[Diagnosis of tuberculosis infection]

The prevalence of tuberculosis infection varies between countries, with an estimate in adults in Spain of 25%. The technique for its diagnosis, in spite of its antiquity, is tuberculin. Even today, this test continues to be in use in the majority of countries. In recent years two methods of immunodiagnosis based on detection of IFN-g released by T cells in response to M. tuberculosis-specific antigens, enables us to diagnose the infection in a laboratory without all of the problems deriving from the administration of tuberculin. From the contact studies made it has been shown that these techniques correlate better with the degree and duration of exposure to Mycobacterium tuberculosis and that prior vaccination with BCG does not interfere with their results, which without doubt will result in a reduction in the number of unnecessary chemoprofilaxis.

Mycobacterium bovis in rural Tanzania: Risk factors for infection in human and cattle populations

Although bovine tuberculosis is widespread throughout Africa, very little is known about risk factors for Mycobacterium bovis infection in either human or cattle populations. A human case-control study was conducted in northern Tanzania, comparing risk factors and prevalence of cattle interdermal test positives of cases (cervical adenitis cases from which M. bovis was isolated) with age- and sex-matched controls (selected at random from potential hospital attendees within the community). A cattle cross-sectional study was also set-up involving 27 villages selected at random in four districts, with 10,549 cattle and 622 herds tested, and questionnaire surveys conducted in 239 households. M. bovis was confirmed in seven of 65 (10.8%) human cervical adenitis cases, of which only one came from a household owning infected cattle. M. bovis in human patients was associated with families in which a confirmed diagnosis of tuberculosis had previously been made (p<0.001) and with households far (>100m) from neighbours (p=0.003). In cattle, overall prevalence of intradermal test positives was low at 0.9% (0.70-1.06%), but widespread, with 11.8% (8.44-13.17%) herds containing at least one reactor. Prevalence of intradermal test positives increased significantly with cattle age (p<0.001). Herds with the following risk factors had a significantly greater prevalence of intradermal test positives: >50 cattle in the herd (p=0.024); herds housed inside at night (p=0.021) and herds in contact with wildlife (p=0.041). Furthermore, villages that experienced annual flooding had a higher prevalence of infection (p=0.043).

Effects of pre-culture holding time and temperature on interferon-γ responses in whole blood cultures from Mycobacterium bovis-infected cattle

The Bovigam assay is approved for use within the United States as a complementary tuberculosis test. Prior to whole blood culture and the ensuing ELISA to detect interferon-(IFN)-gamma, samples are subjected to various holding time/temperature combinations due, in part, to practical constraints associated with shipment of samples to approved laboratories. To evaluate these effects, 5-month-old Holstein calves (n = 7) received 10(3) cfu Mycobacterium bovis by aerosol. Heparinized blood was collected 2 months after challenge and held at 4 or 22 degrees C for 0, 8 or 24 h prior to culture with mycobacterial antigens or pokeweed mitogen (PWM). Responses of samples held for 8 or 24 h were comparable and lower than responses of cultures prepared immediately after collection, regardless of holding temperature. Differences in responses of samples held at 4 degrees C versus 22 degrees C were also minimal. A subset of samples was held for 2 h at 37 degrees C at the beginning of the holding period. This subset of samples had diminished responses to all stimulants and increased holding times (i.e., 24 h versus 8 h) negatively impacted the response. Pre-processing conditions, particularly delays in set-up and initial high sample temperatures, reduces IFN-gamma responses of cells from infected cattle increasing the risk of false negatives in this assay of regulatory importance.

[Comparative evaluation of the informative value of the rapid serochek mbt test to determine mycobacterium tuberculosis antibodies and mantoux tuberculin test in adults]

The diagnostic informative value of the Serochek MBT test (Zephyr Biomedicals, India) in detecting serum Mycobacterium tuberculosis antibodies was compared with that of the Mantoux tuberculin test with 2 TE of PPD-L in patients with pulmonary tuberculosis. The informative value of the study rapid method for the diagnosis of tuberculosis was generally 1.8 times less than that of the Mantoux tuberculin test with 2 TE of PPD-L (only intensive and hyperergic tuberculin tests were kept in mind): 6.1 times less in patients with small forms; 1.4 times less in the examinees with disseminated processes; 1.5 times greater than in chronic pulmonary tuberculosis. Since the detection and diagnosis of tuberculosis are very important at an early development stage of the disease, the findings (9% positive serotests in small forms of pulmonary tuberculosis) suggest the low sensitivity of the approved Serochek MBT test in verifying the presence of serum Mycobacterium tuberculosis antibodies and therefore its low informative value as a method to be used for the rapid diagnosis of tuberculosis.

[Diagnostic difficulties in pulmonary tuberculosis in children]

Pulmonary tuberculosis in children remains an important cause of morbidity and mortality around the world.

AIM

To evaluate the difficulty of diagnosis and the epidemiological, clinical, radiological and bacteriological features of pulmonary tuberculosis in children.

MATERIAL AND METHOD

We analyzed in a descriptive and retrospective study, 254 children with pulmonary tuberculosis hospitalized in Pulmonary Pediatric Department of Iaşi during Jan 2000 - Dec 2005. The surveyed parameters include: the history of TB contact and BCG vaccination, the social condition, the nutrition status, the size of PPD induration, the clinical aspects, the microbiological results, chest X-ray, Quantiferon test.

RESULTS

Of the total number of cases: 65.4% had poor social conditions, 72.8% cases with TB contact, almost all patients with malnutrition I, 53.5% cases with BCG scar = 3 mm, 58.35% children with positive tuberculin skin test, 61.8% cases with acute onset, 24.8% with microbiological confirmation, 63.8% with hilar involvement, 18 cases with positive Quantiferon test.

CONCLUSIONS

1. The early diagnosis of pulmonary tuberculosis in children is often difficult. 2. Pulmonary tuberculosis in children must be a priority of the public health programs for extending the area of diagnostic methods.

[Medical students as an independent tuberculosis-risk group]

Of fundamental importance is the detection of tuberculosis among its higher risk population groups. This applies in full measure to medical students. The rates of Mycobacterium tuberculosis infection, its risk, tuberculin sensitivity, and incidence were studied in 2499 students from different higher educational establishments. During the study years, there was a significant increase in these parameters in medical students during study years as compared to humanitarian students, which allows medical students to be considered as an independent social tuberculosis-risk group.

Usefulness of QuantiFERON TB-2G, a diagnostic method for latent tuberculosis infection, in a contact investigation of health care workers

OBJECTIVE

To evaluate the usefulness of QuantiFERON TB-2G (QFT-2G) for detecting latent tuberculosis infection (LTBI) in a contact investigation of health care workers.

METHODS

The investigated subjects were 190 subjects among the health care workers who were examined between January 2005 and June 2006. Background information, including a past history of tuberculosis (TB) or tuberculin skin test (TST) or BCG vaccination, and contact score (infectivity x contact duration) were investigated. The TST and QFT-2G test were performed on all subjects.

RESULTS

In 109 subjects with a negative TST history, the TST results were converted to positive in 38 subjects. While the TST was positive in 48 subjects (25%), the QFT-2G test was positive in only five subjects (3%). The correlation of the QFT-2G with TST results was not significant. There was no relationship between contact score and the TST result. Twenty-nine subjects had TST positive responses (22%), but there were no QFT-2G positive responses in subjects with a mild contact score. Sixteen subjects had TST positive responses (31%), but two subjects showed positive QFT-2G results (4%) in the moderate contact score group. However, the positive response rate of the TST and QFT-2G test was the same percentage in the severe contact score group (33%).

CONCLUSION

The QFT-2G test showed a significant relationship with the contact score when compared with the TST. If the subjects with LTBI in the moderate contact score group were selectively excluded, the contact investigation in the mild contact score group may not be necessary. If there would have been many subjects with the QFT-2G positive responses in the moderate contact score group, we think that the QFT-2G test must be performed even in the mild contact score group.

[Tuberculin susceptibility and Mycobacterium tuberculosis infection in children]

Tuberculin susceptibility was studied from the Mantoux test with 2TE in 253 children aged 14 years and during all previous years of their life. Positive tests were recorded in 72.4% of cases; doubtful tests were in 6.7%, and negative ones in 20.9%. Infection was diagnosed in 33.9 +/- 2.9%. The annual conversion of tubercular tests was 2.2 +/- 0.05%. Positive Mantoux tests with 2TE caused by the administration of BCG vaccine were observed in 45.1%, in most cases, due to persistent allergy after neonatal vaccination. The authors convince of the necessity of regularly making a tuberculin test and qualitative tuberculosis vaccines when clinically indicated.

Gamma interferon assay as an alternative to PPD skin testing in selected patients with granulomatous intraocular inflammatory disease

BACKGROUND

To evaluate the QuantiFERON-TB test (gamma interferon assay), approved by the Centers for Disease Control and Prevention for the detection of latent tuberculosis (LTB), in patients who potentially may require immunosuppressive therapy for ocular inflammatory disease.

METHODS

Blood samples from 12 consecutive patients with granulomatous ocular inflammatory disease were evaluated first with the purified protein derivative (PPD) skin test and then with the QuantiFERON-TB test (11 of 12 patients, 1 declined). The results of the 2 tests in both U.S.- and non-U.S.-born patients were compared with their Bacillus Calmette-Guérin (BCG) vaccination status and chest x-rays.

RESULTS

In our small series there was a high degree of concordance between the QuantiFERON-TB assay and the PPD skin test.

INTERPRETATION

The QuantiFERON-TB test did not demonstrate intrinsic merit over PPD skin testing for screening for LTB in selected patients when immunosuppressive therapy is considered. The confounding effect of BCG vaccination renders interpretation of both tests difficult. Early reports suggest the second-generation tests that are now available may hold promise for use in the uveitis clinic and should be formally evaluated.

Increase in tuberculin skin test converters among health care workers after a change from Tubersol to Aplisol

BACKGROUND

Comparability of the 2 commercially available tuberculin skin testing (TST) preparations, Aplisol (Parkdale Pharmaceuticals, Inc, Rochester, MI) and Tubersol (Aventis Pasteur, Inc, Swiftwater, PA), remains uncertain, particularly in groups that undergo repeated testing, such as health care workers.

METHODS

Data from the annual tuberculosis screening program for health care workers at the Kennedy Krieger Institute in Baltimore, Maryland, were analyzed. Conversion rates during 1997-2003 in workers screened with Tubersol (n = 8897 screenings) were compared with 1203 workers who underwent screening with Aplisol in 2004. Repeat testing with Tubersol was examined in those who converted in 2004 with Aplisol.

RESULTS

Annual TST conversion rates ranged from 0.3% to 0.9% between 1997 and 2003 using Tubersol. After switching to Aplisol in 2004, the TST conversion rate significantly increased to 2% (P < .001). Among 24 health care workers who were converters with Aplisol in 2004, only 6 of 23 (26%) were converters on repeat testing with Tubersol (1 declined retesting). None of the apparent converters (n = 24) had radiographic evidence of Mycobacterium tuberculosis infection, and there was no epidemiologic evidence of transmission. Reclassification based on Tubersol testing in 2004 resulted in conversion rates comparable with previous years.

CONCLUSION

We conclude that the change from Tubersol to Aplisol resulted in falsely elevated conversion rates. Our results support the guidelines from the Centers for Disease Control and Prevention recommendations that 1 product should be used consistently in populations undergoing periodic testing.

Diagnosis of latent tuberculosis infection: The potential role of new technologies

Tuberculosis (TB) is a major cause of morbidity and mortality worldwide. TB control programmes need improvement in the diagnosis of latent TB infection. The tuberculin skin test (TST) is far from a 'gold' standard as it often gives false results. Interferon-gamma assays are newly available tests to detect latent TB infection, but they are currently not routinely used. They are based on immune responses to purified protein derivative (PPD) or to region of difference 1 (RD1) specific antigens. Assays based on RD-1 specific antigens perform better than both PPD based assays and TST. They correlate with TB exposure and are less likely to give false results in non-tuberculous mycobacterial disease, Bacille Calmette-Guerin (BCG) vaccination and immunosuppression. More accurate diagnosis of latent TB infection with RD-1 specific antigen based interferon-gamma assays may allow targeting of chemoprophylaxis to reduce the burden of active TB while decreasing wastage of health care resources due to false results associated with TST. However, further research and development is required to verify that new tests can predict the risk of later development of active TB and to make it feasible to perform these tests in a reproducible fashion at low cost, particularly in developing countries.

Comparative prevalence of tuberculosis in two dairy herds in India

Holstein Friesian cows and their crossbred progeny on a farm in northern India were tested for tuberculosis (TB) infection using a single intradermal tuberculin test. The results showed that the animals persistently harboured TB infection for periods of two to four years. The recent comparative intradermal tuberculin test revealed that at least five out of nine of these cattle reacted positively to bovine tuberculin purified protein derivative. A high (15.76%) prevalence rate resulted because none of the infected animals had been segregated or culled from the herd since the first incidence was detected in 1992. In contrast, another farm in western India that practiced segregation and culling was able to contain the level of prevalence of TB between 0.65% and 1.85%. These findings call for stricter regulations on the management of TB at farm, state and country level and a revision in the mode of breeding programmes adopted by farms.

Reducing tuberculosis incidence by tuberculin skin testing, preventive treatment, and antiretroviral therapy in an area of low tuberculosis transmission

BACKGROUND

Tuberculin skin testing (TST) and preventive treatment of tuberculosis (TB) are recommended for all persons with human immunodeficiency virus (HIV) infection. We aimed to assess the effect of TST and preventive treatment of TB on the incidence of TB in the era of combination antiretroviral therapy in an area with low rates of TB transmission.

METHODS

We calculated the incidence of TB among participants who entered the Swiss HIV Cohort Study after 1995, and we studied the associations of TST results, epidemiological and laboratory markers, preventive TB treatment, and combination antiretroviral therapy with TB incidence.

RESULTS

Of 6160 participants, 142 (2.3%) had a history of TB at study entry, and 56 (0.91%) developed TB during a total follow-up period of 25,462 person-years, corresponding to an incidence of 0.22 cases per 100 person-years. TST was performed for 69% of patients; 9.4% of patients tested had positive results (induration > or = 5 mm in diameter). Among patients with positive TST results, TB incidence was 1.6 cases per 100 person-years if preventive treatment was withheld, but none of the 193 patients who received preventive treatment developed TB. Positive TST results (adjusted hazard ratio [HR], 25; 95% confidence interval [CI], 11-57), missing TST results (HR, 12; 95% CI, 4.8-20), origin from sub-Saharan Africa (HR, 5.8; 95% CI, 2.7-12.5), low CD4+ cell counts, and high plasma HIV RNA levels were associated with an increased risk of TB, whereas the risk was reduced among persons receiving combination antiretroviral therapy (HR, 0.44; 95% CI, 0.2-0.8).

CONCLUSION

Screening for latent TB using TST and administering preventive treatment for patients with positive TST results is an efficacious strategy to reduce TB incidence in areas with low rates of TB transmission. Combination antiretroviral therapy reduces the incidence of TB.

The effect of tuberculin testing on the development of cell-mediated immune responses during Mycobacterium bovis infection

Protection against tuberculosis (TB) is associated with Th1-type cell-mediated immunity (CMI). Whilst the intradermal injection of partially purified derivatives of tuberculin (PPD) represents the classic test assessing the delayed type hypersensitivity (DTH) response used in both humans and cattle for diagnosing TB, it has been suggested that the test may modulate host CMI responses. To investigate the kinetics of the development of the DTH response and its subsequent effect on CMI responses, groups of 6-month old calves were inoculated intranasally with 8 x 10(4) cfu of Mycobacterium bovis, subjected to the comparative intradermal tuberculin test (TT) using bovine and avian PPD (PPD-B, PPD-A) at various time intervals post-infection, and immune responses compared. These included DTH, lymphocyte proliferation, IgG production, and synthesis of the cytokines: IFNgamma, IL-10, IL-4, IL-6, and IL-13. All animals were subjected to post-mortem examination. The kinetics of the development of the DTH response assessed in the TT was such that infected cattle could be identified as early as 3 weeks post-infection, which correlated with the detection of an antigen-specific IFNgamma response. Transient increases in plasma-derived IFNgamma as a result of TT during an established TB infection were more pronounced when blood was stimulated with PPD-A compared with PPD-B stimulation. This has the potential to mask diagnosis of infection as a result of the stronger avian-bias if the IFNgamma test is used the week following TT. Disease pathology was not affected by TT. A transient failure to a second TT was observed in 1 of 30 animals and the time (post-infection) at which the TT is administered may be of significance. In serum, IgG responses to PPD-B, which were undetectable prior to TT, were elevated after TT and were most pronounced in cattle that were TT at 6 weeks post-infection. Other cytokines were also affected by the TT; IL-4 mRNA levels increased and IL-6 mRNA levels decreased, whilst PPD-B specific IL-10 protein synthesis was enhanced. These observations may offer the potential for further diagnostic assays that could complement the TT and IFNgamma test.

Is tuberculin skin testing useful to diagnose latent tuberculosis in BCG-vaccinated children?

BACKGROUND

The tuberculin skin test (TST) is the most commonly used tool to detect infection with Mycobacterium tuberculosis. We sought to determine whether tuberculin skin testing is useful to detect latent infection by M. tuberculosis in a population that was vaccinated with the Bacille Calmette Guérin (BCG) vaccine.

METHODS

We performed a cross-sectional study during October 2000-February 2001, enrolling first and sixth graders from a random, stratified sample of public elementary schools in Orizaba, Veracruz, Mexico. We assessed the relationship between sociodemographic and epidemiological information, BCG scars, and TST reactivity.

RESULTS

There were 858 children enrolled in the study with a completed questionnaire and TST result. The prevalence of a positive TST result (> or =10 mm) was 12.4%. Controlling for BCG scar, age, and other characteristics, close contact with pulmonary tuberculosis patients (odds ratio 6.56, 95% confidence interval 2.05-21.07, P = 0.001) was independently associated with TST reactivity.

CONCLUSIONS

TST results helped identify children in a BCG-vaccinated population who had recent exposure to persons with pulmonary tuberculosis, were probably infected with M. tuberculosis, and could benefit from treatment for their latent tuberculosis infection.

Safety of ESAT-6

A recombinant dimer of the Mycobacterium tuberculosis (MTb) 6 kDa early secreted antigenic target (ESAT-6) was produced in Lactococcus lactis. Pharmacodynamic and safety studies were carried out in guinea pigs, rats, mice and dogs with intradermal (id), subcutaneous (sc) and intravenous (iv) administration of the antigen. In contrast to tuberculin purified protein derivative (PPD) the recombinant dimer (rdESAT-6) was able to discriminate MTb infection from BCG vaccination in vivo. In guinea pigs sensitized by infection with MTb, 1 microg rdESAT-6 gave a mean delayed-type hypersensitivity (DTH) response of 22 mm, a significantly stronger reaction than in animals sensitised by the environmental mycobacteria M. kansasii, M. szulgai and M. marinum. rdESAT-6 proved to be a safe tuberculin reagent in a dose range of 1-1000 microg with no or only minor local reactions.

Mixture analysis of tuberculin survey data from northern Malawi and critique of the method

SETTING

Various methods have been used to estimate the prevalence of Mycobacterium tuberculosis infection from tuberculin survey data. All are complicated by prior sensitisation to environmental mycobacteria and bacille Calmette-Guérin (BCG) vaccination. Mixture analysis has recently been proposed as a means of overcoming misclassification and improving infection prevalence estimates.

OBJECTIVE

To compare conventional and mixture model estimates of M. tuberculosis infection prevalence.

DESIGN

Mixture models with two or three univariate normal components were fitted to the results of 53 909 tuberculin tests conducted in northern Malawi during 1980-1984. Data were stratified by BCG status, sex and age and corrected for digit preference. Prevalence estimates derived from mixture models were compared with those of conventional methods.

RESULTS

The optimal model was age-dependent, with three- and one-component solutions preferred in younger and older age groups, respectively. In contrast with findings from elsewhere, a component corresponding to BCG vaccination was indistinguishable from that attributable to environmental mycobacterial exposure, and infection prevalence estimates in younger individuals with a BCG scar were inflated, irrespective of the method used.

CONCLUSION

The validity of infection prevalence and incidence estimates based on mixture modelling is probably locale-dependent, and the assumptions underlying mixture models may not realistically reflect underlying immunological processes.

Early antibody responses to experimental Mycobacterium bovis infection of cattle

Bovine tuberculosis persists as a costly zoonotic disease in numerous countries despite extensive eradication and control efforts. Sequential serum samples obtained from Mycobacterium bovis-infected cattle were evaluated for seroreactivity to mycobacterial antigens. Animals received M. bovis by aerosol, intratonsil, intranasal, or intratracheal inoculation. Assays included the multiantigen print immunoassay for determination of antigen recognition patterns, immunoblot analysis for sensitive kinetic studies, and the VetTB STAT-PAK test, a novel, rapid test based on lateral-flow technology. Responses to MPB83 were detected for all M. bovis-infected animals regardless of the route or strain of M. bovis used for inoculation. Other less commonly recognized antigens included ESAT-6, CFP-10, and MPB70. Responses to MPB83 were detectable as early as 4 weeks after inoculation, were boosted upon injection of purified protein derivatives for skin testing, and persisted throughout the course of each of the four challenge studies. MPB83-specific immunoglobulin M (IgM) was detected prior to MPB83-specific IgG detection; however, early IgM responses rapidly waned, suggesting a benefit of tests that detect both IgM- and IgG-specific antibodies. The VetTB STAT-PAK test detected responses in sera from 60% (15/25) of the animals by 7 weeks after challenge and detected responses in 96% (24/25) of the animals by 18 weeks. These findings demonstrate the potential for new-generation antibody-based tests for the early detection of M. bovis infection in cattle.

A university hospital's 10-year experience with tuberculin testing: value of the 2-step tuberculin skin test

BACKGROUND

The usefulness of the 2-step tuberculin skin test as a tool for monitoring tuberculosis exposure among health care workers is controversial.

OBJECTIVES

We aimed to determine the cost-effectiveness and influence of initiation of a preemployment, 2-step tuberculin skin-testing program on the annual tuberculin skin conversion rate among a university hospital's health care workers.

METHODS

The tuberculin skin test conversion rates among the recipients of 31,729 tuberculin skin tests over 10 years were retrospectively analyzed. Data from the first 6 years of this study were generated when a single preemployment tuberculin skin test was utilized. Data from the last 4 years were gathered after the advent of a preemployment 2-step program. A cost analysis of the 2-step tuberculin skin test process was performed to determine the annual cost of this program.

RESULTS

Relative risk of a conversion was 8.43 times less during the 2-step period when compared with the years when a single tuberculin skin test was given at the start of employment (P < .001). A cost analysis showed that the annual added cost of the 2-step program was approximately 9,565 US dollars.

CONCLUSION

A greater than 8-fold reduction in the number of annual tuberculin skin test conversion coincided with, but could not be attributed solely to, the initiation of a 2-step program in our hospital. The Infection Control Committee concluded that the 2-step testing program is essential to achieve the hospital's goal of a 0% annual tuberculin skin test conversion rate and that the annual cost is justified.

Boosted tuberculin skin testing in hemodialysis patients

BACKGROUND

Tuberculosis remains a significant health problem for patients receiving long-term hemodialysis (HD). The tuberculin skin test (TST) is an important method of detecting Mycobacterium tuberculosis infection. Cutaneous anergy decreases the accuracy of the test in these patients. Higher and repeating doses have been mentioned in the immunosuppressed patients. This study examined the significance and frequency of the booster phenomenon in 2-step tuberculin testing of these patients.

METHODS

A total of 106 outpatients in a hospital-based HD center in Turkey were screened with 5 and 10 tuberculin units (TU) and Candida antigen. To determine the frequency of booster phenomenon, patients with <10 mm indurations to the initial TST with 5 TU were given a second test with 10 TU, 7 days later.

RESULTS

Forty (37.7%) of 106 patients had a significant tuberculin reaction (>or=10 mm) on the initial TST with 5 TU. The booster effect was detected in 16 (24.3%) of 66 patients who had a negative reaction (<or=10 mm) to the initial test. Overall, 56 (52.8%) patients showed a significant reaction on both tests. Anergy was found in 39 (36.8%) of 106 patients.

CONCLUSION

Even with the high rate of anergy, TST seems to be useful for these patients; also, it is inexpensive and easy to perform. We suggest repeating the test with higher doses in patients with a high risk for tuberculosis. Anergy testing with Candida antigen may be helpful in determining the value of TST.

Diagnosis of latent Mycobacterium tuberculosis infection: is the demise of the Mantoux test imminent?

Tuberculosis is responsible for more then 2 million deaths worldwide each year and vies with HIV as the world's most fatal infectious disease. In many developing countries, attempts to control the spread of infection rely solely on identification and treatment of those with active disease, ignoring subclinical infection. However, in developed countries, large efforts are also expended to identify and give prophylactic drugs to people with latent tuberculosis infection. Until recently, the 100-year-old tuberculin skin test (Mantoux) has been the only available diagnostic test for latent tuberculosis infection, despite its many well-known limitations. Advances in scientific knowledge have led to the development of tests for tuberculosis that measure the production of interferon-gamma by T-cells stimulated in vitro with Mycobacterium tuberculosis-specific antigens. These interferon-gamma tests are highly specific and unaffected by prior Bacille Calmette-Guérin vaccination or immune reactivity to most atypical mycobacteria. They are more sensitive than the tuberculin skin test in detecting people with active tuberculosis, and their results correlate more closely with M. tuberculosis exposure risk factors than the tuberculin skin test in people likely to have latent tuberculosis infection. Science has caught up with one of the oldest diagnostic tests still in use worldwide, and the adoption of new, tuberculosis-specific interferon-gamma-based tests should move us one step closer to better control of this insidious pathogen.

New tools and emerging technologies for the diagnosis of tuberculosis: part I. Latent tuberculosis

Nearly a third of the world's population is estimated to be infected with Mycobacterium tuberculosis. This enormous pool of latently infected individuals poses a major hurdle for global tuberculosis (TB) control. Currently, diagnosis of latent TB infection (LTBI) relies on the tuberculin skin test (TST), a century-old test with known limitations. In this review, the first of a two-part series on new tools for TB diagnosis, recent advances in the diagnosis of LTBI are described. The biggest advance in recent years has been the development of in vitro T-cell-based interferon-gamma release assays (IGRAs) that use antigens more specific to M. tuberculosis than the purified protein derivative used in the TST. Available research evidence on IGRAs suggests they have higher specificity than TST, better correlation with surrogate markers of exposure to M. tuberculosis in low-incidence settings, and less cross-reactivity due to BCG vaccination than the TST. IGRAs also appear to be at least as sensitive as the purified protein derivative-based TST for active TB. In the absence of a gold standard for LTBI, sensitivity and specificity for LTBI are not well defined. Besides high specificity, other potential advantages of IGRAs include logistical convenience, avoidance of poorly reproducible measurements, such as skin induration, need for fewer patient visits and the ability to perform serial testing without inducing the boosting phenomenon. Overall, due to its high specificity, IGRAs may be useful in low-endemic, high-income settings where cross-reactivity due to BCG might adversely impact the utility of TST. However, despite the growing evidence supporting the use of IGRAs, several unresolved and unexplained issues remain. The review concludes by highlighting areas where evidence is lacking, and provides an agenda for future research. Active TB and drug resistance are discussed in Part II; 423-432 of this issue.