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To: ADC Fetal and Neonatal Edition Letters and ADC Education and Practice Letters

Electronic Letters to:

Original articles: Rebecca EB Taylor, Andrew J Cant, and Julia E Clark Potential impact of NICE tuberculosis guidelines in paediatric TB screening Arch Dis Child 2007; 0: adc.2006.106617v1 [Abstract]

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Electronic letters published:

Let's not jump the gun!

Beate Kampmann   (10 March 2008)

IGRA for children in the UK: patchy availability, problems with funding, unclarity about role.

Onajite M Etuwewe, Andrew Riordan   (25 March 2008)

Let's not jump the gun! 10 March 2008
Beate Kampmann, Senior Lecturer in Paediatric Infectious Diseases Imperial College London Send letter to journal: Re: Let's not jump the gun! b.kampmann{at}imperial.ac.uk Beate Kampmann	We welcome the publication of further data regarding the performance of interferon-gamma-release assays (IGRA) in children. Taylor et al conclude from their data that 85% of chemoprophylactic treatment would have been saved by applying IGRA for the diagnosis of latent TB, as recommended by the NICE guidelines. This might sound very attractive to PCTs. However, they also point out the potential for missing cases of active TB, if IGRA is relied upon as a discriminatory diagnostic test. We would like to raise two issues in this context: 1. We agree with Shingadia et al in the accompanying Perspectives that we should not abandon the TST in the absence of long-term surveillance in children with positive Mantoux (> 6mm in non-BCG-vaccinated or > 15 mm in BCG-vaccinated children), but negative IGRA. Funding and infrastructure for long-term follow-up of children with discrepant results needs to be put in place urgently to assess the predictive value of a negative IGRA. In the already stretched national TB services, this is not currently seen as a priority. 2. We held the first Paediatric workshop for the use of IGRA in children in the UK at Imperial College in October 07. With the contribution of the workshop participants we have created a combined database for children with TB who have had IGRA testing as part of their investigations. This database will serve as a baseline to further describe the use of IGRA in children in the UK. Furthermore, we have invited European paediatricians to contribute their experiences via TBNET, a recently formed collaborative initiative for the management of tuberculosis in Europe. We believe that remaining questions, such as the performance of IGRA in children under 2 or in the immunocompromised will only be answered conclusively, if paediatricians combine their efforts- and patient data- in order to correctly recommend these novel tests for children in low-incidence settings.
IGRA for children in the UK: patchy availability, problems with funding, unclarity about role. 25 March 2008
Onajite M Etuwewe, Specialist Registrar, Paediatrics. Dept of Paediatric Infectious Diseases and Immunology. Royal Liverpool Children's Hospital NHS Trust, Andrew Riordan Send letter to journal: Re: IGRA for children in the UK: patchy availability, problems with funding, unclarity about role. onajite.etuwewe{at}nhs.net Onajite M Etuwewe, et al.	We were interested to read the study by Taylor of interferon gamma release assays (IGRA) in paediatric tuberculosis (TB) [1]. The authors highlight reliance on IGRA within NICE guidelines but advise caution when interpreting results. We surveyed paediatricians who manage TB in January 2008, asking about use of IGRA. Paediatricians were identified from a previous TB survey [2]. 39/100 paediatricians completed the survey. Sixty percent had used IGRA. Issues of cost and laboratory access prevented regular use for many. Sixteen percent had IGRA performed in their local laboratory while 22% sent specimens greater than 100 miles away. Prolonged specimen transport can produce inaccurate results [3]. Such practical issues may limit the use of these tests in resource-limited settings [4], but our survey demonstrates these are problems in the UK currently. Only 9% reported no pragmatic problems with IGRA use. Survey participants used IGRA for various clinical applications. IGRA were used outside the indications of the NICE guidelines by 22 paediatricians. Some respondents indicated that uncertainty about the clinical value of IGRA also precluded their use. A recent meta-analysis concluded; “information is currently insufficient to estimate sensitivity, specificity, and reproducibility of IGRA in children” [5]. Longitudinal studies of IGRA in children with latent TB are needed. If these show benefit and cost effectiveness, then availability and funding for these tests will need to be reviewed. References 1. Taylor REB, Cant AJ, Clark JE. Potential effect of NICE tuberculosis guidelines on paediatric tuberculosis screening. Arch Dis Child 2008;93:200-203. 2. Adalat S, Paliwalla M, Novelli V, Riordan FAI. A survey of tuberculosis services in the UK. Arch Dis Child. 2008 (in press) 3. Cellestis International. Clinicians Guide to QuantiFERON-TB Gold. http://www.cellestis.com/IRM/content/gold/QFT-Gold_US_Clinicianguide.pdf. Accessed 21 February 2008. 4. Shingadia D, Novelli V. The tuberculin skin test: a hundred, not out? Arch Dis Child 2008;93:189-190. 5. Menzies D, Pai M, Comstock G. Meta-analysis: New Tests for the Diagnosis of Latent Tuberculosis Infection: Areas of Uncertainty and Recommendations for Research. Ann Intern Med. 2007;146:340-354.