Background UK tuberculosis (TB) notifications are rising due to disease in the immigrant population. National screening guidelines have been revised but cost-effectiveness analyses are hampered by the lack of data on the comparative performance of tuberculin skin tests (TSTs) and interferon γ release assays (IGRAs) in immigrants. Methods Three-way evaluation of TSTs and two IGRAs (QuantiFERON Gold in-tube (QFN-GIT) and T-SPOT.TB) in immigrants aged ≥16 years to quantify test positivity, concordance and factors associated with positivity. Yields were computed at different incidence thresholds and the relative cost-effectiveness of screening was estimated using different latent TB infection (LTBI) screening modalities at varying incidence thresholds with or without port-of-arrival chest x-ray (CXR). Results 231 immigrants were included; median age 29 (IQR 24–37). TSTs were accepted by 80.9%, read in 93.5% and 30.3% were positive – QFN-GIT and T-SPOT.TB positive in 16.6% and 22.5% respectively. Positive TSTs, QFN-GIT and T-SPOT.TB were independently associated with increasing TB incidence in immigrants’ countries of origin (p=0.007, 0.007, 0.037 respectively). Implementing current guidance (threshold 40/100 000 per year) would identify 98–100% of LTBIs (depending on test) but entail testing 97–99% of the cohort; screening at 150/100 000 per year would identify 49–71% of LTBIs but only entail screening half the cohort. The two most cost-effective screening strategies were no port-of-entry chest radiography and screen with single-step QFN-GIT at 250/100 000 per year (incremental cost-effectiveness ratio (ICER)) £21 565.3/case averted); and no port-of-entry CXR and screen with single-step QFN-GIT at 150/100 000 per year (averted additional 7.8 TB cases; ICER £31 867.1/case averted). Conclusions UK immigrant screening could cost-effectively and safely eliminate mandatory CXR on arrival by emphasising systematic screening for LTBI with single-step IGRA. Intermediate incidence thresholds balance the need to identify as many imported LTBIs as possible against limited service capacity.
The results of a one-year clinical, epidemiological and microbiological survey of gonococcal infection presenting to the Patrick Clements Clinic (PCC), a London district general hospital (DGH) genitourinary medicine (GUM) clinic, are presented. Clinical and epidemiological patient data were collected by a combination of questionnaire and retrospective case-note review. Microscopy performance within the PCC, outcome of treatment, return for tests of cure and efficacy of contact tracing were assessed. Isolates were tested for susceptibility to penicillin, tetracycline and ciprofloxacin. The study showed the PCC continues to diagnose and treat over 200 cases of gonorrhoea per year. High level resistance to penicillin, tetracycline and ciprofloxacin was documented among the year's isolates and antibiotic resistance was linked to acquisition of gonorrhoea overseas. Despite interviewing 183 patients concerning health advice and contact tracing issues, only 55% of new episodes re-attended for a first test of cure. In addition, only 29% of reported sexual contacts attended GUM clinics for investigation and treatment.
Background Tuberculosis (TB) notifications in the UK continue to rise due to disease in the foreign-born immigrant population. UK guidelines on immigrant screening have recently been revised but accurate calculation of cost-effectiveness is hampered by a lack of empiric data on the comparative performance of tuberculin skin test (TST) and interferon-g release-assays (IGRA) in immigrants arriving from countries with varying TB incidence. Methods Prospective evaluation of TST and two commercially available IGRAs (QuantiFERON Gold in-tube (QFN-GIT) and T-SPOT.TB) in recent immigrants aged ¼16 years to quantify test positivity, concordance and factors associated with a positive result for all three tests. We computed yields at different incidence thresholds and the relative cost-effectiveness, using a decisionanalysis-model stratified by HIV/drug-resistance, of screening using different latent TB infection (LTBI) screening modalities at varying incidence thresholds supplemented with/without port-of-arrival chest radiography. Results 231 immigrants included; median age 29 (IQR 24e37). TST accepted by 80.9%, read in 93.6%; 30.3% positive. QFN-GIT and T-SPOT.TB positive in 16.6% and 22.5% respectively. Positive TST, QFN-GIT and T-SPOT.TB independently associated with increasing TB incidence in immigrants' countries of origin (p¼0.008, 0.007 and 0.01 respectively). Implementing current guidance (depending on test) would identify 98%e100% of LTBI but also require 97%e99% of the immigrant cohort to be tested; raising the threshold to 150/ 100 000 (includes immigrants from Indian Subcontinent) would identify 49%e71% of LTBI but require half the cohort to be screened. The three most cost-effective screening strategies (which were more cost-effective than current guidance) were: no CXR at port-of-entry and screen with single-step QFN-GIT at 250/100 000 (Incremental cost-effective ratio (ICER) £21 565.3/per case averted),
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