Tuberculosis screening and compliance rate with guidelines among Northern Portuguese Hospitals prescribers of anti-TNF therapy
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(A) Oxygen prescription; (B) transcription by nurses; (C) oxygen administration by nurses (D) oxygen monitoring." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Nunes, J. Maia, J.P. Ferreira, J. Neves, I. Marques" "autores" => array:5 [ 0 => array:2 [ "Iniciales" => "S." "apellidos" => "Nunes" ] 1 => array:2 [ "Iniciales" => "J." "apellidos" => "Maia" ] 2 => array:2 [ "Iniciales" => "J.P." "apellidos" => "Ferreira" ] 3 => array:2 [ "Iniciales" => "J." "apellidos" => "Neves" ] 4 => array:2 [ "Iniciales" => "I." 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Winck, C. LeBlanc, J.L. Soto, F. Plano" "autores" => array:4 [ 0 => array:2 [ "Iniciales" => "J.C." "apellidos" => "Winck" ] 1 => array:2 [ "Iniciales" => "C." "apellidos" => "LeBlanc" ] 2 => array:2 [ "Iniciales" => "J.L." "apellidos" => "Soto" ] 3 => array:2 [ "Iniciales" => "F." "apellidos" => "Plano" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0873215915933092?idApp=UINPBA00004E" "url" => "/08732159/0000002100000002/v0_201604141148/X0873215915933092/v0_201604141148/en/main.assets" ] "en" => array:9 [ "idiomaDefecto" => true "titulo" => "Tuberculosis screening and compliance rate with guidelines among Northern Portuguese Hospitals prescribers of anti-TNF therapy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "99" "paginaFinal" => "101" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "B.A. Ferreira, S. Ribeiro, J. Meireles, A. Correia, R. Duarte" "autores" => array:5 [ 0 => array:4 [ "Iniciales" => "B.A." "apellidos" => "Ferreira" "email" => array:1 [ 0 => "betania_ferreira82@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] ] ] 1 => array:3 [ "Iniciales" => "S." "apellidos" => "Ribeiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "J." "apellidos" => "Meireles" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "A." "apellidos" => "Correia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 4 => array:3 [ "Iniciales" => "R." "apellidos" => "Duarte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Centro Hospitalar Porto-Hospital Santo António, Internal Medicine, Largo Professor Abel Salazar, Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "<span class="elsevierStyleSup">*</span>" "correspondencia" => "Corresponding author. betania_ferreira82@hotmail.com" ] ] ] ] "textoCompleto" => "<p class="elsevierStylePara">Dear Editor,</p><p class="elsevierStylePara">Tumor necrosis factor-alpha (TNF-α) is a pleomorphic cytokine involved in the pathogenesis of many rheumatic diseases. Following anti-TNF therapy, the relative risk for tuberculosis is increased by up to 25 times, often as a rapidly progressive disease, extra-pulmonary or disseminated.<a href="#bib1" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">, </span><a href="#bib2" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">, </span><a href="#bib3" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">, </span><a href="#bib4" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a> Aiming to evaluate compliance with guidelines for tuberculosis screening, the authors conducted an enquiry among northern Portuguese hospitals which prescribe anti-TNF therapy.</p><p class="elsevierStylePara">From all hospitals in northern Portugal the authors identified those that prescribed anti-TNF therapy, and from them randomly selected from among the Internal Medicine medical doctors (the specialty which most commonly prescribed biological therapy in these hospitals) those who had at least, one weekly consultation of autoimmune disease and were familiar with the hospital prescription procedures. One hospital which had only one doctor prescribing was excluded.</p><p class="elsevierStylePara">The enquiry was carried out in September 2012. The interview consisted of ten multiple-choice questions relating to each recommendation: TB screening, diagnostic exams, preventive treatment, when to start anti-TNFα therapy and TB monitoring through the course of anti-TNFα treatment. Compliance rates were determined for each clinical recommendation and each guideline [national, international or European consensus] (<a href="#t0005" class="elsevierStyleCrossRefs">Table 1</a>).<a href="#bib5" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">, </span><a href="#bib1" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">, </span><a href="#bib6" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">, </span><a href="#bib7" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a></p><p class="elsevierStylePara">Table 1. Comparison between TB screening guidelines and the 2010 European consensus.</p><a name="t0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td> </td><td> </td><td>European <span class="elsevierStyleSup">1</span></td><td>Portuguese <span class="elsevierStyleSup">5</span></td><td>UK <span class="elsevierStyleSup">7</span></td><td>USA <span class="elsevierStyleSup">8</span></td></tr><tr align="left"><td rowspan="4">How to screen?</td><td>Clinical history <span class="elsevierStyleSup">a</span></td><td>All</td><td>All</td><td>All</td><td>All</td></tr><tr align="left"><td>Chest radiograph</td><td>All</td><td>All</td><td>All</td><td>TST+ or IGRA+</td></tr><tr align="left"><td>TST</td><td>Without history of BCG vaccination</td><td>All</td><td>Not for patients on IS as unreliable <span class="elsevierStyleSup">b</span></td><td>All</td></tr><tr align="left"><td>IGRA</td><td>Negative TST</td><td>All</td><td>Not used</td><td>All</td></tr><tr align="left"><td colspan="2">TST “Cut-off” for treatment ≥</td><td>10 mm<br></br>5 mm if</td><td>5 mm if IS; 10 mm in others</td><td>Unvaccinated; 15 mm in vaccinated</td><td>5 mm if IS<br></br>10 mm if high<br></br>risk <span class="elsevierStyleSup">c</span><br></br>15 mm in others</td></tr><tr align="left"><td colspan="2">Who should receive prophylaxis?</td><td>TST+ and/or IGRA+</td><td>TST+ and/or IGRA+; Recent TB exposure; CXR sequelae of non-treated TB</td><td>TST+; Previous TB not treated; CXR sequelae of non-treated TB; IS and risk factors for TB exposure <span class="elsevierStyleSup">d</span></td><td>TST+ and/or IGRA+</td></tr><tr align="left"><td colspan="2">LTBI treatment (months)</td><td>9–12 H or 3HR</td><td>9 H, 6 H, 3HR, 4 R</td><td>6 H or 3 HR</td><td>9 H</td></tr><tr align="left"><td rowspan="2">Time delay before TNF antagonist therapy</td><td>LTBI</td><td>4 weeks</td><td>4 weeks</td><td>Abnormal CXR or previous TB: complete prophylaxis; Others: no delay</td><td>4 weeks</td></tr><tr align="left"><td>Active TB</td><td>Full treatment</td><td>6–8 weeks</td><td>2 months</td><td>Full treatment</td></tr><tr align="left"><td rowspan="3">Time to screening</td><td>Before TNF antagonist therapy</td><td>All</td><td>All <span class="elsevierStyleSup">e</span></td><td>All</td><td>All</td></tr><tr align="left"><td>Re-testing</td><td>Annual</td><td>Annual</td><td>If symptoms of active TB; until 6 months stopping anti-TNF</td><td>Annual</td></tr><tr align="left"><td>Close contact with active TB</td><td>All</td><td>All <span class="elsevierStyleSup">f</span></td><td>–</td><td>All</td></tr></table><p class="elsevierStylePara">IS: immunosuppressive medication; H: isoniazid; R: rifampicin; CXR: chest radiograph.<br></br></p><p class="elsevierStylePara">a History of prior TB infection and treatment, close contacts of persons known or suspected to have active TB.<br></br>b TST will only become reliable once treatment has been stopped for 1 month in the case of steroids and for 3 months in the case of all other immunosuppressive drugs.<br></br>c New immigrant and drug users.<br></br>d Risk factors for TB exposure are defined based on a publication from the US Centres for Disease Control and Prevention as: close contacts of persons known or suspected to have active TB; foreign-born persons from areas that have a high incidence of active TB (e.g., Africa, Asia, Eastern Europe, Latin America, and Russia); persons who visit areas with a high prevalence of active TB, especially if the visits are frequent or prolonged; residents and employees of congregate settings whose clients are at an increased risk for active TB (e.g., correctional facilities, long-term care facilities, and homeless shelters); health care workers who serve clients who are at an increased risk for active TB; populations defined locally as having an increased incidence of latent <span class="elsevierStyleItalic">M. tuberculosis</span> infection or active TB, possibly including medically underserved, low-income populations, or persons who abuse drugs or alcohol; and infants, children, and adolescents exposed to adults who are at an increased risk for latent <span class="elsevierStyleItalic">M. tuberculosis</span> infection or active.<br></br>e Validated until 6 months prior initiation anti-TNF.<br></br>f Start chemoprophylaxis immediately, at the same time as TB screening.<br></br></p><p class="elsevierStylePara">Eleven hospitals were identified and ten were eligible. They performed TB screening in all patients treated with anti-TNF therapy. The screening method used by all hospitals was patient history and tuberculin skin test (TST), seven (70%) used interferon-gamma-release-assay (IGRA) and six (60%) used chest radiography (CRX). Compliance rate: 60% for UK guidelines and 50% for European consensus, USA and national guidelines (<a href="#t0010" class="elsevierStyleCrossRefs">Table 2</a>).</p><p class="elsevierStylePara">Table 2. Summary of results and compliance to recommendations (results in percentages).</p><a name="t0010" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td> </td><td>European</td><td>National</td><td>UK</td><td>American</td></tr><tr align="left"><td>Screen tools</td><td>50</td><td>50</td><td>60</td><td>50</td></tr><tr align="left"><td>Screen time</td><td>75</td><td>75</td><td>90</td><td>75</td></tr><tr align="left"><td>TST “cut-off”</td><td>90</td><td>80</td><td>80</td><td>80</td></tr><tr align="left"><td>Diagnosis methods of LTBI</td><td>70</td><td>70</td><td>0</td><td>70</td></tr><tr align="left"><td>LTBI treatment</td><td>80</td><td>80</td><td>20</td><td>80</td></tr><tr align="left"><td>Timing of initiation of anti-TNF if LTBI</td><td>80</td><td>80</td><td>0</td><td>80</td></tr><tr align="left"><td>TB re-testing</td><td>10</td><td>10</td><td>0</td><td>10</td></tr></table><p class="elsevierStylePara">All hospitals performed TB screening prior to anti-TNF treatment (compliance rate of 100% with all guidelines); seven (70%) re-screened during anti-TNF treatment, due to recent exposure to TB (compliance rate of 70% for USA, national guidelines and European consensus, UK guidelines do not give specific recommendations on this subject) and eight hospitals (80%) re-screened due to symptoms (compliance rate of 80% with all guidelines) (<a href="#t0010" class="elsevierStyleCrossRefs">Table 2</a>). Only one hospital (10%) re-tested asymptomatic patients with a previous negative screening, without recent exposure, during anti-TNF treatment (compliance rate 10% with national, American and European consensus, not applicable to UK guidelines) (<a href="#t0010" class="elsevierStyleCrossRefs">Table 2</a>).</p><p class="elsevierStylePara">Three hospitals (30%) screened in their own facilities, 4 (40%) in TB outpatient clinic, 1 (10%) in a primary care center and 2 (20%) in elsewhere.</p><p class="elsevierStylePara">Eight hospitals (80%) used TST cut-off of 5 mm, one (10%) 10 mm and one (10%) 15 mm. The compliance rate was 80% percent with national, UK and USA guidelines and 90% with European consensus (<a href="#t0010" class="elsevierStyleCrossRefs">Table 2</a>).</p><p class="elsevierStylePara">Seven hospitals (70%) initiated preventive therapy, if TST or IGRA were positive; one (10%) if both TST and IGRA were positive; two (20%) if TST was positive, without IGRA result. A compliance rate of 70% with European consensus, national and north-American guidelines was calculated. No compliance for UK guidelines (<a href="#t0010" class="elsevierStyleCrossRefs">Table 2</a>). All centers used isoniazid for preventive treatment. Eight hospitals (80%) treated their patients during nine months and two (20%) during 6 months. Compliance rates: 80% with national, American and European consensus and 20% with UK guidelines (<a href="#t0010" class="elsevierStyleCrossRefs">Table 2</a>). Eight hospitals (80%) initiated anti-TNF therapy 4 weeks after beginning LTBI treatment and two (20%) 3 months after. Compliance rate: 80% with national, American and European consensus; no compliance with UK guidelines (<a href="#t0010" class="elsevierStyleCrossRefs">Table 2</a>).</p><p class="elsevierStylePara">TB screening is performed routinely before anti-TNF treatment, according to the individual physician's awareness of TB risk. In our study, the European consensus was the guideline with highest percentage of compliance, presenting a medium rate of 69.4%%, followed closely by National and American Guidelines (68.1%). UK recommendations had a lower adherence, with 64.3%. This rate is similar to the compliance rate observed by Smith et al. in the Gastroenterology and Dermatology G5 group (including the five foremost industrialized economies – Germany, France, Italy, Spain and the United Kingdom); it was lower than the one observed in the non-G5 Rheumatology group.<a href="#bib8" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a></p><p class="elsevierStylePara">Although this study has serious limitations, as TB screening performance was based on self-reported actions of the physicians concerned, we found that among the protocols followed by experienced anti-TNF prescribers, the rate of compliance with the guidelines is low and there is excessive confidence in the TST. Re-testing is neglected and is a something that needs to be improved. The availability of facilities in Portugal such as the TB outpatient clinic can be considered a real asset but they are not used to their full potential.</p><a name="sec0005" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p class="elsevierStylePara">The authors have no conflicts of interest to declare.</p><p class="elsevierStylePara">Corresponding author. betania_ferreira82@hotmail.com</p>" "pdfFichero" => "320v21n02a90393310pdf001.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "The risk of tuberculosis related to tumour necrosis factor antagonist therapies: aTBNET consensus statement. Eur Respir J. 2010; 36:1185-206." 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Joint Tuberculosis Committee of the British Thoracic Society; 2005; 800-5." "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thoracic Society (BTS) recommendations for assessing risk and managing tuberculosis in patients due to start anti-TNF-alpha treatments." "idioma" => "en" ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "titulo" => "Thoracic Society (BTS) recommendations for assessing risk and managing tuberculosis in patients due to start anti-TNF-alpha treatments." "fecha" => "2005" "paginaInicial" => "800" "paginaFinal" => "805" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res. 2012; 64:625-39." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 6 | 16 |
| 2024 October | 64 | 45 | 109 |
| 2024 September | 64 | 23 | 87 |
| 2024 August | 103 | 42 | 145 |
| 2024 July | 78 | 42 | 120 |
| 2024 June | 85 | 56 | 141 |
| 2024 May | 69 | 28 | 97 |
| 2024 April | 57 | 30 | 87 |
| 2024 March | 41 | 20 | 61 |
| 2024 February | 46 | 35 | 81 |
| 2024 January | 39 | 21 | 60 |
| 2023 December | 38 | 23 | 61 |
| 2023 November | 35 | 30 | 65 |
| 2023 October | 31 | 28 | 59 |
| 2023 September | 33 | 31 | 64 |
| 2023 August | 41 | 37 | 78 |
| 2023 July | 66 | 28 | 94 |
| 2023 June | 64 | 23 | 87 |
| 2023 May | 76 | 29 | 105 |
| 2023 April | 76 | 16 | 92 |
| 2023 March | 147 | 27 | 174 |
| 2023 February | 112 | 29 | 141 |
| 2023 January | 56 | 20 | 76 |
| 2022 December | 99 | 25 | 124 |
| 2022 November | 83 | 43 | 126 |
| 2022 October | 93 | 29 | 122 |
| 2022 September | 79 | 30 | 109 |
| 2022 August | 91 | 48 | 139 |
| 2022 July | 87 | 45 | 132 |
| 2022 June | 78 | 35 | 113 |
| 2022 May | 62 | 41 | 103 |
| 2022 April | 56 | 29 | 85 |
| 2022 March | 48 | 35 | 83 |
| 2022 February | 48 | 38 | 86 |
| 2022 January | 35 | 45 | 80 |
| 2021 December | 32 | 37 | 69 |
| 2021 November | 44 | 44 | 88 |
| 2021 October | 64 | 38 | 102 |
| 2021 September | 39 | 34 | 73 |
| 2021 August | 35 | 25 | 60 |
| 2021 July | 44 | 16 | 60 |
| 2021 June | 41 | 25 | 66 |
| 2021 May | 56 | 19 | 75 |
| 2021 April | 124 | 75 | 199 |
| 2021 March | 90 | 15 | 105 |
| 2021 February | 78 | 18 | 96 |
| 2021 January | 72 | 19 | 91 |
| 2020 December | 40 | 14 | 54 |
| 2020 November | 56 | 23 | 79 |
| 2020 October | 59 | 23 | 82 |
| 2020 September | 62 | 24 | 86 |
| 2020 August | 62 | 18 | 80 |
| 2020 July | 70 | 25 | 95 |
| 2020 June | 60 | 16 | 76 |
| 2020 May | 72 | 19 | 91 |
| 2020 April | 74 | 6 | 80 |
| 2020 March | 77 | 16 | 93 |
| 2020 February | 62 | 22 | 84 |
| 2020 January | 79 | 23 | 102 |
| 2019 December | 62 | 18 | 80 |
| 2019 November | 69 | 18 | 87 |
| 2019 October | 75 | 18 | 93 |
| 2019 September | 73 | 24 | 97 |
| 2019 August | 127 | 19 | 146 |
| 2019 July | 130 | 27 | 157 |
| 2019 June | 129 | 20 | 149 |
| 2019 May | 114 | 17 | 131 |
| 2019 April | 108 | 28 | 136 |
| 2019 March | 99 | 15 | 114 |
| 2019 February | 94 | 7 | 101 |
| 2019 January | 132 | 27 | 159 |
| 2018 December | 48 | 9 | 57 |
| 2018 November | 12 | 1 | 13 |
| 2018 October | 16 | 8 | 24 |
| 2018 September | 29 | 8 | 37 |
| 2018 August | 33 | 26 | 59 |
| 2018 July | 28 | 20 | 48 |
| 2018 June | 24 | 16 | 40 |
| 2018 May | 19 | 24 | 43 |
| 2018 April | 75 | 24 | 99 |
| 2018 March | 44 | 15 | 59 |
| 2018 February | 25 | 11 | 36 |
| 2018 January | 43 | 16 | 59 |
| 2017 December | 53 | 18 | 71 |
| 2017 November | 15 | 16 | 31 |
| 2017 October | 10 | 14 | 24 |
| 2017 September | 10 | 4 | 14 |
| 2017 August | 15 | 12 | 27 |
| 2017 July | 4 | 11 | 15 |
| 2017 June | 18 | 12 | 30 |
| 2017 May | 22 | 10 | 32 |
| 2017 April | 12 | 6 | 18 |
| 2017 March | 6 | 7 | 13 |
| 2017 February | 6 | 3 | 9 |
| 2017 January | 5 | 6 | 11 |
| 2016 December | 7 | 5 | 12 |
| 2016 November | 10 | 4 | 14 |
| 2016 October | 3 | 2 | 5 |
| 2016 September | 7 | 4 | 11 |
| 2016 August | 5 | 2 | 7 |
| 2016 July | 4 | 12 | 16 |
| 2016 June | 0 | 6 | 6 |
| 2016 May | 1 | 12 | 13 |
| 2016 April | 17 | 10 | 27 |
| 2016 March | 30 | 14 | 44 |
| 2016 February | 44 | 24 | 68 |
| 2016 January | 20 | 22 | 42 |
| 2015 December | 30 | 16 | 46 |
| 2015 November | 15 | 15 | 30 |
| 2015 October | 16 | 16 | 32 |
| 2015 September | 33 | 15 | 48 |
| 2015 August | 24 | 10 | 34 |
| 2015 July | 31 | 8 | 39 |
| 2015 June | 33 | 17 | 50 |
| 2015 May | 58 | 23 | 81 |
| 2015 April | 110 | 85 | 195 |
| 2015 March | 79 | 61 | 140 |
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