Novel health system strategies for tuberculin skin testing at primary care clinics: Performance assessment and health economic evaluation.

BACKGROUND: Tuberculin skin test (TST) for guiding initiation of tuberculosis preventive therapy poses major challenges in high tuberculosis burden settings. METHODS: At a primary care clinic in Johannesburg, South Africa, 278 HIV-positive adults self-read their TST by reporting if they felt a bump (any induration) at the TST placement site. TST reading (in mm) was fast-tracked to reduce patient wait time and task-shifted to delegate tasks to lower cadre healthcare workers, and result was compared to TST reading by high cadre research staff. TST reading and placement cost to the health system and patients were estimated. Simulations of health system costs were performed for 5 countries (USA, Germany, Brazil, India, Russia) to evaluate generalizability. RESULTS: Almost all participants (269 of 278, 97%) correctly self-identified the presence or absence of any induration [sensitivity 89% (95% CI 80,95) and specificity 99.5% (95% CI 97,100)]. For detection of a positive TST (induration ≥ 5mm), sensitivity was 90% (95% CI 81,96) and specificity 99% (95% CI 97,100). TST reading agreement between low and high cadre staff was high (kappa 0.97, 95% CI 0.94, 1.00). Total TST cost was 2066 I$ (95% UI 594, 5243) per 100 patients, 87% (95% UI 53, 95) of which were patient costs. Combining fast-track and task-shifting, reduced total costs to 1736 I$ (95% UI 497, 4300) per 100 patients, with 31% (95% UI 15, 42) saving in health system costs. Combining fast-tracking, task-shifting and self-reading, lowered the TST health system costs from 16% (95% UI 8, 26) in Russia to 40% (95% UI 18, 54) in the USA. CONCLUSION: A TST strategy where only patients with any self-read induration are asked to return for fast-tracked TST reading by lower cadre healthcare workers is a promising strategy that could be effective and cost-saving, but real-life cost-effectiveness should be further examined.

Potencial do teste IGRA (Interferon Gama Release Assay) para o diagnóstico de tuberculose ocular. Revisão e análise comparativa com o teste tuberculínico cutâneo (PPD) / The potential of the IGRA (Interferon Gamma Release Assay) test for the diagnosis of ocular tuberculosis. Review and comparative analysis with the tuberculosis skin test

Resumo A detecção precisa da infecção latente por tuberculose está se tornando cada vez mais importante devido ao aumento do uso de medicamentos imunossupressores e da epidemia do vírus da imunodeficiência humana, o que aumentou o risco de reativação à tuberculose ativa (TB). O Teste IGRA QuantiFERON® TB Gold apresenta vantagens frente ao teste de PPD como por exemplo, requer somente uma coleta de amostra sanguínea ; não há necessidade que o paciente retorne ao laboratório para leitura e interpretação dos resultados; Os resultados são objetivos, não requerem interpretação do leitor ou interferência de critérios subjetivos; trata-se de um teste in vitro, portanto não há "efeito booster" (potenciação da reação tuberculínica); o teste não é afetado por vacinação prévia por BCG ou infecção por outras espécies de micobactérias. Limitações são descritas, apesar de raras, como reações cruzadas deste método com infecções por algumas espécies de micobactérias não-tuberculosis (incluindo Mycobacterium kansasii, Mycobacterium szulgai e Mycobacterium marinum). Ainda há poucos dados sobre o teste IGRA em certas populações, como por exemplo, em crianças, pacientes imunocomprometidos e mulheres grávidas. Nestes grupos, a interpretação do teste pode ser difícil e mais estudos se fazem necessários.

Abstract Precise detection of latent tuberculosis infection is becoming increasingly important due to increased use of immunosuppressive drugs and the human immunodeficiency virus epidemic , which increased the risk of reactivation to active tuberculosis (TB).The QuantiFERON® TB Gold IGRA Test has advantages over the skin test for TB, otherwise known as a Mantoux tuberculin test, for example, requires only a blood sample collection; there is no need for the patient to return to the laboratory for reading and interpretation of the results; The results are objective, do not require interpretation of the reader or interference of subjective criteria; it is an in vitro test, so there is no "booster effect" (potentiation of the tuberculin reaction); the test is not affected by prior BCG vaccination or infection with other species of mycobacteria. Limitations are described, although rare, as cross-reactions of this method with infections by some species of non-tuberculosis mycobacteria (including Mycobacterium kansasii, Mycobacterium szulgai and Mycobacterium marinum). There is still little data on the IGRA test in certain populations, such as in children, immunocompromised patients and pregnant women. In these groups, the interpretation of the test can be difficult and more studies are needed.

Mycobacterium bovis en fauna silvestre de la cuenca lechera de Santa Fe, Argentina / Mycobacterium bovis in wildlife of the dairy regions of Santa Fe (Argentina)

El control y la erradicación de la tuberculosis bovina basados en la detección de los animales infectados y su inmediata faena permitió lograr progresos satisfactorios en varios países y regiones, pero no todos pudieron lograrlo debido principalmente a la presencia de fauna silvestre infectada con Mycobacterium bovis. La Argentina aplica desde 1999 estas mismas premisas y ha logrado avances en los rodeos lecheros, aunque no se ha evaluado el factor ambiental como la fauna silvestre. El objetivo de este trabajo fue determinar si la fauna silvestre de la cuenca lechera de Santa Fe está infectada con M. bovis. Se realizó la captura/sacrificio de fauna silvestre presente en 5 rodeos lecheros con altos niveles de reaccionantes positivos a la prueba de tuberculina. Sobre 95 mamíferos silvestres examinados, se aisló M. bovis de 7 individuos de comadreja overa (Didelphis albiventris), de uno de zorro gris (Lycolapex gimnocercus) y de uno de rata (Rattus norvegicus). Los sitios anatómicos que produjeron estos aislamientos variaron de acuerdo con las especies; en ninguno de los ejemplares evaluados se observaron lesiones macroscópicas de tuberculosis. Los espoligotipos de M. bovis aislados con mayor frecuencia de los animales silvestres correspondieron a los tipos 34 (4 aislamientos) y 12 (3 aislamientos); el primero es el más corrientemente aislado del ganado en Argentina. Se discute en este estudio el papel de la comadreja overa (D. albiventris) como hospedador circunstancial de M. bovis

Control eradication campaigns of bovine tuberculosis based on the «test and slaughter¼ approach were successful in many countries and regions; however, in some areas the infection persists and one of the main reasons is Mycobacterium bovis infection in wild life species. Argentina has applied the same approach since 1999, achieving progress in dairy cattle herds. Nonetheless, the wildlife role has never been investigated. The objective of this study was to determine if wildlife from the Santa Fe dairy area is infected with M. bovis. Wildlife species having a positive tuberculin skin test were captured in five dairy farms. Ninety five wildlife mammals were captured; M. bovis was recovered from 7 possums (Didelphys albiventris), from one fox (Lycolapex gimnocercus) and from one rat (Rattus norvegicus). None of the animals exhibited macroscopic lesions. The most frequently isolated M. bovis spoligotypes were types 34 (4 isolates) and 12 (3 isolates). Spoligotype 34 is the most frequently isolated type in Argentine cattle. The role of D. albiventris as spillover host of M. bovis is discussed in this study

Screening for latent tuberculosis in Norwegian health care workers: high frequency of discordant tuberculin skin test positive and interferon-gamma release assay negative results.

BACKGROUND: Tuberculosis (TB) presents globally a significant health problem and health care workers (HCW) are at increased risk of contracting TB infection. There is no diagnostic gold standard for latent TB infection (LTBI), but both blood based interferon-gamma release assays (IGRA) and the tuberculin skin test (TST) are used. According to the national guidelines, HCW who have been exposed for TB should be screened and offered preventive anti-TB chemotherapy, but the role of IGRA in HCW screening is still unclear. METHODS: A total of 387 HCW working in clinical and laboratory departments in three major hospitals in the Western region of Norway with possible exposure to TB were included in a cross-sectional study. The HCW were asked for risk factors for TB and tested with TST and the QuantiFERON®TB Gold In-Tube test (QFT). A logistic regression model analyzed the associations between risk factors for TB and positive QFT or TST. RESULTS: A total of 13 (3.4%) demonstrated a persistent positive QFT, whereas 214 (55.3%) had a positive TST (≥ 6 mm) and 53 (13.7%) a TST ≥ 15 mm. Only ten (4.7%) of the HCW with a positive TST were QFT positive. Origin from a TB-endemic country was the only risk factor associated with a positive QFT (OR 14.13, 95% CI 1.37 - 145.38, p=0.026), whereas there was no significant association between risk factors for TB and TST ≥ 15 mm. The five HCW with an initial positive QFT that retested negative all had low interferon-gamma (IFN-γ) responses below 0.70 IU/ml when first tested. CONCLUSIONS: We demonstrate a low prevalence of LTBI in HCW working in hospitals with TB patients in our region. The "IGRA-only" seems like a desirable screening strategy despite its limitations in serial testing, due to the high numbers of discordant TST positive/IGRA negative results in HCW, probably caused by BCG vaccination or boosting due to repetitive TST testing. Thus, guidelines for TB screening in HCW should be updated in order to secure accurate diagnosis of LTBI and offer proper treatment and follow-up.

Reduced CD27 expression on antigen-specific CD4+ T cells correlates with persistent active tuberculosis.

OBJECTIVE: CD27, a member of the tumor necrosis factor receptor family, has important role in generation of T cell immunity. In this study, association of CD27 expression on mycobacterial antigen-specific CD4+ T cells with pulmonary tuberculosis (TB) was investigated. METHODS: Mycobacterial antigen-specific CD4+ T cells were identified based on CD154 expression and CD27 expression on antigen-specific CD4 T cells was analyzed by flow cytometry. RESULTS: Compared with tuberculin-positive controls, patients with bacterial culture-positive pulmonary TB had significantly reduced CD27 expression on antigen-specific CD4 T cells. The persistent active TB patients had much lower percentages of CD27+ antigen-specific CD4 T cells than culture-positive new TB patients (P=0.008) and healthy controls (P=0.005). Logistic regression analysis on frequencies of CD27-expressing antigen-specific CD4 T cells and TB patients' clinical characteristics indicated that low percentage of CD27+ antigen-specific CD4 T cells correlated significantly with persistent active tuberculosis (P=0.002, odds ratio=19.6). CONCLUSION: It is concluded that frequency of CD27+ antigen-specific CD4 T cells could be used as an immunological marker for persistent active TB.

Prevalência de tuberculose no rebanho bovino de Mossoró, Rio Grande do Norte / A survey of tuberculosis in the cattle from Mossoro, Rio Grande do Norte State

A tuberculose bovina é uma doença infecciosa crônica e debilitante que pode infectar humanos. Uma importante etapa para o controle é a determinação da prevalência nos rebanhos. O objetivo do presente trabalho foi determinar a prevalência da tuberculose bovina em Mossoró, RN. Inicialmente foi realizada uma avaliação de risco para a ocorrência da tuberculose bovina em 21 propriedades da região avaliada. Foram testadas 150 vacas leiteiras por meio do teste da prega caudal. Também foram avaliados outros 120 bovinos pelo teste da tuberculinização cervical comparada. Os resultados revelaram falta de conhecimento dos proprietários sobre o controle da doença, bem como o descuido no momento da aquisição de animais. A prevalência foi de 8,66% e 3,33% nos testes da prega caudal e cervical comparativo, respectivamente. Assim, foi verificada uma prevalência de tuberculose bovina bastante elevada, sendo superior à média nacional.

Bovine tuberculosis is an infectious chronic and debilitating disease that can infect humans. A key step for its controls is to determine the prevalence in the herd. The present study aimed to determine the prevalence of bovine tuberculosis at Mossoró, RN. Initially, it was done an evaluation for infection hazard by tuberculosis in bovines at 21 farms. It were tested 150 dairy cows by caudal-fold tuberculin test. Other 120 bovines were also tested by comparative cervical tuberculin test. The results revealed lack of knowledge by owners about the prevention of the disease, as well as negligence when they buy animals.The prevalence was 8.66% at the cervical test and 3.33% at caudal-fold tuberculin test and comparative cervical tuberculin test, respectively.Thus, it was verified a high prevalence of bovine tuberculosis, which is greater than the national mean prevalence.

Rapid diagnosis of smear-negative tuberculosis by bronchoalveolar lavage enzyme-linked immunospot.

RATIONALE: In a large proportion of patients with active pulmonary tuberculosis (pTB), acid-fast bacilli smear results for sputum and bronchial secretions are negative. Detectable growth of Mycobacterium tuberculosis (MTB) in cultures takes several weeks and MTB-specific DNA amplification results on sputum and bronchial secretions are variable in these patients. OBJECTIVE: We investigated whether a rapid diagnosis of pTB can be established by enumeration of MTB-specific mononuclear cells from bronchoalveolar lavage (BAL) fluid in routine clinical practice. METHODS: Patients presenting to a tertiary hospital with medical histories and pulmonary infiltrates compatible with tuberculosis, and negative acid-fast bacilli smear results (three) from sputum, were prospectively enrolled in this study. An MTB-specific enzyme-linked immunospot assay (ELISPOT [T-SPOT.TB; Oxford Immunotec, Abingdon, UK]) with early antigenic target-6 (ESAT-6) and culture filtrate protein-10 (CFP-10) peptides was performed on peripheral blood mononuclear cells (PBMCs) and mononuclear cells from the BAL fluid (BALMCs). MEASUREMENTS AND MAIN RESULTS: Of 37 patients, 12 were found to have smear-negative pTB and 25 were found to have an alternative diagnosis. Patients with tuberculosis had a median number of 17 ESAT-6-specific cells and 24.5 CFP-10-specific cells per 200,000 PBMCs and 37.5 ESAT-6-specific cells and 49.5 CFP-10-specific cells per 200,000 cells in the BAL fluid. Control patients had a median of 1 ESAT-6-specific cell and 1 CFP-10-specific cell per 200,000 PBMCs and no ESAT-6- and CFP-10-specific cells per 200,000 cells in the BAL fluid (p < 0.0001). All patients with TB but none of the control subjects had more than 5 spot-forming cells per 200,000 BALMCs with either peptide in the BAL fluid ELISPOT. CONCLUSION: Smear-negative pulmonary tuberculosis can be diagnosed rapidly by identification of MTB-specific cells in the BAL fluid.

Follow-up results in tuberculous cervical lymphadenitis.

OBJECTIVE: To investigate the efficacy of medical antituberculous treatment in patients with tuberculous cervical lymphadenitis (TCL). METHODS: In the period 1996-2002, 73 TCL patients were reviewed and the results of clinical and laboratory testing were documented. The efficacy of a four-drug chemotherapy regimen was investigated. RESULTS: Purified protein derivatives (PPD) skin test results were positive in 58 (79 per cent) patients. Chest X-rays revealed changes consistent with tuberculosis in nine (12.3 per cent) patients. The mean duration of medical treatment was 10.04 months. In follow-up evaluation, 14 (20 per cent) patients were considered suspicious for resistant TCL and total excision of all nodes was performed. Histopathology confirmed TB in only 10 of these cases. CONCLUSION: The high incidence of residual disease in our study indicates that medical treatment (at least nine months of four combined antituberculous drugs) did not seem to be effective. If lymphadenopathy persists, total surgical excision of lymph nodes should be the treatment of choice.

Mycobacterium tuberculosis lipid antigens: use of multi-antigen based enzyme immunoassay for free and complex dissociated antibodies.

OBJECTIVE: To test the sensitivity and specificity of four lipid antigens of Mycobacterium tuberculosis: BDA-TDA, DAT, SL-I, and PIMs, adsorbed in the same microplate well, to detect reactive IgG by enzyme-immunoassay (EIA) from plain serum (MA-EIA) and dissociated immune complexes (ICMA-EIA). DESIGN: IgG antibodies against four antigens, placed in the same microplate well, were evaluated in serum from 155 tuberculous (TB) cases non-infected with the human immunodeficiency virus (HIV): 78 patients with positive bacilloscopy and culture, 33 patients with positive culture and 44 patients diagnosed by clinical and radiological criteria; and from 211 HIV negative control subjects: 32 patients with other pulmonary diseases, 100 healthy people and 79 close contacts. RESULTS: MA-EIA had an overall sensitivity and specificity of 61% (94/155) and 95% (200/211), respectively. We further examined whether the dissociation of immune complexes increases the number of positive reactions in those initially found to be seronegative (SN). The subset of 112 (76 controls and 36 TB) MA-EIA SN samples tested using ICMA-EIA yielded an overall sensitivity and specificity of 83% and 100%. The ICMA-EIA results improved the overall sensitivity from 61 to 80% without changing specificity. CONCLUSION: These preliminary results suggest that MA-EIA followed by ICMA-EIA, for SN samples, might serve as a fast, cheap, and easy method for the diagnosis of TB in less than 48 hours.

[Significance of immunologic testing of patients in surgery of pulmonary tuberculosis]. / Znachenie immunologicheskogo testirovaniia bol'nykh v khirurgii tuberkuleza legkikh.

Immunological testing of surgical patients with specific pulmonary tuberculosis revealed specific immunodeficiency in 68% of cases which appeared at higher risk of postoperative complications. A scheme of a simple immunological testing by 2 reactions is provided.

Programa de acreditación de médicos veterinarios zootecnistas: normas y procedimientos de las campañas nacionales contra la tuberculosis bovina y la brucelosis / Program for accrediting zoologist veterinary doctor's degrme: rules and procedures of the national campaigns against the bovine tuberculosis and the brucellosis

Respecto al Programa de la Campaña Nacional Contra la Tuberculosis Bovina, corresponde a la Secretaría de Agricultura y Recursos Hidráulicos, a través de la Dirección General de Salud Animal, la instrumentación legal, la elaboración de normas y procedimientos, así como el control, supervisión administrativa, evaluación epizootiológica, económica y verificación de la calidad de la tuberculina empleada. En relación a los procedimientos, se mencionan los criterios que han de seguirse en: diagnóstico de la situación de la tuberculosis bovina; promoción y control; y, erradicación. En lo que concierne a la certificación y revalidación de hatos libres, se establecen: requisistos para la certificación de hato libre; pruebas diagnósticas; reactores positivos y sospechosos; cuarentena; cancelación del certificado; control de los animales en hatos registrados; requisitos para la revalidación de hatos libres; suspensión de la certificación de hato libre; exportación de ganado de carne; y, corrales de acopio. En cuanto al uso e interpretación de las pruebas de tuberculina, se deben tener en cuenta: las instrucciones para la realización de las pruebas de tuberculina (equipo, identificación, facilidades para el manejo de ganado, sitio de aplicación de la tuberculina, técnica de aplicación, observaciones, procedimiento para registrar y reportar los resultados y archivo de pruebas); pruebas aprobadas de tuberculina (anocaudal, simple o cervical, doble comparativa y excepciones); procedimientos especiales en hatos de alto riesgo; investigación en animales concurrentes (aves, cerdos, cabras, gatos y perros); e, investigación en humanos. Por otra parte, se proporciona una "guía técnica para el Programa de la Campaña Nacional para el Control y Erradicación de la Brucelosis", misma que está integrada por los siguientes apartados: términos empleados; disposiciones generales; procedimiento de aplicación en bovinos; procedimiento de aplicación en caprinos y bovinos; disposiciones generales en zonas de erradicación; y, procedimientos de vigilancia

The killing of tumour cell targets coupled to tuberculin (PPD) by human and murine PPD-reactive T helper clones. I. PPD specificity of killing.

This paper reports on the characteristics of killing by a human and a murine tuberculin (PPD)-specific T helper clone of targets to which PPD was attached via the lectin concanavalin A (Con A). The killing was specific for PPD from M. tuberculosis; and targets coupled to Con A alone or to PPD from M. paratuberculosis were not killed. Target cells carrying Con A-PPD were more effectively lysed than PPD-pulsed cells. This form of lymphocyte killing, though highly significant, was inefficient. Maximum killing of PPD carrying targets was 30-40% at effector to target ratios of 20:1 and at 16 h. Cells carrying 2 x 10(6) molecules of PPD and less than 1.5 x 10(6) molecules Con A per cell were killed most efficiently. A major distinction between this helper T cell killing and that mediated by cytotoxic T cells was that both TH clones displayed bystander lysis and killed PPD uncoupled targets when these were cultured with syngeneic PPD-bound targets. This suggests that the mechanism of cytotoxicity may involve soluble mediators.

The utility of the macrophage migration inhibition test for in vitro titration of tuberculins.

The purpose of this study was to explore the fundamental principle of the potency estimation of tuberculins, as applied in vitro by the macrophage migration inhibition test (MIT) under agarose. The MIT was performed using specifically sensitized mouse and guinea-pig peritoneal macrophages and serial dilutions of the analogous PPD (purified protein derivatives of tuberculin) tuberculins as antigen. Statistical studies performed included (a) the standard deviation of the mean migration areas, (b) the analysis of variance, (c) the regression analysis, (d) its corresponding linearity test and (e) the determination of the related correlation coefficient. It was shown for the first time and in both animal species under study that there is correspondence between the log dose-response relationship of the tuberculin PPD in MIT under agarose and the well known in tuberculin cutaneous reaction. The MIT may therefore successfully replace the in vivo titration of tuberculins.

Synthesis and biological assays of peptides from a tuberculin-active protein.

The octapeptide Asp-Gly-Gly-Ser-Glu-Ser-Glu-Gly and the hexadecapeptide Asp-Gly-Gly-Ser-Glu-Ser-Glu-Gly-Lys-Asn-Gly-Ser-Gln-Met-Arg-Leu, part of a tuberculin-active intracellular mycobacterial protein, were synthesized. The synthetic peptides were shown to possess tuberculin activity by their ability to elicit a delayed-type allergic reaction in skin tests on Mycobacterium tuberculosis-sensitized guinea pigs. Purified protein derivative, the complex mixture of proteins of unknown composition which are excreted into the culture medium by M. tuberculosis and which is in wide use as a tuberculin-active preparation, was shown to cross-react weakly in the radioimmunoassays with the synthetic octapeptide when the 125I-labeled octapeptide and an anti-octapeptide antiserum were used.

Las pruebas intradermicas de evaluacion de competencia celular: estudio comparativo entre antigenos clasicos y otros antigenos / Cellular competence evaluation intradermic tests: comparative study between clasic and other antigens

Se presenta un estudio comparativo en la respuesta de hipersensibilidad demorada frente a 4 antigenos universalmente recomendados. Tuberculina (TU), Candidina (CA), Streptokinasa/Streptodornasa (SK/SD) y virus de parotiditis (PA) con otros antigenos de uso menos comun tal como Antigeno-Respiratorio-Mixto (ARM) y lisado de Staphylococcus Aureus 80/81 (LS). De igual manera se estudio la respuesta al Dinitroclorobenceno (DNCB). La poblacion probada fue de 49 personas normales con edades entre 18-23 anos. Los resultados mostraron que la reactividad para ARM es de 91,8%, para LS 91,8%, para Parotiditis 6,1%. Los estudios con DNCB permiten aconsejar su uso solo en casos muy especiales. El trabajo presentado sugiere una normalizacion en la lectura y el uso de 4 antigenos con la mas alta frecuencia de positividad dentro del grupo probado asi: ARM,LS,CA y TU

Isolation of tuberculin peptides from tuberculin purified protein derivative (PPD).

Tuberculin purified protein derivative (PPD) obtained from the filtrate of Mycobacterium tuberculosis was hydrolysed with proteinase, trypsin, or chymotrypsin. Each hydrolysate consisted of a tuberculin peptides mixture (TPM). From each TPM 16 fractions were obtained by ion-exchange chromatography on Dowex 50W-X8 but only one fraction was isolated from each of the 16 fractions which showed tuberculin activity in guinea pigs sensitized with M. bovis (bcg) or M. tuberculosis. This fraction was designated "purified tuberculin peptide" (PTP). The PTP fraction from the proteinase hydrolysate (PTP-proteinase) was rechromatographed on Dowex 1-X2 and two tuberculin peptide fractions having molecular weights of 3200 and 12,000 were isolated. The potency of these two fractions was assessed in guinea pigs sensitized with M. bovis (BCG) and with M. tuberculosis and they were approximately 4 to 7 times more potent than either the international standaCG and of at least equal potency to either PPD-S or Connaught PPD in guinea pigs sensitized with either M. kansasii, M. scrofulaceum, M. intracellulare, or M. avium whereas very little if any cross-reactivity was elicited by these two fractions. This lack of response indicates that either fraction could be used as an aid to differentiate between sensitization due to M. tuberculosis or M. bovis and sensitization attributed to other mycobacteria.