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Skin Test Screening for Tuberculosis Among Healthcare Students: a Retrospective Cohort Study G.B

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Skin Test Screening for Tuberculosis Among Healthcare Students: a Retrospective Cohort Study G.B Skin test screening for tuberculosis among healthcareAnn Ig 2013; students 25: 311-315 doi:10.7416/ai.2013.1933311 Skin test screening for tuberculosis among healthcare students: a retrospective cohort study G.B. Orsi*, T. Antoniozzi**, M. Ortis**, V. Pippia*, S. Sernia*,** Key words: Tuberculosis, skin test, screening, surveillance Parole chiave: Tubercolosi, test cutanei, screening, sorveglianza Abstract Background: Aim of the study was to document the baseline prevalence of healthcare students positive to tuberculosis skin tests screening. Methods: Between 2008-2010, students admitted to healthcare courses (medicine, nursing, physiotherapy…) at “Sapienza” university in Rome were requested to carry out personal tuberculosis skin test screening in their local district or town healthcare centers according to the italian guidelines. At the time interferon- gamma release assays (IGRA) testing was not adopted for large screening. Demographic characteristics, tuberculosis screening results, healthcare course, tuberculosis vaccination status were recorded. Results: A cohort of 2,500 university healthcare students were screened by several Italian Hygiene Offices using tuberculin skin test and Tine test. Overall 131 (5.2%) healthcare students resulted positive to some tuberculosis skin test screening. Tuberculin skin test was carried out on 2,029 students (81.2%) and conversion was observed in 107 (5.3%), whereas Tine test was carried out on 498 students (19.9%) and positive result was observed in 24 (4.8%). The Tine test use and non optimal (<72h) recording of the forearm induration in tuberculin skin tests was related mostly to some healthcare centers in Lazio and Campania regions. Previous BCG vaccination was reported by 27 healthcare students (1.1%), and only two of them showed tuberculin skin test conversion, whereas the large majority 105 (98.1%) of Mantoux positives had not been vaccinated. In univariate analysis positive tuberculin skin test was associated to growing students age (29.2 ± 10.3 vs. 23.1 ± 6.0; p<0.01). Positive tuberculin skin test was recorded in 25 (20.3%) foreign and 82 (4.3%) italian students showing a higher risk for International students (RR 4.72; 95%CI 3.14 – 7.11; p<0.01). There was no significant correlation between the different Italian regions, the various healthcare courses or gender. Conclusion: The study evaluated the baseline positive skin test rate for tuberculosis among healthcare students in their first university year, showing a higher risk for the international group and revealed some problematic screening practices which need to be improved in the future screening programs. Introduction As the risk of tuberculosis transmission in healthcare workers is well known, it Identification and treatment of represents an important target population individuals with latent tuberculosis for latent tuberculosis infection screening infection is an important component of programs (3). Healthcare workers tuberculosis elimination strategies in low experience greater vulnerability to incidence countries and may contribute to tuberculosis because of close contact and the global tuberculosis control (1, 2). frequent exposure to tubercolotic patients, * Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy ** Centre of Occupational Medicine, Sapienza University of Rome, Italy 312 G.B. Orsi et al. eventual inappropriate environmental Data analysis conditions in hospitals and limited or Statistical analyses were performed insufficient preventive measures (4). using Epi-Info (version 2005; CDC, Therefore tuberculosis infection control Atlanta, GA). The chi-square was used programs in healthcare settings are to examine differences between groups. strongly recommended worldwide and Statistical significance was defined as also in Italy (5, 6). a P value of less than 0.05. Univariate Similarly, healthcare students often relationship was tested using relative risk experience patient contact during the and its 95% confidence interval (CI95). training and are exposed to tuberculosis. However few studies worldwide have evaluated the risk of tuberculosis infection Results among this specific population category (7), showing a wide range of incidence Between 2008-2010 a cohort of 2,500 rates in various countries (8-12). university healthcare students (35.9% Aim of this study was to document the males and 64.1% females) underwent baseline prevalence of healthcare students tuberculosis skin test screening for positive to tuberculin skin tests screening tuberculosis and were included in the in a large Italian university (5, 6). study. The students mean age was 23.3 ± 6.3 years (median 21, range 18-66) and the age distribution was as follows: Methods 18-20 (44.8%), 21-25 (34.4%), 26-30 (9.6%), 31-40 (8.2%), >40 (3.0%). This is a retrospective cohort study Most healthcare students were Italian carried out on healthcare students (94.8%), and the principal area of origin admitted between 2008-2010 to the was represented by Rome and Lazio “Sapienza” university in Rome, Italy. region (65.1%) followed by southern This is the largest Italian university and (28.6%), central (4.6%) and northern the students population is not only from regions (1.7%). Most students belonged Rome area but comes also from all over to Nursing (54.1%), Medicine (16.0%), Italy and abroad. Students admitted to all Laboratory technology (5.5%) and healthcare courses (medicine, nursing, Radiology technology (4.7%) courses. laboratory technology, physiotherapy The 2,500 healthcare students were …) were requested by the university screened in several Hygiene Offices by to carry out personal tuberculosis skin tuberculin skin test and Tine test. Overall test screening in their local district or 131 healthcare students (5.2%) out of 2,500 town healthcare centers. All Hygiene resulted positive to some tuberculosis offices carried out Tuberculin skin test skin test screening. Tuberculin skin according to the Italian guidelines (5), test was carried out on 2,029 students although in some centers also Tine test (81.2%) and conversion was observed was used for tuberculosis screening. At in 107 (5.3%). Following the Mantoux the time interferon-gamma release assays technique, the different healthcare centers (IGRA) testing was not adopted for large recorded the forearm transverse diameter screening. Demographic characteristics, induration after 48h (28%) or 72 h (72%). tuberculosis screening results, healthcare We noticed that a non optimal (<72h) course, tuberculosis vaccination status recording of the forearm induration were recorded in a data-base. was related mostly to some healthcare Skin test screening for tuberculosis among healthcare students 313 centers in Lazio and Campania regions. Discussion Tine test was carried out on 498 students (19.9%) and positive result was observed To our knowledge this is the first in 24 (4.8%). Tine test was adopted more study to evaluate the baseline prevalence frequently in some healthcare centers of healthcare students positive to in Lazio and Campania region. All tuberculosis skin tests screenings in students who resulted positive to any skin an Italian university, and analyzing test underwent following controls and the Hygiene Offices compliance to none presented clinical or radiological tuberculosis surveillance and prevention evidence of active tuberculosis. Previous guidelines (5, 6). BCG vaccination was reported by 27 Problematic screening practices were healthcare students (1.1%). Among them identified among some Hygiene Offices only two showed tuberculin skin test and should be highlighted for the future conversion, whereas the large majority screening programs. Despite published 105 (98.1%) of Mantoux positives had Italian guidelines for tuberculosis not been vaccinated. prevention recommended the use of In univariate analysis, we considered Mantoux method for skin testing (5), only students positive to tuberculin skin 1/5 of students were screened using the test, and results showed an association Tine tests. Multiple puncture devices with growing students age (29.2 ± 10.3 vs. are less specific than Mantoux test, 23.1 ± 6.0; p<0.01), see Table 1. Positive with a possible inconsistent delivery of tuberculin skin test was recorded in 25 tuberculin and Tine induration is semi- (20.3%) foreign and 82 (4.3%) italians, quantitative, whereas Mantoux allows showing a significant association with the more precise measurement. The adoption international students group (RR 4.72; of Tine test instead of tuberculin skin 95%CI 3.14 – 7.11; p<0.01), particularly test was concentrated in some Hygiene those coming from eastern Europe Offices of Lazio and Campania regions. (12/52), South America (6/24) and Tuberculin skin test conversion should Africa (4/10). There was no significant be controlled up to 72h after intradermal correlation between the different Italian injection, but results showed that in regions, the various healthcare courses almost 1/3 of patients the reading was or gender. stopped at 48h. Optimal screening should Table 1 - Dstribution of skin test screening prevalence for tuberculosis among healthcare students Tuberculin skin test Tine Test All skin test Screening Age (years) + - + - + - 18-20 3.4% 96,6% 3.7% 96,3% 3.5% 96,5% 21-25 3.2% 96,8% 4.4% 95,6% 3.5% 96,5% 26-30 6.1% 93,9% 2.0% 98,0% 5.4% 94,6% 31-40 17.3% 82,3% 15.8% 84,2% 17.2% 82,8% >40 20.0% 80,0% 4.2% 95.8% 18.9% 81,1% Total 5.3% 94,7% 4.8% 95,2% 5.2% 94,8% 314 G.B. Orsi et al. be carried out at 72h because readings
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