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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.
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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.
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Pop R, Kaelin MB, Kuster SP, Sax H, Rampini SK, Zbinden R, Relly C, Zacek B, Bassler D, Fontijn JR, Berger C. Low secondary attack rate after prolonged exposure to sputum smear positive miliary tuberculosis in a neonatal unit. Antimicrob Resist Infect Control 2022; 11:148. [PMID: 36471416 PMCID: PMC9720914 DOI: 10.1186/s13756-022-01179-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 10/31/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Several neonatal intensive care units (NICU) have reported exposure to sputum smear positive tuberculosis (TB). NICE guidelines give support regarding investigation and treatment intervention, but not for contact definitions. Data regarding the reliability of any interferon gamma release assay (IGRA) in infants as a screening test for TB infection is scarce. We report an investigation and management strategy and evaluated the viability of IGRA (T-Spot) in infants and its concordance to the tuberculin skin test (TST). METHODS We performed an outbreak investigation of incident TB infection in a NICU after prolonged exposure to sputum smear positive miliary TB by an infant's mother. We defined individual contact definitions and interventions and assessed secondary attack rates. In addition, we evaluated the technical performance of T-Spot in infants and compared the results with the TST at baseline investigation. RESULTS Overall, 72 of 90 (80%) exposed infants were investigated at baseline, in 51 (56.7%) of 54 (60%) infants, follow-up TST at the age of 6 months was performed. No infant in our cohort showed a positive TST or T-Spot at baseline. All blood samples from infants except one responded to phytohemagglutinin (PHA), which was used as a positive control of the T-Spot, demonstrating that cells are viable and react upon stimulation. 149 of 160 (93.1%) exposed health care workers (HCW) were investigated. 1 HCW was tested positive, having no other reason than this exposure for latent TB infection. 5 of 92 (5.5%) exposed primary contacts were tested positive, all coming from countries with high TB incidences. In total, 1 of 342 exposed contacts was newly diagnosed with latent TB infection. The secondary attack rate in this study including pediatric and adult contacts was 0.29%. CONCLUSION This investigation highlighted the low transmission rate of sputum smear positive miliary TB in a particularly highly susceptible population as infants. Our expert definitions and interventions proved to be helpful in terms of the feasibility of a thorough outbreak investigation. Furthermore, we demonstrated concordance of T-Spot and TST. Based on our findings, we assume that T-Spot could be considered a reliable investigation tool to rule out TB infection in infants.
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Affiliation(s)
- Roxana Pop
- grid.7400.30000 0004 1937 0650Department of Infectious Diseases and Hospital Hygiene, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Marisa B. Kaelin
- grid.7400.30000 0004 1937 0650Department of Infectious Diseases and Hospital Hygiene, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Stefan P. Kuster
- grid.7400.30000 0004 1937 0650Department of Infectious Diseases and Hospital Hygiene, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Hugo Sax
- grid.7400.30000 0004 1937 0650Department of Infectious Diseases and Hospital Hygiene, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland ,grid.5734.50000 0001 0726 5157Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Silvana K. Rampini
- grid.7400.30000 0004 1937 0650Department of Internal Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Reinhard Zbinden
- grid.7400.30000 0004 1937 0650Institute of Medical Microbiology, University of Zurich, Zurich, Switzerland
| | - Christa Relly
- grid.7400.30000 0004 1937 0650University Children’s Hospital Zurich, Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, Zurich, Switzerland
| | - Bea Zacek
- TB Centre of the Lung Association of Canton Zurich (Verein Lunge Zürich), Zurich, Switzerland
| | - Dirk Bassler
- grid.7400.30000 0004 1937 0650Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jehudith R. Fontijn
- grid.7400.30000 0004 1937 0650Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christoph Berger
- grid.7400.30000 0004 1937 0650University Children’s Hospital Zurich, Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, Zurich, Switzerland
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Kilinc AA, Onal P, Oztosun B, Yildiz M, Adrovic A, Sahin S, Barut K, Cokugras H, Kasapcopur O. Determination of tuberculin skin test for isoniazid prophylaxis in BCG vaccinated children who are using anti-TNF agents for rheumatologic diseases. Pediatr Pulmonol 2020; 55:2689-2696. [PMID: 32776324 DOI: 10.1002/ppul.24963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/12/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The use of tumor necrosis factor inhibitors (anti-TNF) has a risk of activating latent tuberculosis infection (LTBI). This study was performed to investigate LTBI according to tuberculin skin test (TST) size and to determine the frequency of tuberculosis (TB) in bacillus Calmette-Guerin (BCG)-vaccinated children receiving anti-TNF treatment for rheumatological disease. MATERIALS AND METHODS The study consisted of 559 children. Information on demographics, anti-TNF agents, TST size, and isoniazid (INH) prophylaxis was recorded. Patients (n = 254) with TST size ≥5 mm were divided into three groups according to TST size and INH prophylaxis: group 1, TST size 5 to 9 mm and no INH prophylaxis; group 2, TST size 5 to 9 mm with INH prophylaxis; and group 3, TST size ≥10 mm with INH prophylaxis. RESULTS The 559 patients comprised 314 (56.3%) females and 245 (43.6%) males; they had a mean age of 13.1 ± 4.1 years. The mean TST size in all patients was 4.2 ± 4.7 mm. Group 1 consisted of 76 (29.9%) patients, group 2 consisted of 88 (34.6%) patients, and group 3 consisted of 90 (35.4%) patients. The mean TST sizes for the three groups were 6.8 ± 3.1 mm, 7.2 ± 3.2 mm, and 13.9 ± 2.8 mm, respectively. New TB was diagnosed in only two (0.35%) patients. Both of them were in group 3. CONCLUSIONS A TST size of ≥10 mm in BCG-vaccinated children receiving anti-TNF treatment may distinguish children at high risk for reactivation of LTBI.
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Affiliation(s)
- Ayse Ayzit Kilinc
- Department of Pediatric Pulmonology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Pinar Onal
- Department of Pediatric Infectious Diseases, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Berrak Oztosun
- Department of Pediatrics, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Mehmet Yildiz
- Department of Pediatric Rheumatology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Haluk Cokugras
- Department of Pediatric Pulmonology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, İstanbul, Turkey
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