{"id":1138,"date":"2016-10-11T15:21:08","date_gmt":"2016-10-11T15:21:08","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1138"},"modified":"2017-08-21T10:47:13","modified_gmt":"2017-08-21T10:47:13","slug":"primary-care-corner-with-geoffrey-modest-md-uspstf-ltbi-screening-recommendations","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/10\/11\/primary-care-corner-with-geoffrey-modest-md-uspstf-ltbi-screening-recommendations\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: USPSTF LTBI Screening Recommendations"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>The USPSTF just came out with their recommendations for screening for LTBI (latent TB infection)\u00a0in populations at increased risk, giving it a &#8220;B&#8221; Grade (a\u00a0recommended service, with &#8220;high certainty that the net benefit is moderate, or there is moderate certainty that the\u00a0net benefit is moderate to substantial&#8221;\u00a0\u00a0(see\u00a0<a href=\"http:\/\/www.uspreventiveservicestaskforce.org\/Page\/Document\/UpdateSummaryFinal\/latent-tuberculosis-infection-screening\">http:\/\/www.uspreventiveservicestaskforce.org\/Page\/Document\/UpdateSummaryFinal\/latent-tuberculosis-infection-screening<\/a> ).<\/p>\n<p>Details:<\/p>\n<p>Background:<\/p>\n<ul>\n<li>The Natl Health and Nutrition Examination Survey in 2011-12 found a national prevalence of LTBI of7% of the US population and 20.5% in those foreign-born<\/li>\n<li>5-10% of those with LTBI progress to active TB during their lifetime<\/li>\n<\/ul>\n<p>Results:<\/p>\n<ul>\n<li>Benefits of screening\n<ul>\n<li>No eligible studies were identified showing\u00a0that targeted screening for LTBI in primary care settings in asymptomatic adults improves quality of life or reduces active TB\/transmission\/mortality<\/li>\n<li>Accuracy of tests:\n<ul>\n<li>Pooled estimates for sensitivity\/specificity of TST\u00a0(tuberculin skin testing)depends on degree of induration\n<ul>\n<li>5\u00a0mm: sensitivity 0.79, specificity 0.30-0.97<\/li>\n<li>10\u00a0mm: sensitivity 0.79, specificity 0.97<\/li>\n<li>15 mm: sensitivity 0.52, specificity 0.99<\/li>\n<\/ul>\n<\/li>\n<li>Pooled estimates for sensitivity\/specificity of\u00a0IGRAs (interferon-\u03b3 release assays), for different tests\n<ul>\n<li>T-SPOT: sensitivity 0.90, specificity 0.95<\/li>\n<li>QuantiFERON-Gold: sensitivity 0.77, specificity 0.98<\/li>\n<li>QuantiFERON-Gold In-Tube: sensitivity 0.80, specificity 0.97<\/li>\n<\/ul>\n<\/li>\n<li>No studies were\u00a0identified that evaluated\u00a0sequential\u00a0screeningstrategies of using both TST\u00a0and IGRAs in asymptomatic patients<\/li>\n<\/ul>\n<\/li>\n<li>Benefits of treatment: does CDC-recommended regimes improve quality of life\/reduce progression or transmission of TB?\n<ul>\n<li>INH for 6 months va placebo\u00a0leads to a relative risk reduction of 0.35 (1.4% in placebo group over 5 yrs, vs 0.5% with INH)<\/li>\n<li>Rifampin for 4 months is equivalent to INH for 9 months<\/li>\n<li>Once-weekly rifapentine plus INHx3 months (directly-observed therapy)\u00a0vs INH for 9 months\u00a0were also statistically equivalent<\/li>\n<\/ul>\n<\/li>\n<li>Harms of screening: no eligible studies<\/li>\n<li>Harms of treatment:\n<ul>\n<li>INH hepatitis\n<ul>\n<li>Hepatitis incidence rate\u00a0vs placebo:\u00a0INH had RR=4.59 for 24 weeks (Number-Needed-To-Harm, NNH=279) and RR=6.21 for 52 weeks<\/li>\n<li>Mortality\u00a0rate\u00a0vs placebo:\u00a0INH had RR=2.35 (NNH= 6947, 0.14\/1000 persons treated)<\/li>\n<\/ul>\n<\/li>\n<li>INH discontinuance rate from adverse events: 1.8% vs 1.2% on placebo (mostly GI distress)<\/li>\n<li>Rifampin (in 3 studies comparing Rifampin to INH): for INH in the 3 studies, hepatotoxicity in 5.2%, 3.7% and 11.4%; for Rifampin: 0%, 0.7%, and 4.4%: ie, pooled INH RR of 3.29 vs Rifampin<\/li>\n<li>Also &lt;1\/2\u00a0the rate of discontinuations with Rifampin vs INH<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Commentary:<\/p>\n<ul>\n<li>The USPSTF\u00a0recommendation does appropriately highlight the important\u00a0issue of checking TB status. There are increasing numbers of high risk people in this country, especially in foreign-born. And I\u00a0have seen several untreated people develop active TB late in life, after being here for decades.<\/li>\n<li>I\u00a0do have concerns about the reliability and stability of the IGRAs, as noted in prior blogs (see\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/03\/15\/primary-care-corner-with-geoffrey-modest-md-latent-tb-infections-screening-and-treatment-and-probs-with-igras\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/03\/15\/primary-care-corner-with-geoffrey-modest-md-latent-tb-infections-screening-and-treatment-and-probs-with-igras\/<\/a>, which\u00a0also goes into more detail on\u00a0identifying who are\u00a0high-risk of LTBI. But most importantly, it\u00a0reviews\u00a0a couple of studies finding quite <strong>remarkable inconsistency of IGRAs<\/strong>:\u00a0many\u00a0people\u00a0who were initially positive but subsequently negative on repeat testing within a couple of months and\u00a0without treatment, i.e. high and unexplained &#8220;reversion&#8221; rates<\/li>\n<li>In terms of treatment regimens, the CDC-recommended ones overall are the INH for either 6 or 9 months (though the 9 month is preferred given somewhat better results) or the rifampin for 4 months (reviewed in\u00a0<a href=\"http:\/\/www.cdc.gov\/tb\/publications\/ltbi\/default.htm\">http:\/\/www.cdc.gov\/tb\/publications\/ltbi\/default.htm<\/a>). Over the past several years, I\u00a0have been prescribing\u00a0only the rifampin one (unless there are difficult drug-drug interactions), without a problem. easier\/shorter regimen and better tolerated<\/li>\n<li>Though I\u00a0realize the issues of anecdotal medicine, I\u00a0will still bring up one of my long-term patients who\u00a0reinforced 2 of the above points to me: he is a 60\u00a0yo Haitian man I have known for several decades\u00a0with really bad uncontrolled\u00a0diabetes, hypertension, HIV, and now on dialysis (of those, his HIV has been consistently well controlled, with CD4 in the 250-300 range and viral load consistently suppressed). He worked for decades as a health aide in a nursing home and had repeatedly negative annual PPDs (about as good as one can get for accuracy of\u00a0PPD screening). He was being evaluated by a\u00a0transplant physician who insisted that he go to ID\/HIV clinic to be cleared for surgery. They did a QuantiFERON-Gold test which came back positive for TB. He was started on INH, but within 2 months developed a nearly fatal case of INH\u00a0hepatitis leading to a many week stay in an ICU. He recovered, but I\u00a0decided to check the QuantiFERON-Gold again,\u00a0which turned out to be negative&#8230;&#8230;<\/li>\n<li>So, my bottom line: I still rely on TST screening for TB, based on that prior blog and reinforced by my anecdotal case, though I\u00a0understand the appeal of the \u00a0IGRAs (I had had\u00a0assumed\u00a0I would be using IGRAs\u00a0in my patient population, which is largely foreign-born and has had a high rate of prior BCG vaccination, since it made sense mechanistically\u00a0that it would be more accurate than PPDs\u00a0and there is no need to come back in 48-72 hours for a reading, no need for booster PPDs in those who had not had one for a long time, etc.)\u00a0And, I do find the rifampin based treatment of LTBI to be easy and well-tolerated, though with forewarning about red urine&#8230;.<\/li>\n<\/ul>\n<p>For the CDC recommendations on PPD screening, see\u00a0<a href=\"http:\/\/www.cdc.gov\/tb\/publications\/factsheets\/testing\/skintesting.htm\">http:\/\/www.cdc.gov\/tb\/publications\/factsheets\/testing\/skintesting.htm<\/a> )<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: USPSTF LTBI Screening Recommendations  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/10\/11\/primary-care-corner-with-geoffrey-modest-md-uspstf-ltbi-screening-recommendations\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1138","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1138","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1138"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1138\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1138"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1138"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1138"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}