Educational Workshop

Transcription

1 Educational Workshop EW5: The impact of diagnostics on clinical tuberculosis management Arranged with ESGMYC Convenors: Jon S. Friedland, London, UK Emmanuelle Cambau, Paris, FR Faculty: Emmanuelle Cambau, Paris, FR Jon S. Friedland, London, UK Martina Sester, Homburg, DE

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3 Cambau - PCR and direct amplification for TB PCR and direct amplification for tuberculosis diagnosis Emmanuelle CAMBAU University Paris Diderot, APHP, Saint Louis-Lariboisière Hospital, Paris, France Educational Workshop 5- ECCMID 215 Copenhagen The impact of diagnostics on clinical tuberculosis management Tuberculosis in Europe cases in EU/EEA 36 overall WHO Europe 35 MDR cases detected Nucleic acid amplification direct testing (NAAT) for detection of M. tuberculosis complex from 199 onwards using gene (Hermans JCM 199) RNA (Boddinghaus JCM 199) IS611 (Thierry JCM 199) Pubmed 285 papers on diagnosis: 15 median per year 15 review papers, 8 meta-analyses Several recommendations ATS; CDC; WHO Several commercial kits and home made protocols ATS 1997, Ieven CMR1997, Sarmiento JCM23, Dinnes HTA 27, Greco JCM 29; MMWR 29;58; Lawn LID213

4 Cambau - PCR and direct amplification for TB WHO publications 214 Xpert MTB/RIF assay for direct diagnosis of pulmonary tuberculosis Steingart et al. Cochrane Database Syst Rev. 213 Jan 31;1 Steingart et al. Cochrane Database Syst Rev. 214 Jan 21;1 22 studies, 8998 participants Sensitivity: 89% (95%CrI 85% - 92%) Specificity: 99% ( 95% CrI 98% - 99%) Interpreting results of studies on NAAT/PCR for tuberculosis What is sensitivity? And how much is it important What is specificity? And how much is it important How are predictive values calculated? Positive predictive value Negative predictive value Concordance with smear and culture results

5 Cambau - PCR and direct amplification for TB Sensitivity of NAAT Smear pos Smear neg NAAT sensitivity for TB diagnosis = We would like that all TB patients with Smear-positive specimens are NAAT+ Cochrane review Pooled sensitivity = 98% (95% CrI 97-99%) WHO study group review Pooled sensitivity = 98% (95%Crl 97-99%) NAAT sensitivity for TB diagnosis = We would like that even TB patients with Smear-negative specimens are NAAT+ Cochrane review Sensitivity : 67% (95% CrI 6% -74%) LID Review (Lawn 213) Sensitivity : 75% (range: 47% - 83%) Extrapulmonary TB : 77% (range 25%-97%) WHO expert group review Sensitivity : 68% (95% CrI 61%-74%)

6 Cambau - PCR and direct amplification for TB N per ml specimen Sensitivity of diagnosis tools for tuberculosis Microscopy NA amplification Culture 1 = = 1 7 M+ 1 = = = = = M PCR+ PCR C+ C Specificity of NAAT No mycobacteria 1 BCG 1 BCG Results of the interlaboratory study in detection of M.tuberculosis Noordhoek et al. JCM 1996;34: expert laboratories - 2 external quality controls - 1 = no mycobacteria - 5 = 1 BCG - 5 = 1 BCG NAAT specificity for TB = We would like that patients without TB are NAAT negative Cochrane review Specificity : 98% (95% CrI 97% to 99%) LID Review Specificity : 98.6% (range 88.9% - 1%) WHO study group review Specificity : 99% (95% CrI 98% to 99%) Pr Emmanuelle CAMBAU

7 Cambau - PCR and direct amplification for TB Interpreting study results on NAAT/PCR in tuberculosis Patients tested Positive PCR test Negative PCR test TB* A True positive C False-negative Sensitivity A / A+C notb B False-positive D True-negative Specificity D/ D+ B * Based on smear, culture or clinical signs? Predictive values Are related to the prevalence of TB among the population tested by PCR Interesting if the prevalence is not biaised Positive predictive value (PPV) depends on specificity rate High PPV if the TB prevalence is high (> 1%) Negative predictive value (NPV) depends on sensitivity High NPV if the prevalence is very low (<1%) Interpreting study results on NAAT/PCR in tuberculosis Patients tested Positive PCR test Negative PCR test TB A* True positive C False-negative Sensitivity A / A+C notb B False-positive D True-negative Specificity D/ D+ B * Based on smear, culture or clinical signs? PPV A / A+B NPV D / D+C

8 Cambau - PCR and direct amplification for TB Xpert MTB/RIF assay for direct diagnosis of pulmonary tuberculosis and rifampicin resistance Karen R Steingart1, et al. Cochrane Database Syst Rev. 214 Jan 21;1 22 studies for diagnosis, 8998 participants, 25 cases of TB : prevalence 33% pooled sensitivity 89% (95% CrI 85% to 92%) pooled specificity 99% (95% CrI 98% to 99%) Negative smear microscopy sensitivity 67% (95% CrI 6% to 74%) specificity 99% (95% CrI 98% to 99%) Positive smear microscopy (65%) sensitivity 98% (95% CrI 97% to 99%) The prevalence (PV) varies depending on the specimen tested TB forms Smear-positive pulmonary (and non pulmonary) NTM infection can be also smear-positive Pulmonary smear-negative in occidental countries In endemic countries screened with XRay or other test Extra-pulmonary specimen (e.g. CSF, even if screened on the basis of leucocytes>1/mm3) Prevalence 98% to 1% 2 5% 1% 3%.5% Predictive values depends on the prevalence of TB TB forms PV PPV NPV Pulmonary smear-positive NTM infection also smear-positive Pulmonary smear-negative in occidental countries endemic countries screened with XRay or other test Extra-pulmonary specimen as CSF even if screened on the basis of leucocytes>1/mm3 98% to 1% 2% 5% 1% 3% 98% to 99.5% 34 % to 57% 9% 97% to 99%.5% 8% 99.7% PV, prevalence; PPV, positive predictive value; NPV, negative predictive value

9 Cambau - PCR and direct amplification for TB Number of cases diagnosed, missed, give false diagnosis, per prevalence rate Karen R Steingart, et al. Cochrane Database Syst Rev. 214 Jan 21;1 Prevalence (PV) depends on the specimen (form of TB) TB forms PV PPV NPV Pulmonary smear-positive NTM infection also smear-positive Pulmonary smear-negative in occidental countries endemic countries screened with XRay or other test Extra-pulmonary specimen as CSF even if screened on the basis of Leucocytes>1/mm3 98% to 1% 2 5% 1% 3% 98% to 99.5% 34 to 57% 9% 97 to 99%.5% 8% 99.7% Tricky to test extra-pulmonary smear-negative specimens Prevalence (PV) depends on the specimen (form of TB) TB forms PV PPV NPV Pulmonary smear-positive NTM infection also smear-positive Pulmonary smear-negative in occidental countries endemic countries screened with XRay or other test Extra-pulmonary specimen as CSF Even if screened on the basis of Leucocytes>1/mm3 98% to 1% 2 5% 1% 3% 98% to 99.5% 34 to 57% 9% 97 to 99%.5% 8% 99.7% All smear-positive specimens can/should be tested for PCR

10 Cambau - PCR and direct amplification for TB Molecular detection of Multidrug resistant-tb cases Laboratories should aim to identify TB and rifampicin resistance in over 9% of cases directly from smear + sputum where resources are available for this rapidly within 1-2 days Gene Xpert MTB/RIF Cepheid (USA) Boehme CC et al. NEJM 21 Genotype MTBDRplus HAIN Lifescience (Germany) Hilleman 27; Brossier 28: Barnard 28

11 Cambau - PCR and direct amplification for TB Molecular detection of rifampicin resistance Sensitivity = all Resistant strains are detected Specificity = no Susceptible strains are detected Cochrane review 214 (prevalence 19%) sensitivity : 95% (95% CrI 9% to 97%) specificity : 98% (95% CrI 97% to 99%) WHO study group review sensitivity : 95% (95%Crl 9-97%) specificity : 98% (95%Crl 97-99%) Positive predictive value for detection of rifampicin resistance For 1 patients, sensitivity of 95% and specificity of 98% Prevalence of resistance 3% 15% 5% 2% Nb of resistant isolates Nb of resistant detected Nb of resistant missed Nb of false resistant test PPV of detection of rifampicin resistance 96% 89% 72% 49% Steingart et al. Cochrane Database Syst Rev. 213 and 214 MDR rates among TB cases in EU 4.1% overall, 2.6% in new cases pulmonary TB 17.% in previously treated cases

12 Cambau - PCR and direct amplification for TB Positive predictive value for detection of rifampicin resistance For 1 patients, sensitivity of Previously New 95% and specificity of 98% treated cases Prevalence of resistance 15% 2% Nb of resistant isolates 15 2 Nb of resistant detected Nb of resistant missed 7 1 Nb of false resistant test 17 2 PPV of Confirmation detection of with another molecular 89% test and 49% rifampicin with resistance phenotypic determination is mandatory Steingart et al. Cochrane Database Syst Rev. 213 and 214 Integration of PCR in the new strategy for bacteriological diagnosis of tuberculosis Minimum workflow 1 day for M+ 2 weeks for M Specimen Smear and microscopic exam PCR / NAAT M+ M + = MTBC Culture mutation Rif+ Inh C+ Quick Identification C mutation gyra, rrs, emb, pnca, 2ndline AST Antituberculous Susceptibility Testing TST and IGRAs for contacts Genotyping if needed More sessions on mycobacteria at ECCMID215 Copenhagen Sunday April 26th Hall J: Meet the experts How and when to treat patients with infections due to Mycobacterium abscessus and other NTMs Sunday April 26th 9-11 Hall J: Current topics in tuberculosis Sunday April 26th Hall I: Advances in mycobacterial infections Tuesday April 28th, Hall K: OS35 Clinical aspects of mycobacterial infections Poster sessions: EV17, EP1, P29, P62, P63

13 Cambau - PCR and direct amplification for TB More information on ESGMYC Website : http: // Meeting on Sunday April 26th in Meeting room to Want to become a member? logging to ESCMID go to ESGMYC Study group ask for membership send a short CV and letter You are accepted!!

14 Friedland - Biomarkers Biomarkers in tuberculosis Jon S. Friedland Infectious Diseases & Immunity Hammersmith campus Defining Biomarkers A measured characteristic(s) which indicate normal or pathologic biological responses or a response to a treatment or other intervention Come in many forms Not necessarily related by structure or function May not be of primary functional importance What are biomarkers required for in TB? Diagnosis Prognosis Relapse Drug resistance Treatment Responses new drug trials Immunotherapeutics IRIS in HIV / TB Vaccine responses

15 Friedland - Biomarkers What s different about TB? Epidemiology & Pathology Indolent chronic disease 1.6 billion infected and 2 million die each year - latent disease Variable immune response disease is due to host TB is a disease of multiple tissues 46% in UK is extra-pulmonary TB may be hidden cavitation Most mycobacteria are not TB What s different about TB? Diagnosis & Treatment Diagnosis is difficult no gold standard Disease in children is hard to sort Relapse may occur 2 years out Percentage positive. 1 MODS 5 MBBacT LJ Time (days) N. Engl. J. Med. 26;355:1539-5) 5% all TB may be MDR-TB Rising tide of XDR-TB Co-exists with other diseases HIV Rheumatoid (anti-tnf) Traditional Clinical Biomarkers Clinical presentation fever, night sweats, cough Chest X-rays Tuberculin skin test False positives Booster effect No data on immune status Sputum analysis (quantative) Microscopy Culture (studied at 2/12 most commonly; may remain positive for months; early bacteriocidal activity poor)

16 Friedland - Biomarkers New Clinical Biomarkers FDG-PET / CT scanning Imaging bugs and inflammatory / immune responses Single immune biomarkers of disease Depend on pre-identified understanding of pathology: studies often small and poorly controlled Whole blood killing IGRAs do not distinguish active v. latent disease TNF IP-1 (Ix paediatric & recently as Rx response) sicam-1 Other CD4 T lymphocyte-derived cytokines - vaccines C-Reactive Protein widely used in richer countries Adenosine Deaminase +/- latest new marker (IL-27/33) (Systematic review & meta-analysis in Int. J. Clin. Exp. Med. 214;7: ) Bug Biomarkers Ag 85 in sputum (protein or mrna) Urinary metabolites Fragments of M. tb IS611 (apoptosis driven) Mycobacterial lipoarabinomannans may correlate with sputum bacillary burden Various antibodies to mycobacterial antigens

17 Friedland - Biomarkers Complex biomarkers the Omics Combinatorial approach No assumptions about disease process Can be applied in vivo or ex vivo Issues around using omic approaches Large number of variables in relation to numbers of samples Sample collection may be key Influenced by tissue specificity & leukocyte migration Data crunching & Overfitting Requires verification Genomics &Transcriptomics mrna analysis Focuses on larger changes (+/- 2 SD) at specific time points Key genes may be expressed transiently which has implications for late stage monitoring Interferon-inducible neutrophil-driven blood signature (Nature 21 Aug 19;466(739):973-7) UK training and South Africa testing sets 393 transcripts (>no samples) 2% LTB same Less good after 2/12 Rx mirna Small, non-coding, evolutionary conserved RNA involved in gene regulation and silencing.

18 Friedland - Biomarkers Lipidomics Metabolomics TB has many lipid components Techniques based around HPLC and Mass Spectrometry/NMR Development of a signature some relation to immunological responses relation to treatment responses reported misclassification errors SELDI-TOF MS SURFACE ENHANCED LASER DESORPTION IONISATION TIME OF FLIGHT CM1 weak cationic SELDI-ToF Mass spectrum Next: identify the proteins and raise antibodies for a near-patient dipstick

19 Friedland - Biomarkers Principles of -omics Training set Training Testing Trained classifier Testing set Support vector machines, ANNs, decision tree classifiers Must never filter data by the response that it is supposed to model Heat Map Active TB Mass spectra comparing peaks in active TB and symptomatic controls

20 Friedland - Biomarkers A signature to distinguish TB (26) 179 patients with active TB and 17 diverse controls Diagnostic sensitivity 93% Diagnostic specificity 95% Figures remained high when a smaller protein signature was selected. des-arg SAA & transthyretin identified as biomarkers No fractionation of removal of abundant proteins Latent TB why bother? Must be distinguished from active TB which is life threatening & has more complex Rx (otherwise drives MDR) Detect and Treat reservoir of infection Contact Tracing Monitor health care workers Epidemiological studies PROBLEM no diagnostic gold standard The study site Lima, Peru

21 Friedland - Biomarkers Recruitment 1 randomised training and testing sets cases controls Randomisation 1 cases controls cases controls TRAINING TESTING Classifier 1 Randomisation 2 Randomisation 1 cases controls cases controls cases controls cases controls TRAINING TESTING Classifier 2 TRAINING TESTING Classifier 1 Clustering of patients with active TB and symptomatic controls with or without latent TB using principal component analysis PCA does not rely on disease state so is relatively unbiased

22 Friedland - Biomarkers Classifier distinguishes active TB from symptomatic controls Accuracy Sensitivity Specificity 85% 85% 84% Classifier distinguishes active from latent TB Accuracy Sensitivity Specificity 89% 9% 89% Biomarkers final thoughts Clinical markers are easy to use Imaging holds promise but only in areas where TB is not prevalent Single bug/immune markers hold little promise Combinatorial approach holds out hope both in complex systems and in developing dipstick diagnosis Consortia to investigate are well established Still 5-1 years off to distinguish latent TB but active disease and response to Rx may be nearer.

23 Friedland - Biomarkers Team & Collaborators TB Group present & past Dan Agranoff Radha Asher Sara Brilha Moerida Belton Paul Elkington Carlton Evans Kate Fox Catherine Ong Gurj Sandhu Tara Sathyamoorthy Shivani Singh Ashley Whittington Universidad Cayetano, Peru & Johns Hopkins, USA Bob Gilman Hugo Garcia Many others in hospitals, health stations & labs in Peru National Institute for Medical Research, UK Delmiro Fernandez-Reyes Barry Ely Dept of Experiment Medicine, ICL Rob Edwards

24 Sester Interferon gamma assays Interferon Release Assays Principles, performance, and ability to predict tuberculosis Martina Sester, PhD Saarland University Department of Transplant and Infection Immunology Homburg/Germany The majority of infected individuals will never develop tuberculosis active TB LTBI Diagnosis of LTBI and implications for risk assessment Sester et al. (212) Eur Resp Monograph 58: 23

25 Sester Interferon gamma assays Prevalence of LTBI and risk for progression Horsburgh and Rubin (211) N Engl J Med 364:1441 Immunodiagnosis of latent M. tuberculosis infection PPD ESAT 6/CFP 1/TB7.7 Negative controls Positive control APC T cell IGRA IFN release assay cytokine induction Skin test cytokine induction cytokine induction activation/ cytokine induction ELISA ELISPOT assay Flow cytometry activation marker QuantiFERON TB gold T SPOT.TB cytokine Outline Test performance in immunocompetent individuals Test performance in immunocompromised patients Predictive value for risk assessment Immunocompetent individuals Immunocompromized patients

26 Sester Interferon gamma assays High sensitivity and specificity for infection with M. tuberculosis Skin test ELISA ELISPOT Sensitivity 65 % 8 % 81 % Specificity Low risk controls % 96 % 93 % Sester et al Eur Respir J (211) 37: 1 Pai et al Ann Intern Med (28) 149: 177 Low specificity for active tuberculosis Skin test ELISA ELISPOT Sensitivity 65 % 8 % 81 % Specificity Low risk controls Specificity TB suspects % 96 % 93 % 75 % 79 % 59 % Sester et al Eur Respir J (211) 37: 1 Pai et al Ann Intern Med (28) 149: 177 Low specificity for active tuberculosis 1% Progression TB M. tb. Infektion 9% LTBI live bacilli? LTBI bacilli extinguished? ~1% Never TB IGRAs/TST Consequence for assessment of progression for TB?

27 Sester Interferon gamma assays Test performance in immunocompetent individuals IGRAs have a higher specificity and a similar or higher sensitivity as compared to TST for detection of LTBI Variations exist, especially around cut offs IGRA positivity is associated with extent of exposure IGRAs have a relative advantage in the diagnosis of LTBI IGRAs should not be used for the diagnosis of active tuberculosis Outline Test performance in immunocompetent individuals Test performance in immunocompromised patients Predictive value for risk assessment Immunocompetent individuals Immunocompromized patients Influence of immunosuppression on TST and IGRA APC Corticosteroids Impaired T cell/apc function Calcineurin inhibitors Impaired cytokine secretion T cell IFN ESRD Impaired costimulatory capacity HIV infection Low CD4 counts Depleting antibodies T cell depletion Bumbacea et al. (212) Eur Respir J 4: 99

28 Sester Interferon gamma assays Lowest frequencies of positive test results in TST Percentage of positive results Stimulation with PPD in all assays controls hemodialysis Tx patients Scholman et al. (215) Am J Transplant, in press Test performance in immunocompromized patients 17 centers from 11 European Countries Screening of 1537 patients HIV infection (HIV) Chronic renal failure (CRF) Rheumatoid arthritis (RA) Solid organ transplantation (SOT) Stem cell transplantation (SCT) Screening with TST, ELISA and ELISPOT Follow up after 2 years Sester et al. (214) Am J Respir Crit Care Med 19: 1168 Indeterminate results 25 ELISPOT ELISA % indeterminate results HIV CRF RA SOT SCT Failure of positive control Excess reactivity in negative control

29 Sester Interferon gamma assays Percentage of positive tests Percentage of positive results 4 TST ELISPOT ELISA HIV CRF RA SOT SCT Association with extent of immunodeficiency SOT Percentage of positive results all >1 year post Tx <1 year post Tx Solid organ transplant recipients Dose dependent decrease in specific T cell reactivity in the presence of CNI CyA FK56 12 IFN IL2 12 IFN IL2 % reactive T cells % reactive T cells 8 4 % reactive T cells MFI (amount of cytokine/cell) MFI of reactive T cells IFN IL2 MFI of reactive T cells IFN IL Cyclosporine A [ng/ml] FK56 [ng/ml] Stimulus PPD, same data for ESAT 6/CFP 1 reactivity Sester et al (29) Eur Resp J 34: 72

30 Sester Interferon gamma assays Association with risk factors for M. tuberculosis exposure HIV SOT RA CRF moderate moderate strong no Test performance in immunocompromized patients Similarities in immunodeficiencies primarily affecting T cells (HIV, SOT, SCT) Substantial percentage of indeterminates HIV, SOT, SCT Groups differ in percentages of positive tests In general TST lower than IGRA Substantial agreement between IGRAs No major differences within IGRA Test performance and test interpretation varies with underlying immunodeficiency Overall level of positive tests Relation to risk factors for exposure Sester et al. (214) Am J Respir Crit Care Med 19: 1168 Outline Test performance in immunocompetent individuals Test performance in immunocompromised patients Predictive value for risk assessment Immunocompetent individuals Immunocompromized patients

31 Sester Interferon gamma assays PPV and NPV for development of active tuberculosis Test PPV NPV TST QFT G IT T SPOT.TB Diel et al. (211) Eur Respir J 37: 88 Risk of progression among contacts Contact tracing in 26 centers from 1 European countries 52 contacts from 123 index cases Screening with ELISA or ELISPOT 25 TB cases identified in the course of screening (prevalent cases) 24 TB cases amung 4513 contacts after a cumulative time of years (incident cases) Zellweger et al. (215) Am J Respir Crit Care Med in press Test results Percentage of positive results % 26.6%.6%.3% negative positive indeterminate n=3895 n=1125 Zellweger et al. (215) Am J Respir Crit Care Med in press

32 Sester Interferon gamma assays Progression rates depending on chemoprophylaxis Test result Prophylaxis N PY at risk TB cases Inc NNT negative no negative yes positive no positive yes negative no negative yes positive no positive yes Incidence/1 PY Zellweger et al. (215) Am J Respir Crit Care Med in press IGRAs in contacts from Western Europe Tuberculosis was a rare event Preventive chemotherapy in IGRA positive contacts was effective High negative predictive value Low positive predictive value with both IGRAs Zellweger et al. (215) Am J Respir Crit Care Med in press Progression in contact investigations The Netherlands 9332 contacts of pulmonary TB patients 1 years follow up 74 coprevalent cases (<18 days) 36 incident cases (>18 days) 4774 screened for LTBI (TST and/or IGRA) 739 (16%) evidence of infection Analysis of incident cases depending on preventive chemotherapy Sloot et al. (214) Am J Respir Crit Care Med 19: 144

33 Sester Interferon gamma assays Cumulative TB among contacts with LTBI Only 45% of contacts with LTBI started IPT 5 year risk (all) 5 year risk (close contacts) 45% 42% 2.4% 1.3% 3.5%.7% 4/435 (.99%) incident TB cases in contacts without LTBI Sloot et al. (214) Am J Respir Crit Care Med 19: 144 Progression rates depending on chemoprophylaxis Test result Prophylaxis N TB cases NNT negative no negative yes positive no positive yes 39 4 negative no negative yes positive no 21 8 positive yes All contacts Close contacts Sloot et al. (214) Am J Respir Crit Care Med 19: 144 Contact tracing in Germany no IPT >15 years <15 years IPT no IPT IPT 1579 contacts 36 IGRA positive 254 with follow up 27 without IPT 6 TB cases, all without IPT TB incidence 2./1 PY (CI.7 4.4) 6 TB cases TB cases TB cases TB cases Geis et al. (213) Eur Respir J 42: 1743

34 Sester Interferon gamma assays Predictive value/nnt Test result Prophylaxis N TB cases NNT positive no positive yes 47 Geis et al. (213) Eur Respir J 42: 1743 Study Summary NNT in contact tracing Zellweger Blue 215 western Europe Geis ERJ 213 Germany Sloot Blue 214 Netherlands Sloot Blue 214 close contacts Netherlands Diel Blue 211 Hamburg update Haldar Thorax 213 Leicester UK positive n.d. n.d n.d. negative n.d. n.d n.d. positive negative 86.3 n.d. n.d. 1.2 positive 36.5 n.d. negative 361. n.d. positive negative Predictive value of TST and IGRAs in immunocompetent individuals IGRAs and TST have a high negative predictive value for progression towards active tuberculosis IGRAs have similar or higher positive predictive value for progression towards active tuberculosis than the TST Overall still poor predictor for progression

35 Sester Interferon gamma assays Outline Test performance in immunocompetent individuals Test performance in immunocompromised patients Predictive value for risk assessment Immunocompetent individuals Immunocompromized patients Percentage of positive tests Percentage of positive results 4 TST ELISPOT ELISA HIV CRF RA SOT SCT Sester et al. (214) Am J Respir Crit Care Med 19: 1168 Active TB cases on follow up Country Patient group Gender Ethnicity Birth months after test Germany (D) HIV infected patient male african/afro american Eritrea 55,8 Germany (D) HIV infected patient male african/afro american Eritrea 34,8 Bulgaria (BUL) HIV infected patient male caucasian Bulgaria 1,3 Italy (I) HIV infected patient male hispanic Argentina 1, Italy (I) HIV infected patient male hispanic Argentina 51,6 Portugal (P) HIV infected patient female caucasian Portugal 2,5 Portugal (P) HIV infected patient female caucasian Portugal 21,4 Portugal (P) HIV infected patient male caucasian Portugal 8,3 Portugal (P) HIV infected patient male caucasian Portugal 2, Portugal (P) HIV infected patient male caucasian Portugal 33, Germany (D) organ transplant recipient female caucasian Croatia 24,8 Median 21.4 months Sester et al. (214) Am J Respir Crit Care Med 19: 1168

36 Sester Interferon gamma assays Test results at the time of screening Country Patientgroup TST ELISPOT ELISA Germany (D) HIV infected patient positive negative Germany (D) HIV infected patient negative negative Bulgaria (BUL) HIV infected patient 12 positive positive Italy (I) HIV infected patient 2 positive positive Italy (I) HIV infected patient 1 indeterminate positive Portugal (P) HIV infected patient negative negative Portugal (P) HIV infected patient negative indeterminate Portugal (P) HIV infected patient negative indeterminate Portugal (P) HIV infected patient 5 positive negative Portugal (P) HIV infected patient negative negative Germany (D) organ transplant recipient negative indeterminate Sester et al. (214) Am J Respir Crit Care Med 19: 1168 Progression rates depending on chemoprophylaxis 2 years Test result Prophylaxis N PY at risk TB cases Inc negative no negative yes positive no positive yes negative no negative yes positive no positive yes negative no negative yes positive no positive yes Progression rate depending on test result HIV Incidence per 1 person years 2 years ELISPOT ELISA TST test N At risk TB inc N At risk TB inc N At risk TB inc pos neg Sester et al. (214) Am J Respir Crit Care Med 19: 1168

37 Sester Interferon gamma assays NNT in immunocompromized patients All patients HIV infected HIV infected with positive HIV load positive negative positive negative positive negative adapted from Sester et al. (214) Am J Respir Crit Care Med 19: 1168 Predictive value of TST and IGRA in immunocompromized patients Interpretation of test results depends on the type of immunodeficiency Risk for developing tuberculosis is highest in HIV infected patients TST and IGRAs have similar predictive values About half of all HIV infected patients who developed TB had no evidence of LTBI at the time of screening Sester et al. (214) Am J Respir Crit Care Med 19: 1168 Diagnosis LTBI: Differences in progression risk 1% Progression TB TB therapy M. tb. Infektion 9% LTBI live bacilli? LTBI bacilli extinguished? ~1% Never TB Preventive chemotherapy IGRAs/TST Sester et al. (212) Eur Resp Monograph 58: 23

38 Sester Interferon gamma assays Diagnosis LTBI: Differences in progression risk 1% Progression TB TB therapy M. tb. Infektion LTBI live bacilli? ~1% Preventive chemotherapy efficient Risk factors 9% LTBI bacilli extinguished? Never TB Preventive chemotherapy not necessary Risk factors Sester et al. (212) Eur Resp Monograph 58: 23 Diagnosis LTBI: Differences in progression risk M. tb. Infektion 9% 1% Progression LTBI live bacilli? LTBI bacilli extinguished? ~1% TB Never TB TB therapy Preventive chemotherapy efficient Biomarker Preventive chemotherapy not necessary IGRAs/TST Sester et al. (212) Eur Resp Monograph 58: 23 Summary IGRA Rapid results (8 24h) Discrimination between latent infection and BCG vaccinaton Serial testing is possible Increased practicability and compliance Similar or increased sensitivity in immunocompromised patients Higher PPV/NPV of IGRA vs. TST in low burden settings Limited predictive value in immunocompromised patients New biomarkers to distinguish latent from active tuberculosis/to monitor treatment success

39 Sester Interferon gamma assays Consensus documents Latent infection with M. tuberculosis Mack et al. (29) Eur Respir J 33: 956 Contact investigation in low prevalence countries Erkens et al. (21) Eur Respir J 36: 925 Management of tuberculosis in patients on TNF antagonist treatment Solovic et al. (21) Eur Respir J 36: 1185 Management of tuberculosis in patients after solid organ and stem cell transplantation Bumbacea et al. (212) Eur Respir J 4: 99 Kirsch and Sester (212) Curr Infect Dis Rep 14: 65 Management guidelines to minimise the risk of donor derived tuberculosis Morris et al. (212) Am J Transplant 12: 2288 Thank you! Martina Sester, PhD Department of Transplant and Infection Immunology Saarland University Homburg martina.sester@uks.eu