CDC recommendations IGRA (provisional)

Link here

• IGRA is preferred for testing persons from groups that historically have poor rates of return for TST reading
• IGRA is preferred for testing persons who have received BCG (as a vaccine or for cancer therapy)
• TST is preferred for testing children younger than 5 years of age
• IGRAs may be used in place of TST (without preference) to test recent contacts of persons with infectious tuberculosis with special considerations for follow-up testing
- Negative results prior to 8 wks typically should be confirmed by repeating the test 8–10 weeks after the end of exposure
- Repeating same test minimizes misclassification due to test discordance
• IGRAs may be used in place of TST (without preference) for periodic screening to address occupational exposure to TB with special considerations regarding conversions and reversions

Productivity gains with QFT

In their Pilot Study the US military listed productivity gains from using QFT;

less productivity loss of soldiers due to single visit
reduced lost medical productivity (20%-50% no show rate for 2nd appointment)

San Francisco Department of Public Health found that by switching to QFT their staff cost were reduced;

Referral rate to TB Clinic from immigrant clinics has dropped significantly since switching to IGRAs…..just in time for staff cuts to TB Control

QFT provides much needed productivity gains to both patients and providers.

Tea for the taliban

When reviewing the Vinton study in the Australian Tuberculosis Review "JT" (Dr John Thompson, Canberra) said

It looks as if a negative QFT test will have to be followed by a TST and that 15 mm or more of induration will confirm infection.

As he has already acknowledged that QFT has a greater specificity it doesn't seem logical to then advocate the use of a less accurate test as a check. His rationale is

their (Vinton et al) conclusion does not match their findings that those staff in contact with a tuberculous patient are more likely to have a positive TST result.

which is at odds to what is actually written in the study;

For the TST, receipt of BCG vaccination, an occupation involving patient contact (as opposed to hospital occupations that do not involve such contact, eg, clerical positions), and a greater number of years lived in a high-prevalence country were associated with a positive test result.

What did limit the study was the poor follow up with TST;

117 (24.3%) of the 481 participants originally recruited did not have a TST performed and/or a TST result interpreted, and a large proportion of these individuals had had positive TST results in the past.

This failure to return makes the JT canvassed option of using the less accurate TST as a confirmatory test even sillier;

a strategy that combines the use of both the TST and the QFT–in tube test ... would result in increased cost without reducing any of the inherent problems of TST testing.

Writing in the QFT News March 2009 Cellestis made the following observations of the study;

The study correlated positive results to risk factors, such as country of birth, travel to high-risk areas, or high-risk occupation in the HCW setting, as well as BCG vaccination status.

...The authors concluded that a positive QFT result was associated with demographic and occupational risk factors such as birth in a high prevalence country, or an occupational contact. A positive TST result, on the other hand, was very highly associated with a prior history of BCG vaccination, far more than occupational exposure.

As Vinton et al conclude, the study

findings support the recent Centers for Disease Control and Prevention guidelines, which suggest that the QFT–in tube test is a viable alternative for a widespread HCW screening program

.

Government failure

The much vaunted Grocery Watch was unceremoniously dumped;

A spokesman for the Prime Minister said last night federal Labor had committed to establishing a dedicated website to publish a snapshot of grocery prices. "The Rudd government fulfilled that commitment in the form of Grocery Choice," he said.

"Today, the minister has outlined the reasons why the government is not proceeding further with Grocery Choice.

..Frank Zumbo, associate professor of competition law at the University of NSW, said that, from beginning to end, Grocery Choice was a political disaster.

"Grocery Choice was a gross waste of taxpayers' money," Professor Zumbo said. "The website delivered no meaningful information to consumers and was simply political window dressing. (It) has failed ... and has now been rightly killed off by an embarrassed federal government."

Said the minister for competition policy and consumer affairs Dr Craig Emerson;

"I came to the view that the task of compiling price data for a couple of thousand stores in Australia for several 1000 items would be enormous and would not be feasible,'' he said. "For the site to be of great value to customers it needs to cover all the major stores and the information needs to be relevant at the individual store level in a timely manner. And it is difficult being able to envisage that if the major supermarkets cannot provide it.''

This is even more embarrassing for Prime Minister Rudd who, in his essay on the GFC, criticised "the theories of Hayek and von Mises" and the "the magic of the market". Had Rudd bothered to read Hayek's 1945 publication on Individualism and Economic Order he would have known that Grocery Watch was a folly;

The peculiar character of the problem of a rational economic order is determined precisely by the fact that the knowledge of the circumstances of which we must make use never exists in concentrated or integrated form but solely as the dispersed bits of incomplete and frequently contradictory knowledge which all the separate individuals possess. The economic problem of society is thus not merely a problem of how to allocate “given” resources-if “given” is taken to mean given to a single mind which deliberately solves the problem set by these “data.” It is rather a problem of how to secure the best use of resources known to any of the members of society, for ends whose relative importance only these individuals know. Or, to put it briefly, it is a problem of the utilization of knowledge which is not given to anyone in its totality.

Saudi Arabia and IGRA

We fully approve of the establishment of such diagnostic tools everywhere in the country. It is an expensive test at this particular stage but it is worth using, as delay in diagnosing difficult cases such as extrapulmonary is more costly to the patients (as it might cost them their lives

... it is a very bad practice to give prophylaxis to treat dormant tuberculosis based on skin test results as the test has proved its inability to distinguish real infection from exposure to environment tuberculosis or BCG vaccine...."

Sahal Abdulaziz Al-Hajoj
TB Research Unit, Comparative Medicine,
King Faisal Specialist Hospital and Research Center,
P. O. Box 3354, Riyadh 11211, Saudi Arabia.

Full article here


.

After the party, I think I have a headache

OECD again; looks as if we may have to cut up that credit card;

click on image for FULL SIZE)

Otto Wagner hospital, Vienna

In the Viennese medical weekly Wiener Medizinische Wochenschrift Dr Ralf Harun Zwick et al look at diagnosing latent TB;

According to the present studies IGRAs have less false negative (the sensitivity is higher) - that could mean that we could identify MTB infection better.

The sensitivity of the skin test is approximately 75%, those the IGRAs with approximately 83% (Quantiferon) or more highly (over 90% with T-spots). Also specificity is higher - that could mean that we can expect less false positive results with this tests.

In populations with BCG inoculation IGRAs seem special to be more sensitive and more specific than the skin test.

The message is now everywhere

.

Me, myself and I Incorporated

For all those time challenged freelance CEO's; your very own ying yang planner

(click on image for FULL SIZE)


From David Seah who has spent a lot of time thinking about it..

The Big Picture

From the OECD, by all accounts the Australian economy ranks #1

(click on image for FULL SIZE)


From Peter Martin;

Australia's downturn to be shorter than expected

AUSTRALIA is set to soar out of its economic downturn sooner and more sharply than forecast in the budget, according to updated forecasts from the Organisation for Economic Co-operation and Development understood to have the Australian Treasury's backing.

The OECD says the Australian economy should shrink by a mere 0.3 per cent this year, less than any other OECD economy and far less than the contraction of 1 per cent that underlies the forecasts in the May budget.

Next year, the economy should roar back 2.4 per cent, also more than assumed in the budget and more than any other OECD economy apart from those recovering from collapse in 2009.

Treasurer Wayne Swan greeted the updated forecasts released overnight in Paris as evidence that Australia was "outperforming every other advanced economy in the face of the recession".

The revised forecasts show Australia's unemployment rate reaching 7.9 per cent late next year rather than the 8.25 to 8.5 per cent range assumed in the budget. They also suggest a milder build-up in government debt than forecast at budget time, as increased tax revenues kick in more quickly.

The difference between the Treasury's May forecast and the OECD's June forecast is not thought to represent a difference of opinion between the two organisations. Treasury and Reserve Bank staff worked closely with the OECD in preparing the report. Rather, the change is thought to indicate the speed at which the global economy is improving.

The OECD update is the first in two years to revise up projections instead of down. The Organisation now expects developed economies to shrink by just 2.6 per cent this year, down from the 3.4 per cent it forecast in March. It expects the US economy to shrink by 1.7 instead of 3.5 per cent, and Japan to shrink by 3.6 instead of 4.4 per cent.

"Activity now looks to be approaching its nadir," said OECD cheif economist Jorgen Elmeskov.

While cautioning that risks remained, Mr Elmeskov said that "significantly", the risks were "more balanced than before".

The OECD identifies China as the driving force behind the more-rapid-than-expected global recovery crediting "massive government stimulus" measures with lifting China's expected growth this year from 6.3 per cent to 7.7 per cent and to 9.3 per cent next year.

In a blow to Australia's Opposition, the OECD specifically commends the infrastructure spending and cash bonus payments opposed by the Coalition in the Senate describing them as "welcome" and "boosting" Australia's domestic demand. It cautions policy makers not to ease up on efforts to stimulate their economies and says Australia's Reserve Bank has room to cut its interest rates further.

Referring specifically to Australia, the report says the Rudd Government needs to "maintain the expansionary thrust" of its policy.

20 years young

From Geoff Huston on the Australian Network Operators Mailing List

On the night of the 23rd June 1989 Robert Elz of the University of Melbourne and Torben Neilsen of the University of Hawaii completed the connection work that bought the Internet to Australia. It was a 56kbps satellite circuit, and the Australian end used a Proteon P4100 router.

Since that day we've evidently connected some 56.8% of the population, or 12,073,852 Australians, to the Internet (according to user statistics published by the ITU-T)

I think thats a pretty impressive record, and worth noting!

OECD ECONOMIC OUTLOOK No.85

Here and here

..Overall, this Economic Outlook is the first in two years to revise up the growth projections compared with the previous version -- most clearly for the non-OECD and the United States but also to some extent for Japan.

..In summary, it looks as if the worst scenario has been avoided and that OECD economies are now nearing the bottom.

Web 2.0 coming to you

Somewhat ironically, whilst the fallout of fake emails threatens to destroy the Turnbull led opposition, the Australian Government has just announced their Web 2.0 Taskforce.



The reason for this initiative, according to Deloitte

It is clear that conventional government is unable to address society’s challenges alone and would be in a much better position if it could truly partner with other governments, not-for-profits, businesses and citizens to tackle immense policy changes.

Amongst others the Canadian Government have also been advised that

To be relevant you have to be connected

...citizens will see the benefits of more effective policy, more rapid response and a level of transparency in government that has been unattainable to date.

This process is not without hurdles, as Tim Davies writes;

- The big challenges are not about technology – they are about the content and the process of mobilisation and communication.
- When it comes to technology we’ve not got one big challenge we’ve got 100s of small challenges – and we’ve got no systematic way of dealing with them.

Other criticise the concept as being counter productive and even destructive

In an alarming new book The Cult of the Amateur he (Andrew Keen) argues that many of the ideas promoted by champions of web 2.0 are gravely flawed. Instead of creating masterpieces, the millions of exuberant monkeys are creating an endless digital forest of mediocrity: uninformed political commentary, unseemly home videos, embarrassingly amateurish music, unreadable poems, essays and novels.

Worse still, the supposed “democratisation” of the web has been a sham. “Despite its lofty idealisation it’s undermining truth, souring civic discourse, and belittling expertise, experience and talent,” he says.

The man credited with inventing the internet, Tim Berners-Lee, has also voiced his misgivings describing the term "Web 2.0" as a "piece of jargon": "

Nobody really knows what it means...If Web 2.0 for you is blogs and wikis, then that is people to people. But that was what the Web was supposed to be all along."

Deloittes dont agree and warn that you better change your world or the world will change you;

The days of governments at all levels – national, state/provincial or local – operating primarily as singular entities are over.

Tomorrow’s governments cannot deliver the policy outcomes that society expects if they continue to hold on to yesterday’s monolithic-leadership model.

Active investing - a waste of time and energy?

In the classic 1991 Financial Analysts’ Journal article, Nobel Laureate William F. Sharpe discusses active and passive investment management. From the abstract;

‘If active and passive management styles are defined in sensible ways, it must be the case that:
(1) before costs, the return on the average actively managed dollar will equal the return on the average passively managed dollar; and
(2) after costs, the return on the average actively managed dollar will be less than the return on the average passively managed dollar These assertions will hold for any time period. Moreover, they depend only on the laws of addition, subtraction, multiplication and division. Nothing else is required.’

In other words the effort required to actively manage market investments cannot add to the value of the market.

Sharpe is not without hope;

This need not be taken as a counsel of despair. It is perfectly possible for some active managers to beat their passive brethren, even after costs. Such managers must, of course, manage a minority share of the actively managed dollars within the market in question.

In their essay Why Active Investing Is a Negative Sum Game Fama & French continue to stress the irrefutable logic of the argument;

active investing in any sector is always a zero sum game - before costs. After costs, active investing is a negative sum game.

French puts a $ figure on the losses incurred by active investors;

I compare the fees, expenses, and trading costs society pays to invest in the U.S. stock market with an estimate of what would be paid if everyone invested passively. Averaging over 1980 to 2006, I find investors spend 0.67% of the aggregate value of the market each year searching for superior returns. Society's capitalized cost of price discovery is at least 10% of the current market cap. Under reasonable assumptions, the typical investor would increase his average annual return by 67 basis points over the 1980 to 2006 period if he switched to a passive market portfolio.

Warren Buffett also holds the same view;

“In aggregate they (money managers) have under performed indexed funds and it’s the nature of the game, they simply cannot over perform in aggregate. There are too many of them managing too big a portion of the pool.” AGM 1997 – Morningstar

..“The results of these [investments] companies in some ways resemble the activity of a duck sitting on a pond. When the water (the market) rises, the duck rises; when it falls, back goes the duck. The rise and fall of the lake is hardly something for him to quack about. Buffett Partnership Letter 08/07/1964

In his 1982 letter to Congress Warren Buffett warned against the excessive exuberance displayed by trading firms in financial markets;

"We do not need more people gambling in non-essential instruments identified with the stock market in this country, nor brokers who encourage them to do so. What we need are investors and advisors who look at the long-term prospects for an enterprise and invest accordingly. We need intelligent commitment of investment capital not leveraged market wagers. The propensity to operate in the intelligent, pro-social sector of capital markets is deterred, not enhanced, by an active and exciting casino operating in somewhat the same arena, utilising somewhat similar language and serviced by the same workforce."

Of course subsequent events serve to prove that the maths was correct.

Our fearless leader and that shaky sauce bottle

In his essay titled "The Global Financial Crisis" as published by the journal The Monthly Prime Minister and all round good guy Kevin Rudd gave us the benefit of his knowledge and wisdom on the situation;

The current crisis is the culmination of a 30-year domination of economic policy by a free-market ideology that has been variously called neo-liberalism, economic liberalism, economic fundamentalism, Thatcherism or the Washington Consensus. The central thrust of this ideology has been that government activity should be constrained, and ultimately replaced, by market forces.

Having thus identified the problem he then moved onto the source

Neo-liberal economic philosophy has its roots in the theories of Hayek and von Mises, who believed that society should be characterised by the "spontaneous order" which emerges when individuals pursue their own ends within a framework set by law and tradition. Ideally, the role of governments is simply to enforce contracts and protect the allocation of property rights. All other economic functions should be left to what Reagan called "the magic of the market".

The essay has been given considerable attention and now that it has been translated into Chinese has attracted further scrutiny. Writing in the Chinese newspaper The Economic Observer Professor Xu Xaonian from the China Europe International Business School in Shanghai called the essay "shallow and crude" and Rudd as being either "short of economic knowledge or is misleading his readers"

Dr Xu says "Lu Kewen" - Mr Rudd's Chinese name - made a "big, big mistake" in forming his "confident opinions" based on "the observation that the crisis came as a result of neoliberalism and the absence of supervision".

..Lu smartly transformed a failure of government into a failure of the market - a form of propaganda by him and his social democrat comrades which now looks as if it is working."

Indeed, a failure of government is exactly how Ben Bernanke would describe it

..the origins of most financial crises (excluding, perhaps, those attributable to natural disasters, war, and other nonfinancial events) can be traced to failures of due diligence or "market discipline" by an important group of market participants.

Both of these conditions apply to the current situation of Fannie Mae and Freddie Mac

...Fannie Mae and Freddie Mac were created by acts of the Congress and are thus known as government-sponsored enterprises, or GSEs.

...GSEs face little or no market discipline from their senior debt holders because of the belief among market participants that the U.S. government will back these institutions under almost any circumstances.

An allowance of $1B was made to rescue both Fannie Mae and Freddie Mac from imminent collapse.

In his Nobel Prize speech Friedrich von Hayek touched on the role of government and the role of markets. He sees government policy failure as a "failure of the economists to guide policy more successfully " due to their poor deductive processes

In economics and other disciplines that deal with essentially complex phenomena, the aspects of the events to be accounted for about which we can get quantitative data are necessarily limited and may not include the important ones...

... in the study of such complex phenomena as the market, which depend on the actions of many individuals, all the circumstances which will determine the outcome of a process, for reasons which I shall explain later, will hardly ever be fully known or measurable.

Hayek warns against the "pretence of exact knowledge" by saying;

The recognition of the insuperable limits to his knowledge ought indeed to teach the student of society a lesson of humility which should guard him against becoming an accomplice in men's fatal striving to control society - a striving which makes him not only a tyrant over his fellows, but which may well make him the destroyer of a civilization which no brain has designed but which has grown from the free efforts of millions of individuals.

More on QFT conversions and reversions

Note that in this study TST was not used thereby eliminating the possibility of boosting. The issue now is to determine the range of values which would be acceptable for serial testing in a high incidence country.

Short-term Reproducibility of a Commercial Interferon-gamma Release Assay.

Detjen AK, Loebenberg L, Grewal HM, Stanley K, Gutschmidt A, Kruger C, Du PN, Kidd M, Beyers N, Walzl G, Hesseling AC.

Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, South Africa; DST/NRF Centre of Excellence in Biomedical Tuberculosis Research and MRC Centre for Molecular and Cellular Biology, Department of Biomedical Sciences, Stellenbosch University, South Africa; The Gade Institute, Section for Microbiology and Immunology, University of Bergen and Haukeland Hospital, Bergen, Norway; Centre for Statistical Consultation, Dept of Statistics and Actuarial Sciences, Stellenbosch University, South Africa.

Background. Interferon-gamma (IFN-gamma) release assays (IGRAs) have been shown to be sensitive and highly specific for the detection of immune memory against Mycobacterium tuberculosis. Little is known on the reproducibility and within-person variability of these assays.

Objectives. Various aspects of short-term reproducibility of a commercial IGRA, the QuantiFERON-TB(R) Gold In-Tube (QFT-IT) were assessed. Design. QFT-IT was performed twice within 3 days in 27 health care workers in Cape Town, South Africa. Two sets of tests were performed by different operators on day one, and one set on day 3. Aspects such as inter-operator, intra-operator, day-to-day variability, test-retest variability as well as different storage methods of plasma were investigated.

Results. Seventeen of 27 (63%) of participants had at least one positive QFT-IT; 6 had discordant results. The agreement of all aspects studied was high with kappa values between 0.82 to 1.00 for dichotomous, and inter class correlations (ICC) of 0.809 to 0.965 observed for continuous IFN-gamma measures. The variability of the magnitude of response was highest comparing measures obtained from individuals on different days (ICC 0.809). The magnitude of IFN-gamma response in individual participants ranged from 0.03 to 11 IU/ml, resulting in discordant results in 5 participants.

Conclusions. QFT-IT is a robust and highly reproducible assay. Considerable intra-individual variability occurs in the magnitude of IFN-gamma responses, which may influence the interpretation of serial measures.

Within subject variability of T cell responses during serial testing

Now that longer studies of IGRA are being made some evidence of variability is being noted. Not that this was unexpected, in the article T-Cell Assays for Tuberculosis Infection: Deriving Cut-Offs for Conversions Using Reproducibility Data Pai et al speculate on moving the cut off point to reduce confusion.

In their article Serial Testing for Tuberculosis: Can We Make Sense of T Cell Assay Conversions and Reversions? Pai and OBrien offer the curious notion that

IGRAs may be inherently prone to conversions and reversions, and this dynamic characteristic raises the concern that these assays may be too labile or unstable to be used in serial testing.

In light of such uncertainty I suppose all options must be canvassed.

In a more recent study Within-Subject Variability and Boosting of T-Cell Interferon-g Responses after Tuberculin Skin Testing van Zyl-Smit et al form two important conclusions;

1. IGRA positive and to a lesser extent in IGRA-negative subjects, are influenced by recent TST (PPD-RT23) administration and

2. there is significant within-subject variability over time.. and this may explain much of what was previously regarded as conversions and reversions because of ‘‘movement’’ across the cut-point

They then recommend that for QFT-GIT a true conversion might be better defined as an

increase from below 0.35 IU/ml to above 0.70 IU/ml.

Currently the CDC does not have a proper definition for a QFT-G conversion with the Cellestis FAQ giving it as a

change from negative to positive

However, TST conversion is defined by the CDC as thus;

An increase of more than 10 mm in induration during a maximum of 2 years is defined as a TST conversion for the purposes of a contact investigation.

It now appears that if IGRA are performed within 3 days of a TST and if a broader definition of conversion is applied the issue could be resolved.

Of course those wanting to continue with TST will now be faced with more, not less problems.

In the same issue of AJRCCM Luca Richeldi looks at the evidence

the IGRAs, being dynamic and quantitative, have the potential to detect transient responses to M. tuberculosis in exposed contacts and to monitor the size of the immune response during antimycobacterial treatment. We cannot therefore exclude the possibility that at least some of what we interpret as variations of IGRA results might reflect true biological phenomena not detected by the TST and might be potentially useful in clinical practice.

..If the TST had been repeated with the same frequency, many more variations would likely have been reported.

Back at the coal face in a presentation made at the 2009 CTCA conference Dr Masae Kawamura gave an account of her experience with QFT conversions and discordant results;

High risk: Use the positive predictive value
Low risk: use the negative predictive value
Moderate risk: Use clinical judgement!

For indeterminates she was equally pragmatic;

REPEAT the QFT: Our SF data tells us that you will get a valid result (usually negative) >66% of the time

Despite perceived hurdles and obstacles Dr Kawamura was happy with QFT-GIT saying

QFT-G is a superior CI (contact investigation) tool because of its operational advantages and higher specificity, especially in foreign-born populations

and QFT conversion rates were also useful indicators

Unlike the TST, infection rates and conversion corresponded with contagion of the index case, especially in the FB (foreign born)

At the latest Masae Kawamura has given her

Indeterminate Results: What to do

REPEAT the QFT: Our SF data tells us that you will get a valid result (usually negative) >66% of the time

Low mitogen indeterminate in very young kids (<5): Goal is to maximize sensitivity
Choice 1: Use other available tests (eg. TST, other available IGRAs)
Choice 2: Repeat QFT and TST at the same time


High risk: Use the positive predictive value
Low risk: use the negative predictive value
Moderate risk: Use clinical judgement!


Cautious interpretation of a negative TST or IGRA results in contact investigation

Young children under 5 years old
Immunocompromised individuals
Symptomatic
Remember:
CXR is needed and window prophylaxis is advised for children under 5 and immunocompromised
CI (Contact Investigation) protocols for IGRAs are no different than for TST!!!!

Spanish ayes

Dominguez et al, working principally from institutions located around Barcelona Spain, have had some experience with IGRA and its ability to avoid TST false positives.

The utilization of IFN-γ tests could reduce the false diagnosis of M. tuberculosis infection in children with NTM infection
...our results show enough evidence to state that IFN-γ tests are less affected by BCG vaccination than is TST and could avoid unnecessary latent tuberculosis treatment among adult and child populations.

They have now come forward and recommended that IGRA be used to confirm TST false negatives;

it seems prudent to recommend the utilization of IFN-γ-based tests after a negative TST result, in order to increase the sensitivity of detecting LTBI cases in severely immunosuppressed patients.

Which begs the question, if IGRA are used to be used to confirm both negative and positive TST why bother continuing with the TST?

Legal advice to employers of HCWs

Section 5(a)(1) of the OSH Act, often referred to as the General Duty Clause, requires employers to ”furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees”.

Donald W. Benson from Littler Mendleson reminds health employers of the risks to their employees;

”Public health investigators have estimated that greater than 90% of persons reported to have clinically apparent disease are those who have harbored tuberculosis (TB) infection for at least a year or more; the remaining 10% have an immediate progression of a recently acquired infection (Centers for Disease Control (CDC), unpublished data). The number of persons with latent infection in the United States is estimated to range from 10 million to 15 million (CDC, unpublished data).

..The main risk is exposure to patients with unsuspected tuberculosis. This poses a particular problem when the clinical presentation is atypical, as is often the case when elderly patients or patients with HIV infection are involved. Procedures that induce coughing, such as sputum induction and aerosolized pentamidine treatments, may present a particular hazard to health-care workers.

Mandatory Tuberculin skin testing upon employment should be considered for all persons who work in these healthcare environments. Health administrators and infection control departments in hospitals are responsible for ensuring that these recommendations are implemented. Repeat screening of persons in risk groups should be part of an effective program.”

Host markers in Quantiferon supernatants differentiate active TB from latent TB infection: preliminary report

In conclusion, our preliminary results suggest that active TB may be accurately identified within 24 hours utilizing an adaptation of the commercial QFT assay where detection of a combination of three host markers (selected from EGF, sCD40L, MIP-1β, VEGF, TGF-α or IL-1α) is performed on QFT supernatants. The results hold promise for the development of a rapid and sensitive test for active TB.

Full article here

Never under estimate the need for better communication

Questions over the integrity and transparency of the elections in Iran has led to mass demonstrations of protest accompanied by government retaliations.


More pictures and text here.

From social networker Twitter;

A critical network upgrade must be performed to ensure continued operation of Twitter. In coordination with Twitter, our network host had planned this upgrade for tonight. However, our network partners at NTT America recognize the role Twitter is currently playing as an important communication tool in Iran. Tonight's planned maintenance has been rescheduled to tomorrow between 2-3p PST (1:30a in Iran).

From the newsdesk;

WITH the Iranian government blocking mobile phone networks and access to many websites, the social utility Twitter has emerged as a powerful tool for protesters to get their stories out.

As reports of political violence in Iran intensified after Friday's disputed election won by incumbent President Mahmoud Ahmadinejad, the Islamic republic has managed to shut down most forms of communication with the outside world.

Access to the popular networking site Facebook has been restricted on occasion before, during and after elections, stopping Iranians from sharing their stories with the world.

But Twitter has somehow avoided being blocked and has provided a rare glimpse into the violence that has engulfed the capital, Tehran...

More here

Cost effectiveness of QFT

At the 2nd Global Symposium on IGRAs Dr Kenneth Castro from the CDC was reporting as having presented IGRAs as the "preferred" test in BCG vacinated individuals.

Canadian researchers looked at the costs of testing BCG vaccinated and found that

The most economically attractive strategy was to administer QFT-G in BCG-vaccinated contacts, and to reserve TST for all others

BCG continues to be the most widely used vaccine in the world and with trials of a new adjuvant to BCG underway BCG will be with us for some time yet

With more resources and research committed by international and philanthropic organisations like the World Bank and the Bill and Melinda Gates Foundation, optimism for a new TB vaccine has reached heights last seen when the current TB vaccine, Bacille Calmette-Guerin (BCG), was developed in the 1920s.

The most clinically advanced of the nine vaccine candidates - called MVA85A - will be tested next month among 2,874 children under the age of one. Researchers hope to register a new anti-TB vaccine by 2015.

"All of the clinical trials conducted to date with this vaccine (MVA85A) have shown that it is safe, and it stimulates high levels of the type of immune response we believe is protective against tuberculosis," said the vaccine inventor Dr Helen McShane of the University of Oxford.

University reconsiders TB treatment policy

Once again the problems associated with the testing of foreign born employees raises its head, particularly when latent TB HCW becomes active..

"..foreign-born individuals make up the bulk of the latent tuberculosis cases in the United States. And as more immigrants enter health-related professions here, there has been a rise in health care workers who have the noncontagious infection, according to a 2006 report in the New England Journal of Medicine.

...University Hospital last year began requiring employees who test positive in the skin screening to take a more accurate blood assessment that takes into account the foreign vaccination.

Boone Hospital Center also uses that more accurate test."

-------------

By JANESE HEAVIN

Wednesday, June 10, 2009

University of Missouri Health Care administrators will take another look at a policy that allows those who test positive for latent tuberculosis to forgo treatment after an employee was diagnosed with the active disease last week.

The employee has tested positive for latent TB for years but declined treatment. When a persistent cough worsened, the man sought medical attention and tested positive for active TB. The hospital and Columbia/Boone County Department of Public Health and Human Services have contacted 232 people most at risk of having been exposed to his bacterial infection.

Hospital policies encourage, but do not require, individuals with latent tuberculosis — a noncontagious infection — to undergo nine months of the antibiotic Isoniazid.

“Part of what we’re doing in our due diligence is re-examining that policy to make sure it’s consistent with nationally published guidelines and that it’s indeed the best practice out there,” Chief Medical Officer Les Hall said.

Simply removing all physicians and nurses with latent TB from patient duties, though, would cause a worker shortage and spark a health care crisis, Hall said. “We have to be careful that the cure is not worse than the illness.”

Hospital officials aren’t identifying the employee or where he worked. “We don’t feel there’s an overriding public health need to disclose his identity,” spokeswoman Mary Jenkins said. If none of the high-risk contacts test positive, it’s unlikely those who had brief contact would be infected, she said.

Although the university hasn’t disclosed whether the employee was born in another country, statistically, foreign-born individuals make up the bulk of the latent tuberculosis cases in the United States. And as more immigrants enter health-related professions here, there has been a rise in health care workers who have the noncontagious infection, according to a 2006 report in the New England Journal of Medicine.

The numbers are tricky, though: A common TB vaccine used in other countries can trigger false positive results in a standard skin test, said Tim Sterling, a Vanderbilt researcher who co-authored the report.

That vaccination might account for some of the 415 MU Health workers who have tested positive for latent TB. That number also could include those who have been treated but still show up positive. It includes 48 new hires who tested positive and two cases in which employees converted from negative to positive. University Hospital last year began requiring employees who test positive in the skin screening to take a more accurate blood assessment that takes into account the foreign vaccination.

Boone Hospital Center also uses that more accurate test. Two workers — one new hire and one current employee — tested positive for latent TB at Boone Hospital last year, spokesman Steve Adams said.

Ultimately, it’s tough to say whether having workers with latent TB puts patients at risk.

“When someone has latent infection, when it’s latent, they’re not at risk of transmitting it to others,” Sterling said. “A rule of thumb is of the persons who are infected, 90 to 95 percent will never develop the active disease.”

But, he said, “it’s important that hospitals assess people with the tuberculosis infection, and health care workers who have latent infection should be treated.”

Anyone with specific concerns can contact MU Health Care at 884-2401.

Germany recommends IGRA over skin test

"..tuberculin skin test (TST) results can be expected to be either false-positive or false-negative in these patients.."

As reported above in the latest Zeitschrift für Rheumatologie

Recommendations for tuberculosis screening before initiation of TNF-α-inhibitor treatment in rheumatic diseases

Abstract Due to the increased risk of tuberculosis (TB) under treatment with TNF-α inhibitors for rheumatoid arthritis and other autoimmune diseases, precautionary measures are required before initiating TNF-α-inhibitor therapy. Patients should have active TB ruled out and screening for latent TB infection should be performed. The screening should include chest X-ray, complete medical history, and the administration of a highly specific interferon-γ-release assay (IGRA). (In the future, the reimbursement of IGRA tests under an analogue procedure code is expected to be formalized by the application of a code specific to the TB-IGRA procedure.) As tuberculin skin test (TST) results can be expected to be either false-positive or false-negative in these patients, the TST, as commonly performed in the past, is recommended only in exceptional situations. For chemopreventive treatment of latent TB infection (LTBI), isoniazid is usually given for 9 months.

Pacific threatened by TB

Founded by Australia, France, New Zealand and the United States of America the Secretariat of the Pacific Community covers the 22 Island countries of the Pacific, from Papua New Guinea to Pitcairn.



TB remains a concern to the SPC;

Rates of TB in some Pacific Island countries and territories are among the highest in the Western Pacific region and are higher than in China and Cambodia

Bad news travels fast

According to new SPC data about 1,500 people have been infected with active tuberculosis in the Pacific region each year for the past three years even though the bacterial infection which usually affects the lungs is curable. There is concern that the new data indicates many cases in the region involve a drug-resistant strain.

Micronesia has the highest TB rate with 140 people per 100,000 infected but Melanesian countries have an average of 37 cases per 100,000, while Polynesian countries have 19.

Dr. O'Connor says TB is a huge burden for the region and health officials are alarmed by a rise of the drug-resistant strain which now affects a total of nine countries in the region - Papua New Guinea alone has as many as 900 cases a year.

The greatest concern is the emergence of drug resistant TB;

As of May 2009, MDR-TB, which is resistant to the two most powerful TB drugs available, has been recorded in seven Pacific Island countries and territories. In 2008, an outbreak of MDR-TB occurred in Federated States of Micronesia with 23 cases identified in Chuuk State. The treatment of MDR-TB is lengthy, expensive and resource-intensive. Its prevention and management is therefore a priority for National TB Programmes throughout the Pacific.

HCW guideline - American College of Occupational and Environmental Medicine

Buried within the ACOEM document Guidance For Occupational Health Services In Medical Centers is this line;

Due to its interference with tuberculin skin testing, tuberculosis surveillance among recent BCG recipients must be carried out using the QuantiFERON-TB Gold assay.

NHS gently rebukes TB cost effectiveness study

In 2008 Canadian researchers Tan, Menzies & Schwartzman published a study which

sought to compare four screening interventions for travelers from low-incidence countries, who visit countries with varying tuberculosis incidence.

...In all sensitivity analyses, the single post-trip tuberculin test remained most cost-effective.

The study authors admitted that they did not evaluate the use of interferon-gamma release assays.

The NHS Centre for Review and Dissemination reviewed the study and agreed that the

..screening by means of interferon-gamma release assays...might be more relevant for travellers born in countries where the Bacillus Calmette-Guérin (BCG) vaccination is administered such as in many European countries.

The NHS found that the original study was limited by its failure to provide evidence of clinical analysis;

First, the approach used to identify primary sources of data was not reported.

Second, the types of studies used and their key characteristics (design, patient population, follow-up, types of interventions) were not described.

Third, other potential issues of the analysis such as the heterogeneity of the sources of data and the problems related to mixing different datasets were not addressed.

...This lack of information limits the possibility of judging the validity of the clinical data.

People get ready, there's a train a comin

At 65 years of age Jeff Beck proves that time presents no barrier

HCW contact investigation

Another nail in the skin test coffin, at a German university hospital contacts of a smear-negative, culture-positive TB were tested with both QFT-GIT and the skin test and then followed up for two years;

* 13 QFT-GIT positive and 40 TST positive,
* Age was the only predictor of QFT-GIT positivity,
* TST positives were significantly related to BCG vaccination and foreign origin,
* No secondary cases of active TB were detected over an observational period of two years

..the substantially lower frequency of positive QFT-GIT results compared to the TST may contribute to enhanced TB control in health care

Bio Briefs

As reported in Biotechnology News (subscription required), no doubt extracted from previous announcement by Cellestis

Nick Evans
Tuesday, 9 June 2009

CELLESTIS says its QuantiFERON-TB Gold tuberculosis diagnostic may receive a boost, with the United States delegation to a recent conference on the use of similar diagnostic tests (Interferon Gamma Release Assays – IGRAs) intimating the US may make more use of IGRAs in TB testing.

Cellestis said Dr Ken Castro, director of the division of tuberculosis elimination for the US Centers for Disease Control and Prevention (CDC), presented IGRAs as the “preferred” test in people vaccinated with the Bacillus Calmette-Guerin TB vaccine, and some other populations at the Global Symposium on IGRAs in Croatia last week.

The company said this approach would represent a “significant change” from the previous CDC guidelines, though the new guideline was not yet official and may alter before it is published and circulated by the CDC.

Weight of evidence tips the scales

Having trawled through the enormous amount of literature contained within Medline and LILACS databases (2000-2008) our intrepid reviewers formed the view that;

these new assays based on interferon-gamma release present promising results and should be considered in tuberculosis investigation procedures for all patients

Too easy to see

Our friends from the land of the la dolce vita are obliged to conclude;

Discrepancies between IGRA and TST can be a result of higher specificity of IGRA that is not influenced by previous BCG vaccination. IGRA may be more sensitive in children younger than 48 months.

Even blind freddy could see that in a BCG vaccinated population the TB skin test about as useful as a jam sandwich to a drowning rabbit.

If guidelines are to be believed the number of BCG vaccinated people is numerically significant

One hundred and fifty five countries currently recommend BCG vaccination as a countrywide policy

QFT improves HCW program

From an OHS manager in Wisconsin;

We dropped annual TB testing as we are a very low risk system. We use QFT-G for all new hires and for all exposures. The reduction in the time it took us to do all the employees has allowed us to increase our surveillance program and put more time into training of staff for early identification of TB so that less employees are exposed.

We still do some employees on an annual basis. Mostly those employees that work at other health care facilities that still require annual testing. We are using the QFT-G on these also. Big difference is that our lab does the QFT-G, so, while I still have a cost, I am only paying the actual cost of the test.

QFT-GIT and HCW in Germany

..substantially lower frequency of positive QFT-GIT results compared to the TST may contribute to enhanced TB control in health care

In-hospital contact investigation among health care workers after exposure to smear-negative tuberculosis
Felix C Ringshausen , Stephan Schlosser , Albert Nienhaus , Anja Schablon , Gerhard Schultze-Werninghaus and Gernot Rohde

Journal of Occupational Medicine and Toxicology 2009, 4:11doi:10.1186/1745-6673-4-11

Published: 8 June 2009
Abstract (provisional)

Background
Smear-negative pulmonary tuberculosis (TB) accounts for a considerable proportion of TB transmission, which especially endangers health care workers (HCW). Novel Mycobacterium-tuberculosis-specific interferon-gamma release assays (IGRAs) may offer the chance to define the burden of TB in HCW more accurately than the Mantoux tuberculin skin test (TST), but the data that is available regarding their performance in tracing smear-negative TB in the low-incidence, in-hospital setting, is limited. We conducted a large-scale, in-hospital contact investigation among HCW of a German university hospital after exposure to a single case of extensive smear-negative, culture-positive TB with pulmonary involvement. The objective of the present study was to evaluate an IGRA in comparison to the TST and to identify risk factors for test positivity.

Methods
Contacts were prospectively enrolled, evaluated using a standardized questionnaire, the IGRA QuantiFERON(R)-TB Gold in Tube (QFT-GIT) and the TST, and followed-up for two years. Active TB was ruled out by chest x-ray in QFT-GIT-positive subjects. Independent predictors of test positivity were established through the use of logistic regression analysis.

Results
Out of the 143 subjects analyzed, 82 (57.3%) had close contact, but only four (2.8%) experienced cumulative exposure to the index case >40 hours. QFT-GIT results were positive in 13 subjects (9.1%), while TST results were positive in 40 subjects (28.0%) at an induration >5 mm. Overall agreement was poor between both tests (kappa=0.15). Age was the only predictor of QFT-GIT-positivity (Odds ratio 2.7, 95% confidence interval 1.32-5.46), while TST-positivity was significantly related to Bacillus Calmette-Guerin vaccination and foreign origin. Logistic regression analysis showed no relation between test results and exposure. No secondary cases of active TB were detected over an observational period of two years.

Conclusion
Our findings suggest a low contagiosity of the particular index case. The frequency of positive QFT-GIT results may in fact reflect the pre-existing prevalence of latent TB infection among the study population. TB transmission seems unlikely and contact tracing not generally warranted after cumulative exposure <40 hours. However, the substantially lower frequency of positive QFT-GIT results compared to the TST may contribute to enhanced TB control in health care.

UNITED STATES: "Overseas Screening for Tuberculosis in US-Bound Immigrants and Refugees"

New England Journal of Medicine
Vol. 360; No. 23: P. 2406-2415
(06.04.09):: Yecai Liu, MS; Michelle S. Weinberg, MD; Luis S. Ortega, MD; John A. Painter, DVM; Susan A. Maloney, MD

The authors introduced the current study by noting that TB is the second-most common cause of death from infectious diseases in the world. In the United States in 2007, 57.8 percent of new TB cases were diagnosed in foreign-born persons. Among the foreign-born, the TB rate was 9.8 times higher than among US-born persons (20.6 vs. 2.1 cases per 100,000 population). "Annual arrivals of approximately 400,000 immigrants and 50,000 to 70,000 refugees from overseas are likely to contribute substantially to the TB burden among foreign-born persons in the United States," the authors noted.

CDC compiles information on overseas TB screening among US-bound immigrants and refugees, as well as on follow-up evaluation after their arrival in the United States. The researchers analyzed these data to study the epidemiology of TB among these persons.

The data included results for 2,714,223 US-bound immigrants tested overseas between 1999 and 2005. Among these travelers, testing indicated 26,075 smear-negative TB cases (i.e., a chest radiograph was suggestive of active TB but sputum smears were negative for acid-fast bacilli on three consecutive days) for a prevalence of 961 cases per 100,000 persons (95 percent confidence interval [CI], 949-973), and 22,716 cases of inactive TB (i.e., a chest radiograph was suggestive of TB that was no longer clinically active) for a prevalence of 837 per 100,000 persons (95 percent CI 826-848).

Among 378,506 refugees bound for the United States, smear-negative TB was diagnosed in 3,923 for a prevalence of 1,036 cases per 100,000 (95 percent CI 1,004-1,068), and inactive TB was diagnosed in 10,743 for a prevalence of 2,838 cases per 100,000 population (95 percent CI 2,785-2,891).

"Active pulmonary tuberculosis was diagnosed in the United States in 7.0 percent of immigrants and refugees with an overseas diagnosis of smear-negative tuberculosis and in 1.6 percent of those with an overseas diagnosis of inactive tuberculosis," the authors wrote. "Overseas screening for tuberculosis with follow-up evaluation after arrival in the United States is a high-yield intervention for identifying tuberculosis in US-bound immigrants and refugees and could reduce the number of tuberculosis cases among foreign-born persons in the United States."

Canada takes something simple and makes it complicated

In their updated guidelines Canada says;

If both TST and IGRA testing will be used, it is recommended that blood be drawn for IGRA on or before the day when the TST is read.

Makes it hard if QFT is to confirm a TST;

IGRAs may be used as a confirmatory test for a positive TST in contacts....

The TB skin test as a contaminant.

The very recent American Thoracic Society 2009 conference contained numerous studies on QuantiFERON - grappling with all the information is a study in itself.

Several of the studies arose from the CDC Task Order 18, a comparison of the performance of the skin test, QuantiFERON and T-Spot TB in healthcare workers (HCWs).

One of the studies hypothesised that a recent TST could impact on an IGRA; this hypothesis was confirmed

These results suggest that a recent TST may impact a subsequent IGRA causing a booster-like phenomenon in 7% of QFT-GITs and 9% of T-SPOTS.

Further confirmation by another study from South Africa

When using a two-step screening strategy IGRAs should not be performed more than three days after the TST. A 3 spot or 80% IFN-y level variation on either side of baseline values explains 95% short-term variability, and may be useful for interpreting conversions and reversions, and values close to the cut-point.

Presenting at Dubrovnik Charles Daley is supportive of

TST may “boost” a subsequent IGR and the change in IGRAs occurs early (within 2 weeks)

This now raises the possibility that a vast number of studies comparing TST with IGRA are flawed and invalid. Indeed, Roland Diel looks at some of some of the current crop and identifies their "limitations" and finds that for a study to be scientifically valid a number of points must be satisfied including;

TST and IGRA testing has to be performed simultaneously, not IGRA following a positive TST only

Not only are studies questionable guidelines based on those studies could be equally invalid. Diel makes his position quite clear

Quest again

Adding on to the previous list, Oklohoma City now makes 22

TB guideline panels put on notice

In his excellent presentation at Dubrovnik 2009 Madhukar Pai, MD PhD, McGill University, Canada notes the wide disparity contained within the various guidelines and observed that

• Few of the guidelines explicitly used evidence summaries (e.g. GRADE) and systematic reviews.
• Most based on narrative literature reviews and expert opinion
• Most guidelines did not include a clear description of potential conflicts of interests and industry involvement in guideline development
  

Dr Pai then outlined the steps necessary for guideline authors;

Dubrovnik 2009

The agenda is here and from the agenda access to individual presentations can be made.

Not all presentations are online, there may be more to come.

This is from San Francisco and deals with costs;



This is from Japan and deals with guidelines;



This is from Germany and deals with occupational health

Foreign born HCWs in the US

In light of the recent comments made by Dr Ken Castro, Director of the CDC’s Division of Tuberculosis Elimination placing

IGRAs as the ‘preferred’ test in BCG-vaccinated individuals

it is worth having a look at the rate of foreign born health care workers in the US.

Estimates vary, whilst the Migration Policy Institute assessed the proportion in 2005 to be 15% the New England Journal of Medicine published a study which said that

...In recent decades, the proportion of foreign-born health care workers in this country has increased. One fourth of all practicing physicians in the United States graduated from foreign medical schools, and the number of foreign-born nurses employed here has increased in response to a shortage of registered nurses. Although these health care workers play a crucial role in health care delivery, one consequence is that an increasing proportion of U.S. health care providers are infected with M. tuberculosis.

...Bacille Calmette–Guérin (BCG), the most commonly administered vaccine in the world, may confound the interpretation of the tuberculin skin test. In addition, in countries where tuberculosis is endemic, the prevalence of positive tuberculin skin tests is very high. Many immigrants to the United States assume that they have been infected for several years and are therefore not at risk for active tuberculosis. Furthermore, in many countries outside the United States, treatment of latent tuberculosis infection is not routinely offered.

Update: Charles Daley reports HCW in the US = ~14M

Whatever the proportion it is unlikely that medical institutions will be able to sustain the cost of running parallel testing regimes. In addition they might encourage opposition to what is essentially a policy that discriminates; native born HCWs might well ask why they are being denied the more superior diagnostic.

In the US, and no doubt over the developed world, health care is seen as a growing industry. Figures from the department of Bureau of Labour Statistics predict that the job growth from 2006-2016 specifically in the area "General medical and surgical hospitals, public" to be 13.9%, up from 4.9M to 5.7M.

Registered nurses are set to rise from 2.5M to 3.1M and it is expected that the majority of new employees will be foreign born

The total quantity of HCWs is dependent on how wide you cast your net; available date ranges from 28.4m to 9.2M. What is consistent is the rate of job growth, ~30% over 10 years, and with the growing need for compliance the entire health system will need to engage with the most reliable and cost effective stratagem for employee management.

CST - ASX Announcement

ASX Announcement - 2nd Global Symposium on Interferon Gamma Release Assays
(IGRAs)

Dubrovnik, Croatia; 5 June 2009 – The 2nd Global Symposium on Interferon Gamma Release Assays (IGRAs) concluded this week in Dubrovnik, Croatia. The symposium focused on "putting IGRAs into practice" and provided a forum for international key opinion leaders to describe their experiences and views on IGRAs to a global audience. Most presentations highlighted the performance of Cellestis' QuantiFERON®-TB Gold (QFT™) product, which is the world's leading IGRA for tuberculosis (TB) diagnosis.

Several key topics were discussed comprehensively at the symposium. National guidelines for the use of IGRAs received considerable interest from the 240 delegates, many of whom are involved in drafting guidelines in their respective countries. Of particular importance was the provisional update by the U.S. Centers for Disease Control and Prevention (CDC) of their IGRA guideline. Dr Ken Castro, Director of the CDC’s Division of Tuberculosis Elimination, presented IGRAs as the ‘preferred’ test in BCG- vaccinated individuals and some other populations. The approach is a significant change from the previous guideline and now considers the wide prevalence of BCG-vaccinated populations within the U.S. The new guideline is not yet official and may alter before final publication.

Guidelines from some nations also advocate preferential use of an IGRA, and others suggest IGRA confirmation of a positive skin test (TST). Furthermore, some countries specify that QFT is the preferred IGRA. In Japan, QFT is the preferred test for public health outbreak investigations (i.e. contact investigations) and healthcare worker screening. However, in most guidelines the use of IGRAs in place of the TST is not yet recommended for children under 5 years of age - largely due to the limited number of IGRA studies in very young children.

Cost-benefit and practicality of using IGRAs were other important themes discussed. Studies presented in Dubrovnik demonstrated that QFT is more cost effective than the skin test. One analysis of large-scale QFT use in San Francisco showed considerable cost savings for the City’s TB control program as a whole, as well as health benefits for those tested. Other presentations focused on the application of QFT in various settings and highlighted QFT’s enhanced performance and practicality over the TST.

Not the best China

Whilst the history of the Tiananmen uprising has been deleted within China in the free world the commemoration of the twentieth anniversary of the event proceeded without constraint, including this jab at one R J Hawke

..Our then prime minister Bob Hawke famously broke down on television, announcing that all 20,000 Chinese students then resident in our country could stay permanently. Today, Bob Hawke is a lobbyist with an office in Shanghai, and has spent much of the past week ducking requests for interviews.

..When he spoke to The Australian, back in March, all Mr Hawke was quoted as saying on human rights was that present-day China was markedly different from when he made his first visit in 1978.

“It is an immeasurably much more different society, much more liberal, people have more freedom…obviously there are things that need to be improved but I think it is inevitable that the regime’s move to freer society will continue in the years ahead.”

But by not speaking this past week, Mr Hawke has helped China as it tries to ensure that the Tiananmen Square massacre is not treated as an anniversary at all.

The stark reality about QuantiFERON

Dr Jeffrey J Starke from Texas Children's Hospital currently holds the following positions

• Professor and Vice Chairman of Pediatrics, Baylor College of Medicine
• Chief of Pediatrics, Ben Taub General Hospital
• Infection Control Officer, Texas Children's Hospital

As a member of the CDC Joint Subcommittee on IGRA's he told the 2009 National TB Conference that he thinks that in general IGRAs should replace the TST

(preference for tests refers to QFT and T-Spot TB)

The Conscience of a Liberal

In his regular New York Times column Nobel prize winner Paul Krugman seeks to put down loose talk about inflation by saying that the Fed isnt printing money it is just recycling frozen bank assets;

why the inflation worries? Some claim that the Federal Reserve is printing lots of money, which must be inflationary, ...Banks aren’t lending out their extra reserves. They’re just sitting on them — in effect, they’re sending the money right back to the Fed. So the Fed isn’t really printing money after all.

He then blames economists for spreading wild stories;

it’s hard to escape the sense that the current inflation fear-mongering is partly political, coming largely from economists..

Ah, the irony of it all. Maybe he is referring to fears of inflation generated by rising long term interest rates. Dallas Federal Reserve Bank President Richard Fisher said that he thinks that the increase is due to

..an improvement in the economic outlook, combined with the Treasury's huge borrowing needs.

"I personally don't believe it (the long-end yield rise) is due to inflation fears," Fisher said. "But I want to make sure that it doesn't."

Krugman has previously discussed inflation, indeed in 1998 he recommended it for Japan;

the only way to expand the economy is to reduce the real interest rate; and the only way to do that is to create expectations of inflation.

For the US he thinks that it may also be the answer, but not right now;

the inflation commitment has to be credible. So I don’t think we’re ready for this, not yet

Krugman leaves Mario Rizzio from the Department of Economics, New York University somewhat perplexed;

Under other circumstances, Paul Krugman would have made an excellent pope if we judge by his economics pronouncements. Let me take two examples from a recent New York Times column. This is my interpretation of what he is saying.

1. On the one hand, as Keynesians have always taught: There is no real danger of interest rates rising as the Treasury accumulates massive amounts of debt. This is because there is a vast surplus of (ex ante) savings out there just waiting to buy US treasuries at low interest rates. This is our official teaching.

2. On the other hand, there are economists out there sowing the seeds of heresies. It is understandable in this time of unprecedented events that even wise economists might be tempted to stray from the Truth. They are making statements that confuse the faithful in their daily activities (of buying and selling treasuries). They are frightening them with stories of inflation and high interest rates. Many, perhaps most, of these teachers have evil motives. These heretics are making it more difficult for the “church” to help us all to salvation.

Read the article yourself. Isn’t this what he is saying?

A new broom to sweep out CDC closet

The recent (May 15) appointment of Thomas Frieden to head the CDC has apparently drawn enthusiastic applause from health care workers.

His Wiki entry describes him as a man of many actions;

Dr. Thomas R. Frieden (born December 7, 1960) has been New York City Health Commissioner since 2002. He worked to help control an outbreak of drug-resistant tuberculosis in New York City in the early 1990s, and assisted India in implementing a tuberculosis control program that has saved more than 1.6 million lives since 1997. As head of the New York City Department of Health and Mental Hygiene, he helped lead initiatives to reduce smoking, eliminate artificial trans fat from restaurant food, require posting of calorie information in chain restaurants and expand the use of electronic health records.

We also know Thomas Frieden from his introduction of QuantiFERON to New York City when he said

"Tuberculosis can be both prevented and cured"

President Obama spoke well of his appointee;

Dr. Frieden is an expert in preparedness and response to health emergencies, and has been at the forefront of the fight against heart disease, cancer and obesity, infectious diseases such as tuberculosis and AIDS, and in the establishment of electronic health records. Dr. Frieden has been a leader in the fight for health care reform, and his experiences confronting public health challenges in our country and abroad will be essential in this new role."

Nowhere to Run, Nowhere to Hide

An interesting case from Tallahassee, the capital of Florida. Apparently after a Department of Education employee was diagnosed with active TB the Department of Health tuberculosis bureau tested a further 19 employees, five of whom showed signs of TB exposure. It seems that a squabble over jurisdiction landed in court with Judge Sheffield ruling

all DOE workers in the affected area "need to be placed on notice. "They need to be advised as to what the Health Department feels is the likelihood of them being infected with tuberculosis and told that they can be tested, should they so desire, at no cost to them," he said.

Attorney Steve Andrews said;

"My recommendation is that every employee who tests positive should file a notice of injury under worker’s compensation," said Andrews. "Then their medical bills will be covered by the state in the future if they ever develop TB."

In the past TST false positives were somewhat accepted as a fact of life but now that the responsibility for those false positives has swung from the patient to the employer less tolerance may be shown.

Waiting for TB to progress from latent to active could take a life time. It is imperative that employers take notice, that they need to protect their workers from TB now.

TARP revealed

Here is the proposed total allocation and further below funds made available -vs- funds spent;




From the above it appears that there was greater urgency to secure funds, the both lines are cumulative! (apparently the the negative amount in the bottom line was an "accounting adjustment.")

As of May 22 less than 5% of the $787 billion has been spent.

Source