Latent Tuberculosis Testing Research Articles

Online Survey on the Acceptance of Latent Tuberculosis Testing and Isoniazid Preventive Therapy among Healthcare Workers in Nigeria

Background: Healthcare workers in Nigeria are exposed to myriads of occupational risks including workplace acquired infections such as tuberculosis. Methods: This study was a cross-sectional survey and used google form to administer the questionnaire via social media networks. Descriptive statistical methods were used to summarize data on socio-demographic characteristics and responses to questions, Microsoft excel and SPSS version 20.0 for statistical analysis of data summarized as categorical variables, frequency (n) and percentages (%). Results: About six out of ten of the participants believed that they could be severely ill if they got tuberculosis. Majority of respondents 413 (89.2%) reported acceptance of latent TB testing while 87.7% agreed to take Isoniazid treatment if they test positive for LTBI. The occupational risk group was found to be less likely to accept LTBI testing. Also, respondents from the Northeast (OR = 4.225; 95% CI = 1.216-14.688; p value = 0.023) and southeast (OR = 4.494; 95% CI = 1.382-14.609; p value = 0.012) were four times more likely to accept isoniazid preventive treatment respectively. Participants who held that tuberculosis is a serious disease were more likely to accept isoniazid preventive treatment (OR = 2.220; 95% CI = 1.100-4.480 p value = 0.026). The majority of the HCW (56%) in the study never get tested for LTBI. Conclusion: the majority of the healthcare workers in this study showed that TB is a dangerous disease and agreed to get regular testing and isoniazid therapy to prevent tuberculosis.

Quantiferon in the Diagnosis of Tuberculosis

Quantiferon test (QFT) is an indirect diagnostic test for latent tuberculosis (TB) infection and active TB. Objectives: The aim of this study is to investigate the role of Quantiferon-TB Gold test as one of the interferon-gamma release assays (IGRAs) in detecting LTBI. Research Methodology: This study was conducted at private lab in Tripoli during the period from October 2022 to January 2023, Diagnosis of 254 sample recorded. QFT was performed in accordance with the manufacturer’s instructions. Results: The study include (n= 254 cases), (58 sample 22.8 %) show positive results by Quantiferon test while (196 sample 77.1%) show negative test. Females constituted 118 (46.4%) of the total cases, while the males constituted 136 (53.6%). the age (31-40 years) for the negative include (35 cases 13.7%) while (41-50 years and (61-70 years) for positive include (11cases 4.3%). Discussion: This study confirmed previous reports that the QFT test had greater sensitivity for detecting active TB than the 100-year-old TST. Conclusion: It was concluded that the quantiferon TB-2G test is a more useful diagnostic method for tuberculosis infection. QFT-Plus assay showed good sensitivity for active TB and was particularly useful for the evaluation of children with suspected LTBI, giving a low rate of indeterminate results in this group. More studies are needed to properly evaluate QFT-Plus ability in discriminating active disease from latent infection.

Quantiferon in the Diagnosis of Tuberculosis

Quantiferon test (QFT) is an indirect diagnostic test for latent tuberculosis (TB) infection and active TB. Objectives: The aim of this study is to investigate the role of Quantiferon-TB Gold test as one of the interferon-gamma release assays (IGRAs) in detecting LTBI. Research methodology: This study was conducted at private lab in Tripoli during the period from October 2022 to January 2023, Diagnosis of 254 sample recorded. QFT was performed in accordance with the manufacturer’s instructions. Results: The study include (n= 254 cases), (58 sample 22.8 %) show positive results by Quantiferon test while (196 sample 77.1%) show negative test. Females constituted 118 (46.4%) of the total cases, while the males constituted 136 (53.6%). the age (31-40 years) for the negative includes (35 cases 13.7%) while (41-50 years and (61-70 years) for positive include (11cases 4.3%). Discussion: This study confirmed previous reports that the QFT test had greater sensitivity for detecting active TB than the 100-year-old TST. Conclusion: It was concluded that the quantiferon TB-2G test is a more useful diagnostic method for tuberculosis infection. QFT-Plus assay showed good sensitivity for active TB and was particularly useful for the evaluation of children with suspected LTBI, giving a low rate of indeterminate results in this group. More studies are needed to properly evaluate QFT-Plus ability in discriminating active disease from latent infection.

Do the drug doses of conventional synthetic DMARDs used for the treatment of biologic/targeted-synthetic DMARDs naive rheumatoid arthritis patients affect QuantiFERON-TB Gold Plus test results?

We aimed to obtain the effects of immunosuppressive doses on the QuantiFERON-TB Gold Plus (QFT-Plus) test results in Rheumatoid Arthritis (RA) patients. Besides this, the impact of the TB2 tube in QFT-Plus test was also investigated. This study included RA patients registered to HURBIO and were screened via QFT-Plus test for latent tuberculosis between January 2018 and March 2021, before the initiation of treatment of biologic/targeted-synthetic disease modifying anti-rheumatismal drugs (b/ts-DMARDs). Patients using methotrexate ≥ 10mg or leflunomide (any dose) or steroids (≥ 7.5mg prednisolone) at the time of QFT-Plus test were classified as the "high dose" group and the rest of the patients constituted the "low dose" group. The study included 534 RA patients; 353 [66.1%] in the high-dose group and 181 [33.9%] in the low-dose group. While QFT-Plus test was positive in 10.5% (37/353) patients in the high-dose group, it was positive in 20.4% (37/181) patients in the low-dose group (p < 0.001). The percentage of QFT-Plus indeterminate results were similar (around 2%) in both groups. The contribution of the TB2 tube to QFT-Plus test positivity was 6.89%. During a median (inter-quartile range) follow-up period of 23 (7-38) months under treatment of b/ts-DMARDs, latent TB reactivation was not observed. Primer active tuberculosis disease developed in two patients. Positive test results of Interferon-Gamma Release Assays (IGRAs) could decrease as immunosuppressive treatment doses increase in patients with RA and addition of the TB2 tube could increase test sensitivity.

YIELD OF SERIAL TESTING FOR TUBERCULOSIS EXPOSURE IN THE STUDY OF A PROSPECTIVE ADULT RESEARCH COHORT WITH INFLAMMATORY BOWEL DISEASES (SPARC IBD)

More than 2 million Americans have Inflammatory Bowel Diseases (IBD), including Crohn’s Disease or Ulcerative Colitis. Although tuberculosis is uncommon in the United States, patients with IBD are at an increased risk for active tuberculosis infection due to the immunosuppressant therapies used to treat IBD. Due to this risk, testing for latent tuberculosis is recommended prior to and intermittently throughout administration of most IBD medications. The utility of this practice in a country with a low incidence and prevalence of tuberculosis is unknown. We aimed to determine the proportion of initial and subsequent tuberculosis tests that are positive, negative, or indeterminate.

A Simple Admission Order-set Improves Adherence to Canadian Guidelines for Hospitalized Patients With Severe Ulcerative Colitis.

Individuals hospitalized with severe ulcerative colitis represent a complex group of patients. Variation exists in the quality of care of admitted patients with inflammatory bowel disease. We hypothesized that implementation of a standardized admission order set could result in improved adherence to current best practice guidelines (Toronto Consensus Statements) for the management of this patient population. A retrospective cohort study of patients admitted with severe ulcerative colitis to a Montreal tertiary center was conducted. Two cohorts were defined based on pre- and post-implementation of a standardized order set. Adherence to 11 quality indicators was assessed before and after implementation of the intervention. These included: Clostridioides difficile and stool cultures testing, ordering an abdominal X-ray and CRP, organizing a flexible sigmoidoscopy, documenting latent tuberculosis, initiating thromboprophylaxis, use of intravenous steroids, prescribing infliximab if refractory to steroids, limiting narcotics, and surgical consultation if refractory to medical therapy. Adherence to 6 of the 11 quality indicators was improved in the post-intervention cohort. Significant increases were noted in adherence to C difficile testing (75.5% versus 91.9%, P < 0.05), CRP testing (71.4% versus 94.6%, P < 0.01), testing for latent tuberculosis (38.1% versus 84.6%, P < 0.01), thromboprophylaxis (28.6% versus 94.6%, P < 0.01), adequate corticosteroids prescription (72.9% versus 94.6%, P < 0.01), and limitation of narcotics prescribed (68.8% versus 38.9%, P < 0.01). Implementation of a standardized order set, focused on pre-defined quality indicators for hospitalized patients with severe UC, was associated with meaningful improvements to most quality indicators defined by the Toronto Consensus Statements.

YIELD OF SERIAL TESTING FOR TUBERCULOSIS EXPOSURE IN THE STUDY OF A PROSPECTIVE ADULT RESEARCH COHORT WITH INFLAMMATORY BOWEL DISEASES (SPARC IBD)

Abstract BACKGROUND More than 2 million Americans have Inflammatory Bowel Diseases (IBD), including Crohn’s Disease or Ulcerative Colitis. Although tuberculosis is uncommon in the United States, patients with IBD are at an increased risk for active tuberculosis infection due to the immunosuppressant therapies used to treat IBD. Due to this risk, testing for latent tuberculosis is recommended prior to and intermittently throughout administration of most IBD medications. The utility of this practice in a country with a low incidence and prevalence of tuberculosis is unknown. We aimed to determine the proportion of initial and subsequent tuberculosis tests that are positive, negative, or indeterminate. METHODS Data were acquired from SPARC IBD, a component of the Crohn’s &amp; Colitis Foundation’s IBD Plexus research platform. SPARC IBD is a prospective cohort study conducted at 18 centers throughout the USA and includes more than 4,000 patients. Data are collected from SPARC IBD case report forms and the IBD Smartform, diagnoses, test results and prescriptions within the linked electronic medical records. Patients with one or more interferon gamma release assay (IGRA) test for latent tuberculosis were included in this study. The outcome investigated was a positive, negative, or indeterminate lab result. The proportion of positive and indeterminate tests were computed with 95% confidence intervals (CI). Fisher’s exact test was used to detect a change in positive test proportions following a negative test compared to initial lab results. RESULTS A total of 687 patients with one or more IGRA test were identified. The median age was 37 (IQR 27-50) with 54% female patients. Of the initial lab results, 644 tests were negative (93.7%, 95% CI, 91.7, 95.4), 37 were indeterminate (5.4%, 95% CI, 3.8, 7.3), and six were positive (0.9%, 95% CI, 0.3, 1.9). Following an initial negative result, 269 patients received a second test, of which five were positive (1.9%, 95% CI, 0.6, 4.3). Following two consecutive negative results, 142 patients received an additional IGRA test, of which one was positive (0.7%, 95% CI, 0.02, 3.9). The proportion of positive tests was not significantly lower following one negative (p = 0.20) or two consecutive negative tests (p &amp;gt; 0.99). POTENTIAL LIMITATIONS Many patients only had one test for latent tuberculosis, and it is unclear if the initial IGRA labs in our dataset were their first latent tuberculosis tests. CONCLUSIONS Based on the findings of this study, there appears to be value in continued serial testing following a negative result even in the United States, despite the overall low incidence of tuberculosis.

Universal testing for latent tuberculosis in pregnancy: an evaluation of current performance and cost-effectiveness analysis

Universal testing for latent tuberculosis in pregnancy: an evaluation of current performance and cost-effectiveness analysis

TB DURING THE SEROCONVERSION PHASE

TB DURING THE SEROCONVERSION PHASE

Latent tuberculosis testing through the ages: the search for a sleeping killer.

Tuberculosis has been present in the world’s population for as long as there has been written language. It is a disease known to the ancient Egyptians, Greeks, Romans, and Hebrews, but its etiology eluded the world for thousands of years. Even after the germ theory was accepted and early scientists hypothesized a pathogen as the cause, the identity of the sleeping killer in society remained a mystery. That is until Robert Koch was able to grow and visualize Mycobacterium tuberculosis. Koch introduced his Old Tuberculin solution as a diagnostic therapy of tuberculosis (TB), with the intent to reduce the number of infected persons and stop its spread. Old Tuberculin’s ability to treat TB proved minimal, but its diagnostic potential paved the way for more effective tests from von Pirquet, Calmette, Wolff-Eisner, and Mantoux. Florence Seibert set out to identify and purify the active principle in Koch’s Old Tuberculin and ended up creating purified protein derivative (PPD) tuberculin which is still used as the standard for the tuberculin skin test (TST). Interferon-γ release assays (IGRAs) are a more modern diagnostic tool for detecting latent TB infection that offer some benefits (and some disadvantages) to TST. TSTs and IGRAs can determine if an individual has been infected with M. tuberculosis but are equally unable to predict progression to active tuberculosis, the diagnosis of which relies on assessment of clinical symptoms, radiographic imaging, and sample culture.

AB008. Utility of repeat latent tuberculosis testing in patients with immune-mediated diseases taking biologics

BackgroundGuidelines for repeat latent tuberculosis infection (LTBI) testing while on biologics are not clearly defined. The CDC and U.S. Preventive Services Task Force recommend routine serial LTBI screening in high-risk patients, such as those on immunosuppressive medications. Furthermore, recommendations for annual LTBI screening in patients on biologics have been incorporated into the Medicare Merit-Based Incentive Payment Systems and will impact physician reimbursement. However, little evidence supports that this practice is clinically valuable and/or cost-effective in patients on biologics. To evaluate the utility of serial LTBI screening in patients taking biologics and to identify risk factors in patients who convert from negative to positive QuantiFERON TB test (QFT) results while on biologics.MethodsWe retrospectively reviewed QFT results in patients treated with biologics for chronic immune-mediated inflammatory/autoimmune conditions (IMIDs) at a single, tertiary care center from 2007–2019. For each patient included in our study, detailed clinical information from their medical records was collected.ResultsWe identified 5,212 patients who had IMIDs and >1 repeat QFT result after starting biologic therapy. The most common IMID diagnoses were inflammatory bowel disease (30%), rheumatoid arthritis (28%) and psoriatic disease (24%). The majority of patients had all negative QFTs (87.5%), whereas 172 patients (3.3%) had >1 positive QFT. Amongst patients with positive QFTs, 61/172 patients (35%) converted from a negative to a positive QFT after biologic therapy initiation. Of these 61 patients, only 28 patients were eventually treated for LTBI. Fourteen of the 28 patients treated for LTBI had documented risk factors for TB exposure, such as travel to endemic TB areas and/or exposure to individuals with TB. Only one case of active TB was diagnosed.ConclusionsThis represents the largest single-institution study evaluating rates of QFT test positivity conversion in patients taking biologics. Repeat LTBI testing in patients taking biologics revealed a low rate of conversion (1.17%). Our results suggest clinical utility and cost-effectiveness of repeat LTBI screening in patients on biologics may be more valuable if not performed routinely, but driven by a focused review of TB exposure risk factors in each patient.

Evaluation of role of interferon gamma release assays in the diagnosis of latent tuberculosis in human immunodeficiency virus-infected patients.

Introduction:Tuberculosis (TB) is the most common opportunistic infection in human immunodeficiency virus (HIV)-infected individuals. The risk of eventually developing active TB from latent TB infection (LTBI) is about 10% per year in HIV-positive patients in contrast to 10% lifetime risk in HIV-negative patients. Until recently, the tuberculin skin test (TST) was the only tool available for diagnosing LTBI. Interferon-gamma release assays (IGRAs) were recently developed and address many of the limitations of TST test, especially in immunocompromised state.Aims and Objectives:(1) To determine the prevalence of latent, active pulmonary, and multidrug-resistant (MDR)-TB among HIV-positive patients in and around Aligarh region; (2) sensitivity and specificity of TST and IGRAs for diagnosis of LTBI in HIV positive patients; and (3) to assess drug resistance and mutational patterns of the clinical isolates of MDR-TB in HIV-TB co-infection.Materials and Methods:A cross-sectional study was done on all the patients attended the ICTC centre, JNMC, AMU Aligarh, seropositive for HIV, i.e. 469 (sample size) for the study period of 2 years from October 2015 to October 2017. All 469 HIV-positive patients were screened for latent and active pulmonary TB. Diagnosis of TB (active and latent) was made using clinical, radiological, and microbiological tests. TST and IGRA testing along with CD4 cell counts were also determined. Line probe assay was also done to assess drug resistance and mutational patterns of MDR-TB in HIV patients.Results:In our study, prevalence of HIV infection was 5.04%. Sixty-seven (14.28%) patients were as active TB (HIV-TB co-infection), out of which only one patient (1.49%) was confirmed as MDR-TB, 117 (24.94%) were diagnosed as LTBI. It was also evaluated that IGRA has more sensitivity (75%) and specificity (76%) than TST with sensitivity of 71.7% and specificity 66%.Conclusion:As there is no gold standard test for latent TB, longitudinal follow-up is needed to interpret discordant test results. There is a need to interpret negative QFT results with caution and to test for latent TB at higher CD4 counts, if possible. Interferon gamma assays can become better tool for diagnosis of especially for latent TB. However, more research study required for establish their relevance, especially in immunocompromised states.

17244 Utility of repeated latent tuberculosis testing in psoriatic disease patients taking biologics

Background: The CDC and US Preventive Services Task Force recommend routine serial latent tuberculosis (LTB) screening in high-risk patients, such as those on immunosuppressive medications. However, little evidence supports this practice is clinically valuable and/or cost-effective in patients on biologics.

Workshop: Screening infectious diseases amongst migrants in Europe: The diversity of policies

Abstract In Europe, the prevalence of several infectious diseases such as HIV, hepatitis B, hepatitis C and tuberculosis is higher amongst migrants. Late diagnosis of HIV, hepatitis B and C is a health issue that thwarts prevention efforts. Early diagnosis has obvious benefits, both for the individuals (i.e. earlier access to care with a better life expectancy) and for the community. As regard for HIV, treated patients with an undetectable viral load do not transmit the virus. This is in line with the UNAIDS 90-90-90 target that in every country 90% of people living with HIV should be aware of their positive status, 90% of them should be treated with antiretroviral and within 90% should have an undetectable viral load. Widespread testing of HIV, HBV and HCV is recommended by European guidelines, such those from European Centre for disease Prevention and Control (ECDC). The ECDC recommends that screening for HIV, hepatitis B, hepatitis C and tuberculosis should be offered to every migrant from countries with a high prevalence (≥1% for HIV and ≥2% for hepatitis B and C). Other recommendations include ensuring that screening and vaccination is voluntary and confidential, that migrants have a quick access to care, addressing barriers to screening, and taking into account the particular issues and needs of migrants. However, European countries have developed diverse guidelines and initiatives to address the issue of screening infectious diseases amongst migrants. The objective of this workshop is to present several European initiatives to improve the screening of infectious diseases amongst migrants. Four initiatives will be presented and discussed: screening of active tuberculosis amongst asylum seekers with the use of a questionnaire in Switzerland; replacing the systematic chest X-ray with a screening questionnaire for active tuberculosis and introducing rapid tests for HIV, HBV and HCV for all legal migrants at entry point in France, adding HIV, HBV and HCV testing to the compulsory targeted tuberculosis test in the Netherlands and offering targeted tests for latent tuberculosis, HBV and HCV to migrants registering for primary care in the UK. Key messages Screening of infectious diseases should be targeted to migrants from high-incidence countries. European practices should be harmonized.

Evaluating latent tuberculosis testing and treatment programme for new migrants in South East England

Abstract Background Tuberculosis (TB) cases in England often originate from high burden TB countries due to ’reactivation’ of the latent TB infection (LTBI), an asymptomatic and non-infectious phase lasting years. 5,137 TB cases were notified in England in 2017, and 71% of these patients were born outside the UK. This mixed-method study evaluated the implementation of the four LTBI testing and treatment programme for new migrants in South East (SE) England. Methods A retrospective database (May 2016-Feb 2018) review was undertaken to identify LTBI cases using multiple data sources; LTBI testing laboratories, LTBI programmes, and the national TB team at Public Health England. In addition, a survey questionnaire was emailed to 51 stakeholders (45% response rate) and five in-depth interviews were conducted with LTBI programme leads/TB nurses to explore the challenges of the programme. Quantitative data were analysed using descriptive summary statistics and qualitative interviews were analysed using thematic content analysis. Results Of the 5931 eligible patients, 40 % (n = 2391) accepted the LTBI test and 13.4% (n = 321) tested positive. 93.1% (n = 299) of the positive patients were referred for treatment and 63.8% (n = 191) of these accepted the treatment. The programme also picked up 18 active TB cases, an unexpected incidental finding. Results from the survey and the interviews identified laboratory arrangements, workforce, and data collection/management as the greatest challenges for the LTBI programme. Patient focused care, cultural understanding, success in testing/treating migrants, and raising awareness amongst professionals/communities were highlighted as achievements of the programme. Conclusions This study found that LTBI programmes in SE England are in line with national expectations and other LTBI programmes in England. The study recognises the achievements and good practice of the LTBI teams in SE England and identifies key barriers to improve the service for the future. Key messages Data collection and management is the biggest challenges of the LTBI programmes in SE England. The LTBI programmes in SE England are in line with national expectations.

Tests for latent tuberculosis in candidates for solid organ transplantation: A systematic review and meta-analysis.

Reactivation of latent tuberculosis following solid organ transplantation has serious consequences for the recipient. The most useful diagnostic test for latent TB is not clear. We conducted a systematic review and meta-analysis to assess the relative test performance of interferon gamma release assays (IGRAs) and the tuberculin skin test (TST) in people undergoing solid organ transplantation. The clinical or radiological risk factors were used as the proxy reference standard. Test performance was expressed as an odd ratio (OR). We identified 24 studies (N=7811), 12 studies compared IGRAs with TST directly, nine studies evaluated only TST and three studies only IGRAs. Direct comparison between tests and clinical risk factors indicated both tests were strongly associated with the presence of clinical risk factors for TB (TST: OR 3.17; 95%CI 1.55-6.48, IGRA: OR 2.78; 95%CI 1.55-5.01), and radiological evidence of past TB (TST: OR 3.26; 95%CI 1.85-5.73, IGRA: OR 3.85; 95%CI 2.16-6.86). Relative comparison indicated IGRAs positivity was more strongly associated with presence of radiological evidence of TB than TST (relative OR: 3.24; 95%CI 1.10-9.56). While there is no strong evidence in supporting use of IGRAs over TST for diagnosing latent TB, IGRAs positivity is more associated with the presence of radiological evidence of previous TB.

Myxoedema coma following commencement of anti-TNF therapy and tuberculosis prophylaxis in a patient with RA and latent tuberculosis infection

A 67-year-old man with an 8-year history of seropositive rheumatoid arthritis (RA) on conventional synthetic disease-modifying antirheumatic drug (csDMARD) and history of hypertension and bilateral total knee replacement done 2...

Risk Factors for Indeterminate Outcome on Interferon Gamma Release Assay in Non-US-Born Persons Screened for Latent Tuberculosis Infection.

BackgroundNon-US-born individuals account for the majority of active tuberculosis (TB) in the United States. Interferon gamma release assay (IGRA) is the preferred diagnostic test for latent TB but can produce an indeterminate result. We investigated the prevalence and predictors of an indeterminate IGRA (IND-IGRA) in a diverse cohort of non-US-born individuals and evaluated outcomes after IND-IGRA.MethodsWe identified patient age ≥18 years who had an outpatient IGRA between 2010 and 2017 in our health system and whose primary language was not English. We used univariate and multivariable logistic regression to examine the association of IND-IGRA with a variety of clinical factors.ResultsOf 3128 outpatients with ≥1 IGRA done, 33% were Asian, 30% Hispanic, and 29% black; 44% were men, and the median age was 50 years. An initial IND-IGRA occurred in 118 (3.8%; 95% confidence interval [CI], 3.1%–4.5%); notably, Asian race (55%) and rheumatologic conditions (25%) were prevalent in this group. In multivariable analysis, Asian race was independently associated with IND-IGRA (adjusted odds ratio [aOR], 2.9; 95% CI, 1.9–4.3), in addition to the presence of anemia and hypoalbuminemia (aOR for interaction, 4.3; 95% CI, 1.3–14.3). Only 55% of patients with an initial IND-IGRA underwent repeat testing; of those who did, 66% had a determinate result.ConclusionsAsian race and anemia/hypoalbuminemia were independent risk factors for an indeterminate IGRA outcome in foreign-born patients screened in the United States. Our study underscores the importance of following through on indeterminate results in these key subgroups.

Utilizing the Electronic Health Record to Improve Documentation Adherence With Performance Measures in Outpatient Inflammatory Bowel Disease Care

Inflammatory bowel disease (IBD) is a chronic condition leading to significant health, lifestyle, and cost burdens to patients, their families, and society. Several health care organizations, including The Physician Quality Reporting System (PQRS), have created performance measures to aid in establishing evidence-based standards of care in attempts to improve the quality of IBD care, and ultimately health outcomes. When used effectively, the electronic health record (EHR) should improve adherence to, and documentation of, performance measures for outpatient IBD care. The aim of this study was to assess documentation adherence with selected PQRS performance measures at one academic medical center before and after the implementation of an IBD order set, note template, and patient education handout into the EHR. Fifty patient charts were randomly selected from consecutive outpatient IBD visits at our medical center from September 1, 2015 to June 30, 2016, prior to the availability of the EHR improvements. Another 50 patient charts were randomly selected from consecutive outpatient IBD visits at our medical center from September 1, 2016 to June 30, 2017, just after the addition of the EHR improvements. These charts were reviewed to assess documentation adherence with the pertinent PQRS performance measures for outpatient IBD care, which included the following: documentation of influenza and pneumonia vaccination, tobacco screening and cessation education, evaluation of latent tuberculosis and hepatitis B status prior to the initiation of anti–tumor necrosis factor therapy, and bone loss risk assessment. Documentation of administration, refusal, or prior receipt of both the influenza (19.4% before, 59.5% after; P < .05) and pneumonia (9% before, 63.6% after; P < .05) vaccines improved after the addition of the IBD-specific EHR resources. In addition, documentation of tobacco cessation intervention improved from 28.6% to 77.8% (P < .05). During both the pre- and post-intervention chart reviews, compliance with documentation of testing for latent tuberculosis (66.7% before, 100% after) and hepatitis B virus serology (100% before, 100% after) prior to the initiation of anti–tumor necrosis factor therapy and screening for tobacco use (100% before, 100% after) was high during both periods of time. Documentation of patients at risk for bone loss related to steroid use (0% before, 12.5% after) remained low both before and after the EHR improvements. None of these measures met statistical significance. The availability of customizable electronic resources in the EHR improves documentation compliance of PQRS measures for outpatient IBD care.

Trends in, and factors associated with, HIV infection amongst tuberculosis patients in the era of anti-retroviral therapy: a retrospective study in England, Wales and Northern Ireland

BackgroundHIV increases the progression of latent tuberculosis (TB) infection to active disease and contributed to increased TB in the UK until 2004. We describe temporal trends in HIV infection amongst patients with TB and identify factors associated with HIV infection.MethodsWe used national surveillance data of all TB cases reported in England, Wales and Northern Ireland from 2000 to 2014 and determined HIV status through record linkage to national HIV surveillance. We used logistic regression to identify associations between HIV and demographic, clinical and social factors.ResultsThere were 106,829 cases of TB in adults (≥ 15 years) reported from 2000 to 2014. The number and proportion of TB patients infected with HIV decreased from 543/6782 (8.0%) in 2004 to 205/6461 (3.2%) in 2014. The proportion of patients diagnosed with HIV > 91 days prior to their TB diagnosis increased from 33.5% in 2000 to 60.2% in 2013. HIV infection was highest in people of black African ethnicity from countries with high HIV prevalence (32.3%), patients who misused drugs (8.1%) and patients with miliary or meningeal TB (17.2%).ConclusionsThere has been an overall decrease in TB-HIV co-infection and a decline in the proportion of patients diagnosed simultaneously with both infections. However, high rates of HIV remain in some sub-populations of patients with TB, particularly black Africans born in countries with high HIV prevalence and people with a history of drug misuse. Whilst the current policy of testing all patients diagnosed with TB for HIV infection is important in ensuring appropriate management of TB patients, many of these TB cases would be preventable if HIV could be diagnosed before TB develops. Improving screening for both latent TB and HIV and ensuring early treatment of HIV in these populations could help prevent these TB cases. British HIV Association guidelines on latent TB testing for people with HIV from sub-Saharan Africa remain relevant, and latent TB screening for people with HIV with a history of drug misuse, homelessness or imprisonment should also be considered.