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Girishan Prabhu V, Taaffe KM, Pirrallo RG, Shvorin D. A data driven policy to minimise the tuberculosis testing cost among healthcare workers. Int J Health Plann Manage 2022; 37:2697-2709. [PMID: 35527355 PMCID: PMC9541762 DOI: 10.1002/hpm.3496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 03/20/2022] [Accepted: 04/25/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction The Centres for Disease Control and Prevention (CDC) mandates that healthcare employees at high‐risk exposure to Tuberculosis (TB) undergo annual testing. Currently, two methods of TB testing are used: a two‐step skin test (TST) or a whole‐blood test (IGRA). Healthcare leadership's test selection must account for not only direct costs such as procedure and resources but also indirect costs, including employee workplace absence. Methods A mathematical model based on Upstate South Carolina's largest health system affecting over 18,000 employees on six campuses was developed to investigate the value loss perspective of these testing methods and assist in decision‐making. A process flow map identified the varied direct and indirect costs for each test for four employee types, and 6 travel‐to‐testing‐site times were calculated. Results The switching point between testing procedures that minimised total system costs was most influenced by employee salary compared to travel distance. Switching from the current hospital policy to an integrated TST/IGRA testing could reduce TB compliance costs by 28%. Conclusions This study recommends an integrated approach as cost‐effective for large health systems with multiple campuses while considering the direct and indirect costs. When accounting for ‘inconvenience costs’ (stress, etc.) associated with visits, IGRAs are recommended irrespective of employee salary. High‐risk healthcare workers are required to undergo annual TB testing by CDC Two methods of TB testing are used: a two‐step skin test (TST) or a whole‐blood test (IGRA) While considering the testing and other travel costs, an integrated testing approach is cost‐effective for large health systems with multiple employee types and campuses. However, an IGRA test is recommended for all employees when considering additional inconvenience costs.
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Affiliation(s)
| | - Kevin M. Taaffe
- Department of Industrial Engineering Clemson University Clemson South Carolina USA
| | - Ronald G. Pirrallo
- Department of Emergency Medicine PRISMA Health ‐Upstate Greenville South Carolina USA
| | - Dotan Shvorin
- Department of Industrial Engineering Clemson University Clemson South Carolina USA
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Bi C, Clark RB, Master R, Kapoor H, Kroll MH, Salm AE, Meyer WA. Retrospective Performance Analyses of over Two Million U.S. QuantiFERON Blood Sample Results. Microbiol Spectr 2021; 9:e0009621. [PMID: 34319139 PMCID: PMC8552680 DOI: 10.1128/spectrum.00096-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 11/24/2022] Open
Abstract
Both the QuantiFERON-TB Gold Plus (QFT-Plus) and the QuantiFERON-TB Gold In-Tube (QFT-GIT) tests are interferon gamma (IFN-γ) release assays (IGRAs) intended to detect in vitro cell-mediated immune responses to Mycobacterium tuberculosis antigens. In this study, we retrospectively analyzed performance data for both the QFT-GIT and QFT-Plus test systems from over 2 million samples. QFT-Plus and QFT-GIT testing was performed as specified in the respective package inserts at 23 Quest Diagnostics sites. Blood specimens were collected from individuals in all 50 states from November 2018 through December 2019. Retrospective analyses compared the proportion of positive, indeterminate, and conversion/reversion results. The overall proportion of QFT-positive results was 7% for both the QFT-Plus and QFT-GIT. The proportion of positive results was highest for QFT-GIT (7.5%) followed by the heparin 1-tube QFT-Plus (7.2%); a lower proportion of positives was observed with the 4-tube (all four QFT tubes were used in blood collection) QFT-Plus (6.0%). The proportions of indeterminate results for the 1-tube (heparin-only tube collection) and 4-tube QFT-Plus methods were less than 1% and 4%, respectively. This study indicates a higher proportion of positive results for M. tuberculosis than data from other studies. Additionally, the proportion of indeterminate QFT results were markedly lower when the sample was transported in one lithium-heparin tube instead of direct inoculation into 4 QFT-Plus tubes at the site of blood collection. IMPORTANCE In this study, we retrospectively analyzed results from both the QFT-GIT and QFT-Plus test systems from over 2 million blood specimens. The variables analyzed were (i) QFT positivity rates among various U.S. populations, (ii) indeterminate rates among various types of blood draws and how often an indeterminate result was resolved within 30 days after the initial draw, and (iii) the association of TB1 and TB2 antigen tubes with IGRA reversion and conversion events from serial QFT testing. This is, to our knowledge, the largest QFT study representing patients from an extensive geographic coverage across the United States and U.S. territories.
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Affiliation(s)
- Caixia Bi
- Quest Diagnostics, Secaucus, New Jersey, USA
| | | | | | - Hema Kapoor
- Quest Diagnostics, Secaucus, New Jersey, USA
| | | | - Ann E. Salm
- Quest Diagnostics, Secaucus, New Jersey, USA
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Update of the Mexican College of Rheumatology Guidelines for the Pharmacological Treatment of Rheumatoid Arthritis, 2018. ACTA ACUST UNITED AC 2019; 17:215-228. [PMID: 31103432 DOI: 10.1016/j.reuma.2019.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 03/28/2019] [Accepted: 04/04/2019] [Indexed: 02/07/2023]
Abstract
Therapeutic advances in rheumatoid arthritis require periodic review of treatment guidelines. OBJECTIVE To update the Mexican College of Rheumatology guidelines on the pharmacological treatment of rheumatoid arthritis. METHOD Board certified rheumatologists from different health institutions and regions of the country participated. Work teams were formed that reviewed the previous guidelines, elaborated new questions, reviewed the literature, and scored the evidence that was presented and discussed in plenary session. The conclusions were presented to infectologists, gynaecologists and patients. Recommendations were based on levels of evidence according to GRADE methodology. RESULTS Updated recommendations on the use of available medications for rheumatoid arthritis treatment in Mexico up to 2017 are presented. The importance of adequate and sustained control of the disease is emphasized and relevant safety aspects are described. Bioethical conflicts are included, and government action is invited to strengthen correct treatment of the disease. CONCLUSIONS The updated recommendations of the Mexican College of Rheumatology on the pharmacological treatment of rheumatoid arthritis incorporate the best available information to be used in the Mexican health care system.
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Arya S, Kumar SK, Nath A, Kapoor P, Aggarwal A, Misra R, Sinha S. Synergy between tuberculin skin test and proliferative T cell responses to PPD or cell-membrane antigens of Mycobacterium tuberculosis for detection of latent TB infection in a high disease-burden setting. PLoS One 2018; 13:e0204429. [PMID: 30248144 PMCID: PMC6152960 DOI: 10.1371/journal.pone.0204429] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 09/09/2018] [Indexed: 12/02/2022] Open
Abstract
Tuberculin skin test (TST) is used most widely for the detection of latent tuberculosis infection (LTBI), even though evidences suggest that it could be underreporting the prevalence of LTBI particularly in high disease-burden settings. We have explored whether in vivo (TST) and in vitro (cell-proliferative) T cell responses to PPD can serve as complementary measures. In addition, we also probed whether in vitro T cell response to cell-membrane antigens (Mem) of Mycobacterium tuberculosis (MTB) can serve as a biomarker for LTBI. Study subjects comprised 43 healthcare workers (HCWs), and 9 smear-positive TB patients served as ‘disease control’. To measure proliferative T cell responses, 0.1 ml blood (diluted 1:10) was incubated (5 days) with test or control antigen. Cells were stained with fluorescent antibodies to T cell (CD3+/CD4+/CD8+) surface markers and, after fixation and permeabilization, to nuclear proliferation marker Ki67. Data was acquired on a flow cytometer. HCWs who had an intimate exposure to MTB showed significantly higher TST positivity (85%) than the rest (43%), notwithstanding their BCG vaccination status. The proliferative responses of CD4+ and CD8+ subsets of T cells were comparable. Sixty seven and 100% TST-negative HCWs, respectively, were positive for proliferative T cell response to PPD and MTBMem. Cumulative positivity (TST or in vitro) was 86% with PPD and 100% with MTBMem indicating complementarity of the two responses. As standalone in vitro assay, MTBMem provided a significantly higher positivity (95%) than PPD (67%). T cell responses of TB patients were ‘generally’ depressed, having implications for the development of immunological assays for ‘progressive’ LTBI. Altogether, these results demonstrate that in vivo and in vitro T cell responses to PPD are complementary and in vitro response to MTBMem can be developed as a highly sensitive biomarker for LTBI.
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Affiliation(s)
- Suvrat Arya
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Shashi Kant Kumar
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Alok Nath
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Prerna Kapoor
- DOT Centre, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Amita Aggarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ramnath Misra
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sudhir Sinha
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
- * E-mail:
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Mancuso JD, Diffenderfer JM, Ghassemieh BJ, Horne DJ, Kao TC. The Prevalence of Latent Tuberculosis Infection in the United States. Am J Respir Crit Care Med 2017; 194:501-9. [PMID: 26866439 DOI: 10.1164/rccm.201508-1683oc] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Individuals with latent tuberculosis infection (LTBI) represent a reservoir of infection, many of whom will progress to tuberculosis (TB) disease. A central pillar of TB control in the United States is reducing this reservoir through targeted testing and treatment. OBJECTIVES To estimate the prevalence of LTBI in the United States using the tuberculin skin test (TST) and an IFN-γ release assay. METHODS We used nationally representative data from the 2011-2012 National Health and Nutrition Examination Survey (n = 6,083 aged ≥6 yr). LTBI was measured by both the TST and QuantiFERON-TB Gold In-Tube test (QFT-GIT). Weighted population, prevalence, and multiple logistic regression were used. MEASUREMENTS AND MAIN RESULTS The estimated prevalence of LTBI in 2011-2012 was 4.4% as measured by the TST and 4.8% by QFT-GIT, corresponding to 12,398,000 and 13,628,000 individuals, respectively. Prevalence declined slightly since 2000 among the U.S. born but remained constant among the foreign born. Earlier birth cohorts consistently had higher prevalence than more recent ones. Higher risk groups included the foreign born, close contact with a case of TB disease, and certain racial/ethnic groups. CONCLUSIONS After years of decline, the prevalence of LTBI remained relatively constant between 2000 and 2011. A large reservoir of 12.4 million still exists, with foreign-born persons representing an increasingly larger proportion of this reservoir (73%). Estimates and risk factors for LTBI were generally similar between the TST and QFT-GIT. The updated estimates of LTBI and associated risk groups can help improve targeted testing and treatment in the United States.
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Affiliation(s)
- James D Mancuso
- 1 Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jeffrey M Diffenderfer
- 1 Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,2 Division of Preventive Medicine, Walter Reed Army Institute of Research, Silver Spring, Maryland; and
| | - Bijan J Ghassemieh
- 3 Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | - David J Horne
- 3 Division of Pulmonary and Critical Care Medicine, Department of Medicine.,4 Department of Global Health, and.,5 Firland Northwest TB Center, University of Washington, Seattle, Washington
| | - Tzu-Cheg Kao
- 1 Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Evaluation of QuantiFERON-TB Gold-Plus in Health Care Workers in a Low-Incidence Setting. J Clin Microbiol 2017; 55:1650-1657. [PMID: 28298455 DOI: 10.1128/jcm.02498-16] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/10/2017] [Indexed: 02/07/2023] Open
Abstract
Although launched in 2015, little is known about the accuracy of QuantiFERON-TB Gold-Plus (QFT-Plus) for diagnosis of latent M. tuberculosis infection (LTBI). Unlike its predecessor, QFT-Plus utilizes two antigen tubes to elicit an immune response from CD4+ and CD8+ T lymphocytes. We conducted a cross-sectional study in low-risk health care workers (HCWs) at a single U.S. center to compare QFT-Plus to QuantiFERON-TB Gold in-tube (QFT). A total of 989 HCWs were tested with both QFT and QFT-Plus. Risk factors for LTBI were obtained from a questionnaire. QFT-Plus was considered positive if either antigen tube 1 (TB1) or TB2 tested positive, per the manufacturer's recommendations, or if both TB1 and TB2 tested positive, using a conservative definition. Results were compared using Cohen's kappa and linear regression, respectively. Agreement of QFT with QFT-Plus was high, at 95.6% (95% confidence interval [CI], 94.3 to 96.9; kappa, 0.57). The majority of discordant results between QFT and QFT-Plus TB1 (84.8%) and QFT and QFT-Plus TB2 (88.6%) fell within the range of 0.2 to 0.7 IU/ml. The positivity rate in 626 HCWs with no identifiable risk factors and no self-reported history of positive LTBI tests was 2.1% (CI, 1.0 to 3.2) and 3.0% (CI, 1.7 to 4.3) with QFT and QFT-Plus, respectively. A conservative definition of a QFT-Plus-positive result yielded a positivity rate of 1.0% (CI, 0.2 to 1.7; P value of 0.0002 versus QFT-Plus and 0.07 versus QFT). On follow-up testing, of 11 HCWs with discordant QFT-Plus results, 90.9% (10/11) had a negative QFT result. The QFT-Plus assay showed a high degree of agreement with QFT in U.S. HCWs. A conservative interpretation of QFT-Plus eliminated nearly all nonreproducible positive results in low-risk HCWs. Larger studies are needed to validate the latter finding and to more clearly define conditions under which a conservative interpretation can be used to minimize nonreproducible positive results in low-risk populations.
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Chiappini E, Lo Vecchio A, Garazzino S, Marseglia GL, Bernardi F, Castagnola E, Tomà P, Cirillo D, Russo C, Gabiano C, Ciofi D, Losurdo G, Bocchino M, Tortoli E, Tadolini M, Villani A, Guarino A, Esposito S. Recommendations for the diagnosis of pediatric tuberculosis. Eur J Clin Microbiol Infect Dis 2016; 35:1-18. [PMID: 26476550 DOI: 10.1007/s10096-015-2507-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 10/07/2015] [Indexed: 01/10/2023]
Abstract
Tuberculosis (TB) is still the world's second most frequent cause of death due to infectious diseases after HIV infection, and this has aroused greater interest in identifying and managing exposed subjects, whether they are simply infected or have developed one of the clinical variants of the disease. Unfortunately, not even the latest laboratory techniques are always successful in identifying affected children because they are more likely to have negative cultures and tuberculin skin test results, equivocal chest X-ray findings, and atypical clinical manifestations than adults. Furthermore, they are at greater risk of progressing from infection to active disease, particularly if they are very young. Consequently, pediatricians have to use different diagnostic strategies that specifically address the needs of children. This document describes the recommendations of a group of scientific societies concerning the signs and symptoms suggesting pediatric TB, and the diagnostic approach towards children with suspected disease.
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Pediatric Latent Tuberculosis: Should Travel and Foreign Birth Testing Criteria Be Reassessed? Pediatr Infect Dis J 2016; 35:977-8. [PMID: 27182897 DOI: 10.1097/inf.0000000000001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Simkins J, Kraus K, Morris MI. Demographics and prevalence of positive QuantiFERON-TB Gold In-Tube test in renal transplant candidates. Transpl Infect Dis 2016; 18:5-13. [PMID: 26534762 DOI: 10.1111/tid.12476] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 08/25/2015] [Accepted: 09/12/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Latent tuberculosis infection (LTBI) screening prior to solid organ transplantation is standard of care. QuantiFERON-TB Gold In-Tube (QFT-GIT) test is the preferred diagnostic test for renal transplant candidates (RTC). QFT-GIT reversions and the potential delay of living-donor kidney transplantation (LDKT) because of QFT-GIT positivity have not been examined previously in RTC. METHODS We evaluated the prevalence of positive QFT-GIT in RTC from January 1 through December 31, 2011. In addition, we examined the demographic and renal disease data differences between QFT-GIT-positive and -negative patients, changes in QFT-GIT results, and positive QFT-GIT results reverting to negative. Lastly, we evaluated if QFT-GIT-positive patients were less likely to undergo LDKT within 6 months of QFT-GIT testing. RESULTS In total, 722 RTC were analyzed, 16% of whom had positive QFT-GIT. The QFT-GIT-positive patients were more likely to be older and foreign-born, P < 0.0001. Haitians had the highest prevalence. Of the 119 QFT-GIT-positive patients, 25% had low/intermediate-positive results and were more likely to revert to negative, compared with patients with high-positive QFT-GIT results (50% vs. 0%, P = 0.01). A trend was seen toward fewer QFT-GIT-positive patients undergoing LDKT, compared with QFT-GIT-negative patients (0% vs. 3%, P = 0.09). CONCLUSIONS Our high prevalence was likely a result of the high number of foreign-born RTC. Half of our small subset of low/intermediate-positive QFT-GIT patients reverted to negative. QFT-GIT-positive patients were more likely to have their LDKT delayed.
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Affiliation(s)
- J Simkins
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - K Kraus
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - M I Morris
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
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Islam S. Interferon-γ-Release-Assay Results in Asymptomatic Children--Further Evidence That Testing for Tuberculosis Should Be More Selective. J Pediatric Infect Dis Soc 2015; 4:393-4. [PMID: 26407284 DOI: 10.1093/jpids/piv054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Shamim Islam
- Division of Infectious Diseases, Department of Pediatrics, University at Buffalo, SUNY, Buffalo, New York
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Lee SSJ, Lin HH, Tsai HC, Su IJ, Yang CH, Sun HY, Hung CC, Sy CL, Wu KS, Chen JK, Chen YS, Fang CT. A Clinical Algorithm to Identify HIV Patients at High Risk for Incident Active Tuberculosis: A Prospective 5-Year Cohort Study. PLoS One 2015; 10:e0135801. [PMID: 26280669 PMCID: PMC4539234 DOI: 10.1371/journal.pone.0135801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 07/27/2015] [Indexed: 02/07/2023] Open
Abstract
Background Predicting the risk of tuberculosis (TB) in people living with HIV (PLHIV) using a single test is currently not possible. We aimed to develop and validate a clinical algorithm, using baseline CD4 cell counts, HIV viral load (pVL), and interferon-gamma release assay (IGRA), to identify PLHIV who are at high risk for incident active TB in low-to-moderate TB burden settings where highly active antiretroviral therapy (HAART) is routinely provided. Materials and Methods A prospective, 5-year, cohort study of adult PLHIV was conducted from 2006 to 2012 in two hospitals in Taiwan. HAART was initiated based on contemporary guidelines (CD4 count < = 350/μL). Cox regression was used to identify the predictors of active TB and to construct the algorithm. The validation cohorts included 1455 HIV-infected individuals from previous published studies. Area under the receiver operating characteristic (ROC) curve was calculated. Results Seventeen of 772 participants developed active TB during a median follow-up period of 5.21 years. Baseline CD4 < 350/μL or pVL ≥ 100,000/mL was a predictor of active TB (adjusted HR 4.87, 95% CI 1.49–15.90, P = 0.009). A positive baseline IGRA predicted TB in patients with baseline CD4 ≥ 350/μL and pVL < 100,000/mL (adjusted HR 6.09, 95% CI 1.52–24.40, P = 0.01). Compared with an IGRA-alone strategy, the algorithm improved the sensitivity from 37.5% to 76.5%, the negative predictive value from 98.5% to 99.2%. Compared with an untargeted strategy, the algorithm spared 468 (60.6%) from unnecessary TB preventive treatment. Area under the ROC curve was 0.692 (95% CI: 0.587–0.798) for the study cohort and 0.792 (95% CI: 0.776–0.808) and 0.766 in the 2 validation cohorts. Conclusions A validated algorithm incorporating the baseline CD4 cell count, HIV viral load, and IGRA status can be used to guide targeted TB preventive treatment in PLHIV in low-to-moderate TB burden settings where HAART is routinely provided to all PLHIV. The implementation of this algorithm will avoid unnecessary exposure of low-risk patients to drug toxicity and simultaneously, reduce the burden of universal treatment on the healthcare system.
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Affiliation(s)
- Susan Shin-Jung Lee
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Section of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hsi-Hsun Lin
- Department of Infection Control and Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hung-Chin Tsai
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Section of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ih-Jen Su
- National Health Research Institute, Zhu-nan, Taiwan
| | - Chin-Hui Yang
- Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hsin-Yun Sun
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Chin Hung
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cheng-Len Sy
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Section of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kuan-Sheng Wu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Section of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Jui-Kuang Chen
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Section of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yao-Shen Chen
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Section of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chi-Tai Fang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
- * E-mail:
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Affiliation(s)
- Diala Faddoul
- Descanso Pediatrics, Huntington Medical Foundation, 1346 Foothill Boulevard Suite 201, La Canada, CA 91011, USA.
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Abstract
RATIONALE Interferon gamma (IFN-γ) release assays for latent tuberculosis infection result in a larger-than-expected number of conversions and reversions in occupational screening programs, and reproducibility of test results is a concern. OBJECTIVES Knowledge of the relative contribution and extent of the individual sources of variability (immunological, preanalytical, or analytical) could help optimize testing protocols. METHODS We performed a systematic review of studies published by October 2013 on all potential sources of variability of commercial IFN-γ release assays (QuantiFERON-TB Gold In-Tube and T-SPOT.TB). The included studies assessed test variability under identical conditions and under different conditions (the latter both overall and stratified by individual sources of variability). Linear mixed effects models were used to estimate within-subject SD. MEASUREMENTS AND MAIN RESULTS We identified a total of 26 articles, including 7 studies analyzing variability under the same conditions, 10 studies analyzing variability with repeat testing over time under different conditions, and 19 studies reporting individual sources of variability. Most data were on QuantiFERON (only three studies on T-SPOT.TB). A considerable number of conversions and reversions were seen around the manufacturer-recommended cut-point. The estimated range of variability of IFN-γ response in QuantiFERON under identical conditions was ±0.47 IU/ml (coefficient of variation, 13%) and ±0.26 IU/ml (30%) for individuals with an initial IFN-γ response in the borderline range (0.25-0.80 IU/ml). The estimated range of variability in noncontrolled settings was substantially larger (±1.4 IU/ml; 60%). Blood volume inoculated into QuantiFERON tubes and preanalytic delay were identified as key sources of variability. CONCLUSIONS This systematic review shows substantial variability with repeat IFN-γ release assays testing even under identical conditions, suggesting that reversions and conversions around the existing cut-point should be interpreted with caution.
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Islam S, Grinsdale J, Bristow L, Higashi J. Tuberculin Skin Test and QuantiFERON Performance, and Testing of Populations at Low Risk for Tuberculosis Infection. Clin Infect Dis 2014; 59:1187-8. [DOI: 10.1093/cid/ciu518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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McMullen SE, Pegues DA, Shofer FS, Sheller AC. Reply to Islam et al and Mendy et al. Clin Infect Dis 2014; 59:1189-90. [DOI: 10.1093/cid/ciu519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Mendy A, Albatineh AN, Vieira ER, Gasana J. Higher specificity of tuberculin skin test compared with QuantiFERON-TB Gold for detection of exposure to Mycobacterium tuberculosis. Clin Infect Dis 2014; 59:1188-9. [PMID: 24997053 DOI: 10.1093/cid/ciu516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Angelico Mendy
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City
| | | | | | - Janvier Gasana
- Department of Occupational and Environmental Health, Florida International University, Miami
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Stennis NL, Trieu L, Ahuja SD, Harris TG. Estimated Prevalence of Tuberculosis Infection Among a New York City Clinic Population Using Interferon-gamma Release Assays. Open Forum Infect Dis 2014; 1:ofu047. [PMID: 25734119 PMCID: PMC4281800 DOI: 10.1093/ofid/ofu047] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 06/10/2014] [Indexed: 11/25/2022] Open
Abstract
Using QuantiFERON®-Gold In-Tube (QFT-GIT) data, the prevalence of tuberculosis infection in New York City was estimated. Patient characteristics associated with a positive result were consistent with known tuberculosis risk factors. Results suggest that blood-based tests for tuberculosis infection are reliable. Background Elimination of tuberculosis (TB) in the United States requires treating not only persons with active disease but also those infected with TB. Achieving this goal requires understanding local TB infection prevalence and identifying subgroups at increased risk for infection and disease. Methods The study population included all patients tested with an interferon-gamma release assay (IGRA) test at New York City (NYC) public TB clinics from October 1, 2006 to December 31, 2011. Patients who were not a case or contact at testing (general clinic patients) and who had a positive QuantiFERON-Gold In-Tube (QFT-GIT) test result were compared with those with indeterminate or negative results to identify characteristics associated with positive results. New York City TB surveillance data were used to identify clinic patients later diagnosed with active TB disease. Results A total of 69 273 IGRA tests were conducted. Among 20 066 patients tested with QFT-GIT, 16% tested positive, 83% tested negative, and <1% were indeterminate. Of 18 481 general clinic patients, 14% had a positive QFT-GIT result. Nine percent of United States-born patients compared with 19% of foreign-born patients had a positive result. Increasing age and birth in a high-incidence country were associated with a higher likelihood of having a positive result. One patient with a negative QFT-GIT result was identified as a TB case 2 years later. Conclusions Using QFT-GIT data, the background prevalence of TB infection in NYC was estimated. Patient characteristics associated with a positive QFT-GIT result were consistent with known TB risk factors. Results suggest that IGRAs are reliable tests for TB infection.
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Affiliation(s)
- Natalie L Stennis
- New York City Department of Health and Mental Hygiene, Long Island City, New York
| | - Lisa Trieu
- New York City Department of Health and Mental Hygiene, Long Island City, New York
| | - Shama D Ahuja
- New York City Department of Health and Mental Hygiene, Long Island City, New York
| | - Tiffany G Harris
- New York City Department of Health and Mental Hygiene, Long Island City, New York
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