INT J TUBERC LUNG DIS 9(10):1088–1096 © 2005 The Union Development and evaluation of a new chest radiograph reading and recording system for epidemiological surveys of tuberculosis and lung disease S. Den Boon,* †‡ E. D. Bateman, § D. A. Enarson, ¶ M. W. Borgdorff †‡ S. Verver, ‡ C. J. Lombard, # E. Irusen,** N. Beyers,* N. W. White §† *Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa; † Department of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Centre, Amsterdam, ‡ KNCV Tuberculosis Foundation, The Hague, The Netherlands; § Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa; ¶ International Union Against Tuberculosis and Lung Disease, Paris, France; # Biostatistics Unit, Medical Research Council, Cape Town, ** Department of Internal Medicine, SUMMARY Stellenbosch University, Cape Town, South Africa OBJECTIVE: The development and evaluation of a new chest radiograph reading and recording system (CRRS) for community surveys of tuberculosis (TB) and lung disease. DESIGN: An experienced pulmonologist read 2608 chest X-rays (CXRs) performed as part of a TB preva- lence survey using the newly developed CRRS. The kappa () for inter-reader agreement was calculated after a second reader reported on a stratified random sample of 810 (31%) of the 2608 CXRs. The  for intra- reader agreement was calculated from the repeated re- porting of a stratified random sample of 104 CXRs. RESULTS: The  agreement between the two readers was 0.69 (95%CI 0.64–0.74) for abnormalities consis- tent with TB and 0.47 (95%CI 0.42–0.53) for any ab- normalities. The  for intra-reader agreement was 0.90 (95%CI 0.81–0.99) for abnormalities consistent with TB and 0.85 (95%CI 0.74–0.95) for any abnormalities. CONCLUSION: This standardised method for CXR reading and recording provides satisfactory inter- and intra-reader agreement, making it suitable for surveys of TB and other forms of lung disease in the community. Its use will permit comparisons of results obtained in differ- ent surveys. KEY WORDS: tuberculosis; chest radiograph; kappa; dual reading; reproducibility THE INTERPRETATION of chest X-rays (CXRs), because of its subjectivity, is highly dependent on the reader. Inter-observer differences and lack of consis- tency of reporting, 1–3 even by the same reader, has led chest radiography, although widely used as a diagnos- tic tool, to be not well regarded as a tool in tubercu- losis (TB) surveys. Current practice is to minimise the effects of observer error by employing a second or third reader and then seek consensus, 4–11 which is both costly and effort-intensive. For the study of oc- cupational lung disease, the use of radiology for both clinical purposes and research has been greatly im- proved by the use of a standardised reading method- ology utilising reference radiographs, and a system of accreditation for readers. 12,13 We hypothesised that the use of a method similar to that used for occupational lung disease might be of benefit to researchers and even to practitioners evalu- ating and recording CXRs on individual subjects for the purposes of identifying and systematically re- cording abnormalities. By transforming observed pat- terns into categorical and semi-quantitative forms, these may be used for both screening and follow-up of patients. We report here the development and first results obtained using a chest radiograph reading and recording system (CRRS) that employs prin- ciples similar to those used in the International Union Against Cancer and the International Labour Or- ganization (UICC/ILO) and the National Institute for Occupational Safety and Health (NIOSH) 12,13 radiographic reading methods and may be used in conjunction with the UICC/ILO reference radiographs and scoring system for occupational diseases, but Correspondence to: Ms Saskia Den Boon, Department of Paediatrics and Child Health, Faculty of Health Sciences, Des- mond Tutu TB Centre, Stellenbosch University, P O Box 19063, 7505 Tygerberg, Cape Town, South Africa. Tel: (+27) 21 938 9177. Fax: (+27) 21 938 9138. e-mail: 14321823@sun.ac.za Article submitted 7 June 2005. Final version accepted 1 July 2005. † deceased.