Background: The incidence of tuberculosis (TB) among Inuit is over 400 times that of Canadian-born non-indigenous people. To address this, more patients will need to complete preventative treatment. Methods: First, data were extracted retrospectively for all patients with a tuberculin skin test (TST) implanted in Iqaluit, Nunavut between January 2012 and March 2016 and used to identify sources of loss from the latent TB infection (LTBI) cascade of care. Associations between demographic and clinical factors and treatment non-initiation and treatment non-completion were identified using regression models. Second, using a slightly expanded version of the retrospective dataset plus other sources, a Markov model was utilized to assess the cost-effectiveness of a novel shortened regimen for LTBI (12 weeks of once weekly isoniazid and rifapentine (3HP)) compared to the current standard of care (9 months of isoniazid monotherapy (9H)). Results: Treatment non-initiation and non-completion were the largest sources of loss of TST positive patients from the cascade of care. LTBI testing via employment screening was associated with treatment non-initiation while older age was associated with both treatment noninitiation and non-completion. In cost-effectiveness analysis, 3HP was dominant over 9H: costs were lower ($835 vs $1229 per person) and health outcomes slightly improved (20.14 vs 20.13 QALYs gained per person treated), largely due to an improved treatment completion with 3HP. Conclusions: Interventions to increase LTBI treatment initiation and completion in Iqaluit are needed. This could include the use of 3HP instead of 9H for LTBI treatment which may improve treatment completion and result in cost savings and slightly improved health outcomes.

Introduction: Despite management advances worldwide, tuberculosis still remains a serious uncontrolled disease. The absence of either a ‘gold’ standard diagnostic test, or a conventional rapid ‘reference’ laboratory test for asymptomatic Mycobacterium tuberculosis (MTB) carriers complicates disease control. Through mandatory screening of high-risk groups, early diagnosis of latent tuberculosis infection (LTBI) cases allows recognition and better control of the tuberculosis pandemic. Materials and Methods: The current tuberculosis screening guidelines as recommended by the World Health Organization, chest X-ray and tuberculin skin test were assessed and revealed rises in TB morbidity and fatality trends in the Kuwait population (low incidence country). In order to evaluate options for LTBI diagnosis, the current work implemented a 4-month prospective, observational, repeated-measure and randomly implemented survey on 180 new immigrants to Kuwait using a structured risk factor questionnaire whilst, simultaneously evaluating the performance of the two standard diagnostics (chest X-ray and tuberculin skin test) with the new biomarker interferon gamma release assays (T-SPOT .TB test and QuantiFERON Gold In-Tube test (QNF-GIT)); which detect the release of interferon gamma (INF-γ) released from sensitization to specific MTB antigens. Results: Associations between various epidemiological risk factors - such as socio-demographic status, smoking and environmental exposure-contact - were associated in the laboratory diagnosed LTBI participants. Positive identification of LTBI prevalence detected by two radiologists was 10.1% having ‘moderate’ inter-reader agreement (Kappa = 0.505), compared to no positives being detected by three pulmonologists. TST results were negative (less than 10-mm ‘cut-off’) even in the 86.1% Bacillus Calmette-Guérin vaccinated expatriates. Estimated LTBI using QNFGIT was 28.3% compared to 41.1% positive T-SPOT .TB test. Both interferon gamma assays revealed concordant ‘abnormal’ results in 26.1% with ‘good’ agreement (kappa = 0.627). Conclusion: Detection of latent tuberculosis infection can be facilitated by introducing evidence-based diagnostic classification depending on history taking of epidemiological-related risk factors and chest X-ray plus either interferon gamma assays.

Latent tuberculosis infection (LTBI), a product of exposure to Mycobacterium tuberculosis (Mtb), can lead to tuberculosis (TB) and further cause death if untreated. Fortunately, TB can be prevented with LTBI treatment. Targeting newly arrived visa holders for LTBI screening and treatment is an effective strategy for decreasing future TB burden. However, LTBI treatment completion rates are low, and researches had primarily focused on the nonrural U.S. setting. This study, using a retrospective cohort design under the epidemiological disease triangle framework evaluated (a) the treatment completion rates for 2 cohorts of visa holders (i.e., immigrants, N = 31 and refugees, N = 109) with LTBI residing in the rural setting using Pearson's chi-square analysis, (b) mean times on LTBI treatment using Kaplan-Meier survival analysis, and (c) predictors of time on treatment using Cox proportional hazard regression. Study findings revealed immigrants had higher treatment noncompletion rates over refugees (25.6% and 19.3%). The potential risk factors for noncompletion were being older than 24 years of age (HR = 0.18, p = 0.01). There were also significant interactions for the time on treatment between (a) being < 25 years old and visa type (HR = 0.23, p = 0.04), (b) being < 25 years and traveling longer (miles) to treatment facility (HR = 0.25, p = 0.03), or (c) being < 25 years and Mtb blood-test positive (HR = 0.35, p = 0.05). These findings suggest interventions targeting visa holders older than 24 years may increase the rate of treatment completion and decrease the future TB cases. Therefore, the study promotes social change by providing actionable, rural-population-specific information for the prioritization of visa holders at increased risk of experiencing LTBI treatment noncompletion.

Submitted by Fabio Sobreira Campos da Costa (fabio.sobreira@ufpe.br) on 2016-08-18T14:35:26Z No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) Dissertação_Bernardino_Versão_Final_13_04_2016VF_ATUAL (1).pdf: 1504145 bytes, checksum: 378eee47758feaa1664c834f3a789e0c (MD5) / Made available in DSpace on 2016-08-18T14:35:26Z (GMT). No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) Dissertação_Bernardino_Versão_Final_13_04_2016VF_ATUAL (1).pdf: 1504145 bytes, checksum: 378eee47758feaa1664c834f3a789e0c (MD5) Previous issue date: 2015-08-20 / O diagnóstico e o tratamento da infecção latente pelo Mycobacterium tuberculosis (ILTB) são indicados para grupos nos quais a prevalência da infecção latente é alta, em contactantes de casos novos de tuberculose (TB) e quando o risco de reativação é alto como em pessoas vivendo com HIV/AIDS (PVHA). Tanto o vírus da imunodeficiência humana (HIV) facilita a reativação da ILTB quanto o Mycobacterium tuberculosis contribui para a progressão da doença pelo HIV. O conhecimento acerca do diagnóstico e do tratamento da ILTB em PVHA torna-se fundamental visto que o Relatório Global de Controle da Tuberculose da Organização Mundial da Saúde (OMS) indica que as PVHA estão 26 a 31 vezes mais propensas a desenvolver TB ativa quando comparadas à população geral. Além disso, a taxa de letalidade da TB em PVHA é 3 vezes maior do que a observada na população geral. Apesar de suas limitações, o teste tuberculínico (TT) continua sendo a principal ferramenta de diagnóstico da ILTB, entretanto, isso não parece refletir no número de TT solicitados e realizados e, consequentemente, no número de tratamentos prescritos para ILTB. No Brasil, e em particular na Paraíba, os dados sobre a solicitação e realização do TT e acerca da prescrição do tratamento para ILTB são pouco conhecidos. Esse estudo objetivou verificar a frequência de solicitação e de realização (inoculação do derivado protéico purificado (PPD) e leitura) do TT, a frequência de TT reator e a frequência da prescrição do tratamento para ILTB e caracterizar as PVHA atendidas em serviço de referência em HIV/AIDS e TB no estado da Paraíba quanto a aspectos sociodemográficos e laboratoriais, no período de janeiro de 2009 a dezembro de 2013. Para obtenção dos dados, utilizou-se formulário padronizado, preenchido, retrospectivamente, a partir das informações contidas na primeira consulta registrada nos prontuários dos pacientes atendidos no período do estudo. Dos 3.191 pacientes incluídos na pesquisa, 2.303 (72,2%) tiveram o TT solicitado. Destes, 2.047 (89,0%) foram submetidos a realização do TT que compreendeu a inoculação do PPD e a leitura da induração. Dos 2.047 pacientes que tiveram o PPD inoculado e submetidos a leitura da induração, 90 (4,4%) pacientes tiveram o TT reator sendo o tratamento para ILTB prescrito para todos. Os resultados da pesquisa sugerem que há uma excelente adesão à solicitação do TT e à prescrição do tratamento para ILTB entre os profissionais médicos e baixa prevalência de ILTB no local do estudo. Outrossim, acessibilidade adequada para realização e boa compreensão por parte dos pacientes quanto a sua importância no contexto da atenção à saúde das PVHA garantiram a frequência elevada de realização do TT. / The diagnosis and treatment of latent infection with Mycobacterium tuberculosis (LIMTb) are given to groups in which the prevalence of latent infection is high, in contacts of new cases of tuberculosis (TB) and when the risk of reactivation is high as in people living with HIV/AIDS (PLHA). Both the human immunodeficiency virus (HIV) facilitates the reactivation of LIMTb as Mycobacterium tuberculosis contributes to the progression of HIV disease. The knowledge about the diagnosis and treatment for PLHA in LIMTb becomes critical as the Global Tuberculosis Control Report of the World Health Organization (WHO) indicates that PLHA are 26-31 times more likely to develop active TB compared the general population. In addition, the TB mortality rate PLHA is 3 times higher than that observed in the general population. Despite its limitations, the tuberculin skin test (TST) remains the primary diagnostic tool LIMTb, however, this does not reflect the number of TST ordered and carried out and, consequently, the number of prescription treatments for LIMTb. In Brazil, particularly in Paraiba, data on the application and realization of TST and for prescribing treatment for LIMTb are little known. Thus faces, this study aimed to verify the request frequency and achievement (inoculation of purified protein derivative (PPD) and reading of induration) of TST, the TST frequency of reactor and the frequency of prescription treatment for LIMTb and characterize the PLHA met in reference service on HIV/AIDS and TB in the state of Paraiba as the sociodemographic and laboratory aspects, from January 2009 to December 2013. To obtain the data, we used standardized form filled out retrospectively from information contained on the first visit recorded in the medical records of patients seen during the study period. Of the 3,191 patients included in the study, 2,303 (72.2%) had the TST requested. Of these, 2,047 (89.0%) underwent TST understood that inoculation of the PPD and the reading of induration. Of the 2,047 patients who had the PPD inoculated and subjected to reading of induration, 90 (4.4%) patients had TST reactor being treating LIMTb prescribed for everyone. The survey results suggest there is excellent adhesion to the request of the TST and prescription treatment for LIMTb among medical professionals and low prevalence of LIMTb in the study site. Likewise sufficient access for achievement and good understanding by patients and their importance in the context of attention to health of PLHA ensured the high frequency of TST realization.

Background: Migrant farmworkers are among the highest-risk populations for latent TB infection (LTBI) in the United States with numerous barriers to healthcare access and increased vulnerability to infectious diseases. LTBI is usually diagnosed on the border using the tuberculin skin test (TST). QuantiFERON-TB Gold In-Tube (QFT-GIT) also measures immune response against specific Mycobacterium tuberculosis antigens. The objective of this study is to assess the comparability of TST and QFT-GIT to detect LTBI among migrant farmworkers on the border, as well as to examine the effects of various demographic and clinical factors on test positivity. Methods: Participants were recruited using mobile clinics on the San Luis US-Mexico border and tested with QFT-GIT and TST. Demographic profiles and clinical histories were collected. Kappa coefficients assessed agreement between TST and QFT-GIT using various assay cutoffs. Logistic regression examined factors associated with positive TST or QFT-GIT results. Results: Of 109 participants, 59 of 108 (55 %) were either TST (24/71, 34 %) or QFT-GIT (52/106, 50 %) positive. Concordance between TST and QFT-GIT was fair (71 % agreement,kappa= 0.38, 95 % CI: 0.15, 0.61). Factors associated with LTBI positivity included smoking (OR = 1.26, 95 % CI-1.01-1.58) and diabetes/high blood sugar (OR = 0.70, 95 % CI = 0.51-0.98). Discussion: Test concordance between the two tests was fair, with numerous discordant results observed. Greater proportion of positives detected using QFT-GIT may help avoid LTBI under-diagnosis. Assessment of LTBI status on the border provides evidence whether QFT-GIT should replace the TST in routine practice, as well as identifies risk factors for LTBI among migrant populations.

Introdução: A terapêutica da psoríase foi modificada pela introdução dos imunobiológicos, que permitem melhor controle da doença e melhor qualidade de vida aos pacientes, mas promovem aumento do risco de tuberculose latente, exigindo diagnóstico antecedendo seu início. Objetivo: Avaliar o desempenho do teste T-SPOT.TB no diagnóstico de infecção tuberculosa latente em pacientes com psoríase. Métodos: Em estudo experimental, prospectivo, analítico, com comparação de grupos,de prevenção primária, para validade de teste diagnóstico, 33 pacientes com psoríase (grupo psoríase) e 30 pacientes com outras doenças dermatológicas (grupo base), atendidos nos Ambulatório de Dermatologia Geral ou de Psoríase do Centro de Estudos Dermatológicos do Recife, da Santa Casa de Misericórdia, entre fevereiro e novembro de 2009, foram submetidos aos testes do PPD e T-SPOT.TB. Para ambos os grupos, admitiu-se inclusão com idade mínima de 18 anos e critérios de exclusão doenças ou condições fisiológicas que comprometessem a competência imunológica, exceto psoríase, para o grupo psoríase. Adotou-se a técnica de Mantoux para o teste do PPD e uma variante simplificada da técnica Enzyme-Linked Immunospot para a determinação de células T efetoras, secretoras de IFN-g em resposta à estimulação pelos antígenos específicos do M. tuberculosis para o teste T-SPOT.TB. As variáveis dependentes foram os resultados do teste T-SPOT.TB contra antígenos ESAT-6, CFP-10, e os resultados do teste do PPD, considerando enduração de 0-4 mm: não reator; 5-9 mm: reator fraco; &#8805; 10 mm: reator forte. As variáveis independentes foram: idade, sexo, cor da pele, tempo de evolução da psoríase, ocupação, história de contato intradomiciliar e renda, alcoolismo e gravidade da doença. Foram submetidos a teste Qui quadrado ou exato de Fisher, em nível de significância de 0, 05, assim como ao teste de Mantel-Haenszel, três modelos comparando o teste T-SPOT.TB com teste do PPD, contato intradomiciliar e associação teste do PPD e contato intradomiciliar. A pesquisa foi aprovada pelos Comitês de Ética da Universidade Federal de Pernambuco e Universidade de São Paulo. Resultados: O grupo psoríase diferiu do grupo base quanto a razão de sexo com predomino do masculino (razão=0,7:1; p=0,047); maior idade média 42,1±1,9 anos (contra 34,1±1,4 anos no grupo base, p=0,023); fototipos I e II (p=0,020); menor nível de instrução e renda média mensal e contato intradomiciliar com tuberculose menos freqüente (p=0,001). Os grupos também diferiram quanto à positividade do teste do PPD (maior no grupo base; p=0,001). O teste T-SPOT.TB apresentou sensibilidade e especificidade de 9,1% e 95,5%, no modelo 1, 27,3% e 60%, no modelo 2, e valores de 60% e 53,3%, respectivamente no modelo 3. Foi no modelo 1 do grupo psoríase que o teste TSPOT. TB mostrou a maior concordância e o maior valor de Odds Ratio ponderado pelo teste de Mantel-Haenszel, tendo esses dois parâmetros significância estatística, quando comparados aos outros dois modelos. Conclusões: O teste T-SPOT.TB apresentou maior capacidade de diagnosticar casos negativos para tuberculose latente, constituindo-se numa opção para triagem de pacientes na instituição de terapêutica com imunobiológicos. / Introduction: The therapy for psoriasis was modified by the introduction of immunebiological products that allow better disease control and better quality of life for patients, but promotes increased risk forf latent tuberculosis, requiring diagnosis shortly before its establishment. Purpose: To assess the performance of T-SPOT.TB test for the diagnosis of latent tuberculosis infection in patients with psoriasis. Methods: Within a experimental, prospective, analytic, clinical assay type study, with comparison of groups, to validate a diagnostic test, 33 patients with psoriasis (psoriasis group) and 30 patients with other dermatological diseases (basis group), attempted at General Dermatology and Psoriasis Out-patients Departments of Recife\'s Dermatological Studies Center of Santa Casa de Misericórdia, from February to November 2009, were submitted to PPD and TSPOT. TB tests. For both groups, we admitted 18 years as minimal age for inclusion. The exclusion criteria included disease ou physiological conditions that compromised immunological competence, except psoriasis to psoriasis group. We used Mantoux technique for PPD test and a simplified variant of Enzyme-Linked Immunospot technique to determine effector T cells, secretors of IFN-g in response to M. tuberculosis specific antigens, to T-SPOT.TB test. Dependent variables were the results of T-SPOT.TB test against ESAT-6 and CPF-10 antigens, and the results to PPD test, considering enduration of 0-4 mm as non reactor; 5-10 mm weak reactor and &#8805; 10 mm, strong reactor. Independent variables were age, sex, skin color, psoriasis evolution time, occupation, history of intradomiciliar contact and income, alcoolism and disease grade. Three models, comparing T-SPOT.TB test to PPD test, intradomiciliar contact and both, were submitted to Qui Squared test or Exact Fisher Test, at significance level of 0.05, as well as to Mantel- Haenszel test. The research has been approved by Ethics Committee of Universidade Federal de Pernambuco e Universidade de São Paulo. Results: Psoriasis group differed from base group on sex ratio with predominance of male gender (rate=0.7:1; p=0,047), major mean age (42,1 ± 1.9 years against 34,1 ± 1.4 years in basic group, p = 0,023) phototypes I and II (p = 0,020); lower scholarship, income and less frequent intradomiciliar contact with tuberculosis (p = 0,001). The groups also differed on the positivity of PPD test (greater in base group; p = 0,001). T-SPOT.TB test had sensibility and specificity of 9,1% and 95.5%, in model 1; 27,3% and 60%, in model 2, and values of 60% and 53,3% respectively in model 3. Model 1 showed greater concordance and highest value of Odds Ratio test weighted by Mantel-Haenszel test, having these two parameters statistical significance when compared to the other two models. Conclusions: T-SPOT.TB test had great ability to diagnose negative cases for latent tuberculosis, and constitutes an option for screening patients to immunobiological therapy administration.

Introdução: A tuberculose é uma doença de repercussão mundial que desafia os serviços de saúde (SS). Estima-se que um terço da população mundial apresenta a forma latente da doença. Os profissionais da saúde (PAS) inseridos na assistência direta podem ter maior probabilidade de contágio; entretanto, os índices de ocorrência da doença nesta população não foram, até o momento, reconhecidos de forma sistemática. Objetivo: Estimar a prevalência e a incidência de tuberculose ocupacional nos serviços de saúde. Método: Trata-se de uma revisão sistemática de literatura segundo protocolo do Joanna Briggs Institute, que buscou responder quais os índices de tuberculose ocupacional nos SS. Foram considerados estudos primários que incluíssem dados de incidência e prevalência de tuberculose ocupacional ou de viragem tuberculínica em PAS. Foram definidos como PAS indivíduos em formação ou formados em cursos na área da saúde e que atuam na assistência direta. Quanto a SS, foram consideradas instituições de atendimento em qualquer um dos níveis assistenciais e que realizam atendimento direto a pacientes suspeitos ou portadores de tuberculose em suas fases transmissíveis, de forma a manter a homogeneidade da investigação. Foram excluídos os relatos de surtos e as ações dirigidas a populações em geral. Resultados: Foram identificadas 2.081 citações potencialmente relevantes em dez bases de dados, sem limites de tempo e idioma, a seleção final levou a 17 estudos. Em todos os artigos selecionados o desfecho estudado foi tuberculose latente. Não foram identificados estudos com dados com relação à tuberculose doença. O teste tuberculínico foi utilizado em 88,2% dos estudos. A prevalência de tuberculose latente (TL) variou entre 0,1% e 59,7% e a taxa de incidência anual variou de 3,3% a 26%. Um estudo identificou a densidade de incidência de 547/100.000 pessoas/ano. Conclusão: As evidências demonstram que a tuberculose é um importante agravo entre os PAS nos Serviços de Saúde, com importantes variações de acordo com o contexto. Os resultados indicam que a despeito da relevância do fenômeno, ainda há lacunas de informação sobre a incidência e a prevalência da tuberculose doença em PAS. / Introduction: Tuberculosis is a disease of worldwide repercussion that defies health care services (HS). It is estimated that one-third of the world population has a latent form of the disease. Healthcare workers (HCW) dealing with direct patient assistance may have higher contagion probability. However, the rates of the disease occurrence in this population have not been established in a systematic way yet. Objective: To estimate the global prevalence and incidence of occupational tuberculosis in HS by means of the literature review. Method: This is a systematic literature review according to the Joanna Briggs Institute, which sought to identify the rates of occupational tuberculosis in HCW. Primary studies were considered to include data on the incidence and prevalence of occupational tuberculosis or tuberculin skin test reaction in HCW. Reports of outbreaks and actions addressed to the community in general were excluded. Results: Out of ten cross-referenced databases, 2,081 potentially relevant studies were identified, without time and language limits, and the final selection was 17 studies. In all the articles selected, the outcome was latent tuberculosis. No studies with data regarding the tuberculosis disease were identified. The tuberculin skin test was used in 88.2% of the studies. The prevalence of latent tuberculosis ranged from 0.1 % to 59.7%. The annual incidence rate varied from 3.3% to 26%. As the risk and occupational exposure the absence of vaccination prior, the duration of care and performance in tuberculosis specific services were shown as relevant factors. One study identified the density of incidence of 547/100,000 people per year. Conclusion: Evidence indicates that tuberculosis is a relevant disease with the HCW and has important rates variations according to the context. The results demonstrate that despite the relevance of the phenomenon, there are still gaps in information on the incidence and prevalence of the tuberculosis disease in HCW.

Introdução: A terapêutica da psoríase foi modificada pela introdução dos imunobiológicos, que permitem melhor controle da doença e melhor qualidade de vida aos pacientes, mas promovem aumento do risco de tuberculose latente, exigindo diagnóstico antecedendo seu início. Objetivo: Avaliar o desempenho do teste T-SPOT.TB no diagnóstico de infecção tuberculosa latente em pacientes com psoríase. Métodos: Em estudo experimental, prospectivo, analítico, com comparação de grupos,de prevenção primária, para validade de teste diagnóstico, 33 pacientes com psoríase (grupo psoríase) e 30 pacientes com outras doenças dermatológicas (grupo base), atendidos nos Ambulatório de Dermatologia Geral ou de Psoríase do Centro de Estudos Dermatológicos do Recife, da Santa Casa de Misericórdia, entre fevereiro e novembro de 2009, foram submetidos aos testes do PPD e T-SPOT.TB. Para ambos os grupos, admitiu-se inclusão com idade mínima de 18 anos e critérios de exclusão doenças ou condições fisiológicas que comprometessem a competência imunológica, exceto psoríase, para o grupo psoríase. Adotou-se a técnica de Mantoux para o teste do PPD e uma variante simplificada da técnica Enzyme-Linked Immunospot para a determinação de células T efetoras, secretoras de IFN-g em resposta à estimulação pelos antígenos específicos do M. tuberculosis para o teste T-SPOT.TB. As variáveis dependentes foram os resultados do teste T-SPOT.TB contra antígenos ESAT-6, CFP-10, e os resultados do teste do PPD, considerando enduração de 0-4 mm: não reator; 5-9 mm: reator fraco; &#8805; 10 mm: reator forte. As variáveis independentes foram: idade, sexo, cor da pele, tempo de evolução da psoríase, ocupação, história de contato intradomiciliar e renda, alcoolismo e gravidade da doença. Foram submetidos a teste Qui quadrado ou exato de Fisher, em nível de significância de 0, 05, assim como ao teste de Mantel-Haenszel, três modelos comparando o teste T-SPOT.TB com teste do PPD, contato intradomiciliar e associação teste do PPD e contato intradomiciliar. A pesquisa foi aprovada pelos Comitês de Ética da Universidade Federal de Pernambuco e Universidade de São Paulo. Resultados: O grupo psoríase diferiu do grupo base quanto a razão de sexo com predomino do masculino (razão=0,7:1; p=0,047); maior idade média 42,1±1,9 anos (contra 34,1±1,4 anos no grupo base, p=0,023); fototipos I e II (p=0,020); menor nível de instrução e renda média mensal e contato intradomiciliar com tuberculose menos freqüente (p=0,001). Os grupos também diferiram quanto à positividade do teste do PPD (maior no grupo base; p=0,001). O teste T-SPOT.TB apresentou sensibilidade e especificidade de 9,1% e 95,5%, no modelo 1, 27,3% e 60%, no modelo 2, e valores de 60% e 53,3%, respectivamente no modelo 3. Foi no modelo 1 do grupo psoríase que o teste TSPOT. TB mostrou a maior concordância e o maior valor de Odds Ratio ponderado pelo teste de Mantel-Haenszel, tendo esses dois parâmetros significância estatística, quando comparados aos outros dois modelos. Conclusões: O teste T-SPOT.TB apresentou maior capacidade de diagnosticar casos negativos para tuberculose latente, constituindo-se numa opção para triagem de pacientes na instituição de terapêutica com imunobiológicos. / Introduction: The therapy for psoriasis was modified by the introduction of immunebiological products that allow better disease control and better quality of life for patients, but promotes increased risk forf latent tuberculosis, requiring diagnosis shortly before its establishment. Purpose: To assess the performance of T-SPOT.TB test for the diagnosis of latent tuberculosis infection in patients with psoriasis. Methods: Within a experimental, prospective, analytic, clinical assay type study, with comparison of groups, to validate a diagnostic test, 33 patients with psoriasis (psoriasis group) and 30 patients with other dermatological diseases (basis group), attempted at General Dermatology and Psoriasis Out-patients Departments of Recife\'s Dermatological Studies Center of Santa Casa de Misericórdia, from February to November 2009, were submitted to PPD and TSPOT. TB tests. For both groups, we admitted 18 years as minimal age for inclusion. The exclusion criteria included disease ou physiological conditions that compromised immunological competence, except psoriasis to psoriasis group. We used Mantoux technique for PPD test and a simplified variant of Enzyme-Linked Immunospot technique to determine effector T cells, secretors of IFN-g in response to M. tuberculosis specific antigens, to T-SPOT.TB test. Dependent variables were the results of T-SPOT.TB test against ESAT-6 and CPF-10 antigens, and the results to PPD test, considering enduration of 0-4 mm as non reactor; 5-10 mm weak reactor and &#8805; 10 mm, strong reactor. Independent variables were age, sex, skin color, psoriasis evolution time, occupation, history of intradomiciliar contact and income, alcoolism and disease grade. Three models, comparing T-SPOT.TB test to PPD test, intradomiciliar contact and both, were submitted to Qui Squared test or Exact Fisher Test, at significance level of 0.05, as well as to Mantel- Haenszel test. The research has been approved by Ethics Committee of Universidade Federal de Pernambuco e Universidade de São Paulo. Results: Psoriasis group differed from base group on sex ratio with predominance of male gender (rate=0.7:1; p=0,047), major mean age (42,1 ± 1.9 years against 34,1 ± 1.4 years in basic group, p = 0,023) phototypes I and II (p = 0,020); lower scholarship, income and less frequent intradomiciliar contact with tuberculosis (p = 0,001). The groups also differed on the positivity of PPD test (greater in base group; p = 0,001). T-SPOT.TB test had sensibility and specificity of 9,1% and 95.5%, in model 1; 27,3% and 60%, in model 2, and values of 60% and 53,3% respectively in model 3. Model 1 showed greater concordance and highest value of Odds Ratio test weighted by Mantel-Haenszel test, having these two parameters statistical significance when compared to the other two models. Conclusions: T-SPOT.TB test had great ability to diagnose negative cases for latent tuberculosis, and constitutes an option for screening patients to immunobiological therapy administration.

A TB é a principal doença oportunista a acometer as pessoas vivendo com HIV/aids (PVHA), sendo a coinfecção TB/HIV um importante desafio para os sistemas de saúde. O estudo objetivou descrever a vigilância da tuberculose latente nas PVHA acompanhadas pelos Serviços de Atenção Especializada ao HIV/aids (SAE) da rede municipal de saúde de Ribeirão Preto- SP, nos anos de 2012 e 2013. Trata-se de um estudo epidemiológico, descritivo, do tipo levantamento. Participaram 33 indivíduos que desenvolveram diagnóstico de tuberculose latente em 2012 e 2013, notificadas no Sistema de Informação \"Quimioprofilaxia TB\", e que viviam com HIV/aids, acompanhadas nos cinco SAE de rede pública municipal de Ribeirão Preto- SP. Para proceder à coleta de dados, inicialmente foi realizado um levantamento das PVHA diagnosticadas com tuberculose latente, a partir do número de indivíduos cadastrados no sistema de informação \"Quimioprofilaxia TB\". Posteriormente, foi utilizado um questionário estruturado contendo 30 questões do qual trabalhou-se com as seguintes seções: I - Dados sociodemográficos; II - Dados sobre o perfil clínico das PVHA - no momento do diagnóstico da TB latente; III- Dados sobre o controle da TB nas PVHA; IV- Dados sobre a situação, estratégias de acompanhamento e o desfecho da TB latente nas PVHA. O estudo foi desenvolvido a partir de fontes secundárias de informação: Sistema de Informação (SI) \"Quimioprofilaxia TB\"; Prontuário Clínico; Sistema Informatizado Hygia-Web e Sistema de Informação de Agravos de Notificação (SINAN). De forma complementar, com apoio de um roteiro específico foi realizada entrevista com o ator chave - coordenador do Programa Municipal de Controle da Tuberculose e do Programa de DST/aids/hepatites virais - com o intuito de caracterizar o cenário com enfoque na descrição das ações de prevenção e controle da TB nas pessoas com HIV/aids. A análise dos dados foi realizada por meio de técnica estatística descritiva. Dos 355 casos identificados no SI Quimioprofilaxia TB, 135 foram notificados em 2012 e 220 em 2013, sendo que 44 ocorrências envolviam as PVHA em seguimento na rede pública municipal de saúde, dos quais 21 (47,7%) pertenciam ao SAE \"C\". Foram excluídos 11 casos devido à não localização de prontuários clínicos e equívocos na classificação de indivíduos que não possuíam o diagnóstico de HIV/aids. Das 33 PVHA consideradas na amostra final do estudo, houve predomínio do sexo masculino (54,5%), faixa etária de 31 a 60 anos (72,7%), economicamente ativos e casados/ união estável (36,4%). Em relação ao perfil clínico, 75,8% tinham a aids como situação diagnóstica, faziam uso da TARV, porém apenas 30,3% tinham registros de retirada mensal de tais medicamentos. A contagem de células de proteção (TCD4+) e carga viral indicava estabilização do HIV/aids na maioria dos sujeitos. Quanto ao controle e desfecho da QT, a maioria (93,9%) dos pacientes realizou o tratamento na modalidade autoadministrada, sendo que 22 (66,7%) finalizaram o tratamento, mas observou-se uma taxa de abandono de 18,1%. Sendo a TB a principal doença oportunista a acometer e ser responsável pelo maior número de mortes associadas às PVHA, torna-se essencial a implementação de estratégias que favoreçam a vigilância da TB latente nas PVHA contribuindo como medida fundamental para o controle da doença ativa. A vigilância dos dados contribui para o planejamento e melhoria das ações e intervenções prestadas. Assim, desafios são lançados no que se refere à integração de ambos programas frente à importância da vigilância e manejo dos agravos no contexto das políticas públicas / TB is the main opportunistic infection to affect people living with HIV/AIDS (PLWHA), and TB/HIV coinfection is a major challenge for health systems. The study aimed to describe the monitoring of latent TB in PLWHA followed by HIV/AIDS Specialized Health Services Specialized (SHS) of Ribeirão Preto-SP, in the years 2012 and 2013. It was an epidemiological descriptive study. Were included 33 individuals who developed diagnosis of latent tuberculosis in 2012 and 2013, reported in the System Information \"TB chemoprophylaxis,\" and living with HIV/AIDS, followed by the five SHS municipal public health network of Ribeirão Preto-SP. For data collection, it was initially conducted a survey of PLWHA diagnosed with latent tuberculosis, from the number of individuals registered in the information system (IS) \"TB chemoprophylaxis.\" After, it was used a structured questionnaire containing 30 questions which were considered the following sections: I - Socio-demographic data; II - Data on the clinical profile of PLWHA - at diagnosis of latent TB; III - Data on the control of TB in PLWHA; IV Data on the situation, monitoring strategies and the outcome of latent TB in PLWHA. The study was developed from secondary sources of information: Information System \"TB chemoprophylaxis\"; Health Record; Computerized Hygia-Web system and Notifiable Diseases Information System (SINAN). As a complement, with the support of a particular script we interviewed the key actor - Municipal Program Coordinator for Tuberculosis Control and STD/AIDS - in order to characterize the scenario focusing on the description of the actions about prevention and control of TB in PLWHA. Data analysis was performed using descriptive statistics technique. Of the 355 cases identified in the IS chemoprophylaxis TB, 135 were reported in 2012 and 220 in 2013, with 44 occurrences involving PLWHA in the follow-up in the municipal public health system, of which 21 (47.7%) belonged to the SHS \"C\". Eleven cases were excluded due to non-location clinical records and errors in the classification of individuals who did not have the diagnosis of HIV/AIDS. Of the 33 PLWHA considered in the final study sample, there was a predominance of males (54.5%), aged 31-60 years (72.7%), economically active and married/common-law marriage (36.4%). Regarding the clinical profile, 75.8% had AIDS as a diagnostic situation, made use of ART, but only 30.3% had monthly removal of records of such drugs. The protective cell count (CD4 +) and viral load indicated stabilization of HIV/AIDS in most subjects. As for the control and outcome of QT, the majority (93.9%) of patients held in the self-administered treatment modality, with 22 (66.7%) completed the treatment but there was a dropout rate of 18.1 %. TB being the main opportunistic disease to affect and be responsible for more deaths associated with PLWHA, it is essential to implement strategies that enhance the surveillance of latent TB in PLWHA contributing as a key measure to control active disease. Surveillance data contribute to the planning and improvement of actions and interventions provided. So challenges are launched with regard to the integration of both programs forward the importance of surveillance and management of diseases in the context of public policy

Preventative interventions often demand that resources be consumed in the present in exchange for future benefits. Understanding these trade-offs, in a context of resource constraints, is essential for policy makers. Cost-effectiveness analysis is one tool to inform decision-making. Targeted testing and treatment (TTT) for latent tuberculosis infection (LTBI) consists in identifying people at high risk for LTBI for preventive treatment to decrease the risk that they will develop active tuberculosis disease (ATBD). The state of Tennessee began conducting TTT statewide in 2001. This study uses a decision tree to evaluate the cost and outcomes of TTT for LTBI in Tennessee, compared to passive ATBD case finding (PACF). Key event probabilities were obtained from the Tennessee TTT program and from the literature. Outcomes are measured in terms of Quality Adjusted Life Years (QALY). The cost-effectiveness threshold was set at $100,000/QALY saved. One-way sensitivity analyses around factors related to study design (exclusion of patient costs, secondary transmission, discount rate and analytical horizon), the program’s environment (prevalence of LTBI and drug resistance, ATBD treatment costs) and program performance (program maturity, treatment initiation and completion rate, testing in low-risk group, test characteristics, screening costs) were conducted, as was probabilistic sensitivity analysis (PSA) which takes into account the uncertainty in multiple parameters simultaneously. The base case, with a 25-year time horizon and 3% discount rate, shows that TTT prevents 47 ATBD cases, and saves 31 QALYs per 100,000 patients screened for LTBI at a societal cost of $12,579 (2011 US$) per QALY saved. Sensitivity analyses identified value thresholds that would trigger a change in preferred policy. PSA shows that the likelihood that TTT would be cost-effective is low. Decision makers interested in implementing TTT should carefully assess the characteristics of the local TB epidemic and expected program performance to determine whether TTT is preferable over PACF from a cost-effectiveness viewpoint.