive cases (yield, 82%). Bronchoscopy, performed in 87 of 92 sputum smear-negative cases, yielded four additional smear-positive and six culture-positive cases. Culture confirmation was independently and significantly predicted by obtaining a specimen using bronchoscopy (adjusted odds ratio, 11.0; 95% confidence interval, 1.9-62) and a prior decision to treat (adjusted odds ratio, 3.0; confidence interval, 1.1-8.1).Radiographic anomalies compatible with tuberculosis found during screening are a poor guide to initiation of treatment. Respiratory and systemic symptoms correlated weakly with culture confirmation of tuberculosis. All radiologically selected cases must be examined with on-the-spot and early-morning sputum, regardless of symptoms. If both specimens are smear negative, the yield is increased by bronchoscopy and, to a lesser extent, by two samples of induced sputum. The examination of any single specimen has a low yield of 36 to 63% and is insufficient to exclude active tuberculosis.

Die Tuberkulose (TB) lasst sich in der Regel gut behandeln. Trotzdem gab es auch in der Schweiz in den letzten Jahren Todesfalle, sogar bei Jugendlichen. Zum Teil ist dies auf die Tatsache zuruckzufuhren, dass die grosse Mehrheit der Arzte aufgrund der Seltenheit der TB kaum Erfahrung damit hat. Gleichzeitig ist wegen moglicher Resistenzen gegen TB-Medikamente Spezialwissen erforderlich, das nicht breit vorhanden ist.

En regle generale, la tuberculose (TB) est facilement traitable. Des cas de deces ont neanmoins ete observes en Suisse au cours des dernieres annees, meme parmi les jeunes. Ceci s’explique partiellement par le fait que la grande majorite des medecins n’a que tres peu d’experience en matiere de TB en raison de la rarete de la maladie. Par ailleurs, des connaissances specifiques sont requises au vu du risque de resistance aux medicaments antituberculeux; ces connaissances ne sont neanmoins pas tres repandues.

In July 2014, an outbreak of Salmonella enterica ssp. enterica serovar Bovismorbificans was detected in Switzerland. The goal of the outbreak investigation was to rapidly identify and eliminate the contamination source in order to prevent new cases.; A case-case study design was applied comprising reported cases of S. Bovismorbificans and cases of other serovars. A trawling questionnaire was administered by telephone interview. Data were collected for 34 cases (20 S. Bovismorbificans and 14 Salmonella spp.) pertaining to food consumption during the 72 hours prior to symptom onset.; A statistically significant association between an S. Bovismorbificans infection and the consumption of 'salads' (odds ratio [OR] 14.3, 95% confidence interval [CI] 1.47-138.27) as well as the consumption of 'sprouts' (OR 10.6, 95% CI 1.16-97.59) was found. Principal places of consumption of 'salads' and 'sprouts' in outbreak cases were restaurants in southern Germany (80.0%, 95% CI 56.3%-94.3%). Microbiological analysis in Germany identified S. Bovismorbificans on sprouts, and genotype analysis confirmed that Swiss and German cases shared the same outbreak strain. The contaminated products were removed from the market in Germany, preventing an on-going outbreak.; The combination of the applied methods and the collaboration between the two countries proved to be crucial elements of this investigation. A series of sprouts-associated salmonellosis outbreaks underpin the importance of this vegetable as a potential food-borne pathogen carrier.

Objectives The studies reported here investigated the association between health complaints and the vicinity to the short wave transmitter Schwarzenburg, and looked for evidence for a relationship between magnetic field exposure and sleep disturbances.

Objective To assess outcomes 24 months after treatment start for multidrug-resistant tuberculosis (MDR-TB). Methods Cohort study of all culture-positive MDR-TB cases notified in Switzerland from 01/2003 to 07/2010. Results Fifty-one cases were observed, with a median age of 26 years (range 2-56). Twenty-seven were male, five of Swiss origin, 46 of foreign origin (Asia 18, Africa 13, former Soviet Union 8), including 21 asylum seekers and refugees. Twelve had received a previous treatment for TB and 24 had not (15 unknown). Forty-four cases were pulmonary of which 25 were known to be sputum smear positive. All but two strains showed additional resistances: 29 to ethambutol, 27 to pyrazinamide, 6 to a fluoroquinolone, 5 to amikacin. None was resistant to both of the latter two classes. Molecular analyses showed three pairs of identical strains. Fluoroquinolones were used in 48 patients and second-line injectable drugs in 37. The median duration of MDR treatment was 18 months (range 1-26). The outcome after 24 months was successful in 39 (76%) and unsatisfactory in 12 (24%) patients: two deaths from TB; two treatments terminated owing to side effects of drugs and one owing to pregnancy; four defaults from treatment at months 0, 4, 8, and 21; two transfers abroad with unknown outcome; one outcome unknown. There was no significant association of unfavourable outcomes with age, sex, origin, previous treatment, treatment delay, resistance pattern, and classes of drugs used. Conclusions MDR-TB in Switzerland occurs mostly in persons of foreign origin. Results of decentralised treatments were satisfactory.

To compare acute flaccid paralysis (AFP) surveillance systems used by members of the International Network of Paediatric Surveillance Units (INoPSU) across the five AFP surveillance performance indicators recommended by the World Health Organization (WHO) for the maintenance of polio-free certification.A survey was administered to AFP surveillance co-ordinators in five INoPSU member countries (Australia, Belgium, Canada, New Zealand and Switzerland). Data collected included information on surveillance system processes, WHO-recommended performance indicators, investigative practices and final diagnoses of cases from 2006 to 2010.All countries contacted completed the survey. Each country used similar case definitions and processes for collecting AFP data. All countries used at least one of the WHO indicators for surveillance. No country consistently met the performance indicator for incidence or stool sampling. In all countries, at least one form of neurological testing was used to diagnose cases of AFP. Guillain-Barré syndrome was the most common final diagnosis in all countries for all years examined.Industrialised countries surveyed do not consistently meet the WHO-recommended AFP surveillance performance indicators. An opportunity exists for INoPSU to suggest a standard way for member countries to collect AFP data in order to examine the potential for strengthening the current systems or introducing additional enterovirus surveillance or alternative/complementary neurological performance measures suitable for countries that have eliminated polio. INoPSU member countries are evaluating these possibilities.

Objective: To assess the influence of differential precision in the measurement of the correlated variables total cholesterol and high density lipoprotein (HDL) cholesterol on the estimates of the risk of ischaemic heart disease (IHD) associated with plasma triglyceride levels. Design, setting and participants: The Caerphilly Heart Disease Study (CHDS), a prospective cohort study of 2512 middle-aged men living in the town of Caerphilly, south Wales, UK. The results from two sub-studies were used to estimate the degree of measurement imprecision (laboratory error and within-person variation) in triglycerides, total cholesterol and HDL cholesterol. Main outcome measures: Multivariable risk estimates for major IHD calculated from logistic regression analysis, adjusted and not adjusted for measurement imprecision. Major IHD events were defined as death from IHD, clinical non-fatal myocardial infarction or electrocardiographic myocardial infarction. Results: There were 261 men with major IHD events during follow-up. In age-adjusted analyses, taking measurement imprecision into account strengthened associations with IHD for all lipid factors. The odds ratio (OR) for one S.D. increase in triglycerides, ignoring measurement imprecision, was 1.36 (95% confidence interval [95% CI] 1.20–1.55) but 1.57 (95% CI 1.30–1.89) when taking imprecision into account. The standardised odds ratio for triglycerides adjusted for measurement imprecision and the two other lipid factors was 1.35 (95% CI 1.09–1.69). In this model, the triglyceride level showed a stronger association than total cholesterol (OR 1.28; 95% CI 1.05–1.56) and HDL cholesterol (OR for one S.D. decrease 1.20; 95% CI 0.97–1.49). When adding fasting blood glucose and diastolic blood pressure, however, the effect of triglycerides was reduced and ceased to be statistically significant (OR 1.19; 95% CI 0.95–1.49). This was further attenuated upon inclusion of body mass index, smoking status and history of pre-existing IHD. Total cholesterol remained a statistically significant (P

The spectacular improvements of the 1-h world record in cycling in the last four years have highlighted the importance of aerodynamics in modern bicycle racing. We have investigated the metabolic consequences of the low-crouched aero-positions necessary to reduce air drag. In this study, 14 elite male bicycle racers (24.0 +/- 1.0 yr, VO2max 69.4 +/- 0.5 mL.kg-1.min-1) were tested for oxygen consumption (VO2) and heart rate (HR) at 70% (302.6 +/- 5.3 W) of their individual VO2max in three different riding positions during a single test run. The subjects rode their racing bicycles on a wind braked roller; the sequence of the three following positions was randomized: 1) upright cycling (UP), cadence 90 rpm; 2) hands on drops (DP), 90 rpm; and 3) hands on clip-on aero-handlebars (AP), 90 rpm. VO2 and HR values in AP were significantly higher by 1.5 mL.kg-1.min-1 and 5 beats.min-1, respectively, compared with UP. We concluded that riding a bicycle in an extreme aero-position increases the metabolic cost of cycling when wind resistance is not taken into account. However, when the mechanical power losses of 9 W (estimated by the VO2 increase) are compared with the expected aerodynamic power savings of approximately 100 W, it appears that aerodynamic advantages by far outweight their metabolic cost.

A pilot study was conducted to investigate the influence of electromagnetic fields in the short-wave range (3-30 MHz) radio transmitter signals on salivary melatonin concentration in dairy cattle. The hypothesis to be tested was whether EMF exposure would lower salivary melatonin concentrations, and whether removal of the EMF source would be followed by higher concentration levels. For this pilot study, a controlled intervention trial was designed. Two commercial dairy herds at two farms were compared, one located at a distance of 500 m (exposed), the other at a distance of 4,000 m (unexposed) from the transmitter. At each farm, five cows were monitored with respect to their salivary melatonin concentrations over a period of ten consecutive days. Saliva samples were collected at two-hour intervals during the dark phase of the night. As an additional intervention, the short-wave transmitter was switched off during three of the ten days (off phase). The samples were analyzed using a radioimmunoassay. The average nightly field strength readings were 21-fold greater on the exposed farm (1.59 mA/m) than on the control farm (0.076 mA/m). The mean values of the two initial nights did not show a statistically significant difference between exposed and unexposed cows. Therefore, a chronic melatonin reduction effect seemed unlikely. However, on the first night of re-exposure after the transmitter had been off for three days, the difference in salivary melatonin concentration between the two farms (3.89 pg/ml, CI: 2.04, 7.41) was statistically significant, indicating a two- to seven-fold increase of melatonin concentration. Thus, a delayed acute effect of EMF on melatonin concentration cannot completely be excluded. However, results should be interpreted with caution and further trials are required in order to confirm the results.

The effects of an intermittent high intensity stimulus (running) or a chronic low intensity stimulus (cold acclimation) of oxidative metabolism on maximal oxygen uptake (VO2,max), lung O2 diffusing capacity (DLO2) and skeletal muscle as well as fat tissue mitochondrial content in growing guinea pigs are described. Young male guinea pigs were assigned to three experimental groups (n = 5): control (C), endurance trained (T; at 70% VO2max) or cold acclimated (CA; 5-7 degrees C) for six weeks. Animals were sacrificed at the end of the experimental period and tissue for morphometric analysis of the lung, muscle and interscapular fat was sampled. T and CA animals significantly increased weight specific VO2max by 23% and 29%, respectively. Despite a significant increase in absolute lung volume in T (+10%) and in weight specific lung volume in CA (+20%) neither absolute nor weight specific DLO2 was significantly affected by the experimental treatments. In trained animals the total volume of mitochondria remained unchanged in samples representative for the entire musculature but was significantly increased in M. vastus intermedius (+72%). Intramyocellular lipids increased significantly both in M. vastus intermedius (+244%) as well as in the whole body musculature (+164%). Cold acclimation increased the mitochondrial content of the interscapular fat pad by approximately 20-fold but had no effect on total mitochondrial volume in muscle. We conclude that the increase in oxygen demand resulting from exercise training or from cold acclimation could be accomodated by the existing lung diffusing capacity and did not induce a global change of oxidative capacity in skeletal muscle tissue in growing guinea pigs. Exercise training caused oxidative capacity to increase only in a locomotor muscle activated during running whereas cold acclimation greatly increased interscapular fat tissue oxidative capacity.

Bacterial factors may contribute to the global emergence and spread of drug-resistant tuberculosis (TB). Only a few studies have reported on the interactions between different bacterial factors. We studied drug-resistant Mycobacterium tuberculosis isolates from a nationwide study conducted from 2000 to 2008 in Switzerland. We determined quantitative drug resistance levels of first-line drugs by using Bactec MGIT-960 and drug resistance genotypes by sequencing the hot-spot regions of the relevant genes. We determined recent transmission by molecular methods and collected clinical data. Overall, we analyzed 158 isolates that were resistant to isoniazid, rifampin, or ethambutol, 48 (30.4%) of which were multidrug resistant. Among 154 isoniazid-resistant strains, katG mutations were associated with high-level and inhA promoter mutations with low-level drug resistance. Only katG ( S315T ) (65.6% of all isoniazid-resistant strains) and inhA promoter −15C/T (22.7%) were found in molecular clusters. M. tuberculosis lineage 2 (includes Beijing genotype) was associated with any drug resistance (adjusted odds ratio [OR], 3.0; 95% confidence interval [CI], 1.7 to 5.6; P < 0.0001). Lineage 1 was associated with inhA promoter −15C/T mutations (OR, 6.4; 95% CI, 2.0 to 20.7; P = 0.002). We found that the genetic strain background influences the level of isoniazid resistance conveyed by particular mutations (interaction tests of drug resistance mutations across all lineages; P < 0.0001). In conclusion, M. tuberculosis drug resistance mutations were associated with various levels of drug resistance and transmission, and M. tuberculosis lineages were associated with particular drug resistance-conferring mutations and phenotypic drug resistance. Our study also supports a role for epistatic interactions between different drug resistance mutations and strain genetic backgrounds in M. tuberculosis drug resistance.

BACKGROUND: Tuberculosis (TB) in migrants is an ongoing challenge in several low TB incidence countries since a large proportion of TB in these countries occurs in migrants from high incidence countries. To meet these challenges, several countries utilize TB screening programs. The programs attempt to identify and treat those with active and/or infectious stages of the disease. In addition, screening is used to identify and manage those with latent or inactive disease after arrival. Between nations, considerable variation exists in the methods used in migration-associated TB screening. The present study aimed to compare the TB immigration medical examination requirements in selected countries of high immigration and low TB incidence rates. METHODS: Descriptive study of immigration TB screening programs. RESULTS: 16 out of 18 eligible countries responded to the written standardized survey and phone interview. Comparisons in specific areas of TB immigration screening programs included authorities responsible for TB screening, the primary objectives of the TB screening program, the yield of detection of active TB disease, screening details and aspects of follow up for inactive pulmonary TB. No two countries had the same approach to TB screening among migrants. Important differences, common practices, common problems, evidence or lack of evidence for program specifics were noted. CONCLUSIONS: In spite of common goals, there is great diversity in the processes and practices designed to mitigate the impact of migration-associated TB among nations that screen migrants for the disease. The long-term goal in decreasing migration-related introduction of TB from high to low incidence countries remains diminishing the prevalence of the disease in those high incidence locations. In the meantime, existing or planned migration screening programs for TB can be made more efficient and evidenced based. Cooperation among countries doing research in the areas outlined in this study should facilitate the development of improved screening programs. The study was funded by Citizenship and Immigration Canada (CIC). The funders had no role in study design, data collection and analysis, or preparation of the manuscript. The corresponding author has obtained approval from CIC to publish this paper. This paper represents the views of the authors and does not necessarily reflect the opinions of Citizenship and Immigration Canada, the Public Health Agency of Canada or the Government of Canada. This paper does not represent the views of any of the Governments or Ministries affiliated with the authors of this study and represents solely the views of the authors. Dr. S. Miyano contributed to the acquisition of the data and as such we feel he is entitled to authorship but, despite our extensive efforts, we were unable to contact him to approve the final content of this manuscript and his authorship. Therefore, we acknowledge his contribution here. Sí

Summary This systematic review assesses the evidence for an association between Mycobacterium avium subspecies paratuberculosis (MAP) and Crohn's disease. We analysed 28 case-control studies comparing MAP in patients with Crohn's disease with individuals free of inflammatory bowel disease (IBD) or patients with ulcerative colitis. Compared with individuals free of IBD, the pooled odds ratio (OR) from studies using PCR in tissue samples was 7·01 (95% CI 3·95–12·4) and was 1·72 (1·02–2·90) in studies using ELISA in serum. ORs were similar for comparisons with ulcerative colitis patients (PCR, 4·13 [1·57–10·9]; ELISA, 1·88 [1·26–2·81]). The association of MAP with Crohn's disease seems to be specific, but its role in the aetiology of Crohn's disease remains to be defined.

Problems in tuberculosis are its rarity, drug-resistant strains, and patients' social aspects. Knowing the epidemiology helps to "think tuberculosis" when some anamnestic and clinical findings are present. In a not too seriously ill patient, the emergency consists of excluding infectious tuberculosis by sputum smear examinations. A positive result will lead to the patient's isolation and the initiation of treatment. Negative smears allow to wait for culture results, while following the patient and repeating smears after a non-specific antibiotic treatment. In case of strong suspicion of tuberculosis or risk for a rapid progression, the treatment should begin without delay. Discussion with a specialist is often warranted. A follow-up by the Swiss Pulmonary Association is recommended to prevent the patient from defaulting from treatment.

AIM OF THE STUDY: To evaluate the compliance of doctors and patients with the current recommendations for screening and preventive treatment of immigrants with a positive tuberculin skin test (TST) suggestive of latent tuberculosis infection (LTBI). METHODS: Retrospective cohort study of all asylum seekers entering Switzerland between 1 January 1993 and 31 December 1993 and assigned to the cantons of Aargau, Fribourg, Geneva, Neuchâtel, Valais and Vaud, who underwent a TST at the border. The medical documents of all individuals with a TST size suggestive of LTBI (> or = 10 mm in children or = 18 mm in young adults aged 15-25 years) were reviewed for final diagnosis, therapeutic decision, compliance with treatment if prescribed, and notification for tuberculosis within the next 3 years. RESULTS: Among 2515 asylum seekers, 172 had a positive TST suggestive of LTBI. The documents of 93 persons were available. The final diagnosis was LTBI in 71 cases, possible tuberculosis in 10 cases, an effect of BCG immunisation in 10 cases, and other diagnoses in 2 cases. Among 82 individuals with normal chest X-ray or no radiological examination, only 37 (46%) received a preventive treatment and one a full course of antituberculosis drugs. Among 11 persons with an abnormal chest X-ray, 2 received a full course of antituberculosis drugs, 7 a preventive therapy and 2 had no treatment prescribed. Among the 44 subjects in whom a preventive treatment was prescribed, 30 adhered to the treatment regimen. One case (without prescribed treatment) was notified for tuberculosis two years after entry. CONCLUSIONS: Compliance of doctors and patients with current recommendations for examination and treatment of immigrants with a TST suggestive of LTBI is unsatisfactory. New guidelines are needed to provide a clearer definition of the indications and explain the benefits of treating LTBI.

To assess the health-seeking behaviour, the patient delay (onset of symptoms to first consultation) and the health system delay (first consultation to start of tuberculosis treatment) among patients with pulmonary tuberculosis (TB) diagnosed in Switzerland, and to assess the predictors of the various types of delay. A survey among pulmonary TB patients was carried out in six cantons, covering 42% of all pulmonary adult TB cases notified in Switzerland. Data were collected by collaborators of the cantonal lung associations in charge of the follow-up of TB patients to investigate treatment seeking behaviour and to establish various delays and its predictors. Predictors of percentiles of delay (median and 75th percentile) were assessed using quantile regression. Among 252 eligible patients, 162 patients could be interviewed. Of these, 20.4% were born in Switzerland. Cough as a symptom was mentioned by 76% of the interviewed patients. Almost half of the 162 patients (46%) consulted first a general practitioner in an ambulatory care setting and 26% approached a hospital first. The median delay between symptom onset and first healthcare contact (patient delay) was 5.2 weeks, which is slightly longer than findings in other low prevalence countries. The interquartile range was 1.6 to 14.2 weeks. The median delay between first consultation in Switzerland and the start of TB treatment (health system delay) was 2 weeks. The interquartile range was 0.6 to 7.1 weeks. There were no clear predictors of patient delay. The main predictors of a longer median health system delay were the presence of fever (1.6 weeks, 95% confidence interval [CI] 0.5 to 2.6 weeks), having visited first a general practitioner or a paediatrician (1 week, 95% CI 0.1 to 1.9 weeks) and having seen three or four doctors before beginning TB treatment (2.9 weeks, 95% CI 0.7 to 5.1 weeks). A clear predictor of a shorter median health system delay was having undergone an X-ray at the first consultation (-2.9 weeks, 95% CI -4.8 to -0.9 weeks). Marginally significant for shorter delay was male sex (-2.6 weeks, 95% CI -5.4 to 0.1 weeks). No predictor of patient delay was found among the variables collected. For one fourth of the patients, the health system delay was longer than 7 weeks. General practitioners are commonly approached first, and they have to consider TB, also for patients not considered at high-risk for TB.