Comparison of Heaf and Mantoux Tests in the Cali Area of Colombia GUILLERMO OROZCO, M.D., and GUY S. HAYES, M.D. DECEMBER 1959, the Arden House Con¬ bia, we carried out a series of Heaf tests on a INference on Tuberculosis emphasized the need random sample of the population that included for a simple and accurate tuberculin test that all ages. The tests were included in the survey could be applied and read by nonprofessional at the suggestion of Dr. Robert M. Lennox, then health personnel (1). This need is greatest in visiting professor of pediatrics at the Univer¬ developing countries where tuberculosis is often sidad del Valle and now professor of child a major public health problem and professional health, Tulane University School of Medicine. health personnel are in short supply. In Co¬ Shortly thereafter, we tested a small group of lombia, although the exact magnitude of the school children in Candelaria with both Heaf tuberculosis problem is still unknown, substan¬ and Mantoux techniques. The results en¬ tial evidence indicates that the disease is a ma¬ couraged us to carry out a more extensive field jor cause of disability and death. trial of the two methods in 1962 and 1963. The In 1951, Dr. Frederick Heaf (2) published primary objective of this study was to compare his technique for a multiple-puncture tuberculin Heaf and Mantoux tests in individual subjects. test that seemed to have several advantages over For our purposes, diagnostic implications of the the routine Mantoux procedure: not only did it test results were a side issue. prove relatively consistent, it was also cheap, it Subjects for the field trial, in addition to the could be administered rapidly, and results were school children of Candelaria, were from the easy to read. The Heaf test was subsequently cities of Cali, Yumbo, and Palmira. Cali tried out in Great Britain and the Common¬ (population about 700,000) is located at an al¬ wealth with encouraging results. This method titude of 3,300 feet in the Cauca Valley, be¬ is not widely used in the United States, however, tween the Central and Western Cordilleras; despite the publications of Robins and Daly (3), Yumbo (population 11,500) and Palmira Andersen and Smith Coulter and Martin (population 150,000) are both within 15 miles of (^), Cali and at the same elevation. Candelaria is (5),andHsu(tf). a rural town at the In a nearby (population 22,000) February 1961, during morbidity survey same elevation. The included in the rural town of Candelaria, Valle, Colom- subjects adult and pediatric patients at a university hospital, Dr. Orozco is associate professor of medicine at the a general hospital, three tuberculosis sanatori¬ Universidad del Valle, Cali, Colombia, and Dr. ums, and also medical and nursing students, Hayes, assistant director for medical and natural interns, residents, and staff nurses of the uni¬ sciences of the Rockefeller Foundation, is a visiting versity hospital. professor of preventive medicine at the university. Dr. Hebert Cobo, Dr. Hernando Urrea, Dr. Carlos Materials and Methods Hoyos, and Dr. Oscar Bolanos, residents on the staff of the Hospital Universitario del Valle "Evaristo Tuberculin for the Heaf test was a 50 percent Garcia,'9 collaborated in the performance and read¬ glycerine solution of purified protein deriva¬ ing of the tests. This study was supported in part tive (PPD), prepared by the Connaught Medi¬ with funds from the Rockefeller Foundation. cal Research Laboratories, Toronto, Canada, Vol. 80, No. 4, April 1965 293 with a concentration of 2 mg. of U.S. standard For the Mantoux test we used an intermediate tuberculin PPD in 1.0 ml. We cleaned the PPD-S prepared by Parke Davis & Co. during forearm of the subject with acetone. A drop the 1962 trials, but in 1963 we shifted to a PPD- of undiluted Heaf PPD was transferred to the S supplied by the Public Health Service. The skin of the upper left forearm by means of a Service also provided a Battey antigen (PPD- toothpick, or preferably a bacteriological loop, B) that we applied simultaneously with the and spread over an area roughly 8 mm. in di¬ other two antigens during the 1963 trials. The ameter. We made the intracutaneous injection Parke Davis PPD-S was supplied as tablets with a Sterneedle gun manufactured by the which were dissolved in 1 ml. of diluent im¬ Panray Corp., Englewood, N.J., using a freshly mediately before use. The PPD-S and PPD- sterilized cartridge for each patient. The gun B had been standardized and arrived in liquid with cartridge in place was pressed gently form ready for use without further dilution; against the skin in the middle of the area where the vials were stored in a refrigerator at 3-5° the PPD had been spread. We tensed the skin C. before testing. For the Mantoux tests we at the injection site slightly by gripping the started with new syringes which thereafter linder portion of the forearm. were used only with one kind of antigen, and we Figure 1. Distribution of different sizes in millimeters of Mantoux tests within different grades of Heaf reaction in 1,315 persons of varying age, sex, and tuberculin reactivity 1 Grade of Heaf reaction 1The five large dots indicate the mean of Mantoux reactions (induration) in millimeters for each grade of Heaf reaction. 294 Public Health Reports used sterilized needles of either 25 or 27 gauge, This result failed to meet the criteria of the injecting 0.1 ml. of the PPD solution intra- 1+ reaction, but for the area that did react dermally. This amount was equivalent to 5 TU the induration was of a type classified as 2+. (0.0001 mg.). Such results were assumed to have been caused In general, each member of the survey team by faulty technique, such as holding the Ster- applied only one test at one predetermined lo¬ needle gun at an angle instead of perpendicu¬ cation on the forearm. To avoid confusion we lar to the skin surface; they were therefore consistently applied the Heaf test to the upper eliminated for purposes of the study. left forearm, PPD-S on the upper right, and Composition of study groups. During the 2 PPD-B on the lower right. Many of the sub¬ years of the study we deliberately selected jects received histoplasmin on the lower left groups that varied according to age, sex, and forearm (7). the probability of their having active tuber¬ Two teams of at least two observers each in¬ culous disease. We arbitrarily divided the 1,315 dependently read the skin tests at 48 and 72 subjects into 4 groups. We further subdivided hours. In the event of disagreement between these groups by the calendar year in which they the two groups, consensus was reached by joint were tested since different sources of PPD-S consultation. Results of the Mantoux tests antigens were used in 1962 and 1963. Sources were recorded in millimeters of induration of the 560 subjects tested in 1962 were as without regard to the surrounding area of ery¬ follows: thema. Heaf test results were noted in accord¬ test Number ance with the modi¬ 1962 subjects following classification, Total_560 fied slightly from Heaf's original criteria (#, Group A: Primary school children, Candelaria- 31 8): Pediatric patients, Hospital Universitario, Cali- 64 Negative Group B: Pediatric patients, tuberculosis sanatorium, scar- Absence of reaction at sites of puncture, simple Yumbo _ 53 ring only, or slight erythema without induration. Group C: Adult outpatients, Hospital Universitario, Cali- 60 Adult ward patients, Hospital Universitario, Positive Cali_115 Adult ward patients, Hospital San Juan de Dios, 1+: Discrete palpable induration, with erythema, Cali_173 of at least four puncture points. (Induration at fewer Group D: than four points was classified as negative.) Adult ward patients, tuberculosis sanatorium, 2+: Coalescence of the indurated points to form Cali_ 64 an edematous ring. The small number of children from Cande¬ 3+: Induration more intensive than in a 2+ re¬ action, involving the center of the ring as well in laria are listed with the 1962 group for the sake a so-called coin pattern. of convenience, although they were actually 4+: Induration extending well beyond the circum¬ tested in 1961. ference of the ring or necrosis at any one of the punc¬ ture sites or adjacent areas or both. Following are the sources of the 755 subjects tested in 1963: In rare instances interpretation of the reac¬ tion was difficult. Where there was a typical 1963 test subjects Number 2+ indurated ring with one or more points of Total_755 definition we considered this as Group A: necrosis, by Pediatric patients, Hospital Universitario, Cali- 44 4+. Occasionally, however, there was dis¬ Group B: agreement as to whether or not the center of Pediatric patients, tuberculosis sanatorium, Yumbo -....- 44 the ring was indurated. The decision on this Group C: was left to the Adult ward patients, Hospital Universitario, point subjective interpretation Cali_127 of the observer. Although there might have Medical and nursing students, interns, residents, been an as to whether a reaction of and staff nurses, Hospital Universitario, Cali_ 392 argument Group D: this sort was 2 + or 3+, the question was largely Adult ward patients, tuberculosis sanatorium, academic. More we encountered three Cali_ 78 rarely, Adult ward patients, tuberculosis sanatorium, indurated puncture points joined together. Palmira - 70 Vol. 80, No. 4, April 1965 295 In making these arbitrary groupings we real- Figure 3. Frequency distribution of size of ized that some of the outpatients and ward pa¬ reactions to PPD.S in 744 persons, show¬ tients in both general hospitals in Cali might ing proportion of persons whose reaetion well have active tuberculosis; conversely, the to Battey (PPD-B) antigen was greater results indicated that a few of the children than to PPD-S in the Yumbo tuberculosis sana¬ hospitalized 40h torium were probably not tuberculous.