Screening for tuberculosis infection among newly arrived asylum seekers: Comparison of QuantiFERON®TB Gold with tuberculin skin test

Background: QuantiFERON®TB Gold (QFT) is a promising blood test for tuberculosis infection but with few data so far from immigrant screening. The aim of this study was to compare results of QFT and tuberculin skin test (TST) among newly arrived asylum seekers in Norway and to assess the role of QFT in routine diagnostic screening for latent tuberculosis infection. Methods: The 1000 asylum seekers (age ≥ 18 years) enrolled in the study were voluntarily recruited from 2813 consecutive asylum seekers arriving at the national reception centre from September 2005 to June 2006. Participation included a QFT test and a questionnaire in addition to the mandatory TST and chest X-ray. Results: Among 912 asylum seekers with valid test results, 29% (264) had a positive QFT test whereas 50% (460) tested positive with TST (indurations ≥ 6 mm), indicating a high proportion of latent infection within this group. Among the TST positive participants 50% were QFT negative, whereas 7% of the TST negative participants were QFT positive. There was a significant association between increase in size of TST result and the likelihood of being QFT positive. Agreement between the tests was 71–79% depending on the chosen TST cut-off and it was higher for nonvaccinated individuals. Conclusion: By using QFT in routine screening, further follow-up could be avoided in 43% of the asylum seekers who would have been referred if based only on a positive TST (≥ 6 mm). The proportion of individuals referred will be the same whether QFT replaces TST or is used as a supplement to confirm a positive TST, but the number tested will vary greatly. All three screening approaches would identify the same proportion (88–89%) of asylum seekers with a positive QFT and/or a TST ≥ 15 mm, but different groups will be missed

The role of entry screening in case finding of tuberculosis among asylum seekers in Norway

<p>Abstract</p> <p>Background</p> <p>Most new cases of active tuberculosis in Norway are presently caused by imported strains and not transmission within the country. Screening for tuberculosis with a Mantoux test of everybody and a chest X-ray of those above 15 years of age is compulsory on arrival for asylum seekers.</p> <p>We aimed to assess the effectiveness of entry screening of a cohort of asylum seekers. Cases detected by screening were compared with cases detected later. Further we have characterized cases with active tuberculosis.</p> <p>Methods</p> <p>All asylum seekers who arrived at the National Reception Centre between January 2005 - June 2006 with an abnormal chest X-ray or a Mantoux test ≥ 6 mm were included in the study and followed through the health care system. They were matched with the National Tuberculosis Register by the end of May 2008.</p> <p>Cases reported within two months after arrival were defined as being detected by screening.</p> <p>Results</p> <p>Of 4643 eligible asylum seekers, 2237 were included in the study. Altogether 2077 persons had a Mantoux ≥ 6 mm and 314 had an abnormal chest X-ray. Of 28 cases with tuberculosis, 15 were detected by screening, and 13 at 4-27 months after arrival. Abnormal X-rays on arrival were more prevalent among those detected by screening. Female gender and Somalian origin increased the risk for active TB.</p> <p>Conclusion</p> <p>In spite of an imperfect follow-up of screening results, a reasonable number of TB cases was identified by the programme, with a predominance of pulmonary TB.</p

Tuberculosis screening and follow-up of asylum seekers in Norway: a cohort study

<p>Abstract</p> <p>Background</p> <p>About 80% of new tuberculosis cases in Norway occur among immigrants from high incidence countries. On arrival to the country all asylum seekers are screened with Mantoux test and chest x-ray aimed to identify cases of active tuberculosis and, in the case of latent tuberculosis, to offer follow-up or prophylactic treatment.</p> <p>We assessed a national programme for screening, treatment and follow-up of tuberculosis infection and disease in a cohort of asylum seekers.</p> <p>Methods</p> <p>Asylum seekers ≥ 18 years who arrived at the National Reception Centre from January 2005 to June 2006, were included as the total cohort. Those with a Mantoux test ≥ 6 mm or positive x-ray findings were included in a study group for follow-up.</p> <p>Data were collected from public health authorities in the municipality to where the asylum seekers had moved, and from hospital based internists in case they had been referred to specialist care.</p> <p>Individual subjects included in the study group were matched with the Norwegian National Tuberculosis Register which receive reports of everybody diagnosed with active tuberculosis, or who had started treatment for latent tuberculosis.</p> <p>Results</p> <p>The total cohort included 4643 adult asylum seekers and 97.5% had a valid Mantoux test. At least one inclusion criterion was fulfilled by 2237 persons. By end 2007 municipal public health authorities had assessed 758 (34%) of them. Altogether 328 persons had been seen by an internist. Of 314 individuals with positive x-rays, 194 (62%) had seen an internist, while 86 of 568 with Mantoux ≥ 15, but negative x-rays (16%) were also seen by an internist. By December 31^st2006, 23 patients were diagnosed with tuberculosis (prevalence 1028/100 000) and another 11 were treated for latent infection.</p> <p>Conclusion</p> <p>The coverage of screening was satisfactory, but fewer subjects than could have been expected from the national guidelines were followed up in the community and referred to an internist. To improve follow-up of screening results, a simplification of organisation and guidelines, introduction of quality assurance systems, and better coordination between authorities and between different levels of health care are all required.</p

A cross-sectional survey of the knowledge, attitudes and practices regarding tuberculosis among general practitioners working in municipalities with and without asylum centres in eastern Norway

TB survey among Norwegian GPs survey questionnaire NOR: The survey questionnaire in Norwegian. (PDF 208 kb

School based screening for tuberculosis infection in Norway: comparison of positive tuberculin skin test with interferon-gamma release assay

<p>Abstract</p> <p>Background</p> <p>In Norway, screening for tuberculosis infection by tuberculin skin test (TST) has been offered for several decades to all children in 9th grade of school, prior to BCG-vaccination. The incidence of tuberculosis in Norway is low and infection with <it>M. tuberculosis </it>is considered rare. QuantiFERON^®TB Gold (QFT) is a new and specific blood test for tuberculosis infection. So far, there have been few reports of QFT used in screening of predominantly unexposed, healthy, TST-positive children, including first and second generation immigrants. In order to evaluate the current TST screening and BCG-vaccination programme we aimed to (1) measure the prevalence of QFT positivity among TST positive children identified in the school based screening, and (2) measure the association between demographic and clinical risk factors for tuberculosis infection and QFT positivity.</p> <p>Methods</p> <p>This cross-sectional multi-centre study was conducted during the school year 2005–6 and the TST positive children were recruited from seven public hospitals covering rural and urban areas in Norway. Participation included a QFT test and a questionnaire regarding demographic and clinical risk factors for latent infection. All positive QFT results were confirmed by re-analysis of the same plasma sample. If the confirmatory test was negative the result was reported as non-conclusive and the participant was offered a new test.</p> <p>Results</p> <p>Among 511 TST positive children only 9% (44) had a confirmed positive QFT result. QFT positivity was associated with larger TST induration, origin outside Western countries and known exposure to tuberculosis. Most children (79%) had TST reactions in the range of 6–14 mm; 5% of these were QFT positive. Discrepant results between the tests were common even for TST reactions above 15 mm, as only 22 % had a positive QFT.</p> <p>Conclusion</p> <p>The results support the assumption that factors other than tuberculosis infection are widely contributing to positive TST results in this group and indicate the improved specificity of QFT for latent tuberculosis. Our study suggests a very low prevalence of latent tuberculosis infection among 9th grade school children in Norway. The result will inform the discussion in Norway of the usefulness of the current TST screening and BCG-policy.</p

Tuberculosis infection and disease among asylum seekers in Norway : Screening and follow-up in public health care

Introduction About 80% of new tuberculosis (TB) cases in Norway occur among immigrants from high incidence countries in Africa, Asia and Eastern Europe, and most of them are infected on arrival. Tuberculosis screening of immigrants from such countries is compulsory with a Mantoux test of everybody and a chest X-ray of all above 15 years of age. The aim of the screening is to identify cases of active tuberculosis in order to give treatment and stop transmission of the disease, and to offer treatment or followup for cases with latent tuberculosis. Asylum seekers are screened at the National Reception Centre in Oslo before they are transferred to other asylum seekers centres or relocated to municipalities around the country. Internationally, there is an ongoing discussion about screening of immigrants, as well as the indications for treatment of latent tuberculosis. Aim The aim of the study was to assess the conduct of entry screening among asylum seekers, and the follow-up of results for active and latent tuberculosis. A secondary aim was to assess the predictive properties of QuantiFERON-TB Gold (QFT) as a potentially new screening tool for tuberculosis disease. Methods All asylum seekers above the age of 18 who arrived at the National Reception Centre from January 2005 to June 2006 were eligible for inclusion in the follow-up study. They were included if they had either a Mantoux test 6 mm, a positive chest X-ray, or a positive QFT test. The latter regarded the subset of asylum seekers who arrived between September 2005 and June 2006. Potential participants were excluded if they left the Reception Centre without a new address or left the country directly. Information about the study and a data collection form were sent to the health authorities in the municipalities where the asylum seekers moved to. In case anyone had moved on to another municipality in the meantime, the same information and study form were sent to the authorities in their new place of residence. If we received information that a study participant had been referred to specialist health care, a second form was sent to the health institution in question. All included study subjects were later matched with the National Tuberculosis Register which contains information about everybody diagnosed with active tuberculosis, or who have started treatment for latent tuberculosis. An additional aim of the study of the above mentioned subsample, was to compare QFT and the Mantoux test. Everyone with a valid QFT test result where name and birth date were available were later matched with the National TB Register. Results Of 4643 available asylum seekers, 2237 were included in the follow-up study. We found a valid Mantoux test result in 97.5% of them. We were on the other hand unable to ascertain and document the exact number of X-rays that were taken at the Reception Centre. Fifteen cases of tuberculosis, mainly pulmonary TB, were identified through the screening programme within two months after arrival. Altogether 28 cases of active TB had been diagnosed by the end of May 2008. Female gender, Somalian origin and a positive X-ray on arrival were all associated with active tuberculosis. Of 314 persons with a positive X-ray, 62% had been seen by an internist in order to get a conclusive diagnosis. Similarly, of 568 asylum seekers with a Mantoux 15mm, 16% had been examined by a specialist. Only one third of persons with an elevated Mantoux test had been assessed at the community level and there was no association between the characteristics of the screening result (positive X-ray, and size of Mantoux) and the probability of being assessed. Altogether 30 cases of latent TB were started on treatment, which took place a median 17 months (range 3-36) after arrival. A Mantoux 15mm was the only characteristic that was associated with treatment induction. The positive and negative predictive values (PPV and NPV, respectively) for Mantoux and QFT were the same. The negative predictive value for a Mantoux 6mm in combination with a negative QFT was as good as the NPV for Mantoux &lt;15mm alone. Conclusion The conduct of the screening programme for asylum seekers was by no means in accordance with the official guidelines. Asylum seekers were screened with Mantoux on arrival, but we were unable to document the exact number who had been screened with chest X-ray. The main concern is the lack of a specialist examination of persons with a positive X-ray, but also of persons with a Mantoux 15mm. Compared to other studies, a reasonable number of cases were diagnosed with active TB within 2 months after the arrival screening. Two cases were diagnosed from 3-6 months after arrival and were probably missed by screening, but an unknown number of cases may have been lost because of insufficient follow-up of X-ray results. Six of eight cases of extra-pulmonary TB were diagnosed more than four months after arrival and could well have been ill for months before diagnosis. At the primary health care (PHC) level there was an obvious lack of a common strategy for taking responsibility for the follow-up of TB screening results. A secondary finding was that QFT was as precise as Mantoux in predicting TB, and the negative predictive values for a Mantoux 6mm with a negative QFT were equally as precise as for a negative Mantoux alone

How are private medical colleges collaborating with the National TB Control Programme in Nepal, a qualitative study

Background: Tuberculosis (TB) is an enduring public health problem in Nepal. This study aimed to uncover the experiences and attitudes of health workers at Private medical colleges (PMCs) towards the National TB Control Programme (NTP). Methods: Strategic and convenience sampling were used to identify health personnel participating in TB care at PMCs affiliated to Kathmandu University. Three focus group interviews were held with 19 participants. Audio recordings of the discussions were transcribed, and thematic analysis was conducted. Results: The PMCs treat many TB patients and regularly refer patients to DOTS clinics for treatment, but the PMCs don’t feel well integrated into the NTP. There are gaps between the NTP programmes/ guidelines and clinical realities, and the PMCs would like to participate in developing national guidelines and the NTP`s monitoring and evaluation initiatives. There is also a lack of communication within and between levels. Clear lines of management and responsibility, and more training of staff at all levels, are wanted. Conclusion: Increased involvement of PMCs in national TB control activities is important to improve TB care. Clearer guidelines from the government about the involvement of PMCs in TB control are also needed, as is better collaboration between the NTP and PMCs

Collaboration between municipal and specialist public health care in tuberculosis screening in Norway

Background: About 90% of new tuberculosis (TB) cases in Norway appear among immigrants from high incidence countries. There is a compulsory governmental tuberculosis screening programme for immigrants; immigrants with positive screening results are to be referred from municipal health care to the specialist health care for follow-up. Recent studies of the screening programme have shown inadequate follow-up. One of the main problems has been that patients referred for follow-up have not attended their appointment at the specialist health care. TB screening in the municipality of Trondheim is done by two different teams: the Refugee Healthcare Centre (RHC) screens refugees and the Vaccination and Infection Control Office (VICO) screens all the other groups. Patients with positive findings on screening are referred to the hospital’s Pulmonary Out-patient Department (POPD). The municipal and referral level public health care initiated a project aiming to improve follow-up through closer collaboration. Methods: An intervention group and a pre-intervention control group were established for each screening group. During meetings between staff from the municipality and the POPD, inadequacies in the screening process were identified, and changes in procedures for summoning patients, and time and place for tests were implemented. For both the intervention group and the control group, time from referral until consultation at the POPD and number of patients that attended their first appointment were registered and compared. Results: In the VICO group, 97/134 (72%) of the controls and 109/123 (89%) of the intervention group attended their first appointment at the POPD after 30 weeks (median) and 10 weeks, respectively. In the RHC group 28/46 (61%) of the controls and 55/59 (93%) in the intervention group attended their first appointment after 15 and 8 weeks (median) respectively. Conclusion: Increased collaboration between the municipal and specialist health care can improve the follow-up of positive TB screening results. Keywords: Tuberculosis, Screening, Asylum seekers, Refugees, Contact tracing, Collaboration

A questionnaire of knowledge, attitude and practices on tuberculosis among medical interns in Nepal

Background Tuberculosis (TB) remains a major health problem worldwide, including in Nepal where around 33,000 new cases of TB were diagnosed in 2018 and 5400 patients died. There are challenges in the diagnostic process, treatment, and follow-up. Deaths, increased transmission and development of multi- drug resistant TB could be the consequences. Young doctors play an important role in this struggle, and therefore, their knowledge of and attitudes towards TB are crucial. Objective We surveyed medical interns in Nepal regarding their knowledge, attitude and practices on TB and their adherence to the National Tuberculosis Programmes’ guidelines. The objective was to determine the associations between TB knowledge, and attitude and the factors that influence them. Methods A WHO cross-sectional questionnaire template was modified and piloted. It was distributed anonymously among medical interns at three private medical colleges. Statistical analyses were performed to establish possible associations between TB knowledge and attitude, and the investigated variables, and to investigate differences between the medical colleges. Results Of 270 interns, 185 (69%) interns were included. The mean knowledge score was 13,3 (SD: 2,12) of a maximum of 19. The possible attitude scores ranged from zero to 14 points, whereas the mean attitudes score was 9,4 (SD: 1,89). Some unacceptable attitudes and knowledge gaps were identified, including disease detection and management. There was an association between the knowledge score and attitude score and between the number of TB patients seen and knowledge/attitude. Conclusion The surveyed interns had an adequate level of TB related knowledge, and acceptable attitudes. However, some unacceptable knowledge gaps and attitudes were detected. This survey underlines the considerable need of closing these knowledge gaps, and improving the attitudes, for which it is important for medical students to practice at a TB clinic and see a certain number of TB patient

Risk of developing tuberculosis after brief exposure in Norwegian children: results of a contact investigation

Objective: Prolonged exposure to adults with pulmonary tuberculosis is a risk factor for infecting children. We have studied to what extent a brief exposure may increase the risk of being infected in children. Design: Observational study of a tuberculosis contact investigation. Setting: 7 day-care centres and 4 after-school-care centres in Norway. Participants: 606 1-year-old to 9-year-old children who were exposed briefly to a male Norwegian with smear-positive pulmonary tuberculosis. Main outcome measures: Number of children with latent and active tuberculosis detected by routine clinical examination, chest x-ray and use of a Mantoux tuberculin skin test (TST) and an interferon-γ release assay (IGRA). Results: The children were exposed to a mean of 6.9 h (range 3–18 h). 2–3 months after the exposure, 11 children (1.8%) had a TST ≥6 mm, 6 (1.0%) had TST 4–5 mm, and 587 (97.2%) had a negative TST result. Two children (0.3%) with negative chest x-rays who were exposed 4.75 and 12 h, respectively, had a positive IGRA test result, and were diagnosed with latent tuberculosis. None developed active tuberculosis. Conclusions: Children from a high-income country attending day-care and after-school-care centres had low risk of being infected after brief exposure less than 18 h to an adult day-care helper with smear-positive pulmonary tuberculosis