Tuberculosis Screening In Patients Research Articles

Screening tuberculosis patients for diabetes mellitus in Fiji: notes from the field.

Diabetes (DM) is a problem in Fiji and threatens tuberculosis (TB) control efforts. A review was conducted of all TB patients registered in Fiji in 2011 to assess routine practices of screening for DM. Of 221 TB patients, 138 (62%) had their DM status recorded in their case folders; 18 (13%) had a known history of DM. Random blood glucose (RBG) was performed in 91 (76%) of the remaining 120 patients: 47(52%) had RBG ≥ 6.1 mmol/l, but only three were further investigated, of whom one was diagnosed with DM. There are deficiencies in screening TB patients for DM in Fiji, and improvements are needed.

Rapid Diagnostic Algorithms as a Screening Tool for Tuberculosis: An Assessor Blinded Cross-Sectional Study

BackgroundA major obstacle to effectively treat and control tuberculosis is the absence of an accurate, rapid, and low-cost diagnostic tool. A new approach for the screening of patients for tuberculosis is the use of rapid diagnostic classification algorithms.MethodsWe tested a previously published diagnostic algorithm based on four biomarkers as a screening tool for tuberculosis in a Central European patient population using an assessor-blinded cross-sectional study design. In addition, we developed an improved diagnostic classification algorithm based on a study population at a tertiary hospital in Vienna, Austria, by supervised computational statistics.ResultsThe diagnostic accuracy of the previously published diagnostic algorithm for our patient population consisting of 206 patients was 54% (CI: 47%–61%). An improved model was constructed using inflammation parameters and clinical information. A diagnostic accuracy of 86% (CI: 80%–90%) was demonstrated by 10-fold cross validation. An alternative model relying solely on clinical parameters exhibited a diagnostic accuracy of 85% (CI: 79%–89%).ConclusionHere we show that a rapid diagnostic algorithm based on clinical parameters is only slightly improved by inclusion of inflammation markers in our cohort. Our results also emphasize the need for validation of new diagnostic algorithms in different settings and patient populations.

Position paper on tuberculosis screening in patients with immune mediated inflammatory diseases who are candidates for biological therapy

Chronic immunosuppression is a known risk factor for tuberculosis. Our aim was to reach a consensus on screening and prevention of tuberculosis in patients with immune mediated inflammatory diseases who are candidates to biologic therapy. MethodsCritical appraisal of the literature and expert opinion on immunosuppressive therapies and risk of tuberculosis. Results and conclusionThe currently recommended method for screening is the tuberculin skin test and the interferon gamma assay, after exclusion of active tuberculosis. Positively screened patients should be treated for latent tuberculosis infection. Patients may start biological therapy after 1–2 months, as long as they are strictly adhering to and tolerating their preventive regimen.

2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease‐modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis

The American College of Rheumatology (ACR) most recently published recommendations for use of disease modifying anti-rheumatic drugs (DMARDs) and biologics in the treatment of rheumatoid arthritis (RA) in 2008 (1). These recommendations covered indications for use, monitoring of side-effects, assessment of the clinical response to DMARDs and biologics, screening for tuberculosis (TB), and assessment of the roles of cost and patient preference in decision-making for biologic agents (1). Recognizing the rapidly evolving knowledge in RA management and the accumulation of new evidence regarding the safety and efficacy of existing and newer therapies, the ACR commissioned an update of the 2008 recommendations in select topic areas. The 2012 revision updates the 2008 ACR recommendations in the following areas: (1) indications for DMARDs and biologics; (2) switching between DMARD and biologic therapies; (3) use of biologics in high-risk patients (those with hepatitis, congestive heart failure, and malignancy); (4) screening for TB in patients starting or currently receiving biologics; and (5) vaccination in patients starting or currently receiving DMARDs or biologics (Table 1). Table 1 Overview Comparison of Topics and Medications Included in the 2008 and 2012 ACR RA Recommendations METHODS We utilized the same methodology as described in detail in the 2008 guidelines (1) to maintain consistency and to allow cumulative evidence to inform this 2012 recommendation update. These recommendations were developed by two expert panels: (1) a non-voting working group and Core Expert Panel (CEP) of clinicians and methodologists responsible for the selection of the relevant topic areas to be considered, the systematic literature review, and the evidence synthesis and creation of “clinical scenarios”; and (2) a Task Force Panel (TFP) of 11 internationally-recognized expert clinicians, patient representatives and methodologists with expertise in RA treatment, evidence-based medicine and patient preferences who were tasked with rating the scenarios created using an ordinal scale specified in the Research and Development/University of California at Los Angeles (RAND/UCLA) Appropriateness method (2–4). This method solicited formal input from a multi-disciplinary TFP panel to make recommendations informed by the evidence. The methods used to develop the updated ACR recommendations are described briefly below. Systematic Literature Review – Sources, Databases and Domains Literature searches for both DMARDs and biologics relied predominantly on PubMed searches) with medical subject headings (MeSH) and relevant keywords similar to those used for the 2008 ACR RA recommendations (see Appendices 1 and 2). We included randomized clinical trials (RCTs), controlled clinical trials (CCTs), quasi-experimental designs, cohort studies (prospective or retrospective), and case-control studies, with no restrictions on sample size. More details about inclusion criteria are listed below and in Appendix 3. The 2008 recommendations were based on a literature search that ended on February 14, 2007. The literature search end date for the 2012 Update was February 26, 2010 for the efficacy and safety studies and September 22, 2010 for additional qualitative reviews related to TB screening, immunization and hepatitis (similar to the 2008 methodology). Studies published subsequent to that date were not included. For biologics, we also reviewed the Cochrane systematic reviews and overviews (published and in press) in the Cochrane Database of Systematic Reviews to identify additional studies (5–8) and further supplemented by hand-checking the bibliographies of all included articles. Finally, the CEP and TFP confirmed that relevant literature was included for evidence synthesis. Unless they were identified by the literature search and met the article inclusion criteria (see Appendix 3), we did not review any unpublished data from product manufacturers, investigators, or the Food and Drug Administration (FDA) Adverse Event Reporting System. We searched the literature for the eight DMARDs and nine biologics most commonly used for the treatment of RA. Literature was searched for eight DMARDS including azathioprine, cyclosporine, hydroxychloroquine, leflunomide, methotrexate, minocycline, organic gold compounds and sulfasalazine. As in 2008, azathioprine, cyclosporine and gold were not included in the recommendations based on infrequent use and lack of new data (Table 1). Literature was searched for nine biologics including abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, infliximab, rituximab and tocilizumab; anakinra was not included in the recommendations due to infrequent use and lack of new data. Details of the bibliographic search strategy are listed in Appendix 1.

Identification of False-Positive QuantiFERON-TB Gold In-Tube Assays by Repeat Testing in HIV-Infected Patients at Low Risk for Tuberculosis

The QuantiFERON-TB Gold In-Tube assay (QFT) is increasingly being used for latent tuberculosis screening in patients infected with human immunodeficiency virus (HIV) in the United States. This is a retrospective analysis of repeating positive QFT assays as a strategy to identify false-positive results in HIV-infected patients at low risk for tuberculosis.

Alcohol use disorders (AUD) among tuberculosis patients: a study from Chennai, South India.

BackgroundAlcohol Use Disorders (AUDs) among tuberculosis (TB) patients are associated with nonadherence and poor treatment outcomes. Studies from Tuberculosis Research Centre (TRC), Chennai have reported that alcoholism has been one of the major reasons for default and mortality in under the DOTS programme in South India. Hence, it is planned to conduct a study to estimate prevalence of alcohol use and AUDs among TB patients attending the corporation health centres in Chennai, India.MethodologyThis is a cross-sectional cohort study covering 10 corporation zones at Chennai and it included situational assessment followed by screening of TB patients by a WHO developed Alcohol Use Disorders Identification Test AUDIT scale. Four zones were randomly selected and all TB patients treated during July to September 2009 were screened with AUDIT scale for alcohol consumption.ResultsOut of 490 patients, 66% were males, 66% were 35 years and above, 57% were married, 58% were from the low monthly income group of <Rs 5000 per month. No females reported alcohol use. Overall, out of 490 TB pts, 29% (141) were found to consume alcohol. Among 141 current drinkers 52% (73) had an AUDIT score of >8. Age (>35 years), education (less educated), income (<Rs 5000 per month), marital status (separated/divorced) and treatment category (Category 2) were statistically significant for TB patients with alcohol use than those TB patients without alcohol use.ConclusionsAUD among TB patients needs to be addressed urgently and the findings suggest the importance of integrating alcohol treatment into TB care.

Interferon γ release assay (IGRA) testing in mycobacterium tuberculosis screening prior to anti-tnf treatment: experience across 3 medical specialities

IntroductionAnti-tumour necrosis factor (anti-TNF) agents are important treatments for a range of inflammatory conditions but are associated with a fivefold increase risk of tuberculosis (TB). Newer tests based on T...

Tuberculosis Screening in Patients Starting Antiretroviral Therapy in Sub-Saharan Africa: Stretching Diagnostics to the Limits

TO THE EDITOR—We read with interest the article by Bassett et al [1] about intensive screening for pulmonary tuberculosis (TB) among human immunodeficiency virus (HIV)–infected patients initiating antiretroviral treatment (ART) at an outpatient service in Durban, South Africa. All patients without a pre-existing TB diagnosis (median CD4 cell count, 100 cells/μL) were screened using sputum culture, and 19% were confirmed to have pulmonary TB. Only 52% of patients with TB reported cough, and the sensitivity of sputum smear microscopy was only 9%. The authors concluded that, in settings with high TB prevalence, screening using sputum culture should be routine in this patient population. However, infrastructure to do this is currently lacking in many countries. In similar studies involving patients starting ART in Cape Town, South Africa [2, 3], we also found a very high prevalence of undiagnosed TB of 25% (95% confidence interval, 20%–31%). In view of the low sensitivity of symptom screening and of sputum smear microscopy (14%), compared with liquid culture [2], we similarly concluded that routine sputum culture is required. Intensive screening before ART in our cohort halved the TB incidence rate during the initial months of ART, effectively reducing morbidity and simplifying patient treatment [3]. An important difference between our studies is that Bassett et al [1] collected only a single sputum specimen, compared with our study, in which 2 specimens were obtained at a single clinic visit. Re-examining our data, the first sputum sample yielded 45 TB cases (19% of 235 patients screened), compared with 58 cases (25% of 235) from both samples. Thus, 22% of the TB diagnoses were reliant on a second sample being obtained. This is similar to the 17% incremental yield from a second sample in a study screening for HIV-associated TB in Southeast Asia [4]. Evaluation of intensive TB screening strategies should include analysis of the incremental cost of culturing >1 sample. The substantially increased yield of TB cases from analysis of a second sample may relate to the fact that the numbers of bacilli present in sputum samples are likely to be very low in these immunocompromised patients. This is consistent with our observations that the sensitivity of smear microscopy was very low [2], chest radiographs were normal in one-third of cases, and pulmonary cavitation was rare [5]. More direct evidence of low bacillary numbers is provided by the prolonged time to sputum culture positivity using automated liquid culture, with a mean duration of >3 weeks [2]. When bacillary concentrations approach the limits of detection in liquid culture (10–100 organisms per mL of sputum), the yield of TB diagnoses will be strongly dependent on the number of samples examined. Bassett et al [1] did not report on the time to diagnosis. This is a critical issue in this patient group with predominantly sputum smear-negative disease in view of high rates of mortality and nosocomial transmission from undiagnosed TB [6–8]. New rapid diagnostic tests are urgently needed to expedite diagnosis to reduce these risks. The Xpert MTB/RIF assay (GeneXpert; Cepheid) is a novel, fully automated nucleic acid amplification test and represents a major advancement, providing an extremely rapid (<2 h) and specific TB diagnosis with use of near-patient technology [9, 10]. However, when screening for TB among patients starting ART, the assay is likely to be stretched to its limits of detection (95% sensitivity in sputum samples with 131 bacilli per mL [9]). In a recent clinical field evaluation, sensitivities for smear-negative TB were strongly dependent on the number of samples analyzed, detecting 73%, 85%, and 90% of culture-confirmed cases when analyzing 1, 2, or 3 samples, respectively. It will be important to assess the sensitivity of this assay among patients commencing ART in whom bacillary numbers in sputum are likely to be even lower. Thus, multiple samples may be needed to achieve adequate sensitivity. An additional, much cheaper approach to rapid screening and diagnosis in patients with very advanced immunodeficiency may be provided by detection of urinary lipoarabinomannan. Although sensitivity in this patient group is only moderate [2, 11], a simple lateral flow version is being evaluated as a point-of-care test.

High HIV-TB Co-infection Rates in Marginalized Populations: Evidence from Alberta in Support of Screening TB Patients for HIV

Heretofore we have not seen strong evidence of synergy between HIV and tuberculosis (TB) in Canada. This may simply reflect a lack of concurrent surveillance for the two diseases. To date, the goal of universal HIV testing of TB patients (> 80% tested) in Canada has not been achieved, despite the existence of two national advisories recommending universal HIV testing of TB patients. In response to these advisories, we recently undertook to demonstrate the feasibility of using an 'opt-out' approach to achieve universal HIV testing of TB patients in Alberta--see the Canadian Journal of Public Health 2009;100(2):116-20. In the present commentary, we add two more years of data (2007-2008) to our earlier report and demonstrate for the first time that HIV co-infection is significantly greater in middle-aged (35-64 years) compared to young adult (15-34 years) TB patients and in Aboriginal and sub-Saharan African, compared to Canadian-born non-Aboriginal and foreign-born 'other' TB patients. Our findings underscore the need for universal concurrent testing as well as greater interaction between TB and HIV programs.

Tuberculosis screening in patients with psoriasis before antitumour necrosis factor therapy: comparison of an interferon-γ release assay vs. tuberculin skin test

Antitumour necrosis factor (anti-TNF) treatments may reactivate latent tuberculosis infection (LTBI). For detecting LTBI, the tuberculin skin test (TST) has low sensitivity and specificity. Interferon-gamma release assays (IGRA) have been shown to be more sensitive and specific than TST. To compare the TST and the T-SPOT.TB IGRA for identifying LTBI in patients with psoriasis before anti-TNF treatment. A retrospective study was carried out over a 4-year period on patients with psoriasis requiring anti-TNF treatment. All were subjected to the TST, T-SPOT.TB and chest X-ray. Risk factors for LTBI and history of bacillus Calmette-Guérin (BCG) vaccination were recorded. The association of T-SPOT.TB and TST results with risk factors for LTBI was tested through univariate logistic regression models. Agreement between tests was quantified using kappa statistics. Treatment for LTBI was started 1 month before anti-TNF therapy when indicated. Fifty patients were included; 90% had prior BCG vaccination. A positive T-SPOT.TB was strongly associated with a presumptive diagnosis of LTBI (odds ratio 7.43; 95% confidence interval 1.38-39.9), which was not the case for the TST. Agreement between the T-SPOT.TB and TST was poor, kappa = 0.33 (SD 0.13). LTBI was detected and treated in 20% of the patients. In 20% of the cases, LTBI was not retained in spite of a positive TST but a negative T-SPOT.TB. All patients received an anti-TNF agent for a median of 56 weeks (range 20-188); among patients with a positive TST/negative T-SPOT.TB, no tuberculosis was detected with a median follow-up of 64 weeks (44-188). One case of disseminated tuberculosis occurred after 28 weeks of adalimumab treatment in a patient with LTBI in spite of treatment with rifampicin. This study is the first to underline the frequency of LTBI in patients with psoriasis (20%), and to support the use of IGRA instead of the TST for its detection. Nevertheless, there is still a risk of tuberculosis under anti-TNF therapy, even if LTBI is correctly diagnosed and treated.

Philippine guidelines on the screening for tuberculosis prior to the use of biologic agents

AbstractAim: To develop practice guidelines in tuberculosis screening of patients and their households and close contacts, prior to the use of biologic agents.Method: A technical research committee formulated an evidence‐based draft, based on existing literature regarding the tests used in tuberculosis screening among immunocompromised patients. The evidence‐based draft was then circulated to an expert panel. An en banc meeting of the panelists was held and a consensus was declared if more than 50% agreed on a recommendation. Issues not resolved by consensus were discussed by correspondence and voted upon. The guidelines were presented in a public forum and feedback by stakeholders were reviewed and integrated into the final draft.Recommendations: 1. Patients for biologic therapy should be screened for latent and active tuberculosis prior to initiating treatment. 2. All patients who are candidates for biologic agents should be screened by tuberculin skin test for latent TB, and a chest radiograph for active tuberculosis. 3. Household and close contacts of candidate patients should be screened for active tuberculosis. 4. All household and close contacts of candidate patients should be screened for active TB using chest radiograph. 5. Treat latent and active tuberculosis according to local guidelines. 6. Delay treatment with biologic agents in patients with latent or active tuberculosis. 7. Administer tuberculosis prophylaxis to the patient for biologic therapy exposed to household contacts with active tuberculosis.Conclusion: These recommendations emphasize the importance of screening patients, household and close contacts for latent and active tuberculosis prior to initiating biologic therapy.

Erythrocyte sedimentation rate may be an indicator for screening of tuberculosis patients for underlying HIV infection, particularly in resource-poor settings: an experience from India.

Sir,India has been experiencing the most serious publichealth challenge caused by HIV epidemic since its first detection in 1986 (1). The country has an estimated 4.58 million HIV-infected individuals (2). Prevalence data on HIV infection collected from various parts of the country indicate its spread from urban to rural areas and from high risk to general population (3). Because of continued HIV transmission in the community for the last many years, the country is witnessing several opportunistic infections associated with HIV infection, of which tuberculosis (TB) is the most prominent.Early detection and effective treatment with regular follow-up until complete recovery is the most important strategy to control the spread of tuberculosis in the community. India needs special attention to control TB as the country harbours a large number of TB patients and many of whom are associated with HIV infection. The effects of HIV on TB include: (a) More transmission of TB bacteria in the community, (b) TB progresses faster in HIV-infected people, and (c) TB in HIV-positive people is more likely to be fatal if diagnosed late or left untreated (4).Unfortunately, the HIV status of a sizable number of tuberculosis patients detected by the local physicians remains unknown due to the shortage of HIV testing facilities. The present study, conducted at the National Institute of Cholera and Enteric Diseases (ICMR), Kolkata, India, was aimed at finding a positive predictive factor in tuberculosis patients, particularly in resource-poor settings, so that underlying HIV could be detected to a great extent using minimum diagnostic resources.Data of routine investigations of 34 pulmonary tuberculosis patients associated with HIV infection, diagnosed during July-December 2003, were reviewed. The routine investigations included total count (TC), differential count (DC), haemoglobin (Hb), erythrocyte sedimentation rate (ESR), and mode of diagnosis. The data were compared with data from a similar group of pulmonary tuberculosis patients (n=25), who were detected during the same time but not associated with HIV infection.There was not much difference in basic investigations between these two groups, except in ESR values. Most tuberculosis patients with HIV infection had a much lower ESR value compared to the control group. The mean and median values of ESR, respectively, were 38.5 mm per hour and 30.0 mm per hour among patients with HIV infection (n=34) compared to 102 mm per hour and 108 mm per hour among those without HIV infection (n=25).Table 1 shows the relationship between TB with or without HIV infection and ESR status, and Table 2 shows the age distribution of TB subjects of both the groups. …

Human immunodeficiency virus and tuberculosis co-infection in Saudi Arabia

Our study determined the rate of screening tuberculosis patients for HIV co-infection and the HIV seroprevalence among them. We retrospectively reviewed medical charts of 437 patients diagnosed with tuberculosis from 1995-2000 in Riyadh, Saudi Arabia. Screening was done for 178 [41%] patients: 2 [1.1%] of these were found to be HIV positive. Prior to screening, 4 patients were already known to be HIV positive. Males were screened more often than females [45% and 36% respectively]. All HIV positive patients were males. Screening was not affected by origin of the patient, history of prior tuberculosis or treatment, type of tuberculosis involvement or resistance to first line anti-tuberculosis agents. In Saudi Arabia, screening for HIV in tuberculosis patients remains underutilized. Among screened patients, seropositivity was low.

Frequency And Outcome In AIDS Patients In A University Teaching Hospital – A Five Year Review

This study was carried out as part of a restrospective study on the pattern of in-patient admissions to a tertiary health institution situated in a semi-rural/urban community in Nigeria. It aimed at evaluating the changing frequency of AIDS amongst medical admissions as well as the morbidity and mortality among these patients. A total of 54 AIDS patients were admitted on the medical wards during the period 1993 to 1997, thus constituting 2.3% of all medical admissions. The frequency increased from 1.0% in 1993 to 7.2% in 1997. Out of the 54 AIDS patients seen, 38 were HIV I and II positive, 11 were HIV I positive and 5 were HIV II positive. There were 37 males and 17 females, giving a male:female ratio of 2:1. The commonest age of presentation was in the 4th decade but a rising trend was observed among females in the second and third decades towards the end of the study. Fifty-one of the study group (94%) were in the lower socio-economic class; 20 were long distance truck drivers/conductors (37%), 16 were inter-state traders (30%), 6 were house-wives (11%) and 4 were retired members of the armed forces (7%). Twenty-nine (54%) of the patients were married, 12 (22%) were single, 9 (17%) were divorcees while the marital status of the remaining 4 patients was not stated. Twenty-one patients (39%) were heterosexuals with multiple sexual partners while 25 (46%) were heterosexuals with single sexual partners. Blood transfusion was the predisposing factor in 6 (11%) of the patients while no obvious predisposing factor was identified in 2 (4%) of the patients. Homosexualism and intravenous drug usage were not reported in any of the subjects. The presenting features were diarrhoea, chronic weakness, weight loss chronic cough, generalised dermatitis and oesophageal candidoses. Abnormal haematological indices included anaemia, leucocytosis and leucopenia. Twenty-three patient (42%) died within 6 months of diagnosis in the hospital, 16 (30%) were discharged to Medical/Community medicine out-patient clinic for follow-up, 7 (13%) discharged themselves against medical advice and 8 (15%) were lost to follow-up. In conclusion, this study demonstrated an increasing frequency and mortality of AIDS among medical in-patients in a tertiary health institution located in a semi - rural area. A community based study would be needed to assess the seriousness of this infection and reflect the efficacy or other wise of current control measures. The association of tuberculosis and HIV infection was observed, thereby justifying the screening of such patients for tuberculosis. Nigerian Quarterly Journal of Hospital Medicine Vol.9, No.3 (1999) pp. 177-179

Evaluation of a tuberculosis screening program at a children's hospital

Routine screening of patients for tuberculosis at the time of hospitalization and annual screening of hospital employees continue to be controversial. No data are available concerning tuberculosis screening programs at pediatric facilities. We reviewed the results of patient and employee tuberculosis screening programs in the last decade at the Izaak Walton Killam Hospital for Children. Four (11%) of 37 cases of tuberculosis were unsuspected until identified by the routine screening of all children at their admission to the hospital. No cases of tuberculosis were identified as a result of the employee screening program. Compliance with both screening programs was less than optimal. Review of programs at other Canadian pediatric centers demonstrated a range of practice. We conclude that routine screening of patients at the time of admission to the hospital and the annual screening of employees are unwarranted at present at our children's hospital. However, discontinuation of routine testing necessitates aggressive contact-tracing by public health authorities of patients with identified cases and periodic reevaluation of costs and benefits to determine whether reintroduction of screening is appropriate.

Communication: Synthesis of Me α-L-Rhap-(1↠3)-2-O-Me-α-L-Rhap And Me 2,3,4-Tri-O-Me-α-L-Fucp-(1↠3)-α-L-Rhap-(1↠3)-2-O-Me-α-L-Rhap : Oligosaccha-Ride Segments of Phenolic Glycolipids inMycobacterium Bovis BcgandTuberculosis Strain Canetti

The revived interest in phenolic glycolipids of pathogenic mycobacteria is evoked by a widespread1-3 use of Mycobacterium (M.) leprae specific antigen for serodiagnosis of leprosy patients. As a consequence, a few phenolic glycolipids of other mycobacterias were isolated and structurally elucidated. Recently Vercellone and Puzo4 reported the isolation of new phenolic glycolipids not yet described in M. bovis BCG. The combination of sugars in one of the glycolipids was identified as 3-O-(α-L-rhamnopyranosyl)-2-O-methyl-α-L-rhamnopyranoside (1) which is closely related to the trisaccharide segment (2) of M. tuberculosis strain Canetti.5 The latter contains 2,3,4-tri-O-methyl-L-fucopyranosyl monosaccharide α-linked to 3′ position of 1. It has been emphasised that new found glycolipids of M. bovis BCG could share common epitopes with those of M. tuberculosis, thus leading to false positive immunoabsorbent assay tests during screening of tuberculosis patients. In addition, there is concern regarding the involvement of one of the new found glycolipids in the stimulation of T suppressor cells, thus adding to the conflicting results noted in the protection of M. tuberculosis by M. bovis BCG. In essence the new found phenolic glycolipids of M. bovis BCG are associated with interesting but unclear biological profiles. We now report the synthesis of these closely related oligosaccharides, 1 (R = Me) and 2 (R = Me).

Annual Tuberculin Skin Testing of Employees at a University Hospital: A Cost-Benefit Analysis

The usefulness of routine annual tuberculin skin testing (purified protein derivative [PPD]) of hospital employees has been questioned. Between 1984 and the end of 1987 the PPD conversion rates of hospital employees at a university and psychiatric hospital in North Florida were compared. The number of employees in both hospitals were almost equal and compliance with the annual testing was more than 95%. In the psychiatric hospital tuberculosis screening of patients was practiced on admission and annually thereafter. Although no unsuspected smear-positive tuberculosis patients were diagnosed in the psychiatric hospital as compared to four in the university hospital, the annual conversion rates of employees were 0.42% and 0.13%, respectively (p greater than 0.001). However, the ratios of these conversion rates to the incidence of tuberculosis in the counties where these hospitals are located respectively were similar (20.0 vs 24.3, p = 0.7). The community seems be the major source of the PPD conversion. At the university hospital more than +70,000 was spent on the annual PPD testing to discover 15 converters; nine had no or minimal contact with patients and only two complied with isoniazid (INH) prophylaxis. Annual PPD testing is not cost effective in hospitals with a low annual conversion rate among its employees and with low tuberculosis case rates in the hospital and the surrounding community.