Screening for Latent Tuberculosis Infection in Adults

Jonas, Daniel E; Riley, Sean; Lee, Lindsey C.; Coffey, Cory P; Wang, Shuhua; Asher, Gary; Berry, Anne M.; Williams, Niketa; Balio, Casey P.; Voisin, C; Kahwati, Leila C.

doi:10.1001/jama.2023.3954

Cited by 18 publications

(19 citation statements)

References 129 publications

(243 reference statements)

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“…Three types of IGRA are currently approved by the US Food and Drug Administration: T-SPOT. TB (Oxford Immunotec Global), QuantiFERON-TB Gold In-Tube (Qiagen), and QuantiFERON-Gold Plus (Qiagen) …”

Section: Practice Considerationsmentioning

confidence: 99%

“…The USPSTF commissioned a systematic evidence review to update its 2016 recommendation on screening for LTBI. The review focused on the benefits and harms of LTBI screening and treatment in asymptomatic adults seen in primary care, as well as the accuracy of LTBI screening tests.…”

Section: Supporting Evidencementioning

confidence: 99%

“…Currently available TST and IGRA screening tests are moderately sensitive and highly specific for LTBI . The sensitivity and specificity of TST depends on the threshold used to determine positivity.…”

Section: Supporting Evidencementioning

confidence: 99%

“…The sensitivity and specificity of TST depends on the threshold used to determine positivity. Using a threshold of 5-mm induration, the pooled sensitivity of TST was 80% (12 studies; n = 1323) and the pooled specificity was 95% (3 studies; n = 5149) . Using a threshold of 10-mm induration, the pooled sensitivity was 81% (15 studies; n = 1427) and the pooled specificity was 98% (8 studies; n = 9604) .…”

Section: Supporting Evidencementioning

confidence: 99%

“…Using a threshold of 5-mm induration, the pooled sensitivity of TST was 80% (12 studies; n = 1323) and the pooled specificity was 95% (3 studies; n = 5149) . Using a threshold of 10-mm induration, the pooled sensitivity was 81% (15 studies; n = 1427) and the pooled specificity was 98% (8 studies; n = 9604) . Last, using a threshold of 15-mm induration, the pooled sensitivity was 60% (9 studies; n = 1004) and the pooled specificity was 99% (10 studies; n = 9563) …”

Section: Supporting Evidencementioning

confidence: 99%

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Screening for Latent Tuberculosis Infection in Adults

Mangione

Barry

Nicholson

et al. 2023

JAMA

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ImportanceIn the US, tuberculosis remains an important preventable disease, including active tuberculosis, which may be infectious, and latent tuberculosis infection (LTBI), which is asymptomatic and not infectious but can later progress to active disease. The precise prevalence rate of LTBI in the US is difficult to determine; however, estimated prevalence is about 5.0%, or up to 13 million persons. Incidence of tuberculosis varies by geography and living accommodations, suggesting an association with social determinants of health.ObjectiveTo update its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review on LTBI screening and treatment in asymptomatic adults seen in primary care, as well as the accuracy of LTBI screening tests.PopulationAsymptomatic adults 18 years or older at increased risk for tuberculosis.Evidence AssessmentThe USPSTF concludes with moderate certainty that there is a moderate net benefit in preventing active tuberculosis disease by screening for LTBI in persons at increased risk for tuberculosis infection.RecommendationThe USPSTF recommends screening for LTBI in populations at increased risk. (B recommendation)

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Section: Practice Considerationsmentioning

confidence: 99%

Section: Supporting Evidencementioning

confidence: 99%

Section: Supporting Evidencementioning

confidence: 99%

Section: Supporting Evidencementioning

confidence: 99%

Section: Supporting Evidencementioning

confidence: 99%

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Screening for Latent Tuberculosis Infection in Adults

Mangione

Barry

Nicholson

et al. 2023

JAMA

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Screening for Latent Tuberculosis Infection in Adults

Jonas

Riley

Lee

et al. 2023

JAMA

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ImportanceLatent tuberculosis infection (LTBI) can progress to active tuberculosis disease, causing morbidity and mortality.ObjectiveTo review the evidence on benefits and harms of screening for and treatment of LTBI in adults to inform the US Preventive Services Task Force (USPSTF).Data SourcesPubMed/MEDLINE, Cochrane Library, and trial registries through December 3, 2021; references; experts; literature surveillance through January 20, 2023.Study SelectionEnglish-language studies of LTBI screening, LTBI treatment, or accuracy of the tuberculin skin test (TST) or interferon-gamma release assays (IGRAs). Studies of LTBI screening and treatment for public health surveillance or disease management were excluded.Data Extraction and SynthesisDual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings; meta-analyses conducted when a sufficient number of similar studies were available.Main Outcomes and MeasuresScreening test accuracy; development of active tuberculosis disease, transmission, quality of life, mortality, and harms.ResultsA total of 113 publications were included (112 studies; N = 69 009). No studies directly evaluated the benefits and harms of screening. Pooled estimates for sensitivity of the TST were 0.80 (95% CI, 0.74-0.87) at the 5-mm induration threshold, 0.81 (95% CI, 0.76-0.87) at the 10-mm threshold, and 0.60 (95% CI, 0.46-0.74) at the 15-mm threshold. Pooled estimates for sensitivity of IGRA tests ranged from 0.81 (95% CI, 0.79-0.84) to 0.90 (95% CI, 0.87-0.92). Pooled estimates for specificity of screening tests ranged from 0.95 to 0.99. For treatment of LTBI, a large (n = 27 830), good-quality randomized clinical trial found a relative risk (RR) for progression to active tuberculosis at 5 years of 0.35 (95% CI, 0.24-0.52) for 24 weeks of isoniazid compared with placebo (number needed to treat, 112) and an increase in hepatotoxicity (RR, 4.59 [95% CI, 2.03-10.39]; number needed to harm, 279). A previously published meta-analysis reported that multiple regimens were efficacious compared with placebo or no treatment. Meta-analysis found greater risk for hepatotoxicity with isoniazid than with rifampin (pooled RR, 4.22 [95% CI, 2.21-8.06]; n = 7339).Conclusions and RelevanceNo studies directly evaluated the benefits and harms of screening for LTBI compared with no screening. TST and IGRAs were moderately sensitive and highly specific. Treatment of LTBI with recommended regimens reduced the risk of progression to active tuberculosis. Isoniazid was associated with higher rates of hepatotoxicity than placebo or rifampin.

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Screening for Latent Tuberculosis Infection

Menzies

2023

JAMA Netw Open

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The US Preventive Services Task Force (USPSTF) has recommended screening of adults at increased risk for latent tuberculosis (TB) infection (LTBI). 1 This recommendation (B statement) is based on an evidence review 2 that found that available tests-in particular, the tuberculin skin test and interferon-γ release assays-were sufficiently accurate to identify persons with LTBI and that TB preventive treatment (TPT) regimens now recommended in the US 3 should provide moderate net benefit 1 to persons identified from screening. The USPSTF advised following the recommendations for testing in persons who have immunosuppression made by the American Thoracic Society and Centers for Disease Control and Prevention 2017 4 and recommendations for TPT made by the Centers for Disease Control and Prevention in 2020. 3 The USPSTF noted that this recommendation is for adults not included in other recommendations 3,4 for LTBI testing and treatment, such as persons living with HIV, persons about to receive a solid-organ transplantation or tumor necrosis factor-α inhibitors, or other groups at increased risk because of immune suppression. The task force also noted that this recommendation is not for contacts of persons with a recent diagnosis of active TB disease, who are generally investigated by public health services. Hence, these recommendations are focused on persons who are otherwise healthy but have increased likelihood (risk) of having TB infection. Although this includes some US-born persons, the vast majority of persons who will be affected by this recommendation are individuals who immigrated to the US from countries where TB incidence is much higher. On the basis of estimates of the prevalence of LTBI among persons in the US who were born outside the US, 5 this represents a very substantial increase from the number of persons now screened.Before starting screening, a reminder is needed. The USPSTF also recommends that to achieve the benefit of screening, it is important that persons who screen positive for LTBI receive follow-up and treatment 1 ; if TPT is not completed, then there will be no benefit of screening. Hence, a decision to implement screening for LTBI in any setting or for any population must include a commitment to ensure adequate follow-up of those with positive test results. 6 This includes medical and radiographic evaluation to exclude TB disease, offering TPT to all those who are eligible, and then education and counseling plus subsequent close follow-up of those who accept TPT, to ensure adherence as well as to detect and manage any adverse effects. Substantial time and resources are needed to ensure that care is well organized for all steps in the cascade to minimize losses, or a screening program will have far less benefit than expected. 6 Numerous studies have shown that there are substantial losses in the cascade of LTBI care, at the steps of initial identification of candidates for screening (testing), medical evaluation, and offering TPT, as well as acceptance and completion of TPT by individuals,...

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Screening for Latent Tuberculosis Infection in Adults

Cited by 18 publications

References 129 publications

Screening for Latent Tuberculosis Infection in Adults

Screening for Latent Tuberculosis Infection in Adults

Screening for Latent Tuberculosis Infection in Adults

Screening for Latent Tuberculosis Infection

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