This document discusses tuberculosis (TB) in urban areas and large cities. It finds that: 1) Incidence rates of TB are significantly higher in metropolitan areas like Milan, which notifies 40% of regional cases and 9% of national cases. 2) TB affects younger foreign populations more so than older Italian populations. The highest number of foreign TB cases come from Africa, Asia, Latin America and Eastern Europe. 3) Targeted screening and treatment programs, along with infection control measures, are needed in high-risk urban groups and settings like homeless shelters and prisons to help control the spread of TB in cities.

1. La TB nelle aree metropolitane
L.R. Codecasa, M. Ferrarese
Centro Regionale di Riferimento per il controllo della
TBC
Istituto Villa Marelli. AO Niguarda, Milano

2. The winter of our discontempt….
(W. Shakespeare, Richard III)

3. TBC nelle grandi città europee
50
Casi
x
100000
45
40
35
30
25
20
15
10
5
0
Londra Milano Rotterdam Barcellona Parigi

4. Trend incidenza TBC e media 2000 - 2010
25 Milano Lombardia Italia
Casi
x
100.000
20 19,1
15
10 10,1
5 7,5
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Incidenza nazionale stabile ma con:
• Differenze territoriali rilevanti
• Valori significativamente più elevati nelle aree metropolitane (ASL Milano, notifica il
40% dei casi regionali e il 9% dei casi nazionali di TBC)

5. Numero
casi
TBC
per
fascia
d’età
e
nazionalità
-­‐
2010
Negli
italiani
la
TBC
colpisce
sopra2u2o
gli
anziani,
negli
stranieri
l’età
giovane
–
adulta
con
picco
nella
fascia
30
–
39
anni

6. TBC
in
stranieri
Area di
provenienza
15%
Casi TBC dal Sud 27%
America
- Quota ++ in
rapporto ai residenti -
- Quota femmine + 25%
dei maschi
31%
maschi
femmine

7. RischioTBC
in
stranieri:
10
nazionalità
più
frequen@
a
confronto
con
le
presenze
sul
territorio
* Paesi di origine ad elevata incidenza TBC (≥ 100 casi x

8. " Il numero dei casi anno è il 5%
dei casi totali segnalati
" In media ogni mese viene segnalato 1 caso che
frequenta collettività scolastiche
" La proporzione di bambini stranieri è simile a
quella dei casi adulti
L’andamento della TBC nei bambini non preoccupa, ma esistono nella
popolazione i fattori di rischio per lo sviluppo di micro-epidemie nelle
comunità infantili

9. POLMONITE
BILATERALE?
" Perù,
13
anni
" Calo
ponderale
15
kg,
febbre,
tosse.
" RichiesO
anOcorpi
anOgliadina!
" QuanOferon
+
" Inviata
per
profilassi
con
isoniazide
" Esame
dire2o
posiOvo
per
BAAR+++

10. ..e
il
fratellino!

11. Le Regioni che hanno attivato la sorveglianza ed hanno inviato informazioni sugli esiti sono state Emilia-Romagna, Friuli Venezia
Giulia, Lombardia, Marche, Piemonte, Toscana e Veneto, Regioni che rappresentavano il 71% dei casi di TBC notificati a livello
nazionale nel 2007
Sono pervenute
informazioni sugli esiti
di 1.818 casi di TBC
polmonare su 2.107.
Esiti di trattamento TBC
per pervenuti per Regione
Anno 2007
D.G. Prevenzione Sanitaria
Ufficio Malattie Infettive e
Fonte: La tubercolosi in Italia. Rapporto 2008 – www.salute.gov.it Profilassi Internazionale

12. Esi@
della
terapia
casi
di
TBC
2009
Non
pervenuto Sfavorevole Favorevole
Cause
esito
sfavorevole
7,4 Perso
al
follow
up
(43%)
19,3
Trasferito
17
%
Decesso
17
%
Interro2o
15%
73,3 Fallimento/altro
8%
Obiettivo OMS: trattare con successo 85% dei casi
Differenze significative degli esiti della terapia tra centri ospedalieri:
Villa Marelli tratta con successo oltre il 90% dei malati

15. There is an increased drive to use awareness as a measure for TB control and to
improve the lack of knowledge, also in EU countries [55]. Mass TB awareness
campaigns in general population may not be effective [56], but early suspicion is
more likely when knowledge about TB among is increased in the exposed
population, high-risk groups, staff working with high-risk groups and health care
professionals

16. Infection control in community settings and big cities
Infection control (IC) is an essential component of TB control and prevention, including
WHO´s updated Stop TB strategy and the EU Standards of TB Care [65-73].
Shortcomings in IC were major contributors to nosocomial outbreaks [74-76], even in
European TB reference. Poor ventilation and overcrowding have been drivers of TB
transmission in congregate settings such as homeless shelters, prisons and drug
consumption houses [78-80]. General IC principles for health care settings, described
in detail elsewhere [74, 81], can benefit these specific congregate venues. However,
engeneering control activities may be difficult to implement in existing buildings and
other measures, such as personal protective equipment for employees, cannot be
expected. New interest in IC has been awakened by the emergence of multi-drug
resistant (MDR) and extensively-drug resistant (XDR) TB

17. Active case finding among urban high-risk groups should be complemented by tailored
opportunities for completion of the diagnostic process and treatment, e.g. through low-
threshold public health "One-Stop-TB-Shops" with sufficient nursing, social and community
health care worker staff, clinical follow-up or admission to general hospitals or modern-day
sanatoria, adequate legal frameworks for social support and protection and ensuring
knowledge about and facilitating access to health care services. Contact-tracing may not be
feasible or effective amongst all urban risk groups, but can be in specific populations, e.g.
household or professional contacts [4, 12]. Indiscriminate radiographic screening of
immigrants is described as inefficient and not cost-effective [9, 69, 98, 101, 103]. However,
some interventions may be highly effective or cost-effective when targeted at specific urban
high-risk groups, e.g. homeless persons and prisoners

20. The contribution of DNA fingerprinting to the epidemiological standard data in the
context of urban TB control have been described elsewhere, with an extensive list of
references [142]. Briefly, molecular indications for epidemiological links and
identification of risk factors for transmission are crucial for understanding the specific
epidemiology of TB in big cities, allowing the detection of risk groups and informing
(targeted) public health interventions [12, 19]. Since the 1990's DNA fingerprinting
revealed that a considerable proportion of TB in low-incidence countries was caused
by recent transmission (including reinfection), in particular in urban areas, and not
due to late reactivation of infections acquired domestically or infections acquired
abroad. Molecular epidemiological studies identified factors for a higher risk of
clustering, reflecting the risk of infection, such as alcohol abuse, intravenous drug use
(IDU), homelessness, or ethniticy [142]. They also confirmed high-risk sites for TB
transmission in big cities, e.g. congregate settings such as shelters for homeless
persons or prisons. Not sure this is the best way to phrase this but I was trying to put
here what is in the reco : that molecular tools complement the surveillance data

23. Sostenete
Stop
TB
Italia!
www.stoptb.it