Variability in interpretation of chest radiographs among Russian clinicians and implications for screening programmes: observational study
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7513.379 (Published 11 August 2005) Cite this as: BMJ 2005;331:379All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
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
Competing interests: No competing interests
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
Competing interests: No competing interests