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1 Evaluation of Interferon-γ Release Assays in the Diagnosis of Latent TB Infection in U.S. Healthcare Workers: Update on TBESC Task Order 8 National Tuberculosis Conference 20 Randall Reves, MD, MSc On behalf of the CDC TB Epidemiological Studies Consortium & the TO 8 Protocol Team Presenter disclosures for Randall Reves: no conflicts to report No personal financial relationships with the commercial interests relevant to this presentation Denver Health and Hospitals has received funding from the Centers for Disease Control, Division of Tuberculosis Elimination for the conduct of this research Background LTBI diagnosis and treatment are important components of U.S. TB control HCWs are an important group for targeted testing and treatment (~4 million/year) QuantiFERON -TB Gold In-Tube ( QFT ) and T-SPOT.TB ( T-SPOT ) are FDAapproved Require only client-provider interaction Not affected by BCG Limited longitudinal data on use of these tests in HCWs undergoing periodic testing

2 Objectives To evaluate performance characteristics of QFT and T-SPOT compared with TST for detecting LTBI in HCWs undergoing routine screening Test result stability over time (i.e. conversion, reversion) Reproducibility Test, re-test repeatability Estimated sensitivity and specificity % of failed tests Impact of TST on IGRA results To determine costs, cost-effectiveness To determine and compare acceptability of tests among participants Design and Population Longitudinal study HCWs undergoing routine LTBI testing TST- positive HCW recruited to participate 4 sites: Denver, Houston, Baltimore, NYC Inclusion: 8 yrs; informed consent; undergoing routine screening Exclusion: Current or prior active TB; TST within 6 months prior to enrollment Target sample size 2500 with baseline tests Intervention Interview QFT T-SPOT TST Consent 2 nd step TST 0 Month 6 Month 2 Month 8 2

3 Intervention Interview QFT T-SPOT TST Consent 2 nd step TST repeatability reproducibility 0 Month 6 Month 2 Month 8 Testing Methods TST Mantoux with Tubersol Administered, interpreted by study-trained personnel QuantiFERON -TB Gold In-Tube ( QFT ) Cellestis, Inc: package insert Performed, interpreted by trained technologists T-SPOT.TB ( T-SPOT ) Oxford Immunotec, Ltd: package insert Performed, interpreted by trained technologists Test kits purchased from the companies No financial support or donations from companies Technical representatives from each company assisted in training study laboratory technologists Study status Enrollment completed, follow-up ended, data editing largely done This presentation: Baseline results for 2504 participants Analysis stratified for enrollment: Required 2-step entry no TST in > 3 mo. Annual follow-up after > 2 prior TSTs Prior + TST Describe conversion/reversion for Impact of TST on IGRAs Reproducibility, Repeatability Follow-up with TST & IGRAs at 6 months 3

4 T S T :. ) S t e p 2. ) 5 3 A n n u a l F o l l o w - u p B Enrollment a by TST and LTBI History s e l i n e E n r o 232 (9.6%) Prior (+) TST and/or prior LTBI Treatment Enrollment by entry criteria: variation by site Category Den NY MD TX Total Prior Positive Two-Step Eligible Annual Follow-up Total Demographics (n= 2504) Prior + n=272 2-step n=74 Annual n=53 Total n=2504 Age (median, range) 39.7, , , , 22.2 Foreign-born 6 (50.0) 97 (3.) 25 (4.0) 428 (7.) US-B non-hisp. W 62 (26.7) 380 (5.3) 786 (5.3) 228 (49.0) US-B Hispanic 6 (6.9) 97 (3.) 233 (5.2) 346 (3.8) US-B Black 29 (2.5) 27 (7.) 225 (4.7) 38 (5.2) US-B Other 9 (3.9) 40 (5.4) 72 (4.7) 2 (4.8) HIV+ 3 (.3) 3 (0.4) 4 (0.3) 0 (0.4) Diabetes 2 (5.2) 2 (2.8) 5 (3.3) 84 (3.4) Other Immunodef. 3 (.3) 2 (2.8) 70 (4.6) 94 (3.8) 4

5 Baseline TST results: all participants Negative Positive Total Nativity & race/ethnicity N % N % N % Foreign-born % % % US-born Black/African American % % % US-born Hispanic % 4 4.0% % US-born White, % 23.9%, % US-born Other % 9 7.4% 2 4.8% Total 2, % % 2,504 00% Baseline Results for Routine Group: 2-step & Annual Follow-up (n = 2272) TST QFT T-SPOT Positive 4 (.8) 85 (3.7)* 4 (5.0)* Negative 223 (98.2) 248 (94.5) 958 (86.2) Borderline 68 (3.0) Indeterminate / Fail 39 (.7) 32 (5.8) * p < compared to the TST NOTE: Borderline T-Spots categorized as neg. for remaining slides. Baseline prior + TST: 00 F-born (5, 6.5% excluded indet./failed) TST QFT T-SPOT N % Pos Pos Pos % Pos Pos Neg 0.5% Pos Neg Pos 2 0.9% Pos Neg Neg % Neg Pos Pos 9 4.% Neg Pos Neg 7 3.2% Neg Neg Pos 9 4.% Neg Neg Neg % Total 27 00% 5

6 Baseline 2-step TST: 97 F-born (47, 6.3% excluded, indet./failed) TST QFT T-SPOT N % Pos Pos Pos 7.0% Pos Pos Neg 2 0.3% Pos Neg Neg 2 3.0% Neg Pos Pos 8.2% Neg Pos Neg 6 2.3% Neg Neg Pos % Neg Neg Neg % Total % Baseline Annual follow-up: 25 F-born (5, 6.5% excluded indet./failed) TST QFT T-SPOT N % Pos Pos Pos 8 0.6% Pos Neg Neg 2 0.% Neg Pos Pos 2 0.9% Neg Pos Neg 27.9% Neg Neg Pos % Neg Neg Neg % Total 4 00% Summary of baseline results Prior + N=27 2-step N=694 Annual N=4 TST % % 0 0.7% QFT % % % Tspot % 49 7.% % All % 7.0% 8 0.6% 6

7 Prior + TST group, Baseline Negative or Positive: 6 month Follow-up Conversion Reversion TST 0 / 90 (.) 4 / 33 (42.4) QFT 0 / 64 (6.) 7 / 53 (3.2) T-SPOT 3 / 6 (8.) 0 / 49 (20.4) Conversion = (-) baseline (+) 6 month; TST + at > 0 mm Reversion = (+) baseline (-) 6month 2-step TST, Baseline Negative or Positive: 6 month Follow-up Conversion Reversion TST / 64 (0.2) / 9 (57.9) QFT 26 / 648 (4.0) 3 / 30 (43.3) T-SPOT 32 / 604 (5.3) 25 / 43 (58.) Conversion = (-) baseline (+) 6 month Reversion = (+) baseline (-) 6month Annual f/u TST, Baseline Negative or Positive: 6 month Follow-up Conversion Reversion TST 5 / 337 (0.4) / 4 (25.0) QFT 4 / 36 (3.) 26 / 46 (56.5) T-SPOT 40 / 24 (3.2) 29 / 6 (47.5) Conversion = (-) baseline (+) 6 month Reversion = (+) baseline (-) 6month 7

8 IGRA Conversion at 2 weeks or Less Sub-study Impact TST baseline -3 wks later QFT Conversion (+)TST 0/60 (6.7) (-)TST 3/75 (4.0) T-Spot Conversions 9/60 (5.0) 5/75 (6.7) Reproducibility same phlebotomy at 6 mo. (+)TST /46 (2.2) (-)TST 4/53 (2.6) 4/46 (8.7) 3/53 (2.0) Repeatability done 2 week before 6 mo. (+)TST /44 (2.3) (-)TST 5/52 (3.3) 3/44 (6.8) 6/52 (3.9) Conversion = (-) initial (+) repeat Conclusions (): In this study of 2500 HCW in 4 US institutions Risk for TB infection appears quite low TST-conversion < 0.5 % at 6 months after 2-step testing for new staff even without recommended definition of 0 mm increase to > 0 mm Reversion of positive baseline results to negative at 6 month follow-up are common with TST and both IGRA significance uncertain but to be analyzed in follow-up at 2 and 8 months Major strength of study use of both IGRA & TST provides data to suggest that false-positives explain many of TST and IGRA results - as expected in testing low-risk populations Conclusions (2): For both IGRA compared to Mantoux TST Positive results with are higher in annual routinely testing and 4- to 5-fold higher for HCW in annual f/up Conversion rates are at least 2-4% even done the same day Lack of agreement between IGRA & TST suggest random error in both tests rather than poor TST sensitivity The protocol team is performing variability analysis, examining cut-off values and strategies of repeat assay (for QFT) and repeat testing to identify false-positive results. These findings have application to other lowprevalence populations e. g. expanding contact investigation, students traveling in high-burden settings 8

9 Thank you CDC: Paul Weinfurter, Denise Garrett, Grace Thiongo Denver: Charles Daley, Robert Belknap, Matt Parker, Randall Reves, Kirsten Wall Houston: Ed Graviss, Larry Teeter Baltimore: Wendy Cronin, Elizabeth Munk, Jonathan Golub NYC: Daniel Brodie, Joyce Thomas, Yael Hirsch-Moverman 9

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