Prevalence of Latent Tuberculosis Infection Among Healthy Young Children and Adolescents and a Two-step Approach for the Diagnosis of Tuberculosis Infection in Chengdu, China.

BACKGROUND: China has a high burden of tuberculosis and latent tuberculosis infection (LTBI). The aim of this study was to estimate the prevalence of LTBI among healthy young children and adolescents and test a 2-step approach to explore the threshold for the diagnosis of tuberculosis infection in Chengdu, China. METHODS: Healthy preschool children and school-going children in Chengdu, Sichuan Province, were screened for LTBI using the tuberculin skin test (TST). Preschool children with TST ≥ 5 mm also underwent interferon-γ release assay (IGRA) to explore the threshold of this 2-step approach. RESULTS: In total, 5667 healthy young children and adolescents completed TST test between July 2020 and January 2021 and were included in the present analysis. The age of the participants ranged from 2.4 to 18 years (median 7.25 ± 4.514 years), of which 2093 (36.9%) were younger than 5 years. The overall prevalence of LTBI was 6.37% and 6.64% in children younger than 5 years old. Fourteen of the 341 preschool children with TST ≥5 mm were interferon-γ release assay positive, of which 4 showed a TST result of 5-10 mm, and 6 preschool children received preventive treatment for LTBI. CONCLUSIONS: Healthy young children and adolescents should also be considered as important target populations for LTBI screening. TST can be recommended for first-line screening as part of a 2-step approach for LTBI screening using a positive threshold of 5 mm.

Epidemiology, clinical features and outcomes of incident tuberculosis in children in Canada in 2013-2016: results of a national surveillance study.

PURPOSE: Childhood tuberculosis disease is difficult to diagnose and manage and is an under-recognised cause of morbidity and mortality. Reported data from Canada do not focus on childhood tuberculosis or capture key epidemiologic, clinical and microbiologic details. The purpose of this study was to assess demographics, presentation and clinical features of childhood tuberculosis in Canada. METHODS: We conducted prospective surveillance from 2013 to 2016 of over 2700 paediatricians plus vertical tuberculosis programmes for incident tuberculosis disease in children younger than 15 years in Canada using the Canadian Paediatric Surveillance Program (CPSP). RESULTS: In total, 200 cases are included in this study. Tuberculosis was intrathoracic in 183 patients of whom 86% had exclusively intrathoracic involvement. Central nervous system tuberculosis occurred in 16 cases (8%). Fifty-one per cent of cases were hospitalised and 11 (5.5%) admitted to an intensive care unit. Adverse drug reactions were reported in 9% of cases. The source case, most often a first-degree relative, was known in 73% of cases. Fifty-eight per cent of reported cases were Canadian-born Indigenous children. Estimated study rates of reported cases (per 100 000 children per year) were 1.2 overall, 8.6 for all Indigenous children and 54.3 for Inuit children. CONCLUSION: Childhood tuberculosis may cause significant morbidity and resource utilisation. Key geographies and groups have very high incidence rates. Elimination of childhood tuberculosis in Canada will require well-resourced community-based efforts that focus on these highest risk groups.

Brief Report: Yield of Repeat Tuberculin Skin Testing for People Living With HIV in Brazil.

OBJECTIVES: In Brazil, annual tuberculin skin tests (TSTs) are recommended for people living with HIV (PLWH) with CD4 >350, with tuberculosis preventive therapy provided on test conversion. We aimed to determine the yield of repeat TSTs for PLWH. DESIGN: Secondary analysis of the stepped-wedge, cluster-randomized THRio trial for isoniazid preventive therapy (IPT) to prevent tuberculosis (TB). METHODS: We analyzed data from newly registered PLWH with negative baseline TST results. We calculated the number of TST conversions after 1 and/or 2 years among patients eligible for follow-up TSTs, the proportion of converters initiating IPT, and incidence of TB/death. RESULTS: Among 1770 PLWH with a negative baseline TST, 679 (38%) were female and median age was 36 years (IQR 29-43). Eighty-six (5%) developed TB or died within 1 year. Among 1684 eligible for a follow-up 1-year TST, 582 (35%) were tested and 53 (9%) were positive. Forty-nine converters (92%) started IPT. Of 529 patients with a negative 1-year TST, 7 (1%) developed TB or died over the following year. Of 522 patients eligible for a 2-year TST, 158 (30%) were tested and 13 (8%) were positive. Ten converters (77%) started IPT. Of 1102 patients who did not receive a 1-year TST, 33 (3%) developed TB or died. Of the 1069 patients eligible for a 2-year TST, 259 (24%) were tested and 34 (13%) were positive. Thirty converters (88%) started IPT. CONCLUSIONS: In this cohort of PLWH in Brazil, TST conversion was high among those retested, but only 48% received a follow-up TST within 2 years.

Prevalence of latent tuberculosis before biotherapy initiation in rheumatoid arthritis and spondyloarthritis: data from the Moroccan biotherapy registry.

Before the initiation of biotherapy in the treatment of rheumatic diseases, it is highly recommended for the patients to be screened for latent tuberculosis infection (LTBI). The objective of this study is to identify the prevalence of LTBI among patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) before the initiation of biologic therapy in the Moroccan biotherapy registry (RBSMR). A cross sectional study was conducted using the baseline data of the Moroccan biotherapy registry. Tuberculin skin test or IGRA test or both tests were done before starting anti-TNF treatment for screening LTBI. The comparisons between positive and negative LTBI patients according to rheumatic disease were examined using categorical comparisons. 259 patients were included in this study.94 patients had RA and 165 had SpA. The mean age of the RA patients was 50.49 ± 11.82 years with a majority of females (84%). The mean age for the SpA patients was 36 ± 13.7 years with a majority of males (67.3%). The prevalence of LTBI in the RBSMR was 21.6%. This prevalence was at 24.8% in SpA patients, while it was at 15.9% for RA patients. After the comparison between positive and negative LTBI patients according to rheumatic disease, no demographic, clinical, or therapeutic characteristics were statistically associated with LTBI. This study found that in an endemic TB country like Morocco, a high prevalence of patients with SpA and RA had LTBI, and that RA patients had a lower prevalence than SpA patients.

IgG4-Related Disease With Tuberculosis: A Case Report and Retrospective Review of Patients in a Single Center.

Background: IgG4-related disease (IgG4-RD) is a recently recognized systemic fibro-inflammatory disease of unknown cause involving many organs including pancreas, salivary glands, and lymph nodes. Chronic tuberculosis (TB) infection has been reported in IgG4-RD, but the prevalence of TB infection has not been evaluated in IgG4-RD. Methods: Characterization of a patient with IgG4-RD by physical examination, laboratory tests, magnetic resonance imaging (MRI) and histological examination. TB infection was evaluated by medical history, radiological examinations, sputum examinations, tubercular skin test (TST) and interferon gamma (IFN-γ) release assay test (IGRA). Medical records of IgG4-RD patients were reviewed in our institute from February 2015 to September 2020 to explore the prevalence of TB infection in IgG4-RD. Results: We described a 40-year-old Chinese man presented with headache and diplopia. Physical examination revealed bitemporal hemianopsia and limited abduction of both eyes. MRI revealed uniformly enhancing mass overlying clivus with dural tail sign. Laboratory data revealed elevation of IgG4 (1.9g/L), and TB-IGRA demonstrated significantly elevated IFN-γ (414.21 pg/ml). The clivus lesion was subtotally removed and IgG4 was strongly positive on immunohistochemical staining. The diagnosis of IgG4-RD was established, and the patient received treatment of corticosteroids, methotrexate, and cyclophosphamide with isoniazid prophylaxis. Consequently, the mass shrank remarkably within 3 months. A similar concurrence of TB disease or latent TB infection (LTBI) and IgG4-RD was present in 17/47 (36.2%) patients in our institute. Conclusion: High frequency of TB/LTBI presented in patients with IgG4-RD. Patients with IgG4-RD and LTBI should be closely monitored for resurgence of TB. Whether TB represents a risk for IgG4-RD should be further investigated in prospective cohort.

The regression of the bovine tuberculin reaction: Results from the Reactor Quality Assurance study in Northern Ireland.

Tuberculin skin tests remain widely used in the control of bovine tuberculosis (bTB) in cattle. Little is known about the rate of regression of tuberculin reactions after the comparative intradermal cervical test (CICT) in cattle. This study aimed to collect data to describe tuberculin regression in reactors following the CICT at 72 ± 4 h post injection. Reactors were also tested using the interferon gamma (IFN-γ) assay to establish if any pattern existed between these results and the CICT reaction regression. The data were derived from 108 herds, 112 herd-level CICTs and 1008 animals. A multivariable linear mixed model was built to explore the regression of the bovine tuberculin reaction over time and the influence of potential predictors. The results confirmed a proportional decline in the bovine tuberculin reaction occurred over time. The predictors in the final model demonstrated that regression of the tuberculin reaction differed between reactors according to their IFN-γ test results and whether visible lesions were present at slaughter. Follow-up measurement of tuberculin reactions and the serial use of the IFN-γ assay in large breakdowns has the potential to provide both a mechanism for quality assurance of the current CICT bTB surveillance and the identification of atypical breakdowns or reactors requiring further investigation.

Interferon-γ Release Assays for Tuberculosis Infection Diagnosis in Refugees <5 Years Old.

BACKGROUND: New guidelines support using interferon-γ release assays (IGRAs) in children ≥2 years for diagnosis of latent tuberculosis infection (LTBI). However, lack of experience in young children and concern that IGRAs are less sensitive than tuberculin skin tests (TSTs) limit their use. Our aim was to identify active tuberculosis (TB) cases among high risk children <5 years and tested for LTBI with an IGRA. METHODS: . Retrospective review of domestic TB screening data from California's Refugee Health Electronic Information System for children <5 years old who resettled in California between October, 2013 and December, 2016. Children were crossmatched with the California TB registry to identify cases of TB disease between October 2013 and December 2018. RESULTS: A total of 3371 children <5 years were identified; the majority were born in countries with high TB incidence (>150 cases per 100 000). Half received IGRAs (n = 1878; 56%), a quarter received TSTs (n = 811; 24%); 1.4% of children were IGRA-positive (n = 26) and 13% were TST-positive (n = 106). Twenty-two IGRA results were indeterminate (1.2%). Sixteen children had both tests; 9 were discrepant (positive TST with negative IGRA). No cases of TB disease were identified during 10 797 person-years of follow-up. CONCLUSIONS: IGRA positivity was less than TST positivity in high risk children <5 years old. Despite fewer LTBI diagnoses in the IGRA-tested population, no cases of TB disease among children who tested negative were identified, suggesting IGRA is valuable tool for identifying LTBI in this population.

Interferon-Gamma Release Assay Testing in Children Younger Than 2 Years in a US-Based Health System.

BACKGROUND: Use of interferon-gamma releasing assays (IGRAs) in children <2 years old may derive many of the same advantages, which have led to preference over tuberculin skin test (TST) in older children, but data are limited. Since 2011, we have tested children <2 years old with Quantiferon-TB Gold/Gold Plus (QFT)) in select clinical scenarios at Denver Health, a health system encompassing a TB clinic, refugee and immigrant screening and primary care. METHODS: We identified patients <2 years old tested with QFT between February, 2011 and August, 2019. The primary outcome measure was incident cases of TB among tested patients. Test results and in vitro characteristics were analyzed, as were demographic, epidemiologic and clinical outcomes. RESULTS: We analyzed 116 QFTs ordered in children age 7-23 months. Two were positive, 3 indeterminate, 3 failed/refused phlebotomy and the remainder (93%) were negative. Mitogen tube results were robust. Thirteen patients were TST-positive: 11 were QFT-negative, 1 QFT-positive and 1 failed phlebotomy. Eight patients received some form of TB medication, including 4 QFT-negative patients who were treated for active TB or latent TB infection based on positive TST or clinical findings. Among QFT-negative patients, including 6 TST-positive, not treated for active TB or latent TB infection, no TB disease has been identified over a median follow-up time of 2.96 years. CONCLUSIONS: IGRA use was not limited by barriers of phlebotomy, indeterminate result or gamma-interferon production. The risk of missing an infected but IGRA-negative patient can be reduced by treatment of select patients at higher risk. Current recommendations against IGRA use in children <2 years old could be amended to allow careful introduction, particularly among well-appearing BCG-vaccinated patients.

Tuberculin reactivity in schoolchildren, Kassala State, Sudan.

Background: Tuberculin skin test (TST) is widely used for the assessment of Bacillus Calmette-Guérin (BCG) vaccine efficacy and screening of latent TB infection (LTBI). Poor or no data are available on the reactivity of tuberculin in Kassala State. The aim of the present study was to assess the response to the BCG vaccine and to estimate the prevalence of LTBI and the annual rate annual risk of tuberculous infection (ARTI) among vaccinated school children using TST. Methods: School-based cross-sectional study was conducted in three localities of Kassala State during 2016-2018. A cluster random sampling method was used for the enrolment. Five tuberculin units of 0.1 mL were injected intradermally in the left forearm of 2568 school children aged 5-15 years. The test was performed after the assessment of child health, nutrition status, and BCG scar status. Tuberculin reaction size was interpreted after 48-72 h. The collected data were analyzed using SPSS (v 20). The classical method was used to estimate ARTI. Results: Overall, there was no reaction in 81.5% of children. Only 0.66% of children had induration 10 mm-28 mm, indicating the prevalence of latent TB with an annual risk of 0.1%. Tuberculin reactivity was statistically significant affected by child age, gender, geographical location, and nutrition status (P < 0.05), whereas BCG scar status had no effect (P > 0.05). Conclusion: The study documented a high proportion of tuberculin nonreactivity irrespective of BCG vaccination status and provides data on the prevalence of latent infection among studied groups. Further studies are needed to address the reasons of low and nonreactivity of tuberculin, and evaluation of the BCG vaccine is recommended.

Prevalence of positive TST among healthcare workers in high-burden TB setting in Peru.

BACKGROUND: Tuberculosis (TB) transmission has long been recognized as an important occupational hazard for healthcare workers (HCWs). HCWs have a 5.8% annual risk of exposure and three times greater risk of developing active TB than the general population. METHODS: We conducted an observational cross-sectional study between September 2014 and March 2015 among HCWs in a high-burden TB setting in Lima to estimate the prevalence of positive Tuberculin Skin Test (TST) and to investigate factors associated with a positive TST. RESULTS: Two hundred forty participants were included in the analysis; TST was administered to 190 (79.2%) while the rest were exempt due to a previous positive TST result, history of TB, or test refusal. A positive TST result was found among 56.2% of participants to whom the TST was applied (95% CI: 49.22-63.55%). When considering those who had a previous positive TST result and those with a history of TB, the prevalence of a positive TST result was 64.3% (95% CI: 57.8-70.3%). No significant differences were observed between clinical/paramedical and administrative staff in the health center. The use of N95 masks during work hours was reported by 142 (69.9%) participants. Prevalence ratios (PR) show that workers with more than 120 months as a HCW were 1.44 times more likely to be TST positive. The multivariate analysis found that HCWs with over 10 years of service were 1.52 times more likely to be TST positive. CONCLUSION: This study supports previous reports that TB infection is an occupational hazard for HCWs. Prevention of TB transmission through control measures, as well as timely diagnosis of LTBI in this particular high-risk group, is critical for individual and public health.

Comparison between the Interferon γ Release Assay-QuantiFERON Gold Plus (QFT-Plus)-and Tuberculin Skin Test (TST) in the Detection of Tuberculosis Infection in Immunocompromised Children.

BACKGROUND: Immunocompromised patients are at a higher risk of having latent tuberculosis infection (LTBI). QuantiFERON-TB Gold Plus (QFT-Plus) has been proven to perform effectively in LTBI detection among immunocompromised adults and can overcome the limitations of the tuberculin skin test (TST). However, the role of QFT-Plus in detecting LTBI in immunocompromised paediatric patients has not been well established. Therefore, the aim of this study was to assess the test agreement between QFT-Plus and the TST in LTBI detection among immunocompromised children. METHOD: In this cross-sectional study, we enrolled immunocompromised paediatric patients, aged between 5 and 18 years, who were treated with corticosteroids and/or chemotherapy from June to November 2019. We categorized them into three groups based on the following diseases: hematologic malignancies and nephrological and immunological diseases. We recorded the patient characteristics and QFT-Plus and TST results, in which the positive result of the TST was induration ≥ 5 mm. Within the same group, comparisons between the two tests were performed using the McNemar test, and results were statistically significant for p values of <0.05. The kappa index was used to assess the agreement between the two test results. RESULTS: Among 71 patients (median age: 11.8 years) who underwent TST and QFT-Plus testing, 52% were females, and 69% had a normal nutritional status. Chemotherapy was the most common treatment modality for hematologic malignancy compared to other immunosuppressive treatments. The total number of patients with positive QFT-Plus and TST results was 11/71 (15.5%) and 4/71 (5.6%), respectively, among whom 3/11 patients had positive results in both tests, and one patient with positive TST results exhibited a discrepancy, as this was not followed by positive QFT-Plus results. QFT-Plus generated more positive results than the TST in immunocompromised children (McNemar, p = 0.039 (p < 0.05)). The diagnostic agreement between the tests was fair (K = 0.345, 95% CI: 0.05-0.745). CONCLUSION: QFT-Plus detected LTBI more effectively than the TST in immunocompromised children.

Tuberculin skin test and predictive host factors for false-negative results in patients with pulmonary and extrapulmonary tuberculosis.

INTRODUCTION: Tuberculin skin test (TST) has been the standard test for screening for Mycobacterium tuberculosis infection for decades. Identifying persons with latent tuberculosis infection (LTBI) is crucial, as they constitute a reservoir that sustains the global tuberculosis (TB) epidemic. However, different factors, such as HIV infection, can lower the sensitivity of the test. OBJECTIVES: The aim of this study was to determine the TST sensitivity in active TB patients and to ascertain risk factors that could be associated with false-negative results. METHODS: Retrospective cohort study of all active TB notifications with a TST result (n = 8833), from 2008 to 2015. TST results were interpreted using a 5 mm and 10 mm cutoff. Bivariate and multivariate logistic regression analysis were used to evaluate the association of sociodemographic and clinical factors with false-negative TST results and to develop predictive risk models. RESULTS: TST presented an overall sensitivity of 63.8% (5 mm) and 56.1% (10 mm). HIV infection was the risk factor with the strongest association with false-negative results (aOR 4.65-5 mm; aOR 5.05-10 mm). Other factors such as chronic renal failure (CRF) (aOR 1.55-5 mm; aOR 1.73-10 mm), alcohol abuse (aOR 1.52-5 mm; aOR 1.31-10 mm), drug abuse (aOR 1.90-5 mm; aOR 1.76-10 mm) or age ≥65 years (OR 1.69-5 mm and 10 mm) were also associated with a probability of false-negative results. CONCLUSION: These results highlight the importance of knowing which factors influence TST results, such as HIV status, substance abuse or age, thus improving its usefulness as a screening method for LTBI.

Host factors associated to false negative and indeterminate results in an interferon-γ release assay in patients with active tuberculosis.

INTRODUCTION: Information on host factors that contribute to false negative and indeterminate results in interferon-γ release assays (IGRA) are critical to improve the usefulness of these tests in the fight against tuberculosis (TB) epidemics. The aim of this study was to estimate and compare the sensitivity of an IGRA and the tuberculin skin test (TST), independently and as a combined approach, in patients with TB and to identify risk factors associated with false negative and indeterminate IGRA results. METHODS: Retrospective cohort study of all active TB notifications with an IGRA result (n = 1230), from 2008 to 2015. 68.0 % (n = 727) of these patients had a TST result interpreted using a 5 mm (TST-5 mm) and 10 mm (TST-10 mm) cutoff. Sensitivity was determined for both tests. Logistic regression analysis was used to evaluate the association of sociodemographic and clinical factors to the risk of false negative or indeterminate IGRA results. RESULTS: IGRA, TST-5 mm and TST-10 mm were positive in 82.4 %, 84.5 % and 78.4 % of the patients that performed both tests. When used combined, IGRA/TST-5 mm sensitivity was 91.7 % and IGRA/TST-10 mm sensitivity was 90.6 %. Age≥65 years, alcohol abuse and pulmonary TB were predictive factors for indeterminate results. Inflammatory diseases and pulmonary TB were statistically associated with false negative IGRA results. CONCLUSION: Inflammatory diseases and pulmonary TB were identified as factors for false negative IGRA results. Our results indicate that the use of both tests in a combined approach, especially in specific risk groups of the population, could increase the sensitivity of the screening process and accelerate the achievement of the WHO End TB Strategy goals.

Robustness of NHANES Estimates of the US Prevalence of a Positive Tuberculin Skin Test.

BACKGROUND: A single 2-year National Health and Nutrition Examination Survey (NHANES) cycle is designed to provide accurate and stable estimates of conditions with prevalence of at least 10%. Recent NHANES-based estimates of a tuberculin skin test (TST) ≥10 mm in the noninstitutionalized US civilian population are at most 6.3%. METHODS: NHANES included a TST in 1971-1972, 1999-2000, and 2011-2012. We examined the robustness of NHANES-based estimates of the US population prevalence of a skin test ≥10 mm with a bias analysis that considered the influence of non-US birth distributions and within-household skin test results, reclassified borderline-positive results, and adjusted for TST item nonresponse. RESULTS: The weighted non-US birth distribution among NHANES participants was similar to that in the overall US population; further adjustment was unnecessary. We found no evidence of bias due to sampling multiple participants per household. Prevalence estimates changed 0.3% with reclassification of borderline-positive TST results and 0.2%-0.3% with adjustment for item nonresponse. CONCLUSIONS: For estimating the national prevalence of a TST ≥10 mm during these three survey cycles, a conventional NHANES analysis using the standard participant weights and masked design parameters that are provided in the public-use datasets appears robust. See video abstract at, http://links.lww.com/EDE/B636.

Performance of a household tuberculosis exposure survey among children in a Latin American setting.

OBJECTIVE: To evaluate the performance of a survey that quantifies the intensity of household tuberculosis (TB) exposure among children.METHODS: Children aged 0-14 years in Lima, Peru, with ≥1 signs and/or symptoms of TB and a history of contact with an adult TB patient were included. The 10-question survey was administered to caregivers and addressed sleep proximity, frequency of exposure, and infectiousness of the contact. Infection status was determined using tuberculin skin tests (TSTs). The exposure scale was evaluated for association with TST positivity using mixed-effects regression analyses.RESULTS: The exposure score was significantly associated with TST positivity (age-adjusted odds ratio [aOR] 1.14, 95%CI 1.02-1.28). We observed a stronger association with TST positivity in children aged ≤5 years; (aOR 1.23, 95%CI 1.07-1.41) and no association in children 6-14 years of age (aOR 0.99, 95%CI 0.82-1.20).CONCLUSION: This survey was easy to use and modestly successful in predicting TST positivity in children aged ≤5 years. It may be a useful resource for clinicians for diagnosing TB in children, and for national TB programs aiming to scale up preventive therapy initiatives.

Inequality in uptake of isoniazid prevention therapy and Mantoux test among pregnant women with HIV in the Eastern Cape, South Africa.

BACKGROUND: HIV-associated tuberculosis (TB) is a major cause of death among pregnant women in South Africa. Isoniazid prevention therapy (IPT) strategy was implemented in South Africa concurrently with life-long antiretroviral therapy (ART) to reduce the TB-associated morbidity and mortality in individuals living with HIV. This study assessed the extent of the implementation of IPT and the performance of the Mantoux test by geographic settings of health facilities and residences of pregnant women living with HIV in the Eastern Cape, South Africa. METHODS: We conducted a data analysis of 1709 pregnant women enrolled in the new electronic database of the prevention of mother-to-child transmission programme of the East London Prospective Cohort Study. Relevant data on place of residence and antenatal care, performance of the Mantoux test and subsequent initiation of IPT were obtained. Descriptive and inferential statistics were employed to analyse the geographical variations and accessibility to Mantoux test and IPT. RESULTS: The analysis shows that Mantoux test was performed on 803 pregnant women (47%) with significant geographical variation. After controlling for relevant covariates, pregnant women who resided in rural areas (AOR:0.63; CI: 0.47-0.84) compared to those who resided in urban areas were significantly less likely to receive Mantoux test. The rate of uptake of IPT was 79% with significant geographic variations. In the unadjusted model, rural place of residence (UOR:0.68; CI: 0.49-0.96) was independently associated with lower likelihood of uptake of INH prophylaxis; however, the effect was not significant after controlling for important covariates. CONCLUSIONS: The high uptake rate of isoniazid prevention therapy in pregnant women living with HIV at the study sites is commendable; however, concerted efforts are needed to address the inequality gaps in the roll-out of IPT. Poor performance of Mantoux test is a serious concern and requires the attention of TB programme managers and other relevant authorities.

[Concordance between the test of the tuberculin and Interferon Gamma Release Assay-IGRA in patients with immune-mediated inflammatory diseases]. / Concordancia entre la prueba de la tuberculina y el Interferon Gamma Release Assay-IGRA en pacientes con enfermedades inflamatorias mediadas por la inmunidad.

OBJECTIVE: The immunosuppressive therapies in the treatment of the immune-mediated inflammatory diseases (EIMI) predispose individuals to the tuberculosis, so the screening of latent tuberculosis infection (ITL) and the treatment reduces the likelihood of a progression to an active tuberculosis. The aim of the study was to analyze the concordance between the test of the tuberculin (PT) and "Interferon Gamma Release Assay-IGRA" in relation to the type of EIMI and the immunosuppressive treatment (IS). METHODS: Transversal study of patients with EIMI candidates or in treatment IS forwarded to the ITL screening, from April 2017 until May 2018. The outcome variables were PT and IGRA. The explicative variables were: EIMI, IS, age, gender, prior BCG vaccination and tuberculosis risk factors. RESULTS: A total of 146 patients were analyzed (33[22.6%] vaccinated with BCG, 1 [0.7%] with a pre-diagnosis of tuberculosis, and 22 [15.1%] from an endemic country). Kappa index (k) was 0,338 between PT and IGRA for the whole sample. A lower concordance was found in patients with the Crohn's disease (k=0.125), in the ones treated with corticosteroids (k=0.222), vaccinated with BCG (k=0.122) and in patients from tuberculosis endemic countries (k=0.128). CONCLUSIONS: The concordance between PT and IGRA is affected in patients with EIMI, and to a greater extent to patients with the inflammatory bowel disease, with the corticotherapy, with the BCG vaccination, or in the ones from endemic countries.

Implementation of latent tuberculosis infection screening and treatment among newly arriving immigrants in the Netherlands: A mixed methods pilot evaluation.

INTRODUCTION: To reach pre-elimination levels of tuberculosis (TB) incidence in the Netherlands, prevention of TB among immigrants through diagnosis and treatment of latent TB infection (LTBI) is needed. We studied the feasibility of a LTBI screening and treatment program among newly arriving immigrants for national implementation. METHODS: We used mixed methods to evaluate the implementation of LTBI screening and treatment in five Public Health Services (PHS) among immigrants from countries with a TB incidence >50/100,000 population. We used Poisson regression models with robust variance estimators to assess factors associated with LTBI diagnosis and LTBI treatment initiation and reported reasons for not initiating or completing LTBI treatment. We interviewed five PHS teams using a semi-structured method to identify enhancing and impeding factors for LTBI screening and treatment. RESULTS: We screened 566 immigrants; 94 (17%) were diagnosed with LTBI, of whom 49 (52%) initiated and 34 (69%) completed LTBI treatment. LTBI diagnosis was associated with male gender, higher age group, higher TB incidence in the country of origin and lower level of education. Treatment initiation was associated with PHS (ranging from 29% to 86%), lower age group, longer intended duration of stay in the Netherlands, and lower level of education. According to TB physicians, clients and their consulted physicians in the home country lacked awareness about benefits of LTBI treatment. Furthermore, TB physicians questioned the individual and public health benefit of clients who return to their country of origin within the foreseeable future. CONCLUSIONS: Doubt of physicians in both host country and country of origin about individual and public health benefits of LTBI screening and treatment of immigrants hampered treatment initiation: the high initiation proportion in one PHS shows that if TB physicians are committed, the LTBI treatment uptake can be higher.

Nationwide Shortage of Tuberculin Skin Test Antigens: CDC Recommendations for Patient Care and Public Health Practice.

CDC is expecting a 3-10 month nationwide shortage of Aplisol, a product of Par Pharmaceuticals, and one of two purified-protein derivative (PPD) tuberculin antigens licensed by the Food and Drug Administration (FDA) for use in performing tuberculin skin tests. This time frame is the manufacturer's current estimate and is subject to change. The manufacturer notified CDC that they anticipate an interruption of supply of Aplisol 5 mL (50 multidose vials) beginning in June 2019, followed by an interruption of the supply of Aplisol 1 mL (10 multidose vials) in November 2019. The expected shortage of Aplisol 1 mL could occur before November 2019 if demand increases before then. Information on the status of this supply interruption will be updated at FDA's Center for Biologics Evaluation and Research-Regulated Products: Current Shortages website (https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/cber-regulated-products-current-shortages). This report includes CDC recommendations for mitigating a reduction in tuberculosis (TB) testing capability resulting from the anticipated Aplisol shortage (1).

Patient satisfaction with pharmacist-administered Mantoux tuberculin skin test in a community-based pharmacy setting.

OBJECTIVES: The objective of this study was to determine patient satisfaction with pharmacist-administered Mantoux tuberculin skin test (TST) in a community-based pharmacy. METHODS: A prospective 6-month convenience sample study was conducted in an independent community pharmacy. Initial and follow-up surveys were developed with content and design informed by the literature. Surveys were peer reviewed and pretested with a sample group of 2 patients for clarity. The initial survey consisted of 26 questions including Likert-type scale, multiple choice, and free response. There were 7 demographic questions, 17 patient satisfaction questions divided into 2 domains (satisfaction with the pharmacy setting and the pharmacist), 1 question about "how you heard about us," and 1 free-response question. The follow-up survey consisted of 20 questions, also including Likert-type scale, multiple choice, and free response. There were 17 questions related to patient satisfaction identical to the initial survey. Patients who were 18 years of age and older completed the initial survey when the Mantoux TST was administered and the follow-up survey when the test was read by the pharmacist. Patients created a unique identifier code to match the follow-up survey to the initial survey. The data were evaluated with the use of univariate and bivariate analysis. RESULTS: Sixty-four matched surveys were completed and included in the data analysis, with a response rate of 51.6%. Ninety-two percent of the patients were female, and the most frequent age range was 25-34 years (20%). Satisfaction scores between the initial survey and follow-up survey were not statistically different regarding pharmacy setting or pharmacist services. All satisfaction scores were above 90% except for the initial satisfaction scores for convenience and timeliness, which were both 88% in the initial survey. CONCLUSION: Patient satisfaction is consistently high with pharmacist-provided Mantoux TST in a community-based pharmacy.