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PAPERS: Y Balabanova, R Coker, I Fedorin, S Zakharova, S Plavinskij, N Krukov, R Atun, and F Drobniewski Variability in interpretation of chest radiographs among Russian clinicians and implications for screening programmes: observational study BMJ 2005; 331: 379-382 [Abstract] [Full text]

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Variability in interpretation of chest radiographs among Russian clinicians: Conclusions are inappropriate for targeted TB screening programmes in other countries

Rob van Hest, Henk van Deutekom, Paul van Gerven, and Andrew Hayward.   (1 September 2005)

Variability in interpretation of chest radiographs among Russian clinicians - findings not relevant for targeted TB screening in Western countries

Ken M Citron   (14 October 2005)

Variability in interpretation of chest radiographs among Russian clinicians: Conclusions are inappropriate for targeted TB screening programmes in other countries 1 September 2005
Rob van Hest, Consultant TB physician Municipal Health Service, Schiedamsedijk 95, 3011 EN Rotterdam, the Netherlands, Henk van Deutekom, Paul van Gerven, and Andrew Hayward. Send response to journal: Re: Variability in interpretation of chest radiographs among Russian clinicians: Conclusions are inappropriate for targeted TB screening programmes in other countries	EDITOR- Balabanova et al extrapolate the findings of an observational study in a Russian region to other countries. (1) However, the biases of the method used, including the quantity, quality and representativeness of the study material, limit validity. The different tuberculosis (TB) screening experience of the observers and complexity of the Russian TB classification system limit generalisability. (2) “Observer error” is not exclusive to radiological TB screening but described for various radiological (breast cancer) and non-radiological (cervical cancer) screening programmes, which are therefore performed by specialised radiologists and pathologists to increase sensitivity and specificity. State-of-the-art screening, contrary to clinical work and the study performed, seeks to detect the one relevant abnormality among many normal findings. In the Netherlands extensive experience and evaluation of static and mobile radiological TB screening shows that the quality of reading by specialised TB physicians is high, relevant inter-observer disagreement very low (<1%) and few cases are missed or false-positive. The high TB rates found justify this screening in the Netherlands. (3) The epidemiological pattern of TB in Western countries is changing, with more explicit “metropolitan TB”, due to urban risk groups such as homeless persons, hard drug users and prisoners. (4) TB prevalence rates between 500 and 1500/100.000 among these groups have been reported in London and other European cities. Conventional TB control methods, such as contact-tracing, skin-testing and effective preventive treatment, are inadequate among disenfranchised care-avoiders. Mobile digital X-ray screening allows immediate reading of chest X-rays and facilitates direct interventions among otherwise difficult-to-reach groups who fuel transmission. In Rotterdam such screening was introduced successfully in 2002. (5) TB rates in London have nearly doubled over the past 15 years despite “established strategies for diagnosis”. The introduction of a carefully evaluated targeted mobile TB screening project in London is an appropriate response to the problem. 1. Balabanova Y, Coker R, Fedorin I, Zakharova S, Plavinskij S, Krukov N, et al. Variability in interpretation of chest radiographs among Russian clinicians and implications for screening programmes: observational study. BMJ 2005: 379-82. 2. Coker RJ, Dimitrova B, Drobniewski F, Samyshkin Y, Balabanova Y, Kuznetsov S, et al. Tuberculosis control in Samara Oblast, Russia: institutional and regulatory environment. Int J Tuberc Lung Dis 2003;7: 920-32. 3. KNCV Tuberculosis Foundation. Index tuberculosis 2001-2002. The Hague: KNCV Tuberculosis Foundation, 2005. 4. Ruddy MC, Davies AP, Yates MD, Yates S, Balasegaram S, Drabu Y, et al. Outbreak of isoniazid resistant tuberculosis in north London. Thorax 2004;59: 279-85. 5. De Vries G, van Hest NAH, Šebek MMGG. Active tuberculosis screening with mobile digital X-ray units among drug addicts and homeless people in Rotterdam. In: International Union against Tuberculosis and Lung Disease (IUATLD). Abstract Book 3-rd Congress of European Region. Moscow: IUATLD, 2004. Rob van Hest (vanhestr@ggd.rotterdam.nl) Consultant TB physician, Department of Tuberculosis Control, Municipal Health Service, Schiedamsedijk 95, 3011 EN Rotterdam, the Netherlands Henk van Deutekom Consultant chest physician, Department of Tuberculosis Control, Municipal Health Service, Nieuwe Achtergracht 100, 1018 WT Amsterdam, the Netherlands Paul van Gerven Consultant TB physician, National Unit, KNCV Tuberculosis Foundation, Parkstraat 17, 2514 JD the Hague, the Netherlands Andrew Hayward Senior Lecturer in Infectious Diseases, Centre for Infectious Disease Epidemiology, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, Hampstead Campus, NW3 2PF London Competing interests: None declared
Variability in interpretation of chest radiographs among Russian clinicians - findings not relevant for targeted TB screening in Western countries 14 October 2005
Ken M Citron, Emeritus Professor of Medicine Royal Brompton Hospital SW3 6NP Send response to journal: Re: Variability in interpretation of chest radiographs among Russian clinicians - findings not relevant for targeted TB screening in Western countries	Editor – Contrary to the authors’ assertion, the findings of an observational study on variability in interpretation of chest radiographs among Russian clinicians (1) are not relevant for targeted tuberculosis (TB) control programmes in Western countries where high levels of concordance have been reported between experienced TB practitioners and radiologists interpreting chest x-rays from modern targeted screening programmes. (2,3) In 1992 and 1993 a mobile x-ray TB screening project in homeless shelters in London detected a prevalence rate of 1,500/100,000 among 595 persons x-rayed despite loss to follow up of some suspected cases. (4) TB among the homeless in London remains a cause for concern and control programmes designed to meet the needs of homeless people are required. (5) TB control is founded on early case detection, diagnosis and effective follow-up and treatment. The mobile digital x-ray screening pilot in London can identify undetected cases of pulmonary TB among homeless people and make on-the-spot referrals to specialist teams. The importance of well organised and appropriately resourced teams including specialist TB physicians, nurses and outreach workers with access to radiological and laboratory services cannot be overstated. The specialisation and high volume of the work will optimise the quality and efficiency of these services. (1) Balabanova Y, Coker R, Fedorin I, Zakharova S, Plavinskij S, Krukov N, Atun R, Drobniewski F. Variability in interpretation of chest radiographs among Russian clinicians and implications for screening programmes: observational study. BMJ. 2005 Aug 13;331(7513):379-82. (2) Richards B, Kozak R, Brassard P, Menzies D, Schwartzman K. Tuberculosis surveillance among new immigrants in Montreal. Int J Tuberc Lung Dis. 2005 Aug;9(8):858-64. (3) Van Hest R, Van Deutekom H, Van Gerven P, Hayward A C. Variability in interpretation of chest radiographs among Russian clinicians: Conclusions are inappropriate for targeted TB screening programmes in other countries. BMJ 2005 http://bmj.bmjjournals.com/cgi/eletters/331/7513/379 (4) Kumar D, Citron KM, Leese J, Watson JM. Tuberculosis among the homeless at a temporary shelter in London: report of a chest x ray screening programme. J Epidemiol Community Health. 1995 Dec;49(6):629-33 (5) Citron K. Tuberculosis among homeless people. J Epidemiol Community Health. 1996 Jun;50(3):382. Competing interests: None declared