NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

National Collaborating Centre for Chronic Conditions (UK). Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for Its Prevention and Control. London: Royal College of Physicians (UK); 2006. (NICE Clinical Guidelines, No. 33.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Tuberculosis

Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for Its Prevention and Control.

Show details

15Priorities for future research

Research recommendation 1

A diagnostic and qualitative study, assessing whether interferon-gamma tests are acceptable to patients and more effective than tuberculin skin tests for:
  • predicting subsequent development of active TB, or
  • diagnosing or ruling out current active TB
when undertaking TB screening in:
  • new immigrants from high TB prevalence countries
  • healthcare workers
  • children in high-risk areas who missed neonatal BCG
  • contacts of sputum smear-positive TB
  • HIV-positive patients.
This study should compare strategies of TST only, TST then IGT if positive, and IGT only.
Population
  • New immigrants from high TB prevalence countries.
  • Healthcare workers.
  • Children in high-risk areas who missed neonatal BCG.
  • Contacts of sputum-positive TB.
  • HIV-positive patients.
InterventionInterferon-gamma tests.
ComparisonTuberculin skin tests.
OutcomeSubsequent development of active TB. Qualitative patient acceptability outcome.

Research recommendation 2

A cluster RCT of DOT compared to self-administered treatment for latent and/or active TB should be conducted in a UK population. This should be targeted at homeless people, and those with a history of non-adherence, alcoholism, drug abuse or mental illness.
PopulationHomeless people, those with a history of non-adherence, alcoholism, drug abuse, or mental illness.
InterventionDOT.
ComparisonSelf-administered treatment.
OutcomeTreatment completion, cure and relapse rates.

Research recommendation 3

A study is needed of people found by new entrant screening (as set out above in 12.7) to be Mantoux positive and interferon-gamma positive, to establish better estimates of the cost-effectiveness of screening and treatment for latent TB infection in this population. This could identify factors predisposing people to developing active TB so that more effective targeted treatment for latent TB infection programmes can be developed.
PopulationNew entrants with latent TB infection.
InterventionScreening and treatment for latent TB infection.
ComparisonNot applicable.
OutcomeRisk factors for the development of active TB and the cost-effectiveness of screening and treatment for latent TB infection (£/QALY).

Research recommendation 4

A case control study, comparing people who developed active or latent TB with those who did not, and comparing the proportion vaccinated and the time since vaccination. The aim will be to derive improved estimates of protective efficacy and duration of protection of the BCG vaccine.
PopulationPatients eligible to receive BCG vaccine (this could be neonates, contacts, healthcare workers, new immigrants, schoolchildren).
InterventionBCG.
ComparisonNo BCG.
OutcomeDevelopment of active TB. Possibly the development of latent TB infection as assessed by interferon gamma test (to avoid BCG effects on TST).

Research recommendation 5

A study to ascertain quality of life score estimates from those with TB disease and latent infection including adverse treatment effects, using an appropriate, validated quality of life instrument. This will improve economic decision-making throughout TB.
PopulationThose with TB disease or latent infection.
InterventionQuality of life instrument.
ComparisonNone.
OutcomeQuality of life score (single score estimate of health status).

Research recommendation 6

Is contact tracing more effective (in terms of identifying cases of latent infection and active TB disease) among household contacts, than among homeless contacts, of patients with confirmed TB disease?
PopulationAdult contacts of index case patients with confirmed:
  • pulmonary smear-positive TB
  • pulmonary smear-negative TB
  • non-pulmonary TB.
InterventionContact screening of household contacts.
ComparisonContact screening of homeless contacts.
OutcomeCase yields for latent TB infection and active TB disease among screened contacts.

Research recommendation 7

Do port of arrival scheme referrals with incentives for attendance of screening identify more cases of latent TB infection and active TB disease in comparison to port of arrival scheme referrals with no incentives for screening attendance in the new immigrant population?
PopulationNew immigrants from high TB prevalence (40+/100,000) countries.
InterventionPort of arrival referrals with screening attendance incentives.
ComparisonPort of arrival referrals with no screening attendance incentives.
OutcomeCase yields for TB infection and active TB disease in intervention and comparison groups.

Research recommendation 8

Are incentives for attending chest X-ray screening more effective than no incentives in identifying cases of latent TB infection and active TB disease in the homeless population?
PopulationIndividuals in temporary accommodation, hostels, and street homeless.
InterventionInvitation with incentives to attend chest X-ray screening.
ComparisonInvitation without incentives to attend chest X-ray screening.
OutcomeCase yields for TB infection and active TB disease in intervention and comparison groups.

Other potential research recommendations

These are other topics where evidence is lacking, and where new research could improve future guidelines. They are not developed to the extent of the eight priorities above.

  • □ A multicentre RCT in patients with bacteriologically confirmed tuberculous meningitis, comparing six to 11 months of chemotherapy with 12 months of treatment to ascertain if different treatment duration affects mortality and residual disability.
  • □ Effectiveness of skills training for TB key workers, eg in motivational interviewing methods.
  • □ An RCT of prisoners being treated for TB disease or latent infection who are discharged early, to assess whether contingency plans are cost-effective and improve treatment completion, cure and relapse rates.
  • □ Is contact tracing using one method (eg home screening and follow-up of contacts) more effective than another (eg clinic-based screening and follow-up of contacts) in identifying cases of latent infection and active TB disease among adult and child household contacts of patients with confirmed TB disease?
  • □ What is the impact of screening casual (low exposure) vs. close (high exposure) contacts of patients with confirmed TB on the yield of latent tuberculosis infection and active TB disease cases?
  • □ Does screening of patient contacts in the same hospital bay as a pulmonary smear-positive index case of TB yield more cases of latent TB infection and active disease compared to other patient contacts on the same hospital ward?

A number of studies were suggested in areas not addressed by guideline questions, therefore the current evidence base for these areas is not known. These were:

  • a study investigating risk factors for adverse outcomes from tuberculosis (deaths, acquired resistance and loss to follow-up)
  • studies on patient and healthcare delay, to identify how to shorten the period of infectivity of active cases
  • a diagnostic study of the efficacy of interferon-gamma testing in confirming active non-respiratory tuberculosis if other tests have remained inconclusive
  • a study on whether interferon-gamma tests are more effective than chest X-ray screening for identifying cases of active TB disease in new immigrants undergoing TB screening.
Copyright © 2006, Royal College of Physicians of London.

All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher.

Bookshelf ID: NBK45810
PubReader format: click here to try

Views

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...