Primary Care Screening and Treatment for Latent Tuberculosis Infection in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force.
OBJECTIVE
Five to ten percent of individuals with latent tuberculosis infection (LTBI) progress to active tuberculosis (TB) disease. Identifying and treating LTBI is a key component of the strategy for reducing the burden of TB disease.


OBJECTIVE
To review the evidence about targeted screening and treatment for LTBI among adults in primary care settings to support the US Preventive Services Task Force in updating its 1996 recommendation.


METHODS
MEDLINE, Cochrane Library, and trial registries, searched through August 3, 2015; references from pertinent articles; and experts. Literature surveillance was conducted through May 31, 2016.


METHODS
English-language studies of LTBI screening, LTBI treatment with recommended pharmacotherapy, or accuracy of the tuberculin skin test (TST) or interferon-gamma release assays (IGRAs). Studies of individuals for whom LTBI screening and treatment is part of public health surveillance or disease management were excluded.


METHODS
Two investigators independently reviewed abstracts and full-text articles. When at least 3 similar studies were available, random-effects meta-analysis was used to generate pooled estimates of outcomes.


METHODS
Sensitivity, specificity, reliability, active TB disease, mortality, hepatotoxicity, and other harms.


RESULTS
The review included 72 studies (n = 51 711). No studies evaluated benefits and harms of screening compared with no screening. Pooled estimates for sensitivity of the TST at both 5-mm and 10-mm induration thresholds were 0.79 (5-mm: 95% CI, 0.69-0.89 [8 studies, n = 803]; 10 mm: 95% CI, 0.71-0.87 [11 studies; n = 988]), and those for IGRAs ranged from 0.77 to 0.90 (57 studies; n = 4378). Pooled estimates for specificity of the TST at the 10-mm and 15-mm thresholds and for IGRAs ranged from 0.95 to 0.99 (34 studies; n = 23 853). A randomized clinical trial (RCT) of 24 weeks of isoniazid in individuals with pulmonary fibrotic lesions and LTBI (n = 27 830) found a reduction in absolute risk of active TB at 5 years from 1.4% to 0.5% (relative risk [RR], 0.35 [95% CI, 0.24-0.52]) and an increase in absolute risk for hepatoxicity from 0.1% to 0.5% (RR, 4.59 [95% CI, 2.03-10.39]) for 24 weeks of daily isoniazid compared with placebo. An RCT (n = 6886) found that 3 months of once-weekly rifapentine plus isoniazid was noninferior to 9 months of isoniazid alone for preventing active TB. The risk difference for hepatoxicity comparing isoniazid with rifampin ranged from 3% to 7%, with a pooled RR of 3.29 (95% CI, 1.72-6.28 [3 RCTs; n = 1327]).


CONCLUSIONS
No studies evaluated the benefits and harms of screening compared with no screening. Both the TST and IGRAs are moderately sensitive and highly specific within countries with low TB burden. Treatment reduced the risk of active TB among the populations included in this review. Isoniazid is associated with higher rates of hepatotoxicity than placebo or rifampin.
RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center2RTI International, Research Triangle Park, North Carolina.
Leila C
LC
Kahwati
RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center3Department of Medicine, University of North Carolina at Chapel Hill4Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.
Cynthia
C
Feltner
RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center2RTI International, Research Triangle Park, North Carolina.
Michael
M
Halpern
RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center2RTI International, Research Triangle Park, North Carolina.
Carol L
CL
Woodell
RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center2RTI International, Research Triangle Park, North Carolina.
Erin
E
Boland
RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center4Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.
Halle R
HR
Amick
RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center4Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.
Rachel Palmieri
RP
Weber
RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center3Department of Medicine, University of North Carolina at Chapel Hill4Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.
Daniel E
DE
Jonas
D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use*; D006801:Humans; D059425:Interferon-gamma Release Tests; D055985:Latent Tuberculosis / Q000175:diagnosis* / Q000188:drug therapy*; D008403:Mass Screening / Q000592:standards*; D011320:Primary Health Care / Q000592:standards*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D014374:Tuberculin Test
D000995:Antitubercular Agents