Pediatric and adolescent tuberculosis in the United States, 2008-2010

Tuberculosis in pediatric oncology and bone marrow transplantation patients

Five children with malignancies (3 hematologic, 1 medulloblastoma, 1 hepatoblastoma) and one bone marrow transplant patient were treated for tuberculosis over a 30-year period. Three had pulmonary disease, 3 disseminated tuberculosis, and 1 had scrofula. Four of five had positive tuberculin skin tests, cultures were positive in 5/6 children. One child died of disseminated TB after engraftment, and one child had hepatotoxicity likely related to tuberculosis therapy. All cases were potentially preventable had they been screened due to established risk factors of foreign birth (4/6) or parental foreign birth (2/6). All children should be screened for latent tuberculosis before chemotherapy.

Tuberculosis exposure, infection and disease among children with medical comorbidities

Sixty-nine children with medical comorbidities were treated for tuberculosis (TB) exposure (7), infection (40) or disease (22). The most common comorbidities in children with TB disease were malignancy (23%), cyanotic heart disease (18%), hemoglobinopathies (18%) and autoimmune disease (14%). Ninety-six percent who received TB medications had no adverse events and 98% completed therapy. Two (9%) died of TB.

Epidemiology and disease burden of tuberculosis in children: a global perspective

Our understanding of the tuberculosis (TB) epidemic in children is incomplete due to challenges in diagnosis and reporting. Children have also been largely excluded from research and advocacy. However, the tide appears to be turning and interest in pediatric TB is increasing. In this article, we explore the epidemiology of childhood TB by first reviewing the natural history of TB in children and the factors that impact on each of the stages from exposure to disease. We then discuss how these factors affect what we see at a country and regional level. Finally, we assess the burden of childhood TB globally.

The epidemiology of childhood tuberculosis in the Netherlands: still room for prevention

Background

The occurrence of tuberculosis (TB) among children has long been neglected as a public health concern. However, any child with TB is a sentinel event indicating recent transmission. Vaccination, early case finding and treatment of those latently infected with TB can prevent cases, severe morbidity and unnecessary death.

Method

The objective of the study was to describe the occurrence of TB events among children in the Netherlands which may be avoided through preventive measures. For this purpose we performed a trend analysis of routine Dutch TB and LTBI (surveillance data in 1993–2012 and a descriptive analysis of children with TB and with LTBI diagnosed in 2005–2012).

Results

Overall childhood TB incidence has declined over the last two decades from 3.6 in 1993 to 1.9 per 100,000 children in 2012. The decline was stronger among Dutch-born children compared to foreign-born children. In 2005–2012 64% of childhood TB cases were detected through active case finding. Foreign-born children with TB were less likely to be detected through active case finding, when not detected through post-entry TB screening. Childhood TB diagnosis was culture confirmed in 68% of passively detected cases and 12% of actively detected cases. Of 1,049 children with LTBI started on preventive treatment in 2005–2012, 90% completed treatment. In 37% of all childhood TB cases there was at least one ‘missed opportunity’ for prevention. Thirty nine percent of child TB patients eligible for BCG were not vaccinated.

Conclusion

Children with TB in the Netherlands are generally detected at an early stage and treatment completion rates are high. However, more TB cases among children can be prevented through enhancing TB case finding and screening and preventive treatment of latent TB infection among migrant children, and improving the coverage of BCG vaccination among eligible risk groups.

Epidemiology of childhood tuberculosis in Switzerland between 1996 and 2011

Approximately 9 million cases of tuberculosis (TB) are reported annually and half a million occur in children <15 years of age. Globally, TB notifications in children have been neglected for decades although childhood TB may represent a sentinel for ongoing transmission. Data included in this study were collected from the TB database of the Swiss Federal Office of Public Health, which includes culture-confirmed TB and/or cases treated with ≥3 anti-mycobacterial drugs. Data from all children <15 years of age reported between 1996 and 2011 were analyzed. A total of 320 cases of TB (166 cultures confirmed, 5 confirmed by nucleic acid amplification, 149 other than definite cases) were reported with an overall incidence rate of 1.6 per 100,000 children (range 1.2-2.2). A total of 154 (48 %) children were younger than 5 years of age and 141 (44 %) were born in Switzerland. Children below 5 years of age were more likely to be Swiss-born compared to children aged 10 to 14 years (74 % versus 26 %). When analyzing the country of origin, only 55 children (17 %) were of Swiss origin. Of all children with foreign origin, 117 (47 %) were from a country within the WHO European Region. In 288 (90 %) of all notified cases, the site of disease was the lung. Mycobacterial culture was positive in 166 cases (51.9 %) with 1.8 % multi-drug-resistance. The overall incidence of childhood TB disease reported in Switzerland remained stable over a 16-year period with a remarkable high rate of very young patients of foreign origin. Only half of the reported cases were culture confirmed, highlighting the need for better diagnostic tests in childhood TB.

Epidemiology of tuberculosis in young children in the United States

OBJECTIVES

To estimate tuberculosis (TB) rates among young children in the United States by children's and parents' birth origins and describe the epidemiology of TB among young children who are foreign-born or have at least 1 foreign-born parent.

METHODS

Study subjects were children <5 years old diagnosed with TB in 20 US jurisdictions during 2005-2006. TB rates were calculated from jurisdictions' TB case counts and American Community Survey population estimates. An observational study collected demographics, immigration and travel histories, and clinical and source case details from parental interviews and health department and TB surveillance records.

RESULTS

Compared with TB rates among US-born children with US-born parents, rates were 32 times higher in foreign-born children and 6 times higher in US-born children with foreign-born parents. Most TB cases (53%) were among the 29% of children who were US born with foreign-born parents. In the observational study, US-born children with foreign-born parents were more likely than foreign-born children to be infants (30% vs. 7%), Hispanic (73% vs. 37%), diagnosed through contact tracing (40% vs. 7%), and have an identified source case (61% vs. 19%); two-thirds of children were exposed in the United States.

CONCLUSIONS

Young children who are US born of foreign-born parents have relatively high rates of TB and account for most cases in this age group. Prompt diagnosis and treatment of adult source cases, effective contact investigations prioritizing young contacts, and targeted testing and treatment of latent TB infection are necessary to reduce TB morbidity in this population.

Old and new approaches to diagnosing and treating latent tuberculosis in children in low-incidence countries

PURPOSE OF REVIEW

The primary purpose is to review guidance on the testing and treatment of latent tuberculosis infection (LTBI) in children. Most children and adults with LTBI have positive tuberculin skin test (TST) or interferon gamma release assay (IGRA) results, normal examinations, and normal chest radiographs. Diagnosis of and treatment completion for LTBI are critical to diminish future cases of tuberculosis (TB) disease.

RECENT FINDINGS

Children should be screened for TB risk factors, and only children with risk factors should be tested with either a TST or an IGRA. IGRAs measure interferon gamma production by lymphocytes after they are stimulated ex vivo by antigens that are primarily Mycobacterium tuberculosis-specific. The foundation of LTBI therapy in the United States has been 9 months of daily isoniazid, but shorter treatment regimens now exist, including a 12-dose regimen of weekly isoniazid and rifapentine. These shorter regimens are associated with higher completion rates.

SUMMARY

There are two distinct modalities for LTBI diagnosis and several treatment regimens that can prevent TB disease in infected children. The selection of treatment regimen should take several factors into consideration, including adherence, drug susceptibility results of the presumed source case (if known), safety, cost, and patient preference.

Tuberculosis in children

Tuberculosis (TB) in children is a neglected aspect of the TB epidemic despite it constituting 20% or more of all TB cases in many countries with high TB incidence. Childhood TB is a direct consequence of adult TB but remains overshadowed by adult TB because it is usually smear-negative. Infants and young children are more likely to develop life-threatening forms of TB than older children and adults due to their immature immune systems. Therefore, prompt diagnoses are extremely important although difficult since clinical and radiological signs of TB can be non-specific and variable in children. Despite undeniable advances in identifying definite, probable, or possible TB markers, pediatricians still face many problems when diagnosing TB diagnosis. Moreover, curing TB can be difficult when treatment is delayed and when multi-drug resistant (MDR) pathogens are the cause of the disease. In these cases, the prognosis in children is particularly poor because MDR-TB treatment and treatment duration remain unclear. New studies of diagnostic tests and optimal treatment in children are urgently needed with the final goal of developing an effective anti-TB vaccine.

Increasing incidence of tuberculosis in Tuscan youth, 1997 to 2011

Data from 484 children (median age: 6 years; 46.5% immigrants) hospitalized for tuberculosis in 31 Tuscan hospitals in 1997-2011 were analyzed. Incidence increased from 7.3 (95% confidence interval: 4.9-9.4) to 12.5 (95% confidence interval: 9.6-15.4) per 100,000 (P=0.009). Increases were particularly profound in children<5 years of age, reaching 13.3 (95% confidence interval: 7.8-18.9; P<0.0001 for 2011 vs.1997) per 100,000. Pediatric tuberculosis is a major issue in Tuscany.

Pulmonary tuberculosis in severely-malnourished or HIV-infected children with pneumonia: a review

Presentation of pulmonary tuberculosis (PTB) as acute pneumonia in severely-malnourished and HIV-positive children has received very little attention, although this is very important in the management of pneumonia in children living in communities where TB is highly endemic. Our aim was to identify confirmed TB in children with acute pneumonia and HIV infection and/or severe acute malnutrition (SAM) (weight-for-length/height or weight-for-age z score <-3 of the WHO median, or presence of nutritional oedema). We conducted a literature search, using PubMed and Web of Science in April 2013 for the period from January 1974 through April 2013. We included only those studies that reported confirmed TB identified by acid fast bacilli (AFB) through smear microscopy, or by culture-positive specimens from children with acute pneumonia and SAM and/or HIV infection. The specimens were collected either from induced sputum (IS), or gastric lavage (GL), or broncho-alveolar lavage (BAL), or percutaneous lung aspirates (LA). Pneumonia was defined as the radiological evidence of lobar or patchy consolidation and/or clinical evidence of severe/ very severe pneumonia according to the WHO criteria of acute respiratory infection. A total of 17 studies met our search criteria but 6 were relevant for our review. Eleven studies were excluded as those did not assess the HIV status of the children or specify the nutritional status of the children with acute pneumonia and TB. We identified only 747 under-five children from the six relevant studies that determined a tubercular aetiology of acute pneumonia in children with SAM and/or positive HIV status. Three studies were reported from South Africa and one each from the Gambia, Ethiopia, and Thailand where 610, 90, 35, and 12 children were enrolled and 64 (10%), 23 (26%), 5 (14%), and 1 (8%) children were identified with active TB respectively, with a total of 93 (12%) children with active TB. Among 610 HIV-infected children in three studies from South Africa and 137 SAM children from other studies, 64 (10%) and 29 (21%) isolates of M. tuberculosis were identified respectively. Children from South Africa were infected with HIV without specification of their nutritional status whereas children from other countries had SAM but without indication of their HIV status. Our review of the existing data suggests that pulmonary tuberculosis may be more common than it is generally suspected in children with acute pneumonia and SAM, or HIV infection. Because of the scarcity of data, there is an urgent need to investigate PTB as one of the potential aetiologies of acute pneumonia in these children in a carefully-conducted larger study, especially outside Africa.

Adolescents with tuberculosis: a review of 145 cases

BACKGROUND

Adolescents comprise one-third of pediatric tuberculosis (TB) cases in the United States, but there are few specific data on the epidemiology and clinical course in this population.

METHODS

This was a retrospective review of adolescents (12-18 years old) seen at a Children's Tuberculosis Clinic in Houston, TX, from 1987 to 2012.

RESULTS

One hundred forty-five adolescents were identified; median age was 15.4 years: 50% female, 55% were Hispanic, 26% black, 13% Asian and 1% white; 54 were born abroad. Diagnoses were made after symptomatic presentation in 79%, during contact investigations in 14% and after screening tuberculin skin testing in the remainder. The most common symptoms were fever (63%), cough (60%) and weight loss (30%), but 21% were asymptomatic at diagnosis. Only 8% of adolescents with intrathoracic TB had hemoptysis. One hundred fourteen (78.6%) had isolated intrathoracic TB, 4 (2.8%) had intra- and extrathoracic TB and 27 (18.6%) had extrathoracic TB. The most common sites of extrathoracic TB were peripheral lymphadenopathy (10) and meningitis (6). The most common radiographic findings were infiltrates (34%), lymphadenopathy (27%), cavitary lesions (26%), pleural effusions (19%) and miliary disease (10%). Acid-fast bacillus smears and mycobacterial cultures were attempted for 97 of 118 adolescents with intrathoracic and 22 of 27 with extrathoracic disease, respectively, resulting in smear/culture positivity in 25% and 54% and 18% and 45%, respectively. Two patients died, 2 had relapse, 7 had significant sequelae and 92% recovered without complication. Seventy three percent of cases potentially were preventable.

CONCLUSIONS

The clinical, radiologic and microbiologic findings in adolescents with TB have features seen in both younger children and adults; most cases were preventable.