IGRA Pada

LATEN TB INFECTION

Dewi Indah Noviana Pratiwi

Divisi Infeksi laboratorium Patologi Klinik
FK Unlam/RSUD Ulin Banjarmasin
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 Epidemiologi
Permasalahan
Insiden - Prevalensi
Kesehatan

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 GLOBAL IMPACT OF TB
More than 2 billion people, equal to one-third of the
world’s population, are infected with TB bacilli

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 GLOBAL IMPACT OF TB
TB occurs in every part of the world. According to the 2012 WHO report, the
largest number of TB cases occurred in Asia,
accounting for 60% of cases globally.

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 PENDAHULUAN
TB di Indonesia - EPIDEMIOLOGI

TB day
Global01/17/19
TB report 2013 5
6 TB day 01/17/19
 HOW TO DETECT TB INFECTION

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 PEMERIKSAAN TUBERKULOSIS
• Pemeriksaan tuberkulosis :
- X-ray Thorax
- Mikroskopik (pewarnaan BTA dalam sputum)
- Kultur
- Serologi/Antibodi
- Uji Tuberculin (TST/Mantoux Test)
- IFN-gamma Release Assay (IGRA test)

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 DIAGNOSTIC TOOLS FOR TB
Diagnostic tools for Sputum culture
active TB

Sputum
GeneXpert Quantiferon TST smear Diagnostic
MTB/RIF (QFT) microscopy tools for TB
Infection

Elispot-based IGRA
Chest Symptom
(EBI)
X-ray screen

Nucleic acid
amplification
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day 9
 LATENT TB INFECTION / LTBI

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 LTBI vs TB Disease
Latent TB Infection (LTBI) TB Disease (in the lungs)
Inactive, contained tubercle bacilli Active, multiplying tubercle bacilli
in the body in the body
TST or blood test results usually TST or blood test results usually
positive positive
Chest x-ray usually normal Chest x-ray usually abnormal
Sputum smears and cultures Sputum smears and cultures may
negative be positive
No symptoms Symptoms such as cough, fever,
weight loss
Not infectious Often infectious before treatment
Not a case of TB A case of TB

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Masalah 
LATENT TB INFECTION

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 Tuberculin Skin Test (TST)/ Mantoux Test

TST has been used for 100 years

Standard way to diagnose
Latent TB
Many issues with
interpretation.
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 Some issues with TST

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 False Reaction of TST
False Positive False Negative

 Infection with nontuberculous

mycobacteria  Anergy

 BCG vaccination  Recent TB infection

 Administration of incorrect
antigen  Younger than 6 months

 Incorrect measuring or  Recent live-virus (e.g. measles or

interpretation of TST reaction smallpox) vaccination

 Incorrect method of giving the

TST

 Incorrect measuring or
interpretation of TST reaction
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 PDPI Guideline for LTBI

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 PDPI GUIDELINE FOR LTBI
Ask for any symptoms of tuberculosis in individuals from the risk groups*

Yes No

TST or IGRA

Positive Negative**

Chest Radiography

TB and other disease Any abnormality No abnormality

investigations***

Treat for LTBI

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 REKOMENDASI
Pemeriksaan dan pengobatan TB laten yang dilakukan secara
sistematis harus dilakukan pada:
ODHA
Kontak dengan TB aktif baik dewasa maupun anak anak
Pasien yang mendapat pengobatan anti-TNF
Pasien yang menjalani Hemodialisis
Pasien yang akan menjalani transplantasi organ atau hematologi
Pasien dengan silikosis.

Baik IGRA or Mantoux (TST) dapat digunakan untuk pemeriksaan

TB laten
(Strong recommendation, low to very low quality of evidence)

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 REKOMENDASI
Pemeriksaan dan pengobatan TB laten yang dilakukan secara
sistematis harus dipertimbangkan untuk:

Warga binaan penjara,

Petugas kesehatan,
Imigran dari negara endemis TB
Tuna wisma dan pengguna obat-obatan terlarang

Baik IGRA or Mantoux (TST) dapat digunakan untuk pemeriksaan

TB laten
(Conditional recommendation, low to very low quality of
evidence)
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 What is IGRA ??
New Technologies – Blood tests
Blood test that detect TB infection by measuring CMI response to
TB infection but with significantly higher specificity and sensitivity

IGRA detect gamma IFN that easy to measure when TB is present

Asses response to synthetic overlapping peptides that represent

specific M.tb protein such as early secretory antigenic target-6
(ESAT-6) and culture filtrate protein 10 (CFP-10)

Can not differentiate latent and active disease

www.cdc.gov/mmwr
Kawamura. 2012. Lifescience India

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 IGRA merupakan bentuk
modern TST (Mantoux)

IGRA dapat diaplikasikan pada setiap

kasus dimana TST biasa digunakan

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 TST and IGRA are indirect measures of TB infection: Immunodiagnostics

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 Immunological Basis of QFT
Modern Tb Diagnsotics Measure IFN-γ

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 Immunological Basis of IGRA

o Individu dg infeksi TB memiliki limfosit yg akan bereaksi terhadap

stimulasi antigen
o QFT memiliki teknologi yg dapat menstimulasi sampel darah
dengan antigen spesifik

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 Immunological Basis of IGRA

o T-cell yang telah terstimulasi antigen spesifik tersebut akan

mengeluarkan IFN-γ
o Kadar dari IFN-γ yang terbentuk akan diukur untuk menilai adanya
infeksi M. tuberculosis

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 COMPARISON
IGRA TST
Proses Hanya butuh satu kali kedatangan Membutuhkan 2x visit untuk proses
pasien, tes dilakukan di laboratorium injeksi & untuk pembacaan hasil. Tes ini
yang terstandar tidak memiliki kontrol.

Sensitivitas & Sensitivitas – 84 % Sensitivitas – 70 %

Spesifisitas Spesifisitas – 99 % Spesifisitas – sangat bervariasi (59% pada
populasi ygmendapat vaksinasi BCG)

Cara Darah lengkap yang diinkubasi PPD diinjeksikan ke kulit

pemeriksaan
Performa pada Performa telah terbukti pd pasien dg tx Sensitifitas terbatas, terutama pada
populasi obat immunosuppresan (methotrexate, pasien immunosuppresi
immunosuppresi kortikosteroid, Inhibitor TNF-α)

Pengukuran Deteksi IFN-γ dengan pengukuran Pengukuran indurasi di kulit, sangat

densitas optik subjektif, variabilitas antar pemeriksan
sangat tinggi

Reaksi silang Tidak terpengaruh oleh vaksinasi BCG Hasil terpengaruh oleh vaksinasi BCG dan
dengan BCG atau sebagian besar mycobacterium lain mycobacterium lain

Objektifitas hasil Hasil lebih objektif dengan Hasil subjektif, interpretasi hasil secara
menggunakan metoda analisa software visual setelah 48-72 jam
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Interferon Gamma Release Assays (IGRAs)

T SPOT TM.TB QuantiFERON®-

Tb Gold In-Tube

• ELISPOT
• In vitro stimulation of
PBMCs with
ESAT-6 and CFP-10
• Incubation 16-20 h
• Count spots which are
related to the number of
cells releasing Gamma
Interferon.
• Positive: > 5 Spots
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• ELISA
• In vitro stimulation of
whole blood with ESAT-6,
CFP-10 and Tb7.7
• Incubation 16-20 h
• Measure IFN - Gamma
ELISA
• Positive: > 0.35 IU/l
27
 Specificity Studies

IGRA specificity in
head-to-head studies T-SPOT.TB In-Tube
with low risk control

Higuchi et al. IJTLD

99,1% (110/111) 99,0% (96/97)
(2012)

Mancuso et al.
98,7% (1336/1354) 98.8% (1338/1354)
AJRccm (2012)

Total 98,7% (1446/1465) 98,8% (1434/1451)

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 IFN - Gamma Release Assay (IGRA)

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 IGRA RESULT INTERPRETATION

Positif • Ada infeksi M. TB

Negatif • Tidak ada Infeksi M. TB

• Sampel tidak responsif

Indeterminate
terhadap paparan Antigen
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 IGRAs

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01/17/19 TB day 36
 KESIMPULAN

TB day
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 Thank
you

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39 TB day 01/17/19
 Penelitian IGRA pada LTBI

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01/17/19 TB day 41
 IGRA untuk monitoring

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• v

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 Interpretasi IGRA

• Penting  Interpretasi
– Usia
– Status vaksinasi BCG (Jika + TST)
– Riwayat kontak TB
– Faktor risiko

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 International Guidelines
Clin Microbiol Infect 2011; 17: 806–814

• 33 guidelines and position papers from 25 countries and two supranational

organizations.
• The results show considerable diversity in the recommendations on IGRAs
(i) Two-step approach of tuberculin skin test (TST) first, followed by
IGRA either when
• the TST is negative (to increase sensitivity, mainly in
immunocompromised individuals),
• or when the TST is positive (to increase specificity, mainly in BCG
vaccinated individuals);
(ii) Either TST or IGRA, but not both;
(iii) IGRA and TST together (to increase sensitivity);
(iv) IGRA only, replacing the TST.
• Overall, the use of IGRAs is increasingly recommended

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 KESIMPULAN
Manfaat IGRA :
 Skrining anak yang hidup dgn kasus TB BTA + (risiko tinggi LTBI dan penyakit TB)

 Rule out/eksklusi infeksi dengan reliabilitas yang tinggi

 Deteksi LTBI pada dewasa kelompok high priority untuk mencegah transmisi dan juga
mencegah perkembangan penyakit menjadi aktif

 Diagnosis infeksi TB pada anak (alternatif TST)

 IGRA harus diinterpretasi dengan hati-hati pada anak-anak imunokompromais baik pada
high/low prevalence

 Skrining pra-karyawan dan regular

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 MESSAGE . ETHICAL and INTENDED USE

Lessons learnt

! Never use IGRAs as a stand alone test for active TB diagnosis

! An IGRA result is never a replacement for sputum smear, biopsy

or culture in a symptomatic patient, or when active TB is suspected
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Title, Location, Date 47
 IFN Gamma Release Assay
(IGRA)

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Advantages of QuantiFERON® -TB Gold (QFT®)

QFT is more accurate than TST

• QFT is over 99 % specific, virtually
eliminating false positives seen
with the TST

• QFT is unaffected by BCG

vaccination
• Strongly predictive of true infection
 6 times more accurate
than TST at predicting which
TB-exposed individuals will
develop TB disease
1. QuantiFERON-TB Gold Package Insert. Available at: www.QuantiFERON.com.
2. Mori et al. Am J Respir Crit Care Med, 2004
3. Diel et al. Am J Respir Crit Care Med, 2008
01/17/19 TB
4. Paiday
et al, Annals Int Med, 2008 50
QuantiFERON® -TB Gold (QFT®)
QFT is more accurate than TST

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 What is IGRA ???

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 Adenosine Deaminase
(ADA)

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 Adenosine
Adenosine Deaminase
Deaminase (ADA)
(ADA)
Enzim yang merubah adenosine menjadi inosine
dan deoxyadenosine menjadi deoxyinosine pada
jalur katabolisme purin.
ClickBerperan
to pada
add title
proliferasi dan differensiasi
limfosit; pematangan/maturasi monosit.

Indikator imunitas selular yang aktif.

Konsentrasi ADA serum meningkat pada berbagai

penyakit dimana imunitas seluler distimulasi.

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 Adenosine
Adenosine Deaminase
Deaminase (ADA)
(ADA)
- Ditemukan pada hampir
ADA 1 semua sel -sel tubuh
- Btk monomer dan dimer

Click to add title

Isoform ADA - Hanya ada di monosit dan
makrofag dan coexist dgn
ADA1
ADA 2 - Btk predominan di plasma
darah, meningkat di byk
penyakit yg terkait sistem
imun
- Meningkat pada TB pleura

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 ADA pada Non TB

Click to add title

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 SENSITIVITAS
SENSITIVITASDAN
DANSPESIFISITAS
SPESIFISITAS
ADA
ADAutk
utkTB
TBPleura
Pleura
Peneliti/tahun Sensitivitas Spesifisitas

Click to 92%add title

Krenke R/ 2008 89%

Perez (2000) 77-100% 81-97%

Click to add subtitle
Chen (2204) Click to 79-100%
add subtitle 80,5 – 96%

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 MANFAAT PEMERIKSAAN ADA

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 INDIKASI PEMERIKSAAN ADA

TB day
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 Adenosine Deaminase Assay

 Method : Enzimatik kolorimetri (Non Giusti)

Clickascites/peritoneal,
 Sample : Cairan pleura, to add subtitle CSF
Click to add subtitle
 Jadwal kerja : Setiap hari
 Sample Stability : segera disimpan di 2-8oC (stabil 7 hari), 1 bln
dibekukan
 Nilai rujukan :
Cairan Pleura : < = 30 U/L
CSF : <= 9 U/L
Ascites/ cairan peritoneal : < 30 U/L

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 INTERPRETASI
INTERPRETASIHASIL
HASIL
ADA cairan pleura
(symptomatic Prevalensi TB Interpretasi
patient)

MeningkatClick to add title High Kemungkinan besar infeksi TB di

area pleura

Mungkin TB atau ADA meningkat

Meningkat/sedikit Low krn sebab lain
meningkat Click to add subtitle
Click to add Kemungkinan
subtitle bukan TB pleura,
Rendah Low/high namun tdk menyingkirkan adanya
infeksi TB di bagian tubuh lain

Jika ADA meningkat di CSF atau cairan peritoneal, kemungkinan TB ada di area tsb
Jika ADA meningkat di CSF atau cairan peritoneal, kemungkinan TB ada di area tsb

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 Penelitian IGRA pada anak

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 What is IGRA ???

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 Specificity of ESAT-6 and CFP-10
orange = Specificity, red = Cross-reactivity = false positive

Tuberculosis Antigens Environmental Antigens

complex strains ESAT CFP
ESAT CFP M abcessus - -
M avium - -
M. tuberculosis + + M branderi - -
M celatum - -
M. africanum + +
M chelonae - -
M. bovis + + M flavescens + +
M. microti   +   + M fortuitum - -
M. canetti + + M gordonae - -
BCG substrain M intracellulare - -
M kansasii + +
gothenburg - -
M malmoense - -
moreau - - M marinum + +
tice - - M oenavense - -
tokyo - - M scrofulaceum - -
M smegmatis - -
danish - -
M szulgai + +
glaxo - - M terrae - -
montreal - - M vaccae - -
pasteur - - M xenopi - -
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