Screening for latent tuberculosis in UK health care workers

Screening for latent tuberculosis in UK health care workers Occupational Medicine 2018;68:72 LETTER TO THE EDITOR doi:10.1093/occmed/kqx181 from the national surveillance centre for communicable Screening for latent tuberculosis in UK diseases in Ireland (the Health Protection Surveillance health care workers Centre) confirm transmission from a HCW was not implicated in any case of TB notified over the 3 years of Dear Sir, our study (O’Donnell, personal communication). In their recent paper, Henderson and Howard [1] follow- In conclusion, our results broadly mirror the findings of ing detection of two cases of pulmonary Mycobacterium Henderson et  al. We support their assertion that ‘the cost tuberculosis (TB) in health care workers (HCWs) from effectiveness of the [current screening] exercise is uncer- high-endemicity countries in a National Health Service tain, as is the level of risk mitigated’ [1]. Indeed, there (NHS) trust investigated the number of HCWs within appears to be little evidence that the pre-placement TB their organization at risk of reactivation of previous TB screening programme as presently configured is sufficiently infection. In response the trust occupational health ser- proportionate or necessary in terms of risk to patients from vice screened 469 current clinical employees from high- forward transmission of TB from HCW. It is also ques- incidence countries and found an incidence rate of latent tionable whether the NNS supports the current screen- TB to be 27%. ing approach (i.e. one based on the current definitions of We carried out a similar study across two multicen- ‘high-risk’ groups or high-endemicity countries) in terms of tre occupational health services in Ireland. Our study optimizing employee health and reducing sickness-related had similar numbers (n = 505); however in contrast, we absenteeism. We suggest that the occupational health TB prospectively screened all HCWs arriving from high- screening programme be revised and refocused to maxi- incidence countries over a three-year period. We found a mize the cost benefit and effectiveness of scarce occupa- lower latent TB rate of 17%, compared with 27% in the tional health resources in protecting and promoting health. above study. The reason for this is unclear; however, this likely reflects unmeasured confounders such as different rates of prevalence in different countries of origin. Of the Sarah Kelly 17% of our cohort who tested positive for latent tubercu- Peter Noone losis infection (LTBI), 26% completed treatment, com- Alex Reid pared with 33% of those with LTBI in the Henderson e-mail: sarah21kelly@hotmail.com study who commenced treatment. We examined the very References low treatment uptake in our study, but it is possible the discrepancy could be explained by our measure of ‘treat- 1. Henderson M, Howard SJ. Screening for latent tuberculosis ment completion’ versus ‘treatment commencement’. in UK health care workers. Occup Med (Lond) 2017; 67: Given the issue of multidrug resistant TB, one could 641–643. argue treatment completion as a more valid measure of 2. International Union Against Tuberculosis Committee on effectiveness. Prophylaxis. Efficacy of various durations of isoniazid pre- To explore the effectiveness of the screening pro- ventive therapy for tuberculosis: five years of follow-up in gramme, we calculated the number needed to screen the IUAT trial. Bull World Health Organ 1982;60:555–564. (NNS) in order to prevent one active case of TB. Based 3. Lobue P, Menzies D. Treatment of latent tuberculosis infec- tion: an update. Respirology 2010;15:603–622. on our figures, assuming a 10% lifetime risk of reactiva- 4. Comstock GW, Livesay VT, Woolpert SF. The prognosis of tion [2] and a 70% risk reduction of reactivation after a positive tuberculin reaction in childhood and adolescence. 6  months of treatment of isoniazid [3], a NNS of 333 Am J Epidemiol 1974;99:131–138. was obtained. This is likely to underestimate the actual 5. Nienhaus A, Schablon A, Preisser AM, Ringshausen FC, figure, as it does not allow for LTBI cases that reflect Diel R. Tuberculosis in healthcare workers—a narrative exposure to M. tuberculosis in the distant past which are review from a German perspective. J Occup Med Toxicol known to be at much lower risk of reactivation [4,5]. 2014;9:9. When considering whether screening for LTBI reduces 6. Schepisi MS, Sotgiu G, Contini S, Puro V, Ippolito G, the potential risk of transmission to patients, it should Girardi E. Tuberculosis transmission from healthcare work- be borne in mind that TB transmission from HCWs to ers to patients and co-workers: a systematic literature review patients is rare [6]. Consistent with this, data available and meta-analysis. PLoS One 2015;10:e0121639. © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com Downloaded from https://academic.oup.com/occmed/article-abstract/68/1/72/4866349 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Occupational Medicine Oxford University Press

Screening for latent tuberculosis in UK health care workers

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com
ISSN
0962-7480
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1471-8405
D.O.I.
10.1093/occmed/kqx181
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Abstract

Occupational Medicine 2018;68:72 LETTER TO THE EDITOR doi:10.1093/occmed/kqx181 from the national surveillance centre for communicable Screening for latent tuberculosis in UK diseases in Ireland (the Health Protection Surveillance health care workers Centre) confirm transmission from a HCW was not implicated in any case of TB notified over the 3 years of Dear Sir, our study (O’Donnell, personal communication). In their recent paper, Henderson and Howard [1] follow- In conclusion, our results broadly mirror the findings of ing detection of two cases of pulmonary Mycobacterium Henderson et  al. We support their assertion that ‘the cost tuberculosis (TB) in health care workers (HCWs) from effectiveness of the [current screening] exercise is uncer- high-endemicity countries in a National Health Service tain, as is the level of risk mitigated’ [1]. Indeed, there (NHS) trust investigated the number of HCWs within appears to be little evidence that the pre-placement TB their organization at risk of reactivation of previous TB screening programme as presently configured is sufficiently infection. In response the trust occupational health ser- proportionate or necessary in terms of risk to patients from vice screened 469 current clinical employees from high- forward transmission of TB from HCW. It is also ques- incidence countries and found an incidence rate of latent tionable whether the NNS supports the current screen- TB to be 27%. ing approach (i.e. one based on the current definitions of We carried out a similar study across two multicen- ‘high-risk’ groups or high-endemicity countries) in terms of tre occupational health services in Ireland. Our study optimizing employee health and reducing sickness-related had similar numbers (n = 505); however in contrast, we absenteeism. We suggest that the occupational health TB prospectively screened all HCWs arriving from high- screening programme be revised and refocused to maxi- incidence countries over a three-year period. We found a mize the cost benefit and effectiveness of scarce occupa- lower latent TB rate of 17%, compared with 27% in the tional health resources in protecting and promoting health. above study. The reason for this is unclear; however, this likely reflects unmeasured confounders such as different rates of prevalence in different countries of origin. Of the Sarah Kelly 17% of our cohort who tested positive for latent tubercu- Peter Noone losis infection (LTBI), 26% completed treatment, com- Alex Reid pared with 33% of those with LTBI in the Henderson e-mail: sarah21kelly@hotmail.com study who commenced treatment. We examined the very References low treatment uptake in our study, but it is possible the discrepancy could be explained by our measure of ‘treat- 1. Henderson M, Howard SJ. Screening for latent tuberculosis ment completion’ versus ‘treatment commencement’. in UK health care workers. Occup Med (Lond) 2017; 67: Given the issue of multidrug resistant TB, one could 641–643. argue treatment completion as a more valid measure of 2. International Union Against Tuberculosis Committee on effectiveness. Prophylaxis. Efficacy of various durations of isoniazid pre- To explore the effectiveness of the screening pro- ventive therapy for tuberculosis: five years of follow-up in gramme, we calculated the number needed to screen the IUAT trial. Bull World Health Organ 1982;60:555–564. (NNS) in order to prevent one active case of TB. Based 3. Lobue P, Menzies D. Treatment of latent tuberculosis infec- tion: an update. Respirology 2010;15:603–622. on our figures, assuming a 10% lifetime risk of reactiva- 4. Comstock GW, Livesay VT, Woolpert SF. The prognosis of tion [2] and a 70% risk reduction of reactivation after a positive tuberculin reaction in childhood and adolescence. 6  months of treatment of isoniazid [3], a NNS of 333 Am J Epidemiol 1974;99:131–138. was obtained. This is likely to underestimate the actual 5. Nienhaus A, Schablon A, Preisser AM, Ringshausen FC, figure, as it does not allow for LTBI cases that reflect Diel R. Tuberculosis in healthcare workers—a narrative exposure to M. tuberculosis in the distant past which are review from a German perspective. J Occup Med Toxicol known to be at much lower risk of reactivation [4,5]. 2014;9:9. When considering whether screening for LTBI reduces 6. Schepisi MS, Sotgiu G, Contini S, Puro V, Ippolito G, the potential risk of transmission to patients, it should Girardi E. Tuberculosis transmission from healthcare work- be borne in mind that TB transmission from HCWs to ers to patients and co-workers: a systematic literature review patients is rare [6]. Consistent with this, data available and meta-analysis. PLoS One 2015;10:e0121639. © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com Downloaded from https://academic.oup.com/occmed/article-abstract/68/1/72/4866349 by Ed 'DeepDyve' Gillespie user on 16 March 2018

Journal

Occupational MedicineOxford University Press

Published: Jan 1, 2018

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