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Screening for latent tuberculosis infection in adults
Updated evidence report and systematic review for the US preventive services task force
Jonas, D. E., Riley, S. R., Lee, L. C., Coffey, C. P., Wang, S.-H., Asher, G. N., Berry, A. M., Williams, N., Balio, C., Voisin, C. E., & Kahwati, L. C. (2023). Screening for latent tuberculosis infection in adults: Updated evidence report and systematic review for the US preventive services task force. JAMA, 329(17), 1495-1509. https://doi.org/10.1001/jama.2023.3954
IMPORTANCE: Latent tuberculosis infection (LTBI) can progress to active tuberculosis disease, causing morbidity and mortality.
OBJECTIVE: To review the evidence on benefits and harms of screening for and treatment of LTBI in adults to inform the US Preventive Services Task Force (USPSTF).
DATA SOURCES: PubMed/MEDLINE, Cochrane Library, and trial registries through December 3, 2021; references; experts; literature surveillance through January 20, 2023.
STUDY SELECTION: English-language studies of LTBI screening, LTBI treatment, or accuracy of the tuberculin skin test (TST) or interferon-gamma release assays (IGRAs). Studies of LTBI screening and treatment for public health surveillance or disease management were excluded.
DATA EXTRACTION AND SYNTHESIS: Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings; meta-analyses conducted when a sufficient number of similar studies were available.
MAIN OUTCOMES AND MEASURES: Screening test accuracy; development of active tuberculosis disease, transmission, quality of life, mortality, and harms.
RESULTS: A total of 113 publications were included (112 studies; N = 69 009). No studies directly evaluated the benefits and harms of screening. Pooled estimates for sensitivity of the TST were 0.80 (95% CI, 0.74-0.87) at the 5-mm induration threshold, 0.81 (95% CI, 0.76-0.87) at the 10-mm threshold, and 0.60 (95% CI, 0.46-0.74) at the 15-mm threshold. Pooled estimates for sensitivity of IGRA tests ranged from 0.81 (95% CI, 0.79-0.84) to 0.90 (95% CI, 0.87-0.92). Pooled estimates for specificity of screening tests ranged from 0.95 to 0.99. For treatment of LTBI, a large (n = 27 830), good-quality randomized clinical trial found a relative risk (RR) for progression to active tuberculosis at 5 years of 0.35 (95% CI, 0.24-0.52) for 24 weeks of isoniazid compared with placebo (number needed to treat, 112) and an increase in hepatotoxicity (RR, 4.59 [95% CI, 2.03-10.39]; number needed to harm, 279). A previously published meta-analysis reported that multiple regimens were efficacious compared with placebo or no treatment. Meta-analysis found greater risk for hepatotoxicity with isoniazid than with rifampin (pooled RR, 4.22 [95% CI, 2.21-8.06]; n = 7339).
CONCLUSIONS AND RELEVANCE: No studies directly evaluated the benefits and harms of screening for LTBI compared with no screening. TST and IGRAs were moderately sensitive and highly specific. Treatment of LTBI with recommended regimens reduced the risk of progression to active tuberculosis. Isoniazid was associated with higher rates of hepatotoxicity than placebo or rifampin.
