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The Booster Effect in Two-Step Tuberculin Testing among Young Adults in Montreal

Richard Menzies, MD; Bilkis Vissandjee, MSc; Isabelle Rocher, BScN; and Yves St. Germain, BScN
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From Montreal Chest Hospital, McGill University, and Universite de Montreal, Montreal, Canada. Requests for Reprints: Richard Menzies, MD, Montreal Chest Hospital, 3650 St. Urbain Street, Montreal, P.Q., H2X 2P4, Canada. Acknowledgments: The authors thank Ms. Braithewaite and Ms. Desrosiers for assistance in collecting data, Dr. J. Hanley and M. Olivier for assistance with data analysis, Dr. J. Martin for review of the manuscript, and the Faculties of Health Sciences as well as those responsible for student health services in the following institutions: McGill University, Universite de Montreal, and Edouard Montpetit, Dawson, and John Abbott Colleges. Grant Support: By the Association Pulmonaire du Quebec and the Royal Edward Laurentian Foundation. Dr. Menzies was supported by The Respiratory Health Network of Centres of Excellence from 1990 to 1992.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1994;120(3):190-198. doi:10.7326/0003-4819-120-3-199402010-00003
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Objectives: No consensus exists regarding the definition and interpretation of a significant boosting reaction after sequential tuberculin testing. The booster phenomenon is thought to represent remote tuberculous infection where tuberculin reactivity has waned, but it has also been described among persons with previous exposure to other mycobacteria or bacille Calmette–Guérin (BCG) vaccine. We studied the factors affecting the booster phenomenon among Canadian-born young adults to determine the definition that would maximize sensitivity and specificity of a positive booster reaction in these persons.

Design: Point-prevalence survey of initial tuberculin reactions and response to repeated tuberculin testing after 1 to 4 weeks.

Setting: Community-based study of all students entering health professional training programs at six post-secondary institutions.

Measurements: In 1989, 1990, and 1991, students completed self-administered questionnaires, underwent two-step tuberculin testing with purified protein derivative-tuberculin (PPd-T), and had their childhood BCG vaccination status verified. In 1991, students were also tested with purified protein derivative-Battey (PPd-B) (for Mycobacterium intracellulare).

Results: Overall, 74 students (5.2%) had positive booster reactions, which were significantly associated with older age (P < 0.001), larger initial tuberculin reactions (P < 0.001), previous BCG vaccination (P < 0.001), older age when vaccinated (P < 0.02), longer interval from vaccination to testing (P < 0.01), and sensitivity to PPd-B (P < 0.001). Boosting was not associated with the number of BCG vaccinations, sex, or risk factors for tuberculous infection. The pattern, mean, and mode of the frequency distributions of booster reactions among those with BCG vaccination and sensitivity to PPd-B were similar to those with assumed tuberculous infection.

Conclusions: In young adults, booster reactions due to previous tuberculous infection are uncommon and cannot be distinguished from false-positive reactions due to past exposure to other mycobacteria.

Figures

Grahic Jump Location
Figure 1.
Frequency distributions of the booster effect (PPd-T2 minus PPd-T1) among participants who were vaccinated with BCG compared with those who were not vaccinated.

Those with BCG vaccination were compared with all the participants who were not vaccinated. Those with initial and second tuberculin reactions measuring 0 mm are not shown but are included in calculation of the total percentage. Those whose second tuberculin test reaction was smaller than the first are shown in the first group (−1 to −9 mm).

Grahic Jump Location
Grahic Jump Location
Figure 2.
Effect of size of reaction to PPd-B on booster effect (PPd-T2 minus PPd-T1). P

< 0.001 for difference among means of four groups.

Grahic Jump Location
Grahic Jump Location
Figure 3.
Frequency distributions of the booster effect (PPd-T2 minus PPd-T1) among participants who were and were not sensitive to PPd-B.

Those with initial and second tuberculin reactions measuring 0 mm are not shown but are included in calculation of total percentage. Those whose second tuberculin reaction was smaller than the first are shown in the first group (−1 to −9 mm).

Grahic Jump Location
Grahic Jump Location
Figure 4.
Effect of sensitivity to PPd-B and BCG vaccination on booster effect (PPd-T2 minus PPd-T1) P < 0.001 for difference among mean booster effects in four groups.
Grahic Jump Location

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