Impact of HIV infection on the development, clinical presentation, and outcome of tuberculosis among children in Abidjan, Côte d'Ivoire

Cost-effectiveness of Routine Provider-Initiated Testing and Counseling for Children With Undiagnosed HIV in South Africa

BACKGROUND

We compared the cost-effectiveness of pediatric provider-initiated HIV testing and counseling (PITC) vs no PITC in a range of clinical care settings in South Africa.

METHODS

We used the Cost-Effectiveness of Preventing AIDS Complications Pediatric model to simulate a cohort of children, aged 2-10 years, presenting for care in 4 settings (outpatient, malnutrition, inpatient, tuberculosis clinic) with varying prevalence of undiagnosed HIV (1.0%, 15.0%, 17.5%, 50.0%, respectively). We compared "PITC" (routine testing offered to all patients; 97% acceptance and 71% linkage to care after HIV diagnosis) with no PITC. Model outcomes included life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs) from the health care system perspective and the proportion of children with HIV (CWH) diagnosed, on antiretroviral therapy (ART), and virally suppressed. We assumed a threshold of $3200/year of life saved (YLS) to determine cost-effectiveness. Sensitivity analyses varied the age distribution of children seeking care and costs for PITC, HIV care, and ART.

RESULTS

PITC improved the proportion of CWH diagnosed (45.2% to 83.2%), on ART (40.8% to 80.4%), and virally suppressed (32.6% to 63.7%) at 1 year in all settings. PITC increased life expectancy by 0.1-0.7 years for children seeking care (including those with and without HIV). In all settings, the ICER of PITC vs no PITC was very similar, ranging from $710 to $1240/YLS. PITC remained cost-effective unless undiagnosed HIV prevalence was <0.2%.

CONCLUSIONS

Routine testing improves HIV clinical outcomes and is cost-effective in South Africa if the prevalence of undiagnosed HIV among children exceeds 0.2%. These findings support current recommendations for PITC in outpatient, inpatient, tuberculosis, and malnutrition clinical settings.

Immunopathogenesis in HIV-associated pediatric tuberculosis

Tuberculosis (TB) is an increasing global emergency in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients, in which host immunity is dysregulated and compromised. However, the pathogenesis and efficacy of therapeutic strategies in HIV-associated TB in developing infants are essentially lacking. Bacillus Calmette-Guerin vaccine, an attenuated live strain of Mycobacterium bovis, is not adequately effective, which confers partial protection against Mycobacterium tuberculosis (Mtb) in infants when administered at birth. However, pediatric HIV infection is most devastating in the disease progression of TB. It remains challenging whether early antiretroviral therapy (ART) could maintain immune development and function, and restore Mtb-specific immune function in HIV-associated TB in children. A better understanding of the immunopathogenesis in HIV-associated pediatric Mtb infection is essential to provide more effective interventions, reducing the risk of morbidity and mortality in HIV-associated Mtb infection in infants. IMPACT: Children living with HIV are more likely prone to opportunistic infection, predisposing high risk of TB diseases. HIV and Mtb coinfection in infants may synergistically accelerate disease progression. Early ART may probably induce immune reconstitution inflammatory syndrome and TB pathology in HIV/Mtb coinfected infants.

Treatment outcome of pediatric tuberculosis in eastern Ethiopia

BACKGROUND

Children are more vulnerable to developing active Mycobacterium tuberculosis infection which causes significant morbidity and mortality. However, the contribution of childhood tuberculosis and its treatment outcomes have not been well documented, and no research has been conducted in eastern Ethiopia.

OBJECTIVE

This study aimed to assess the treatment outcome and its predictors of pediatric tuberculosis in eastern Ethiopia from September 1, 2017 to January 30, 2018.

METHODS

A retrospective study was conducted in eight selected hospitals in eastern Ethiopia. Data on 2002 children with tuberculosis was extracted by using the standard checklist of the national tuberculosis treatment format. Treatment outcomes were determined according to the standard definitions of the National Tuberculosis and Leprosy Control Programme. Data were entered into Epi Data software version 3.1 and exported to Statistical Package for Social Science (SPSS) version 20 for analysis. Bivariable and multivariable regression analyses were carried out to examine the associations between dependent and independent variables. A P-value of <0.05 was considered statistically significant.

RESULT

The overall successful treatment rate was 1,774 (88.6%) [95% confidence interval (CI): (80.59-97.40)]. A total of 125 (6.2%), 1,648 (82.3%), 59 (2.9%), and 19 (0.9%) children with tuberculosis (TB) were cured, completed, defaulted, and died, respectively. A high number of defaulters and deaths were reported in the age group <10 years. More children with smear-positive pulmonary TB (74.4%) were cured, while smear-negative tuberculosis had higher treatment completion rates. Being male in sex (adjusted odds ratio (AOR): 0.71, 95% CI: 0.53, 0.96) and those with human immunodeficiency virus (HIV) positive sero status (AOR: 0.51, 95% CI: 0.29, 0.90) had a lower chance of a successful treatment outcome.

CONCLUSION

In this study, thee treatment success rate was higher than the recent World Health Organization report. Those males and HIV seropositive status were less likely to have a successful treatment outcome. Therefore, efforts should be made by each health institution in eastern Ethiopia by giving emphasis on male and HIV-positive individuals.

Abnormal Tryptophan Metabolism in HIV and Mycobacterium tuberculosis Infection

Host metabolism has recently gained more attention for its roles in physiological functions and pathologic conditions. Of these, metabolic tryptophan disorders generate a pattern of abnormal metabolites that are implicated in various diseases. Here, we briefly highlight the recent advances regarding abnormal tryptophan metabolism in HIV and Mycobacterium tuberculosis infection and discuss its potential impact on immune regulation, disease progression, and neurological disorders. Finally, we also discuss the potential for metabolic tryptophan interventions toward these infectious diseases.

Mortality in South African Children and Adolescents Routinely Treated for Tuberculosis

BACKGROUND

In South Africa, tuberculosis (TB) is a leading cause of death among those <20 years of age. We describe changes in TB mortality among children and adolescents in South Africa over a 13-year period, identify risk factors for mortality, and estimate excess TB-related mortality.

METHODS

Retrospective analysis of all patients <20 years of age routinely recorded in the national electronic drug-susceptible TB treatment register (2004-2016). We developed a multivariable Cox regression model for predictors of mortality and used estimates of mortality among the general population to calculate standardized mortality ratios (SMRs).

RESULTS

Between 2004 and 2016, 729 463 children and adolescents were recorded on TB treatment; 84.0% had treatment outcomes and 2.5% (18 539) died during TB treatment. The case fatality ratio decreased from 3.3% in 2007 to 1.9% in 2016. In the multivariable Cox regression model, ages 0 to 4, 10 to 14, and 15 to 19 years (compared with ages 5 to 9 years) were associated with increased risk of mortality, as was HIV infection, previous TB treatment, and extrapulmonary involvement. The SMR of 15 to 19-year-old female patients was more than double that of male patients the same age (55.3 vs 26.2). Among 10 to 14-year-olds and those who were HIV-positive, SMRs increased over time.

CONCLUSIONS

Mortality in South African children and adolescents treated for TB is declining but remains considerable, with 2% dying during 2016. Adolescents (10 to 19 years) and those people living with HIV have the highest risk of mortality and the greatest SMRs. Interventions to reduce mortality during TB treatment, specifically targeting those at highest risk, are urgently needed.

Tuberculosis in Children Hospitalized in a Low-burden Country: Description and Risk Factors of Severe Disease

BACKGROUND

In high-income countries, few pediatric studies have described the clinical expression of tuberculosis (TB) according to age, and their results are discordant. Patients <2 years of age are usually considered to be at higher risk for severe disease than older children. Our aim was to better describe pediatric TB disease severity in a low-incidence country.

METHODS

All children (<18 years of age) admitted with TB disease to the Robert Debré University Hospital, Paris, between 1992 and 2015 were included. Patients were classified by the severity of TB disease based on the original classification of Wiseman et al. Risk factors associated with severity were analyzed.

RESULTS

We included 304 patients with a median age of 9.9 years (interquartile range 3.3-13.3) and a male to female ratio of 1.04. Overall, 280/304 (92%) were classified: 168/304 (55%) were classified as showing severe TB and 112/304 (37%) as showing non-severe TB. Central nervous system disease was more frequent among patients <2 years of age than patients 2-17 years of age (5/54; 9% vs. 5/229; 2% P = 0.024). An age of ≥10 years (P = 0.001) and being born abroad (P = 0.011) were both associated with disease severity in univariate analysis. In multivariate analysis, diagnosis through symptom-based screening was independently associated with severity (odds ratio 7.1, 95% confidence interval: 3.9-12.9, P < 0.0001).

CONCLUSIONS

This description of the clinical spectrum of pediatric TB in a low-burden setting demonstrates that adolescents are the group most at risk of experiencing severe TB.

Childhood tuberculosis treatment outcome and its association with HIV co-infection in Ethiopia: a systematic review and meta-analysis

Background

Tuberculosis is the second leading cause of death from an infectious disease worldwide, next to HIV. Hence, initiating and determining the national tuberculosis treatment program and outcome is crucial. However, the childhood tuberculosis treatment outcome in Ethiopia was not investigated.

Objective

This study determined the pooled estimate of childhood tuberculosis treatment outcome and its association with HIV co-infection.

Methods

PubMed, Google Scholar, Web of Science, reference lists of included studies, and Ethiopian institutional research repositories were used to retrieve all available studies. Searching was limited to the studies that had been conducted in Ethiopia and published in the English language. In this study, observational studies, including cohort, cross-sectional, and case-control studies, were included. The estimate of childhood tuberculosis treatment outcome was determined using a weighted inverse variance random-effects model. The overall variation between studies was checked by the heterogeneity test (I ²). The Joanna Briggs Institute (JBI) quality appraisal criteria were used for quality assessment of the studies. The summary estimates were presented with forest plots and tables. Publication bias was also checked with the funnel plot and Egger's regression test. The outcome measures were successful and unsuccessful treatment outcomes. Successful treatment outcomes are defined as patients who are cured and treatment completed, whereas, an unsuccessful treatment outcome means those patients with defaulter, failure, and death treatment outcomes.

Result

To estimate the overall pooled estimate of successful treatment outcome, 6 studies with 5389 participants were considered. Consequently, the overall pooled estimate of successful treatment outcome was 79.62% (95% CI 73.22, 86.02) of which 72.44% was treatment completed. On the other hand, unsuccessful treatment outcomes, including treatment failure, defaulter, and death, were 0.15%, 5.36%, and 3.54%, respectively. Moreover, this study found that HIV co-infection was significantly associated with childhood tuberculosis treatment outcomes. Poor treatment outcome was higher among children with HIV co-infection with an odds ratio of 3.15 (95% CI 1.67, 5.94) compared to that of HIV-negative children.

Conclusion

The summary estimate of successful childhood tuberculosis treatment outcome was low compared to the threshold suggested by the World Health Organization. HIV co-infection is significantly associated with poor treatment outcome of childhood tuberculosis. Therefore, special attention is better to be given to children infected with HIV. Moreover, adherence to anti-TB has to be strengthened.

Trial registration

The protocol has been registered in PROSPERO with a registration number of CRD42018110570.

Effect of First-Line Antituberculosis Therapy on Nevirapine Pharmacokinetics in Children Younger than Three Years Old

Nevirapine-based antiretroviral therapy (ART) is one of the limited options in HIV-infected children younger than 3 years old (young children) with tuberculosis (TB) coinfection. To date, there are insufficient data to recommend nevirapine-based therapy during first-line antituberculosis (anti-TB) therapy in young children. We compared nevirapine pharmacokinetics (PK) in HIV-infected young children with and without TB coinfection. In the coinfected group, nevirapine PK was evaluated while on anti-TB therapy and after completing an anti-TB therapy regimen. Of 53 participants, 23 (43%) had TB-HIV coinfection. While the mean difference in nevirapine PK parameters between the two groups was not significant (P > 0.05), 14/23 (61%) of the children with TB-HIV coinfection and 9/30 (30%) with HIV infection had a nevirapine minimum concentration (Cmin) below the proposed target of 3.0 mg/liter (P = 0.03). In multivariate analysis, anti-TB therapy and the CYP2B6 516G>T genotype were joint predictors of nevirapine PK parameters. Differences in nevirapine PK parameters between the two groups were significant in children with CYP2B6 516GG but not the GT or TT genotype. Among 14 TB-HIV-coinfected participants with paired data, the geometric mean Cmin and area under the drug concentration-time curve from time zero to 12 h (AUC0-12) were about 34% lower when patients were taking anti-TB therapy, while the nevirapine apparent oral clearance (CL/F) was about 45% higher. While the induction effect of anti-TB therapy on nevirapine PK in our study was modest, the CYP2B6 genotype-dependent variability in the TB drug regimen effect would complicate any dose adjustment strategy in young children with TB-HIV coinfection. Alternate ART regimens that are more compatible with TB treatment in this age group are needed. (This study has been registered at ClinicalTrials.gov under identifier NCT01699633.).

Tuberculosis and HIV co-infection in Congolese children: risk factors of death

Introduction

Human immunodeficiency virus (HIV) and tuberculosis (TB) are the leading causes of death from infectious disease worldwide. The prevalence of HIV among children with TB in moderate to high prevalence countries ranges between 10% and 60%. This study aimed to determine the prevalence of HIV infection among children treated for TB in Directly Observed Treatment Short-Course (DOTS) clinics in Lubumbashi and to identify risk of death during this co-infection.

Methods

This is a cross-sectional study of children under-15, treated for tuberculosis from January 1, 2013 to December 31, 2015. Clinical, paraclinical and outcome data were collected in 22 DOTS of Lubumbashi. A statistical comparison was made between dead and survived HIV-infected TB children. We performed the multivariate analyzes and the significance level set at p-value <0.05.

Results

A total of 840 children with TB were included. The prevalence of HIV infection was 20.95% (95% CI: 18.34-23.83%). The mortality rate was higher for HIV-infected children (47.73%) compared to HIV-uninfected children (17.02%) (p<0.00001). Age <5 years (aOR=6.50 [1.96-21.50]), a poor nutritional status (aOR=23.55 [8.20-67.64]), and a negative acid-fast bacilli testing (aOR=4.51 [1.08-18.70]) were associated with death during anti-TB treatment.

Conclusion

TB and HIV co-infection is a reality in pediatric settings in Lubumbashi. High mortality highlights the importance of early management.

Effect of Rifampin-Isoniazid-Containing Antituberculosis Therapy on Efavirenz Pharmacokinetics in HIV-Infected Children 3 to 14 Years Old

We compared efavirenz pharmacokinetic (PK) parameters in children with tuberculosis (TB)/human immunodeficiency virus (HIV) coinfection on and off first-line antituberculosis therapy to that in HIV-infected children. Children 3 to 14 years old with HIV infection, with and without TB, were treated with standard efavirenz-based antiretroviral therapy without any efavirenz dose adjustments. The new World Health Organization-recommended antituberculosis drug dosages were used in the coinfected participants. Steady-state efavirenz concentrations after 4 weeks of antiretroviral therapy were measured using validated liquid chromatography with tandem mass spectrometry (LC-MS/MS) assays. Pharmacokinetic parameters were calculated using noncompartmental analysis. Between groups, PK parameters were compared by Wilcoxon rank-sum test and within group by signed-rank test. Of the 105 participants, 43 (41.0%) had TB coinfection. Children with TB/HIV coinfection compared to those with HIV infection were younger, had lower median weight-for-age Z score, and received a higher median efavirenz weight-adjusted dose. Geometric mean (GM) efavirenz peak concentration (Cmax), concentration at 12 h (C12h), Cmin, and total area under the curve from time 0 to 24 h (AUC0-24h) values were similar in children with HIV infection and those with TB/HIV coinfection during anti-TB therapy. Geometric mean efavirenz C12h, Cmin, and AUC0-24h values were lower in TB/HIV-coinfected patients off anti-TB therapy than in the children with HIV infection or TB/HIV coinfection on anti-TB therapy. Efavirenz clearance was lower and AUC0-24h was higher on than in patients off anti-TB therapy. Reduced efavirenz clearance by first-line anti-TB therapy at the population level led to similar PK parameters in HIV-infected children with and without TB coinfection. Our findings do not support modification of efavirenz weight-band dosing guidelines based on TB coinfection status in children. (The study was registered with ClinicalTrials.gov under registration number NCT01704144.).

Isoniazid for the Prevention of Tuberculosis in HIV-Infected Children: A Systematic Review and Meta-Analysis

BACKGROUND

Isoniazid is recommended for prevention of tuberculosis (TB) in HIV-infected adults, but its efficacy in children living with HIV (CLHIV) is not known. We performed a systematic review to assess the efficacy of isoniazid for the prevention of TB in CLHIV.

METHODS

We searched PubMed, Cochrane Clinical Trial Registry and Google Scholar from inception to December 2016. Any randomized controlled trial assessing the role of isoniazid for the prevention of TB in CLHIV was eligible for inclusion. The primary endpoint was TB incidence; secondary end points were mortality, overall survival and severe adverse events. Dual independent extraction of all data was performed. Data were pooled under a random effects model and summarized either as risk ratio (RR) or hazard ratio along with 95% confidence intervals (CIs).

RESULTS

Of 931 references, 3 randomized controlled trials enrolling 977 patients met the inclusion criteria. Pooled results showed a statistically nonsignificant reduction in TB incidence (RR: 0.70; 95% CI: 0.47-1.04; P = 0.07) and mortality (RR: 0.94; 95% CI: 0.39-2.23; P = 0.88) with the use of isoniazid compared with placebo. One study was stopped early because of excess deaths in the placebo arm. However, results from subgroup analysis restricted to only completed trials did not change the overall findings.

CONCLUSIONS

Isoniazid did not reduce the incidence of TB in CLHIV. All included studies were performed in regions with high prevalence of TB making the overall generalizability limited.

Excellent Treatment Outcomes in Children Treated for Tuberculosis Under Routine Operational Conditions in Cape Town, South Africa

Background

Tuberculosis (TB) remains a leading cause of death in children globally. It is recognized that human immunodeficiency virus (HIV) infection increases the risk of developing TB, but our understanding of the impact of HIV on risk of mortality for children treated for TB is limited. We aimed to identify predictors of mortality in children treated for drug-susceptible TB.

Methods

A retrospective analysis of all children (<15 years of age) routinely treated between 2005 and 2012 for drug-susceptible TB in Cape Town was conducted using the programmatic electronic TB treatment database. Survival analysis using Cox regression was used to estimate hazard ratios for death. Logistic regression was used to estimate the odds of unfavorable outcomes.

Results

Of 29519 children treated for and notified with TB over the study period, <1% died during TB treatment and 89.5% were cured or completed treatment. The proportion of children with known HIV status increased from 13% in 2005 to 95% in 2012. Children aged <2 years had an increased hazard of death (adjusted hazard ratio [aHR], 3.13; 95% confidence interval [CI], 1.78-5.52) and greater odds of unfavorable outcome (adjusted odds ratio [aOR], 1.44; 95% CI, 1.24-1.66) compared with children aged 10-14 years. HIV-infected children had increased mortality compared to HIV-negative children (aHR, 6.85; 95% CI, 4.60-10.19) and increased odds of unfavorable outcome (aOR, 2.01; 95% CI, 1.81-2.23). Later year of TB treatment was a protective predictor for both mortality and unfavorable outcome.

Conclusions

We demonstrate a dramatic improvement in HIV testing in children with TB over time and excellent overall treatment outcomes. HIV infection and young age were associated with increased risk of death and unfavorable outcome.

Childhood Tuberculosis in Nigeria: Disease Presentation and Treatment Outcomes

Objectives

Understanding the factors that influence tuberculosis (TB) treatment outcomes in children is key to designing interventions to address them. This study aimed to determine the case category distribution of childhood TB in Nigeria and assess which clinical and demographic factors are associated with different treatment outcomes in childhood TB.

Materials and methods

This was a retrospective cohort study involving a review of medical records of children (0-14 years) with TB in 3 states in Nigeria in 2015.

Results

Of 724 childhood TB cases registered during the review period, 220 (30.4%) were aged 0-4 years. A high proportion of patients had pulmonary TB 420/724 (58.0%), new TB infection 713/724 (98.5%), and human immunodeficiency virus (HIV) coinfection 108/724 (14.7%). About 28% (n = 201) were bacteriologically diagnosed. The proportion of TB treatment success was 601/724 (83.0%). Treatment success was significantly higher in children aged 5-14 years than those 0-4 years (85.3% vs 77.7%, P = .01). Factors associated with unsuccessful outcomes in patients aged 0-4 years are male sex (adjusted odds ratio [aOR]: 1.2), HIV-positive status (aOR: 1.2), and clinical method of diagnosis (aOR: 5.6).

Conclusions

Efforts should be made to improve TB treatment outcomes in children by ensuring early and accurate diagnosis, focused training of health workers on childhood TB-HIV care, and effective adherence counseling of caregivers.

Burden of disease and risk factors for death among children treated for tuberculosis in Malawi

SETTING

Tuberculosis (TB) is a leading cause of childhood death. Patient-level data on pediatric TB in Malawi that can be used to guide programmatic interventions are limited.

OBJECTIVE

To describe pediatric TB case burden, disease patterns, treatment outcomes, and risk factors for death and poor outcome.

DESIGN

We conducted a retrospective cohort study utilizing routine data. Odds ratios (ORs) for factors associated with poor outcome and death were calculated using generalized estimating equations.

RESULTS

Children represented 8% (371/4642) of TB diagnoses. The median age was 7 years (interquartile range 2.8-11); 32.8% (113/345) were human immunodeficiency virus (HIV) infected. Of these, 54.0% were on antiretroviral therapy (ART) at the time of anti-tuberculosis treatment (ATT) initiation, 21.2% started ART during ATT, and 24.8% had no documented ART. The treatment success rate was 77.3% (11.2% cured, 66.1% completed treatment), with 22.7% experiencing poor outcomes (9.5% died, 13.2% were lost to follow-up). Being on ART at the time of ATT initiation was associated with increased odds of death compared to beginning ART during treatment (adjusted OR 2.75, 95%CI 1.27-5.96).

CONCLUSION

Children represent a small proportion of diagnosed TB cases and experience poor outcomes. Higher odds of death among children already on ART raises concerns over the management of these children. Further discussion of and research into pediatric-specific strategies is required to improve case finding and outcomes.

Assessment of airway compression on chest radiographs in children with pulmonary tuberculosis

BACKGROUND

Because small, pliable paediatric airways are easily compressed by enlarged lymph nodes, detection of radiographic airway compression might be an objective criterion for diagnosing pulmonary tuberculosis.

OBJECTIVE

To investigate the frequency and inter-observer agreement of airway compression on chest radiographs in children with pulmonary tuberculosis compared to those with a different lower respiratory tract infection.

MATERIALS AND METHODS

Chest radiographs of children with suspected pulmonary tuberculosis were read by two readers according to a standardised format and a third reader when there was disagreement. Radiographs of children with proven pulmonary tuberculosis were compared to those with a different lower respiratory tract infection. We evaluated frequency and location of radiographic airway compression. Findings were correlated with human immunodeficiency virus (HIV) status and age. We assessed inter-observer agreement using kappa statistics.

RESULTS

We reviewed radiographs of 505 children (median age 25.9 months, interquartile range [IQR] 14.3-62.2). Radiographic airway compression occurred in 54/188 (28.7%) children with proven pulmonary tuberculosis and in 24/317 (7.6%) children with other types of lower respiratory tract infection (odds ratio [OR] 4.9; 95% confidence interval [CI] 2.9-8.3). A higher frequency of radiographic airway compression occurred in infants (22/101, or 21.8%) compared to older children (56/404, or 13.9%; OR 1.7; 95% CI 1.0-3.0). We found no association between airway compression and HIV infection. Inter-observer agreement ranged from none to fair (kappa of 0.0-0.4).

CONCLUSION

There is a strong association between airway compression on chest radiographs and confirmed pulmonary tuberculosis. However this finding's clinical use as an objective criterion for diagnosis of pulmonary tuberculosis in children is limited by poor inter-observer agreement.

Isoniazid for preventing tuberculosis in HIV-infected children

BACKGROUND

Tuberculosis (TB) is an important cause of illness and death in HIV-positive children living in areas of high TB prevalence. We know that isoniazid prophylaxis prevents TB in HIV-negative children following TB exposure, but there is uncertainty related to its role in TB preventive treatment in HIV-positive children.

OBJECTIVES

To summarise the effects of TB preventive treatment versus placebo in HIV-positive children with no known TB contact on active TB, death, and reported adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE/PubMed, Embase and two trial registers up to February 2017.

SELECTION CRITERIA

We included trials of HIV-positive children with and without known TB exposure, randomized to receive TB preventive treatment or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently used the study selection criteria, assessed risk of bias, and extracted data. We assessed effects using risk, incidence rate and hazard ratios and assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included three trials, involving 991 participants, below the age of 13 years, from South Africa and Botswana. Children were randomized to isoniazid prophylaxis or placebo, given daily or three times weekly. The median length of follow-up ranged from 5.7 to 34 months; some were on antiretroviral therapy (ART).In HIV-positive children not on ART, isoniazid prophylaxis may reduce the risk of active TB (hazard ratio (HR) 0.31, 95% confidence interval (CI) 0.11 to 0.87; 1 trial, 240 participants, low certainty evidence), and death (HR 0.46, 95% CI 0.22 to 0.95; 1 trial, 240 participants, low certainty evidence). One trial (182 participants) reported number of children with laboratory adverse events, which was similar between the isoniazid prophylaxis and placebo groups. No clinical adverse events were reported.In HIV-positive children on ART, we do not know if isoniazid prophylaxis reduces the risk of active TB (risk ratio (RR) 0.76, 95% CI 0.50 to 1.14; 3 trials, 737 participants, very low certainty evidence) or death (RR 1.45, 95% CI 0.78 to 2.72; 3 trials, 737 participants, very low certainty evidence). Two trials (714 participants) reported number of clinical adverse events and three trials (795 participants) reported number of laboratory adverse events; for both categories, the number of adverse events were similar between the isoniazid prophylaxis and placebo groups.

AUTHORS' CONCLUSIONS

Isoniazid prophylaxis given to all children diagnosed with HIV may reduce the risk of active TB and death in HIV-positive children not on ART in studies from Africa. For children on ART, no clear benefit was detected. .

Deaths during tuberculosis treatment among paediatric patients in a large tertiary hospital in Nigeria

Background

Despite availability of effective cure, tuberculosis (TB) remains a leading cause of death in children. In many high-burden countries, childhood TB is underdiagnosed and underreported, and care is often accessed too late, resulting in adverse treatment outcomes. In this study, we examined the time to death and its associated factors among a cohort of children that commenced TB treatment in a large treatment centre in northern Nigeria.

Methods

This is a retrospective cohort study of children that started TB treatment between 2010 and 2014. We determined mortality rates per 100 person-months of treatment, as well as across treatment and calendar periods. We used Cox proportional hazards regression to determine adjusted hazard ratios (aHR) for factors associated with mortality.

Results

Among 299 children with a median age 4 years and HIV prevalence of 33.4%; 85 (28.4%) died after 1,383 months of follow-up. Overall mortality rate was 6.1 per 100 person-months. Deaths occurred early during treatment and declined from 42.4 per 100 person-months in the 1^st week of treatment to 2.2 per 100 person-months after at the 3^rd month of treatment. Mortality was highest between October to December period (9.1 per 100 pm) and lowest between July and September (2.8 per 100 pm). Risk factors for mortality included previous TB treatment (aHR 2.04:95%CI;1.09–3.84); HIV infection (aHR 1.66:95%CI;1.02–2.71), having either extra-pulmonary disease (aHR 2.21:95%CI;1.26–3.89) or both pulmonary and extrapulmonary disease (aHR 3.03:95%CI;1.70–5.40).

Conclusions

Mortality was high and occurred early during treatment in this cohort, likely indicative of poor access to prompt TB diagnosis and treatment. A redoubling of efforts at improving universal health coverage are required to achieve the End TB Strategy target of zero deaths from TB.

The impact of HIV and antiretroviral therapy on TB risk in children: a systematic review and meta-analysis

BACKGROUND

Children (<15 years) are vulnerable to TB disease following infection, but no systematic review or meta-analysis has quantified the effects of HIV-related immunosuppression or antiretroviral therapy (ART) on their TB incidence.

OBJECTIVES

Determine the impact of HIV infection and ART on risk of incident TB disease in children.

METHODS

We searched MEDLINE and Embase for studies measuring HIV prevalence in paediatric TB cases ('TB cohorts') and paediatric HIV cohorts reporting TB incidence ('HIV cohorts'). Study quality was assessed using the Newcastle-Ottawa tool. TB cohorts with controls were meta-analysed to determine the incidence rate ratio (IRR) for TB given HIV. HIV cohort data were meta-analysed to estimate the trend in log-IRR versus CD4%, relative incidence by immunological stage and ART-associated protection from TB.

RESULTS

42 TB cohorts and 22 HIV cohorts were included. In the eight TB cohorts with controls, the IRR for TB was 7.9 (95% CI 4.5 to 13.7). HIV-infected children exhibited a reduction in IRR of 0.94 (95% credible interval: 0.83-1.07) per percentage point increase in CD4%. TB incidence was 5.0 (95% CI 4.0 to 6.0) times higher in children with severe compared with non-significant immunosuppression. TB incidence was lower in HIV-infected children on ART (HR: 0.30; 95% CI 0.21 to 0.39). Following initiation of ART, TB incidence declined rapidly over 12 months towards a HR of 0.10 (95% CI 0.04 to 0.25).

CONCLUSIONS

HIV is a potent risk factor for paediatric TB, and ART is strongly protective. In HIV-infected children, early diagnosis and ART initiation reduces TB risk.

TRIAL REGISTRATION NUMBER

CRD42014014276.

Pharmacokinetics of the First-Line Antituberculosis Drugs in Ghanaian Children with Tuberculosis with or without HIV Coinfection

Although human immunodeficiency virus (HIV) coinfection is the most important risk factor for a poor antituberculosis (anti-TB) treatment response, its effect on the pharmacokinetics of the first-line drugs in children is understudied. This study examined the pharmacokinetics of the four first-line anti-TB drugs in children with TB with and without HIV coinfection. Ghanaian children with TB on isoniazid, rifampin, pyrazinamide, and ethambutol for at least 4 weeks had blood samples collected predose and at 1, 2, 4, and 8 hours postdose. Drug concentrations were determined by validated liquid chromatography-mass spectrometry methods and pharmacokinetic parameters calculated using noncompartmental analysis. The area under the concentration-time curve from 0 to 8 h (AUC0-8), maximum concentration (Cmax), and apparent oral clearance divided by bioavailability (CL/F) for each drug were compared between children with and without HIV coinfection. Of 113 participants, 59 (52.2%) had HIV coinfection. The baseline characteristics were similar except that the coinfected patients were more likely to have lower weight-for-age and height-for-age Z scores (P < 0.05). Rifampin, pyrazinamide, and ethambutol median body weight-normalized CL/F values were significantly higher, whereas the plasma AUC0-8 values were lower, in the coinfected children than in those with TB alone. In the multivariate analysis, drug dose and HIV coinfection jointly influenced the apparent oral clearance and AUC0-8 for rifampin, pyrazinamide, and ethambutol. Isoniazid pharmacokinetics were not different by HIV coinfection status. HIV coinfection was associated with lower plasma exposure of three of the four first-line anti-TB drugs in children. Whether TB/HIV-coinfected children need higher dosages of rifampin, pyrazinamide, and ethambutol requires further investigation. (This study has been registered at ClinicalTrials.gov under identifier NCT01687504.).

Mortality in children diagnosed with tuberculosis: a systematic review and meta-analysis

BACKGROUND

Case fatality ratios in children with tuberculosis are poorly understood-particularly those among children with HIV and children not receiving tuberculosis treatment. We did a systematic review of published work to identify studies of population-representative samples of paediatric (ie, <15 years) tuberculosis cases.

METHODS

We searched PubMed and Embase for reports published in English, French, Portuguese, or Spanish before Aug 12, 2016, that included terms related to tuberculosis, children, mortality, and population representativeness. We also reviewed our own files and reference lists of articles identified by this search. We screened titles and abstracts for inclusion, excluding studies in which outcomes were unknown for 10% or more of the children and publications detailing non-representative samples. We used random-effects meta-analysis to produce pooled estimates of case fatality ratios from the included studies, which we divided into three eras: the pre-treatment era (ie, studies before 1946), the middle era (1946-80), and the recent era (after 1980). We stratified our analyses by whether or not children received tuberculosis treatment, age (0-4 years, 5-14 years), and HIV status.

FINDINGS

We identified 31 papers comprising 35 datasets representing 82 436 children with tuberculosis disease, of whom 9274 died. Among children with tuberculosis included in studies in the pre-treatment era, the pooled case fatality ratio was 21·9% (95% CI 18·1-26·4) overall. The pooled case fatality ratio was significantly higher in children aged 0-4 years (43·6%, 95% CI 36·8-50·6) than in those aged 5-14 years (14·9%, 11·5-19·1). In studies in the recent era, when most children had tuberculosis treatment, the pooled case fatality ratio was 0·9% (95% CI 0·5-1·6). US surveillance data suggest that the case fatality ratio is substantially higher in children with HIV receiving treatment for tuberculosis (especially without antiretroviral therapy) than in those without HIV.

INTERPRETATION

Without adequate treatment, children with tuberculosis, especially those younger than 5 years, are at high risk of death. Children with HIV have an increased mortality risk, even when receiving tuberculosis treatment.

FUNDING

US National Institutes of Health, Janssen Global Public Health.

The chest X-ray features of chronic respiratory disease in HIV-infected children--a review

Several features of human immunodeficiency virus (HIV) infection contribute to the development of chronic respiratory disease in children. These include the frequency and severity of acute chest infections, as well as the increased risk of pulmonary tuberculosis, aspiration, cardiovascular disease, lymphocytic interstitial pneumonitis or pulmonary neoplasia. The chest radiograph (CXR) remains the most accessible investigation for respiratory disease and plays an important role in the baseline assessment and follow-up. This review focuses on the CXR abnormalities of HIV-related chronic respiratory disease in children. The most commonly documented chronic CXR abnormalities are homogeneous opacification and pulmonary nodules, with pulmonary tuberculosis and lymphocytic interstitial pneumonitis the leading respective causes. Deficiencies in radiographic reporting methodology and relative paucity of radiographic data contribute to current limitations in knowledge and understanding of this field. The review highlights the need for standardised terminology and systematic reporting methodology in future studies. Prospective research on the natural history of lymphocytic interstitial pneumonitis, response to anti-tuberculous therapy, the impact of anti-retroviral therapy and HIV-associated bronchiectasis are needed.

TB screening among people living with HIV/AIDS in resource-limited settings

Tuberculosis (TB) continues to be the leading cause of morbidity and mortality among people living with HIV (PLHIV), making improved prevention and treatment of HIV-associated TB critical to ensuring long-term survival of PLHIV. TB screening among PLHIV is central to implementation of the World Health Organization's 3 I's interventions for reducing the impact of the TB and HIV syndemics. Effective TB screening will result in the identification of PLHIV with presumptive TB disease (ie, those with a positive symptom screen who require appropriate evaluation, including the use of diagnostic tools such as the Xpert MTB/RIF assay) and those eligible for isoniazid preventive therapy (ie, those who have a negative clinical symptom screen or who have a positive screen but are found not to have TB disease). Identification of PLHIV with presumptive TB also facilitates implementation of basic administrative measures for TB infection control, including fast tracking of coughing patients and separation from noncoughing PLHIV to reduce TB transmission. By contributing to the early diagnosis of TB disease among PLHIV, TB screening is also critical to facilitate early initiation of antiretroviral treatment among PLHIV diagnosed with TB disease who might not otherwise be eligible for antiretroviral treatment based on CD4 count or clinical staging. TB screening thus serves as a gateway for multiple TB/HIV interventions and is an integral part of routine clinical services for PLHIV at each clinic visit.

Childhood tuberculosis and its treatment outcomes in Addis Ababa: a 5-years retrospective study

BACKGROUND

Tuberculosis (TB) remains a significant public health problem leading to high morbidity and mortality both in adults and children. Reports on childhood TB and its treatment outcome are limited. In this retrospective study, we analyzed the epidemiology and treatment outcomes of TB among children in Addis Ababa.

METHODS

Children registered for TB treatment over 5 years (2007 to 2011) were included in the analysis. Demographic and clinical data including treatment outcomes were extracted from TB unit registers of 23 health centers in Addis Ababa. Multivariate logistic regression was used to identify predictors of poor treatment outcomes.

RESULTS

Among 41,254 TB patients registered for treatment at the 23 health centers, 2708 (6.6%) were children. Among children with TB, the proportions of smear positive PTB, smear negative PTB and EPTB were 9.6%, 43.0% and 47.4%, respectively. Treatment outcomes were documented for 95.2% of children of whom 85.5% were successfully treated while rates of mortality and defaulting from treatment were 3.3% and 3.8%, respectively. The proportion of children with TB tested for HIV reached 88.3% during the final year of the study period compared to only 3.9% at the beginning of the study period. Mortality was significantly higher among under-five children (p < 0.001) and those with HIV co-infection (p < 0.001). On multivariate logistic regression, children 5-9 years [AOR = 2.50 (95% CI 1.67-3.74)] and 10-14 years [AOR = 2.70 (95% CI 1.86-3.91)] had a significantly higher successful treatment outcomes. On the other hand, smear positive PTB [AOR = 0.44 (95% CI 0.27-0.73), HIV co-infection (AOR = 0.49(95% CI 0.30-0.80)] and unknown HIV sero-status [AOR = 0.60 (95% CI 0.42-0.86)] were predictors of poor treatment outcomes.

CONCLUSION

The proportion of childhood TB in this study is lower than the national estimate. The overall treatment success rate has met the WHO target. Nonetheless, younger children (< 5 years), children with smear positive PTB and those with HIV co-infection need special attention to reduce poor treatment outcomes among children in the study area.

Tuberculosis and HIV co-infection in children

HIV is the top and tuberculosis is the second leading cause of death from infectious disease worldwide, with an estimated 8.7 million incident cases of tuberculosis and 2.5 million new HIV infections annually. The World Health Organization estimates that HIV prevalence among children with tuberculosis, in countries with moderate to high prevalence, ranges from 10 to 60%. The mechanisms promoting susceptibility of people with HIV to tuberculosis disease are incompletely understood, being likely caused by multifactorial processes. Paediatric tuberculosis and HIV have overlapping clinical manifestations, which could lead to missed or late diagnosis. Although every effort should be made to obtain a microbiologically-confirmed diagnosis in children with tuberculosis, in reality this may only be achieved in a minority, reflecting their paucibacillary nature and the difficulties in obtain samples. Rapid polymerase chain reaction tests, such as Xpert MTB/RIF assay, are increasingly used in children. The use of less or non invasive methods of sample collection, such as naso-pharyngeal aspirates and stool samples for a polymerase chain reaction-based diagnostic test tests and mycobacterial cultures is promising technique in HIV negative and HIV positive children. Anti-tuberculosis treatment should be started immediately at diagnosis with a four drug regimen, irrespective of the disease severity. Moreover, tuberculosis disease in an HIV infected child is considered to be a clinical indication for initiation of antiretroviral treatment. The World Health Organization recommends starting antiretroviral treatment in children as soon as anti-tuberculosis treatment is tolerated and within 2- 8 weeks after initiating it. The treatment of choice depends on the child's age and availability of age-appropriate formulations, and potential drug interactions and resistance. Treatment of multidrug resistant tuberculosis in HIV-infected children follows same principles as for HIV uninfected children. There are conflicting results on effectiveness of isoniazid preventive therapy in reducing incidence of tuberculosis disease in children with HIV.

CONCLUSION

Data on HIV/TB co-infection in children are still lacking. There are on-going large clinical trials on the prevention and treatment of TB/HIV infection in children that hopefully will help to guide an evidence-based clinical practice in both resource-rich and resource-limited settings.HIV is the top and tuberculosis is the second leading cause of death from infectious disease worldwide, with an estimated 8.7 million incident cases of tuberculosis and 2.5 million new HIV infections annually. The World Health Organization estimates that HIV prevalence among children with tuberculosis, in countries with moderate to high prevalence, ranges from 10 to 60%. The mechanisms promoting susceptibility of people with HIV to tuberculosis disease are incompletely understood, being likely caused by multifactorial processes.

Tuberculosis among children in Kenya: epidemiology and impact of HIV in two provinces

We collected clinical register data on children in two provinces of Kenya and conducted bivariate and multivariate analyses to assess characteristics associated with death. Among 987 children with tuberculosis (TB), pulmonary disease was diagnosed in 689 (70%) children. Final outcomes were known for 830 children, 40 (5%) of whom died during TB treatment. HIV test results were available for 670 (68%) children; 371 (55%) of whom tested positive. Only 63 of 134 (47%) of children <1 year were tested for HIV. There were no data on CD4 or anti-retroviral use. The relative risk for death for HIV-infected children compared to HIV-uninfected children was 9.3 for children <1 year [95% confidence interval (CI) 1.2-69.2], 3.9 for children aged 1-4 (95% CI 0.9-17.7) and 0.9 for children aged 5-14 (95% CI 0.3-2.6). In Kenya, HIV infection in children with TB is common, and our data suggest that HIV is particularly deadly in TB patients <1 year, the group with the lowest rate of testing. Poor data recording and reporting limit our understanding of TB in this age group. Expansion of HIV testing may improve survival, and more complete data recording and reporting will enhance our understanding of pediatric TB.

[The impact of HIV infection on childhood tuberculosis in Yaounde, Cameroon]

OBJECTIVES

To define the prevalence of HIV infection in childhood tuberculosis and investigate its impact on the clinical presentation, radiographic findings and outcomes among children suffering from tuberculosis in Yaounde.

METHODS

The medical records of 101 children aged less than 15years, hospitalized with tuberculosis in the chest clinic of the Yaounde Jamot Hospital between January 2005 and June 2010, were retrospectively reviewed.

RESULTS

Twenty-five (24.8%) of the 101 patients were HIV positive. The occurrence of concomitant intrathoracic and extrathoracic tuberculosis was more frequently observed in HIV infected children (P=0.021). Parenchymal pulmonary lesions were bilateral in 20 (90.9%) of the HIV infected children against 31 (56.1%) in the non-infected children (P=0.003). Cavitating lesions were present in 49.1% of the cases in HIV negative group versus 13.6% in HIV positive group (P=0.004), but sub-group analysis restricted to those with confirmed tuberculosis no longer showed a significant difference. The success rate of treatment was 78.9% among HIV negative patients and 56% among HIV positive patients (P=0.024).

CONCLUSION

HIV infection modifies the clinical presentation and radiographic features of tuberculosis in children. The treatment success rate is lower in HIV positive children, indicating a stricter medical supervision of these children and more targeted education of their parents.

A proposed comprehensive classification of tuberculosis disease severity in children

BACKGROUND

Tuberculosis (TB) in children has conventionally been classified as pulmonary TB (PTB) and extrapulmonary TB (EPTB) disease, including disseminated TB (TB meningitis and miliary disease). There is no existing approach that comprehensively characterizes the spectrum and severity of pediatric TB. This limits accurate classification of patients and comparison across cohorts.

AIMS

To develop a classification of pediatric TB that reflects the spectrum and severity of clinical disease better than currently available approaches.

METHODS

We propose a framework for the standard classification of TB disease severity in children. From a literature search, the following sources of information were used: clinical data, bacteriologic, histopathologic, and imaging data (including information from chest radiography, computerized tomography, and bronchoscopy). Each individual disease entity was systematically considered. Based on the extent and the presence of complications, each entity was then classified as "severe" or "nonsevere." As an initial application, we compared the proposed classification with the convention (PTB, EPTB) in a cohort of HIV-infected and -uninfected infants with culture-confirmed TB. Agreement between the 2 systems was poor.

CONCLUSIONS

The proposed comprehensive disease classification system may more accurately reflect the clinical TB disease spectrum in children, is relevant to clinical management, and may be valuable to inform research on diagnostic tools and TB treatment strategies in children. Prospective studies are required to evaluate this approach in representative pediatric populations, correlating TB disease severity with diagnostic yield, treatment response, and application in existing and novel treatment strategies.

HIV and tuberculosis: a deadly human syndemic

A syndemic is defined as the convergence of two or more diseases that act synergistically to magnify the burden of disease. The intersection and syndemic interaction between the human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics have had deadly consequences around the world. Without adequate control of the TB-HIV syndemic, the long-term TB elimination target set for 2050 will not be reached. There is an urgent need for additional resources and novel approaches for the diagnosis, treatment, and prevention of both HIV and TB. Moreover, multidisciplinary approaches that consider HIV and TB together, rather than as separate problems and diseases, will be necessary to prevent further worsening of the HIV-TB syndemic. This review examines current knowledge of the state and impact of the HIV-TB syndemic and reviews the epidemiological, clinical, cellular, and molecular interactions between HIV and TB.

Clinical Outcomes and Hospitalizations among Children Perinatally Infected with HIV-1 in Baja California, Mexico

This study characterizes temporal trends in HIV disease progression among perinatally infected children at a clinic in Baja California, Mexico. A total of 73 children were followed, 52% were categorized under US Centers for Disease Control and Prevention (CDC) classification group C with a mean age of 2.3 years (SD ± 3.16) at HIV diagnosis. For the years 1998 to 2001, 2002 to 2003, 2004 to 2005, and 2006 to 2007, highly active antiretroviral therapy (HAART) use increased to 60%, 75%, 83%, and 94% ( P < .001) as did mean CD4 percentage of 23.4%, 23.2%, 26.9%, and 29.0%, respectively ( P = .009), while HIV plasma RNA log10 decreased significantly (4.49, 4.23, 4.00, and 3.79, respectively; P = .019). Overall mortality was 31% (23 of 73), with pneumonia being the most common cause of death (43% of all deaths) followed by tuberculosis (22%). Mortality rates declined from 30.4% to 25%, 8.9%, and 9.3% ( p = 0.035) for the years 1998 to 2001, 2002 to 2003, 2004 to 2005, and 2006 to 2007, respectively. Kaplan-Meier survival analysis showed that median survival was 11.2 years; 1-, 2-, and 5-year survival was 87%, 83%, and 67%, respectively. These findings document a high but improving trend in morbidity and mortality of children perinatally infected with HIV in Tijuana, Baja California, Mexico.

Development of a standardized screening rule for tuberculosis in people living with HIV in resource-constrained settings: individual participant data meta-analysis of observational studies

BACKGROUND

The World Health Organization recommends the screening of all people living with HIV for tuberculosis (TB) disease, followed by TB treatment, or isoniazid preventive therapy (IPT) when TB is excluded. However, the difficulty of reliably excluding TB disease has severely limited TB screening and IPT uptake in resource-limited settings. We conducted an individual participant data meta-analysis of primary studies, aiming to identify a sensitive TB screening rule.

METHODS AND FINDINGS

We identified 12 studies that had systematically collected sputum specimens regardless of signs or symptoms, at least one mycobacterial culture, clinical symptoms, and HIV and TB disease status. Bivariate random-effects meta-analysis and the hierarchical summary relative operating characteristic curves were used to evaluate the screening performance of all combinations of variables of interest. TB disease was diagnosed in 557 (5.8%) of 9,626 people living with HIV. The primary analysis included 8,148 people living with HIV who could be evaluated on five symptoms from nine of the 12 studies. The median age was 34 years. The best performing rule was the presence of any one of: current cough (any duration), fever, night sweats, or weight loss. The overall sensitivity of this rule was 78.9% (95% confidence interval [CI] 58.3%-90.9%) and specificity was 49.6% (95% CI 29.2%-70.1%). Its sensitivity increased to 90.1% (95% CI 76.3%-96.2%) among participants selected from clinical settings and to 88.0% (95% CI 76.1%-94.4%) among those who were not previously screened for TB. Negative predictive value was 97.7% (95% CI 97.4%-98.0%) and 90.0% (95% CI 88.6%-91.3%) at 5% and 20% prevalence of TB among people living with HIV, respectively. Abnormal chest radiographic findings increased the sensitivity of the rule by 11.7% (90.6% versus 78.9%) with a reduction of specificity by 10.7% (49.6% versus 38.9%).

CONCLUSIONS

Absence of all of current cough, fever, night sweats, and weight loss can identify a subset of people living with HIV who have a very low probability of having TB disease. A simplified screening rule using any one of these symptoms can be used in resource-constrained settings to identify people living with HIV in need of further diagnostic assessment for TB. Use of this algorithm should result in earlier TB diagnosis and treatment, and should allow for substantial scale-up of IPT.

Low rates of hepatotoxicity in HIV-infected children on anti-retroviral therapy with and without isoniazid prophylaxis

This study investigates the incidence of hepatotoxicity in HIV-infected children during anti-retroviral therapy (ART) and the impact of concomitant use of isoniazid preventive therapy. It is a retrospective cohort analysis of HIV-infected children who commenced ART or were followed up between September 1998 and November 2005. Alanine transferase levels were measured at baseline, at 1, 3 and 6 months and then 6 monthly thereafter. Of the 598 children included in the study, 425 were taking ART alone, 73 ART and isoniazid, 39 isoniazid alone and 61 neither isoniazid nor ART. There was no increased risk of hepatotoxicity with ART with or without isoniazid compared to the control group over a 2-year period. Grade 3 or 4 ALT elevations occurred in 19 (3.4%) children, with no cases of fulminant hepatic failure. Severe hepatic events are uncommon in children on ART or isoniazid. There is no increased risk of hepatotoxicity with ART and concurrent isoniazid preventive therapy.

Effect on mortality and virological response of delaying antiretroviral therapy initiation in children receiving tuberculosis treatment

OBJECTIVE

To estimate the effect of delaying antiretroviral treatment (ART) for 15, 30, or 60 days after tuberculosis (TB) treatment initiation on mortality and virological suppression.

DESIGN

Cohort of 573 ART-naive HIV-infected children initiated on TB treatment at an outpatient clinic in South Africa between April 2004 and March 2008.

METHODS

Hazard ratios for mortality and viral suppression were estimated using marginal structural models and multivariate Cox models, respectively.

RESULTS

During follow-up (median 9.64 months), 37 HIV-infected children died after a median of 62 days of TB treatment. ART was initiated in 461 children at a median of 17 days after TB treatment initiation, 415 (90%) achieved viral suppression. The hazard ratios of death for initiating ART more than 15, more than 30, or more than 60 days of TB treatment compared with initiating within 15, 30 and 60 days, respectively, were 0.82 (95% CI: 0.48, 1.41), 0.86 (95% CI: 0.46, 1.60), and 1.32 (95% CI: 0.55, 3.16). Hazard ratios for analysis restricted to severely immunosuppressed children were: 0.92 (95% CI: 0.51, 1.63), 1.08 (95% CI: 0.56, 2.08), and 2.23 (95% CI: 0.85, 5.80), respectively. Hazard ratios for viral suppression were 0.98 (95% CI: 0.76, 1.26), 0.95, (95% CI: 0.73, 1.23), 0.84 (95% CI: 0.61, 1.15), respectively and did not change with restriction to children severely immunosuppressed.

CONCLUSION

In this observational study, we found that delaying ART for 2 months or more in children diagnosed with TB may be associated with poorer virological response and increased mortality, particularly in children with severe immunosuppression. These findings should be confirmed in a randomized controlled trial.

Diagnosis of pulmonary tuberculosis in children: new advances

The global burden of childhood pulmonary TB has been underappreciated, in part due to difficulties in obtaining microbiological confirmation of disease. Most HIV-uninfected children can be diagnosed using a combination of clinical and epidemiological features, tuberculin skin testing and chest radiography, as represented in different scoring systems. However, accurate microbiologic diagnosis has become increasingly important for timely use of effective treatment. Mycobacterial culture confirms the diagnosis of TB and provides drug susceptibility data but is not available in most areas with a high TB prevalence. Moreover, culture has poor sensitivity in children who usually have paucibacillary disease. The HIV epidemic has made definitive diagnosis even more challenging due to nonspecific clinical and radiological signs. In high HIV-prevalence areas, scoring systems have been especially variable, lacking sensitivity and specificity. Newer methods for diagnosis are aimed either at detecting the organism or a specific host immune response. Methods for organism detection have focused on collection of better samples, improved culture techniques, molecular methods or antigen detection. Recent advances include the use of sputum induction for obtaining a more reliable specimen, faster and more sensitive culture methods, and rapid detection of the organism and drug resistance based on nucleic acid amplification. Improved methods for detecting a specific host response have largely focused on the use of IFN-g release assays. Even with newer methods, accurately diagnosing childhood TB may be challenging. Greater efforts to obtain a microbiologic diagnosis should be made in children, even in primary care settings. Further research to develop a more accurate, cost-effective and simple diagnostic test for childhood TB is urgently needed.

Impact of tuberculosis preventive therapy on tuberculosis and mortality in HIV-infected children

BACKGROUND

Children with HIV are at increased risk of acquiring tuberculosis (TB), a common cause of acute and chronic respiratory disease and death in HIV-infected children living in areas where prevalence of the disease is high. Children infected with HIV and TB have worse outcomes than HIV-uninfected children who have TB; thus, preventing the infection and disease in HIV-infected children is potentially an important public health intervention. Isoniazid, an anti-tuberculosis medication, has been used effectively to prevent TB in HIV-uninfected children, but currently there are no guidelines on the use of TB preventive therapy in HIV-infected children.

OBJECTIVES

To determine the impact of TB preventive therapy on TB-related incidence and death in HIV-infected children

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (CENTRAL/CCTR), Cochrane HIV/AIDS Group Specialized Register, MEDLINE/PubMed, EMBASE, and AIDSearch. In addition, we scanned reference lists, manually searched conference abstracts, and contacted content experts.

SELECTION CRITERIA

We included studies of HIV-infected children randomised to receive TB preventive therapy or placebo, or an alternative TB preventive regimen. Participants could have tuberculin skin test results that were positive or negative.

DATA COLLECTION AND ANALYSIS

Two authors independently used the study selection criteria, assessed methodological quality and extracted data. Effects were assessed using hazard ratios.

MAIN RESULTS

One trial met the selection criteria for the review. The trial participants were HIV-infected children, most of whom were not taking antiretroviral therapy. Subjects were randomised to isoniazid and cotrimoxazole or placebo and cotrimoxazole, given daily or three times a week. The trial showed a marked reduction in TB incidence and death in the isoniazid group. As yet, however, there are no long-term follow-up data on the durability of the protective effect or on possible long-term adverse events. This trial also was unable to assess the impact of isoniazid prophylaxis on children receiving antiretroviral therapy.

AUTHORS' CONCLUSIONS

Isoniazid prophylaxis in HIV-infected children has the potential to play a major public health role by reducing TB incidence and death. As yet, however, data are insufficient to guide the duration of prophylaxis and to support its use in children using highly active antiretroviral therapy (HAART) and in those living in areas of low TB prevalence. Further studies are needed to assess whether TB preventive therapy is of benefit in all HIV-infected children, irrespective of use of antiretroviral treatment, the optimal duration of preventive therapy, or long-term adverse events.

Paediatric tuberculosis

Tuberculosis continues to cause an unacceptably high toll of disease and death among children worldwide, particularly in the wake of the HIV epidemic. Increased international travel and immigration have led to a rise in childhood tuberculosis rates even in traditionally low burden, industrialised settings, and threaten to promote the emergence and spread of multidrug-resistant strains. Whereas intense scientific and clinical research efforts into novel diagnostic, therapeutic, and preventive interventions have focused on tuberculosis in adults, childhood tuberculosis has been relatively neglected. However, children are particularly vulnerable to severe disease and death following infection, and those with latent infection become the reservoir for future transmission following disease reactivation in adulthood, fuelling future epidemics. Further research into the epidemiology, immune mechanisms, diagnosis, treatment, and prevention of childhood tuberculosis is urgently needed. Advances in our understanding of tuberculosis in children would provide insights and opportunities to enhance efforts to control this disease.

Childhood TB epidemiology and treatment outcomes in Thailand: a TB active surveillance network, 2004 to 2006

BACKGROUND

Of the 9.2 million new TB cases occurring each year, about 10% are in children. Because childhood TB is usually non-infectious and non-fatal, national programs do not prioritize childhood TB diagnosis and treatment. We reviewed data from a demonstration project to learn more about the epidemiology of childhood TB in Thailand.

METHODS

In four Thai provinces and one national hospital, we contacted healthcare facilities monthly to record data about persons diagnosed with TB, assist with patient care, provide HIV counseling and testing, and obtain sputum for culture and susceptibility testing. We analyzed clinical and treatment outcome data for patients age < 15 years old registered in 2005 and 2006.

RESULTS

Only 279 (2%) of 14,487 total cases occurred in children. The median age of children was 8 years (range: 4 months, 14 years). Of 197 children with pulmonary TB, 63 (32%) were bacteriologically-confirmed: 56 (28%) were smear-positive and 7 (4%) were smear-negative, but culture-positive. One was diagnosed with multi-drug resistant TB. HIV infection was documented in 75 (27%). Thirteen (17%) of 75 HIV-infected children died during TB treatment compared with 4 (2%) of 204 not known to be HIV-infected (p < 0.01).

CONCLUSION

Childhood TB is infrequently diagnosed in Thailand. Understanding whether this is due to absence of disease or diagnostic effort requires further research. HIV contributes substantially to the childhood TB burden in Thailand and is associated with high mortality.

Clinical presentation and outcome of tuberculosis in human immunodeficiency virus infected children on anti-retroviral therapy

Background

The tuberculosis (TB) and human immunodeficiency virus (HIV) epidemics are poorly controlled in sub-Saharan Africa, where highly active antiretroviral treatment (HAART) has become more freely available. Little is known about the clinical presentation and outcome of TB in HIV-infected children on HAART.

Methods

We performed a comprehensive file review of all children who commenced HAART at Tygerberg Children's Hospital from January 2003 through December 2005.

Results

Data from 290 children were analyzed; 137 TB episodes were recorded in 136 children; 116 episodes occurred before and 21 after HAART initiation; 10 episodes were probably related to immune reconstitution inflammatory syndrome (IRIS). The number of TB cases per 100 patient years were 53.3 during the 9 months prior to HAART initiation, and 6.4 during post HAART follow-up [odds ratio (OR) 16.6; 95% confidence interval (CI) 12.5–22.4]. A positive outcome was achieved in 97/137 (71%) episodes, 6 (4%) cases experienced no improvement, 16 (12%) died and the outcome could not be established in 18 (13%). Mortality was less in children on HAART (1/21; 4.8%) compared to those not on HAART (15/116; 12.9%).

Conclusion

We recorded an extremely high incidence of TB among HIV-infected children, especially prior to HAART initiation. Starting HAART at an earlier stage is likely to reduce morbidity and mortality related to TB, particularly in TB-endemic areas. Management frequently deviated from standard guidelines, but outcomes in general were good.

Chronic lung disease in human immunodeficiency virus (HIV) infected children

The development of chronic lung disease is common in HIV-infected children. The spectrum of chronic HIV-associated lung disease includes lymphocytic interstitial pneumonia (LIP), chronic infections, immune reconstitution inflammatory syndrome (IRIS), bronchiectasis, malignancies, and interstitial pneumonitis. Chronic lung disease may result from recurrent or persistent pneumonia due to bacterial, mycobacterial, viral, fungal or mixed infections. In high tuberculosis (TB) prevalence areas, M. tuberculosis is an important cause of chronic respiratory illness. With increasing availability of highly active antiretroviral therapy (HAART) for children in developing countries, a rise in the incidence of IRIS due to mycobacterial or other infections is being reported. Diagnosis of chronic lung disease is based on chronic symptoms and persistent chest X-ray changes but definitive diagnosis can be difficult as clinical and radiological findings may be non-specific. Distinguishing LIP from miliary TB remains a difficult challenge in HIV-infected children living in high TB prevalence areas. Treatment includes therapy for specific infections, pulmonary clearance techniques, corticosteroids for children with LIP who are hypoxic or who have airway compression from tuberculous nodes and HAART. Children who are taking TB therapy and HAART need adjustments in their drug regimes to minimize drug interactions and ensure efficacy. Preventative strategies include immunization, chemoprophylaxis, and micronutrient supplementation. Early use of HAART may prevent the development of chronic lung disease.

International perspectives, progress, and future challenges of paediatric HIV infection

Paediatric HIV infection is a growing health challenge worldwide, with an estimated 1500 new infections every day. In developed countries, well established prevention programmes keep mother-to-child transmission rates at less than 2%. However, in developing countries, where transmission rates are 25-40%, interventions are available to only 5-10% of women. Children with untreated natural infection progress rapidly to disease, especially in resource-poor settings where mortality is greater than 50% by 2 years of age. As in adult infection, antiretroviral therapy has the potential to rewrite the natural history of HIV, but is accessible only to a small number of children needing therapy. We focus on the clinical and immunological features of HIV that are specific to paediatric infection, and the formidable challenges ahead to ensure that all children worldwide have access to interventions that have proved successful in developed countries.

Childhood tuberculosis - global epidemiology and the impact of HIV

The burden of tuberculosis (TB), worldwide, is influenced by the human immunodeficiency virus (HIV) epidemic. Between 1990 and 2004, the tuberculosis incidence stabilised or fell steadily in most parts of the world, with the exception of Africa. HIV and HIV-associated TB affects young adults, which may result in increased rates of TB transmission to children. Moreover, HIV-infected children are at increased risk of TB and of more severe forms of TB compared with immunocompetent children. There is evidence that TB is more common in children living in households affected by HIV. Owing to the higher mortality during and after TB treatment, the outcome of TB is also worse among HIV-infected children, with lower cure and higher recurrence rates. Although available reports still show low levels of drug resistance among children, continued surveillance will be important to detect any increase in resistance rates, including multidrug-resistant TB. As BCG is still the only vaccine available, research needs to be focused on better methods of preventing TB. Furthermore, the development of better diagnostics for infection and disease will improve the management of TB in children.

T cell-based diagnosis of childhood tuberculosis infection

PURPOSE OF REVIEW

T-cell interferon-gamma release assays (TIGRAs), available as enzyme-linked immunospot (ELISpot) and enzyme-linked immunoassay (ELISA), potentially significantly advance on the tuberculin skin test (TST) for diagnosis of tuberculosis infection. We review all publications using TIGRAs in children to appraise paediatricians of the advantages and limitations of these new blood tests.

RECENT FINDINGS

Unlike TST, both tests are independent of Bacille Calmette-Guérin vaccination status, providing higher diagnostic specificity. In children with active tuberculosis ELISpot is more sensitive than TST and is unaffected by HIV infection, age under 3 years or malnutrition; ELISA data are currently limited. In the absence of a gold-standard test for latent tuberculosis infection, tuberculosis exposure was used as a surrogate marker; ELISpot generally correlates better with tuberculosis exposure than TST, while ELISA correlates broadly similarly. Indeterminate test results in young children are rare with ELISpot and are more common with ELISA.

SUMMARY

Although longitudinal studies quantifying risk of progression to tuberculosis in tuberculosis-exposed children with positive TIGRA results are required urgently, the small but rapidly expanding evidence-base since the first application of TIGRAs to childhood tuberculosis in 2003 combined with recent national guidelines makes a strong case for judicious use of TIGRAs in clinical management of paediatric tuberculosis.

Care and treatment of HIV-infected children in Africa: issues and challenges at the district hospital level

More than 90% of pediatric HIV infection occurs in sub-Saharan Africa and 75% of these children currently die before their fifth birthday. Most HIV-infected children in Africa rely on district hospitals for HIV treatment, but insufficient attention has been paid to improving HIV/AIDS care at this level. Considerable confusion exists about optimal use of combination antiretroviral treatment, prophylaxis for opportunistic infections and other rational healthcare interventions that can greatly improve the quality of life for these children. A simple and inexpensive infant HIV diagnostic assay and alternative laboratory markers of pediatric HIV disease progression would be highly beneficial. Routine anthropometric and neurodevelopmental assessments could help guide initiation and monitoring of antiretroviral therapy. Even in the absence of antiretroviral therapy, interventions such as immunizations, provision of micronutrients and nutrition counseling, prevention and treatment of opportunistic as well as endemic infections (such as helminths and malaria) can substantially reduce pediatric HIV-related morbidity and mortality. The need for pain relief, palliative care, counseling and emotional support is often underestimated. Surmounting the sense of hopelessness by providing district healthcare workers with training in basic pediatric HIV/AIDS care is an urgent priority.