Accurate diagnosis of latent tuberculosis in children, people who are immunocompromised or at risk from immunosuppression and recent arrivals from countries with a high incidence of tuberculosis: systematic review and economic evaluation

Auguste, Peter; Tsertsvadze, Alexander; Pink, Joshua; Court, Rachel; Seedat, Farah; Gurung, Tara; Freeman, Karoline; Taylor‐Phillips, Sian; Walker, Clare; Madan, Jason; Kandala, Ngianga‐Bakwin; Clarke, Aileen; Sutcliffe, Paul

doi:10.3310/hta20380

Cited by 34 publications

(44 citation statements)

References 151 publications

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“…However, this value needs to be taken with caution, given the uncertainties discussed here, and the lower rates reported in some other studies e.g. 19,20 .…”

Section: Authors' Contributionsmentioning

confidence: 65%

Latent tuberculous screening of recent migrants attending language classes: a cohort study and cost analysis

Usdin

Dedicoat

Gajraj³

et al. 2017

int j tuberc lung dis

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Summary :Setting: A key recommendation of the National TB Strategy for England is testing and treatment of latent Tuberculosis infection (LTBI) among new migrants. Programmatic testing is based in primary care; however, this may be inaccessible to some individuals. Current strategies therefore could be complemented with screening in other settings.Objective: To investigate the feasibility and effectiveness of LTBI screening in a community college.Design: We performed a cohort study, based on observational data collected during and after the pilot project. Eligible language students from high TB incidence countries were consented and tested with a single-step Interferon Gamma Release Assay (IGRA) and enrolled in the cohort. We used single and multivariable analyses to estimate effectiveness of LTBI screening and to explore effectiveness in different sub-groups.Results: Screening uptake was 75% and the treatment completion rate was 85%. 71/440 students (16%) were LTBI positive and two had active TB. There was an association of positivity with age and TB incidence in the country of origin. We included costs from a UK National Health Service perspective. Three potential TB incidence thresholds met our cost effectiveness criteria for screening: countries with incidences of more than 40, more than 100 and more than 200 per 100,000 plus students from sub-Saharan Africa. Conclusion:We found that LTBI screening can be offered effectively in a community college setting, and could be a feasible complement to primary care-based programmes in low-incidence countries.

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“…However, this value needs to be taken with caution, given the uncertainties discussed here, and the lower rates reported in some other studies e.g. 19,20 .…”

Section: Authors' Contributionsmentioning

confidence: 65%

Latent tuberculous screening of recent migrants attending language classes: a cohort study and cost analysis

Usdin

Dedicoat

Gajraj³

et al. 2017

int j tuberc lung dis

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“…The second stage of the Warwick Evidence model 102 (Figure 4) was a transmission model, operationalised using discrete event simulation (DES), programmed using R (The R Foundation for Statistical Computing, Vienna, Austria). Individuals arriving from the decision tree were grouped as (1) having active TB, (2) already successfully treated for LTBI and, hence, free of LTBI/TB or (3) untreated for LTBI.…”

Section: Notesmentioning

confidence: 99%

“…The Warwick Evidence analysis 102 presented per-patient costs as well as a breakdown of total costs (including costs of diagnosis, LTBI treatment, active TB and treatment-related hepatitis) for all of the strategies, based on the mean values of all parameters after 250,000 individual patient simulations. The incidence rates (IRs) of active TB in the initial cohort, the number of secondary infections and the mean life-years and QALYs per strategy were also presented.…”

Section: Notesmentioning

confidence: 99%

“…It was assumed that participants aged ≤ 35 years who tested positive for LTBI would be offered CPX. Parameters related to the uptake of CPX in this eligible group, and the incidence and consequences of adverse reactions to CPX, were based on those used in the Warwick Evidence economic analysis by Auguste et al 102 ( Table 7). We assumed that, of those participants who experienced a non-fatal adverse event, 50% would resume CPX.…”

Section: Chemoprophylaxismentioning

confidence: 99%

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Two interferon gamma release assays for predicting active tuberculosis: the UK PREDICT TB prognostic test study

Abubakar

Lalvani

Southern

et al. 2018

Health Technol Assess

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Background Despite a recent decline in the annual incidence of tuberculosis (TB) in the UK, rates remain higher than in most Western European countries. The detection and treatment of latent TB infection (LTBI) is an essential component of the UK TB control programme. Objectives To assess the prognostic value and cost-effectiveness of the current two interferon gamma release assays (IGRAs) compared with the standard tuberculin skin test (TST) for predicting active TB among untreated individuals at increased risk of TB: (1) contacts of active TB cases and (2) new entrants to the UK from high-TB-burden countries. Design A prospective cohort study and economic analysis. Participants and setting Participants were recruited in TB clinics, general practices and community settings. Contacts of active TB cases and migrants who were born in high-TB-burden countries arriving in the UK were eligible to take part if they were aged ≥ 16 years. Main outcome measures Outcomes include incidence rate ratios comparing the incidence of active TB in those participants with a positive test result and those with a negative test result for each assay, and combination of tests and the cost per quality-adjusted life-year (QALY) for each screening strategy. Results A total of 10,045 participants were recruited between May 2010 and July 2015. Among 9610 evaluable participants, 97 (1.0%) developed active TB. For the primary analysis, all test data were available for 6380 participants, with 77 participants developing active TB. A positive result for TSTa (positive if induration is ≥ 5 mm) was a significantly poorer predictor of progression to active TB than a positive result for any of the other tests. Compared with TSTb [positive if induration is ≥ 6 mm without prior bacillus Calmette–Guérin (BCG) alone, T-SPOT®.TB (Oxford Immunotec Ltd, Oxford, UK), TSTa + T-SPOT.TB, TSTa + IGRA and the three combination strategies including TSTb were significantly superior predictors of progression. Compared with the T-SPOT.TB test alone, TSTa + T-SPOT.TB, TSTb + QuantiFERON® TB Gold In-Tube (QFT-GIT; QIAGEN GmbH, Hilden, Germany) and TSTb + IGRA were significantly superior predictors of progression and, compared with QFT-GIT alone, T-SPOT.TB, TSTa + T-SPOT.TB, TSTa + QFT-GIT, TSTa + IGRA, TSTb + T-SPOT.TB, TSTb + QFT-GIT and TSTb + IGRA were significantly superior predictors of progression. When evaluating the negative predictive performance of tests and strategies, negative results for TSTa + QFT-GIT were significantly poorer predictors of non-progression than negative results for TSTa, T-SPOT.TB and TSTa + IGRA. The most cost-effective LTBI testing strategies are the dual-testing strategies. The cost and QALY differences between the LTBI testing strategies were small; in particular, QFT-GIT, TSTb + T-SPOT.TB and TSTb + QFT-GIT had very similar incremental net benefit estimates. Conclusion This study found modest differences between tests, or combinations of tests, in identifying individuals who would go on to develop active TB. However, a two-step approach that combined TSTb with an IGRA was the most cost-effective testing option. Implications for practice and future research The two-step TSTb strategy, which stratified the TST by prior BCG vaccination followed by an IGRA, was the most cost-effective approach. The limited ability of current tests to predict who will progress limits the clinical utility of tests. The implications of these results for the NHS England/Public Health England national TB screening programme for migrants should be investigated. Study registration This study is registered as NCT01162265. Funding The National Institute for Health Research Health Technology Assessment programme.

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“…A "stone in the pond principle" approach was adopted, whereby the screening pool would be expanded to more casual contacts if the first round of screening identified higher than background levels of TB transmission. 16 This approach recognized the significance Fig. 1 Summary of incidents.…”

Section: Incidentmentioning

confidence: 99%

Screening Young Children for Latent Tuberculosis in England: Lessons Learned from the Field

Phipps

Clear

Holland

et al. 2019

J Pediatr Infect Dis

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Objective Tuberculosis (TB) can affect young children, resulting in serious disease at a young age or reactivation later in life. Identifying cases of latent TB infection (LTBI) in children exposed to active cases is important to prevent morbidity and mortality. There is currently limited guidance on appropriate testing methods in situations involving mass screening of children in low TB incidence settings such as England. This study describes case reports of two separate occasions in which nursery-age children in England underwent LTBI screening and explores the decisions involved in choosing the most appropriate test and screening process. Methods A literature search, review of health protection case and incident management notes, and interviews with key stakeholders were conducted. Results Two different tests—tuberculin skin testing and interferon gamma release assay—were used in each respective screening situation and the decision between the two was taken based on cohort, organizational, and index case risk factors. Screening took place in dedicated secondary care clinics. No cases of LTBI were identified from either screening incident. Conclusion Our study highlights the lack of definitive guidance for mass LTBI screening of young children and presents the approaches to decision making that can be adopted by others. Further research is required to test the approach suggested in this article and to ensure that evidence-based national guidance provides a consistent and effective approach to such incidents.

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Accurate diagnosis of latent tuberculosis in children, people who are immunocompromised or at risk from immunosuppression and recent arrivals from countries with a high incidence of tuberculosis: systematic review and economic evaluation

Cited by 34 publications

References 151 publications

Latent tuberculous screening of recent migrants attending language classes: a cohort study and cost analysis

Latent tuberculous screening of recent migrants attending language classes: a cohort study and cost analysis

Two interferon gamma release assays for predicting active tuberculosis: the UK PREDICT TB prognostic test study

Screening Young Children for Latent Tuberculosis in England: Lessons Learned from the Field

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