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Zavala S, Winglee K, Ho CS, Pettit AC, Ahmed A, Katz DJ, Belknap RW, Stout JE. Examining Test Cutoffs to Optimize Diagnosis of Latent Tuberculosis Infection in People Born Outside the United States. Ann Am Thorac Soc 2023; 20:1258-1266. [PMID: 37159954 PMCID: PMC10938364 DOI: 10.1513/annalsats.202212-1005oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/09/2023] [Indexed: 05/11/2023] Open
Abstract
Rationale: Detection of latent tuberculosis infection (LTBI) in persons born in high tuberculosis (TB) incidence countries living in low TB incidence countries is key to TB elimination in low-incidence countries. Optimizing LTBI tests is critical to targeting treatment. Objectives: To compare the sensitivity and specificity of tuberculin skin test (TST) and two interferon-γ release assays at different cutoffs and of a single test versus dual testing. Methods: We examined a subset (N = 14,167) of a prospective cohort of people in the United States tested for LTBI. We included non-U.S.-born, human immunodeficiency virus-seronegative people ages 5 years and older with valid TST, QuantiFERON-TB Gold-in-Tube (QFT), and T-SPOT.TB (TSPOT) results. The sensitivity/specificity of different test cutoffs and test combinations, obtained from a Bayesian latent class model, were used to construct receiver operating characteristic (ROC) curves and assess the area under the curve (AUC) for each test. The sensitivity/specificity of dual testing was calculated. Results: The AUC of the TST ROC curve was 0.81 (95% credible interval (CrI), 0.78-0.86), with sensitivity/specificity at cutoffs of 5, 10, and 15 mm of 86.5%/61.6%, 81.7%/71.3%, and 55.6%/88.0%, respectively. The AUC of the QFT ROC curve was 0.89 (95% CrI, 0.86-0.93), with sensitivity/specificity at cutoffs of 0.35, 0.7, and 1.0 IU/mL of 77.7%/98.3%, 66.9%/99.1%, and 61.5%/99.4%. The AUC of the TSPOT ROC curve was 0.92 (95% CrI, 0.88-0.96) with sensitivity/specificity for five, six, seven, and eight spots of 79.2%/96.7%, 76.8%/97.7%, 74.0%/98.6%, and 71.8%/99.5%. Sensitivity/specificity of TST-QFT, TST-TSPOT, and QFT-TSPOT at standard cutoffs were 73.1%/99.4%, 64.8%/99.8%, and 65.3%/100%. Conclusion: Interferon-γ release assays have a better predictive ability than TST in people at high risk of LTBI.
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Affiliation(s)
- Sofia Zavala
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Kathryn Winglee
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christine S. Ho
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - April C. Pettit
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amina Ahmed
- Department of Pediatrics, Atrium Health, Charlotte, North Carolina
| | - Dolly J. Katz
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Jason E. Stout
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Salas-Coronas J, Cabezas-Fernández MT, Lozano-Serrano AB, Soriano-Pérez MJ, Vázquez-Villegas J, Cuenca-Gómez JÁ. Newly Arrived African Migrants to Spain: Epidemiology and Burden of Disease. Am J Trop Med Hyg 2018; 98:319-325. [PMID: 29165212 DOI: 10.4269/ajtmh.17-0604] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The aim of this study is to describe the epidemiological profile, clinical characteristics, and microbiological findings in African immigrants newly arrived to Spain attended at a specialized reference unit from October 2004 to February 2017. A common protocol for the screening of imported and cosmopolitan diseases was designed to evaluate patients with ≤ 12 months of stay in Spain. A total of 523 patients were included in the study, 488 (93.3%) of sub-Saharan origin. A high number of helminthic infections were diagnosed in sub-Saharan patients, including geohelminthiasis (hookworms 14.3%; Trichuris trichiura 4.1%; Ascaris lumbricoides 3.1%), schistosomiasis (12.3%), strongyloidiasis (17.2%), and filariasis (8.4%). Thirty-five patients (7.2%) had malaria, most by Plasmodium falciparum. Among communicable diseases, 33.6% of sub-Saharans presented HBsAg positivity compared with 5.7% of North African patients (P = 0.001). Thirteen patients were diagnosed with active tuberculosis. Seventy percent of the sub-Saharans and 40% of the North Africans who were tested had a latent tuberculosis infection (LTI). Treatment of LTI was administered in selected cases (14%), achieving end of treatment in 80% of them. In light of these results, effective screening strategies, particularly within the sub-Saharan immigrant population, including potentially communicable diseases and certain potentially serious parasitic diseases (Strongyloides, Schistosoma), should be implemented. It is necessary to facilitate fully and free of charge access to the public health system to newly arrived immigrants, as well as to implement programs and actions aimed at favoring care and follow-up, especially for communicable diseases. Empirical treatment of some parasitic diseases could be a cost-effective action.
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Affiliation(s)
- Joaquín Salas-Coronas
- CEMyRI (Center for the Study of Migration and Intercultural Relations) of the University of Almería, Almería, Spain.,Tropical Medicine Unit, Hospital de Poniente, El Ejido, Almería, Spain.,RICET (Red de Investigación Cooperativa en Enfermedades Tropicales)
| | - María Teresa Cabezas-Fernández
- RICET (Red de Investigación Cooperativa en Enfermedades Tropicales).,CEMyRI (Center for the Study of Migration and Intercultural Relations) of the University of Almería, Almería, Spain.,Biotechnology Service, Hospital de Poniente, El Ejido, Almería, Spain.,Tropical Medicine Unit, Hospital de Poniente, El Ejido, Almería, Spain
| | - Ana Belén Lozano-Serrano
- RICET (Red de Investigación Cooperativa en Enfermedades Tropicales).,Tropical Medicine Unit, Hospital de Poniente, El Ejido, Almería, Spain
| | - Manuel Jesús Soriano-Pérez
- RICET (Red de Investigación Cooperativa en Enfermedades Tropicales).,Tropical Medicine Unit, Hospital de Poniente, El Ejido, Almería, Spain
| | - José Vázquez-Villegas
- Tropical Medicine Unit, Distrito Poniente, Almería, Spain.,RICET (Red de Investigación Cooperativa en Enfermedades Tropicales)
| | - José Ángel Cuenca-Gómez
- RICET (Red de Investigación Cooperativa en Enfermedades Tropicales).,Tropical Medicine Unit, Hospital de Poniente, El Ejido, Almería, Spain
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Serre-Delcor N, Treviño-Maruri B, Tórtola MT, Fernández-Quevedo M, Soriano-Arandes A, Oliveira-Souto I, Espasa M, Molina I, Ascaso C. Estrategia secuencial para el cribado de la ITBL en inmigrantes recién llegados en situación social vulnerable. Enferm Infecc Microbiol Clin 2018; 36:550-554. [DOI: 10.1016/j.eimc.2017.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 10/12/2017] [Indexed: 11/26/2022]
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Faust L, McCarthy A, Schreiber Y. Recommendations for the screening of paediatric latent tuberculosis infection in indigenous communities: a systematic review of screening strategies among high-risk groups in low-incidence countries. BMC Public Health 2018; 18:979. [PMID: 30081879 PMCID: PMC6090746 DOI: 10.1186/s12889-018-5886-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 07/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background Tuberculosis (TB) continues to be a global public health concern. Due to the presence of multiple risk factors such as poor housing conditions and food insecurity in Canadian Indigenous communities, this population is at particularly high risk of TB infection. Given the challenges of screening for latent TB infection (LTBI) in remote communities, a synthesis of the existing literature regarding current screening strategies among high-risk groups in low-incidence countries is warranted, in order to provide an evidence base for the optimization of paediatric LTBI screening practices in the Canadian Indigenous context. Methods A literature search of the Embase and Medline databases was conducted, and studies pertaining the evaluation of screening strategies or screening tools for LTBI in paediatric high-risk groups in low-incidence countries were included. Studies focusing on LTBI screening in Indigenous communities were also included, regardless of whether they focused on a paediatric population. Their results were summarized and discussed in the context of their relevance to screening strategies suitable to the Canadian Indigenous setting. Grey literature sources such as government reports or policy briefs were also consulted. Results The initial literature search returned 327 studies, with 266 being excluded after abstract screening, and 36 studies being included in the final review (original research studies: n = 25, review papers or policy recommendations: n = 11). In the examined studies, case identification and cost-effectiveness of universal screening were low in low-incidence countries. Therefore, studies generally recommended targeted screening of high-risk groups in low-incidence countries, however, there remains a lack of consensus regarding cut-offs for the incidence-based screening of high-risk communities, as well as regarding the utility and prioritization of individual risk-factor-based screening of high-risk groups. The utility of the TST compared to IGRAs for LTBI detection in the pediatric population also remains contested. Conclusions Relevant strategies for targeted screening in the Canadian Indigenous context include community-level incidence-based screening (screening based on geographic location within high-incidence communities), as well as individual risk-factor-based screening, taking into account pertinent risk factors in Indigenous settings, such as poor housing conditions, malnutrition, contact with an active case, or the presence of relevant co-morbidities, such as renal disease.
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Affiliation(s)
- Lena Faust
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Anne McCarthy
- Department of Medicine, University of Ottawa, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada
| | - Yoko Schreiber
- Department of Medicine, University of Ottawa, Ottawa, Canada. .,Ottawa Hospital Research Institute, Ottawa, Canada.
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Doan TN, Eisen DP, Rose MT, Slack A, Stearnes G, McBryde ES. Interferon-gamma release assay for the diagnosis of latent tuberculosis infection: A latent-class analysis. PLoS One 2017; 12:e0188631. [PMID: 29182688 PMCID: PMC5705142 DOI: 10.1371/journal.pone.0188631] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/11/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Accurate diagnosis and subsequent treatment of latent tuberculosis infection (LTBI) is essential for TB elimination. However, the absence of a gold standard test for diagnosing LTBI makes assessment of the true prevalence of LTBI and the accuracy of diagnostic tests challenging. Bayesian latent class models can be used to make inferences about disease prevalence and the sensitivity and specificity of diagnostic tests using data on the concordance between tests. We performed the largest meta-analysis to date aiming to evaluate the performance of tuberculin skin test (TST) and interferon-gamma release assays (IGRAs) for LTBI diagnosis in various patient populations using Bayesian latent class modelling. METHODS Systematic search of PubMeb, Embase and African Index Medicus was conducted without date and language restrictions on September 11, 2017 to identify studies that compared the performance of TST and IGRAs for LTBI diagnosis. Two IGRA methods were considered: QuantiFERON-TB Gold In Tube (QFT-GIT) and T-SPOT.TB. Studies were included if they reported 2x2 agreement data between TST and QFT-GIT or T-SPOT.TB. A Bayesian latent class model was developed to estimate the sensitivity and specificity of TST and IGRAs in various populations, including immune-competent adults, immune-compromised adults and children. A TST cut-off value of 10 mm was used for immune-competent subjects and 5 mm for immune-compromised individuals. FINDINGS A total of 157 studies were included in the analysis. In immune-competent adults, the sensitivity of TST and QFT-GIT were estimated to be 84% (95% credible interval [CrI] 82-85%) and 52% (50-53%), respectively. The specificity of QFT-GIT was 97% (96-97%) in non-BCG-vaccinated and 93% (92-94%) in BCG-vaccinated immune-competent adults. The estimated figures for TST were 100% (99-100%) and 79% (76-82%), respectively. T-SPOT.TB has comparable specificity (97% for both tests) and better sensitivity (68% versus 52%) than QFT-GIT in immune-competent adults. In immune-compromised adults, both TST and QFT-GIT display low sensitivity but high specificity. QFT-GIT and TST are equally specific (98% for both tests) in non-BCG-vaccinated children; however, QFT-GIT is more specific than TST (98% versus 82%) in BCG-vaccinated group. TST is more sensitive than QFT-GIT (82% versus 73%) in children. CONCLUSIONS This study is the first to assess the utility of TST and IGRAs for LTBI diagnosis in different population groups using all available data with Bayesian latent class modelling. Our results challenge the current beliefs about the performance of LTBI screening tests, and have important implications for LTBI screening policy and practice. We estimated that the performance of IGRAs is not as reliable as previously measured in the general population. However, IGRAs are not or minimally affected by BCG and should be the preferred tests in this setting. Adoption of IGRAs in settings where BCG is widely administered will allow for a more accurate identification and treatment of LTBI.
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Affiliation(s)
- Tan N. Doan
- Department of Medicine at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
- * E-mail:
| | - Damon P. Eisen
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Morgan T. Rose
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew Slack
- Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Grace Stearnes
- Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Emma S. McBryde
- Department of Medicine at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
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Serre Delcor N, Maruri BT, Arandes AS, Guiu IC, Essadik HO, Soley ME, Romero IM, Ascaso C. Infectious Diseases in Sub-Saharan Immigrants to Spain. Am J Trop Med Hyg 2016; 94:750-6. [PMID: 26880782 DOI: 10.4269/ajtmh.15-0583] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 12/08/2015] [Indexed: 12/17/2022] Open
Abstract
Immigrants may be carriers of infectious diseases because of the prevalence of these diseases in their country of origin, exposure during migration, or conditions during resettlement, with this prevalence being particularly high in sub-Saharan Africans. We performed a retrospective review of 180 sub-Saharan immigrants screened for infectious diseases at an International Health Center from January 2009 to December 2012. At least one pathogenic infectious disease was diagnosed in 72.8% patients: 60.6% latent tuberculosis infection, 36.8% intestinal parasites (intestinal protozoa or helminths), 28.1% helminths, 14.8% hepatitis B surface antigen positive, 1.2% anti-hepatitis C virus positive, 1.2% human immunodeficiency virus-positive, and 1.2% malaria. Coinfections were present in 28.4%. There was significant association between eosinophilia (absolute count or percentage) or hyper-IgE and the presence of helminths (P< 0.001). Relative eosinophilia and hyper-IgE were better indicators of helminth infection than absolute eosinophilia, particularly for schistosomiasis and strongyloidiasis. We found a high prevalence of infectious diseases in sub-Saharan immigrants, which could lead to severe health problems (in the absence of prompt treatment), representing a high cost to the public health system and possible transmission in the host country. Accurate screening and tailored protocols for infectious diseases are recommended in sub-Saharan immigrants.
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Affiliation(s)
- Núria Serre Delcor
- Tropical Medicine and International Health Unit Vall d'Hebron-Drassanes, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Microbiology Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Infectious Diseases Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Public Health Department, Hospital Clínic, Barcelona, Spain
| | - Begoña Treviño Maruri
- Tropical Medicine and International Health Unit Vall d'Hebron-Drassanes, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Microbiology Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Infectious Diseases Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Public Health Department, Hospital Clínic, Barcelona, Spain
| | - Antoni Soriano Arandes
- Tropical Medicine and International Health Unit Vall d'Hebron-Drassanes, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Microbiology Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Infectious Diseases Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Public Health Department, Hospital Clínic, Barcelona, Spain
| | - Isabel Claveria Guiu
- Tropical Medicine and International Health Unit Vall d'Hebron-Drassanes, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Microbiology Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Infectious Diseases Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Public Health Department, Hospital Clínic, Barcelona, Spain
| | - Hakima Ouaarab Essadik
- Tropical Medicine and International Health Unit Vall d'Hebron-Drassanes, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Microbiology Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Infectious Diseases Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Public Health Department, Hospital Clínic, Barcelona, Spain
| | - Mateu Espasa Soley
- Tropical Medicine and International Health Unit Vall d'Hebron-Drassanes, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Microbiology Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Infectious Diseases Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Public Health Department, Hospital Clínic, Barcelona, Spain
| | - Israel Molina Romero
- Tropical Medicine and International Health Unit Vall d'Hebron-Drassanes, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Microbiology Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Infectious Diseases Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Public Health Department, Hospital Clínic, Barcelona, Spain
| | - Carlos Ascaso
- Tropical Medicine and International Health Unit Vall d'Hebron-Drassanes, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Microbiology Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Infectious Diseases Department, (PROSICS) Hospital Vall d'Hebron, Institut Català de la Salut, Barcelona, Spain; Public Health Department, Hospital Clínic, Barcelona, Spain
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