A Scandalous Incompetence … Continued
1998; Elsevier BV; Volume: 113; Issue: 5 Linguagem: Inglês
10.1378/chest.113.5.1153
ISSN1931-3543
Autores Tópico(s)Infectious Diseases and Tuberculosis
ResumoThe tuberculin skin test1Reichman LB. Tuberculin skin testing: the state of the art.Chest. 1979; 76: 764S-770SAbstract Full Text Full Text PDF PubMed Google Scholar is arguably one of the most widely used biologic tests in the world. It is, because of the absence of any competing test, considered the “gold standard” for latent tuberculosis (TB) infection, much like the Mycobacterial culture is considered the gold standard for TB disease.One of the foremost reasons for the well-publicized resurgence of TB in the 1980s and 1990s was neglect—by practitioners, policymakers, and researchers.2Reichman LB. Defending the public's health against tuberculosis.JAMA. 1997; 278: 865-867Crossref PubMed Google Scholar It is demonstrative of such neglect that this, the most widely used diagnostic test for TB, was first introduced in 1880, with few modifications since. This fact, in an era of high-tech solutions for lesser problems, is unconscionable. However, the test is all we have so far.The reason that the diagnosis of latent tuberculosis infection (and thus the tuberculin test) is so important is that the latent infection stage of the disease3Geiter LJ. Preventive therapy for tuberculosis.in: Reichman LB Hershfield EH 1st ed. Tuberculosis: a comprehensive international approach. Marcel Dekker, New York1993: 241-248Google Scholar is the target of all contact investigations, employee tuberculosis control programs, and epidemiologic surveillance. Patients who are infected with the tubercle bacillus are considered at variable risk of progressing to active tuberculosis. It is well recognized and universally accepted that such progression can usually be prevented by prescription of medication (usually isoniazid preventive therapy for 6 months).3Geiter LJ. Preventive therapy for tuberculosis.in: Reichman LB Hershfield EH 1st ed. Tuberculosis: a comprehensive international approach. Marcel Dekker, New York1993: 241-248Google Scholar Thus, the tuberculin test is the only test that allows highly effective strategies for the prevention of TB to be implemented.The paper by Kendig and colleagues in this issue of CHEST (see page 1175) presents shocking and sobering findings on the accuracy and utility of the tuberculin test that extend and enhance previous descriptions of deficiencies in TB management and prevention in general. A subject with a documented 15-mm tuberculin skin test reaction (consistent with diagnostic criteria for TB infection across all risk and age groups)3Geiter LJ. Preventive therapy for tuberculosis.in: Reichman LB Hershfield EH 1st ed. Tuberculosis: a comprehensive international approach. Marcel Dekker, New York1993: 241-248Google Scholar had independent skin reaction readings performed by 52 practicing pediatricians, 33 pediatric house officers, 10 pediatric academicians, 11 registered nurses, and a pediatric nurse practitioner.Ninety-nine of 107 participants (93%) read the reactions as less than 15 mm, and 17 (30%) read the reactions as less than 10 mm. Only 8 of 107 participants (7%) correctly read the reaction at 15 mm or greater!It is known that hospital staff are as reluctant to take isoniazid as they are reluctant to prescribe it.4Reichman LB Mangura BT. State-of-the-art tuberculosis prevention [editorial].Chest. 1996; 109: 301-302Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The present data clearly show that diagnosing patients into a category where isoniazid clearly would be beneficial is even more problematic, since tuberculin tests are seriously underread across the board.In the late 1980s, the National Tuberculosis Elimination Plan was promulgated.5Dowdle WR. A strategic plan for the elimination of tuberculosis in the United States.MMWR. 1989; 38: l-25Google Scholar Because of the perceived lack of TB knowledge and the necessity of education for any possibility of control, much less elimination, in 1989 (prior to recognition of the resurgence of TB) the Centers for Disease Control and Prevention (CDC), the American Thoracic Society (ATS), and 20 other national medical and nursing organizations, including the American College of Chest Physicians, created a National Tuberculosis Training Initiative.6Reichman LB. The National Tuberculosis Training Initiative.Ann Intern Med. 1989; 111: 197-198Crossref PubMed Scopus (5) Google Scholar The objectives of the National Tuberculosis Training Initiative included promoting the adoption of the ATS-CDC standards by US physicians and nurses and increased TB education in medical schools and postgraduate medical training programs. This effort led to the CDC's Core Curriculum on Tuberculosis,7Center for Disease Control and Prevention: Core curriculum on tuberculosis: what the clinician should know. 3rd ed. CDC, Atlanta, Ga1994: 17-23Google Scholar in which the tuberculosis skin test and its technique are widely covered.If Board-eligible practitioners couldn't read chest radiographs, they would be flunked! If underdiagnosing of abnormal ECGs was found to be even half as prevalent, it would be scandalous. Kendig and colleagues have shown that in their study, which is likely highly representative of practitioners in general, tuberculin skin test reading is highly deficient.Similarly, practitioners have been shown to lack competence in most other aspects of TB control, therapy, and practice, especially prevention,8Kissner DG. Tuberculosis: missed opportunities.Arch Intern Med. 1987; 147: 2040-2097Crossref Scopus (4) Google Scholar treatment,9Mahmoudi A Iseman MD. Pitfalls in the care of patients with tuberculosis: common errors and their association with the acquisition of drug resistance.JAMA. 1993; 270: 65-68Crossref PubMed Scopus (258) Google Scholar and even basic knowledge and understanding.10Lardizabal A Sundaram A Riegel L et al.Calls to 1-800-TB information line may represent public and health care worker misinformation [abstract].Am J Respir Crit Care Med. 1996; 153: A328Google ScholarIn an era when TB was a mere curiosity, this would be intolerable. In the current era, with TB being cited as a global health emergency, with recent ongoing transmission to health-care workers as well as with the advent of managed care corporations being more and more involved in both TB diagnosis, treatment, and hopefully prevention,11Reichman LB. How to ensure the continued resurgence of tuberculosis.Lancet. 1996; 347: 175-177Abstract PubMed Scopus (40) Google Scholar such a deficiency demands action by licensure and regulatory bodies and professional associations on an emergent basis. To ignore, downplay, or postpone consideration of the findings of Kendig and colleagues would be the height of irresponsibility. The tuberculin skin test1Reichman LB. Tuberculin skin testing: the state of the art.Chest. 1979; 76: 764S-770SAbstract Full Text Full Text PDF PubMed Google Scholar is arguably one of the most widely used biologic tests in the world. It is, because of the absence of any competing test, considered the “gold standard” for latent tuberculosis (TB) infection, much like the Mycobacterial culture is considered the gold standard for TB disease. One of the foremost reasons for the well-publicized resurgence of TB in the 1980s and 1990s was neglect—by practitioners, policymakers, and researchers.2Reichman LB. Defending the public's health against tuberculosis.JAMA. 1997; 278: 865-867Crossref PubMed Google Scholar It is demonstrative of such neglect that this, the most widely used diagnostic test for TB, was first introduced in 1880, with few modifications since. This fact, in an era of high-tech solutions for lesser problems, is unconscionable. However, the test is all we have so far. The reason that the diagnosis of latent tuberculosis infection (and thus the tuberculin test) is so important is that the latent infection stage of the disease3Geiter LJ. Preventive therapy for tuberculosis.in: Reichman LB Hershfield EH 1st ed. Tuberculosis: a comprehensive international approach. Marcel Dekker, New York1993: 241-248Google Scholar is the target of all contact investigations, employee tuberculosis control programs, and epidemiologic surveillance. Patients who are infected with the tubercle bacillus are considered at variable risk of progressing to active tuberculosis. It is well recognized and universally accepted that such progression can usually be prevented by prescription of medication (usually isoniazid preventive therapy for 6 months).3Geiter LJ. Preventive therapy for tuberculosis.in: Reichman LB Hershfield EH 1st ed. Tuberculosis: a comprehensive international approach. Marcel Dekker, New York1993: 241-248Google Scholar Thus, the tuberculin test is the only test that allows highly effective strategies for the prevention of TB to be implemented. The paper by Kendig and colleagues in this issue of CHEST (see page 1175) presents shocking and sobering findings on the accuracy and utility of the tuberculin test that extend and enhance previous descriptions of deficiencies in TB management and prevention in general. A subject with a documented 15-mm tuberculin skin test reaction (consistent with diagnostic criteria for TB infection across all risk and age groups)3Geiter LJ. Preventive therapy for tuberculosis.in: Reichman LB Hershfield EH 1st ed. Tuberculosis: a comprehensive international approach. Marcel Dekker, New York1993: 241-248Google Scholar had independent skin reaction readings performed by 52 practicing pediatricians, 33 pediatric house officers, 10 pediatric academicians, 11 registered nurses, and a pediatric nurse practitioner. Ninety-nine of 107 participants (93%) read the reactions as less than 15 mm, and 17 (30%) read the reactions as less than 10 mm. Only 8 of 107 participants (7%) correctly read the reaction at 15 mm or greater! It is known that hospital staff are as reluctant to take isoniazid as they are reluctant to prescribe it.4Reichman LB Mangura BT. State-of-the-art tuberculosis prevention [editorial].Chest. 1996; 109: 301-302Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The present data clearly show that diagnosing patients into a category where isoniazid clearly would be beneficial is even more problematic, since tuberculin tests are seriously underread across the board. In the late 1980s, the National Tuberculosis Elimination Plan was promulgated.5Dowdle WR. A strategic plan for the elimination of tuberculosis in the United States.MMWR. 1989; 38: l-25Google Scholar Because of the perceived lack of TB knowledge and the necessity of education for any possibility of control, much less elimination, in 1989 (prior to recognition of the resurgence of TB) the Centers for Disease Control and Prevention (CDC), the American Thoracic Society (ATS), and 20 other national medical and nursing organizations, including the American College of Chest Physicians, created a National Tuberculosis Training Initiative.6Reichman LB. The National Tuberculosis Training Initiative.Ann Intern Med. 1989; 111: 197-198Crossref PubMed Scopus (5) Google Scholar The objectives of the National Tuberculosis Training Initiative included promoting the adoption of the ATS-CDC standards by US physicians and nurses and increased TB education in medical schools and postgraduate medical training programs. This effort led to the CDC's Core Curriculum on Tuberculosis,7Center for Disease Control and Prevention: Core curriculum on tuberculosis: what the clinician should know. 3rd ed. CDC, Atlanta, Ga1994: 17-23Google Scholar in which the tuberculosis skin test and its technique are widely covered. If Board-eligible practitioners couldn't read chest radiographs, they would be flunked! If underdiagnosing of abnormal ECGs was found to be even half as prevalent, it would be scandalous. Kendig and colleagues have shown that in their study, which is likely highly representative of practitioners in general, tuberculin skin test reading is highly deficient. Similarly, practitioners have been shown to lack competence in most other aspects of TB control, therapy, and practice, especially prevention,8Kissner DG. Tuberculosis: missed opportunities.Arch Intern Med. 1987; 147: 2040-2097Crossref Scopus (4) Google Scholar treatment,9Mahmoudi A Iseman MD. Pitfalls in the care of patients with tuberculosis: common errors and their association with the acquisition of drug resistance.JAMA. 1993; 270: 65-68Crossref PubMed Scopus (258) Google Scholar and even basic knowledge and understanding.10Lardizabal A Sundaram A Riegel L et al.Calls to 1-800-TB information line may represent public and health care worker misinformation [abstract].Am J Respir Crit Care Med. 1996; 153: A328Google Scholar In an era when TB was a mere curiosity, this would be intolerable. In the current era, with TB being cited as a global health emergency, with recent ongoing transmission to health-care workers as well as with the advent of managed care corporations being more and more involved in both TB diagnosis, treatment, and hopefully prevention,11Reichman LB. How to ensure the continued resurgence of tuberculosis.Lancet. 1996; 347: 175-177Abstract PubMed Scopus (40) Google Scholar such a deficiency demands action by licensure and regulatory bodies and professional associations on an emergent basis. To ignore, downplay, or postpone consideration of the findings of Kendig and colleagues would be the height of irresponsibility.
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