Childhood tuberculosis and treatment outcomes in Accra: a retrospective analysis

Mortality of children and adolescents co-infected with tuberculosis and HIV: a systematic review and meta-analysis

OBJECTIVE

Children and adolescents with HIV infection are well known to face a heightened risk of tuberculosis. However, the exact mortality rates and temporal trends of those with HIV-tuberculosis (TB) co-infection remain unclear. We aimed to identify the overall mortality and temporal trends within this population.

METHODS

PubMed, Web of Science, and Embase were employed to search for publications reporting on the mortality rates of children and adolescents with HIV-TB co-infection from inception to March 2, 2024. The outcome is the mortality rate for children and adolescents with HIV-TB co-infection during the follow-up period. In addition, we evaluate the temporal trends of mortality.

RESULTS

During the follow-up period, the pooled mortality was 16% [95% confidence interval (CI) 13-20]. Single infection of either HIV or TB exhibit lower mortality rates (6% and 4%, respectively). We observed elevated mortality risks among individuals aged less than 12 months, those with extrapulmonary TB, poor adherence to ART, and severe immunosuppression. In addition, we observed a decreasing trend in mortality before 2008 and an increasing trend after 2008, although the trends were not statistically significant ( P  = 0.08 and 0.2 respectively).

CONCLUSIONS

Children and adolescents with HIV-TB co-infection bear a significant burden of mortality. Timely screening, effective treatment, and a comprehensive follow-up system contribute to reducing the mortality burden in this population.

Epidemiology of tuberculosis among children in Beijing, China, 2012-2021

Data on epidemiology trends of paediatric tuberculosis (TB) are limited in China. So, we investigated the clinical and epidemiological profiles in diagnosed TB disease and TB infection patients at Beijing Children's Hospital. Of 3 193 patients, 51.05% had pulmonary TB (PTB) and 15.16% had extrapulmonary TB (EPTB). The most frequent forms of EPTB were TB meningitis (39.05%), pleural TB (29.75%), and disseminated TB (10.33%). PTB patients were significantly younger and associated with higher hospitalization frequency. Children aged 1-4 years exhibited higher risk of PTB and TB meningitis, and children aged 5-12 years had higher risk of EPTB. The proportion of PTB patients increased slightly from 40.9% in 2012 to 65% in 2019, and then decreased to 17.8% in 2021. The percentage of EPTB cases decreased from 18.3% in 2012 to 15.2% in 2019, but increased to 16.4% in 2021. Among EPTB cases, the largest increase was seen in TB meningitis. In conclusion, female and young children had higher risk of PTB in children. TB meningitis was the most frequent forms of EPTB among children, and young children were at high risk of TB meningitis. The distribution of different types of EPTB differed by age.

Evaluation of treatment outcomes among adult patients diagnosed with tuberculosis in Ghana: A 10 year retrospective review

Objectives

The study determined tuberculosis (TB) treatment outcomes in Southern Ghana from 2012 to 2021.

Methods

A retrospective analysis of service data on TB cases was conducted. Treatment success was defined as TB cure or completion of treatment course, whereas unsuccessful outcomes was defined as death, failure of treatment and lost to follow up. Bivariate and multivariate logistic regression was used to determine factors associated with treatment outcomes.

Results

A total of 4106 adult TB cases were reported with a median age of 41 (interquartile range 32-52) years. Of these, 93.1% (n = 3823) were newly diagnosed. The treatment success rate declined from 71.0% in 2012 to 55.7% in 2021 (ktau-b = -0.56, P = 0.0318). Clinically diagnosed TB and extra-pulmonary TB had 7.0% (adjusted prevalence ratio [aPR]: 0.93, 95% confidence interval [CI]: 0.88-1.00) and 24.0% (aPR: 0.76, 95% CI: 0.69-0.84) respectively, less successful treatment outcome compared to pulmonary TB patients. HIV negative status was associated with 22% higher successful treatment outcome compared with being HIV positive (aPR: 1.22, 95% CI: 1.12-1.33).

Conclusion

Tuberculosis treatment success rate declined over the period. There is a need for the TB Control Programme to review the national and sub-national TB data to ascertain poor performing TB treatment sites to identify and address context specific challenges with treatment interventions and system inadequacies to improve treatment success rates.

Improving TB detection among children in routine clinical care through intensified case finding in facility-based child health entry points and decentralized management: A before-and-after study in Nine Sub-Saharan African Countries

In 2022, an estimated 1.25 million children <15 years of age developed tuberculosis (TB) worldwide, but >50% remained undiagnosed or unreported. WHO recently recommended integrated and decentralized models of care as an approach to improve access to TB services for children, but evidence remains limited. The Catalyzing Paediatric TB Innovation project (CaP-TB) implemented a multi-pronged intervention to improve TB case finding in children in nine sub-Saharan African countries. The intervention introduced systematic TB screening in different facility-based child-health entry-points, decentralisation of TB diagnosis and management, improved sample collection with access to Xpert® MTB/RIF or MTB/RIF Ultra testing, and implementation of contact investigation. Pre-intervention records were compared with those during intervention to assess effect on paediatric TB cascade of care. The intervention screened 1 991 401 children <15 years of age for TB across 144 health care facilities. The monthly paediatric TB case detection rate increased significantly during intervention versus pre-intervention (+46.0%, 95% CI 36.2-55.8%; p<0.0001), with variability across countries. The increase was greater in the <5 years old compared to the 5-14 years old (+53.4%, 95% CI 35.2-71.9%; p<0.0001 versus +39.9%, 95% CI 27.6-52.2%; p<0.0001). Relative contribution of lower-tier facilities to total case detection rate increased from 37% (71.8/191.8) pre-intervention to 50% (139.9/280.2) during intervention. The majority (89.5%) of children with TB were identified through facility-based intensified case-finding and primarily accessed care through outpatient and inpatient departments. In this multi-country study implemented under real-life conditions, the implementation of integrated and decentralized interventions increased paediatric TB case detection. The increase was driven by lower-tier facilities that serve as the primary point of healthcare contact for most patients. The effect was greater in children < 5 years compared to 5-14 years old, representing an important achievement as the TB detection gap is higher in this subpopulation. (Study number NCT03948698).

Childhood tuberculosis and factors associated with mortality and loss to follow-up at a major paediatric treatment centre in Southern Ghana

Introduction

tuberculosis (TB) is a major cause of morbidity and mortality in children in low- and middle-income countries. This study described the clinical presentation and identified factors contributing to poor outcome of childhood TB at Korle Bu Teaching Hospital (KBTH), Accra, Ghana.

Methods

this was a retrospective cohort study of children aged ≤ 14 years with TB registered for treatment at KBTH from 2015 to 2019. Treatment outcomes were recorded as treatment success and unsuccessful outcomes (died and loss to follow-up). Multivariable logistics regression was conducted to assess factors associated with an unsuccessful outcome.

Results

of 407 children with TB registered during the period, 269 (66.1%) patients had pulmonary tuberculosis (PTB). Of the 138 patients with extra-pulmonary TB (EPTB), 68 (49.3%) had TB lymphadenitis. The TB/HIV coinfection rate was 42.8%. The overall treatment success rate was 68.3%, whilst 71(17.4%) died, and 58 (14.3%) were lost to follow-up. Factors associated with death were age below 1 year (AOR: 3.46, 95% CI: 1.48-8.10, p=0.004) and having HIV coinfection (AOR: 1.89, 95% CI: 1.04-3.43, p=0.037). Factors associated with loss to follow-up were age below 1 year (AOR: 2.91, 95% CI: 1.12-8.59, p=0.029) and having EPTB (AOR: 2.40, 95% CI: 1.24-4.65, p=0.009).

Conclusion

childhood TB treatment success in our population was below the national target of 85%, with high mortality and loss to follow-up rates, especially in younger children and those with HIV coinfection or EPTB. Tailored treatment strategies may be needed for children at risk of unsuccessful treatment outcome, especially among infants.

Epidemiology of Pediatric Tuberculosis and Factors Associated with Unsuccessful Treatment Outcomes in the Centre Region of Cameroon: A Three-Year Retrospective Cohort Study

Background

In Cameroon, there are limited data on treatment outcomes of pediatric tuberculosis (TB). We sought to identify the factors associated with unsuccessful treatment outcomes and the risk factors for mortality among children receiving TB treatment in the Centre Region of Cameroon.

Methods

This was a multicentre facility-based retrospective cohort study using routinely collected programmatic data. All children <15 years old treated for TB between 2018 and 2020 in 21 health facilities were included. We assessed risk factors for experiencing an unsuccessful treatment outcome and mortality through multivariable logistic regression analysis.

Results

Of the 610 children with TB, 307 (50.3%) were females and the median age was 6 years (IQR = 2–12). One hundred and fifty-three (25.1%) of the children were TB/HIV co-infected patients. TB treatment success (cases categorized as cured and completed treatment) was observed in 488 (80.0%) of the patients. Unsuccessful treatment outcomes were experienced by 122 (20.0%) children. Of these, 73 (12.0%) died, 4 (0.6%) had treatment failure, 25 (4.1%) were lost to follow-up, and the outcomes of 20 (3.3%) children were not evaluated. In multivariable analysis, HIV-positive status (adjusted odds ratio [AOR] = 2.43; 95% CI, 1.55–3.80, p < 0.001) and clinical method of TB diagnosis (AOR = 2.46; 95% CI, 1.55–3.91, p < 0.001] were associated with unsuccessful treatment outcomes. HIV-positive status (AOR = 4.23; 95% CI, 2.44–7.33, p < 0.001) and clinical method of TB diagnosis (AOR = 2.22; 95% CI, 1.25–3.91, p=0.006) were the risk factors for mortality among children on TB treatment.

Conclusion

The study found that HIV-TB co-infected children and those clinically diagnosed with TB were significantly more likely to have had unsuccessful TB treatment outcomes and mortality. Our findings underscore the need for healthcare workers to closely monitor and support HIV-TB co-infected children on TB treatment. TB/HIV collaborative activities should be strengthened by implementing TB preventive interventions among HIV-infected children.

Machine learning in the loop for tuberculosis diagnosis support

The use of machine learning (ML) for diagnosis support has advanced in the field of health. In the present paper, the results of studying ML techniques in a tuberculosis diagnosis loop in a scenario of limited resources are presented. Data are analyzed using a tuberculosis (TB) therapy program at a health institution in a main city of a developing country using five ML models. Logistic regression, classification trees, random forest, support vector machines, and artificial neural networks are trained under physician supervision following physicians' typical daily work. The models are trained on seven main variables collected when patients arrive at the facility. Additionally, the variables applied to train the models are analyzed, and the models' advantages and limitations are discussed in the context of the automated ML techniques. The results show that artificial neural networks obtain the best results in terms of accuracy, sensitivity, and area under the receiver operating curve. These results represent an improvement over smear microscopy, which is commonly used techniques to detect TB for special cases. Findings demonstrate that ML in the TB diagnosis loop can be reinforced with available data to serve as an alternative diagnosis tool based on data processing in places where the health infrastructure is limited.

High burden of childhood tuberculosis in migrants: a retrospective cohort study from the Thailand-Myanmar border

BACKGROUND

Tuberculosis (TB) is a leading cause of morbidity and mortality in children but epidemiological data are scarce, particularly for hard-to-reach populations. We aimed to identify the risk factors for unsuccessful outcome and TB mortality in migrant children at a supportive residential TB programme on the Thailand-Myanmar border.

METHODS

We conducted retrospective analysis of routine programmatic data for children (aged ≤ 15 years old) with TB diagnosed either clinically or bacteriologically between 2013 and 2018. Treatment outcomes were described and risk factors for unsuccessful outcome and death were identified using multivariable logistic regression.

RESULTS

Childhood TB accounted for a high proportion of all TB diagnoses at this TB programme (398/2304; 17.3%). Bacteriological testing was done on a quarter (24.9%) of the cohort and most children were diagnosed on clinical grounds (94.0%). Among those enrolled on treatment (n = 367), 90.5% completed treatment successfully. Unsuccessful treatment outcomes occurred in 42/398 (10.6%) children, comprising 26 (6.5%) lost to follow-up, one (0.3%) treatment failure and 15 (3.8%) deaths. In multivariable analysis, extra-pulmonary TB [adjusted OR (aOR) 3.56 (95% CI 1.12-10.98)], bacteriologically confirmed TB [aOR 6.07 (1.68-21.92)] and unknown HIV status [aOR 42.29 (10.00-178.78)] were independent risk factors for unsuccessful outcome. HIV-positive status [aOR 5.95 (1.67-21.22)] and bacteriological confirmation [aOR 9.31 (1.97-44.03)] were risk factors for death in the secondary analysis.

CONCLUSIONS

Children bear a substantial burden of TB disease within this migrant population. Treatment success rate exceeded the WHO End TB target of 90%, suggesting that similar vulnerable populations could benefit from the enhanced social support offered by this TB programme, but better child-friendly diagnostics are needed to improve the quality of diagnoses.

Tuberculosis Treatment Outcome and Predictors in Africa: A Systematic Review and Meta-Analysis

This review aimed to summarize and estimate the TB treatment success rate and factors associated with unsuccessful TB treatment outcomes in Africa. Potentially eligible primary studies were retrieved from PubMed and Google Scholar. The risk of bias and quality of studies was assessed using The Joanna Briggs Institute's (JBI) appraisal criteria, while heterogeneity across studies was assessed using Cochran's Q test and I2 statistic. Publication bias was checked using the funnel plot and egger's test. The protocol was registered in PROSPERO, numbered CRD42019136986. A total of 26 eligible studies were considered. The overall pooled estimate of TB treatment success rate was found to be 79.0% (95% CI: 76-82%), ranging from 53% (95% CI: 47-58%) in Nigeria to 92% (95% CI: 90-93%) in Ethiopia. The majority of unsuccessful outcomes were attributed to 48% (95% CI: 40-57%) death and 47% (95% CI: 39-55%) of defaulter rate. HIV co-infection and retreatment were significantly associated with an increased risk of unsuccessful treatment outcomes compared to HIV negative and newly diagnosed TB patients with RR of 1.53 (95% CI: 1.36-1.71) and 1.48 (95% CI: 1.14-1.94), respectively. TB treatment success rate was 79% below the WHO defined threshold of 85% with significant variation across countries. Countries need to explore contextual underlining factors and more effort is required in providing TB preventive treatment, improve case screening and linkage for TB treatment among HIV high-risk groups and use confirmatory TB diagnostic modality. Countries in Africa need to strengthen counseling and follow-up, socio-economic support for patients at high risk of loss to follow-up and poor treatment success is also crucial for successful TB control programs.

Treatment Outcomes and Associated Factors in Tuberculosis Patients at Atwima Nwabiagya District, Ashanti Region, Ghana: A Ten-Year Retrospective Study

INTRODUCTION

Tuberculosis poses a great threat to public health around the globe and affects persons mostly in their productive age, notwithstanding; everyone is susceptible to tuberculosis (TB) infection. To assess the effectiveness and performance of the tuberculosis control program activities, the percentage of cases with treatment success outcome is key. To control tuberculosis, interrupting transmission through effective treatment cannot be overemphasized. The study was conducted to determine factors associated with TB treatment outcome, in the Atwima Nwabiagya District from 2007-2017.

METHOD

A Retrospective review of routine/standard TB registers was carried out in five directly observed therapy short-course (DOTS) centres at the Atwima Nwabiagya District from January 2007 to December 2017. Demographic characteristics, clinical characteristics, and treatment outcomes were assessed. Bivariate and multivariate logistic regression was conducted to determine the predictors of successful treatment outcome.

RESULTS

Of the 891 TB client's data that was assessed in the district, the treatment success rate was 68.46%. Patients, aged ≤ 20 years (adjusted odds ratio (aOR) = 4.74, 95%CI = 1.75 - 12.83) and 51-60 years (aOR = 1.94, 95%CI = 1.12 - 3.39), having a pretreatment weight of 35-45 kg (aOR = 2.54, 95%CI = 1.32 - 4.87), 46-55 kg (aOR = 2.75, 95%CI = 1.44 - 5.27) and 56-65 kg (aOR = 3.04, 95%CI = 1.50 - 6.14) were associated with treatment success. However, retreatment patients (aOR = 0.31, 95%CI = 0.11 - 0.84) resulted in unsuccessful treatment outcome.

CONCLUSION

Successful treatment outcome among TB patients was about 20.00% and 30.00% lower compared to the national average treatment success rate and WHO target, respectively. Active monitoring, motivation, and counselling of retreatment patients and patients with advanced age are key to treatment success.

Treatment Outcomes of Childhood Tuberculosis in Three Districts of Balochistan, Pakistan: Findings from a Retrospective Cohort Study

BACKGROUND

This study aimed to evaluate treatment outcomes and factors associated unsuccessful outcomes among pediatric tuberculosis (TB) patients (age ≤14 years).

METHODS

This was a retrospective cohort study conducted at three districts (Quetta, Zhob and Killa Abdullah) of Balochistan, Pakistan. All childhood TB patients enrolled for treatment at Bolan Medical Complex Hospital (BMCH) Quetta and District Headquarter Hospitals of Zhob and Killa Abdullah from 1 January 2016 to 31 December 2018 were included in the study and followed until their treatment outcomes were reported. Data were collected through a purpose developed standardized data collection form and analyzed by using SPSS 20. A p-value <0.05 was considered statistically significant.

RESULTS

Out of 5152 TB patients enrolled at the study sites, 2184 (42.4%) were children. Among them, 1941 childhood TB patients had complete medical record were included in the study. Majority of the study participants were <5 years old (66.6%) and had pulmonary TB (PTB; 65%). A total of 45 (2.3%) patients were cured, 1680 (86.6%) completed treatment, 195 (10%) lost to follow-up, 15 (0.8%) died, 5 (0.3%) failed treatment and 1 (0.1%) was not evaluated for outcomes. In multivariate binary logistic regression analysis, treatment at BMCH Quetta (OR = 25.671, p-value < 0.001), rural residence (OR = 3.126, p-value < 0.001) and extra-PTB (OR = 1.619, p-value = 0.004) emerged as risk factors for unsuccessful outcomes.

CONCLUSION

The study sites collectively reached the World Health Organization's target of treatment success (>85%). Lost to follow-up was the major reason for unsuccessful outcomes. Special attention to patients with identified risk factors for unsuccessful outcomes may improve outcomes further.

Predictors of unsuccessful tuberculosis treatment outcomes in children from a prospective cohort study in Pakistan

Background

Every year, about 239 000 children die from tuberculosis (TB), despite availability of highly effective regimens. Few studies have evaluated predictors for poor treatment outcomes in children treated for TB.

Methods

We assessed predictors of unsuccessful TB treatment outcomes in a prospective cohort of children diagnosed by an intensified TB patient-finding intervention at four facilities in Pakistan between 2014 and 2016. A case of TB disease was determined through either bacteriologic confirmation of disease or a clinical diagnosis. To estimate characteristics predictive of experiencing an unsuccessful treatment outcome, we used a multi-level model with a modified Poisson approach, accounting for clustering at the facility level. We report estimated relative risks (RR) and 95% confidence intervals (CI).

Results

During the study period, 1404 children less than 15 years old were initiated on treatment for drug-susceptible TB. In total, 709 (50.5%) were 0-4, 406 (28.9%) were 5-9 years, and 289 (20.6%) were 10-14 years old; 614 (43.7%) were female; and of the 1377 children assessed for malnourishment, 1161 (84.3%) were malnourished. A total of 1322 (94.2%) children experienced a successful treatment outcome, 14 (1.0%) children transferred out to a different facility, and 68 (4.8%) children experienced an unsuccessful treatment outcome: 14 (1.0%) died, 20 (1.4%) failed treatment, and 34 (2.4%) were lost to follow-up. After adjustment for age group, sex, and malnutrition status, we identified increased risk of unsuccessful treatment outcome in children presenting with fever (RR = 2.56, 95% CI = 1.02-6.44; P = 0.05) or an abdominal examination suggestive of TB disease (RR = 2.34, 95% CI = 1.20-4.58; P = 0.01), and a decreased risk in children who initiated treatment at a rural facility (RR = 0.05, 95% CI = 0.00-0.74; P = 0.03).

Conclusions

More than 94% of children experienced successful treatment outcomes. We identified individual-, facility-, and clinical-factors predictive of experiencing unsuccessful treatment outcomes. Children with fevers and abdominal findings suggestive of TB disease should be tested for TB and followed closely throughout treatment to ensure necessary support for successful completion of treatment.

Epidemiological Trends in the Form of Childhood Tuberculosis in a Referral Tuberculosis Hospital in Shandong, China

Background

In China, the prevalence of tuberculosis (TB) diseases and epidemiological trends in the TB forms among children are still unclear; a retrospective study was conducted aiming to assess it.

Methods

Between January 2007 and September 2020, 1577 consecutive childhood TB patients (aged ≤ 15 years) were included in the study. Data, including demographic information and underlying diseases, were collected from medical records. Then, patients were categorized and reported according to the anatomical site of TB disease. To analyze the epidemiological trends in the proportion of each form of TB disease, a linear-by-linear association was used, and a P value of <0.05 was considered to indicate that a significant change had occurred in the proportion of TB disease over the studied period.

Results

During the fourteen-year study period, a total of 1577 children patients were enrolled, including 954 boys (60.5%) and 623 girls (39.5%), with a mean age of 9.26 ± 5.18 years. Among the studied patients, 810 (51.4%) patients have pulmonary TB, 1137 (72.1%) have extrapulmonary TB, 372 (23.6%) have both conditions, and another 765 (48.5%) extrapulmonary cases presented in isolated form. Pleural TB (29.0%) and tuberculous lymphadenitis (23.7%) were the most frequent two forms of childhood TB. In addition, during the past decade, the proportions of pulmonary TB, pleural TB, and tuberculous lymphadenitis showed an increasing trend (all P < 0.05). However, no significant trends in the proportions of other forms of TB disease, such as extrapulmonary TB (P > 0.05), tuberculous meningitis (P > 0.05), endobronchial TB (P > 0.05), and disseminated TB (P > 0.05), were found.

Conclusion

Our findings suggest that childhood TB is facing new challenges, and the policy should be adjusted timely to fit the real situation.

Factors predictive of the success of tuberculosis treatment: A systematic review with meta-analysis

OBJECTIVE

To produce pooled estimates of the global results of tuberculosis (TB) treatment and analyze the predictive factors of successful TB treatment.

METHODS

Studies published between 2014 and 2019 that reported the results of the treatment of pulmonary TB and the factors that influenced these results. The quality of the studies was evaluated according to the Newcastle-Ottawa quality assessment scale. A random effects model was used to calculate the pooled odds ratio (OR) and 95% confidence interval (CI). This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) in February 2019 under number CRD42019121512.

RESULTS

A total of 151 studies met the criteria for inclusion in this review. The success rate for the treatment of drug-sensitive TB in adults was 80.1% (95% CI: 78.4-81.7). America had the lowest treatment success rate, 75.9% (95% CI: 73.8-77.9), and Oceania had the highest, 83.9% (95% CI: 75.2-91.0). In children, the success rate was 84.8% (95% CI: 77.7-90.7); in patients coinfected with HIV, it was 71.0% (95% CI: 63.7-77.8), in patients with multidrug-resistant TB, it was 58.4% (95% CI: 51.4-64.6), in patients with and extensively drug-resistant TB it was 27.1% (12.7-44.5). Patients with negative sputum smears two months after treatment were almost three times more likely to be successfully treated (OR 2.7; 1.5-4.8), whereas patients younger than 65 years (OR 2.0; 1.7-2.4), nondrinkers (OR 2.0; 1.6-2.4) and HIV-negative patients (OR 1.9; 1.6-2.5 3) were two times more likely to be successfully treated.

CONCLUSION

The success of TB treatment at the global level was good, but was still below the defined threshold of 85%. Factors such as age, sex, alcohol consumption, smoking, lack of sputum conversion at two months of treatment and HIV affected the success of TB treatment.