1
|
Turner NA, Ahmed A, Haley CA, Starke JR, Stout JE. Use of Interferon-Gamma Release Assays in Children <2 Years Old. J Pediatric Infect Dis Soc 2023; 12:481-485. [PMID: 37478309 DOI: 10.1093/jpids/piad053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/20/2023] [Indexed: 07/23/2023]
Abstract
While interferon-gamma release assays (IGRAs) are widely used for detecting tuberculosis (TB) infection, tuberculin skin tests (TSTs) remain preferred for children under the age of 2 years. The preference for TST stems from concern over IGRA sensitivity in young children. However, TSTs are susceptible to false-positive results following Bacille Calmette-Guérin (BCG) vaccination, which is common in infancy, and exposure to nontuberculous mycobacteria. We reviewed available data for IGRA performance in children under age 2 years. Across four cohorts of high-risk children under age 2 (mostly case contacts or those born in tuberculosis endemic regions), 0 of 575 untreated children with negative IGRA test results progressed to tuberculosis disease-including 0 of 70 who were TST positive but IGRA negative. While neither TSTs nor IGRAs are perfectly sensitive for the diagnosis of tuberculosis infection, IGRAs are an acceptable alternative to TST in children <2 years of age.
Collapse
Affiliation(s)
- Nicholas A Turner
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amina Ahmed
- Pediatric Infectious Disease and Immunology, Levine Children's Hospital, Charlotte, North Carolina, USA
| | - Connie A Haley
- Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jeffrey R Starke
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Jason E Stout
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
2
|
Tabatneck ME, He W, Lamb GS, Sun M, Goldmann D, Sabharwal V, Sandora TJ, Haberer JE, Campbell JI. Interferon Gamma Release Assay Results and Testing Trends Among Patients Younger Than 2 Years Old at Two US Health Centers. Pediatr Infect Dis J 2023; 42:189-194. [PMID: 36729979 PMCID: PMC10368003 DOI: 10.1097/inf.0000000000003794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Interferon-gamma release assays (IGRAs) are approved for children ≥2 years old to aid in diagnosis of Mycobacterium tuberculosis (TB) infection and disease. Tuberculin skin tests (TSTs) continue to be the recommended method for diagnosis of TB infection in children <2 years, in part due to limited data and concern for high rates of uninterpretable results. METHODS We performed a retrospective cohort study of IGRA use in patients <2 years old in 2 large Boston healthcare systems. The primary outcome was the proportion of valid versus invalid/indeterminate IGRA results. Secondary outcomes included concordance of IGRAs with paired TSTs and trends in IGRA usage over time. RESULTS A total of 321 IGRA results were analyzed; 308 tests (96%) were valid and 13 (4%) were invalid/indeterminate. Thirty-seven IGRAs were obtained in immunocompromised patients; the proportion of invalid/indeterminate results was significantly higher among immunocompromised (27%) compared with immunocompetent (1%) patients ( P < 0.001). Paired IGRAs and TSTs had a concordance rate of 64%, with most discordant results in bacille Calmette-Guérin-vaccinated patients. The proportion of total TB tests that were IGRAs increased over the study period (Pearson correlation coefficient 0.85, P < 0.001). CONCLUSIONS The high proportion of valid IGRA test results in patients <2 years of age in a low TB prevalence setting in combination with the known logistical and interpretation challenges associated with TSTs support the adoption of IGRAs for this age group in certain clinical scenarios. Interpretation of IGRAs, particularly in immunocompromised patients, should involve consideration of the broader clinical context.
Collapse
Affiliation(s)
- Mary E Tabatneck
- From the Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Wei He
- Center for Research Information Science and Computing, Massachusetts General Hospital, Boston, Massachusetts
| | - Gabriella S Lamb
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Mingwei Sun
- Center for Research Information Technology, Boston Children's Hospital, Boston, Massachusetts
| | - Don Goldmann
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Vishakha Sabharwal
- Division of Pediatric Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Thomas J Sandora
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeffrey I Campbell
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
- Division of Pediatric Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| |
Collapse
|
3
|
Calzada-Hernández J, Anton J, Martín de Carpi J, López-Montesinos B, Calvo I, Donat E, Núñez E, Blasco Alonso J, Mellado MJ, Baquero-Artigao F, Leis R, Vegas-Álvarez AM, Medrano San Ildefonso M, Pinedo-Gago MDC, Eizaguirre FJ, Tagarro A, Camacho-Lovillo M, Pérez-Gorricho B, Gavilán-Martín C, Guillén S, Sevilla-Pérez B, Peña-Quintana L, Mesa-Del-Castillo P, Fortuny C, Tebruegge M, Noguera-Julian A. Dual latent tuberculosis screening with tuberculin skin tests and QuantiFERON-TB assays before TNF-α inhibitor initiation in children in Spain. Eur J Pediatr 2023; 182:307-317. [PMID: 36335186 PMCID: PMC9829583 DOI: 10.1007/s00431-022-04640-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 09/20/2022] [Accepted: 09/26/2022] [Indexed: 11/07/2022]
Abstract
UNLABELLED Tumor-necrosis-factor-α inhibitors (anti-TNF-α) are associated with an increased risk of tuberculosis (TB) disease, primarily due to reactivation of latent TB infection (LTBI). We assessed the performance of parallel LTBI screening with tuberculin skin test (TST) and QuantiFERON-TB Gold In-Tube assays (QFT-GIT) before anti-TNF-α treatment in children with immune-mediated inflammatory disorders in a low TB-burden setting. We conducted a multicenter cohort study involving 17 pediatric tertiary centers in Spain. LTBI was defined as the presence of a positive TST and/or QFT-GIT result without clinical or radiological signs of TB disease. A total of 270 patients (median age:11.0 years) were included, mainly with rheumatological (55.9%) or inflammatory bowel disease (34.8%). Twelve patients (4.4%) were diagnosed with TB infection at screening (LTBI, n = 11; TB disease, n = 1). Concordance between TST and QFT-GIT results was moderate (TST+/QFT-GIT+, n = 4; TST-/QFT-GIT+, n = 3; TST+/QFT-GIT-, n = 5; kappa coefficient: 0.48, 95% CI: 0.36-0.60). Indeterminate QFT-GIT results occurred in 10 patients (3.7%) and were associated with young age and elevated C-reactive protein concentrations. Eleven of 12 patients with TB infection uneventfully completed standard LTBI or TB treatment. During a median follow-up period of 6.4 years, only 2 patients developed TB disease (incidence density: 130 (95% CI: 20-440) per 100,000 person-years), both probable de novo infections. CONCLUSION A substantial number of patients were diagnosed with LTBI during screening. The dual strategy identified more cases than either of the tests alone, and test agreement was only moderate. Our data show that in children in a low TB prevalence setting, a dual screening strategy with TST and IGRA before anti-TNF-α treatment is effective. WHAT IS KNOWN • The optimal screening strategy for latent tuberculosis in children with immune-mediated inflammatory disorders remains uncertain. • Children receiving anti-TNF-α drugs are at increased risk of developing severe tuberculosis disease. WHAT IS NEW • A dual screening strategy, using TST and an IGRA assay, identified more children with latent tuberculosis than either of the tests alone. • Identification and treatment of latent tuberculosis before initiation of anti-TNF-α therapy averted incident tuberculosis cases.
Collapse
Affiliation(s)
- Joan Calzada-Hernández
- grid.411160.30000 0001 0663 8628Pediatric Rheumatology Division, Hospital Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Jordi Anton
- grid.411160.30000 0001 0663 8628Pediatric Rheumatology Division, Hospital Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Barcelona, Spain ,grid.5841.80000 0004 1937 0247Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Javier Martín de Carpi
- grid.5841.80000 0004 1937 0247Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain ,grid.411160.30000 0001 0663 8628Servei de Gastroenterologia, Hepatologia I Nutrició Pediàtrica, Hospital Sant Joan de Déu - Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Berta López-Montesinos
- grid.84393.350000 0001 0360 9602Rheumatology Unit, Pediatrics Department, University Hospital La Fe, Valencia, Spain
| | - Inmaculada Calvo
- grid.84393.350000 0001 0360 9602Rheumatology Unit, Pediatrics Department, University Hospital La Fe, Valencia, Spain
| | - Ester Donat
- grid.84393.350000 0001 0360 9602Pediatric Gastroenterology and Hepatology Unit, Pediatrics Department, University Hospital La Fe, Valencia, Spain
| | - Esmeralda Núñez
- grid.411457.2UGC de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Javier Blasco Alonso
- grid.411457.2UGC de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - María José Mellado
- Servicio de Pediatria, Enfermedades Infecciosas Y Patología Tropical, Hospital La Paz, Madrid, Spain ,Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,grid.512890.7Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Fernando Baquero-Artigao
- Servicio de Pediatria, Enfermedades Infecciosas Y Patología Tropical, Hospital La Paz, Madrid, Spain ,Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,grid.512890.7Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Rosaura Leis
- grid.411048.80000 0000 8816 6945Unit of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatrics Department, University Clinical Hospital of Santiago (CHUS), Santiago de Compostela, Spain
| | - Ana María Vegas-Álvarez
- grid.411280.e0000 0001 1842 3755Gastroenterología Infantil, Hospital Universitario Río Hortega de Valladolid, Valladolid, Spain
| | - Marta Medrano San Ildefonso
- grid.411106.30000 0000 9854 2756Reumatología Pediátrica, Hospital Universitario Miguel Servet, Saragossa, Spain
| | | | - Francisco Javier Eizaguirre
- grid.414651.30000 0000 9920 5292Unidad de Gastroenterología Infantil, Hospital Universitario Donostia, San Sebastián, Spain
| | - Alfredo Tagarro
- Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,grid.119375.80000000121738416Paediatrics Department, Hospital Universitario Infanta Sofía; Paediatrics Research Group, Universidad Europea de Madrid, Madrid, Spain ,grid.144756.50000 0001 1945 5329Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain
| | - Marisol Camacho-Lovillo
- grid.411109.c0000 0000 9542 1158Servicio de Inmunología, Reumatología e Infectología Pediátrica, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Beatriz Pérez-Gorricho
- grid.411107.20000 0004 1767 5442Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - César Gavilán-Martín
- grid.411263.3Servicio de Pediatría, Hospital Universitario San Juan de Alicante, Alicante, Spain
| | - Sara Guillén
- grid.512890.7Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain ,grid.411244.60000 0000 9691 6072Department of Pediatrics, Hospital Universitario de Getafe, Madrid, Spain
| | - Belén Sevilla-Pérez
- grid.459499.cUnidad de Reumatología, Servicio de Pediatría del Hospital Universitario San Cecilio de Granada, Granada, Spain
| | - Luis Peña-Quintana
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Mother and Child Insular University Hospital,, Las Palmas, Spain ,grid.512890.7Centro de Investigación Biomédica en Red de Obesidad Y Nutrición (CIBEROBN), Madrid, Spain ,grid.4521.20000 0004 1769 9380University Institute for Research in Biomedical and Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Pablo Mesa-Del-Castillo
- grid.411372.20000 0001 0534 3000Department of Rheumatology, Hospital Clínico Universitario Virgen de La Arrixaca, Murcia, Spain
| | - Clàudia Fortuny
- grid.5841.80000 0004 1937 0247Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain ,Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,grid.411160.30000 0001 0663 8628Malalties Infeccioses I Resposta Inflamatòria Sistèmica en Pediatria, Unitat d’Infeccions, Servei de Pediatria, Institut de Recerca Sant Joan de Déu, Barcelona, Spain ,grid.466571.70000 0004 1756 6246Centro de Investigación Biomédica en Red de Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain
| | - Marc Tebruegge
- grid.83440.3b0000000121901201Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, UK ,grid.1008.90000 0001 2179 088XDepartment of Paediatrics, University of Melbourne, Parkville, VIC Australia ,Department of Paediatrics, Klinik Ottakring, Wiener Gesundheitsverbund, Vienna, Austria
| | - Antoni Noguera-Julian
- Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain. .,Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain. .,Malalties Infeccioses I Resposta Inflamatòria Sistèmica en Pediatria, Unitat d'Infeccions, Servei de Pediatria, Institut de Recerca Sant Joan de Déu, Barcelona, Spain. .,Centro de Investigación Biomédica en Red de Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain.
| |
Collapse
|
4
|
Abstract
Tuberculosis (TB) remains an important problem among children in the United States and throughout the world. There is no diagnostic reference standard for latent tuberculosis infection (also referred to as tuberculosis infection [TBI]). The tuberculin skin test (TST) has many limitations, including difficulty in administration and interpretation, the need for a return visit by the patient, and false-positive results caused by cross-reaction with Mycobacterium bovis-bacille Calmette-Guerin vaccines and many nontuberculous mycobacteria. Interferon-gamma release assays (IGRAs) are blood tests that use antigens specific for M tuberculosis; as a result, IGRAs yield fewer false-positive results than the TST. Both IGRAs and the TST have reduced sensitivity in immunocompromised children, including children with severe TB disease. Both methods have high positive predictive value when applied to children with risk factors for TBI, especially recent contact with a person who has TB disease. The advantages of using IGRAs and diminished experience with the placement and interpretation of the TST favor expanded use of IGRAs in children in the United States. There are now several effective and safe regimens for the treatment of TBI in children. For improved adherence to therapy, the 3 rifamycin-based regimens are preferred because of their short duration. Daily isoniazid can be used if there is intolerance or drug interactions with rifamycins. A TB specialist should be involved when there are questions regarding testing interpretation, selection of an appropriate treatment regimen, or management of adverse effects.
Collapse
Affiliation(s)
- Dawn Nolt
- Department of Pediatrics, Division of Infectious Diseases, Oregon Health and Science University, Portland, Oregon
| | - Jeffrey R Starke
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
5
|
Kerani RP, Shapiro AE, Strick LB. A Pilot TB Screening Model in a U.S. Prison Population Using Tuberculin Skin Test and Interferon Gamma Release Assay Based on Country of Origin. JOURNAL OF CORRECTIONAL HEALTH CARE 2021; 27:259-264. [PMID: 34652245 DOI: 10.1089/jchc.19.07.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The objective of this study was to compare tuberculosis (TB) screening results before and after implementation of a stratified testing strategy screening pilot study, incorporating interferon gamma release assay (IGRA) and tuberculin skin test (TST), based on country of origin. In 2015, the Washington State Department of Corrections began screening people born outside of the United States for TB with IGRA, while U.S.-born people continued screening by TST. Of 405 (75%) foreign-born men screened with IGRA, 403 had valid test results and IGRA screening positivity was 10.4% (N = 42). In contrast, among 5,940 primarily U.S-born men screened with TST, 24 (0.4%) were positive. Overall positivity was 1.05%, similar to TST-only positivity in 2013 (1.05%) and 2014 (0.85%). Incorporating IGRA screening among foreign-born persons was feasible in this state prison system.
Collapse
Affiliation(s)
- Roxanne P Kerani
- Department of Medicine, University of Washington, Seattle, Washington, USA.,HIV/STD Program, Public Health-Seattle and King County, Seattle, Washington, USA
| | - Adrienne E Shapiro
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Lara B Strick
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Washington State Department of Corrections, Tumwater, Washington, USA
| |
Collapse
|
6
|
Dale KD, Karmakar M, Snow KJ, Menzies D, Trauer JM, Denholm JT. Quantifying the rates of late reactivation tuberculosis: a systematic review. THE LANCET. INFECTIOUS DISEASES 2021; 21:e303-e317. [PMID: 33891908 DOI: 10.1016/s1473-3099(20)30728-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/12/2020] [Accepted: 08/29/2020] [Indexed: 11/17/2022]
Abstract
The risk of tuberculosis is greatest soon after infection, but Mycobacterium tuberculosis can remain in the body latently, and individuals can develop disease in the future, sometimes years later. However, there is uncertainty about how often reactivation of latent tuberculosis infection (LTBI) occurs. We searched eight databases (inception to June 25, 2019) to identify studies that quantified tuberculosis reactivation rates occurring more than 2 years after infection (late reactivation), with a focus on identifying untreated study cohorts with defined timing of LTBI acquisition (PROSPERO registered: CRD42017070594). We included 110 studies, divided into four methodological groups. Group 1 included studies that documented late reactivation rates from conversion (n=14) and group 2 documented late reactivation rates in LTBI cohorts from exposure (n=11). Group 3 included 86 studies in LTBI cohorts with an unknown exposure history, and group 4 included seven ecological studies. Since antibiotics have been used to treat tuberculosis, only 11 studies have documented late reactivation rates in infected, untreated cohorts from either conversion (group 1) or exposure (group 2); six of these studies lasted at least 4 years and none lasted longer than 10 years. These studies found that tuberculosis rates declined over time, reaching approximately 200 cases per 100 000 person-years or less by the fifth year, and possibly declining further after 5 years but interpretation was limited by decreasing or unspecified cohort sizes. In cohorts with latent tuberculosis and an unknown exposure history (group 3), tuberculosis rates were generally lower than those seen in groups 1 and 2, and beyond 10 years after screening, rates had declined to less than 100 per 100 000 person-years. Reinfection risks limit interpretation in all studies and the effect of age is unclear. Late reactivation rates are commonly estimated or modelled to prioritise tuberculosis control strategies towards tubuculosis elimination, but significant gaps remain in our understanding that must be acknowledged; the relative importance of late reactivation versus early progression to the global burden of tuberculosis remains unknown.
Collapse
Affiliation(s)
- Katie D Dale
- Victorian Tuberculosis Program, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia; Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia.
| | - Malancha Karmakar
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia; Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Kathryn J Snow
- Centre for International Child Health, Department of Paediatrics, Royal Children's Hospital, University of Melbourne, Parkville, VIC, Australia; Australia Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Dick Menzies
- Respiratory Epidemiology and Clinical Research Unit, McGill International TB Centre, Montreal, QC, Canada
| | - James M Trauer
- Victorian Tuberculosis Program, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Justin T Denholm
- Victorian Tuberculosis Program, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia; Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
7
|
Tornheim JA, Madugundu AK, Paradkar M, Fukutani KF, Queiroz ATL, Gupte N, Gupte AN, Kinikar A, Kulkarni V, Balasubramanian U, Sreenivasamurthy S, Raja R, Pradhan N, Shivakumar SVBY, Valvi C, Hanna LE, Andrade BB, Mave V, Pandey A, Gupta A. Transcriptomic Profiles of Confirmed Pediatric Tuberculosis Patients and Household Contacts Identifies Active Tuberculosis, Infection, and Treatment Response Among Indian Children. J Infect Dis 2021; 221:1647-1658. [PMID: 31796955 DOI: 10.1093/infdis/jiz639] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/03/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Gene expression profiling is emerging as a tool for tuberculosis diagnosis and treatment response monitoring, but limited data specific to Indian children and incident tuberculosis infection (TBI) exist. METHODS Sixteen pediatric Indian tuberculosis cases were age- and sex-matched to 32 tuberculosis-exposed controls (13 developed incident TBI without subsequent active tuberculosis). Longitudinal samples were collected for ribonucleic acid sequencing. Differential expression analysis generated gene lists that identify tuberculosis diagnosis and tuberculosis treatment response. Data were compared with published gene lists. Population-specific risk score thresholds were calculated. RESULTS Seventy-one genes identified tuberculosis diagnosis and 25 treatment response. Within-group expression was partially explained by age, sex, and incident TBI. Transient changes in gene expression were identified after both infection and treatment. Application of 27 published gene lists to our data found variable performance for tuberculosis diagnosis (sensitivity 0.38-1.00, specificity 0.48-0.93) and treatment response (sensitivity 0.70-0.80, specificity 0.40-0.80). Our gene lists found similarly variable performance when applied to published datasets for diagnosis (sensitivity 0.56-0.85, specificity 0.50-0.85) and treatment response (sensitivity 0.49- 0.86, specificity 0.50-0.84). CONCLUSIONS Gene expression profiles among Indian children with confirmed tuberculosis were distinct from adult-derived gene lists, highlighting the importance of including distinct populations in differential gene expression models.
Collapse
Affiliation(s)
- Jeffrey A Tornheim
- Center for Clinical Global Health Education, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anil K Madugundu
- Institute of Bioinformatics, Bangalore, Karnataka, India.,Center for Molecular Medicine, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India.,Department of Laboratory Medicine and Pathology and Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mandar Paradkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Kiyoshi F Fukutani
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Faculdade de Tecnologia e Ciências (FTC), Salvador, Brazil
| | - Artur T L Queiroz
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
| | - Nikhil Gupte
- Center for Clinical Global Health Education, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Akshay N Gupte
- Center for Clinical Global Health Education, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Usha Balasubramanian
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Sreelakshmi Sreenivasamurthy
- Institute of Bioinformatics, Bangalore, Karnataka, India.,Center for Molecular Medicine, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Remya Raja
- Institute of Bioinformatics, Bangalore, Karnataka, India.,Center for Molecular Medicine, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India
| | - Neeta Pradhan
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | | | - Chhaya Valvi
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | | | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Faculdade de Tecnologia e Ciências (FTC), Salvador, Brazil.,Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Brazil.,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil
| | - Vidya Mave
- Center for Clinical Global Health Education, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Akhilesh Pandey
- Institute of Bioinformatics, Bangalore, Karnataka, India.,Center for Molecular Medicine, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Department of Laboratory Medicine and Pathology and Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, USA.,McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amita Gupta
- Center for Clinical Global Health Education, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | |
Collapse
|
8
|
Wendorf KA, Lowenthal P, Feraud J, Cabanting N, Murto C. Interferon-γ Release Assays for Tuberculosis Infection Diagnosis in Refugees <5 Years Old. Pediatrics 2020; 146:peds.2020-0715. [PMID: 32994177 DOI: 10.1542/peds.2020-0715] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND New guidelines support using interferon-γ release assays (IGRAs) in children ≥2 years for diagnosis of latent tuberculosis infection (LTBI). However, lack of experience in young children and concern that IGRAs are less sensitive than tuberculin skin tests (TSTs) limit their use. Our aim was to identify active tuberculosis (TB) cases among high risk children <5 years and tested for LTBI with an IGRA. METHODS . Retrospective review of domestic TB screening data from California's Refugee Health Electronic Information System for children <5 years old who resettled in California between October, 2013 and December, 2016. Children were crossmatched with the California TB registry to identify cases of TB disease between October 2013 and December 2018. RESULTS A total of 3371 children <5 years were identified; the majority were born in countries with high TB incidence (>150 cases per 100 000). Half received IGRAs (n = 1878; 56%), a quarter received TSTs (n = 811; 24%); 1.4% of children were IGRA-positive (n = 26) and 13% were TST-positive (n = 106). Twenty-two IGRA results were indeterminate (1.2%). Sixteen children had both tests; 9 were discrepant (positive TST with negative IGRA). No cases of TB disease were identified during 10 797 person-years of follow-up. CONCLUSIONS IGRA positivity was less than TST positivity in high risk children <5 years old. Despite fewer LTBI diagnoses in the IGRA-tested population, no cases of TB disease among children who tested negative were identified, suggesting IGRA is valuable tool for identifying LTBI in this population.
Collapse
Affiliation(s)
| | | | | | - Nuny Cabanting
- Office of Refugee Health, California Department of Public Health, Sacramento, California
| | - Christine Murto
- Office of Refugee Health, California Department of Public Health, Sacramento, California
| |
Collapse
|
9
|
Interferon-Gamma Release Assay Testing in Children Younger Than 2 Years in a US-Based Health System. Pediatr Infect Dis J 2020; 39:803-807. [PMID: 32804462 DOI: 10.1097/inf.0000000000002711] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Use of interferon-gamma releasing assays (IGRAs) in children <2 years old may derive many of the same advantages, which have led to preference over tuberculin skin test (TST) in older children, but data are limited. Since 2011, we have tested children <2 years old with Quantiferon-TB Gold/Gold Plus (QFT)) in select clinical scenarios at Denver Health, a health system encompassing a TB clinic, refugee and immigrant screening and primary care. METHODS We identified patients <2 years old tested with QFT between February, 2011 and August, 2019. The primary outcome measure was incident cases of TB among tested patients. Test results and in vitro characteristics were analyzed, as were demographic, epidemiologic and clinical outcomes. RESULTS We analyzed 116 QFTs ordered in children age 7-23 months. Two were positive, 3 indeterminate, 3 failed/refused phlebotomy and the remainder (93%) were negative. Mitogen tube results were robust. Thirteen patients were TST-positive: 11 were QFT-negative, 1 QFT-positive and 1 failed phlebotomy. Eight patients received some form of TB medication, including 4 QFT-negative patients who were treated for active TB or latent TB infection based on positive TST or clinical findings. Among QFT-negative patients, including 6 TST-positive, not treated for active TB or latent TB infection, no TB disease has been identified over a median follow-up time of 2.96 years. CONCLUSIONS IGRA use was not limited by barriers of phlebotomy, indeterminate result or gamma-interferon production. The risk of missing an infected but IGRA-negative patient can be reduced by treatment of select patients at higher risk. Current recommendations against IGRA use in children <2 years old could be amended to allow careful introduction, particularly among well-appearing BCG-vaccinated patients.
Collapse
|
10
|
Ahmed A, Feng PJI, Gaensbauer JT, Reves RR, Khurana R, Salcedo K, Punnoose R, Katz DJ. Interferon-γ Release Assays in Children <15 Years of Age. Pediatrics 2020; 145:peds.2019-1930. [PMID: 31892518 PMCID: PMC9301964 DOI: 10.1542/peds.2019-1930] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The tuberculin skin test (TST) has been preferred for screening young children for latent tuberculosis infection (LTBI) because of concerns that interferon-γ release assays (IGRAs) may be less sensitive in this high-risk population. In this study, we compared the predictive value of IGRAs to the TST for progression to tuberculosis disease in children, including those <5 years old. METHODS Children <15 years old at risk for LTBI or progression to disease were tested with TST, QuantiFERON-TB Gold In-Tube test (QFT-GIT), and T-SPOT.TB test (T-SPOT) and followed actively for 2 years, then with registry matches, to identify incident disease. RESULTS Of 3593 children enrolled September 2012 to April 2016, 92% were born outside the United States; 25% were <5 years old. Four children developed tuberculosis over a median 4.3 years of follow-up. Sensitivities for progression to disease for TST and IGRAs were low (50%-75%), with wide confidence intervals (CIs). Specificities for TST, QFT-GIT, and T-SPOT were 73.4% (95% CI: 71.9-74.8), 90.1% (95% CI: 89.1-91.1), and 92.9% (95% CI: 92.0-93.7), respectively. Positive and negative predictive values for TST, QFT-GIT, and T-SPOT were 0.2 (95% CI: 0.1-0.8), 0.9 (95% CI: 0.3-2.5), and 0.8 (95% CI: 0.2-2.9) and 99.9 (95% CI: 99.7-100), 100 (95% CI: 99.8-100), and 99.9 (95% CI: 99.8-100), respectively. Of 533 children with TST-positive, IGRA-negative results not treated for LTBI, including 54 children <2 years old, none developed disease. CONCLUSIONS Although both types of tests poorly predict disease progression, IGRAs are no less predictive than the TST and offer high specificity and negative predictive values. Results from this study support the use of IGRAs for children, especially those who are not born in the United States.
Collapse
Affiliation(s)
- Amina Ahmed
- Levine Children's Hospital at Atrium Health, Charlotte, North Carolina;
| | - Pei-Jean I. Feng
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Renuka Khurana
- Maricopa County Department of Public Health, Phoenix, Arizona
| | - Katya Salcedo
- Tuberculosis Control Branch, California Department of Public Health, Richmond, California
| | | | - Dolly J. Katz
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | |
Collapse
|
11
|
Gaensbauer J, Broadhurst R. Recent Innovations in Diagnosis and Treatment of Pediatric Tuberculosis. Curr Infect Dis Rep 2019; 21:4. [PMID: 30767077 DOI: 10.1007/s11908-019-0662-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Tuberculosis is leading cause of global morbidity and mortality and a significant proportion of the burden of disease occurs in children. In the past 5 years, a number of innovations have improved the diagnosis and treatment for children with both latent tuberculosis infection and active disease. RECENT FINDINGS This review discusses three key areas of innovation. First, we assess utilization and performance of interferon-gamma release assays (IGRAs) in different clinical and epidemiologic scenarios. Recent literature has demonstrated good performance of IGRAs for diagnosis of latent tuberculosis infection, particularly in low-incidence settings such as TB control programs in North America. For high-incidence populations, or when testing is done for possible active TB disease, IGRA performance has some important limitations, but IGRA sensitivity when measured against culture proven disease may be better than earlier studies suggested. The second area of innovation is in increased uptake of nucleic acid amplification (NAA) tests and broader application in non-sputum samples for both pediatric pulmonary and extrapulmonary tuberculosis. Finally, recent studies have provided solid evidence in support of shorter treatment courses for pediatric latent tuberculosis infection, such as 12 weeks of weekly isoniazid and rifapentine or 4 months daily rifampin, that improve compliance and may reduce resources required for TB control. Many recent innovations in pediatric tuberculosis relate to an improved understanding of how to optimally use existing tests and treatments. Until diagnostic tests and interventions such as vaccination are developed that can dramatically alter the paradigm of pediatric TB management and control, it is important for stakeholders to have a nuanced understanding of tools currently available.
Collapse
Affiliation(s)
- James Gaensbauer
- Denver Metro Tuberculosis Clinic, Pavilion C, Denver Health Medical Center, MC 0590, 777 Bannock Street, Denver, CO, 80204, USA. .,Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Richard Broadhurst
- Medicine-Pediatric Residency Training Program, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
12
|
Abstract
Mycobacterium tuberculosis is the leading cause of death worldwide from a single bacterial pathogen. The World Health Organization estimates that annually 1 million children have tuberculosis (TB) disease and many more harbor a latent form. Accurate estimates are hindered by under-recognition and challenges in diagnosis. To date, an accurate diagnostic test to confirm TB in children does not exist. Treatment is lengthy but outcomes are generally favorable with timely initiation. With the End TB Strategy, there is an urgent need for improved diagnostics and treatment to prevent the unnecessary morbidity and mortality from TB in children.
Collapse
Affiliation(s)
- Tania A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801340, Charlottesville, VA 22908-1340, USA.
| |
Collapse
|
13
|
Meier NR, Volken T, Geiger M, Heininger U, Tebruegge M, Ritz N. Risk Factors for Indeterminate Interferon-Gamma Release Assay for the Diagnosis of Tuberculosis in Children-A Systematic Review and Meta-Analysis. Front Pediatr 2019; 7:208. [PMID: 31192175 PMCID: PMC6548884 DOI: 10.3389/fped.2019.00208] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 05/08/2019] [Indexed: 12/26/2022] Open
Abstract
Background: Interferon-gamma release assays (IGRA) are well-established immunodiagnostic tests for tuberculosis (TB) in adults. In children these tests are associated with higher rates of false-negative and indeterminate results. Age is presumed to be one factor influencing cytokine release and therefore test performance. The aim of this study was to systematically review factors associated with indeterminate IGRA results in pediatric patients. Methods: Systematic literature review guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) searching PubMed, EMBASE, and Web of Science. Studies reporting results of at least one commercially available IGRA (QuantiFERON-TB, T-SPOT.TB) in pediatric patient groups were included. Random effects meta-analysis was used to assess proportions of indeterminate IGRA results. Heterogeneity was assessed using the I2 value. Risk differences were calculated for studies comparing QuantiFERON-TB and T-SPOT.TB in the same study. Meta-regression was used to further explore the influence of study level variables on heterogeneity. Results: Of 1,293 articles screened, 133 studies were included in the final analysis. These assessed QuantiFERON-TB only in 77.4% (103/133), QuantiFERON-TB and T-SPOT.TB in 15.8% (21/133), and T-SPOT.TB only in 6.8% (9/133) resulting in 155 datasets including 107,418 participants. Overall 4% of IGRA results were indeterminate, and T-SPOT.TB (0.03, 95% CI 0.02-0.05) and QuantiFERON-TB assays (0.05, 95% CI 0.04-0.06) showed similar proportions of indeterminate results; pooled risk difference was-0.01 (95% CI -0.03 to 0.00). Significant differences with lower proportions of indeterminate assays with T-SPOT.TB compared to QuantiFERON-TB were only seen in subgroup analyses of studies performed in Africa and in non-HIV-infected immunocompromised patients. Meta-regression confirmed lower proportions of indeterminate results for T-SPOT.TB compared to QuantiFERON-TB only among studies that reported results from non-HIV-infected immunocompromised patients (p < 0.001). Conclusion: On average indeterminate IGRA results occur in 1 in 25 tests performed. Overall, there was no difference in the proportion of indeterminate results between both commercial assays. However, our findings suggest that in patients in Africa and/or patients with immunocompromising conditions other than HIV infection the T-SPOT.TB assay appears to produce fewer indeterminate results.
Collapse
Affiliation(s)
- Noëmi R Meier
- Mycobacterial Research Laboratory, University of Basel Children's Hospital, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Thomas Volken
- School of Health Professions, Zürich University of Applied Sciences, Winterthur, Switzerland
| | - Marc Geiger
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Ulrich Heininger
- Faculty of Medicine, University of Basel, Basel, Switzerland.,Paediatric Infectious Diseases and Vaccinology Unit, University of Basel Children's Hospital, Basel, Switzerland
| | - Marc Tebruegge
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom.,Department of Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.,Royal Children's Hospital Melbourne, Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Nicole Ritz
- Mycobacterial Research Laboratory, University of Basel Children's Hospital, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland.,Paediatric Infectious Diseases and Vaccinology Unit, University of Basel Children's Hospital, Basel, Switzerland.,Royal Children's Hospital Melbourne, Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
14
|
Gaensbauer J, Gonzales B, Belknap R, Wilson ML, O'Connor ME. Interferon-Gamma Release Assay-Based Screening for Pediatric Latent Tuberculosis Infection in an Urban Primary Care Network. J Pediatr 2018; 200:202-209. [PMID: 29866596 DOI: 10.1016/j.jpeds.2018.04.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/10/2018] [Accepted: 04/17/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess outcomes from a QuantiFERON-tuberculosis (TB) Gold (QFT)-based screening for pediatric latent TB infection (LTBI) in the Denver Health Community Health System (CHS), an urban primary-care network in the US. STUDY DESIGN We retrospectively analyzed all QFTs (n = 6685) performed on children aged 2-18 years between January 5, 2011, and August 18, 2014. Risk factors for positive testing in the CHS population were identified by logistic regression, and further assessed using a case-control comparison. Results from CHS were compared with higher-TB-risk populations (refugee and TB clinics) in our health system. RESULTS Positive QFT occurred in 79 of 3745 (2.1%) CHS patients. Positive rates increased with age (0.3% in age 2-5 years to 4.9% in age 13-18 years). Indeterminate results were uncommon (0.8%) including in children <5 (1.3%). Risk factors for positive tests in the CHS population included non-Medicaid insured/uninsured and non-English/Spanish preferred language. In the case-control analysis, birth/travel to/residence in a TB-endemic country was the only identified risk factor for positive testing (OR 5.2 [95% CI 1.04-25.5]). Rates of positive testing were lower in the CHS population than the refugee/TB clinic populations, including among children age 2-5. DISCUSSION QFT-based LTBI screening was successfully introduced in our pediatric primary-care health system, and supported our programmatic goals of identifying LTBI cases while limiting unnecessary LTBI treatment courses. Increasing positive rates with age, and higher rates in the refugee/TB populations compared with CHS, add indirect evidence of adequate test sensitivity, even among young children, for whom data on interferon-gamma release assay performance are limited.
Collapse
Affiliation(s)
- James Gaensbauer
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO; Denver Metro Tuberculosis Clinic, Denver Public Health, Denver, CO; Department of Pediatrics, Section of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO; Department of Epidemiology, Colorado School of Public Health; Aurora, CO.
| | - Bryn Gonzales
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO
| | - Robert Belknap
- Denver Metro Tuberculosis Clinic, Denver Public Health, Denver, CO; Department of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO
| | - Michael L Wilson
- Department of Pathology and Laboratory Services, Denver Health and Hospital Authority, Denver, CO; Department of Pathology, University of Colorado School of Medicine, Aurora, CO
| | - Mary E O'Connor
- Department of Pediatrics, University of Colorado School of Medicine, Aurora CO; Children's Hospital, Dartmouth-Hitchcock, Lebanon, NH; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH
| |
Collapse
|
15
|
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.
Collapse
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.
| |
Collapse
|
16
|
Chee CBE, Reves R, Zhang Y, Belknap R. Latent tuberculosis infection: Opportunities and challenges. Respirology 2018; 23:893-900. [PMID: 29901251 DOI: 10.1111/resp.13346] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 05/22/2018] [Accepted: 05/30/2018] [Indexed: 12/17/2022]
Abstract
Diagnosing and treating latent tuberculosis (TB) infection (LTBI) is recognized by the World Health Organization as an important strategy to accelerate the decline in global TB and achieve TB elimination. Even among low-TB burden countries that have achieved high rates of detection and successful treatment for active TB, a number of barriers have prevented implementing or expanding LTBI treatment programmes. Of those infected with TB, relatively few will develop active disease and the current diagnostic tests have a low predictive value. LTBI treatment using isoniazid (INH) has low completion rates due to the long duration of therapy and poor tolerability. Both patients and physicians often perceive the risk of toxicity to be greater than the risk of reactivation TB. As a result, LTBI treatment has had a limited or negligible role outside of countries with high resources and low burden of disease. New tools have emerged including the interferon-gamma release assays that more accurately diagnose LTBI, particularly in people vaccinated with Bacillus Calmette-Guerin (BCG). Shorter, better tolerated treatment using rifamycins are proving safe and effective alternatives to INH. While still imperfect, TB prevention using these new diagnostic and treatment tools appear cost effective in modelling studies in the United States and have the potential to improve TB prevention efforts globally. Continued research to understand the host-organism interactions within the spectrum of LTBI is needed to develop better tools. Until then, overcoming the barriers and optimizing our current tools is essential for progressing toward TB elimination.
Collapse
Affiliation(s)
- Cynthia B E Chee
- TB Control Unit, Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Randall Reves
- Denver Health and Hospital Authority, Denver Public Health Department, CO, USA.,University of Colorado, Division of Infectious Diseases, Health Sciences Center, Denver, CO, USA
| | - Ying Zhang
- Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Robert Belknap
- Denver Health and Hospital Authority, Denver Public Health Department, CO, USA.,University of Colorado, Division of Infectious Diseases, Health Sciences Center, Denver, CO, USA
| |
Collapse
|
17
|
Flood J, Wendorf KA. Mounting Evidence for IFN-γ Release Assay Use in Young Children. Am J Respir Crit Care Med 2018; 197:983-985. [DOI: 10.1164/rccm.201712-2527ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jennifer Flood
- Tuberculosis Control BranchCalifornia Department of Public HealthRichmond, California
| | - Kristen A. Wendorf
- Tuberculosis Control BranchCalifornia Department of Public HealthRichmond, California
| |
Collapse
|
18
|
Carvalho I, Goletti D, Manga S, Silva DR, Manissero D, Migliori G. Managing latent tuberculosis infection and tuberculosis in children. Pulmonology 2018; 24:106-114. [PMID: 29502937 DOI: 10.1016/j.rppnen.2017.10.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 10/27/2017] [Indexed: 02/02/2023] Open
Abstract
Tuberculosis (TB) is a major cause of childhood morbidity and mortality worldwide. The aim of this review is to describe the management of the child with TB and latent tuberculosis infection (LTBI). To develop this article, a working group reviewed relevant epidemiological and other scientific studies and established practices in conducting LBTI and TB in children. The article describes how to manage the child with LTBI, considering transmission and infectiousness of tuberculosis, contact screening and prioritization of contacts and recommendations on treatment of children with LTBI and how to manage the child with TB considering the susceptibility of children to developing tuberculosis, epidemiology and classification of tuberculosis in children, diagnosis and treatment.
Collapse
Affiliation(s)
- I Carvalho
- Pediatric Pulmonologist, Centro Diagnostico Pneumológico de Gaia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.
| | - D Goletti
- Translational Research Unit, National Institute for Infectious Diseases, Roma, Italy
| | - S Manga
- Associate Professor at Public Health and Preventive Medicine, Department San Marcos National University, Principal Professor of Infectious Diseases Lung Diseases at Hermilio Valdizan University, Peru
| | - D R Silva
- Professor of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Pulmonology Division, Porto Alegre, Brazil
| | - D Manissero
- Honorary Senior Lecturer, University College of London, Institute for Global Health, London, UK
| | - G Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Maugeri Care and Research Institute! Tradate, Italy
| |
Collapse
|
19
|
Abstract
Mycobacterium tuberculosis is the leading cause of death worldwide from a single bacterial pathogen. The World Health Organization estimates that annually 1 million children have tuberculosis (TB) disease and many more harbor a latent form. Accurate estimates are hindered by under-recognition and challenges in diagnosis. To date, an accurate diagnostic test to confirm TB in children does not exist. Treatment is lengthy but outcomes are generally favorable with timely initiation. With the End TB Strategy, there is an urgent need for improved diagnostics and treatment to prevent the unnecessary morbidity and mortality from TB in children.
Collapse
Affiliation(s)
- Tania A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801340, Charlottesville, VA 22908-1340, USA.
| |
Collapse
|
20
|
Cano APG, Romaneli MTN, Pereira RM, Tresoldi AT. TUBERCULOSIS IN PEDIATRIC PATIENTS: HOW HAS THE DIAGNOSIS BEEN MADE? ACTA ACUST UNITED AC 2017; 35:165-170. [PMID: 28977322 PMCID: PMC5496715 DOI: 10.1590/1984-0462/;2017;35;2;00004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 10/09/2016] [Indexed: 12/02/2022]
Abstract
Objective: To describe clinical, radiological, epidemiological, and microbiological characteristics of pediatric patients with diagnosis of tuberculosis in a period of 15 years. Methods: Retrospective study including children and adolescents younger than 18 years diagnosed with tuberculosis in the Clinical Hospital of the Universidade Estadual de Campinas in São Paulo State, Brazil. Active tuberculosis was defined by the identification of Mycobacterium tuberculosis in culture, microscopy, or histopathological examination. Children with positive clinical history and radiological tests who had been exposed to sick adults or with positive tuberculin skin test were also considered as having active tuberculosis. Statistical analysis compared the data obtained from children younger and older than 10 years of age, since they present a disease pattern more similar to adults. Results: There were 145 identified cases, 61.4% in patients under 10 years of age. The main symptoms reported were coughing (55.9%) and fever (46.9%), and the variables of fever, coughing, weight-loss, and pain were significantly influenced by age, with a higher frequency in older children. Diagnosis was confirmed by culture, microscopy, or histopathology in 67.6% of the cases. The other cases (32.4%) had the diagnosis of tuberculosis based on clinical, radiological, and epidemiological characteristics, as well as tuberculin skin test. The positivity for culture, microscopy, and tuberculin skin test was, respectively, 65.8, 35.7, and 72.3%. History of contact with a sick adult was confirmed in 37.2%, without influence of age. Conclusions: Diagnosis of tuberculosis in children is still a challenge, since all the confirmation tests have low positivity. These results demonstrate the need for new diagnostic methods and improved strategies for searching sick contacts.
Collapse
Affiliation(s)
- Ana Paula Ghussn Cano
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | | | - Ricardo Mendes Pereira
- Departamento de Pediatria da Faculdade de Ciências Médicas da Unicamp, Campinas, SP, Brasil
| | | |
Collapse
|
21
|
|