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In July 2013, a passenger died of infectious extensively drug-resistant tuberculosis (XDR-TB) on board of an aircraft after a 3-hour flight from Turkey to Germany. Initial information indicated the patient had moved about the aircraft coughing blood. We thus aimed to contact and inform all persons exposed within the aircraft and to test them for newly acquired TB infection. Two-stage testing within 8 weeks from exposure and at least 8 weeks after exposure was suggested, using either interferon gamma release assays (IGRAs) or tuberculin skin test (TST). The TST cut-off was defined at a diameter > 10 mm; for differentiation between conversion and boosting, conversion was defined as increase of skin induration > 5 mm. Overall, 155 passengers and seven crew members were included in the investigation: the questionnaire response rate was 83%; 112 (69%) persons were tested at least once for TB infection. In one passenger, who sat next to the area where the patient died, a test conversion was registered. As of March 2017, no secondary active TB cases have been reported. We describe an unusual situation in which we applied contact tracing beyond existing European guidelines; we found one latent tuberculosis infection in a passenger, which we consider probably newly acquired.


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  1. Robert Koch Institut (RKI). Bericht zur Epidemiologie der Tuberkulose in Deutschland für 2012. [Report on the epidemiology of tuberculosis in Germany in 2012]. Berlin: RKI; 2013. German. Available from: http://edoc.rki.de/series/rki-bericht-zur-epidemiologie-der-tuberkulose-in-deutschland/2012/PDF/2012.pdf
  2. World Health Organization (WHO). Use of high burden country lists for TB by WHO in the post-2015 era. Geneva: WHO; 2015. Available from: http://www.who.int/tb/publications/global_report/high_tb_burdencountrylists2016-2020.pdf
  3. European Centre for Disease Prevention and Control (ECDC). Risk assessment guidelines for infectious diseases transmitted on aircraft (RAGIDA) – Tuberculosis. Stockholm: ECDC; 2014. Available from: http://ecdc.europa.eu/en/publications/Publications/tuberculosis-risk-assessment-guidelines-aircraft-May-2014.pdf
  4. Abubakar I. Tuberculosis and air travel: a systematic review and analysis of policy. Lancet Infect Dis. 2010;10(3):176-83.  https://doi.org/10.1016/S1473-3099(10)70028-1  PMID: 20185096 
  5. Kotila SM, Payne Hallström L, Jansen N, Helbling P, Abubakar I. Systematic review on tuberculosis transmission on aircraft and update of the European Centre for Disease Prevention and Control risk assessment guidelines for tuberculosis transmitted on aircraft (RAGIDA-TB). Euro Surveill. 2016;21(4).  https://doi.org/10.2807/1560-7917.ES.2016.21.4.30114  PMID: 26848520 
  6. Diel R, Loytved G, Nienhaus A, Castell S, Detjen A, Geerdes-Fenge H, et al. [New recommendations for contact tracing in tuberculosis. German Central Committee against Tuberculosis]. Pneumologie. 2011;65(6):359-78.  https://doi.org/10.1055/s-0030-1256439  PMID: 21560113 
  7. Hizel K, Maral I, Karakus R, Aktas F. The influence of BCG immunisation on tuberculin reactivity and booster effect in adults in a country with a high prevalence of tuberculosis. Clin Microbiol Infect. 2004;10(11):980-3.  https://doi.org/10.1111/j.1469-0691.2004.00970.x  PMID: 15522000 
  8. Menzies D. Interpretation of repeated tuberculin tests. Boosting, conversion, and reversion. Am J Respir Crit Care Med. 1999;159(1):15-21.  https://doi.org/10.1164/ajrccm.159.1.9801120  PMID: 9872812 
  9. The German Protection against Infection Act – Infektionsschutzgesetz (IfSG). Reckinger, 2013. German.
  10. World Health Organization (WHO). International Health Regulations. Third Edition. Geneva: WHO; 2005. Available from: http://apps.who.int/iris/bitstream/10665/246107/1/9789241580496-eng.pdf
  11. World Health Organization (WHO). Tuberculosis and air travel: Guidelines for prevention and control. Geneva: WHO; 2008. Available from: http://www.who.int/tb/publications/2008/WHO_HTM_TB_2008.399_eng.pdf
  12. International Air Transport Association (IATA). Medical incident report form. IATA; [Accessed 19 March 2017]. Available from: https://www.iata.org/whatwedo/safety/health/Documents/medical-incident-report-form.pdf
  13. World Health Organization (WHO). Recommendations for investigating contacts of persons with infectious tuberculosis in low- and middle-income countries. Geneva: WHO; 2012. Available from: http://apps.who.int/iris/bitstream/10665/77741/1/9789241504492_eng.pdf
  14. Chemardin J, Paty MC, Renard-Dubois S, Veziris N, Antoine D. Contact tracing of passengers exposed to an extensively drug-resistant tuberculosis case during an air flight from Beirut to Paris, October 2006. Euro Surveill. 2007;12(12):E071206.2. Available from: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3325 PMID: 18067848 
  15. Scholten D, Saunders A, Dawson K, Wong T, Ellis E. Air travel by individuals with active tuberculosis: reporting patterns and epidemiologic characteristics, Canada 2006-2008. Travel Med Infect Dis. 2010;8(2):113-9.  https://doi.org/10.1016/j.tmaid.2010.02.002  PMID: 20478519 
  16. Marienau KJ, Burgess GW, Cramer E, Averhoff FM, Buff AM, Russell M, et al. Tuberculosis investigations associated with air travel: U. S. Centers for Disease Control and Prevention, January 2007-June 2008. Travel Med Infect Dis. 2010;8(2):104-12.  https://doi.org/10.1016/j.tmaid.2010.02.003  PMID: 20478518 
  17. Mori T, Sakatani M, Yamagishi F, Takashima T, Kawabe Y, Nagao K, et al. Specific detection of tuberculosis infection: an interferon-gamma-based assay using new antigens. Am J Respir Crit Care Med. 2004;170(1):59-64.  https://doi.org/10.1164/rccm.200402-179OC  PMID: 15059788 
  18. Ravn P, Munk ME, Andersen AB, Lundgren B, Lundgren JD, Nielsen LN, et al. Prospective evaluation of a whole-blood test using Mycobacterium tuberculosis-specific antigens ESAT-6 and CFP-10 for diagnosis of active tuberculosis. Clin Diagn Lab Immunol. 2005;12(4):491-6. PMID: 15817755 
  19. Moreno S, Blázquez R, Novoa A, Carpena I, Menasalvas A, Ramírez C, et al. The effect of BCG vaccination on tuberculin reactivity and the booster effect among hospital employees. Arch Intern Med. 2001;161(14):1760-5.  https://doi.org/10.1001/archinte.161.14.1760  PMID: 11485509 
  20. Kazanci F, Güler E, Eren Dagli C, Garipardic M, Davutoglu M, Ispiroglu E. The prevalence of tuberculin skin test positivity and the effect of BCG vaccinations on tuberculin induration size in the eastern Mediterranean region of Turkey. Turk J Med Sci. 2001;41(4):711-8.
  21. Zwerling A, Behr MA, Verma A, Brewer TF, Menzies D, Pai M. The BCG World Atlas: a database of global BCG vaccination policies and practices. PLoS Med. 2011;8(3):e1001012.  https://doi.org/10.1371/journal.pmed.1001012  PMID: 21445325 
  22. Public Health England (PHE). World Health Organization (WHO) estimates of tuberculosis incidence by country, 2013. Updated 11 Dec 2014. London: PHE. Available from: http://webarchive.nationalarchives.gov.uk/20150624110511/https:/www.gov.uk/government/uploads/system/uploads/attachment_data/file/393840/Worldwide_TB_Surveillance_2013_Data_High_and_Low_Incidence_Tables____2_.pdf

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