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. 2025 Mar 25;20(3):e0319568. doi: 10.1371/journal.pone.0319568

An interoperable web-based platform to support health surveillance against latent tuberculosis infection in health care workers and students: The evolution of CROSSWORD study protocol

Angela Rizzi 1,#, Eleonora Nucera 1,2,#, Walter Mazzucco 3, Pierpaolo Palumbo 4, Domenico Staiti 5,6, Umberto Moscato 7,8, Francesco Maria De Simone 5, Michela Sali 9,10, Luca Boldrini 11, Nikola Dino Capocchiano 12, Stefano Patarnello 12, Gabriele Rumi 1, Raffaella Chini 1, Valentina Carusi 1, Michele Centrone 1, Alessia Di Rienzo 1, David Longhino 1, Chiara Laface 1, Sabato Mellone 13, Carmelo Massimo Maida 3, Emanuele Cannizzaro 3, Luigi Cirrincione 3, Maria Gabriella Verso 3, Annalisa Saracino 14, Francesco Di Gennaro 14, Luigi Vimercati 15, Luigi De Maria 15, Stefania Sponselli 15, Giancarlo Scoppettuolo 16, Roberta Pastorino 17, Antonio Gasbarrini 1,18,19, Riccardo Inchingolo 20,*
Editor: Nicola Serra21
PMCID: PMC11936157  PMID: 40132007

Abstract

Background

Tuberculosis (TB) prevention is a major goal in teaching hospital setting. Because of the possible progression or reactivation of latent disease, the screening of both health-care workers (HCWs) and students is an important issue in the TB control program.

Objective

to deploy a web-based platform interoperating health surveillance systems from different hospitals to define models based on the highlighted risk factors to predict the occurrence of Latent Tuberculosis Infection (LTBI) and to define prevention strategies and interventions.

Methods

This is a cross-sectional ambispective observational study without drug and device. The primary endpoint is the prevalence of LTBI. The secondary endpoint is the identification of possible risk factors of LTBI in a large cohort of HCWs and students.

Conclusions

This study aims to enrich the primary prevention measures against TB, having a high socio-economic-health impact in high-risk populations (HCWs and students) through an interoperable digital approach based on data obtained in three large Italian teaching hospitals.

ClinicalTrials.gov: NCT05756582

Introduction

Mycobacterium tuberculosis (Mtb) may develop symptoms and signs of disease (TB disease), in a subset of subjects, or may have no clinical evidence of disease (latent tuberculosis infection [LTBI]) [1]. TB disease remains one of the major causes of morbidity and mortality in the world [1]. The WHO estimates that the annual incidence of tuberculosis has been raising worldwide from 10.0 million in 2020 to 10.6 million people in 2022 [1].

Mtb is transmitted from person to person via the airborne route [2]. Several factors determine the probability of Mtb transmission: (1) infectiousness of the source patient—a positive sputum smear for acid-fast bacilli (AFB) or a cavity on chest radiograph being strongly associated with infectiousness; (2) host susceptibility of the contact; (3) duration of exposure of the contact to the source patient; (4) the environment in which the exposure takes place (a small, poorly ventilated space providing the highest risk); and (5) infectiousness of the Mtb strain.

In 2021, a systematic review explored the status and risk factors of TB infection among HCWs through the evaluation of all published reports from 1 August 2010 to 31 December 2018. The TB infection rate in HCWs was higher than that of the general population. Based on 39 studies, the prevalence of TB in HCWs (tuberculin skin test positive) was 29.94%. In contrast, the global burden of latent TB infection was 23.0% (95% uncertainty interval: 20.4%–26.4%) in 2014. The risk factors of TB among HCWs were aging, long duration of employment, nursing professionals, lack of Bacillus Calmette-Guerin vaccination, and low body mass index [3].

In 2020, a meta-analysis examined population-level incident TB risk in a pooled data set of more than 80,000 individuals tested for LTBI in 20 countries with low M. tuberculosis transmission (annual incidence ≤ 20 per 100,000 persons). Cumulative 5-year risk of incident TB among people with untreated LTBI approached 16% among child contacts and approximately 5% among recent adult contacts, migrants from high TB-burden settings and immunocompromised individuals. Most cumulative 5-year risk was accrued during the first year among risk groups with an index exposure. The substantial variation in incidence rates even within these risk groups suggests that an individual-level approach to risk stratification is required. The first direct data-driven model was developed to incorporate the magnitude of the T cell response to M. tuberculosis with readily available clinical metadata to capture heterogeneity within risk groups and generate personalized risk predictions for incident TB [4].

Health-care workers (HCWs) are at higher risk of being exposed to tuberculosis compared to the general population [5], even in countries with low TB incidence, such as Italy. In these workers, the assessment of LTBI and TB disease is part of the annual health surveillance program aimed to prevent occupational diseases [6].

Because of the severity of their symptoms, individuals with an active contagious form of tuberculosis have a higher chance of being hospitalized and can remain for hours or days at the health care facility with a pending diagnosis.

For these reasons, the prevention of nosocomial transmission of tuberculosis represents prominent public health and occupational requirement [7,8]. However, it is also important to note that health-care providers (HCPs) may contract an infectious disease outside of the workplace, thus representing a source of infection to colleagues and patients that are more likely to be affected.

It is estimated that one patient with untreated active infectious pulmonary tuberculosis can affect 10–15 people within a year [9]. Of these individuals, a percentage between 3 and 10% will be infected, half of whom will become ill within one to two years while the others might develop the illness at any point of their residual life [7]. On average, 10% of people with LTBI develop TB disease in their lifetime, half of which become ill within 2 years after exposure [5,7,9]. About 70% of incident cases of TB are a result of the reactivation of a past infection [5,7,9,10], especially in countries with a low TB prevalence [11–13]. Furthermore, the pharmacological management of patients with TB can be complicated by drug-induced reactions [14].

For these reasons, the identification and prophylactic treatment of individuals with LTBI are crucial for the elimination of the disease. Health-care students involved in clinical training could be exposed to occupational risks like those of HCWs. Therefore, the screening for LTBI of both HCWs and undergraduate students attending teaching hospitals is recommended especially in low-incidence countries, including Italy, in order to obtain an early diagnosis of cases and prevent progression to active disease [8,15].

Despite the higher risk of TB infection reported in high TB burden countries among both HCWs and healthcare students compared to the general population [16,17], such TB control activities are difficult to be implemented in these settings [18].

According to Italian law [19,20], it is mandatory for employers to evaluate all risks in the workplace, including the risk of exposure to biological agents, and to implement measures to prevent the spread to operators or to limit the severity of its consequences. For this purpose, great importance is given to health surveillance of tuberculosis infection. In fact, the surveillance of LTBI in HCWs is considered fundamental for tuberculosis prevention.

Very few studies have investigated the epidemiology of TB infection among undergraduate healthcare students worldwide, and few, with a large sample, in areas with a low-incidence of TB [17,21–27].

The ongoing CROSSWORD study, aimed at collecting big data on the prevalence of LTBI in HCWs and students and the identification of possible risk factors for LTBI, in a single center, presents, as main current criticality, the monocentric nature of the study. The translation of the same methodologies of the CROSSWORD study within the research project entitled “Implementing an interoperable web-based platform to support health surveillance against latent tuberculosis infection in health care workers and students to define prevention strategies and interventions: the evolution of CROSSWORD Study” and the involvement of more centers will allow the creation of a shared interoperable digital platform and the definition of primary prevention strategies for LTBI.

Our research project is inspired by TB risk prediction model elaborated in a recent meta-analysis (PERISKOPE-TB) that combines a quantitative measure of T cell sensitization and clinical covariates [4]. We adopted some candidate predictors included in the final version of prognostic model described by Gupta et al.: exposure, HIV status and history of hematological or solid organ transplant [4].

Here we present the protocol of the Evolution of CROSSWORD study.

Materials and methods

The aim

The Evolution of CROSSWORD Study is an ambispective observational study aimed at: 1) estimating the prevalence of LTBI in HCWs and students attending University Hospitals with focus on the association between LTBI and potential risk factors, and 2) creating a web-based platform interoperating health surveillance systems from different hospitals to define models based on the highlighted risk factors to predict the occurrence of LTBI and to define prevention strategies and interventions.

Design

The Evolution of CROSSWORD study includes a retrospective phase focused on the analysis of data derived from the ongoing CROSSWORD Study conducted at Fondazione Policlinico Universitario A. Gemelli IRCCS (FPG) and Università Cattolica del Sacro Cuore (UCSC) in Rome, Italy. The subsequent prospective phase will collect data from two centers in southern Italy, the University of Palermo (UNIPA) and the University of Bari (UNIBA)/ University Hospital of Bari. It is part of the national research project “DARE - Digital Lifelong Prevention”, funded by the Ministry of University and Research (MUR) as part of the National Plan for Complementary Investments to the PNRR, with the goal of maximizing the potential of data to enhance health promotion and enable lifelong prevention. DARE focuses on improving health trajectories by leveraging data. Furthermore, DARE Project aims to create a community focused on digital prevention through research, innovation, and engagement of all stakeholders [28].

With the support of the University of Bologna, partner of the national DARE project, the Research Team will then proceed with the analysis of the data collected at three clinical centers and the definition of a single data platform necessary for the assessment of the prevalence of LTBI and the identification of risk factors. Furthermore, prediction algorithms will be validated in all university hospitals involved through the recruitment of a new cohort of HCWs and students.

Setting of the study

The participants will be recruited at: 1) the Health Surveillance Unit of Fondazione Policlinico Universitario A. Gemelli IRCCS, in Rome (FPG and UCSC), 2) the Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE) of University of Palermo (UNIPA), 3) Dipartimento di Medicina di Precisione e Rigenerativa e Area Jonica (DiMePRe-J) of University of Bari (UNIBA) and 4) Unit of Occupational Medicine of University Hospital of Bari.

The sample size

From the literature, Coppeta et al. [29] found a rate of LTBI prevalence of 2.1% in a population of Italian HCWs in Rome, and Verso et al. reported a prevalence rate of LTBI of 0.62% among Italian healthcare students and postgraduates in Palermo [26]. Therefore, we assumed a prevalence of LTBI of 1% in our population. The sample size was calculated considering the objectives of estimating the prevalence of LTBI and identifying its risk factors.

As regards the estimate based on the first outcome, considering 1) the assumed prevalence of LTBI of P = 1% in each teaching hospital involved in the research project, 2) an error estimate of d = 0.3%, and 3) a chosen confidence level of 90%, we obtained a total sample size of 2,977 subjects to be enrolled. The following formula [30] was used:

n=Z2P1−Pd2

where Z = Z statistic for a level of confidence (1.64 for 90% confidence level) [30]

The potential involvement of all employees and students attending medical, specialization and health professions degree courses, in the three university hospital centers involved in the project, will reasonably allow us to reach a higher sample size than the minimum target of 2,977 subjects. Indeed, for detecting an odds ratio (OR) as low as 1.69 (OR for male gender in [29]) with a type I error α=0.05 and power β=0.95, it would be required to reach a sample size of 3,503 subjects (z-test on logistic regression)

The calculation was performed using R statistical software (R Core Team, 2021).

Participants

During the study period, all HCWs and students, who refer to Health Surveillance Unit of FPG/UCSC, UNIPA and to Unit of Occupational Medicine of University Hospital of Bari for the annual scheduled medical visit for judgment of suitability for work/activity, will be invited to participate to the study giving written informed consent. Participation in the study is proposed to all HCWs and students of three University Hospitals involved in the project (Fig 1). There are no other specific inclusion criteria. Exclusion criteria include known history of tuberculosis, previous chemoprophylaxis, positive tuberculin skin test (TST) performed within 12 months prior to enrollment and refusal of informed consent.

Fig 1. Schedule of enrolment, interventions, and assessments.

Fig 1

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Procedures

Primary outcome

The general objective of the research project is to develop an interoperable web-based platform to provide epidemiological and health surveillance against LTBI in the hospital setting. The primary outcome of the study is the prevalence of LTBI defined as 1) positive TST at enrollment, 2) tuberculin conversion defined as negative TST before enrollment and positive at enrollment, 3) subsequent positive QuantiFERON-TB Gold (QFT) test result performed on the same day as the positive TST result or within 5 days of tubulin conversion [higher response than the cut-off value of 0.35 IU/ ml of INF-γ was detected in at least one test tube (TB1 or TB2)], 4) chest imaging excluding pleural and/or pulmonary lesions suggestive of active tuberculosis and 5) final medical evaluation done by a Specialist in Infectious Diseases which excluded active disease. All five criteria must be met. One TST is scheduled for each participant. Furthermore, the study does not provide follow-up. Each participant continues regular annual follow-up as per routine clinical practice.

Secondary outcomes

The secondary outcomes are a) the identification of possible risk factors of LTBI in a large cohort of HCWs and students, and b) the validation of the prediction models through the enrolment of a subsequent new cohort of HCWs and students at the teaching hospitals.

The following list of possible risk factors will be recorded:

  • Age and sex.

  • Bacillus Calmette–Guérin (BCG) vaccination history.

  • Previous work or stay in other countries with high TB rates including Armenia, Azerbaijan, Belarus, Bulgaria, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Romania, Russia, Tajikistan, Turkey, Turkmenistan, Ukraine, and Uzbekistan.

  • Known recent (within 6 months) exposure to TB-infected patient, which makes HCW or student a close contact of individuals with tuberculosis [31].

  • Current smoking.

  • Co-morbidities/ medical history (HIV, diabetes, silicosis, chronic kidney disease, solid organ transplant, malignant hematologic malignancies or undergoing chemotherapy, gastrectomy or fasting bypass, biological drugs).

  • Median QuantiFERON-TB Gold In-Tube level (TB Ag-Nil).

  • Occupation (doctor, nurse, laboratory technicians, paramedical personnel, “preclinical” students with no contact with patients inside the hospital, and “clinical” students attending various medical, laboratory, and surgical departments of the hospital, including the infectious disease wards).

  • Working/ training Unit

  • Years working as HCW

Data management plans

All enrolled participants, who will agree to participate in the study and answer the questionnaire, will respond to a cross-sectional questionnaire survey through dedicated tool only once.

The survey contains a brief explanation of the study aims and an invitation to respond to a 9-item multiple-choice questionnaire.

During the first phase of the project, the Research Team adopted Microsoft Forms included in Microsoft Office 365 subscription of FPG and UCSC. Once the results start to roll in, the survey author is then able to use the simple built – in analytic tools within Forms to analyze the results and construct them into reports such as Excel tables. Although there are other surveying tools available (Google Forms, Survey Monkey etc.) Microsoft Forms is the standard for FPG and UCSC as all data is held securely within the university’s Office 365 tenancy. The questionnaire is created following instructions available in the Microsoft Forms web site, and responses are automatically re-directed to the Research Team.

A specific 9 items self-test questionnaire, developed for the specific purpose and never administered before, is administered to the enrolled HCWs and students (Fig 2).

Fig 2. Health care workers and students questionnaire (English version).

Fig 2

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The specific 9 items self-test questionnaire, developed for the specific purpose and never administered before, administered to the enrolled HCWs and students.

The questionnaire was firstly validated through the following procedure

  • A Delphi Method structured on a panel of experts to achieve mutual agreement.

  • The questionnaire was the object of a first validation phase on the first 25 responding subjects and results were analyzed to test its applicability and generalizability.

In addition to demographic information, a list of possible risk factors includes age and sex, Bacillus Calmette–Guérin (BCG) vaccination history, previous work or stay in other countries with high TB rates, known recent (within 6 months) exposure to TB-infected patient, current smoking, co morbidities/ medical history, median QuantiFERON-TB Gold In-Tube level (TB Ag-Nil) if available, occupation, working/ training Unit and years working as HCWs [32]. All positive QFT results on the first determination are repeated to confirm the finding. All conversions of QFTs are collected for the final analysis. No incentives will be offered to complete the survey. A first predictive model for LTBI will be set up through analysis performed by Real World Data GENERATOR.

All HCWs and students enrolled in UNIPA and in University Hospital of Bari will undergo the same methodologies adopted in FPG/UCSC.

Statistical analysis

Descriptive statistics will be performed to characterize responses to the survey. The distribution of the qualitative variables will be shown in percentages, whereas the quantitative variable means, and standard deviations will be used after performing the Shapiro-Wilk test to verify their parametric distribution. Categorical variables will be compared using the Chi-squared test.

Logistic regression analysis will be performed to assess the association between LTBI and possible risk factors including age and sex, Bacillus Calmette–Guérin (BCG) vaccination history, previous work or stay in other countries with high TB rates, known recent (within 6 months) exposure to TB-infected patient, current smoking, co morbidities/ medical history, median QuantiFERON-TB Gold In-Tube level (TB Ag-Nil) if available, occupation, working/ training Unit and years working as HCWs.

The results of the risk-assessment analysis will be stratified according to sex, nationality, TB incidence of the country of birth and BCG vaccination and possible change in the roles of the participants and consequently in the risks of exposure.

Specific data visualization techniques will be used to provide a qualitative representation of the outcomes.

For the purposes of the project, cloud-based applications will be used to collect and store the data coming from the three healthcare centres. Data analytics will be adopted to measure the associations of risk factors with LTBI development. Finally, machine learning techniques will be used to predict the presence of LTBI with respect to health data and identified risk factors.

The final deliverable of the project will be a computerized decision support system able to deliver alerts in the case of LTBI presence.

p-values ≤ 0.05 will be considered statistically significant.

All the statistical analyses will be carried out using R statistical software (R Core Team, 2021).

Ethical considerations and declarations

The authors declare that the procedures will follow the ethical standards of the Declaration of Helsinki and the guidelines of good clinical practice. The Territorial Ethics Committee (CET) Lazio Area 3 has given its approval for the amendment prot. 3 of October 2nd, 2023 (ID: 3528, Prot. N. 0000627/23, December 11th, 2023), relating to the CROSSWORD Study (ID: 3528, Prot. N. 0046362/20, November 16th, 2020).

The authors confirm that all ongoing and related trials for this intervention are registered on ClinicalTrials.gov [NCT05756582].

The document informing participants about the study contains the reasons for completing the questionnaire and the potential benefits arising from analyzing the results. The participants will be informed that participation in the study is completely voluntary and that they can withdraw from the study at any time without negative consequences. The answers to the questionnaires will be treated confidentially and anonymously, and the handling of the data will also be confidential. The members of the Research Team will hand out the consent forms to the participants and will be available to answer any questions they may have about the study. The site PI and Co-PIs had access to information that could identify individual participants during or after data collection.

The status and timeline of the study

The retrospective phase of the project started on November 17, 2021. The final data analysis will be completed by November 2024. The multicenter prospective phase started in September 2024. The estimated primary completion date is June 30, 2026. The estimated study completion date is December 15, 2026. The expected time for publication of results is the last quarter of 2026 (Fig 3).

Fig 3. Chrono program of the Evolution of CROSSWORD Study.

Fig 3

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The Evolution of CROSSWORD study is an ambispective study including a retrospective phase focused on the analysis of data derived from the ongoing CROSSWORD Study, conducted at Fondazione Policlinico Universitario A. Gemelli IRCCS (FPG) and Università Cattolica del Sacro Cuore (UCSC) in Rome, and a prospective phase during which data will be collected from the University of Palermo (UNIPA) and the University of Bari (UNIBA)/ University Hospital of Bari, Italy.

Discussion

This study aims to enrich the primary prevention measures against TB, having a high socio-economic-health impact in high-risk populations (health-care workers and students) through an interoperable digital approach based on data obtained in three large Italian teaching hospitals (Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, University of Palermo, and University Hospital of Bari).

The purpose of conducting LTBI prevention program for HCWs and students is to block the spread of TB by preventing infected persons from progressing to active TB. However, currently available diagnostic tests for LTBI have several limitations, such as variable specificity.

The enrolment of many HCWs and students through an ambispective clinical observation design will provide robust data on the prevalence of LTBI. Furthermore, the study will allow us to identify risk factors associated with the occurrence of LTBI. This data will make it possible to develop an interoperable digital platform integrating the health surveillance systems already in use with other data flows (medical record). Next, prediction models of LTBI, based on the identified risk factors, will be outlined. Finally, the accuracy of the prediction model will be evaluated through a validation phase which will include a new cohort of HCWs and students enrolled in the aforementioned teaching hospitals.

After initiation of the trial, any changes to the protocol that impact the study objectives, study design, subject population, study procedures, or significant management aspects will require a formal protocol amendment. Any changes must be approved by Ethics Committees before implementation. Any deviation from the protocol must be documented and justified by a rationale and be subjected to approval. Any deviation from the protocol will be documented and justified by a rationale and will be subjected to approval. There will be no request for additional consent for the collection and use of data and biological materials from participants in ancillary studies. All complete confidential information relating to the study will be managed by the core Research Team (PI, Co-PI e site PI). Furthermore, the core Research Team will be responsible for the quality of data collection and their confidentiality. Only the team involved in the study will have access to the study documents which will be kept in a secure environment in accordance with ICH-GCP. Patient personal data, which is included in the investigator database, will be processed in accordance with all applicable laws and regulations. To protect patient identity, a unique patient identification code will be assigned to each patient/subject in the study and will be used in place of the patient/subject’s name when the investigator reports any study data. Therefore, this number, rather than the patient/subject’s name, will appear on all documents and will be referenced to the patient/subject’s date of birth.

The researchers intend to communicate the results of the trial to participants, healthcare professionals, and other relevant groups through scientific publications and national and international conference proceedings.

Data Availability

The minimal anonymized data set necessary to replicate study findings is openly available from BioStudies, S-BSST1682 (https://www.ebi.ac.uk/biostudies/studies/S-BSST1682. DOI: 10.6019/S-BSST1682).

Funding Statement

This research was co-funded by the Italian Complementary National Plan PNC-I.1 "Research initiatives for innovative technologies and pathways in the health and welfare sector” D.D. 931 of 06/06/2022, "DARE - DigitAl lifelong pRevEntion" initiative, code PNC0000002. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Nicola Serra

29 Sep 2024

PONE-D-24-34897Protocol the Evolution of CROSSWORD Study: Implementing an interoperable web-based platform to support health surveillance against latent tuberculosis infection in health care workers and students to define prevention strategies and interventionsPLOS ONE

Dear Dr. Inchingolo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

ACADEMIC EDITOR:

Dear Authors, 

  the manuscript is interesting, but it needs some changes. Both reviewers suggested some changes to be made that I think are appropriate. Finally, I suggest providing more details in the sample size section, describing how the percentages were identified, and the sample size formula used.

Best regards,

Nicola, Serra

==============================

Please submit your revised manuscript by Nov 13 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Nicola Serra

Academic Editor

PLOS ONE

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[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The protocol titled "Protocol the Evolution of CROSSWORD Study: Implementing an interoperable web-based platform to support health surveillance against latent tuberculosis infection in healthcare workers and students to define prevention strategies and interventions" is well-structured and addresses a crucial area in tuberculosis (TB) prevention. This study has the potential to make a significant impact on the development of TB preventive strategies in low-TB-burden countries, especially for healthcare workers (HCWs) and students. However, some aspects need clarification and further elaboration:

1. Methods for LTBI Detection Tests:

o The manuscript did not clearly define the methods for latent tuberculosis infection (LTBI) detection tests. Both Interferon-Gamma Release Assay (IGRA) and Tuberculin Skin Test (TST) were mentioned in determining the primary endpoint. It is essential to specify whether the IGRA or TST will be used. Since the study involves the conversion of TST, multiple tests are assumed to be done. Information on how often follow-up testing will occur is needed to provide a comprehensive understanding of the testing process.

2. Interaction with the Developed Web-Based Framework:

o The article mentions the development of a web-based interactive platform but does not elaborate on how this framework will engage in the prediction and detection of LTBI. It would be helpful to describe how the platform will interact with collected data, monitor participants, or offer decision support for LTBI prediction.

3. Rationale for the Estimated Prevalence:

o The protocol estimates an LTBI prevalence of 1% in the participating institutes. However, the rationale behind this estimate is not sufficiently explained. Is it derived from the ongoing CROSSWORD study? Clarifying how this estimate was derived, considering factors such as the previous prevalence rates in similar settings or literature, would strengthen the study's methodology.

4. Consideration of Changes in Participants’ Roles Over Time:

o Since the study involves a potentially prolonged follow-up period, there is a high likelihood that participants’ roles and exposure risks may change (e.g., from students to practicing HCWs). This factor should be taken into account when identifying risk factors and analyzing LTBI risk. Clarifying how these changes will be tracked and integrated into the analysis is crucial for ensuring accurate risk assessment.

Overall Recommendations:

• The study protocol is valuable and has the potential to contribute significantly to TB prevention efforts. Addressing these points will enhance the clarity and comprehensiveness of the study. The authors are encouraged to provide detailed explanations regarding the LTBI detection protocols, web-based framework interaction, rationale for prevalence estimation, and adjustments for role changes during the study follow-up.

Reviewer #2: The authors describe the protocol of a longitudinal study (retrospective and prospective), aimed at providing a large amount of data on the incidence and prevalence of latent tuberculosis infection, on the incidence of tuberculosis and on the results of screening tests among health workers and students enrolled in 3 university hospitals in Central and Southern Italy. The objective would be achieved through the digital registration of some selected variables reported in a self-administered questionnaire. The objective is ambitious and the study protocol could validly contribute to scientific progress on a pathology present throughout the world, slightly increasing after the pandemic and with a significant socioeconomic burden even in low-incidence countries, such as Italy. Moreover, university students, an undestudied population strata, are included.

However, I think that the submitted description of the protocol should be enriched with details and few methodological aspects should be further clarify. I recommend substantial revisions that take into account the considerations reported below.

First of all, it's necessary to know how many employees and students are in the 3 hospitals considered, this to have information on the feasibility of reaching the sample size in the expected period. It might be useful to know how many people are divided into different age groups, how many students, whether only medical courses or other types of courses, such as engineering, are included, how many men and how many women. It might also be useful to know what is the incidence of tuberculosis in the reference population of the 3 hospitals considered and what is the estimated incidence of active or latent tuberculosis in previous periods among the healthcare workers and students. As regards the feasibility, add information on the progress of the Crossword study, which represents the retrospective phase of the study protocol. Moreover, it's necessary to provide more details on which aspects of the Periskope-TB study were captured in the described protocol, to better support the choice of selected variables.

The DARE project is mentioned but its contribution to this protocol is unclear. More information on the Dare study (blibliographic citation, if available) could clarify how the predictive algorithms adopted in this protocol were digitized and created.

It's necessary to stratify the sample size calculation by workers and students, sex and age groups, considering that the enrolled population includes workers and students probably in a wide age range.

Since workers and students are subjected to annual health surveillance, it is not clear whether they will answer only once or multiple times (and how many?) to the proposed questionnaire.

Authors should consider adding to the exclusion criteria, having had tuberculosis or having already undergone chemoprophylaxis .

About the primary outcomes, consider to add a symptom questionnaire. It should also be clarified how to consider the possible movement between working units.

Among the secondary outcomes, it would be better to add a definition of exposure to TB-infected patients, to avoid different descriptions

I would like the authors to explain the reasons why they collect health information through a self-administered questionnaire and not through medical records, which would avoid recall bias and inaccuracies. For question 4 I would put an indicative time (1 month or 3 months of stay).

Consider to add a table or a figure to list the recorded variables . Line 243: it's not clear if the items listed will be recorded.

Furthermore, authors should reread the text to make the English grammar more fluent. Few typos should be corrected: uniform the acronym TB or TBC, replace the word tuberculosis with the somewhat long acronym in the text; add title and description of figure 2 and 3.

I would encourage the authors to consider making the dataset public, possibly removing variables that could identify the respondent (e.g. department, course of study, etc.).

Authors should check bibliography according to the journal's instructions, in particular citations 1, 5, 6, 7, 9, 19, 20.

**********

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Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2025 Mar 25;20(3):e0319568. doi: 10.1371/journal.pone.0319568.r003

Author response to Decision Letter 0

18 Oct 2024

October, 10th 2024

To Editor and Reviewers

PLOS ONE

We would like to greatly thank the Editor and Reviewers who encouraged a revision of the manuscript.

Please find enclosed the revised version (vers. 2) of the Study Protocol article entitled “Protocol the Evolution of CROSSWORD Study: Implementing an interoperable web-based platform to support health surveillance against latent tuberculosis infection in health care workers and students to define prevention strategies and interventions” by Angela Rizzi, Eleonora Nucera, Walter Mazzucco, Pierpaolo Palumbo, Domenico Staiti, Umberto Moscato, Francesco Maria De Simone, Michela Sali, Luca Boldrini, Nikola Dino Capocchiano, Stefano Patarnello, Gabriele Rumi, Raffaella Chini, Valentina Carusi, Michele Centrone, Alessia Di Rienzo, David Longhino, Chiara Laface, Sabato Mellone, Carmelo Massimo Maida, Emanuele Cannizzaro, Luigi Cirrincione, Maria Gabriella Verso, Annalisa Saracino, Francesco Di Gennaro, Luigi Vimercati, Luigi De Maria, Stefania Sponselli, Giancarlo Scoppettuolo, Roberta Pastorino, Antonio Gasbarrini and Riccardo Inchingolo.

PONE-D-24-34897

Protocol the Evolution of CROSSWORD Study: Implementing an interoperable web-based platform to support health surveillance against latent tuberculosis infection in health care workers and students to define prevention strategies and interventions

PLOS ONE

ACADEMIC EDITOR:

Dear Authors,

the manuscript is interesting, but it needs some changes. Both reviewers suggested some changes to be made that I think are appropriate. Finally, I suggest providing more details in the sample size section, describing how the percentages were identified, and the sample size formula used.

We thank the Academic Editor for the comment. We reviewed and reported the formula adopted for the sample size based on both the first and the second outcomes. We modified the manuscript accordingly. Lines: 222-240.

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

We thank for the comment. The manuscript was modified accordingly.

2. We note that you have selected “Clinical Trial” as your article type. PLOS ONE requires that all clinical trials are registered in an appropriate registry. Please state the name of the registry and the registration number (e.g. ISRCTN or ClinicalTrials.gov) in the submission data and on the title page of your manuscript.

We thank for the comment. The manuscript was modified accordingly. Lines: 89-90 and 348-349.

a) Please provide the complete date range for participant recruitment and follow-up in the methods section of your manuscript.

We thank for the comment. The manuscript was modified accordingly. Lines: 361-364.

b) If you have not yet registered your trial in an appropriate registry, we now require you to do so and will need confirmation of the trial registry number before we can pass your paper to the next stage of review. Please include in the Methods section of your paper your reasons for not registering this study before enrolment of participants started. Please confirm that all related trials are registered by stating: “The authors confirm that all ongoing and related trials for this drug/intervention are registered”.

We thank for the comment. The trial was registered on ClinicalTrial.gov before submission of the first version of the manuscript. We added dedicated sentence in the section “Ethical Considerations and declarations”. Lines: 348-349.

3. Thank you for stating the following financial disclosure:

“This research was co-funded by the Italian Complementary National Plan PNC-I.1 "Research initiatives for innovative technologies and pathways in the health and welfare sector” D.D. 931 of 06/06/2022, "DARE - DigitAl lifelong pRevEntion" initiative, code PNC0000002.”

Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

We thank for the comment. We added dedicated sentence in the section “Funding”. Lines: 65-66.

4. We note that you have indicated that there are restrictions to data sharing for this study. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

Before we proceed with your manuscript, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see

https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible.

We will update your Data Availability statement on your behalf to reflect the information you provide.

We thank for the comment. The minimal anonymized data set necessary to replicate study findings is openly available from BioStudies, S-BSST1682 (https://www.ebi.ac.uk/biostudies/studies/S-BSST1682. DOI: 10.6019/S-BSST1682). Lines: 72-73.

5. Please include a caption for figures 2 and 3.

We thank for the comment. We left the first figure as a graphical abstract, if possible, according to editorial guidelines, and added captions for the other 2 figures. Lines: 412-420.

6. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

We thank for the comment. The manuscript was modified accordingly. Lines: 409-420.

Reviewers' comments:

Reviewer #1: The protocol titled "Protocol the Evolution of CROSSWORD Study: Implementing an interoperable web-based platform to support health surveillance against latent tuberculosis infection in healthcare workers and students to define prevention strategies and interventions" is well-structured and addresses a crucial area in tuberculosis (TB) prevention. This study has the potential to make a significant impact on the development of TB preventive strategies in low-TB-burden countries, especially for healthcare workers (HCWs) and students. However, some aspects need clarification and further elaboration:

1. Methods for LTBI Detection Tests:

The manuscript did not clearly define the methods for latent tuberculosis infection (LTBI) detection tests. Both Interferon-Gamma Release Assay (IGRA) and Tuberculin Skin Test (TST) were mentioned in determining the primary endpoint. It is essential to specify whether the IGRA or TST will be used. Since the study involves the conversion of TST, multiple tests are assumed to be done. Information on how often follow-up testing will occur is needed to provide a comprehensive understanding of the testing process.

We thank the Reviewer for the comment. The diagnosis of LTBI requires both conversion to tuberculin after a documented negative tuberculin skin test (TST) at baseline and subsequent positive QuantiFERON-TB Gold test result performed on the same day as the positive TST result. The manuscript was modified accordingly. Lines: 256-262.

2. Interaction with the Developed Web-Based Framework:

The article mentions the development of a web-based interactive platform but does not elaborate on how this framework will engage in the prediction and detection of LTBI. It would be helpful to describe how the platform will interact with collected data, monitor participants, or offer decision support for LTBI prediction.

We thank the Reviewer for the comment. We modified the section “Statistical Analysis” describing the enabling technologies that the research team is adopting for the purposes of the project and mentioning the web-based platform that will be developed as final deliverable of the project. Lines: 332-337.

3. Rationale for the Estimated Prevalence:

The protocol estimates an LTBI prevalence of 1% in the participating institutes. However, the rationale behind this estimate is not sufficiently explained. Is it derived from the ongoing CROSSWORD study? Clarifying how this estimate was derived, considering factors such as the previous prevalence rates in similar settings or literature, would strengthen the study's methodology.

We thank the Reviewer for the comment. The assumed prevalence of LTBI of 1% was based on both the prevalence rate of LTBI (0.62%) among healthcare students and postgraduates described by Verso et al. [Ref. 26] and a reasonable estimate derived from the LTBI prevalence (2.1%) described by Coppeta et al. [Ref. 29] in a population of Italian HCWs in Rome. The manuscript was modified accordingly. Lines: 222-226.

4. Consideration of Changes in Participants’ Roles Over Time:

Since the study involves a potentially prolonged follow-up period, there is a high likelihood that participants’ roles and exposure risks may change (e.g., from students to practicing HCWs). This factor should be taken into account when identifying risk factors and analysing LTBI risk. Clarifying how these changes will be tracked and integrated into the analysis is crucial for ensuring accurate risk assessment.

We thank the Reviewer for the comment. The section “Statistical Analysis” was modified accordingly. Lines: 328-330.

Overall Recommendations:

The study protocol is valuable and has the potential to contribute significantly to TB prevention efforts. Addressing these points will enhance the clarity and comprehensiveness of the study. The authors are encouraged to provide detailed explanations regarding the LTBI detection protocols, web-based framework interaction, rationale for prevalence estimation, and adjustments for role changes during the study follow-up.

We thank the Reviewer for the comment. The manuscript was modified accordingly.

Reviewer #2: The authors describe the protocol of a longitudinal study (retrospective and prospective), aimed at providing a large amount of data on the incidence and prevalence of latent tuberculosis infection, on the incidence of tuberculosis and on the results of screening tests among health workers and students enrolled in 3 university hospitals in Central and Southern Italy. The objective would be achieved through the digital registration of some selected variables reported in a self-administered questionnaire. The objective is ambitious, and the study protocol could validly contribute to scientific progress on a pathology present throughout the world, slightly increasing after the pandemic and with a significant socioeconomic burden even in low-incidence countries, such as Italy. Moreover, university students, an understudied population strata, are included.

However, I think that the submitted description of the protocol should be enriched with details and few methodological aspects should be further clarify. I recommend substantial revisions that take into account the considerations reported below.

We thank the Reviewer for the comment.

First of all, it's necessary to know how many employees and students are in the 3 hospitals considered, this to have information on the feasibility of reaching the sample size in the expected period. It might be useful to know how many people are divided into different age groups, how many students, whether only medical courses or other types of courses, such as engineering, are included, how many men and how many women. It might also be useful to know what is the incidence of tuberculosis in the reference population of the 3 hospitals considered and what is the estimated incidence of active or latent tuberculosis in previous periods among the healthcare workers and students. As regards the feasibility, add information on the progress of the Crossword study, which represents the retrospective phase of the study protocol. Moreover, it's necessary to provide more details on which aspects of the Periskope-TB study were captured in the described protocol, to better support the choice of selected variables.

We thank the Reviewer for the comment. We specified the potential involvement of all employees and students attending medical, specialization and health professions degree courses in the 3 university hospital centers involved in the project making it possible to reach the target population. We modified the section “The sample size”. Lines: 222-240.

Regarding the incidence of tuberculosis in the reference population of the 3 hospitals considered, we have published data on prevalence rate of LTBI (0.62%) among healthcare students and postgraduates described by Verso et al. [Ref. 26]. Therefore, we assumed a reasonable estimate derived also from the LTBI prevalence (2.1%) described by Coppeta et al. [Ref. 29] in a population of Italian HCWs in Rome. The manuscript was modified accordingly. Lines: 222-225.

Regarding the retrospective phase of the study, the final data analysis will be completed by November 2024. We added this detail in the manuscript. Lines: 360-361.

Finally, we specified the predictors, reported by Gupta et al. [Ref. 4] in the final version of prognostic model described in PERISKOPE-TB, included in our questionnaire. We modified the manuscript accordingly. Lines: 179-181.

The DARE project is mentioned but its contribution to this protocol is unclear. More information on the Dare study (bibliographic citation, if available) could clarify how the predictive algorithms adopted in this protocol were digitized and created.

We thank the Reviewer for the comment. We added details on DARE Project and reference n° 28. Lines: 200-205.

It's necessary to stratify the sample size calculation by workers and students, sex and age groups, considering that the enrolled population includes workers and students probably in a wide age range.

Since workers and students are subjected to annual health surveillance, it is not clear whether they will answer only once or multiple times (and how many?) to the proposed questionnaire.

We thank the Reviewer for the comment. We reviewed and reported the formula adopted for the sample size based on both the first and the second outcomes. The stratification of sample size calculation in subgroups was not a priori planned due to expected impact on the number of subjects to be enrolled, mining the feasibility of the whole project. Lines: 222-240.

HCWs and students will respond to the questionnaire survey only once. We modified the manuscript accordingly. Lines: 289-290.

Authors should consider adding to the exclusion criteria, having had tuberculosis or having already undergone chemoprophylaxis.

We thank the Reviewer for the comment. We modified the manuscript accordingly. Lines: 248-249.

About the primary outcomes, consider adding a symptom questionnaire. It should also be clarified how to consider the possible movement between working units. Among the secondary outcomes, it would be better to add a definition of exposure to TB-infected patients, to avoid different descriptions.

We thank the Reviewer for the comment, but symptom assessment was not included in the study protocol. The possible movement between working units is considered among the list of possible risk factors. The meaning of exposure to an infected patient was clarified. We modified the manuscript accordingly. Lines: 275-276.

I would like the auth

Attachment

Submitted filename: Response to Reviewers.docx

pone.0319568.s002.docx (26.6KB, docx)

Decision Letter 1

Nicola Serra

5 Jan 2025

PONE-D-24-34897R1Protocol the Evolution of CROSSWORD Study: Implementing an interoperable web-based platform to support health surveillance against latent tuberculosis infection in health care workers and students to define prevention strategies and interventionsPLOS ONE

Dear Dr. Inchingolo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================Dear Authors, your manuscript has been greatly improved and both reviewers agree on minor revisions. Please submit the revision by the deadline and also provide a general check of the English language. Best regards==============================

Please submit your revised manuscript by Feb 19 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Nicola Serra

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #3: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: No

Reviewer #3: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1. The author described the primary outcome as prevalence of LTBI. The LTBI was defined as positive TST plus positive QuantiFERON for participants with a baseline negative TST. Will participants with a baseline positive TST be excluded from the cohort? Base one such definition, the primary outcome seems to be the incidence of TB infection instead of prevalence of TB infection.

2. How many TST tests will be done for each participant? When will a follow-up TST test be done for a participant?

Reviewer #3: Management of latent tuberculosis infection (LTBI) is a key component of any TB elimination strategy, as people with LTBI represent a large "human reservoir" for the disease. In these purposes the European Centre for Disease Prevention and Control (ECDC), provides evidence-based guidance for the implementation of public health programmes for the management of LTBI in the European Union (EU) and the European Economic Area (EEA), which includes, beyond the prevalence of the LBT, the identification of risk groups. In this context, the present article fits well.

The authors made most of the changes requested by the reviewer 2; in the references the 7 must be corrected.

In addition, if possible, choose for pubblication a title more impactful, which is currently too long.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #3: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

PLoS One. 2025 Mar 25;20(3):e0319568. doi: 10.1371/journal.pone.0319568.r005

Author response to Decision Letter 1

15 Jan 2025

January, 15th 2025

To Editor and Reviewers

PLOS ONE

We would like to greatly thank the Editor and Reviewers who encouraged a further revision of the manuscript.

Please find enclosed the revised version (vers. 3) of the Study Protocol article entitled “Protocol the Evolution of CROSSWORD Study: Implementing an interoperable web-based platform to support health surveillance against latent tuberculosis infection in health care workers and students to define prevention strategies and interventions” by Angela Rizzi, Eleonora Nucera, Walter Mazzucco, Pierpaolo Palumbo, Domenico Staiti, Umberto Moscato, Francesco Maria De Simone, Michela Sali, Luca Boldrini, Nikola Dino Capocchiano, Stefano Patarnello, Gabriele Rumi, Raffaella Chini, Valentina Carusi, Michele Centrone, Alessia Di Rienzo, David Longhino, Chiara Laface, Sabato Mellone, Carmelo Massimo Maida, Emanuele Cannizzaro, Luigi Cirrincione, Maria Gabriella Verso, Annalisa Saracino, Francesco Di Gennaro, Luigi Vimercati, Luigi De Maria, Stefania Sponselli, Giancarlo Scoppettuolo, Roberta Pastorino, Antonio Gasbarrini and Riccardo Inchingolo.

PONE-D-24-34897

Protocol the Evolution of CROSSWORD Study: Implementing an interoperable web-based platform to support health surveillance against latent tuberculosis infection in health care workers and students to define prevention strategies and interventions

PLOS ONE

ACADEMIC EDITOR:

Dear Authors,

your manuscript has been greatly improved, and both reviewers agree on minor revisions. Please submit the revision by the deadline and provide a general check of the English language.

We thank the Academic Editor for the comment. We modified the manuscript accordingly.

Reviewers' comments:

Reviewer #1: The author described the primary outcome as prevalence of LTBI. The LTBI was defined as positive TST plus positive QuantiFERON for participants with a baseline negative TST. Will participants with a baseline positive TST be excluded from the cohort? Base one such definition, the primary outcome seems to be the incidence of TB infection instead of prevalence of TB infection.

2. How many TST tests will be done for each participant? When will a follow-up TST test be done for a participant?

We thank the Reviewer for the comment. We detailed the definition of the primary outcome including both the evidence of positive results of TST at enrollment and tuberculin conversion defined as negative TST before enrollment and positive at enrollment. All criteria are verified at enrollment due to cross-sectional nature of the study protocol. Furthermore, we added the exclusion criterion of positive TST performed within 12 months prior to enrollment to exclude subjects from the cohort and specified the number of scheduled TST for each subject. Finally, we specified that the study protocol does not provide follow-up for research purposes, however, each participant continues regular annual follow-up as per routine clinical practice. Lines: 249-265.

Reviewer #3: Management of latent tuberculosis infection (LTBI) is a key component of any TB elimination strategy, as people with LTBI represent a large "human reservoir" for the disease. In these purposes the European Centre for Disease Prevention and Control (ECDC), provides evidence-based guidance for the implementation of public health programmes for the management of LTBI in the European Union (EU) and the European Economic Area (EEA), which includes, beyond the prevalence of the LBT, the identification of risk groups. In this context, the present article fits well.

The authors made most of the changes requested by the reviewer 2; in the references the 7 must be corrected. In addition, if possible, choose for publication a title more impactful, which is currently too long.

We thank the Reviewer for the comment. We removed reference n°7 from the list due to inability to access. Finally, we modified the title as required. Lines: 4-6.

With the best regards,

Angela Rizzi, Eleonora Nucera, Walter Mazzucco, Pierpaolo Palumbo, Domenico Staiti, Umberto Moscato, Francesco Maria De Simone, Michela Sali, Luca Boldrini, Nikola Dino Capocchiano, Stefano Patarnello, Gabriele Rumi, Raffaella Chini, Valentina Carusi, Michele Centrone, Alessia Di Rienzo, David Longhino, Chiara Laface, Sabato Mellone, Carmelo Massimo Maida, Emanuele Cannizzaro, Luigi Cirrincione, Maria Gabriella Verso, Annalisa Saracino, Francesco Di Gennaro, Luigi Vimercati, Luigi De Maria, Stefania Sponselli, Giancarlo Scoppettuolo, Roberta Pastorino, Antonio Gasbarrini and Riccardo Inchingolo.

Corresponding Author:

Riccardo Inchingolo, MD, PhD

UOC Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS. Largo A. Gemelli, 8 – 00168 – Rome, Italy.

riccardo.inchingolo@policlinicogemelli.it

Corresponding Author will receive all editorial communications

The authors declare that the manuscript, or specified parts of it, have not been and will not be submitted elsewhere for publication.

Attachment

Submitted filename: Response_to_Reviewers_auresp_2.docx

pone.0319568.s003.docx (16.6KB, docx)

Decision Letter 2

Nicola Serra

28 Jan 2025

PONE-D-24-34897R2An interoperable web-based platform to support health surveillance against latent tuberculosis infection in health care workers and students: the Evolution of CROSSWORD Study ProtocolPLOS ONE

Dear Dr. Inchingolo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

ACADEMIC EDITOR:  Dear Authors,Please consider an important final suggestion from Reviewer 1 regarding the timing of the QuantiFERON-TB Gold (QFT) test. Best regards, Nicola Serra

==============================

Please submit your revised manuscript by Mar 14 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Nicola Serra

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #3: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #3: Partly

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The author addressed my concern. One minor suggestion:

I appreciate the comprehensive definition of LTBI used in the study; however, I would like to suggest a minor revision regarding the timing of the QuantiFERON-TB Gold (QFT) test. The current definition requires the QFT test to be performed on the same day as the positive TST result. In clinical practice, logistical challenges such as laboratory processing delays, sample collection issues, or the need for repeat blood draws may prevent same-day testing. This strict requirement could lead to unnecessary exclusions due to protocol deviations, even in cases where the QFT result is positive within a reasonable timeframe. To improve the feasibility of the study without compromising diagnostic accuracy, I recommend allowing a reasonable time window for QFT testing rather than requiring it strictly on the same day. This adjustment would better align with real-world clinical workflows and help avoid potential difficulties in data interpretation and patient classification.

Reviewer #3: The authors made the changes required and now I belive that the articol can be accepted.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #3: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

PLoS One. 2025 Mar 25;20(3):e0319568. doi: 10.1371/journal.pone.0319568.r007

Author response to Decision Letter 2

1 Feb 2025

February, 1st 2025

To Editor and Reviewers

PLOS ONE

We would like to greatly thank the Editor and Reviewers who encouraged a further revision of the manuscript.

Please find enclosed the revised version (vers. 4) of the Study Protocol article entitled “An interoperable web-based platform to support health surveillance against latent tuberculosis infection in health care workers and students: the Evolution of CROSSWORD Study Protocol” by Angela Rizzi, Eleonora Nucera, Walter Mazzucco, Pierpaolo Palumbo, Domenico Staiti, Umberto Moscato, Francesco Maria De Simone, Michela Sali, Luca Boldrini, Nikola Dino Capocchiano, Stefano Patarnello, Gabriele Rumi, Raffaella Chini, Valentina Carusi, Michele Centrone, Alessia Di Rienzo, David Longhino, Chiara Laface, Sabato Mellone, Carmelo Massimo Maida, Emanuele Cannizzaro, Luigi Cirrincione, Maria Gabriella Verso, Annalisa Saracino, Francesco Di Gennaro, Luigi Vimercati, Luigi De Maria, Stefania Sponselli, Giancarlo Scoppettuolo, Roberta Pastorino, Antonio Gasbarrini and Riccardo Inchingolo.

PONE-D-24-34897R2

An interoperable web-based platform to support health surveillance against latent tuberculosis infection in health care workers and students: the Evolution of CROSSWORD Study Protocol

PLOS ONE

ACADEMIC EDITOR:

Dear Authors,

Please consider an important final suggestion from Reviewer 1 regarding the timing of the QuantiFERON-TB Gold (QFT) test.

We thank the Academic Editor for the comment. We modified the manuscript accordingly.

Reviewers' comments:

Reviewer #1: The author addressed my concern. One minor suggestion:

I appreciate the comprehensive definition of LTBI used in the study; however, I would like to suggest a minor revision regarding the timing of the QuantiFERON-TB Gold (QFT) test. The current definition requires the QFT test to be performed on the same day as the positive TST result. In clinical practice, logistical challenges such as laboratory processing delays, sample collection issues, or the need for repeat blood draws may prevent same-day testing. This strict requirement could lead to unnecessary exclusions due to protocol deviations, even in cases where the QFT result is positive within a reasonable timeframe. To improve the feasibility of the study without compromising diagnostic accuracy, I recommend allowing a reasonable time window for QFT testing rather than requiring it strictly on the same day. This adjustment would better align with real-world clinical workflows and help avoid potential difficulties in data interpretation and patient classification.

We thank the Reviewer for the comment. To improve the feasibility of the study without compromising diagnostic accuracy, we introduced a reasonable time window of 5days for QFT testing. We modified accordingly. Lines: 257-258.

Reviewer #3: The authors made the changes required and now I believe that the article can be accepted.

We thank the Reviewer for the comment.

With the best regards,

Angela Rizzi, Eleonora Nucera, Walter Mazzucco, Pierpaolo Palumbo, Domenico Staiti, Umberto Moscato, Francesco Maria De Simone, Michela Sali, Luca Boldrini, Nikola Dino Capocchiano, Stefano Patarnello, Gabriele Rumi, Raffaella Chini, Valentina Carusi, Michele Centrone, Alessia Di Rienzo, David Longhino, Chiara Laface, Sabato Mellone, Carmelo Massimo Maida, Emanuele Cannizzaro, Luigi Cirrincione, Maria Gabriella Verso, Annalisa Saracino, Francesco Di Gennaro, Luigi Vimercati, Luigi De Maria, Stefania Sponselli, Giancarlo Scoppettuolo, Roberta Pastorino, Antonio Gasbarrini and Riccardo Inchingolo.

Corresponding Author:

Riccardo Inchingolo, MD, PhD

UOC Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS. Largo A. Gemelli, 8 – 00168 – Rome, Italy.

riccardo.inchingolo@policlinicogemelli.it

Corresponding Author will receive all editorial communications

The authors declare that the manuscript, or specified parts of it, have not been and will not be submitted elsewhere for publication.

Attachment

Submitted filename: Response_to_Reviewers_auresp_3.docx

pone.0319568.s004.docx (16.4KB, docx)

Decision Letter 3

Nicola Serra

5 Feb 2025

An interoperable web-based platform to support health surveillance against latent tuberculosis infection in health care workers and students: the Evolution of CROSSWORD Study Protocol

PONE-D-24-34897R3

Dear Dr. Inchingolo,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Nicola Serra

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Authors,

Congratulations for the great work done. Your article is now ready for publication

Best regards.

Nicola Serra

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thanks to the authors for the revision. I have no further comments. I recommend accept the paper as current version.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

**********

Acceptance letter

Nicola Serra

PONE-D-24-34897R3

PLOS ONE

Dear Dr. Inchingolo,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

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Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0319568.s002.docx (26.6KB, docx)
    Attachment

    Submitted filename: Response_to_Reviewers_auresp_2.docx

    pone.0319568.s003.docx (16.6KB, docx)
    Attachment

    Submitted filename: Response_to_Reviewers_auresp_3.docx

    pone.0319568.s004.docx (16.4KB, docx)

    Data Availability Statement

    The minimal anonymized data set necessary to replicate study findings is openly available from BioStudies, S-BSST1682 (https://www.ebi.ac.uk/biostudies/studies/S-BSST1682. DOI: 10.6019/S-BSST1682).

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