Interpretation and management of discordant tuberculin skin test and interferon‐gamma release assays results in children
Notice bibliographique
Résumé
We read with interest the retrospective analysis by Elliot et al.1 comparing the results of tuberculin skin test (TST) and QuantiFERON Gold In-Tube assays in children of a refugee background. Interpretation of TST and interferon-gamma release assays (IGRA) is a perpetual challenge for those working in child tuberculosis (TB) and immigrant health services, and we commend the authors' attempt to provide guidance. However, we have a different interpretation of the study findings and the implications for practice and policy. As highlighted by the authors, discordant results are common and problematic. This study suggests that clinicians in the Illawarra-Shoalhaven region place greater weight on the result of IGRA than TST results. The majority (87.2% (41/47)) of TST+/IGRA− discordant children were not offered preventive therapy, compared with 12.5% (2/16) of TST−/IGRA+ patients. This indicates an assumption that TST+/IGRA discordance reflects false-positive TST results (due to prior Bacille Calmette Guerin (BCG) vaccination or non-tuberculous mycobacterial exposure) rather than false-negative IGRA (due to imperfect sensitivity). We recognise that the decision to treat was primarily based on clinician perception of risk in this observational study. However, false-positive TSTs related to BCG vaccination are uncommon. A meta-analysis of more than 240 000 subjects vaccinated with BCG in infancy (as is common for immigrant children in Australia) found that only 8.5% had a positive TST result attributable to BCG vaccination and that the effect of BCG on TST results waned quickly over time.2 Furthermore, immunological studies provide strong evidence that a significant proportion of TST+/IGRA− discordant patients are, in fact, infected with Mycobacterium tuberculosis.3 As the authors note, there is no gold standard for TB infection. Therefore, using IGRA as a standard against which to assess TST sensitivity is inappropriate. TST and IGRA are both imperfect screening tests for TB infection, and there is compelling evidence for the limited sensitivity of IGRA in both active TB disease and latent TB infection (LTBI).4 The limitations of IGRA are particularly relevant for infants and young children,5 and national and international guidelines therefore continue to advise the use of TST in preference to IGRA for screening children under 5 years of age.6 Discordant results in this age group, especially those children who have received BCG at birth, is especially problematic given that they will potentially benefit the most from preventive therapy as they have the highest risk to progress to active TB disease. Missing LTBI and thereby the opportunity to provide preventive therapy has far greater implications in children than adults as they are more likely to develop TB disease, especially severe disease. Based on the current evidence, the safest option for managing children with a positive IGRA or TST, including those with discordant results, is to offer preventive therapy.
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Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,007 | 0,058 |
| Méta-épidémiologie (sens strict) | 0,001 | 0,001 |
| Méta-épidémiologie (sens large) | 0,001 | 0,001 |
| Bibliométrie | 0,002 | 0,001 |
| Études des sciences et des technologies | 0,001 | 0,002 |
| Communication savante | 0,002 | 0,002 |
| Science ouverte | 0,002 | 0,002 |
| Intégrité de la recherche | 0,003 | 0,004 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,001 | 0,001 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».