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Tameris M, Mearns H, Penn-Nicholson A, Gregg Y, Bilek N, Mabwe S, Geldenhuys H, Shenje J, Luabeya AKK, Murillo I, Doce J, Aguilo N, Marinova D, Puentes E, Rodríguez E, Gonzalo-Asensio J, Fritzell B, Thole J, Martin C, Scriba TJ, Hatherill M. Live-attenuated Mycobacterium tuberculosis vaccine MTBVAC versus BCG in adults and neonates: a randomised controlled, double-blind dose-escalation trial. THE LANCET RESPIRATORY MEDICINE 2019; 7:757-770. [PMID: 31416768 DOI: 10.1016/s2213-2600(19)30251-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Infants are a key target population for new tuberculosis vaccines. We assessed the safety and immunogenicity of the live-attenuated Mycobacterium tuberculosis vaccine candidate MTBVAC in adults and infants in a region where transmission of tuberculosis is very high. METHODS We did a randomised, double-blind, BCG-controlled, dose-escalation trial at the South African Tuberculosis Vaccine Initiative site near Cape Town, South Africa. Healthy adult community volunteers who were aged 18-50 years, had received BCG vaccination as infants, were HIV negative, had negative interferon-γ release assay (IGRA) results, and had no personal history of tuberculosis or current household contact with someone with tuberculosis were enrolled in a safety cohort. Infants born to HIV-negative women with no personal history of tuberculosis or current household contact with a person with tuberculosis and who were 96 h old or younger, generally healthy, and had not yet received routine BCG vaccination were enrolled in a separate infant cohort. Eligible adults were randomly assigned (1:1) to receive either BCG Vaccine SSI (5 × 105 colony forming units [CFU] of Danish strain 1331 in 0·1 mL diluent) or MTBVAC (5 × 105 CFU in 0·1 mL) intradermally in the deltoid region of the arm. After favourable review of 28-day reactogenicity and safety data in the adult cohort, infants were randomly assigned (1:3) to receive either BCG Vaccine SSI (2·5 × 105 CFU in 0·05 mL diluent) or MTBVAC in three sequential cohorts of increasing MTBVAC dose (2·5 × 103 CFU, 2·5 × 104 CFU, and 2·5 × 105 CFU in 0·05 mL) intradermally in the deltoid region of the arm. QuantiFERON-TB Gold In-Tube IGRA was done on days 180 and 360. For both randomisations, a pre-prepared block randomisation schedule was used. Participants (and their parents or guardians in the case of infant participants), investigators, and other clinical and laboratory staff were masked to intervention allocation. The primary outcomes, which were all measured in the infant cohort, were solicited and unsolicited local adverse events and serious adverse events until day 360; non-serious systemic adverse events until day 28 and vaccine-specific CD4 and CD8 T-cell responses on days 7, 28, 70, 180, and 360. Secondary outcomes measured in adults were local injection-site and systemic reactions and haematology and biochemistry at study day 7 and 28. Safety analyses and immunogenicity analyses were done in all participants who received a dose of vaccine. This trial is registered with ClinicalTrials.gov, number NCT02729571. FINDINGS Between Sept 29, 2015, and Nov 16, 2015, 62 adults were screened and 18 were enrolled and randomly assigned, nine each to the BCG and MTBVAC groups. Between Feb 12, 2016, and Sept 21, 2016, 36 infants were randomly assigned-eight to the BCG group, nine to the 2·5 × 103 CFU MTBVAC group, nine to the 2·5 × 104 CFU group, and ten to the 2·5 × 105 CFU group. Mild injection-site reactions occurred only in infants in the BCG and the 2·5 × 105 CFU MTBVAC group, with no evidence of local or regional injection-site complications. Systemic adverse events were evenly distributed across BCG and MTBVAC dose groups, and were mostly mild in severity. Eight serious adverse events were reported in seven vaccine recipients (one adult MTBVAC recipient, one infant BCG recipient, one infant in the 2·5 × 103 CFU MTBVAC group, two in the 2·5 × 104 CFU MTBVAC group, and two in the 2·5 × 105 CFU MTBVAC group), including one infant in the 2·5 × 103 CFU MTBVAC group treated for unconfirmed tuberculosis and one in the 2·5 × 105 CFU MTBVAC group treated for unlikely tuberculosis. One infant died as a result of possible viral pneumonia. Vaccination with all MTBVAC doses induced durable antigen-specific T-helper-1 cytokine-expressing CD4 cell responses in infants that peaked 70 days after vaccination and were detectable 360 days after vaccination. For the highest MTBVAC dose (ie, 2·5 × 105 CFU), these responses exceeded responses induced by an equivalent dose of the BCG vaccine up to 360 days after vaccination. Dose-related IGRA conversion was noted in three (38%) of eight infants in the 2·5 × 103 CFU MTBVAC group, six (75%) of eight in the 2·5 × 104 CFU MTBVAC group, and seven (78%) of nine in the 2·5 × 105 CFU MTBVAC group at day 180, compared with none of seven infants in the BCG group. By day 360, IGRA reversion had occurred in all three infants (100%) in the 2·5 × 103 CFU MTBVAC group, four (67%) of the six in the 2·5 × 104 CFU MTBVAC group, and three (43%) of the seven in the 2·5 × 105 CFU MTBVAC group. INTERPRETATION MTBVAC had acceptable reactogenicity, and induced a durable CD4 cell response in infants. The evidence of immunogenicity supports progression of MTBVAC into larger safety and efficacy trials, but also confounds interpretation of tests for M tuberculosis infection, highlighting the need for stringent endpoint definition. FUNDING Norwegian Agency for Development Cooperation, TuBerculosis Vaccine Initiative, UK Department for International Development, and Biofabri.
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Affiliation(s)
- Michele Tameris
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Helen Mearns
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Adam Penn-Nicholson
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Yolande Gregg
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Nicole Bilek
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Simbarashe Mabwe
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Hennie Geldenhuys
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Justin Shenje
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Angelique Kany Kany Luabeya
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | | | | | - Nacho Aguilo
- Department of Microbiology, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain; CIBERES and Research Network on Respiratory Diseases, Spanish Ministry of Health and Instituto de Salud Carlos III, Madrid, Spain
| | - Dessislava Marinova
- Department of Microbiology, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain; CIBERES and Research Network on Respiratory Diseases, Spanish Ministry of Health and Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Jesús Gonzalo-Asensio
- Department of Microbiology, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain; CIBERES and Research Network on Respiratory Diseases, Spanish Ministry of Health and Instituto de Salud Carlos III, Madrid, Spain
| | | | - Jelle Thole
- Tuberculosis Vaccine Initiative, Lelystad, Netherlands
| | - Carlos Martin
- Department of Microbiology, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain; CIBERES and Research Network on Respiratory Diseases, Spanish Ministry of Health and Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Miguel Servet, ISS Aragon, Zaragoza, Spain
| | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa.
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Wang B, Li M, Ma H, Han F, Wang Y, Zhao S, Liu Z, Yu T, Tian J, Dong D, Peng Y. Computed tomography-based predictive nomogram for differentiating primary progressive pulmonary tuberculosis from community-acquired pneumonia in children. BMC Med Imaging 2019; 19:63. [PMID: 31395012 PMCID: PMC6688341 DOI: 10.1186/s12880-019-0355-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 06/24/2019] [Indexed: 01/16/2023] Open
Abstract
Background To investigate the value of predictive nomogram in optimizing computed tomography (CT)-based differential diagnosis of primary progressive pulmonary tuberculosis (TB) from community-acquired pneumonia (CAP) in children. Methods This retrospective study included 53 patients with clinically confirmed pulmonary TB and 62 patients with CAP. Patients were grouped at random according to a 3:1 ratio (primary cohort n = 86, validation cohort n = 29). A total of 970 radiomic features were extracted from CT images and key features were screened out to build radiomic signatures using the least absolute shrinkage and selection operator algorithm. A predictive nomogram was developed based on the signatures and clinical factors, and its performance was assessed by the receiver operating characteristic curve, calibration curve, and decision curve analysis. Results Initially, 5 and 6 key features were selected to establish a radiomic signature from the pulmonary consolidation region (RS1) and a signature from lymph node region (RS2), respectively. A predictive nomogram was built combining RS1, RS2, and a clinical factor (duration of fever). Its classification performance (AUC = 0.971, 95% confidence interval [CI]: 0.912–1) was better than the senior radiologist’s clinical judgment (AUC = 0.791, 95% CI: 0.636-0.946), the clinical factor (AUC = 0.832, 95% CI: 0.677–0.987), and the combination of RS1 and RS2 (AUC = 0.957, 95% CI: 0.889–1). The calibration curves indicated a good consistency of the nomogram. Decision curve analysis demonstrated that the nomogram was useful in clinical settings. Conclusions A CT-based predictive nomogram was proposed and could be conveniently used to differentiate pulmonary TB from CAP in children. Electronic supplementary material The online version of this article (10.1186/s12880-019-0355-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bei Wang
- Department of Radiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi Road, Beijing, 100045, China
| | - Min Li
- Sino-Dutch Biomedical and Information Engineering School, Northeastern University, No. 3-11 Wenhua Road, Shenyang, China.,CAS Key Laboratory of Molecular Imaging, State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, No.95 Zhongguancun East Road, Beijing, 100190, China
| | - He Ma
- Sino-Dutch Biomedical and Information Engineering School, Northeastern University, No. 3-11 Wenhua Road, Shenyang, China
| | - Fangfang Han
- Sino-Dutch Biomedical and Information Engineering School, Northeastern University, No. 3-11 Wenhua Road, Shenyang, China
| | - Yan Wang
- Department of Radiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi Road, Beijing, 100045, China
| | - Shunying Zhao
- Department of Respiratory Medicine, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No.56 Nanlishi Road, Beijing, 100045, China
| | - Zhimin Liu
- Department of Radiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi Road, Beijing, 100045, China
| | - Tong Yu
- Department of Radiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi Road, Beijing, 100045, China
| | - Jie Tian
- CAS Key Laboratory of Molecular Imaging, State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, No.95 Zhongguancun East Road, Beijing, 100190, China.,Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Medicine, Beihang University, No. 37 Xueyuan Road, Beijing, 100191, China
| | - Di Dong
- CAS Key Laboratory of Molecular Imaging, State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, No.95 Zhongguancun East Road, Beijing, 100190, China. .,University of Chinese Academy of Sciences, No.19 Yuquan Road, Beijing, China.
| | - Yun Peng
- Department of Radiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi Road, Beijing, 100045, China. .,CAS Key Laboratory of Molecular Imaging, State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, No.95 Zhongguancun East Road, Beijing, 100190, China.
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153
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Nicol MP, Wood RC, Workman L, Prins M, Whitman C, Ghebrekristos Y, Mbhele S, Olson A, Jones-Engel LE, Zar HJ, Cangelosi GA. Microbiological diagnosis of pulmonary tuberculosis in children by oral swab polymerase chain reaction. Sci Rep 2019; 9:10789. [PMID: 31346252 PMCID: PMC6658562 DOI: 10.1038/s41598-019-47302-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 07/15/2019] [Indexed: 11/10/2022] Open
Abstract
Microbiological diagnosis of pediatric pulmonary tuberculosis (TB) is challenging due to the difficulty of collecting and testing sputum from children. We investigated whether easily-obtained oral swab samples are useful alternatives or supplements to sputum. Oral swabs and induced sputum (IS) were collected from 201 South African children with suspected pulmonary TB. IS samples were tested by mycobacterial culture and Xpert MTB/RIF. Oral swabs were tested by PCR targeting IS6110. Children were categorized as Confirmed TB (microbiologic confirmation on IS), Unconfirmed TB (clinical diagnosis only), or Unlikely TB (recovery without TB treatment). Relative to Confirmed TB, PCR on two oral swabs per child was 43% sensitive and 93% specific. This sensitivity fell below that of sputum Xpert (64%). Among children with either Confirmed or Unconfirmed TB, PCR on two oral swabs per child was 31% sensitive and 93% specific, which was more sensitive than sputum testing among this group (21%). Although oral swab analysis had low sensitivity in sputum-positive children, it detected TB in a significant proportion of sputum-negative children who were clinically diagnosed with TB. Specificity at 93% was suboptimal but may improve with the use of automated methods. With further development, oral swabs may become useful supplements to sputum as samples for diagnosis of pulmonary TB in children.
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Affiliation(s)
- Mark P Nicol
- Division of Medical Microbiology and Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Rachel C Wood
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, WA, USA
| | - Lesley Workman
- Department of Paediatrics and Child Health, and MRC Unit on Child & Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Margaretha Prins
- Department of Paediatrics and Child Health, and MRC Unit on Child & Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Cynthia Whitman
- Department of Paediatrics and Child Health, and MRC Unit on Child & Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Yonas Ghebrekristos
- Division of Medical Microbiology and Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Slindile Mbhele
- Division of Medical Microbiology and Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Alaina Olson
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, WA, USA
| | | | - Heather J Zar
- Department of Paediatrics and Child Health, and MRC Unit on Child & Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Gerard A Cangelosi
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, WA, USA.
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154
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Ganmaa D, Khudyakov P, Buyanjargal U, Baigal D, Baatar M, Enkhamgalan N, Erdenebaatar S, Ochirbat B, Burneebaatar B, Purevdorj E, Purevsuren Y, Garmaa G, Ganbaatar E, Martineau AR. Risk factors for active tuberculosis in 938 QuantiFERON-positive schoolchildren in Mongolia: a community-based cross-sectional study. BMC Infect Dis 2019; 19:532. [PMID: 31208362 PMCID: PMC6580591 DOI: 10.1186/s12879-019-4160-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/04/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND There is controversy regarding the relative influence of 'exogenous' versus 'endogenous' factors on the risk of progression from latent tuberculosis infection to active tuberculosis (TB) disease in children. METHODS We conducted a cross-sectional analysis to identify risk factors for active tuberculosis in QuantiFERON®-TB Gold (QFT-G)-positive children aged 6-13 years attending 18 schools in Ulaanbaatar, Mongolia. Children underwent clinical and radiological screening for active tuberculosis, and data relating to potential risk factors for disease progression were collected by questionnaire and determination of serum 25-hydroxyvitamin D (25[OH]D) concentrations. Risk ratios were calculated using generalized estimating equations with adjustment for potential confounders. RESULTS 129/938 (13.8%) QFT-positive children were diagnosed with active tuberculosis. Risk of active tuberculosis was independently associated with household exposure to pulmonary TB (adjusted risk ratio [aRR] 2.40, 95% CI 1.74 to 3.30, P < 0.001), month of sampling (adjusted risk ratio [aRR] for March-May vs. June-November 3.31, 95% CI 1.63 to 6.74, P < 0.001; aRR for December-February vs. June-November 2.53, 95% CI 1.23 to 5.19, P = 0.01) and active smoking by the child (aRR 5.23, 95% CI 2.70 to 10.12, P < 0.001). No statistically significant independent association was seen for age, sex, socio-economic factors, presence of a Bacillus Calmette-Guérin (BCG) scar, tobacco exposure or vitamin D status. CONCLUSIONS Household exposure to active TB, winter or spring season and active smoking were independently associated with risk of active tuberculosis in QFT-positive children. Our findings highlight the potentially high yield of screening child household contacts of infectious index cases for active tuberculosis in low- and middle-income countries.
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Affiliation(s)
- Davaasambuu Ganmaa
- Harvard T.H. Chan School of Public Health, Building 2, Room 211, 655 Huntington Ave, Boston, MA 02115 USA
- Mongolian Health Initiative, Royal Plaza, Bayanzurkh District, Ulaanbaatar, Mongolia
| | - Polyna Khudyakov
- Harvard T.H. Chan School of Public Health, Building 2, Room 211, 655 Huntington Ave, Boston, MA 02115 USA
| | - Uyanga Buyanjargal
- Mongolian Health Initiative, Royal Plaza, Bayanzurkh District, Ulaanbaatar, Mongolia
| | - Delgerekh Baigal
- Mongolian Health Initiative, Royal Plaza, Bayanzurkh District, Ulaanbaatar, Mongolia
| | - Munkhzul Baatar
- National Center for Communicable Disease, Ulaanbaatar, Mongolia
| | - Nomin Enkhamgalan
- Mongolian Health Initiative, Royal Plaza, Bayanzurkh District, Ulaanbaatar, Mongolia
| | - Sumiya Erdenebaatar
- Mongolian Health Initiative, Royal Plaza, Bayanzurkh District, Ulaanbaatar, Mongolia
| | - Batbayar Ochirbat
- Mongolian Health Initiative, Royal Plaza, Bayanzurkh District, Ulaanbaatar, Mongolia
| | | | | | | | - Gantsetseg Garmaa
- Mongolian Health Initiative, Royal Plaza, Bayanzurkh District, Ulaanbaatar, Mongolia
| | | | - Adrian R. Martineau
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AB, London, UK
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Kay AW, González Fernández L, Takwoingi Y, Eisenhut M, Vu RD, Steingart KR, Detjen AK, Mandalakas AM. Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for active tuberculosis and rifampicin resistance in children. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2019. [DOI: 10.1002/14651858.cd013359] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Alexander W Kay
- Baylor College of Medicine; Pediatrics; PO Box 110 Mbabane Swaziland H100
| | - Lucia González Fernández
- Baylor College of Medicine; Department of Paediatrics; 1102 Bates Street - FC630 Houston Texas USA 77030
| | - Yemisi Takwoingi
- University of Birmingham; Institute of Applied Health Research; Edgbaston Birmingham UK B15 2TT
| | - Michael Eisenhut
- Luton & Dunstable University Hospital NHS Foundation Trust; Paediatric Department; Lewsey Road Luton UK LU4 0DZ
| | - Ryan D Vu
- Baylor College of Medicine; Pediatrics; 1102 Bates Street - FC630 Houston Texas USA 77030
| | - Karen R Steingart
- Department of Clinical Sciences, Liverpool School of Tropical Medicine; Honorary Research Fellow; Pembroke Place Liverpool UK
| | - Anne K Detjen
- UNICEF; Health Section; 3 UN Plaza New York New York USA 10017
| | - Anna M Mandalakas
- Baylor College of Medicine; Pediatrics; 1102 Bates Street - FC630 Houston Texas USA 77030
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156
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Specimen Pooling as a Diagnostic Strategy for Microbiologic Confirmation in Children with Intrathoracic Tuberculosis. Pediatr Infect Dis J 2019; 38:e128-e131. [PMID: 30418355 PMCID: PMC6509014 DOI: 10.1097/inf.0000000000002240] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Three-hundred four young children with suspected pulmonary tuberculosis had a gastric aspirate, induced sputum and nasopharyngeal aspirate collected on each of 2 consecutive weekdays. Specimens collected on the second day were pooled in the laboratory for each child individually. The diagnostic yield by Xpert and culture from pooled specimens was not significantly different to a single gastric aspirate.
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157
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Diagnostic Accuracy of Stool Xpert MTB/RIF for Detection of Pulmonary Tuberculosis in Children: a Systematic Review and Meta-analysis. J Clin Microbiol 2019; 57:JCM.02057-18. [PMID: 30944200 PMCID: PMC6535592 DOI: 10.1128/jcm.02057-18] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/24/2019] [Indexed: 11/20/2022] Open
Abstract
Invasive collection methods are often required to obtain samples for the microbiological evaluation of children with presumptive pulmonary tuberculosis (PTB). Nucleic acid amplification testing of easier-to-collect stool samples could be a noninvasive method of diagnosing PTB. Invasive collection methods are often required to obtain samples for the microbiological evaluation of children with presumptive pulmonary tuberculosis (PTB). Nucleic acid amplification testing of easier-to-collect stool samples could be a noninvasive method of diagnosing PTB. We conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of testing stool with the Xpert MTB/RIF assay (“stool Xpert”) for childhood PTB. Four databases were searched for publications from January 2008 to June 2018. Studies assessing the diagnostic accuracy among children of stool Xpert compared to a microbiological reference standard of conventional specimens tested by mycobacterial culture or Xpert were eligible. Bivariate random-effects meta-analyses were performed to calculate pooled sensitivity and specificity of stool Xpert against the reference standard. From 1,589 citations, 9 studies (n = 1,681) were included. Median participant ages ranged from 1.3 to 10.6 years. Protocols for stool processing and testing varied substantially, with differences in reagents and methods of homogenization and filtering. Against the microbiological reference standard, the pooled sensitivity and specificity of stool Xpert were 67% (95% confidence interval [CI], 52 to 79%) and 99% (95% CI, 98 to 99%), respectively. Sensitivity was higher among children with HIV (79% [95% CI, 68 to 87%] versus 60% [95% CI, 44 to 74%] among HIV-uninfected children). Heterogeneity was high. Data were insufficient for subgroup analyses among children under the age of 5 years, the most relevant target population. Stool Xpert could be a noninvasive method of ruling in PTB in children, particularly those with HIV. However, studies focused on children under 5 years of age are needed, and generalizability of the evidence is limited by the lack of standardized stool preparation and testing protocols.
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158
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Hanrahan CF, Dansey H, Mutunga L, France H, Omar SV, Ismail N, Bassett J, Van Rie A. Diagnostic strategies for childhood tuberculosis in the context of primary care in a high burden setting: the value of alternative sampling methods. Paediatr Int Child Health 2019; 39:88-94. [PMID: 30378470 DOI: 10.1080/20469047.2018.1533321] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background: Hospital studies have demonstrated the usefulness of alternative sampling strategies to expectorated sputum and new diagnostics for the diagnosis of childhood tuberculosis (TB) but there is limited evidence of how these approaches work in the primary-care setting. Aim: To assess the feasibility and yield of a variety of sample types and diagnostic tests for childhood TB at a primary-care clinic. Methods: A prospective cohort of children (<10 years) with signs and symptoms of TB was enrolled at a primary-care clinic in Johannesburg, South Africa. Tuberculin skin testing (TST) and chest X-ray (CXR) were performed in all. In those unable to expectorate, one induced sputum (IS), one ambulatory gastric aspirate (GA) and two nasopharyngeal aspirates (NPA) were collected. Stool was collected from all. Samples were processed for smear microscopy, liquid culture and Xpert MTB/RIF. The Determine TB LAM Ag (LAM) test was used for HIV-positive children. Results: From July 2013-December 2014, 119 children were enrolled, 21 (18%) of whom were HIV-positive. TST was positive in 25/105 (24%) and 70/116 (70%) had a positive CXR. Four (3%) had confirmed TB, 101 (85%) unconfirmed TB and 15 (13%) unlikely TB. Of the 469 samples collected, smear microscopy was positive in none, Xpert was positive in four (<1%) and culture was positive in two (<1%). Three of 11 (27%) HIV-positive patients were positive by LAM. Treatment was commenced in 48/119 (40%). Conclusions: At primary-care, alternative sampling strategies proved feasible but resulted in a low diagnostic yield. Extensive efforts to bacteriologically diagnose children did not contribute to clinical management.
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Affiliation(s)
- Colleen F Hanrahan
- a Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Heather Dansey
- b Witkoppen Health and Welfare Centre , Gauteng , South Africa
| | - Lillian Mutunga
- b Witkoppen Health and Welfare Centre , Gauteng , South Africa
| | - Holly France
- b Witkoppen Health and Welfare Centre , Gauteng , South Africa
| | - Shaheed V Omar
- c Centre for Tuberculosis, National Institute for Communicable Diseases , National Health Laboratory Service , Johannesburg , South Africa
| | - Nazir Ismail
- c Centre for Tuberculosis, National Institute for Communicable Diseases , National Health Laboratory Service , Johannesburg , South Africa
| | - Jean Bassett
- b Witkoppen Health and Welfare Centre , Gauteng , South Africa
| | - Annelies Van Rie
- d Department of Epidemiology and Social Medicine , University of Antwerp , Antwerp , Belgium
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159
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Dos Santos TCS, Setúbal S, Dos Santos AASMD, Boechat M, Cardoso CAA. Radiological aspects in computed tomography as determinants in the diagnosis of pulmonary tuberculosis in immunocompetent infants. Radiol Bras 2019; 52:71-77. [PMID: 31019334 PMCID: PMC6472858 DOI: 10.1590/0100-3984.2018.0025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Objective To describe the chest computed tomography (CT) findings in immunocompetent
children under 36 months of age with pulmonary tuberculosis. Materials and Methods This was a descriptive case series conducted in the city of Rio de Janeiro,
Brazil, between January 2004 and July 2013, involving 20 young children who
underwent CT after undergoing chest X-rays that did not provide a definitive
diagnosis. Results All of the participants had lymph node enlargement and consolidations. In 15
cases (75%), the consolidations were accompanied by atelectasis. Pulmonary
cavitation was seen in 10 cases (50%), and cavitation within consolidations
was seen in 7 (35%). The areas of cavitation and parenchymal destruction
were not seen on conventional chest X-rays. Conclusion The radiological presentation of pulmonary tuberculosis in young children
differs from that described in older children and adults. CT is an effective
method for the early diagnosis of pulmonary tuberculosis in immunocompetent
infants, allowing the rapid institution of specific treatment, which is
crucial for halting disease progression, as well as for preventing local and
systemic complications.
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Affiliation(s)
- Teresa Cristina Sarmet Dos Santos
- Universidade Federal Fluminense (UFF) - Hospital Universitário Antônio Pedro (HUAP), Niterói, RJ, Brazil.,Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF/Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Sérgio Setúbal
- Universidade Federal Fluminense (UFF) - Hospital Universitário Antônio Pedro (HUAP), Niterói, RJ, Brazil
| | | | - Marcia Boechat
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF/Fiocruz), Rio de Janeiro, RJ, Brazil
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160
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Heuvelings CC, Bélard S, Andronikou S, Jamieson-Luff N, Grobusch MP, Zar HJ. Chest ultrasound findings in children with suspected pulmonary tuberculosis. Pediatr Pulmonol 2019; 54:463-470. [PMID: 30632712 DOI: 10.1002/ppul.24230] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 12/08/2018] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Chest ultrasound is increasingly used for the diagnosis of pediatric lung disease but there are limited data for its use in pediatric pulmonary tuberculosis (PTB). AIM To describe chest ultrasound findings in children with suspected PTB. METHODS Consecutive children, presenting with suspected PTB to a tertiary children's hospital in Cape Town between July 2014 and March 2016, were enrolled in this cohort study. Children were categorized into three groups based on microbiological and clinical features; confirmed PTB (microbiologically confirmed), unconfirmed PTB (clinical diagnosis only), and unlikely PTB (respiratory disease not due to PTB). A clinician, blinded to categorization, performed chest and mediastinal ultrasound for consolidation, pleural gaps, pleural effusions, B-lines or enlarged mediastinal lymph nodes at enrolment and 1, 3, and 6 months thereafter. Two readers interpreted the ultrasounds independently. RESULTS One hundred seventy children (median age 26.6 months) were enrolled; 40 (24%) confirmed PTB, 85 (50%) unconfirmed PTB, and 45 (26%) unlikely PTB. In children with confirmed PTB, pleural effusion was more common (30% vs 9% in unlikely PTB, P = 0.024), mediastinal lymph nodes were larger (median size 1.5 cm vs 1.0 cm in unlikely PTB, P = 0.027), resolution of consolidation occurred less commonly at 1-month follow-up (24% vs 67% unlikely TB, P = 0.014) and the proportional size reduction of a consolidation was lower (44% vs 80% in unlikely PTB, P = 0.009). Inter-reader agreement was perfect to moderate. CONCLUSION Chest ultrasound identified abnormalities suggestive of PTB with a high inter-reader agreement. Consolidation showed slower resolution in children with confirmed PTB.
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Affiliation(s)
- Charlotte C Heuvelings
- Center of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Department of Paediatrics and Child Health and SA-MRC Unit on Child and Adolescent Health, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Sabine Bélard
- Center of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Department of Paediatrics and Child Health and SA-MRC Unit on Child and Adolescent Health, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa.,Department of Pediatric Pneumology and Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Savvas Andronikou
- Department of Paediatrics and Child Health and SA-MRC Unit on Child and Adolescent Health, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa.,Department of Paediatric Radiology, Children's Hospital Philadelphia, Philadelphia, Pennsylvania
| | - Norme Jamieson-Luff
- Department of Paediatrics and Child Health and SA-MRC Unit on Child and Adolescent Health, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Martin P Grobusch
- Center of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Heather J Zar
- Department of Paediatrics and Child Health and SA-MRC Unit on Child and Adolescent Health, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
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161
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Andriyoko B, Janiar H, Kusumadewi R, Klinkenberg E, de Haas P, Tiemersma E. Simple stool processing method for the diagnosis of pulmonary tuberculosis using GeneXpert MTB/RIF. Eur Respir J 2019; 53:13993003.01832-2018. [PMID: 30578382 DOI: 10.1183/13993003.01832-2018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/24/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Basti Andriyoko
- Molecular Biology Division, Dept of Clinical Pathology, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Harini Janiar
- KNCV TB Foundation, Indonesia office, Jakarta, Indonesia
| | | | - Eveline Klinkenberg
- KNCV Tuberculosis Foundation, The Hague, The Netherlands.,Dept of Global Health, Amsterdam Institute for Global Health and Development, Academic Medical Centre, Amsterdam, The Netherlands
| | - Petra de Haas
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
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162
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Nguyen DT, Phan H, Trinh T, Nguyen H, Doan H, Pham N, Nguyen H, Nguyen H, Nguyen HV, Le HV, Nguyen N, Graviss EA. Sensitivity and characteristics associated with positive QuantiFERON-TB Gold-Plus assay in children with confirmed tuberculosis. PLoS One 2019; 14:e0213304. [PMID: 30830945 PMCID: PMC6398855 DOI: 10.1371/journal.pone.0213304] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/19/2019] [Indexed: 01/02/2023] Open
Abstract
Background Although QuantiFERON-TB Gold Plus (QFT-Plus), a new interferon-gamma release assay, has shown good performance in adults, little data is available in children. Methods De-identified data from TB-suspected patients age <18 years with QFT-Plus results, who were admitted or screened at the National Lung Hospital (NLH) in Ha Noi, Vietnam in 2017, were assessed. Logistic regression analyses were performed to determine the characteristics associated with having a positive QFT-Plus result. Sensitivity, both overall and in subgroups of pulmonary TB only (PTB), extra-pulmonary TB (EPTB) only, and both PTB and EPTB were calculated. Results Of 222 children with available QFT-Plus results, 33 were classified as confirmed TB, of whom 18 had QFT-Plus (+) and 15 had QFT-Plus (-). Multiple logistic regression modeling suggested that age, history of TB, and confirmed TB were significantly associated with having a positive QFT-Plus result with an area under the ROC curve of 0.77. QFT-Plus sensitivity in PTB only, EPTB, and both PTB and EPTB patients was 84.2%, 14.3% and 14.3%, respectively. The overall sensitivity of the QFT-Plus assay (regardless PTB or EPTB) in children was 54.5%. Conclusion Although QFT-Plus had a good sensitivity in children having exclusive PTB, it had poor sensitivity in EPTB.
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Affiliation(s)
- Duc T. Nguyen
- Houston Methodist Research Institute, Houston, TX, United States of America
| | - Ha Phan
- Center for Promotion of Advancement of Society (CPAS), Lot A4 15 Dong Quan, Cau Giay, Ha Noi, Vietnam
- Vietnam National Tuberculosis Program/University of California San Francisco Research Collaboration, Ha Noi, Vietnam
| | - Trang Trinh
- Center for Promotion of Advancement of Society (CPAS), Lot A4 15 Dong Quan, Cau Giay, Ha Noi, Vietnam
| | - Hang Nguyen
- National Lung Hospital, Hoang Hoa Tham, Ba Dinh District, Ha Noi, Vietnam
| | - Ha Doan
- National Lung Hospital, Hoang Hoa Tham, Ba Dinh District, Ha Noi, Vietnam
| | - Nam Pham
- Vietnam National Tuberculosis Program/University of California San Francisco Research Collaboration, Ha Noi, Vietnam
| | - Hung Nguyen
- Center for Promotion of Advancement of Society (CPAS), Lot A4 15 Dong Quan, Cau Giay, Ha Noi, Vietnam
- Vietnam National Tuberculosis Program/University of California San Francisco Research Collaboration, Ha Noi, Vietnam
| | - Hanh Nguyen
- Center for Promotion of Advancement of Society (CPAS), Lot A4 15 Dong Quan, Cau Giay, Ha Noi, Vietnam
- Vietnam National Tuberculosis Program/University of California San Francisco Research Collaboration, Ha Noi, Vietnam
| | - Hung V. Nguyen
- National Lung Hospital, Hoang Hoa Tham, Ba Dinh District, Ha Noi, Vietnam
| | - Hoi V. Le
- National Lung Hospital, Hoang Hoa Tham, Ba Dinh District, Ha Noi, Vietnam
| | - Nhung Nguyen
- National Lung Hospital, Hoang Hoa Tham, Ba Dinh District, Ha Noi, Vietnam
| | - Edward A. Graviss
- Houston Methodist Research Institute, Houston, TX, United States of America
- * E-mail:
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163
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Towards better management of latent tuberculosis infection in children and young adults in the Maghreb. Conclusions of an expert meeting, Paris, 16 March 2018. Arch Pediatr 2019; 26:126-129. [DOI: 10.1016/j.arcped.2018.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/05/2018] [Accepted: 12/02/2018] [Indexed: 11/16/2022]
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164
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Seddon JA, Garcia-Prats AJ, Purchase SE, Osman M, Demers AM, Hoddinott G, Crook AM, Owen-Powell E, Thomason MJ, Turkova A, Gibb DM, Fairlie L, Martinson N, Schaaf HS, Hesseling AC. Levofloxacin versus placebo for the prevention of tuberculosis disease in child contacts of multidrug-resistant tuberculosis: study protocol for a phase III cluster randomised controlled trial (TB-CHAMP). Trials 2018; 19:693. [PMID: 30572905 PMCID: PMC6302301 DOI: 10.1186/s13063-018-3070-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 11/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multidrug-resistant (MDR) tuberculosis (TB) presents a challenge for global TB control. Treating individuals with MDR-TB infection to prevent progression to disease could be an effective public health strategy. Young children are at high risk of developing TB disease following infection and are commonly infected by an adult in their household. Identifying young children with household exposure to MDR-TB and providing them with MDR-TB preventive therapy could reduce the risk of disease progression. To date, no trials of MDR-TB preventive therapy have been completed and World Health Organization guidelines suggest close observation with no active treatment. METHODS The tuberculosis child multidrug-resistant preventive therapy (TB-CHAMP) trial is a phase III cluster randomised placebo-controlled trial to assess the efficacy of levofloxacin in young child contacts of MDR-TB cases. The trial is taking place at three sites in South Africa where adults with MDR-TB are identified. If a child aged < 5 years lives in their household, we assess the adult index case, screen all household members for TB disease and evaluate any child aged < 5 years for trial eligibility. Eligible children are randomised by household to receive daily levofloxacin (15-20 mg/kg) or matching placebo for six months. Children are closely monitored for disease development, drug tolerability and adverse events. The primary endpoint is incident TB disease or TB death by one year after recruitment. We will enrol 1556 children from approximately 778 households with an average of two eligible children per household. Recruitment will run for 18-24 months with all children followed for 18 months after treatment. Qualitative and health economic evaluations are embedded in the trial. DISCUSSION If the TB-CHAMP trial demonstrates that levofloxacin is effective in preventing TB disease in young children who have been exposed to MDR-TB and that it is safe, well tolerated, acceptable and cost-effective, we would expect that that this intervention would rapidly transfer into policy. TRIAL REGISTRATION ISRCTN Registry, ISRCTN92634082 . Registered on 31 March 2016.
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Affiliation(s)
- James A. Seddon
- Centre for International Child Health, Department of Paediatrics, Imperial College London, Norfolk Place, London, W2 1PG UK
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Anthony J. Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Susan E. Purchase
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Anne-Marie Demers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Angela M. Crook
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Ellen Owen-Powell
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Margaret J. Thomason
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Anna Turkova
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Diana M. Gibb
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Lee Fairlie
- Wits Reproductive Health & HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - H. Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Anneke C. Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
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165
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Weber SF, Saravu K, Heller T, Kadavigere R, Vishwanath S, Gehring S, Bélard S, And Pocus Eti Study Group. Point-of-Care Ultrasound for Extrapulmonary Tuberculosis in India: A Prospective Cohort Study in HIV-Positive and HIV-Negative Presumptive Tuberculosis Patients. Am J Trop Med Hyg 2018; 98:266-273. [PMID: 29141727 DOI: 10.4269/ajtmh.17-0486] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Diagnosing extrapulmonary tuberculosis (EPTB) is challenging. Point-of-care ultrasound (POCUS) for human immunodeficiency virus (HIV)-associated EPTB is applied in sub-Saharan Africa. This study aimed at evaluating the applicability of POCUS for diagnosing EPTB in HIV-positive and HIV-negative presumptive tuberculosis (TB) patients in India, a country of moderate relative TB and HIV burden. Presumptive TB patients at Kasturba Hospital, Manipal, India, prospectively underwent POCUS evaluating for pericardial, pleural and ascitic effusion, abdominal lymphadenopathy, and hepatic and splenic microabscesses. Findings were correlated with TB category (confirmed TB, clinical TB, unlikely TB), HIV status, and discharge diagnoses. A total of 425 patients underwent POCUS; 81 (20%) were HIV-positive. POCUS findings were more common in HIV/TB coinfected patients than in HIV-positive patients with unlikely TB (24/40 (60%) versus 9/41 (22%), P < 0.001). Abdominal lymphadenopathy and splenic microabscesses were strongly associated with TB in HIV-positive patients (P = 0.002 and P = 0.001). POCUS findings did not correlate with TB in HIV-negative patients; a third of HIV-negative patients with unlikely TB and POCUS findings had cancer, another third other infectious diseases. Sonographic findings were common in HIV-positive and HIV-negative presumptive TB patients. POCUS was a useful bedside test for the detection of HIV-associated EPTB. In HIV-negative patients, POCUS detected features associated with EPTB but also of malignancy and other infectious diseases.
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Affiliation(s)
- Stefan F Weber
- Department of Pediatrics, RWTH Aachen University, Aachen, Germany.,Department of Pediatrics, University Clinics, Mainz, Germany
| | - Kavitha Saravu
- Department of Medicine, Kasturba Medical College, Manipal University, Manipal, India.,Manipal McGill Center for Infectious Diseases, Manipal, India
| | | | - Rajagopal Kadavigere
- Department of Radiodiagnosis, Kasturba Medical College, Manipal University, Manipal, India
| | - Shashidhar Vishwanath
- Department of Microbiology, Kasturba Medical College, Manipal University, Manipal, India
| | - Stephan Gehring
- Department of Pediatrics, University Clinics, Mainz, Germany
| | - Sabine Bélard
- Berlin Institute of Health, Berlin, Germany.,Department of Pediatric Pneumology and Immunology, Charité University Medicine, Berlin, Germany
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166
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Rebecca B, Chacko A, Verghese V, Rose W. Spectrum of Pediatric Tuberculosis in a Tertiary Care Setting in South India. J Trop Pediatr 2018; 64:544-547. [PMID: 29447374 DOI: 10.1093/tropej/fmy007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Pediatric tuberculosis (TB) is often underdiagnosed with poor estimate of its true burden. Availability of Xpert MTB/RIF assay enhances diagnostic capacity of pediatric TB. METHODS A 3-year retrospective review of hospital records was done for all children diagnosed with confirmed and unconfirmed TB. Comparison was made between intrathoracic, single-site extrathoracic and disseminated TB. RESULTS In total, 274 children had TB with 130 (47.4%) having confirmed TB. Pulmonary (23.4%), lymph node (23%) and central nervous system (12.8%) TB were the three commonest forms. HIV TB coinfection was 2.9%. Mycobacterial culture was positive in 90 (32.8%) and XPert MTB/RIF in 85 patients (31%). Mycobacterial confirmation was obtained in 45 (56.3%) intrathoracic TB, 69 (45.4%) extrathoracic TB and 16 (38.1%) disseminated TB. Correlation between positive Xpert and mycobacterial culture was poor (kappa 0.38). Rifampicin resistance was present in 25 (19.2%) of the 130 microbiologically confirmed TB. CONCLUSION Extrathoracic TB is common in children. Mycobacterial confirmation in pediatric TB is improved with use of Xpert.
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Affiliation(s)
- Betsy Rebecca
- Department of Pediatrics, Christian Medical College, Vellore, 632004, India
| | - Anila Chacko
- Department of Pediatrics, Christian Medical College, Vellore, 632004, India
| | - Valsan Verghese
- Department of Pediatrics, Christian Medical College, Vellore, 632004, India
| | - Winsley Rose
- Department of Pediatrics, Christian Medical College, Vellore, 632004, India
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167
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Ollier V, Antoun F, Thouvenin G, Faye A, Kone-Paut I, Benoist G, Antoine D, Charlois C, Delacourt C. Potentially preventable tuberculosis cases in children exposed to a contaminant case. Arch Pediatr 2018; 25:421-425. [DOI: 10.1016/j.arcped.2018.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 06/11/2018] [Accepted: 07/23/2018] [Indexed: 11/16/2022]
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168
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Abstract
We determined the accuracy of the new Xpert MTB/RIF Ultra assay for diagnosis of pulmonary tuberculosis in children, using banked-induced sputum. Sensitivity and specificity were 75.3% and 96.9%, respectively, compared with a culture result from the same specimen. Of those children with microbiologically confirmed tuberculosis (positive Xpert, Ultra or culture), Xpert detected 63.2%, Ultra 73.7% and culture 82.9%.
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169
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Delacourt C, Guerin S, Pommelet V. [Interferon gamma release assay tests in children less than 15 years old]. Rev Mal Respir 2018; 35:875-878. [PMID: 30224212 DOI: 10.1016/j.rmr.2018.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 03/21/2018] [Indexed: 11/15/2022]
Affiliation(s)
- C Delacourt
- Hôpital Necker-Enfants-Malades, AP-HP, 75015 Paris, France.
| | - S Guerin
- Hôpital Necker-Enfants-Malades, AP-HP, 75015 Paris, France
| | - V Pommelet
- Service de pédiatrie générale, hôpital Robert-Debré, AP-HP, 75019 Paris, France
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170
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Togun TO, MacLean E, Kampmann B, Pai M. Biomarkers for diagnosis of childhood tuberculosis: A systematic review. PLoS One 2018; 13:e0204029. [PMID: 30212540 PMCID: PMC6136789 DOI: 10.1371/journal.pone.0204029] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 08/31/2018] [Indexed: 12/14/2022] Open
Abstract
Introduction As studies of biomarkers of tuberculosis (TB) disease provide hope for a simple, point-of-care test, we aimed to synthesize evidence on biomarkers for diagnosis of TB in children and compare their accuracy to published target product profiles (TPP). Methods We conducted a systematic review of biomarkers for diagnosis of pulmonary TB in exclusively paediatric populations, defined as age less than 15 years. PubMed, EMBASE and Web of Science were searched for relevant publications from January 1, 2000 to November 27, 2017. Studies using mixed adult and paediatric populations or reporting biomarkers for extrapulmonary TB were excluded. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies—2 (QUADAS-2) framework. No meta-analysis was done because the published childhood TB biomarkers studies were mostly early stage studies and highly heterogeneous. Results The 29 studies included in this systematic review comprise 20 case-control studies, six cohort studies and three cross-sectional studies. These studies reported diverse and heterogeneous forms of biomarkers requiring different types of clinical specimen and laboratory assays. Majority of the studies (27/29 [93%]) either did not meet the criteria in at least one of the four domains of the QUADAS-2 reporting framework or the assessment was unclear. However, the diagnostic performance of biomarkers reported in 22 studies met one or both of the WHO-recommended minimal targets of 66% sensitivity and 98% specificity for a new diagnostic test for TB disease in children, and/or 90% sensitivity and 70% specificity for a triage test. Conclusion We found that majority of the biomarkers for diagnosis of TB in children are promising but will need further refining and optimization to improve their performances. As new data are emerging, stronger emphasis should be placed on improving the design, quality and general reporting of future studies investigating TB biomarkers in children.
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Affiliation(s)
- Toyin Omotayo Togun
- McGill International TB Centre, and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- * E-mail:
| | - Emily MacLean
- McGill International TB Centre, and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Beate Kampmann
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | - Madhukar Pai
- McGill International TB Centre, and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Manipal McGill Centre for Infectious Diseases, Manipal University, Manipal, India
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171
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Walters E, Scott L, Nabeta P, Demers AM, Reubenson G, Bosch C, David A, van der Zalm M, Havumaki J, Palmer M, Hesseling AC, Ncayiyana J, Stevens W, Alland D, Denkinger C, Banada P. Molecular Detection of Mycobacterium tuberculosis from Stools in Young Children by Use of a Novel Centrifugation-Free Processing Method. J Clin Microbiol 2018; 56:e00781-18. [PMID: 29997199 PMCID: PMC6113478 DOI: 10.1128/jcm.00781-18] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 07/05/2018] [Indexed: 11/20/2022] Open
Abstract
The microbiological diagnosis of tuberculosis (TB) in children is challenging, as it relies on the collection of relatively invasive specimens by trained health care workers, which is not feasible in many settings. Mycobacterium tuberculosis is detectable from the stools of children using molecular methods, but processing stool specimens is resource intensive. We evaluated a novel, simple, centrifugation-free processing method for stool specimens for use on the Xpert MTB/RIF assay (Xpert), using two different stool masses: 0.6 g and a swab sample. Two hundred eighty children (median age, 15.5 months; 35 [12.5%] HIV infected) with suspected intrathoracic TB were enrolled from two sites in South Africa. Compared to a single Xpert test on respiratory specimens, the sensitivity of Xpert on stools using the 0.6-g and swab samples was 44.4% (95% confidence interval [CI], 13.7 to 78.8%) for both methods, with a specificity of >99%. The combined sensitivities of two stool tests versus the first respiratory Xpert were 70.0% (95% CI, 34.8 to 93.3) and 50.0% (95% CI, 18.7 to 81.3) for the 0.6-g and swab sample, respectively. Retesting stool specimens with nondeterminate Xpert results improved nondeterminate rates from 9.3% to 3.9% and from 8.6% to 4.3% for 0.6-g and swab samples, respectively. Overall, stool Xpert detected 14/94 (14.9%) children who initiated antituberculosis treatment, while respiratory specimens detected 23/94 (24.5%). This stool processing method is well suited for settings with low capacity for respiratory specimen collection. However, the overall sensitivity to detect confirmed and clinical TB was lower than that of respiratory specimens. More sensitive rapid molecular assays are needed to improve the utility of stools for the diagnosis of intrathoracic TB in children from resource-limited settings.
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Affiliation(s)
- Elisabetta Walters
- Desmond Tutu TB Centre, Stellenbosch University, Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Lesley Scott
- Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Pamela Nabeta
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Anne-Marie Demers
- Desmond Tutu TB Centre, Stellenbosch University, Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Gary Reubenson
- Rahima Moosa Mother & Child Hospital, University of the Witwatersrand, Faculty of Health Sciences, Paediatrics and Child Health, Johannesburg, South Africa
| | - Corné Bosch
- Desmond Tutu TB Centre, Stellenbosch University, Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Anura David
- Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Marieke van der Zalm
- Desmond Tutu TB Centre, Stellenbosch University, Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Joshua Havumaki
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan Palmer
- Desmond Tutu TB Centre, Stellenbosch University, Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Stellenbosch University, Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Jabulani Ncayiyana
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wendy Stevens
- Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Priority Program of the National Health Laboratory Service, Johannesburg, South Africa
| | - David Alland
- Rutgers, New Jersey Medical School, Faculty of Medicine, Newark, New Jersey, USA
| | | | - Padmapriya Banada
- Rutgers, New Jersey Medical School, Faculty of Medicine, Newark, New Jersey, USA
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172
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Abstract
BACKGROUND Point-of-care ultrasound (POCUS) detects extrapulmonary tuberculosis (EPTB) in HIV infected adults but has not been evaluated in children despite their higher risk of EPTB. This study's aims were to investigate feasibility of POCUS for EPTB in children, frequency of POCUS findings suggestive of EPTB and time to sonographic resolution of findings with treatment. METHODS This prospective South African cohort study enrolled children with suspected pulmonary tuberculosis (PTB). POCUS for pleural, pericardial or ascitic effusion, abdominal lymphadenopathy or splenic or hepatic microabscesses was performed and repeated at 1, 3 and 6 months of tuberculosis (TB) treatment. Prevalence of POCUS findings and their association with HIV infection was investigated in children with confirmed PTB (microbiologically proven), unconfirmed PTB (clinically diagnosed) or unlikely TB (respiratory disease that improved during follow-up without TB treatment). RESULTS Of 232 children [median age 37 months (interquartile range, 18-74)], 39 (17%) were HIV infected. Children with confirmed or unconfirmed PTB had a higher prevalence of POCUS findings than children with unlikely TB [18 of 58 (31%) and 36 of 119 (30%) vs. 8 of 55 (15%); P = 0.04 and P = 0.03, respectively]. Pleural effusion [n = 30 (13%)] or abdominal lymphadenopathy [n = 28 (12%)] were the most common findings; splenic microabscesses [n = 12 (5%)] were strongly associated with confirmed PTB. Children coinfected with HIV and TB were more likely than HIV-uninfected children with TB to have abdominal lymphadenopathy (37% vs. 10%; P < 0.001) or splenic microabscesses (23% vs. 3%; P < 0.001]. Most ultrasound findings were resolved by 3 months with appropriate TB treatment. CONCLUSIONS POCUS for EPTB in children with PTB is feasible. The high prevalence of findings suggests that POCUS can contribute to timely diagnosis of childhood TB and to monitoring treatment response.
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173
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Kay AW, Islam SM, Wendorf K, Westenhouse J, Barry PM. Interferon-γ Release Assay Performance for Tuberculosis in Childhood. Pediatrics 2018; 141:peds.2017-3918. [PMID: 29728429 DOI: 10.1542/peds.2017-3918] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Interferon-γ release assays (IGRAs) are important adjunctive tests for diagnosing tuberculosis (TB) disease in children. METHODS We analyzed California TB registry data for patients ≤18 years with laboratory-confirmed TB disease during 2010-2015 to identify case characteristics associated with test selection and performance and measure IGRA sensitivity. RESULTS In total, 778 cases of TB were reported; 360 were laboratory confirmed. Indeterminate IGRAs were associated with being <1 year old (prevalence rate ratio 9.23; 95% confidence interval 2.87 to 29.8) and having central nervous system disease (prevalence rate ratio 2.69; 95% confidence interval 1.06 to 6.86) on multivariable analysis. Ninety-five children had both an IGRA and tuberculin skin test (TST) performed. Among those, the sensitivity of IGRA in 5- to 18-year-olds was 96% (66 out of 69) vs 83% (57 out of 69) for TST (P = .01); IGRA sensitivity compared with TST in children ages 2 to 4 was 91% (10 out of 11) vs 91% (10 out of 11) (P > .99), and the sensitivity compared with TST in children aged <2 years was 80% (12 out of 15) vs 87% (13 out of 15) (P > .99). CONCLUSIONS This is the largest North American analysis of IGRA use and performance among children with TB disease. In children <5 years old, IGRA sensitivity is similar to TST, but sensitivity of both tests are reduced in children <2 years old. Indeterminate results are higher in children <1 year old and in central nervous system disease. In children ≥5 years old with laboratory-confirmed TB, IGRA has greater sensitivity than TST and should be considered the preferred immunodiagnostic test..
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Affiliation(s)
- Alexander W Kay
- California Department of Public Health, Richmond, California; and
| | - Shamim M Islam
- University at Buffalo, State University of New York, Buffalo, New York
| | - Kristen Wendorf
- California Department of Public Health, Richmond, California; and
| | | | - Pennan M Barry
- California Department of Public Health, Richmond, California; and
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174
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LaCourse SM, Cranmer LM, Njuguna IN, Gatimu J, Stern J, Maleche-Obimbo E, Walson JL, Wamalwa D, John-Stewart GC, Pavlinac PB. Urine Tuberculosis Lipoarabinomannan Predicts Mortality in Hospitalized Human Immunodeficiency Virus-Infected Children. Clin Infect Dis 2018; 66:1798-1801. [PMID: 29324985 PMCID: PMC5961239 DOI: 10.1093/cid/ciy011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/05/2018] [Indexed: 12/21/2022] Open
Abstract
Clinical Trials Registration NCT02063880.
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Affiliation(s)
- Sylvia M LaCourse
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle
| | - Lisa M Cranmer
- Department of Pediatrics, Division of Infectious Diseases, Emory University School of Medicine
- Children’s Healthcare of Atlanta, Georgia
| | - Irene N Njuguna
- Department of Epidemiology, University of Washington, Seattle
- Kenyatta National Hospital, Nairobi, Kenya
| | - John Gatimu
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Joshua Stern
- Department of Global Health, University of Washington, Seattle
| | | | - Judd L Walson
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace C John-Stewart
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
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175
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Birungi FM, van Wyk B, Uwimana J, Ntaganira J, Graham SM. Xpert MTB/RIF assay did not improve diagnosis of pulmonary tuberculosis among child contacts in Rwanda. Pan Afr Med J 2018; 30:39. [PMID: 30167066 PMCID: PMC6110558 DOI: 10.11604/pamj.2018.30.39.12600] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 04/19/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction To report on the diagnostic yield using the Xpert MTB/RIF assay on gastric lavage samples from children (<15 years) who were household contacts of tuberculosis (TB) cases in Kigali, Rwanda. Methods A cross-sectional study was conducted among 216 child contacts of index cases with sputum smear-positive TB over a 7 month period, from 1st August 2015 to 29th February 2016. Child contacts with tuberculosis-related symptoms or abnormal chest X-ray had sputum collected by gastric lavage on two consecutive days and samples were examined by smear microscopy, Xpert MTB/RIF assay and solid culture. Results Of the 216 child contacts, 94 (44%) were less than 5 years of age. Most of them 84 (89%) were receiving isoniazid preventive therapy at the time of screening. Thirty seven out of 216 children had TB-related symptoms. Only 4 (10.8%) were clinically diagnosed with TB; and none had bacteriologically confirmed tuberculosis. Conclusion The use of Xpert MTB/RIF assay did not contribute to bacteriological confirmation of active TB in child contacts in this study. The low prevalence of tuberculosis in child contacts in this study may reflect the high coverage of preventive therapy in young (<5 years) child contacts. The low sensitivity of Xpert MTB/RIF assay in contacts may also suggest likely reflection of paucibacillary disease.
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Affiliation(s)
- Francine Mwayuma Birungi
- Department of Epidemiology and Biostatistics, School of Public Health of the College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.,Faculty of Community and Health Sciences, University of Western Cape, Cape Town, South Africa
| | - Brian van Wyk
- Faculty of Community and Health Sciences, University of Western Cape, Cape Town, South Africa
| | - Jeannine Uwimana
- Department of Epidemiology and Biostatistics, School of Public Health of the College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.,Faculty of Community and Health Sciences, University of Western Cape, Cape Town, South Africa
| | - Joseph Ntaganira
- Department of Epidemiology and Biostatistics, School of Public Health of the College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Stephen Michael Graham
- Centre for International Child Health, University of Melbourne Department of Paediatrics and Murdoch Children's, Research Institute, Royal Children's Hospital, Melbourne, Australia.,International Union Against Tuberculosis and Lung Disease, Paris, France
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176
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Dhawan V, Bown J, Lau A, Langlois-Klassen D, Kunimoto D, Bhargava R, Chui L, Collin SM, Long R. Towards the elimination of paediatric tuberculosis in high-income, immigrant-receiving countries: a 25-year conventional and molecular epidemiological case study. ERJ Open Res 2018; 4:00131-2017. [PMID: 29750144 PMCID: PMC5938491 DOI: 10.1183/23120541.00131-2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 03/09/2018] [Indexed: 11/21/2022] Open
Abstract
The epidemiology of tuberculosis (TB) in high-income countries is increasingly dictated by immigration. The influence of this trend on paediatric TB and TB elimination are not well defined. We undertook a 25-year conventional and molecular epidemiologic study of paediatric TB in Alberta, one of four major immigrant-receiving provinces in Canada. All isolates of Mycobacterium tuberculosis were DNA fingerprinted using standard methodology. Between 1990 and 2014, 176 children aged 0–14 years were diagnosed with TB. Foreign-born children or Canadian-born children of foreign-born parents accounted for an increasingly large proportion of total cases during the study period (from 32.1% to 89.5%). Of the 78 culture-positive cases, 35 (44.9%) had a putative source case identified by conventional epidemiology, with 34 (97.1%) having a concordant molecular profile. Of the remaining 43 culture-positive cases, molecular profiling identified spatially and temporally related sources in six cases (14.0%). These six children, along with four other children whose source cases were discovered through reverse-contact tracing, had a high morbidity and mortality. The increasing burden of paediatric TB in both foreign-born children and Canadian-born children of foreign-born parents calls for more timely diagnosis of source cases and more targeted screening for latent TB infection. Conventional and molecular epidemiology can inform paediatric TB elimination strategy in high-income countrieshttp://ow.ly/mwbn30iY1WF
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Affiliation(s)
- Vivek Dhawan
- Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Bown
- Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Angela Lau
- Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Dennis Kunimoto
- Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ravi Bhargava
- Dept of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Linda Chui
- Dept of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada.,Provincial Laboratory for Public Health, Alberta Health Services, Edmonton, AB, Canada.,Provincial Laboratory for Public Health, Alberta Health Services, Calgary, AB, Canada
| | - Simon M Collin
- Centre for Child and Adolescent Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard Long
- Dept of Medicine, University of Alberta, Edmonton, AB, Canada
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177
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Chabala C, Turkova A, Thomason MJ, Wobudeya E, Hissar S, Mave V, van der Zalm M, Palmer M, Kapasa M, Bhavani PK, Balaji S, Raichur PA, Demers AM, Hoddinott G, Owen-Powell E, Kinikar A, Musoke P, Mulenga V, Aarnoutse R, McIlleron H, Hesseling A, Crook AM, Cotton M, Gibb DM. Shorter treatment for minimal tuberculosis (TB) in children (SHINE): a study protocol for a randomised controlled trial. Trials 2018; 19:237. [PMID: 29673395 PMCID: PMC5909210 DOI: 10.1186/s13063-018-2608-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/15/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) in children is frequently paucibacillary and non-severe forms of pulmonary TB are common. Evidence for tuberculosis treatment in children is largely extrapolated from adult studies. Trials in adults with smear-negative tuberculosis suggest that treatment can be effectively shortened from 6 to 4 months. New paediatric, fixed-dose combination anti-tuberculosis treatments have recently been introduced in many countries, making the implementation of World Health Organisation (WHO)-revised dosing recommendations feasible. The safety and efficacy of these higher drug doses has not been systematically assessed in large studies in children, and the pharmacokinetics across children representing the range of weights and ages should be confirmed. METHODS/DESIGN SHINE is a multicentre, open-label, parallel-group, non-inferiority, randomised controlled, two-arm trial comparing a 4-month vs the standard 6-month regimen using revised WHO paediatric anti-tuberculosis drug doses. We aim to recruit 1200 African and Indian children aged below 16 years with non-severe TB, with or without HIV infection. The primary efficacy and safety endpoints are TB disease-free survival 72 weeks post randomisation and grade 3 or 4 adverse events. Nested pharmacokinetic studies will evaluate anti-tuberculosis drug concentrations, providing model-based predictions for optimal dosing, and measure antiretroviral exposures in order to describe the drug-drug interactions in a subset of HIV-infected children. Socioeconomic analyses will evaluate the cost-effectiveness of the intervention and social science studies will further explore the acceptability and palatability of these new paediatric drug formulations. DISCUSSION Although recent trials of TB treatment-shortening in adults with sputum-positivity have not been successful, the question has never been addressed in children, who have mainly paucibacillary, non-severe smear-negative disease. SHINE should inform whether treatment-shortening of drug-susceptible TB in children, regardless of HIV status, is efficacious and safe. The trial will also fill existing gaps in knowledge on dosing and acceptability of new anti-tuberculosis formulations and commonly used HIV drugs in settings with a high burden of TB. A positive result from this trial could simplify and shorten treatment, improve adherence and be cost-saving for many children with TB. Recruitment to the SHINE trial begun in July 2016; results are expected in 2020. TRIAL REGISTRATION International Standard Randomised Controlled Trials Number: ISRCTN63579542 , 14 October 2014. Pan African Clinical Trials Registry Number: PACTR201505001141379 , 14 May 2015. Clinical Trial Registry-India, registration number: CTRI/2017/07/009119, 27 July 2017.
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Affiliation(s)
- Chishala Chabala
- University Teaching Hospital, Children’s Hospital, Private Bag RW IX, Ridgeway, Lusaka, Zambia
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - Margaret J. Thomason
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - Eric Wobudeya
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
| | - Syed Hissar
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | | | - Megan Palmer
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Monica Kapasa
- University Teaching Hospital, Children’s Hospital, Private Bag RW IX, Ridgeway, Lusaka, Zambia
| | - Perumal K. Bhavani
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Sarath Balaji
- India Institute of Child Health and Hospital for Children, Chennai, India
| | | | - Anne-Marie Demers
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Ellen Owen-Powell
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Philippa Musoke
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
| | - Veronica Mulenga
- University Teaching Hospital, Children’s Hospital, Private Bag RW IX, Ridgeway, Lusaka, Zambia
| | - Rob Aarnoutse
- Radbound University Medical Center, Nijmegen, The Netherlands
| | | | - Anneke Hesseling
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Angela M. Crook
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - Mark Cotton
- Family Infectious Diseases Clinical Research Unit, Stellensbosch University, Cape Town, South Africa
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - on behalf of the SHINE trial team
- University Teaching Hospital, Children’s Hospital, Private Bag RW IX, Ridgeway, Lusaka, Zambia
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
- Byramjee Jeejeebhoy Government Medical College, Pune, India
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
- India Institute of Child Health and Hospital for Children, Chennai, India
- Radbound University Medical Center, Nijmegen, The Netherlands
- University of Cape Town, Cape Town, South Africa
- Family Infectious Diseases Clinical Research Unit, Stellensbosch University, Cape Town, South Africa
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178
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Carvalho I, Goletti D, Manga S, Silva DR, Manissero D, Migliori G. Managing latent tuberculosis infection and tuberculosis in children. Pulmonology 2018; 24:106-114. [PMID: 29502937 DOI: 10.1016/j.rppnen.2017.10.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 10/27/2017] [Indexed: 02/02/2023] Open
Abstract
Tuberculosis (TB) is a major cause of childhood morbidity and mortality worldwide. The aim of this review is to describe the management of the child with TB and latent tuberculosis infection (LTBI). To develop this article, a working group reviewed relevant epidemiological and other scientific studies and established practices in conducting LBTI and TB in children. The article describes how to manage the child with LTBI, considering transmission and infectiousness of tuberculosis, contact screening and prioritization of contacts and recommendations on treatment of children with LTBI and how to manage the child with TB considering the susceptibility of children to developing tuberculosis, epidemiology and classification of tuberculosis in children, diagnosis and treatment.
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Affiliation(s)
- I Carvalho
- Pediatric Pulmonologist, Centro Diagnostico Pneumológico de Gaia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.
| | - D Goletti
- Translational Research Unit, National Institute for Infectious Diseases, Roma, Italy
| | - S Manga
- Associate Professor at Public Health and Preventive Medicine, Department San Marcos National University, Principal Professor of Infectious Diseases Lung Diseases at Hermilio Valdizan University, Peru
| | - D R Silva
- Professor of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Pulmonology Division, Porto Alegre, Brazil
| | - D Manissero
- Honorary Senior Lecturer, University College of London, Institute for Global Health, London, UK
| | - G Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Maugeri Care and Research Institute! Tradate, Italy
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179
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Abstract
PURPOSE OF REVIEW Although tuberculosis (TB) causes much morbidity and mortality in children, diagnosis and treatment remain challenging. Recently, children have gained increasing attention in research and clinical trials driving improved contact management, case identification and treatment of both drug-susceptible and drug-resistant TB. This review highlights some recent advances. RECENT FINDINGS The tuberculin skin test is the most widely used test to distinguish Mycobacterium tuberculosis (M. tuberculosis) infection from active TB, however, using M. tuberculosis-specific, antigenic stimulation of CD4 and CD8 cells appear more effective. The use of Xpert MTB/RIF to identify M. tuberculosis in clinical samples, together with novel sampling methods have in part, overcome the difficulty of sampling and increased case identification capacity. Advances in treating both drug-susceptible and drug-resistant childhood TB show promise in being more paediatric friendly and improving adherence. Dosing strategies for drug-sensitive TB have improved with dispersible fixed drug combinations now available. In the treatment and prevention of drug-resistant TB, however, research involving the use of newer and more effective drugs currently recommended for adults, are still ongoing in children. SUMMARY The World Health Organization aims to end the TB epidemic by 2035 whereas the United Nations' Sustainable Developmental Goals sets this ambitious target for 2030. Therefore, adequate funding and implementing effective national TB programs must be prioritized, particularly in high-burden, low-income settings.
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180
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Abstract
BACKGROUND Mortality among children with presumptive tuberculosis (TB) empiric TB treatment can be high. We describe the predictors of death among children with presumptive TB, and the relation between treatment and mortality. METHODS A prospective cohort of children with presumptive TB who underwent clinical assessment, chest radiograph, tuberculin skin test and sputum bacterial tests for TB was followed up for 3 months. TB diagnosis was based on mycobacterial, clinical and radiologic findings. Predictors of deaths were determined using cox regression model. RESULTS Of 360 children included in the analysis, 31.4% were younger than 2 years; 31.6% were HIV infected and 11.3% were severely malnourished. One hundred forty (38.9%) were diagnosed with TB, 18 (13%) of whom were bacteriologically confirmed. At 3 months of follow up, 25 of 360 (6.9%) children had died: 15 of 140 (10.7%) were receiving TB treatment versus 10 of 220 (4.5%) were not receiving treatment (P = 0.025). Severely malnourished children [adjusted hazard ratio (aHR), 9.86; 95% confidence interval (CI): 3.11-31.23] and those with chest radiographs suggestive of TB (aHR, 4.20; 95% CI: 0.93-19.01) were more likely to die. Children receiving empiric TB treatment had an increased risk of death (aHR, 2.37; 95% CI: 1.01-5.55) compared with children without treatment after adjustment for age, sex, HIV status and Bacillus Calmette-Guérin (BCG) vaccination. CONCLUSIONS The high mortality in children receiving empirically TB treatment highlights the difficulty in diagnosing childhood TB, the increased likelihood of starting treatment in critically ill children and in children with chronic disease, and the possibility of misdiagnosis. It strengthens the need to invest further in early TB detection and diagnosing nonsevere illness.
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181
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Stool Xpert MTB/RIF and urine lipoarabinomannan for the diagnosis of tuberculosis in hospitalized HIV-infected children. AIDS 2018; 32:69-78. [PMID: 29028662 DOI: 10.1097/qad.0000000000001662] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tuberculosis (TB) causes substantial morbidity and mortality in HIV-infected children. Sample collection and the paucibacillary nature of TB in children makes diagnosis challenging. Rapid diagnostic tools using easily obtained specimens are urgently needed. METHODS Hospitalized, HIV-infected children aged 12 years or less enrolled in a randomized controlled trial (NCT02063880) comparing urgent to post-stabilization antiretroviral therapy initiation in Kenya underwent TB evaluation. At enrollment, sputum or gastric aspirates were collected for TB culture and Xpert, stool for Xpert, and urine for lipoarabinomannan (LAM). When possible, a second sputum/gastric aspirate for culture was obtained. Stool Xpert and urine LAM performance were compared to reference sputum/gastric aspirate culture. RESULTS Among 165 HIV-infected children, median age was 24 months [interquartile range (IQR) 13-58], median CD4% was 14.3 (IQR 8.9-22.0%), and 114 (69.5%) had severe immunosuppression. Thirteen (7.9%) children had confirmed TB (positive culture and/or Xpert). Sputum/gastric aspirate Xpert, stool Xpert, and urine LAM sensitivities were 60% [95% confidence interval (CI) 26-88%], 63% (95% CI 25-92%), and 43% (95% CI 10-82%), respectively. Specificity was 98% (95% CI 94-100%) for sputum/gastric aspirate Xpert, 99% (95% CI 95-100%) for stool Xpert, and 91% (95% CI 84-95%) for urine LAM. Stool Xpert and urine LAM sensitivity increased among children with severe immunosuppression [80% (95% CI 28-100) and 60% (95% Cl 15-95%)]. CONCLUSION Stool Xpert had similar performance compared with sputum/gastric aspirate Xpert to detect TB. Urine LAM had lower sensitivity and specificity, but increased among children with severe immunosuppression. Stool Xpert and urine LAM can aid rapid detection of TB in HIV-infected children using easily accessible samples.
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182
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Mellado Peña MJ, Santiago García B, Baquero-Artigao F, Moreno Pérez D, Piñeiro Pérez R, Méndez Echevarría A, Ramos Amador JT, Gómez-Pastrana Durán D, Noguera Julian A. Tuberculosis treatment for children: An update. An Pediatr (Barc) 2018. [DOI: 10.1016/j.anpede.2017.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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183
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Nonyane BAS, Nicol MP, Andreas NJ, Rimmele S, Schneiderhan-Marra N, Workman LJ, Perkins MD, Joos T, Broger T, Ellner JJ, Alland D, Kampmann B, Dorman SE, Zar HJ. Serologic Responses in Childhood Pulmonary Tuberculosis. Pediatr Infect Dis J 2018; 37:1-9. [PMID: 28719497 PMCID: PMC6261442 DOI: 10.1097/inf.0000000000001683] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Identification of the Mycobacterium tuberculosis immunoproteome and antigens associated with serologic responses in adults has renewed interest in developing a serologic test for childhood tuberculosis (TB). We investigated IgG antibody responses against M. tuberculosis antigens in children with well-characterized TB. METHODS We studied archived sera obtained from hospitalized children with suspected pulmonary TB, and classified as having confirmed TB (culture-confirmed), unlikely TB (clinical improvement without TB treatment), or unconfirmed TB (all others). A multiplexed bead-based assay for IgG antibodies against 119 M. tuberculosis antigens was developed, validated and used to test sera. The area under the curves (AUCs) of the empiric receiver-operator characteristic curves were generated as measures of predictive ability. A cross-validated generalized linear model was used to select the most predictive combinations of antigens. RESULTS For the confirmed TB versus unlikely TB comparison, the maximal single antigen AUC was 0.63, corresponding to sensitivity 0.60 and specificity 0.60. Older (age: 60+ months old) children's responses were better predictive of TB status than younger (age: 12-59 months old) children's, with a maximal single antigen AUC of -0.76. For the confirmed TB versus unlikely TB groups, the most predictive combinations of antigens assigned TB risk probabilities of 0.33 and 0.33, respectively, when all ages were considered, and 0.57 (interquartile range: 0.48-0.64) and 0.35 (interquartile range: 0.32-0.40) when only older children were considered. CONCLUSION An antigen-based IgG test is unlikely to meet the performance characteristics required of a TB detection test applicable to all age groups.
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Affiliation(s)
- Bareng A. S. Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mark P. Nicol
- Division of Medical Microbiology and Institute for Infectious Diseases and Molecular Medicine, University of Cape Town
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Nicholas J. Andreas
- Centre for International Child Health, Department of Paediatrics, Imperial College London, St. Mary’s Hospital, London, W2 1NY, United Kingdom
| | - Stefanie Rimmele
- Natural and Medical Sciences Institute at the University of Tuebingen, Reutlingen, Germany
| | | | - Lesley J. Workman
- Department of Paediatrics & Child Health and MRC Unit on Child & Adolescent Health University of Cape Town, Cape Town, South Africa
| | | | - Thomas Joos
- Natural and Medical Sciences Institute at the University of Tuebingen, Reutlingen, Germany
| | | | - Jerrold J. Ellner
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - David Alland
- Department of Medicine, Rutgers-New Jersey Medical Center, Newark, New Jersey
| | - Beate Kampmann
- Centre for International Child Health, Department of Paediatrics, Imperial College London, St. Mary’s Hospital, London, W2 1NY, United Kingdom
- Vaccines & Immunity Theme, MRC Unit The Gambia, Serrekunda, Gambia
| | - Susan E. Dorman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Heather J. Zar
- Department of Paediatrics & Child Health and MRC Unit on Child & Adolescent Health University of Cape Town, Cape Town, South Africa
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Njuguna IN, Cranmer LM, Otieno VO, Mugo C, Okinyi HM, Benki-Nugent S, Richardson B, Stern J, Maleche-Obimbo E, Wamalwa DC, John-Stewart GC. Urgent versus post-stabilisation antiretroviral treatment in hospitalised HIV-infected children in Kenya (PUSH): a randomised controlled trial. Lancet HIV 2018; 5:e12-e22. [PMID: 29150377 PMCID: PMC5777310 DOI: 10.1016/s2352-3018(17)30167-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/30/2017] [Accepted: 09/04/2017] [Indexed: 12/03/2022]
Abstract
BACKGROUND Urgent antiretroviral therapy (ART) among hospitalised HIV-infected children might accelerate recovery or worsen outcomes associated with immune reconstitution. We aimed to compare urgent versus post-stabilisation ART among hospitalised HIV-infected children in Kenya. METHODS In this unmasked randomised controlled trial, we randomly assigned (1:1) HIV-infected, ART-naive children aged 0-12 years who were eligible for treatment to receive ART within 48 h (urgent group) or in 7-14 days (post-stabilisation group) at four hospitals in Kenya (two in Nairobi and two in western Kenya). We excluded children with suspected or confirmed CNS infection. A statistician not involved in study procedures did block randomisation with variable block sizes generated using STATA version 12. We followed children for 6 months for primary outcomes: mortality, drug toxicity, and immune reconstitution inflammatory syndrome (IRIS). We did all analyses in a modified intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02063880. FINDINGS We began enrolment on April 24, 2013, and completed follow-up on Nov 17, 2015. We enrolled 191 (76%) of 250 hospitalised HIV-infected children. Of these, 183 children were randomly assigned: 90 to urgent ART and 93 to post-stabilisation ART. 181 (99%) of 183 children were included in the modified intention-to-treat analysis. Median age was 1·9 years (IQR 0·8-4·8). Baseline sociodemographic, clinical, and virological characteristics did not differ between groups except median CD4 cell percentage, which was lower in the urgent group (13% [IQR 9-18] vs 17% [IQR 9-24]; p=0·052). Of 181 admission diagnoses, 118 (65%) were pneumonia, 58 (32%) malnutrition, and 27 (15%) suspected tuberculosis. Median time to ART was 1 day (IQR 1-1) in the urgent group and 8 days (IQR 7-11) in the post-stabilisation group. Overall, mortality risk at 6 months was 61 per 100 person-years. Mortality risk did not differ by group (70 per 100 person-years in the urgent group vs 54 per 100 person-years in the post-stabilisation group; hazard ratio [HR] 1·26, 95% CI 0·67-2·37) p=0.47, even after adjusting for baseline CD4 cell percentage (adjusted HR 1·30, 95% CI 0·69-2·45; p=0·41). The incidence of IRIS, and drug toxicity was not significantly different between trial arms. There were no differences between treatment groups in the proportion of grade 3 or 4 adverse events (34 [38%] of 90 children in the urgent group vs 40 [44%] of 91 children in the post-stabilisation group; p=0·40) or the proportion of any change in ART regimen (five [7%] vs six [8%]; p=0·79). We discontinued randomisation at interim review when the futility boundary was crossed. INTERPRETATION Early mortality risk was extremely high among hospitalised HIV-infected children. Urgent ART did not improve survival. FUNDING National Institute of Child Health and Human Development, National Institutes of Health, USA.
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Affiliation(s)
- Irene N Njuguna
- Kenyatta National Hospital, Nairobi, Kenya; Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Lisa M Cranmer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Cyrus Mugo
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Hellen M Okinyi
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | - Barbra Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joshua Stern
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace C John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
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Martinez L, Shen Y, Handel A, Chakraburty S, Stein CM, Malone LL, Boom WH, Quinn FD, Joloba ML, Whalen CC, Zalwango S. Effectiveness of WHO's pragmatic screening algorithm for child contacts of tuberculosis cases in resource-constrained settings: a prospective cohort study in Uganda. THE LANCET RESPIRATORY MEDICINE 2017; 6:276-286. [PMID: 29273539 DOI: 10.1016/s2213-2600(17)30497-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/01/2017] [Accepted: 11/02/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Tuberculosis is a leading cause of global childhood mortality; however, interventions to detect undiagnosed tuberculosis in children are underused. Child contact tracing has been widely recommended but poorly implemented in resource-constrained settings. WHO has proposed a pragmatic screening approach for managing child contacts. We assessed the effectiveness of this screening approach and alternative symptom-based algorithms in identifying secondary tuberculosis in a prospectively followed cohort of Ugandan child contacts. METHODS We identified index patients aged at least 18 years with microbiologically confirmed pulmonary tuberculosis at Old Mulago Hospital (Kampala, Uganda) between Oct 1, 1995, and Dec 31, 2008. Households of index patients were visited by fieldworkers within 2 weeks of diagnosis. Coprevalent and incident tuberculosis were assessed in household contacts through clinical, radiographical, and microbiological examinations for 2 years. Disease rates were compared among children younger than 16 years with and without symptoms included in the WHO pragmatic guideline (presence of haemoptysis, fever, chronic cough, weight loss, night sweats, and poor appetite). Symptoms could be of any duration, except cough (>21 days) and fever (>14 days). A modified WHO decision-tree designed to detect high-risk asymptomatic child contacts was also assessed, in which all asymptomatic contacts were classified as high risk (children younger than 3 years or immunocompromised [HIV-infected]) or low risk (aged 3 years or older and immunocompetent [HIV-negative]). We also assessed a more restrictive algorithm (ie, assessing only children with presence of chronic cough and one other tuberculosis-related symptom). FINDINGS Of 1718 household child contacts, 126 (7%) had coprevalent tuberculosis and 24 (1%) developed incident tuberculosis, diagnosed over the 2-year study period. Of these 150 cases of tuberculosis, 95 (63%) were microbiologically confirmed with a positive sputum culture. Using the WHO approach, 364 (21%) of 1718 child contacts had at least one tuberculosis-related symptom and 85 (23%) were identified as having coprevalent tuberculosis, 67% of all coprevalent cases detected (diagnostic odds ratio 9·8, 95% CI 6·8-14·5; p<0·0001). 1354 (79%) of 1718 child contacts had no symptoms, of whom 41 (3%) had coprevalent tuberculosis. The WHO approach was effective in contacts younger than 5 years: 70 (33%) of 211 symptomatic contacts had coprevalent disease compared with 23 (6%) of 367 asymptomatic contacts (p<0·0001). This approach was also effective in contacts aged 5 years and older: 15 (10%) of 153 symptomatic contacts had coprevalent disease compared with 18 (2%) of 987 asymptomatic contacts (p<0·0001). More coprevalent disease was detected in child contacts recommended for screening when the study population was restricted by HIV-serostatus (11 [48%] of 23 symptomatic HIV-seropositive child contacts vs two [7%] of 31 asymptomatic HIV-seropositive child contacts) or to only culture-confirmed cases (47 [13%] culture confirmed cases of 364 symptomatic child contacts vs 29 [2%] culture confirmed cases of 1354 asymptomatic child contacts). In the modified algorithm, high-risk asymptomatic child contacts were at increased risk for coprevalent disease versus low-risk asymptomatic contacts (14 [6%] of 224 vs 27 [2%] of 1130; p=0·0021). The presence of tuberculosis infection did not predict incident disease in either symptomatic or asymptomatic child contacts: in symptomatic contacts, eight (5%) of 169 infected contacts and six (5%) of 111 uninfected contacts developed incident tuberculosis (p=0·80). Among asymptomatic contacts, incident tuberculosis occurred in six (<1%) of 795 contacts infected at baseline versus four (<1%) of 518 contacts uninfected at baseline, respectively (p=1·00). INTERPRETATION WHO's pragmatic, symptom-based algorithm was an effective case-finding tool, especially in children younger than 5 years. A modified decision-tree identified 6% of asymptomatic child contacts at high risk for subclinical disease. Increasing the feasibility of child-contact tracing using these approaches should be encouraged to decrease tuberculosis-related paediatric mortality in high-burden settings, but this should be partnered with increasing access to microbiological point-of-care testing. FUNDING National Institutes of Health, Tuberculosis Research Unit, AIDS International Training and Research Program of the Fogarty International Center, and the Center for AIDS Research.
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Affiliation(s)
- Leonardo Martinez
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA; Institute of Global Health, University of Georgia, Athens, GA, USA; Division of Infectious Diseases and Geographic Medicine, School of Medicine, Stanford University, Stanford, CA, USA.
| | - Ye Shen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Andreas Handel
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Catherine M Stein
- Department of Population and Quantitative Health Sciences, Tuberculosis Research Unit & Department of Medicine, Case Western Reserve University, Cleveland, OH, USA; Uganda-CWRU Research Collaboration, Makerere University and Mulago Hospital, Kampala, Uganda
| | - LaShaunda L Malone
- Division of Infectious Disease, Department of Medicine and Tuberculosis Research Unit, Case Western Reserve University, Cleveland, OH, USA; Uganda-CWRU Research Collaboration, Makerere University and Mulago Hospital, Kampala, Uganda
| | - W Henry Boom
- Division of Infectious Disease, Department of Medicine and Tuberculosis Research Unit, Case Western Reserve University, Cleveland, OH, USA; Uganda-CWRU Research Collaboration, Makerere University and Mulago Hospital, Kampala, Uganda
| | - Frederick D Quinn
- University of Georgia, Department of Veterinary Medicine, Athens, GA, USA
| | - Moses L Joloba
- Department of Immunology/Molecular Biology and Department of Medical Microbiology, School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Christopher C Whalen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA; Institute of Global Health, University of Georgia, Athens, GA, USA
| | - Sarah Zalwango
- Uganda-CWRU Research Collaboration, Makerere University and Mulago Hospital, Kampala, Uganda
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Marais BJ. Symptom-based screening of children with household tuberculosis contact. THE LANCET RESPIRATORY MEDICINE 2017; 6:235-237. [PMID: 29273537 DOI: 10.1016/s2213-2600(17)30496-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 11/14/2017] [Indexed: 11/20/2022]
Affiliation(s)
- Ben J Marais
- The Children's Hospital at Westmead, Centre for Research Excellence in Tuberculosis and the Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, NSW, 2145, Australia.
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Marcy O, Tejiokem M, Msellati P, Truong Huu K, Do Chau V, Tran Ngoc D, Nacro B, Ateba-Ndongo F, Tetang-Ndiang S, Ung V, Dim B, Neou L, Berteloot L, Borand L, Delacourt C, Blanche S. Mortality and its determinants in antiretroviral treatment-naive HIV-infected children with suspected tuberculosis: an observational cohort study. Lancet HIV 2017; 5:e87-e95. [PMID: 29174612 DOI: 10.1016/s2352-3018(17)30206-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 08/01/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Tuberculosis is a major cause of morbidity and mortality in HIV-infected children, but is difficult to diagnose. We studied mortality and its determinants in antiretroviral treatment (ART)-naive HIV-infected children presenting with suspected tuberculosis. METHODS In this observational cohort study, HIV-infected children aged 13 years or younger with suspected tuberculosis were followed up for 6 months as part of the ANRS 12229 PAANTHER 01 cohort in eight hospitals in four countries (Burkina Faso, Cambodia, Cameroon, and Vietnam). Children started ART and antituberculosis treatment at the clinician's discretion and were retrospectively classified into one of three groups by tuberculosis documentation: confirmed by culture or Xpert MTB/RIF, unconfirmed, and unlikely. We assessed mortality and associated factors using Kaplan-Meier methods and Cox proportional hazard models. The ANRS 12229 PAANTHER 01 study is registered at ClinicalTrials.gov, number NCT01331811. FINDINGS 266 (61%) of 438 children enrolled in the study between April 27, 2011, and May 31, 2014, were ART-naive and included in the analysis (40 had confirmed tuberculosis, 119 unconfirmed tuberculosis, and 107 unlikely tuberculosis). 112·5 person-years of follow-up were available. 154 children (58%) started antituberculosis treatment and 212 (80%) started ART. 50 children (19%) died. Mortality by 6 months was higher in children with confirmed tuberculosis (14 deaths; 2 month survival probability 65·0% [95% CI 50·2-79·8]) compared with unconfirmed tuberculosis (19 deaths; 83·5% [76·8-90·3]) and unlikely tuberculosis (17 deaths; 83·5% [76·3-90·7]; log-rank p=0·0141) and was lower in children with confirmed or unconfirmed tuberculosis who started antituberculosis treatment (p<0·0001 for both). In a multivariate analysis, ART started during the first month of follow-up (hazard ratio 0·08; 95% CI 0·01-0·67), confirmed tuberculosis (6·33; 2·15-18·64), young age (5·90; 2·02-17·19), CD4 less than 10% (2·63; 1·25-5·53), miliary features (4·08; 1·56-10·66), and elevated serum transaminases (4·40; 1·82-10·65) were all independently associated with mortality. INTERPRETATION In our cohort, mortality was high in the first 6 months after suspicion of tuberculosis in ART-naive children. ART should be started early, particularly in children with factors associated with high mortality. Documented or empirical tuberculosis treatment decision should be accelerated to reduce mortality and allow early ART initiation. FUNDING ANRS and Fondation Total.
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Affiliation(s)
- Olivier Marcy
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia; Bordeaux Population Health Centre U1219, Université de Bordeaux, Bordeaux, France.
| | - Mathurin Tejiokem
- Service d'Epidémiologie et de Santé Publique, Centre Pasteur du Cameroun, Réseau International des Instituts Pasteur, Yaounde, Cameroon
| | - Philippe Msellati
- UMI 233-U1175 TransVIHMI, Institut de Recherche pour le Développement, Université de Montpellier, Montpellier, France
| | - Khanh Truong Huu
- Infectious Disease Department, Pediatric Hospital Nhi Dong 1, Ho Chi Minh City, Vietnam
| | - Viet Do Chau
- Infectious Disease Department, Pediatric Hospital Nhi Dong 2, Ho Chi Minh City, Vietnam
| | - Duong Tran Ngoc
- Pediatric Department, Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | - Boubacar Nacro
- Service de Pédiatrie, Centre Hospitalier Universitaire Souro Sanou, Bobo Dioulasso, Burkina Faso
| | | | | | - Vibol Ung
- Tuberculosis/HIV Department, National Pediatric Hospital, Phnom Penh, Cambodia; Planning and Research Department, University of Health Sciences, Phnom Penh, Cambodia
| | - Bunnet Dim
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Leakhena Neou
- Neonatal Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Laureline Berteloot
- Pediatric Radiology Department, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Laurence Borand
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Christophe Delacourt
- Service de Pneumologie et d'Allergologie Pédiatriques, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Stéphane Blanche
- Unité d'Immunologie Hématologie Rhumatologie Pédiatrique, Hôpital Necker Enfants Malades, AP-HP, Paris, France
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Stool Culture for Diagnosis of Pulmonary Tuberculosis in Children. J Clin Microbiol 2017; 55:3355-3365. [PMID: 28904186 PMCID: PMC5703802 DOI: 10.1128/jcm.00801-17] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/05/2017] [Indexed: 12/13/2022] Open
Abstract
Bacteriological confirmation of Mycobacterium tuberculosis is achieved in the minority of young children with tuberculosis (TB), since specimen collection is resource intensive and respiratory secretions are mostly paucibacillary, leading to limited sensitivity of available diagnostic tests. Although molecular tests are increasingly available globally, mycobacterial culture remains the gold standard for diagnosis and determination of drug susceptibility and is more sensitive than molecular methods for paucibacillary TB. We evaluated stool culture as an alternative to respiratory specimens for the diagnosis of suspected intrathoracic TB in a subgroup of 188 children (median age, 14.4 months; 15.4% HIV infected) enrolled in a TB diagnostic study at two local hospitals in Cape Town, South Africa. One stool culture was compared to overall bacteriological confirmation by stool Xpert and by Xpert and culture of multiple respiratory specimens. After decontamination/digestion with NALC (N-acetyl-l-cysteine)-NaOH (1.25%), concentrated fluorescent smear microscopy, Xpert MTB/RIF, and liquid culture were completed for all specimens. Culture contamination of stool specimens was high at 41.5%. Seven of 90 (7.8%) children initiating TB treatment were stool culture positive for M. tuberculosis. Excluding contaminated cultures, the sensitivity of stool culture versus confirmed TB was 6/25 (24.0%; 95% confidence interval [CI] = 9.4 to 45.1%). In addition, stool culture detected TB in 1/93 (1.1%) children with “unconfirmed TB.” Testing the same stool by Xpert increased sensitivity to 33.3% (95% CI = 18.0 to 51.8%). In conclusion, stool culture had low sensitivity for M. tuberculosis detection in children with intrathoracic TB. Reducing culture contamination through improved laboratory protocols may enable more reliable estimates of its diagnostic utility.
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Xpert MTB/RIF on Stool Is Useful for the Rapid Diagnosis of Tuberculosis in Young Children With Severe Pulmonary Disease. Pediatr Infect Dis J 2017; 36:837-843. [PMID: 28151842 PMCID: PMC5558052 DOI: 10.1097/inf.0000000000001563] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Tuberculosis (TB) continues to result in high morbidity and mortality in children from resource-limited settings. Diagnostic challenges, including resource-intense sputum collection methods and insensitive diagnostic tests, contribute to diagnostic delay and poor outcomes in children. We evaluated the diagnostic utility of stool Xpert MTB/RIF (Xpert) compared with bacteriologic confirmation (combination of Xpert and culture of respiratory samples). METHODS In a hospital-based study in Cape Town, South Africa, we enrolled children younger than 13 years of age with suspected pulmonary TB from April 2012 to August 2015. Standard clinical investigations included tuberculin skin test, chest radiograph and HIV testing. Respiratory samples for smear microscopy, Xpert and liquid culture included gastric aspirates, induced sputum, nasopharyngeal aspirates and expectorated sputum. One stool sample per child was collected and tested using Xpert. RESULTS Of 379 children enrolled (median age, 15.9 months, 13.7% HIV infected), 73 (19.3%) had bacteriologically confirmed TB. The sensitivity and specificity of stool Xpert versus overall bacteriologic confirmation were 31.9% [95% confidence interval (CI): 21.84%-44.50%] and 99.7% (95% CI: 98.2%-100%), respectively. A total of 23/51 (45.1%) children with bacteriologically confirmed TB with severe disease were stool Xpert positive. Cavities on chest radiograph were associated with Xpert stool positivity regardless of age and other relevant factors [odds ratios (OR) 7.05; 95% CI: 2.16-22.98; P = 0.001]. CONCLUSIONS Stool Xpert can rapidly confirm TB in children who present with radiologic findings suggestive of severe TB. In resource-limited settings where children frequently present with advanced disease, Xpert on stool samples could improve access to rapid diagnostic confirmation and appropriate treatment.
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[Recommendations for the diagnosis and prevention of infectious diseases in pediatric and adolescent refugees in Germany : Statement of the German Society of Pediatric Infectious Diseases, the Society of Tropical Pediatrics and International Child Health, and the Professional Association of Pediatricians]. Internist (Berl) 2017; 57:416-33. [PMID: 27138489 DOI: 10.1007/s00108-016-0040-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Child and adolescent refugees in Germany represent a particularly vulnerable social group and treating infectious diseases forms a crucial part of providing their medical care. From an infectious diseases perspective, refugees themselves, as a result of their difficult personal circumstances, are the ones at highest risk. Even in crisis situations, medical practitioners are medically and ethically obliged to provide a high standard of care. The guidelines presented here propose recommendations for diagnosing and preventing infectious diseases among refugees under 18 in Germany. The guidelines are intended to assist in optimizing vaccine protection and treatment of diseases while taking into consideration factors such as refugees' challenging living conditions, cultural differences and potential language barriers.Upon refugees' arrival at the first housing sites, it is recommended that a basic clinical screening (and not just a brief visual inspection) be provided in order to identify and initiate treatment for acute medical problems and potentially contagious diseases (including tuberculosis), as well as to close gaps in vaccination coverage. Documentation of the clinical findings is critical, both to avoid redundant investigations and to optimize individual medical care. For this, an effective communication system must be established.Once refugees have been transferred into their destination community, outpatient and inpatient care providers should collaborate to bring refugees up-to-date with all vaccines recommended by STIKO (German Standing Committee on Vaccination). The same high standard of medical care should be delivered to refugees as would be to the general population. Due to the high prevalence of multi-resistant organisms (MRO) in the refugees' countries of origin, MRO screening is recommended for most patients receiving inpatient care.
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Mellado Peña MJ, Santiago García B, Baquero-Artigao F, Moreno Pérez D, Piñeiro Pérez R, Méndez Echevarría A, Ramos Amador JT, Gómez-Pastrana Durán D, Noguera Julian A. [Tuberculosis treatment for children: An update]. An Pediatr (Barc) 2017; 88:52.e1-52.e12. [PMID: 28729186 DOI: 10.1016/j.anpedi.2017.05.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 05/30/2017] [Indexed: 01/06/2023] Open
Abstract
Tuberculosis (TB) is the most important infectious disease all over the world, with a high morbidity and mortality. Pediatric tuberculosis has been a neglected epidemic, due to the difficulties in assessing its global impact, reduced incidence and lower infectivity compared to adults. In 2015, the WHO reported 1 million cases of paediatric TB and 169,000 deaths. In Europe, the emergence of MDR TB is a major concern, representing 16% of the new diagnosis in Eastern Europe. In 2014, it was estimated that about 219,000 children were infected by MDR-TB-strains in Europe, and 2,120 developed the disease. Spain is the Western European country with more paediatric cases, with an incidence 4.3/100,000 inhabitants in 2014. Paediatric tuberculosis mortality in Spain is rare, but extra-pulmonary disease is associated with significant complications. The prevalence of paediatric drug resistant TB in Spain is over 4%, higher than the estimated incidence in adult population, representing mayor difficulties for therapeutic intervention. These data reveal that paediatric TB is still a Public Health priority in our country. The difficulties in diagnosis and the lack of optimal paediatric drug formulations are the major challenges for controlling the childhood's tuberculosis epidemic. A group of national paeditric TB experts has reviewed the international guidelines and the most recent evidences, and has established new recommendations for the management of paediatric TB contacts, latent infection and active TB disease, especially focused in drug resistant cases. This document replaces the former national guidelines from the Spanish Society for Pediatric Infectios Diseases, although the prior recommendations on the diagnosis remain valid.
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Affiliation(s)
- María José Mellado Peña
- Red Española de Estudio de la Tuberculosis Pediátrica (pTBred), España; Sociedad Española de Infectología Pediátrica (SEIP), España; Red Española de Investigación Traslacional en Infectología Pediátrica (RITIP), España; European Network of Excellence for Paediatric Clinical Research (TEDDY), España.
| | - Begoña Santiago García
- Red Española de Estudio de la Tuberculosis Pediátrica (pTBred), España; Sociedad Española de Infectología Pediátrica (SEIP), España; Red Española de Investigación Traslacional en Infectología Pediátrica (RITIP), España
| | - Fernando Baquero-Artigao
- Red Española de Estudio de la Tuberculosis Pediátrica (pTBred), España; Sociedad Española de Infectología Pediátrica (SEIP), España; Red Española de Investigación Traslacional en Infectología Pediátrica (RITIP), España
| | - David Moreno Pérez
- Red Española de Estudio de la Tuberculosis Pediátrica (pTBred), España; Sociedad Española de Infectología Pediátrica (SEIP), España; Red Española de Investigación Traslacional en Infectología Pediátrica (RITIP), España
| | - Roi Piñeiro Pérez
- Red Española de Estudio de la Tuberculosis Pediátrica (pTBred), España; Sociedad Española de Infectología Pediátrica (SEIP), España; Red Española de Investigación Traslacional en Infectología Pediátrica (RITIP), España; European Network of Excellence for Paediatric Clinical Research (TEDDY), España
| | - Ana Méndez Echevarría
- Red Española de Estudio de la Tuberculosis Pediátrica (pTBred), España; Sociedad Española de Infectología Pediátrica (SEIP), España; Red Española de Investigación Traslacional en Infectología Pediátrica (RITIP), España
| | - José Tomás Ramos Amador
- Red Española de Estudio de la Tuberculosis Pediátrica (pTBred), España; Sociedad Española de Infectología Pediátrica (SEIP), España; Red Española de Investigación Traslacional en Infectología Pediátrica (RITIP), España
| | - David Gómez-Pastrana Durán
- Red Española de Estudio de la Tuberculosis Pediátrica (pTBred), España; Sociedad Española de Neumología Pediátrica (SENP), España
| | - Antoni Noguera Julian
- Red Española de Estudio de la Tuberculosis Pediátrica (pTBred), España; Sociedad Española de Infectología Pediátrica (SEIP), España; Red Española de Investigación Traslacional en Infectología Pediátrica (RITIP), España
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Wang Z, Dendukuri N, Pai M, Joseph L. Taking Costs and Diagnostic Test Accuracy into Account When Designing Prevalence Studies: An Application to Childhood Tuberculosis Prevalence. Med Decis Making 2017. [PMID: 28627302 DOI: 10.1177/0272989x17713456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND When planning a study to estimate disease prevalence to a pre-specified precision, it is of interest to minimize total testing cost. This is particularly challenging in the absence of a perfect reference test for the disease because different combinations of imperfect tests need to be considered. We illustrate the problem and a solution by designing a study to estimate the prevalence of childhood tuberculosis in a hospital setting. METHODS All possible combinations of 3 commonly used tuberculosis tests, including chest X-ray, tuberculin skin test, and a sputum-based test, either culture or Xpert, are considered. For each of the 11 possible test combinations, 3 Bayesian sample size criteria, including average coverage criterion, average length criterion and modified worst outcome criterion, are used to determine the required sample size and total testing cost, taking into consideration prior knowledge about the accuracy of the tests. RESULTS In some cases, the required sample sizes and total testing costs were both reduced when more tests were used, whereas, in other examples, lower costs are achieved with fewer tests. CONCLUSION Total testing cost should be formally considered when designing a prevalence study.
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Affiliation(s)
- Zhuoyu Wang
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada (ZW, ND, MP, LJ)
| | - Nandini Dendukuri
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada (ZW, ND, MP, LJ).,Technology Assessment Unit, McGill University Health Center, Montreal, QC, Canada (ND).,Division of Clinical Epidemiology, Department of Medicine, McGill University Health Center, Montreal, QC, Canada (ND, LJ)
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada (ZW, ND, MP, LJ)
| | - Lawrence Joseph
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada (ZW, ND, MP, LJ).,Division of Clinical Epidemiology, Department of Medicine, McGill University Health Center, Montreal, QC, Canada (ND, LJ)
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193
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Iskandar A, Nursiloningrum E, Arthamin MZ, Olivianto E, Chandrakusuma MS. The Diagnostic Value of Urine Lipoarabinomannan (LAM) Antigen in Childhood Tuberculosis. J Clin Diagn Res 2017; 11:EC32-EC35. [PMID: 28511392 PMCID: PMC5427318 DOI: 10.7860/jcdr/2017/20909.9542] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 12/06/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Diagnosis of Tuberculosis (TB) in children is difficult because the clinical presentation is not specific, the chest X-ray interpretation has low accuracy and sputum sample is difficult to obtain. Antigen detection test such as rapid urine LAM is a non-invasive alternative for diagnosing TB . Lipoarabinomannan (LAM) is the main component of M.tuberculosis cell wall. AIM To determine the diagnostic value of urinary LAM antigen for diagnosis of childhood TB. MATERIALS AND METHODS In the present cross-sectional study, subjects were included using consecutive sampling method. All the children aged 0-14 years Suspected of pulmonary or extra pulmonary TB suffering from cough more than two weeks, fever without clear aetiology, loss of body weight or poor weight gain, fatigue, malaise, chronic lymph node enlargement, spine angulation, joint swelling and had history of contact with positive sputum smear adult TB patient were enrolled in the study. Pulmonary and extra pulmonary diagnosis was based on clinical presentation, Tuberculin Skin Test (TST), chest X-ray, Acid Fast Bacillus (AFB) staining and or sputum culture. Urinary LAM level was measured by using Enzyme-Linked Immunosorbent Assay (ELISA). Cut off value and Area Under the Curve (AUC) were determined using ROC statistical analysis (SPSS 21.0). Sensitivity and specificity was measured from 2x2 cross table. RESULTS Out of 61 subjects suspected as TB, 49 (80.3%) were eventually diagnosed with TB. Of those diagnosed with TB, 21 (42.9%) were microbiologically confirmed cases either by sputum microscopy (34.7%) or culture (8.2%), whereas 28 subjects were unconfirmed cases (57.1%). The urinary LAM level was higher in subjects with TB (1.80+1.02) mg/l compared to non-TB group (0.46+0.3) mg/l; p<0.001(independent t-test). Urine LAM had 83% sensitivity and 85% specificity with cut off value 0.98 mg/l using microbiological and clinical confirmation as standard reference and 33% sensitivity and 60% specificity with cut off value 1.69 mg/l using microbiological confirmation only. CONCLUSION Urinary LAM has good diagnostic value for childhood TB diagnosis.
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Affiliation(s)
- Agustin Iskandar
- Consultant, Department of Clinical Pathology, Universitas Brawijaya, Malang, East Java, Indonesia
| | - Erlin Nursiloningrum
- Consultant, Department of Clinical Pathology, Universitas Brawijaya, Malang, East Java, Indonesia
| | | | - Ery Olivianto
- Consultant, Department of Child Health, Universitas Brawijaya, Malang, East Java, Indonesia
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194
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Bennet R, Eriksson M. Tuberculosis infection and disease in the 2015 cohort of unaccompanied minors seeking asylum in Northern Stockholm, Sweden. Infect Dis (Lond) 2017; 49:501-506. [PMID: 28276801 DOI: 10.1080/23744235.2017.1292540] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Minors with a stated age <18 years unaccompanied by a responsible adult form an increasing part of refugees to Europe. They are older than other asylum-seeking children and many come from countries with a high tuberculosis (TB) incidence. During the 2015 refugee crisis, 35,369 of 162,877 refugees (22%) seeking asylum in Sweden were unaccompanied minors, which gave us the opportunity to study their burden of TB infection and disease. METHODS Of the unaccompanied minors seeking asylum in Sweden during 2015, 2936 (8.3%) were allocated to northern Stockholm. Of these, 2422 were from countries with an incidence of TB exceeding 100/105, and were screened for TB infection with a Mantoux tuberculin skin test or a QuantiFERON-TB Gold®. Those from countries with a lower TB incidence were screened only if they had other risk factors for TB exposure. RESULTS Of those screened, 349 had a positive test and were referred to the northern paediatric TB clinic at Astrid Lindgren Children's Hospital. Of these, 16 had TB disease and 278 latent tuberculosis infection (LTBI), while we considered 53 uninfected. In addition, eight sought medical attention with symptomatic TB outside the screening system. Cohort rates were 6.8% of LTBI and 0.5% of TB in minors from Afghanistan and 26-32% of LTBI and 3.4-3.5% of TB among those from Eritrea, Ethiopia or Somalia. CONCLUSION We conclude that TB infection and disease is common among asylum-seeking unaccompanied minors, especially among those from the Horn of Africa.
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Affiliation(s)
- Rutger Bennet
- a Department of Emergency Paediatrics , Astrid Lindgren Children´s Hospital, Karolinska University Hospital , Stockholm , Sweden
| | - Margareta Eriksson
- a Department of Emergency Paediatrics , Astrid Lindgren Children´s Hospital, Karolinska University Hospital , Stockholm , Sweden
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195
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Serial QuantiFERON testing and tuberculosis disease risk among young children: an observational cohort study. THE LANCET RESPIRATORY MEDICINE 2017; 5:282-290. [PMID: 28215501 DOI: 10.1016/s2213-2600(17)30060-7] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 12/06/2016] [Accepted: 12/19/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The value of quantitative interferon-γ release assay results for predicting progression from Mycobacterium tuberculosis infection to active disease is unknown. We aimed to investigate the relation between QuantiFERON-TB Gold In-Tube (QFT) conversion interferon-γ values and risk of subsequent active tuberculosis disease and of QFT reversion. METHODS We analysed data from a reported vaccine efficacy trial of the tuberculosis vaccine MVA85A in South Africa. QFT negative, HIV uninfected young children aged 18-24 weeks were enrolled. We stratified participants by quantitative QFT result (interferon-γ <0·35 IU/mL, 0·35-4·00 IU/mL, and >4·00 IU/mL) at the intermediate study visit (day 336) and determined risk of progression to active tuberculosis disease over the subsequent 6-24 months. No QFT differences were observed between placebo and MVA85A groups at day 336 or end of study; therefore, both groups were included in analyses. Study clinicians were not masked to QFT values, but strict case definitions were used that excluded QFT results. We used generalised additive models to evaluate the quantitative relation between day 336 QFT value and subsequent disease risk, and we compared disease rates between QFT strata using a two-sample Poisson test. FINDINGS Among 2512 young children with QFT tests done at day 336, 172 (7%) were positive; 87 (7%) of 1267 in placebo group and 85 (7%) of 1245 in the MVA85A group (p=1·00). Compared with QFT non-converters (tuberculosis disease incidence 0·7 per 100 person-years [95% CI 0·4-1·1]), children with QFT conversion at interferon-γ values between 0·35-4·00 IU/mL did not have significantly increased risk of disease (2·5 per 100 person-years [95% CI 0·4-9·4]; incidence rate ratio (IRR) 3·7 (95% CI 0·4-15·8; p=0·23). However, QFT conversion at interferon-γ values higher than 4·00 IU/mL was associated with substantially increased disease incidence (28·0 per 100 person-years [95% CI 14·9-45·7]) compared with non-converters (IRR 42·5 [95% CI 17·2-99·7]; p<0·0001), and compared with children with interferon-γ values between 0·35-4·00 IU/mL (IRR 11·4 [95% CI 2·4-107·2]; p=0·00047). Among 91 QFT converters who were given a repeat test, 53 (58%) reverted from positive to negative. QFT reversion risk was inversely associated with interferon-γ value at QFT conversion and was highest with interferon-γ values less than 4·00 IU/mL (47 [77%] of 61). INTERPRETATION In young children, tuberculosis disease risk was not significantly increased, and QFT reversion was common, following QFT conversion at interferon-γ values up to 10 times the recommended test threshold (0·35 IU/mL). By contrast, QFT conversion at very high interferon-γ values (>4·00 IU/mL) warrants intensified diagnostic and preventive intervention because of the extremely high risk of tuberculosis disease in these young children. FUNDING Aeras, Wellcome Trust, and Oxford-Emergent Tuberculosis Consortium (OETC) were the funders of the MVA85A 020 Trial. National Institute of Allergy and Infectious Diseases supported this analysis.
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196
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Bacha JM, Ngo K, Clowes P, Draper HR, Ntinginya EN, DiNardo A, Mangu C, Sabi I, Mtafya B, Mandalakas AM. Why being an expert - despite xpert -remains crucial for children in high TB burden settings. BMC Infect Dis 2017; 17:123. [PMID: 28166728 PMCID: PMC5294844 DOI: 10.1186/s12879-017-2236-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 01/31/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As access to Xpert expands in high TB-burden settings, its performance against clinically diagnosed TB as a reference standard provides important insight as the majority of childhood TB is bacteriologically unconfirmed. We aim to describe the characteristics and outcomes of children with presumptive TB and TB disease, and assess performance of Xpert under programmatic conditions against a clinical diagnosis of TB as a reference standard. METHODS Retrospective review of children evaluated for presumptive TB in Mbeya, Tanzania. Baseline characteristics were compared by TB disease status and, for patients diagnosed with TB, by TB confirmation status using Wilcoxon rank sum test for continuous variables and the Chi-square test for categorical variables. Sensitivity and specificity were calculated to assess the performance of Xpert, smear, and culture against clinical TB. Kappa statistics were calculated to assess agreement between Xpert and smear to culture. RESULTS Among children (N = 455) evaluated for presumptive TB, 70.3% (320/455) had Xpert and 62.8% (286/455) had culture performed on sputa. 34.5% (157/455) were diagnosed with TB: 80.3% (126/157) pulmonary TB, 13.4% (21/157) bacteriologically confirmed, 53.5% (84/157) HIV positive, and 48.4% (76/157) inpatients. Compared to the reference standard of clinical diagnosis, sensitivity of Xpert was 8% (95% CI 4-15), smear 6% (95% CI 3-12) and culture 16% (95% CI 9-24), and did not differ based on patient disposition, nutrition or HIV status. CONCLUSION Despite access to Xpert, the majority of children with presumptive TB were treated based on clinical diagnosis. Reflecting the reality of clinical practice in resource limited settings, new diagnostics such as Xpert serve as important adjunctive tests but will not obviate the need for astute clinicians and comprehensive diagnostic algorithms.
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Affiliation(s)
- Jason M Bacha
- Baylor College of Medicine Children's Foundation - Tanzania, Centre of Excellence at Mbeya Zonal Referral Hospital, Mbeya, Tanzania. .,Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Katherine Ngo
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics Baylor College of Medicine, Houston, TX, 77030, USA
| | - Petra Clowes
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Heather R Draper
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics Baylor College of Medicine, Houston, TX, 77030, USA
| | - Elias N Ntinginya
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Andrew DiNardo
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics Baylor College of Medicine, Houston, TX, 77030, USA
| | - Chacha Mangu
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Issa Sabi
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Bariki Mtafya
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics Baylor College of Medicine, Houston, TX, 77030, USA
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Schumacher SG, van Smeden M, Dendukuri N, Joseph L, Nicol MP, Pai M, Zar HJ. Diagnostic Test Accuracy in Childhood Pulmonary Tuberculosis: A Bayesian Latent Class Analysis. Am J Epidemiol 2016; 184:690-700. [PMID: 27737841 DOI: 10.1093/aje/kww094] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/25/2016] [Indexed: 11/13/2022] Open
Abstract
Evaluation of tests for the diagnosis of childhood pulmonary tuberculosis (CPTB) is complicated by the absence of an accurate reference test. We present a Bayesian latent class analysis in which we evaluated the accuracy of 5 diagnostic tests for CPTB. We used data from a study of 749 hospitalized South African children suspected to have CPTB from 2009 to 2014. The following tests were used: mycobacterial culture, smear microscopy, Xpert MTB/RIF (Cepheid Inc.), tuberculin skin test (TST), and chest radiography. We estimated the prevalence of CPTB to be 27% (95% credible interval (CrI): 21, 35). The sensitivities of culture, Xpert, and smear microscopy were estimated to be 60% (95% CrI: 46, 76), 49% (95% CrI: 38, 62), and 22% (95% CrI: 16, 30), respectively; specificities of these tests were estimated in accordance with prior information and were close to 100%. Chest radiography was estimated to have a sensitivity of 64% (95% CrI: 55, 73) and a specificity of 78% (95% CrI: 73, 83). Sensitivity of the TST was estimated to be 75% (95% CrI: 61, 84), and it decreased substantially among children who were malnourished and infected with human immunodeficiency virus (56%). The specificity of the TST was 69% (95% CrI: 63%, 76%). Furthermore, it was estimated that 46% (95% CrI: 42, 49) of CPTB-negative cases and 93% (95% CrI: 82; 98) of CPTB-positive cases received antituberculosis treatment, which indicates substantial overtreatment and limited undertreatment.
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198
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Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, Lienhardt C, Menzies R, Merrifield C, Narita M, O'Brien R, Peloquin CA, Raftery A, Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147-e195. [PMID: 27516382 PMCID: PMC6590850 DOI: 10.1093/cid/ciw376] [Citation(s) in RCA: 655] [Impact Index Per Article: 81.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 06/06/2016] [Indexed: 02/06/2023] Open
Abstract
The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Julie M. Higashi
- Tuberculosis Control Section, San Francisco Department
of Public Health, California
| | - Christine S. Ho
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
| | | | | | | | | | | | - Masahiro Narita
- Tuberculosis Control Program, Seattle and King County Public Health, and
University of Washington, Seattle
| | - Rick O'Brien
- Ethics Advisory Group, International Union Against TB
and Lung Disease, Paris,
France
| | | | | | | | - H. Simon Schaaf
- Department of Paediatrics and Child Health, Stellenbosch University, Cape
Town, South Africa
| | | | | | - Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri Care and
Research Institute, Tradate, Italy
| | - Andrew Vernon
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
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DiNardo AR, Detjen A, Ustero P, Ngo K, Bacha J, Mandalakas AM. Culture is an imperfect and heterogeneous reference standard in pediatric tuberculosis. Tuberculosis (Edinb) 2016; 101S:S105-S108. [PMID: 27727131 DOI: 10.1016/j.tube.2016.09.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In pediatric tuberculosis (pTB), culture is the accepted reference standard for assessing new diagnostic tests despite culture only confirming 10-50% of clinically diagnosed cases. METHODS Using the studies previously included in the systematic review of Gene Xpert, we evaluated the diagnostic yield of culture. Children with symptoms and signs suggestive of TB were considered to have a clinical diagnosis if they were 1) culture positive or 2) followed clinically for at least one month and started on Anti-Tuberculosis Therapy (ATT). RESULTS Of 1989 children with presumptive pTB, 229 (11.5%) had culture-confirmation. Of the remaining 1760 culture negative children, 710 (24.4) were classified as culture-negative clinical TB and 821 were classified as "not TB". Diagnostic yield of culture was 24.4% (median 28.7% IQR 15.6%-42.4%; range 1.5%-65%). CONCLUSION Culture, the accepted reference standard for pediatric TB diagnostics, has a low and variable yield that impacts how diagnostic studies should be reported as well as everyday clinical care.
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Affiliation(s)
- Andrew R DiNardo
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Baylor College of Medicine, Houston, TX, USA.
| | - Anne Detjen
- The International Union Against Tuberculosis and Lung Disease (The Union), 61 Broadway, Suite 1720, New York, NY 10006, USA.
| | - Pilar Ustero
- The Global Tuberculosis Program, Texas Children's Hospital, Baylor College of Medicine Children's Foundation-Swaziland, Baylor College of Medicine, Mbabane, Swaziland.
| | - Katherine Ngo
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
| | - Jason Bacha
- The Global Tuberculosis Program, Texas Children's Hospital, Baylor International Pediatric AIDS Initiative, Baylor Tanzania Center of Excellence, Baylor College of Medicine, Mbeya, Tanzania.
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
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200
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Zar HJ, Workman LJ, Little F, Nicol MP. Diagnosis of Pulmonary Tuberculosis in Children: Assessment of the 2012 National Institutes of Health Expert Consensus Criteria. Clin Infect Dis 2016; 61Suppl 3:S173-8. [PMID: 26409280 DOI: 10.1093/cid/civ622] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The 2012 National Institutes of Health (NIH) consensus criteria for standardized diagnostic categories of pulmonary tuberculosis in children have not been validated. We aimed to assess the NIH diagnostic criteria in children with culture-confirmed pulmonary tuberculosis and those in whom tuberculosis has been excluded. METHODS We performed a retrospective analysis of consecutive children hospitalized with suspected pulmonary tuberculosis in Cape Town, South Africa, who were enrolled in a diagnostic study. Children were categorized as definite tuberculosis (culture positive), probable tuberculosis (chest radiograph consistent), possible tuberculosis (chest radiograph inconsistent), or not tuberculosis (improved without tuberculosis treatment). We applied the NIH diagnostic categories to the cohort and evaluated their performance specifically in children with definite tuberculosis and not tuberculosis. RESULTS Four hundred sixty-four children (median age, 25.1 months [interquartile range, 13.5-61.5 months]) were included; 96 (20.7%) were HIV infected. Of these, 165 (35.6%) were definite tuberculosis, and 299 (64.4%) were not tuberculosis. If strict NIH symptom criteria were applied, 100 (21.6%) were unclassifiable including 21 (21.0%) with definite pulmonary tuberculosis, as they did not meet the NIH criteria due to short duration of symptoms; 71 (71%) had cough <14 days, 48 (48%) had recent weight loss, and 39 (39%) had fever <7 days. Of 364 classifiable children, there was moderate agreement (κ = 0.48) with 100% agreement for definite tuberculosis and moderate agreement for not tuberculosis (220 [60.4%] vs 89 [24.5%]). CONCLUSIONS Entry criteria for diagnostic studies should not be restrictive. Data from this analysis have informed revision of the NIH definitions.
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Affiliation(s)
- Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town and Medical Research Council Unit on Child and Adolescent Health
| | - Lesley J Workman
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town and Medical Research Council Unit on Child and Adolescent Health
| | | | - Mark P Nicol
- Division of Medical Microbiology and Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, National Health Laboratory Service, Groote Schuur Hospital, South Africa
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