NEW TUBERCULOSIS RECOMMENDATIONS IN FRANCE (AND EVENTUAL INTEREST FOR ROMANIA ??)
Fadi ANTOUN, Paris Public Health Service, France, 2014
In France TB incidence have decreased regularly since 30 years. It was divided by twice since 15 years to reach 7.6/105 in 2012 (4975 new cases), which classified France among lowest incidence European countries. However TB remains in high-risk groups, specially migrants and homeless people. Furthermore the incidence is twice to three times the national incidence in Paris and its suburbs because of high proportions of risk groups. TB MDR remains less than 2 % of all TB cases even if the number has doubled in 2012-2013 due to new “migrants” from eastern European countries. HIV percentage among TB case is not precisely known (around 6 to 8%) because it is banned to notify it in TB official statement. Proportions of migrants reached 56 % among new cases.
National recommendations were edited to face these epidemiological facts and take into account the new situation and new diagnosis tools: national Program TB 2008-2011, and recent indications to use IGRA (July 2011) highlights the need in low incidence countries with high income to consider the latent infection as a health goal and to screen it in precise situations: contact subject, recent migrants under 15 years old, HIV and immuno compromised patients (including treatment with anti-TNF drugs) ; moreover there was no indication to use IGRA in TB disease diagnosis.
National Health Service experts set also new recommendations in contact tracing subjects (May 2013): IGRA is allowed to be used in children above 5 years old. IGRA or tuberculin test is done when delay is superior 8 weeks between test and last contact, only latent infection presumed to be recent is treated, focusing is made on contact subjects living in the same house. Furthermore indications for good screening are proposed as a goal, with par example more than 80% of identified contact subjects to be screened and more than 60% of positive “ITL tests” to be treated.
Considering TB MDR, recommendations have not been edited yet (November 2014). But due to increasing number of cases (80 instead of 40 cases per year) some recommendations have been suggested until definitive decisions : treatment is reserved to special health units, bacteriological diagnosis has to be systematically realized with rapid genotypic methods, confirmed by phenotypic methods. Furthermore, fours drugs efficient on Mycobacterium are to be introduced for 8 months and then 2 drugs for 10 more months. Surgical indications are reserved to precise situations: bleeding risk and cavitary lesion unhealed after 6 months treatment.