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Rajendran P, Thomas SV, Balaji S, Selladurai E, Jayachandran G, Malayappan A, Bhaskar A, Palanisamy S, Ramamoorthy T, Hasini S, Hissar S. Paediatric pulmonary disease-are we diagnosing it right? Front Pediatr 2024; 12:1370687. [PMID: 38659699 PMCID: PMC11039875 DOI: 10.3389/fped.2024.1370687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/11/2024] [Indexed: 04/26/2024] Open
Abstract
Background It has been reported that differential diagnosis of bacterial or viral pneumonia and tuberculosis (TB) in infants and young children is complex. This could be due to the difficulty in microbiological confirmation in this age group. In this study, we aimed to assess the utility of a real-time multiplex PCR for diagnosis of respiratory pathogens in children with pulmonary TB. Methods A total of 185 respiratory samples [bronchoalveolar lavage (15), gastric aspirates (98), induced sputum (21), and sputum (51)] from children aged 3-12 years, attending tertiary care hospitals, Chennai, India, were included in the study. The samples were processed by N acetyl L cysteine (NALC) NAOH treatment and subjected to microbiological investigations for Mycobacterium tuberculosis (MTB) diagnosis that involved smear microscopy, Xpert® MTB/RIF testing, and liquid culture. In addition, DNA extraction from the processed sputum was carried out and was subjected to a multiplex real-time PCR comprising a panel of bacterial and fungal pathogens. Results Out of the 185 samples tested, a total of 20 samples were positive for MTB by either one or more identification methods (smear, culture, and GeneXpert). Out of these 20 MTB-positive samples, 15 were positive for one or more bacterial or fungal pathogens, with different cycle threshold values. Among patients with negative MTB test results (n = 165), 145 (87%) tested positive for one or more than one bacterial or fungal pathogens. Conclusion The results suggest that tuberculosis could coexist with other respiratory pathogens causing pneumonia. However, a large-scale prospective study from different geographical settings that uses such simultaneous detection methods for diagnosis of childhood tuberculosis and pneumonia will help in assessing the utility of these tests in rapid diagnosis of respiratory infections.
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Affiliation(s)
| | | | | | | | | | | | - Adhin Bhaskar
- ICMR—National Institute for Research in TB, Chennai, India
| | | | | | - Sindhu Hasini
- ICMR—National Institute for Research in TB, Chennai, India
| | - Syed Hissar
- ICMR—National Institute for Research in TB, Chennai, India
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2
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Wen B, Farooqui A, Bourdon C, Tarafdar N, Ngari M, Chimwezi E, Thitiri J, Mwalekwa L, Walson JL, Voskuijl W, Berkley JA, Bandsma RHJ. Intestinal disturbances associated with mortality of children with complicated severe malnutrition. COMMUNICATIONS MEDICINE 2023; 3:128. [PMID: 37773543 PMCID: PMC10541881 DOI: 10.1038/s43856-023-00355-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 09/11/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Children admitted to hospital with complicated severe malnutrition (CSM) have high mortality despite compliance with standard WHO management guidelines. Limited data suggests a relationship between intestinal dysfunction and poor prognosis in CSM, but this has not been explicitly studied. This study aimed to evaluate the role of intestinal disturbances in CSM mortality. METHODS A case-control study nested within a randomized control trial was conducted among children hospitalized with CSM in Kenya and Malawi. Children who died (cases, n = 68) were compared with those who were discharged, propensity matched to the cases on age, HIV and nutritional status (controls, n = 68) on fecal metabolomics that targeted about 70 commonly measured metabolites, and enteropathy markers: fecal myeloperoxidase (MPO), fecal calprotectin, and circulating intestinal fatty acid binding protein (I-FABP). RESULTS The fecal metabolomes of cases show specific reductions in amino acids, monosaccharides, and microbial fermentation products, when compared to controls. SCFA levels did not differ between groups. The overall fecal metabolomics signature moderately differentiates cases from controls (AUC = 0.72). Enteropathy markers do not differ between groups overall, although serum I-FABP is elevated in cases in a sensitivity analysis among non-edematous children. Integrative analysis with systemic data suggests an indirect role of intestinal inflammation in the causal path of mortality. CONCLUSIONS Intestinal disturbances appear to have an indirect association with acute mortality. Findings of the study improve our understanding of pathophysiological pathways underlying mortality of children with CSM.
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Affiliation(s)
- Bijun Wen
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
| | - Amber Farooqui
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
| | - Celine Bourdon
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Nawar Tarafdar
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
| | - Moses Ngari
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Laura Mwalekwa
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Paediatrics, Coast General Hospital, Mombasa, Kenya
| | - Judd L Walson
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Departments of Global Health, Medicine, Pediatrics and Epidemiology, University of Washington, Seattle, WA, USA
| | - Wieger Voskuijl
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences (formerly College of Medicine), Blantyre, Malawi
| | - James A Berkley
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Robert H J Bandsma
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada.
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.
- Department of Biomedical Sciences, Kamuzu University of Health Sciences (formerly College of Medicine), Blantyre, Malawi.
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Citrulline and kynurenine to tryptophan ratio: potential EED (environmental enteric dysfunction) biomarkers in acute watery diarrhea among children in Bangladesh. Sci Rep 2023; 13:1416. [PMID: 36697429 PMCID: PMC9876903 DOI: 10.1038/s41598-023-28114-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 01/12/2023] [Indexed: 01/26/2023] Open
Abstract
Two emerging biomarkers of environmental enteric dysfunction (EED) include plasma citrulline (CIT), and the kynurenine (KYN): tryptophan (TRP)/ (KT) ratio. We sought to investigate the plasma concentration of CIT and KT ratio among the children having dehydrating diarrhea and examine associations between concentrations of CIT and KT ratio with concurrent factors. For this analysis, we used cross-sectional data from a total of 102, 6-36 months old male children who suffered from non-cholera acute watery diarrhea and had some dehydration admitted to an urban diarrheal hospital, in Bangladesh. CIT, TRP, and KYN concentrations were determined at enrollment from plasma samples using ELIZA. At enrollment, the mean plasma CIT concentration was 864.48 ± 388.55 µmol/L. The mean plasma kynurenine, tryptophan concentrations, and the KT ratio (× 1000) were 6.93 ± 3.08 µmol/L, 33.44 ± 16.39 µmol/L, and 12.12 ± 18.10, respectively. With increasing child age, KYN concentration decreased (coefficient: - 0.26; 95%CI: - 0.49, - 0.04; p = 0.021); with increasing lymphocyte count, CIT concentration decreased (coef.: - 0.01; 95% CI: - 0.02,0.001, p = 0.004); the wasted child had decreased KT ratio (coef.: - 0.6; 95% CI: - 1.18, - 0.02; p = 0.042) after adjusting for potential covariates. The CIT concentration was associated with blood neutrophils (coef.: 0.02; 95% CI: 0.01, 0.03; p < 0.001), lymphocytes (coef.: - 0.02; 95% CI: - 0.03, - 0.02; p < 0.001) and monocyte (coef.: 0.06; 95% CI: 0.01, 0.11; p = 0.021); KYN concentration was negatively associated with basophil (coef.: - 0.62; 95% CI: - 1.23, - 0.01; p = 0.048) after adjusting for age. In addition, total stool output (gm) increased (coef.: 793.84; 95% CI: 187.16, 1400.52; p = 0.011) and also increased duration of hospital stay (hour) (coef.: 22.89; 95% CI: 10.24, 35.54; p = 0.001) with increasing CIT concentration. The morphological changes associated with EED may increase the risk of enteric infection and diarrheal disease among children. Further research is critically needed to better understand the complex mechanisms by which EED biomarkers may impact susceptibility to dehydrating diarrhea in children.
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Sabi I, Olomi W, Nkereuwem E, Togun T, Gomez MP, Sylla M, Diarra B, Sanogo M, Sichone E, Mahiga H, Njeleka F, Ebonyi AO, Egere U, Ntinginya NE, Hoelscher M, Heinrich N, Kampmann B. Diagnosis of paediatric TB using Xpert ® MTB/RIF Ultra on fresh respiratory samples. Int J Tuberc Lung Dis 2022; 26:862-868. [PMID: 35996291 PMCID: PMC9423021 DOI: 10.5588/ijtld.22.0007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE: To evaluate the diagnostic accuracy of Xpert® MTB/RIF Ultra (Ultra) on fresh respiratory samples for the diagnosis of pulmonary TB (PTB) in children.METHODS: Between July 2017 and December 2019, children with presumed TB were prospectively enrolled at clinical sites in three African countries. Children were assessed using history, physical examination and chest X-ray. Sputum or gastric aspirate samples were analysed using Ultra and culture. The diagnostic accuracy of Ultra was calculated against culture as the reference standard.RESULTS: In total, 547children were included. The median age was 4.7 years, 77 (14.1%) were HIV infected and 77 (14.1%) had bacteriologically confirmed TB. Ultra detected an additional 20 cases in the group of children with negative culture results. The sensitivity of Ultra was 66.3% (95% CI 47-82), and the specificity was 95.4% (95% CI 89-99) when assessed against culture as the reference standard.CONCLUSION: Despite the improved performance of Ultra as compared to Xpert as was previously reported, its sensitivity remains sub-optimal for the detection of TB in children. Ultra detected additional 20 cases which otherwise could not have been detected by culture alone, suggesting that the latter is an imperfect reference standard.
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Affiliation(s)
- I Sabi
- National Institute for Medical Research, Mbeya Medical Research Center, Mbeya, Tanzania, Center for International Health, University Hospital, Ludwig Maximilian University (LMU) Munich, Germany
| | - W Olomi
- National Institute for Medical Research, Mbeya Medical Research Center, Mbeya, Tanzania
| | - E Nkereuwem
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - T Togun
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - M P Gomez
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - M Sylla
- Paediatrics Department, University Teaching Hospital Gabriel Toure, Bamako, Mali
| | - B Diarra
- University Clinical Research Centre, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - M Sanogo
- University Clinical Research Centre, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - E Sichone
- National Institute for Medical Research, Mbeya Medical Research Center, Mbeya, Tanzania
| | - H Mahiga
- National Institute for Medical Research, Mbeya Medical Research Center, Mbeya, Tanzania
| | - F Njeleka
- National Institute for Medical Research, Mbeya Medical Research Center, Mbeya, Tanzania
| | - A O Ebonyi
- Department of Paediatrics, Jos University Teaching Hospital, Jos, Nigeria
| | - U Egere
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - N E Ntinginya
- National Institute for Medical Research, Mbeya Medical Research Center, Mbeya, Tanzania
| | - M Hoelscher
- Center for International Health, University Hospital, Ludwig Maximilian University (LMU) Munich, Germany, German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany, Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich, Germany
| | - N Heinrich
- Center for International Health, University Hospital, Ludwig Maximilian University (LMU) Munich, Germany, German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany, Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich, Germany
| | - B Kampmann
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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5
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Kazi S, Corcoran H, Abo YN, Graham H, Oliwa J, Graham SM. A systematic review of clinical, epidemiological and demographic predictors of tuberculosis in children with pneumonia. J Glob Health 2022; 12:10010. [PMID: 35939347 PMCID: PMC9527007 DOI: 10.7189/jogh.12.10010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Tuberculosis (TB) can present as acute, severe pneumonia in children, but features which distinguish TB from other causes of pneumonia are not well understood. We conducted a systematic review to determine the prevalence and to explore clinical and demographic predictors of TB in children presenting with pneumonia over three decades. Methods We searched for peer-reviewed, English language studies published between 1990 and 2020 that included children aged between 1 month and 17 years with pneumonia and prospectively evaluated for TB. There were 895 abstracts and titles screened, and 72 full text articles assessed for eligibility. Results Thirteen clinical studies, two autopsy studies and one systematic review were included in analyses. Majority of studies were from Africa (12/15) and included children less than five years age. Prevalence of bacteriologically confirmed TB in children with pneumonia ranged from 0.2% to 14.8% (median = 3.7%, interquartile range (IQR) = 5.95) and remained stable over the three decades. TB may be more likely in children with pneumonia if they have a history of close TB contact, HIV infection, malnutrition, age less than one year or failure to respond to empirical antibiotics. However, these features have limited discriminatory value as TB commonly presents as acute severe pneumonia – with a short duration of cough, and clinical and radiographic features indistinguishable from other causes of pneumonia. Approximately half of patients with TB respond to initial empirical antibiotics, presumably due to bacterial co-infection, and follow-up may be critical to detect and treat TB. Conclusion TB should be considered as a potential cause or comorbidity in all children presenting with pneumonia in high burden settings. Clinicians should be alert to the presence of known risk factors for TB and bacteriological confirmation sought whenever possible. Quality data regarding clinical predictors of TB in childhood pneumonia are lacking. Further, prospective research is needed to better understand predictors and prevalence of TB in childhood pneumonia, particularly in TB endemic settings outside of Africa and in older children. Children of all ages with pneumonia should be included in research on improved, point-of-care TB diagnostics to support early case detection and treatment.
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Affiliation(s)
- Saniya Kazi
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Monash Health, Melbourne, Victoria, Australia
| | - Hannah Corcoran
- Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Yara-Natalie Abo
- Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Hamish Graham
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,University of Melbourne Department of Paediatrics, Melbourne, Victoria, Australia
| | - Jacquie Oliwa
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,University of Nairobi, Nairobi, Kenya
| | - Stephen M Graham
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Monash Health, Melbourne, Victoria, Australia.,University of Melbourne Department of Paediatrics, Melbourne, Victoria, Australia
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6
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von Mollendorf C, Berger D, Gwee A, Duke T, Graham SM, Russell FM, Mulholland EK. Aetiology of childhood pneumonia in low- and middle-income countries in the era of vaccination: a systematic review. J Glob Health 2022; 12:10009. [PMID: 35866332 PMCID: PMC9305023 DOI: 10.7189/jogh.12.10009] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background This systematic review aimed to describe common aetiologies of severe and non-severe community acquired pneumonia among children aged 1 month to 9 years in low- and middle-income countries. Methods We searched the MEDLINE, EMBASE, and PubMed online databases for studies published from January 2010 to August 30, 2020. We included studies on acute community-acquired pneumonia or acute lower respiratory tract infection with ≥1 year of continuous data collection; clear consistent case definition for pneumonia; >1 specimen type (except empyema studies where only pleural fluid was required); testing for >1 pathogen including both viruses and bacteria. Two researchers reviewed the studies independently. Results were presented as a narrative summary. Quality of evidence was assessed with the Quality Assessment Tool for Quantitative Studies. The study was registered on PROSPERO [CRD42020206830]. Results We screened 5184 records; 1305 duplicates were removed. The remaining 3879 titles and abstracts were screened. Of these, 557 articles were identified for full-text review, and 55 met the inclusion criteria - 10 case-control studies, three post-mortem studies, 11 surveillance studies, eight cohort studies, five cross-sectional studies, 12 studies with another design and six studies that included patients with pleural effusions or empyema. Studies which described disease by severity showed higher bacterial detection (Streptococcus pneumoniae, Staphylococcus aureus) in severe vs non-severe cases. The most common virus causing severe disease was respiratory syncytial virus (RSV). Pathogens varied by age, with RSV and adenovirus more common in younger children. Influenza and atypical bacteria were more common in children 5-14 years than younger children. Malnourished and HIV-infected children had higher rates of pneumonia due to bacteria or tuberculosis. Conclusions Several viral and bacterial pathogens were identified as important targets for prevention and treatment. Bacterial pathogens remain an important cause of moderate to severe disease, particularly in children with comorbidities despite widespread PCV and Hib vaccination.
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Affiliation(s)
- Claire von Mollendorf
- Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Daria Berger
- Royal Children's Hospital, Parkville, Victoria, Australia
| | - Amanda Gwee
- Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Royal Children's Hospital, Parkville, Victoria, Australia
| | - Trevor Duke
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Royal Children's Hospital, Parkville, Victoria, Australia
| | - Stephen M Graham
- Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Royal Children's Hospital, Parkville, Victoria, Australia
| | - Fiona M Russell
- Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - E Kim Mulholland
- Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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7
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Atalell KA, Haile RN, Techane MA. Magnitude of tuberculosis and its associated factors among under-five children admitted with severe acute malnutrition to public hospitals in the city of Dire Dawa, Eastern Ethiopia, 2021: multi-center cross-sectional study. IJID REGIONS 2022; 3:256-260. [PMID: 35755465 PMCID: PMC9216649 DOI: 10.1016/j.ijregi.2022.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The aim of this study was to assess the prevalence of tuberculosis (TB) and its associated factors among children under 5 years of age with severe acute malnutrition. METHODS A multi-center, institution-based, retrospective cross-sectional study was conducted at public hospitals in Dire Dawa City Administration, Eastern Ethiopia from January 1, 2018 to December 30, 2020. A binary logistic regression model was fitted to identify factors associated with the prevalence of TB. RESULTS The overall prevalence of TB among children under 5 years of age admitted with severe acute malnutrition to public hospitals in the city of Dire Dawa, Eastern Ethiopia was 10.39% (95% confidence interval (CI) 7.61-13.73%). Repeated admission (adjusted odds ratio (AOR) 2.5, 95% CI 1.08-6.07), a TB contact history (AOR 3.58, 95% CI 1.21-10.6), pneumonia (AOR 2.8, 95% CI 1.29-6.23), stage IV HIV/AIDS (AOR 4.41, 95% CI 1.29-15.13), and being immunized (AOR 0.19, 95% CI 0.08-0.43) were variables significantly associated with the prevalence of TB. CONCLUSIONS The results of this study showed that the prevalence of TB among under-five children with severe acute malnutrition was high. The prevalence of TB was associated with having HIV/AIDS, having pneumonia, having a TB contact history, admission status, and immunization status. Integrated TB prevention and screening strategies with nutritional rehabilitation care should be implemented.
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Affiliation(s)
- Kendalem Asmare Atalell
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Ribka Nigatu Haile
- School of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Masresha Asmare Techane
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Maternal Underweight and Its Association with Composite Index of Anthropometric Failure among Children under Two Years of Age with Diarrhea in Bangladesh. Nutrients 2022; 14:nu14091935. [PMID: 35565901 PMCID: PMC9105738 DOI: 10.3390/nu14091935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/30/2022] [Accepted: 04/30/2022] [Indexed: 01/13/2023] Open
Abstract
Malnutrition in women has been a long-standing public health concern, with serious effects on child survival and development. Maternal body mass index (BMI) is an important maternal nutritional indicator. There are few published studies although child anthropometric failures do not occur in isolation and identifying children with single versus several co-occurring failures can better capture cases of growth failure in combination: stunting, wasting, and underweight. In the context of multiple anthropometric failures, traditional markers used to assess children's nutritional status tend to underestimate overall undernutrition. Using the composite index of anthropometric failure (CIAF), we aimed to assess the association between maternal undernutrition and child undernutrition among children with diarrhea under the age of two and to investigate the correlates. Using 1431 mother-child dyads from the Antibiotic for Children with Diarrhea (ABCD) trial, we extracted children's data at enrollment and on day 90 and day 180 follow-ups. ABCD was a randomized, multi-country, multi-site, double-blind, placebo-controlled clinical trial. The Bangladesh site collected data from July 2017 to July 2019. The outcome variable, CIAF, allows combinations of height-for-age, height-for-weight, and weight-for-age to determine the overall prevalence of undernutrition. The generalized estimating equation was used to explore the correlates of CIAF. After adjusting all the potential covariates, maternal undernutrition status was found to be strongly associated with child undernutrition using the CIAF [aOR: 1.4 (95% CI: 1.0, 1.9), p-value = 0.043] among the children with diarrhea under 2 years old. Maternal higher education had a protective effect on CIAF [aOR: 0.7 (95% CI: 0.5, 0.9), p-value = 0.033]. Our study findings highlight the importance of an integrated approach focusing on maternal nutrition and maternal education could affect a reduction in child undernutrition based on CIAF.
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Physical Quality of Life of Sepsis Survivor Severely Malnourished Children after Hospital Discharge: Findings from a Retrospective Chart Analysis. Life (Basel) 2022; 12:life12030379. [PMID: 35330130 PMCID: PMC8954014 DOI: 10.3390/life12030379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/01/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Quality of life (QoL) among pediatric sepsis survivors in resource-limited countries is poorly understood. We aimed to evaluate the QoL among sepsis survivors, by comparing them with non-sepsis survivors three months after hospital discharge. Methodology: In this retrospective chart analysis with a case–control design, we compared children having sepsis and non-sepsis at hospital admission and during their post-hospitalization life, where the study population was derived from a hospital cohort of 405 severely malnourished children having pneumonia. Results: The median age (months, inter-quartile range) of the children having sepsis and non-sepsis was 10 (5, 17) and 9 (5, 18), respectively. Approximately half of the children among the sepsis survivors had new episodes of respiratory symptoms at home. Though death was significantly higher (15.8% vs. 2.7%, p ≤ 0.001) at admission among the sepsis group, deaths during post-hospitalization life (7.8% vs. 8.8%, p = 0.878) were comparable. A verbal autopsy revealed that before death, most of the children from the sepsis group had respiratory complaints, whereas gastrointestinal complaints were more common among the non-sepsis group. Conclusions: Pediatric sepsis is life-threatening both during hospitalization and post-discharge. The QoL after sepsis is compromised, including re-hospitalization and the development of new episodes of respiratory symptoms especially before death.
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10
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Vonasek BJ, Radtke KK, Vaz P, Buck WC, Chabala C, McCollum ED, Marcy O, Fitzgerald E, Kondwani A, Garcia-Prats AJ. Tuberculosis in children with severe acute malnutrition. Expert Rev Respir Med 2022; 16:273-284. [PMID: 35175880 PMCID: PMC9280657 DOI: 10.1080/17476348.2022.2043747] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION With growing attention globally to the childhood tuberculosis epidemic after decades of neglect, and with the burden of severe acute malnutrition (SAM) remaining unacceptably high worldwide, the collision of these two diseases is an important focus for improving child health. AREAS COVERED This review describes the clinical and public health implications of the interplay between tuberculosis and SAM, particularly for children under the age of five, and identifies priority areas for improved programmatic implementation and future research. We reviewed the literature on PubMed and other evidence known to the authors published until August 2021 relevant to this topic. EXPERT OPINION To achieve the World Health Organization's goal of eliminating deaths from childhood tuberculosis and to improve the abysmal outcomes for children with SAM, further research is needed to 1) better understand the epidemiologic connections between child tuberculosis and SAM, 2) improve case finding of tuberculosis in children with SAM, 3) assess unique treatment considerations for tuberculosis when children also have SAM, and 4) ensure tuberculosis and SAM are strongly addressed in decentralized, integrated models of providing primary healthcare to children.
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Affiliation(s)
- Bryan J Vonasek
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA,Corresponding Author: Bryan Vonasek, , University of Wisconsin School of Medicine & Public Health, Department of Pediatrics, 600 Highland Ave, Madison, WI, USA 53792-4108, Phone: +1-763-333-8071, Fax: +1-608-265-9243
| | - Kendra K Radtke
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Paula Vaz
- Fundação Ariel Glaser, Maputo, Mozambique
| | - W Chris Buck
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Chishala Chabala
- Children’s Hospital, University Teaching Hospitals, Lusaka, Zambia
| | - Eric D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Olivier Marcy
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux, France
| | - Elizabeth Fitzgerald
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Alexander Kondwani
- Centre of Excellence for Nutrition, North West University, Potchefstroom, South Africa
| | - Anthony J Garcia-Prats
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Ledesma JR, Ma J, Vongpradith A, Maddison ER, Novotney A, Biehl MH, LeGrand KE, Ross JM, Jahagirdar D, Bryazka D, Feldman R, Abolhassani H, Abosetugn AE, Abu-Gharbieh E, Adebayo OM, Adnani QES, Afzal S, Ahinkorah BO, Ahmad SA, Ahmadi S, Ahmed Rashid T, Ahmed Salih Y, Aklilu A, Akunna CJ, Al Hamad H, Alahdab F, Alemayehu Y, Alene KA, Ali BA, Ali L, Alipour V, Alizade H, Al-Raddadi RM, Alvis-Guzman N, Amini S, Amit AML, Anderson JA, Androudi S, Antonio CAT, Antony CM, Anwer R, Arabloo J, Arja A, Asemahagn MA, Atre SR, Azhar GS, B DB, Babar ZUD, Baig AA, Banach M, Barqawi HJ, Barra F, Barrow A, Basu S, Belgaumi UI, Bhagavathula AS, Bhardwaj N, Bhardwaj P, Bhattacharjee NV, Bhattacharyya K, Bijani A, Bikbov B, Boloor A, Briko NI, Buonsenso D, Burugina Nagaraja S, Butt ZA, Carter A, Carvalho F, Charan J, Chatterjee S, Chattu SK, Chattu VK, Christopher DJ, Chu DT, Claassens MM, Dadras O, Dagnew AB, Dai X, Dandona L, Dandona R, Daneshpajouhnejad P, Darwesh AM, Dhamnetiya D, Dianatinasab M, Diaz D, Doan LP, Eftekharzadeh S, Elhadi M, Emami A, Enany S, Faraon EJA, Farzadfar F, Fernandes E, Ferro Desideri L, Filip I, Fischer F, Foroutan M, Frank TD, Garcia-Basteiro AL, Garcia-Calavaro C, Garg T, Geberemariyam BS, Ghadiri K, Ghashghaee A, Golechha M, Goodridge A, Gupta B, Gupta S, Gupta VB, Gupta VK, Haider MR, Hamidi S, Hanif A, Haque S, Harapan H, Hargono A, Hasaballah AI, Hashi A, Hassan S, Hassankhani H, Hayat K, Hezam K, Holla R, Hosseinzadeh M, Hostiuc M, Househ M, Hussain R, Ibitoye SE, Ilic IM, Ilic MD, Irvani SSN, Ismail NE, Itumalla R, Jaafari J, Jacobsen KH, Jain V, Javanmardi F, Jayapal SK, Jayaram S, Jha RP, Jonas JB, Joseph N, Joukar F, Kabir Z, Kamath A, Kanchan T, Kandel H, Katoto PDMC, Kayode GA, Kendrick PJ, Kerbo AA, Khajuria H, Khalilov R, Khatab K, Khoja AT, Khubchandani J, Kim MS, Kim YJ, Kisa A, Kisa S, Kosen S, Koul PA, Koulmane Laxminarayana SL, Koyanagi A, Krishan K, Kucuk Bicer B, Kumar A, Kumar GA, Kumar N, Kumar N, Kwarteng A, Lak HM, Lal DK, Landires I, Lasrado S, Lee SWH, Lee WC, Lin C, Liu X, Lopukhov PD, Lozano R, Machado DB, Madhava Kunjathur S, Madi D, Mahajan PB, Majeed A, Malik AA, Martins-Melo FR, Mehta S, Memish ZA, Mendoza W, Menezes RG, Merie HE, Mersha AG, Mesregah MK, Mestrovic T, Mheidly NM, Misra S, Mithra P, Moghadaszadeh M, Mohammadi M, Mohammadian-Hafshejani A, Mohammed S, Molokhia M, Moni MA, Montasir AA, Moore CE, Nagarajan AJ, Nair S, Nair S, Naqvi AA, Narasimha Swamy S, Nayak BP, Nazari J, Neupane Kandel S, Nguyen TH, Nixon MR, Nnaji CA, Ntsekhe M, Nuñez-Samudio V, Oancea B, Odukoya OO, Olagunju AT, Oren E, P A M, Parthasarathi R, Pashazadeh Kan F, Pattanshetty SM, Paudel R, Paul P, Pawar S, Pepito VCF, Perico N, Pirestani M, Polibin RV, Postma MJ, Pourshams A, Prashant A, Pribadi DRA, Radfar A, Rafiei A, Rahim F, Rahimi-Movaghar V, Rahman M, Rahman M, Rahmani AM, Ranasinghe P, Rao CR, Rawaf DL, Rawaf S, Reitsma MB, Remuzzi G, Renzaho AMN, Reta MA, Rezaei N, Rezahosseini O, Rezai MS, Rezapour A, Roshandel G, Roshchin DO, Sabour S, Saif-Ur-Rahman KM, Salam N, Samadi Kafil H, Samaei M, Samy AM, Saroshe S, Sartorius B, Sathian B, Sawyer SM, Senthilkumaran S, Seylani A, Shafaat O, Shaikh MA, Sharafi K, Shetty RS, Shigematsu M, Shin JI, Silva JP, Singh JK, Sinha S, Skryabin VY, Skryabina AA, Spurlock EE, Sreeramareddy CT, Steiropoulos P, Sufiyan MB, Tabuchi T, Tadesse EG, Tamir Z, Tarkang EE, Tekalegn Y, Tesfay FH, Tessema B, Thapar R, Tleyjeh II, Tobe-Gai R, Tran BX, Tsegaye B, Tsegaye GW, Ullah A, Umeokonkwo CD, Valadan Tahbaz S, Vo B, Vu GT, Waheed Y, Walters MK, Whisnant JL, Woldekidan MA, Wubishet BL, Yahyazadeh Jabbari SH, Yazie TSY, Yeshaw Y, Yi S, Yiğit V, Yonemoto N, Yu C, Yunusa I, Zastrozhin MS, Zastrozhina A, Zhang ZJ, Zumla A, Mokdad AH, Salomon JA, Reiner Jr RC, Lim SS, Naghavi M, Vos T, Hay SI, Murray CJL, Kyu HH. Global, regional, and national sex differences in the global burden of tuberculosis by HIV status, 1990-2019: results from the Global Burden of Disease Study 2019. THE LANCET. INFECTIOUS DISEASES 2022; 22:222-241. [PMID: 34563275 PMCID: PMC8799634 DOI: 10.1016/s1473-3099(21)00449-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/21/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tuberculosis is a major contributor to the global burden of disease, causing more than a million deaths annually. Given an emphasis on equity in access to diagnosis and treatment of tuberculosis in global health targets, evaluations of differences in tuberculosis burden by sex are crucial. We aimed to assess the levels and trends of the global burden of tuberculosis, with an emphasis on investigating differences in sex by HIV status for 204 countries and territories from 1990 to 2019. METHODS We used a Bayesian hierarchical Cause of Death Ensemble model (CODEm) platform to analyse 21 505 site-years of vital registration data, 705 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, and 680 site-years of mortality surveillance data to estimate mortality due to tuberculosis among HIV-negative individuals. We used a population attributable fraction approach to estimate mortality related to HIV and tuberculosis coinfection. A compartmental meta-regression tool (DisMod-MR 2.1) was then used to synthesise all available data sources, including prevalence surveys, annual case notifications, population-based tuberculin surveys, and tuberculosis cause-specific mortality, to produce estimates of incidence, prevalence, and mortality that were internally consistent. We further estimated the fraction of tuberculosis mortality that is attributable to independent effects of risk factors, including smoking, alcohol use, and diabetes, for HIV-negative individuals. For individuals with HIV and tuberculosis coinfection, we assessed mortality attributable to HIV risk factors including unsafe sex, intimate partner violence (only estimated among females), and injection drug use. We present 95% uncertainty intervals for all estimates. FINDINGS Globally, in 2019, among HIV-negative individuals, there were 1·18 million (95% uncertainty interval 1·08-1·29) deaths due to tuberculosis and 8·50 million (7·45-9·73) incident cases of tuberculosis. Among HIV-positive individuals, there were 217 000 (153 000-279 000) deaths due to tuberculosis and 1·15 million (1·01-1·32) incident cases in 2019. More deaths and incident cases occurred in males than in females among HIV-negative individuals globally in 2019, with 342 000 (234 000-425 000) more deaths and 1·01 million (0·82-1·23) more incident cases in males than in females. Among HIV-positive individuals, 6250 (1820-11 400) more deaths and 81 100 (63 300-100 000) more incident cases occurred among females than among males in 2019. Age-standardised mortality rates among HIV-negative males were more than two times greater in 105 countries and age-standardised incidence rates were more than 1·5 times greater in 74 countries than among HIV-negative females in 2019. The fraction of global tuberculosis deaths among HIV-negative individuals attributable to alcohol use, smoking, and diabetes was 4·27 (3·69-5·02), 6·17 (5·48-7·02), and 1·17 (1·07-1·28) times higher, respectively, among males than among females in 2019. Among individuals with HIV and tuberculosis coinfection, the fraction of mortality attributable to injection drug use was 2·23 (2·03-2·44) times greater among males than females, whereas the fraction due to unsafe sex was 1·06 (1·05-1·08) times greater among females than males. INTERPRETATION As countries refine national tuberculosis programmes and strategies to end the tuberculosis epidemic, the excess burden experienced by males is important. Interventions are needed to actively communicate, especially to men, the importance of early diagnosis and treatment. These interventions should occur in parallel with efforts to minimise excess HIV burden among women in the highest HIV burden countries that are contributing to excess HIV and tuberculosis coinfection burden for females. Placing a focus on tuberculosis burden among HIV-negative males and HIV and tuberculosis coinfection among females might help to diminish the overall burden of tuberculosis. This strategy will be crucial in reaching both equity and burden targets outlined by global health milestones. FUNDING Bill & Melinda Gates Foundation.
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12
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Afroze F, Faruk MT, Kamal M, Kabir F, Sarmin M, Chakraborty M, Hossain MR, Shikha SS, Chowdhury VP, Islam MZ, Ahmed T, Chisti MJ. The Utility of Bedside Assessment Tools and Associated Factors to Avoid Antibiotic Overuse in an Urban PICU of a Diarrheal Disease Hospital in Bangladesh. Antibiotics (Basel) 2021; 10:antibiotics10101255. [PMID: 34680835 PMCID: PMC8532929 DOI: 10.3390/antibiotics10101255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/25/2021] [Accepted: 09/28/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Antibiotic exposure in the pediatric intensive care unit (PICU) is very high, although 50% of all antibiotics may be unnecessary. We aimed to determine the utility of simple bedside screening tools and predicting factors to avoid antibiotic overuse in the ICU among children with diarrhea and critical illness. METHODS We conducted a retrospective, single-center, case-control study that included children aged 2-59 months who were admitted to PICU with diarrhea and critical illness between 2017 and 2020. RESULTS We compared young children who did not receive antibiotics (cases, n = 164) during ICU stay to those treated with antibiotics (controls, n = 346). For predicting the 'no antibiotic approach', the sensitivity of a negative quick Sequential Organ Failure Assessment (qSOFA) was similar to quick Pediatric Logistic Organ Dysfunction-2 (qPELOD-2) and higher than Systemic Inflammatory Response Syndrome (SIRS). A negative qSOFA or qPELOD-2 score calculated during PICU admission is superior to SIRS to avoid antibiotic overuse in under-five children. The logistic regression analysis revealed that cases were more often older and independently associated with hypernatremia. Cases less often had severe underweight, altered mentation, age-specific fast breathing, lower chest wall in-drawing, adventitious sound on lung auscultation, abdominal distension, developmental delay, hyponatremia, hypocalcemia, and microscopic evidence of invasive diarrhea (for all, p < 0.05). CONCLUSION Antibiotic overuse could be evaded in PICU using simple bedside screening tools and clinical characteristics, particularly in poor resource settings among children with diarrhea.
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Affiliation(s)
- Farzana Afroze
- Correspondence: (F.A.); (M.J.C.); Tel.: +880-(0)2-2222-77001-10 (ext. 2187) (F.A.); +880-(0)2-2222-77001-10 (ext. 2334) (M.J.C.)
| | | | | | | | | | | | | | | | | | | | | | - Mohammod Jobayer Chisti
- Correspondence: (F.A.); (M.J.C.); Tel.: +880-(0)2-2222-77001-10 (ext. 2187) (F.A.); +880-(0)2-2222-77001-10 (ext. 2334) (M.J.C.)
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Risk Factors and Outcomes of Hospital Acquired Pneumonia in Young Bangladeshi Children. Life (Basel) 2021; 11:life11101030. [PMID: 34685401 PMCID: PMC8541107 DOI: 10.3390/life11101030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/23/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022] Open
Abstract
Hospital acquired pneumonia (HAP) is common and often associated with high mortality in children aged five or less. We sought to evaluate the risk factors and outcome of HAP in such children. We compared demographic, clinical, and laboratory characteristics in children <5 years using a case control design during the period of August 2013 and December 2017, where children with HAP were constituted as cases (n = 281) and twice as many randomly selected children without HAP were constituted as controls (n = 562). HAP was defined as a child developing a new episode of pneumonia both clinically and radiologically after at least 48 h of hospitalization. A total of 4101 children were treated during the study period. The mortality was significantly higher among the cases than the controls (8% vs. 4%, p = 0.014). In multivariate logistic regression analysis, after adjusting for potential confounders, it was found that persistent diarrhea (95% CI = 1.32–5.79; p = 0.007), severe acute malnutrition (95% CI = 1.46–3.27; p < 0.001), bacteremia (95% CI = 1.16–3.49; p = 0.013), and prolonged hospitalization of >5 days (95% CI = 3.01–8.02; p < 0.001) were identified as independent risk factors for HAP. Early identification of these risk factors and their prompt management may help to reduce HAP-related fatal consequences, especially in resource limited settings.
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Vonasek B, Ness T, Takwoingi Y, Kay AW, van Wyk SS, Ouellette L, Marais BJ, Steingart KR, Mandalakas AM. Screening tests for active pulmonary tuberculosis in children. Cochrane Database Syst Rev 2021; 6:CD013693. [PMID: 34180536 PMCID: PMC8237391 DOI: 10.1002/14651858.cd013693.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Globally, children under 15 years represent approximately 12% of new tuberculosis cases, but 16% of the estimated 1.4 million deaths. This higher share of mortality highlights the urgent need to develop strategies to improve case detection in this age group and identify children without tuberculosis disease who should be considered for tuberculosis preventive treatment. One such strategy is systematic screening for tuberculosis in high-risk groups. OBJECTIVES To estimate the sensitivity and specificity of the presence of one or more tuberculosis symptoms, or symptom combinations; chest radiography (CXR); Xpert MTB/RIF; Xpert Ultra; and combinations of these as screening tests for detecting active pulmonary childhood tuberculosis in the following groups. - Tuberculosis contacts, including household contacts, school contacts, and other close contacts of a person with infectious tuberculosis. - Children living with HIV. - Children with pneumonia. - Other risk groups (e.g. children with a history of previous tuberculosis, malnourished children). - Children in the general population in high tuberculosis burden settings. SEARCH METHODS We searched six databases, including the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase, on 14 February 2020 without language restrictions and contacted researchers in the field. SELECTION CRITERIA Cross-sectional and cohort studies where at least 75% of children were aged under 15 years. Studies were eligible if conducted for screening rather than diagnosing tuberculosis. Reference standards were microbiological (MRS) and composite reference standard (CRS), which may incorporate symptoms and CXR. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality using QUADAS-2. We consolidated symptom screens across included studies into groups that used similar combinations of symptoms as follows: one or more of cough, fever, or poor weight gain and one or more of cough, fever, or decreased playfulness. For combination of symptoms, a positive screen was the presence of one or more than one symptom. We used a bivariate model to estimate pooled sensitivity and specificity with 95% confidence intervals (CIs) and performed analyses separately by reference standard. We assessed certainty of evidence using GRADE. MAIN RESULTS Nineteen studies assessed the following screens: one symptom (15 studies, 10,097 participants); combinations of symptoms (12 studies, 29,889 participants); CXR (10 studies, 7146 participants); and Xpert MTB/RIF (2 studies, 787 participants). Several studies assessed more than one screening test. No studies assessed Xpert Ultra. For 16 studies (84%), risk of bias for the reference standard domain was unclear owing to concern about incorporation bias. Across other quality domains, risk of bias was generally low. Symptom screen (verified by CRS) One or more of cough, fever, or poor weight gain in tuberculosis contacts (4 studies, tuberculosis prevalence 2% to 13%): pooled sensitivity was 89% (95% CI 52% to 98%; 113 participants; low-certainty evidence) and pooled specificity was 69% (95% CI 51% to 83%; 2582 participants; low-certainty evidence). Of 1000 children where 50 have pulmonary tuberculosis, 339 would be screen-positive, of whom 294 (87%) would not have pulmonary tuberculosis (false positives); 661 would be screen-negative, of whom five (1%) would have pulmonary tuberculosis (false negatives). One or more of cough, fever, or decreased playfulness in children aged under five years, inpatient or outpatient (3 studies, tuberculosis prevalence 3% to 13%): sensitivity ranged from 64% to 76% (106 participants; moderate-certainty evidence) and specificity from 37% to 77% (2339 participants; low-certainty evidence). Of 1000 children where 50 have pulmonary tuberculosis, 251 to 636 would be screen-positive, of whom 219 to 598 (87% to 94%) would not have pulmonary tuberculosis; 364 to 749 would be screen-negative, of whom 12 to 18 (2% to 3%) would have pulmonary tuberculosis. One or more of cough, fever, poor weight gain, or tuberculosis close contact (World Health Organization four-symptom screen) in children living with HIV, outpatient (2 studies, tuberculosis prevalence 3% and 8%): pooled sensitivity was 61% (95% CI 58% to 64%; 1219 screens; moderate-certainty evidence) and pooled specificity was 94% (95% CI 86% to 98%; 201,916 screens; low-certainty evidence). Of 1000 symptom screens where 50 of the screens are on children with pulmonary tuberculosis, 88 would be screen-positive, of which 57 (65%) would be on children who do not have pulmonary tuberculosis; 912 would be screen-negative, of which 19 (2%) would be on children who have pulmonary tuberculosis. CXR (verified by CRS) CXR with any abnormality in tuberculosis contacts (8 studies, tuberculosis prevalence 2% to 25%): pooled sensitivity was 87% (95% CI 75% to 93%; 232 participants; low-certainty evidence) and pooled specificity was 99% (95% CI 68% to 100%; 3281 participants; low-certainty evidence). Of 1000 children, where 50 have pulmonary tuberculosis, 63 would be screen-positive, of whom 19 (30%) would not have pulmonary tuberculosis; 937 would be screen-negative, of whom 6 (1%) would have pulmonary tuberculosis. Xpert MTB/RIF (verified by MRS) Xpert MTB/RIF, inpatient or outpatient (2 studies, tuberculosis prevalence 1% and 4%): sensitivity was 43% and 100% (16 participants; very low-certainty evidence) and specificity was 99% and 100% (771 participants; moderate-certainty evidence). Of 1000 children, where 50 have pulmonary tuberculosis, 31 to 69 would be Xpert MTB/RIF-positive, of whom 9 to 19 (28% to 29%) would not have pulmonary tuberculosis; 969 to 931 would be Xpert MTB/RIF-negative, of whom 0 to 28 (0% to 3%) would have tuberculosis. Studies often assessed more symptoms than those included in the index test and symptom definitions varied. These differences complicated data aggregation and may have influenced accuracy estimates. Both symptoms and CXR formed part of the CRS (incorporation bias), which may have led to overestimation of sensitivity and specificity. AUTHORS' CONCLUSIONS We found that in children who are tuberculosis contacts or living with HIV, screening tests using symptoms or CXR may be useful, but our review is limited by design issues with the index test and incorporation bias in the reference standard. For Xpert MTB/RIF, we found insufficient evidence regarding screening accuracy. Prospective evaluations of screening tests for tuberculosis in children will help clarify their use. In the meantime, screening strategies need to be pragmatic to address the persistent gaps in prevention and case detection that exist in resource-limited settings.
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Affiliation(s)
- Bryan Vonasek
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Department of Pediatrics, Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Tara Ness
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alexander W Kay
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine , Houston, Texas, USA
| | - Susanna S van Wyk
- Centre for Evidence-based Health Care, Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
- Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine , Houston, Texas, USA
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Vessière A, Font H, Gabillard D, Adonis-Koffi L, Borand L, Chabala C, Khosa C, Mavale S, Moh R, Mulenga V, Mwanga-Amumpere J, Taguebue JV, Eang MT, Delacourt C, Seddon JA, Lounnas M, Godreuil S, Wobudeya E, Bonnet M, Marcy O. Impact of systematic early tuberculosis detection using Xpert MTB/RIF Ultra in children with severe pneumonia in high tuberculosis burden countries (TB-Speed pneumonia): a stepped wedge cluster randomized trial. BMC Pediatr 2021; 21:136. [PMID: 33743621 PMCID: PMC7980598 DOI: 10.1186/s12887-021-02576-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background In high tuberculosis (TB) burden settings, there is growing evidence that TB is common in children with pneumonia, the leading cause of death in children under 5 years worldwide. The current WHO standard of care (SOC) for young children with pneumonia considers a diagnosis of TB only if the child has a history of prolonged symptoms or fails to respond to antibiotic treatments. As a result, many children with TB-associated severe pneumonia are currently missed or diagnosed too late. We therefore propose a diagnostic trial to assess the impact on mortality of adding the systematic early detection of TB using Xpert MTB/RIF Ultra (Ultra) performed on nasopharyngeal aspirates (NPA) and stool samples to the WHO SOC for children with severe pneumonia, followed by immediate initiation of anti-TB treatment in children testing positive on any of the samples. Methods TB-Speed Pneumonia is a pragmatic stepped-wedge cluster randomized controlled trial conducted in six countries with high TB incidence rate (Côte d’Ivoire, Cameroon, Uganda, Mozambique, Zambia and Cambodia). We will enrol 3780 children under 5 years presenting with WHO-defined severe pneumonia across 15 hospitals over 18 months. All hospitals will start managing children using the WHO SOC for severe pneumonia; one hospital will be randomly selected to switch to the intervention every 5 weeks. The intervention consists of the WHO SOC plus rapid TB detection on the day of admission using Ultra performed on 1 nasopharyngeal aspirate and 1 stool sample. All children will be followed for 3 months, with systematic trial visits at day 3, discharge, 2 weeks post-discharge, and week 12. The primary endpoint is all-cause mortality 12 weeks after inclusion. Qualitative and health economic evaluations are embedded in the trial. Discussion In addition to testing the main hypothesis that molecular detection and early treatment will reduce TB mortality in children, the strength of such pragmatic research is that it provides some evidence regarding the feasibility of the intervention as part of routine care. Should this intervention be successful, safe and well tolerated, it could be systematically implemented at district hospital level where children with severe pneumonia are referred. Trial registration ClinicalTrials.gov, NCT03831906. Registered 6 February 2019.
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Affiliation(s)
- Aurélia Vessière
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France.
| | - Hélène Font
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
| | - Delphine Gabillard
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
| | | | - Laurence Borand
- Epidemiology and Public Health Unit, Pasteur Institute in Cambodia, Phnom Penh, Cambodia
| | - Chishala Chabala
- University of Zambia School of Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Celso Khosa
- Instituto Nacional de Saúde, Maputo, Mozambique
| | - Sandra Mavale
- Paediatrics Department, Maputo Central Hospital, Maputo, Mozambique
| | - Raoul Moh
- Programme PAC-CI, CHU de Treichville, Abidjan, Ivory Coast
| | - Veronica Mulenga
- Children's Hospital, University Teaching Hospital, Lusaka, Zambia
| | | | | | - Mao Tan Eang
- National Center for Tuberculosis and Leprosy (CENAT/NTP), Ministry of Health, Phnom Penh, Cambodia
| | - Christophe Delacourt
- Department of Paediatric Pulmonology, Necker University Teaching Hospital, Paris, France
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, UK
| | | | | | - Eric Wobudeya
- Makerere University-Johns Hopkins University Research Collaboration (MU-JHU) Care Ltd, Kampala, Uganda
| | - Maryline Bonnet
- IRD UMI233/Inserm U1175, University of Montpellier, Montpellier, France
| | - Olivier Marcy
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
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Zhang L, Wang H, Li N, Hu P, Zhu Z, Wang W, Song Y, Wen Z, Yu X, Zhang S. Label-Free Mass Spectrometry-Based Plasma Proteomics Identified LY6D, DSC3, CDSN, SERPINB12, and SLURP1 as Novel Protein Biomarkers For Pulmonary Tuberculosis. CURR PROTEOMICS 2021. [DOI: 10.2174/1570164617666191210105122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Aim:
We aimed to identify new plasma biomarkers for the diagnosis of Pulmonary Tuberculosis
(PTB).
Background:
Tuberculosis is an ancient infectious disease that remains one of the major global health problems.
Until now, effective, convenient, and affordable methods for diagnosis of PTB were still lacking.
Objective:
This study focused on constructing a label-free LC-MS/MS-based comparative proteomics
between six tuberculosis patients and six healthy controls to identify Differentially Expressed Proteins
(DEPs) in plasma.
Methods:
To reduce the influences of high-abundant proteins, albumin and globulin were removed from
plasma samples using affinity gels. Then DEPs from the plasma samples were identified using a label-free
Quadrupole-Orbitrap LC-MS/MS system. The results were analyzed by the protein database search algorithm
SEQUEST-HT to identify mass spectra to peptides. The predictive abilities of combinations of host
markers were investigated by General Discriminant Analysis (GDA), with Leave-One-Out Cross-
Validation (LOOCV).
Results:
A total of 572 proteins were identified and 549 proteins were quantified. The threshold for
DEPs was set as adjusted p-value < 0.05 and fold change ≥1.5 or ≤0.6667, 32 DEPs were found. ClusterVis,
TBtools, and STRING were used to find new potential biomarkers of PTB. Six proteins, LY6D,
DSC3, CDSN, FABP5, SERPINB12, and SLURP1, which performed well in the LOOCV method validation,
were termed as potential biomarkers. The percentage of cross-validated grouped cases correctly
classified and original grouped cases correctly classified is greater than or equal to 91.7%.
Conclusion:
We successfully identified five candidate biomarkers for immunodiagnosis of PTB in
plasma, LY6D, DSC3, CDSN, SERPINB12, and SLURP1. Our work supported this group of proteins
as potential biomarkers for PTB, and be worthy of further validation.
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Affiliation(s)
- Lu Zhang
- School of Biological and Pharmaceutical Engineering, Wuhan Polytechnic University, Wuhan, China
| | - Hualin Wang
- School of Biological and Pharmaceutical Engineering, Wuhan Polytechnic University, Wuhan, China
| | - Na Li
- School of Biological and Pharmaceutical Engineering, Wuhan Polytechnic University, Wuhan, China
| | - Peng Hu
- School of Biological and Pharmaceutical Engineering, Wuhan Polytechnic University, Wuhan, China
| | - Zhaoqin Zhu
- Shanghai Public Health Clinical Center, Shanghai, China
| | - Wei Wang
- Henan Provincial Chest Hospital, Zhengzhou, China
| | - Yanzheng Song
- Shanghai Public Health Clinical Center, Shanghai, China
| | - Zilu Wen
- Shanghai Public Health Clinical Center, Shanghai, China
| | - Xiaoli Yu
- School of Biological and Pharmaceutical Engineering, Wuhan Polytechnic University, Wuhan, China
| | - Shulin Zhang
- Shanghai Public Health Clinical Center, Shanghai, China
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17
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Kay AW, González Fernández L, Takwoingi Y, Eisenhut M, Detjen AK, Steingart KR, Mandalakas AM. Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for active tuberculosis and rifampicin resistance in children. Cochrane Database Syst Rev 2020; 8:CD013359. [PMID: 32853411 PMCID: PMC8078611 DOI: 10.1002/14651858.cd013359.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Every year, at least one million children become ill with tuberculosis and around 200,000 children die. Xpert MTB/RIF and Xpert Ultra are World Health Organization (WHO)-recommended rapid molecular tests that simultaneously detect tuberculosis and rifampicin resistance in adults and children with signs and symptoms of tuberculosis, at lower health system levels. To inform updated WHO guidelines on molecular assays, we performed a systematic review on the diagnostic accuracy of these tests in children presumed to have active tuberculosis. OBJECTIVES Primary objectives • To determine the diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for (a) pulmonary tuberculosis in children presumed to have tuberculosis; (b) tuberculous meningitis in children presumed to have tuberculosis; (c) lymph node tuberculosis in children presumed to have tuberculosis; and (d) rifampicin resistance in children presumed to have tuberculosis - For tuberculosis detection, index tests were used as the initial test, replacing standard practice (i.e. smear microscopy or culture) - For detection of rifampicin resistance, index tests replaced culture-based drug susceptibility testing as the initial test Secondary objectives • To compare the accuracy of Xpert MTB/RIF and Xpert Ultra for each of the four target conditions • To investigate potential sources of heterogeneity in accuracy estimates - For tuberculosis detection, we considered age, disease severity, smear-test status, HIV status, clinical setting, specimen type, high tuberculosis burden, and high tuberculosis/HIV burden - For detection of rifampicin resistance, we considered multi-drug-resistant tuberculosis burden • To compare multiple Xpert MTB/RIF or Xpert Ultra results (repeated testing) with the initial Xpert MTB/RIF or Xpert Ultra result SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and the International Standard Randomized Controlled Trials Number (ISRCTN) Registry up to 29 April 2019, without language restrictions. SELECTION CRITERIA Randomized trials, cross-sectional trials, and cohort studies evaluating Xpert MTB/RIF or Xpert Ultra in HIV-positive and HIV-negative children younger than 15 years. Reference standards comprised culture or a composite reference standard for tuberculosis and drug susceptibility testing or MTBDRplus (molecular assay for detection of Mycobacterium tuberculosis and drug resistance) for rifampicin resistance. We included studies evaluating sputum, gastric aspirate, stool, nasopharyngeal or bronchial lavage specimens (pulmonary tuberculosis), cerebrospinal fluid (tuberculous meningitis), fine needle aspirates, or surgical biopsy tissue (lymph node tuberculosis). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2). For each target condition, we used the bivariate model to estimate pooled sensitivity and specificity with 95% confidence intervals (CIs). We stratified all analyses by type of reference standard. We assessed certainty of evidence using the GRADE approach. MAIN RESULTS For pulmonary tuberculosis, 299 data sets (68,544 participants) were available for analysis; for tuberculous meningitis, 10 data sets (423 participants) were available; for lymph node tuberculosis, 10 data sets (318 participants) were available; and for rifampicin resistance, 14 data sets (326 participants) were available. Thirty-nine studies (80%) took place in countries with high tuberculosis burden. Risk of bias was low except for the reference standard domain, for which risk of bias was unclear because many studies collected only one specimen for culture. Detection of pulmonary tuberculosis For sputum specimens, Xpert MTB/RIF pooled sensitivity (95% CI) and specificity (95% CI) verified by culture were 64.6% (55.3% to 72.9%) (23 studies, 493 participants; moderate-certainty evidence) and 99.0% (98.1% to 99.5%) (23 studies, 6119 participants; moderate-certainty evidence). For other specimen types (nasopharyngeal aspirate, 4 studies; gastric aspirate, 14 studies; stool, 11 studies), Xpert MTB/RIF pooled sensitivity ranged between 45.7% and 73.0%, and pooled specificity ranged between 98.1% and 99.6%. For sputum specimens, Xpert Ultra pooled sensitivity (95% CI) and specificity (95% CI) verified by culture were 72.8% (64.7% to 79.6%) (3 studies, 136 participants; low-certainty evidence) and 97.5% (95.8% to 98.5%) (3 studies, 551 participants; high-certainty evidence). For nasopharyngeal specimens, Xpert Ultra sensitivity (95% CI) and specificity (95% CI) were 45.7% (28.9% to 63.3%) and 97.5% (93.7% to 99.3%) (1 study, 195 participants). For all specimen types, Xpert MTB/RIF and Xpert Ultra sensitivity were lower against a composite reference standard than against culture. Detection of tuberculous meningitis For cerebrospinal fluid, Xpert MTB/RIF pooled sensitivity and specificity, verified by culture, were 54.0% (95% CI 27.8% to 78.2%) (6 studies, 28 participants; very low-certainty evidence) and 93.8% (95% CI 84.5% to 97.6%) (6 studies, 213 participants; low-certainty evidence). Detection of lymph node tuberculosis For lymph node aspirates or biopsies, Xpert MTB/RIF pooled sensitivity and specificity, verified by culture, were 90.4% (95% CI 55.7% to 98.6%) (6 studies, 68 participants; very low-certainty evidence) and 89.8% (95% CI 71.5% to 96.8%) (6 studies, 142 participants; low-certainty evidence). Detection of rifampicin resistance Xpert MTB/RIF pooled sensitivity and specificity were 90.0% (67.6% to 97.5%) (6 studies, 20 participants; low-certainty evidence) and 98.3% (87.7% to 99.8%) (6 studies, 203 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We found Xpert MTB/RIF sensitivity to vary by specimen type, with gastric aspirate specimens having the highest sensitivity followed by sputum and stool, and nasopharyngeal specimens the lowest; specificity in all specimens was > 98%. Compared with Xpert MTB/RIF, Xpert Ultra sensitivity in sputum was higher and specificity slightly lower. Xpert MTB/RIF was accurate for detection of rifampicin resistance. Xpert MTB/RIF was sensitive for diagnosing lymph node tuberculosis. For children with presumed tuberculous meningitis, treatment decisions should be based on the entirety of clinical information and treatment should not be withheld based solely on an Xpert MTB/RIF result. The small numbers of studies and participants, particularly for Xpert Ultra, limits our confidence in the precision of these estimates.
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MESH Headings
- Adolescent
- Antibiotics, Antitubercular/therapeutic use
- Bias
- Child
- Feces/microbiology
- Gastrointestinal Contents/microbiology
- Humans
- Molecular Typing/methods
- Molecular Typing/standards
- Mycobacterium tuberculosis/drug effects
- Mycobacterium tuberculosis/isolation & purification
- Rifampin/therapeutic use
- Sensitivity and Specificity
- Sputum/microbiology
- Tuberculosis, Lymph Node/diagnosis
- Tuberculosis, Lymph Node/drug therapy
- Tuberculosis, Lymph Node/microbiology
- Tuberculosis, Meningeal/cerebrospinal fluid
- Tuberculosis, Meningeal/diagnosis
- Tuberculosis, Meningeal/drug therapy
- Tuberculosis, Meningeal/microbiology
- Tuberculosis, Multidrug-Resistant/diagnosis
- Tuberculosis, Multidrug-Resistant/drug therapy
- Tuberculosis, Multidrug-Resistant/microbiology
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/microbiology
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Affiliation(s)
- Alexander W Kay
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Michael Eisenhut
- Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | | | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Vonasek B, Ness T, Takwoingi Y, Kay AW, van Wyk SS, Ouellette L, Marais BJ, Steingart KR, Mandalakas AM. Screening tests for active pulmonary tuberculosis in children. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2020. [DOI: 10.1002/14651858.cd013693] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Bryan Vonasek
- The Global Tuberculosis Program, Texas Children’s Hospital, Section of Global and Immigrant Health, Department of Pediatrics; Baylor College of Medicine; Houston Texas USA
| | - Tara Ness
- The Global Tuberculosis Program, Texas Children’s Hospital, Section of Global and Immigrant Health, Department of Pediatrics; Baylor College of Medicine; Houston Texas USA
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research; University of Birmingham; Birmingham UK
| | - Alexander W Kay
- The Global Tuberculosis Program, Texas Children’s Hospital, Section of Global and Immigrant Health, Department of Pediatrics; Baylor College of Medicine; Houston Texas USA
| | - Susanna S van Wyk
- Centre for Evidence-based Health Care, Epidemiology and Biostatistics, Department of Global Health; Organisation:Faculty of Medicine and Health Sciences, Stellenbosch University; Cape Town South Africa
| | | | - Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity; University of Sydney; Sydney Australia
| | - Karen R Steingart
- Honorary Research Fellow; Department of Clinical Sciences, Liverpool School of Tropical Medicine; Liverpool UK
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children’s Hospital, Section of Global and Immigrant Health, Department of Pediatrics; Baylor College of Medicine; Houston Texas USA
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19
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Tickell KD, Sharmin R, Deichsel EL, Lamberti LM, Walson JL, Faruque ASG, Pavlinac PB, Kotloff KL, Chisti MJ. The effect of acute malnutrition on enteric pathogens, moderate-to-severe diarrhoea, and associated mortality in the Global Enteric Multicenter Study cohort: a post-hoc analysis. LANCET GLOBAL HEALTH 2020; 8:e215-e224. [PMID: 31981554 PMCID: PMC7025322 DOI: 10.1016/s2214-109x(19)30498-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 11/18/2019] [Accepted: 11/25/2019] [Indexed: 01/09/2023]
Abstract
Background Host vulnerabilities associated with acute malnutrition could facilitate the ability of specific enteric pathogens to cause diarrhoea and associated mortality. Using data from the Global Enteric Multicenter Study, we assessed whether acute malnutrition modifies the association between common enteric pathogens and moderate-to-severe diarrhoea, and whether associations between enteric pathogens and death were modified by acute malnutrition. Methods Children with moderate-to-severe diarrhoea and age-matched and community-matched controls were included in this post-hoc analysis if their mid-upper arm circumference had been measured and if they were older than 6 months of age. Acute malnutrition was defined as mid-upper arm circumference below 12·5 cm, capturing both severe acute malnutrition (<11·5 cm) and moderate acute malnutrition (≥11·5 cm and <12·5 cm). We tested whether acute malnutrition modified associations between enteric pathogens and moderate-to-severe diarrhoea in conditional logistic regression models. Among children with moderate-to-severe diarrhoea, Cox proportional hazards regression evaluated the modifying effect of acute malnutrition on the relationship between pathogens and 60-day fatality rate. Findings The age, site, and co-infection adjusted odds ratios (aORs) for moderate-to-severe diarrhoea associated with typical enteropathogenic Escherichia coli among children aged 6–11 months was 2·08 (95% CI 1·14–3·79) in children with acute malnutrition, and 0·97 (0·77–1·23) in children with better nutritional status, compared with healthy controls. Enterotoxigenic E coli producing heat-stable toxin among children aged 12–23 months also had a stronger association with moderate-to-severe diarrhoea in children with acute malnutrition (aOR 7·60 [2·63–21·95]) than among similarly aged children with better nutritional status (aOR 2·39 [1·76–3·25]). Results for Shigella spp, norovirus, and sapovirus suggested they had a stronger association with moderate-to-severe diarrhoea than other pathogens among children with better nutritional status, although Shigella spp remained associated with moderate-to-severe diarrhoea in both nutritional groups. 92 (64%) of 144 children with moderate-to-severe diarrhoea who died had acute malnutrition. Pathogen-specific 60-day fatality rates for all pathogens were higher among children with acute malnutrition, but no individual pathogen had a significantly larger increase in its relative association with mortality. Interpretation Acute malnutrition might strengthen associations between specific pathogens and moderate-to-severe diarrhoea. However, the strong link between acute malnutrition and mortality during moderate-to-severe diarrhoea in children is not limited to specific infections, and affects a broad spectrum of enteric pathogens. Interventions addressing acute malnutrition could be an effective way to lower the mortality of both childhood malnutrition and diarrhoea. Funding The Bill & Melinda Gates Foundation.
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Affiliation(s)
- Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya.
| | - Rumana Sharmin
- International Centre for Diarrheal Disease Research (icddr, b), Dhaka, Bangladesh
| | - Emily L Deichsel
- Center for Vaccine Development and Global Health, School of Medicine, University of Maryland, Baltimore, MD, USA
| | | | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
| | - A S G Faruque
- International Centre for Diarrheal Disease Research (icddr, b), Dhaka, Bangladesh
| | | | - Karen L Kotloff
- Center for Vaccine Development and Global Health, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Mohammod J Chisti
- Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya; International Centre for Diarrheal Disease Research (icddr, b), Dhaka, Bangladesh
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20
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Chowdhury F, Shahid ASMSB, Ghosh PK, Rahman M, Hassan MZ, Akhtar Z, Muneer SME, Shahrin L, Ahmed T, Chisti MJ. Viral etiology of pneumonia among severely malnourished under-five children in an urban hospital, Bangladesh. PLoS One 2020; 15:e0228329. [PMID: 32017782 PMCID: PMC6999894 DOI: 10.1371/journal.pone.0228329] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 01/13/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In Bangladesh, pneumonia has a higher mortality among malnourished children aged <5 years. Evaluating pneumonia etiology among malnourished children may help improve empiric treatment guidelines. METHODS During April 2015-December 2017, we conducted a case-control study among severe acute malnourished (SAM) children aged <5 years admitted to the Dhaka hospital of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). We enrolled hospital admitted SAM children with clinical or radiological pneumonia as cases (during April 2015 to March 2017) and hospital admitted SAM children without any respiratory symptom in the past 10 days before admission as controls (during February 2016 to December 2017). We tested nasopharyngeal wash from both case and control for respiratory syncytial virus (RSV), human metapneumovirus (HMPV), influenza viruses, human parainfluenza viruses (HPIV), rhinovirus and adenovirus by singleplex real-time reverse transcriptase polymerase chain reaction. To identify the independent association of pneumonia with viral pathogens during February 2016 to March 2017, we used multivariable logistic regression for calculating adjusted odds ratios. RESULTS We enrolled 360 cases and 334 controls. For case and control the median age was 8 months (IQR: 5-13) and 11 months (IQR: 6-18) (p = 0.001) respectively. Weight/age Z-score was -4.3 (SD ±0.7) for cases and -4.1 (SD ±1.1) for controls (p = 0.01). Among cases 68% had both clinical and radiological pneumonia, 1% had clinical pneumonia and 31% had only radiological pneumonia. Respiratory virus detection was high in cases compared to controls [69.9% (251) vs. 44.8% (148), p = 0.0001]. The most frequently detected viruses among cases were rhinoviruses (79, 22.0%) followed by RSV (32, 8.9%), adenovirus (23, 6.4%), HPIV (22, 6.1%), influenza virus (16, 4.5%), and HMPV (16, 4.5%). Among the controls, rhinoviruses (82, 24.8%) were most commonly detected one followed by adenovirus (26,7.9%), HMPV (5, 1.5%), HPIV (4, 1.2%), RSV (3, 0.9%), and influenza virus (2, 0.6%). RSV (OR 13.1; 95% CI: 1.6, 106.1), influenza virus (OR 8.7; 95% CI: 1.0, 78.9), HPIV (3.8; 95% CI: 1.0, 14.8), and HMPV (2.7; 95% CI: 1.3, 5.5) were independently associated with pneumonia while compared between 178 cases and 174 controls. CONCLUSION Viral etiology of pneumonia in SAM children were mainly attributable to RSV, influenza, HPIV and HMPV. Our study findings may help in planning further studies targeting vaccines or drugs against common respiratory viruses responsible for pneumonia among SAM children.
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Affiliation(s)
- Fahmida Chowdhury
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Probir Kumar Ghosh
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mustafizur Rahman
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md. Zakiul Hassan
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Zubair Akhtar
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - S. Mah-E- Muneer
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Lubaba Shahrin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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21
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Detjen AK, Essajee S, Grzemska M, Marais BJ. Tuberculosis and integrated child health - Rediscovering the principles of Alma Ata. Int J Infect Dis 2019; 80S:S9-S12. [PMID: 30825651 DOI: 10.1016/j.ijid.2019.02.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 01/29/2023] Open
Affiliation(s)
- Anne K Detjen
- United Nations Children's Fund (UNICEF), New York, United States.
| | - Shaffiq Essajee
- United Nations Children's Fund (UNICEF), New York, United States.
| | | | - Ben J Marais
- Centre for Research Excellence in Tuberculosis and the Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia.
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22
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High burden of co-morbidity and mortality among severely malnourished children admitted to outpatient therapeutic programme facilities in the conflict setting of Borno, Nigeria: a retrospective review. Public Health Nutr 2019; 22:1786-1793. [PMID: 30741140 DOI: 10.1017/s1368980018003968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To present evidence on the burden and outcomes of co-morbidities among severely malnourished (SAM) children admitted to outpatient therapeutic programme (OTP) facilities in the conflict setting of Borno, Nigeria. DESIGN Retrospective medical chart review. SETTING Facility-based study.ParticipantsChildren aged 6-59 months with SAM enrolled in OTP between June and November 2016 whose medical records were analysed. Only pneumonia and diarrhoea were examined due to data limitations. Stata software was used for descriptive, multivariate and survival analyses. RESULTS Records of 396 children with median age of 15 months were identified and analysed from the date of enrolment to exit from OTP. Mean length of stay in OTP was 61d, with co-infected SAM children having shorter stay (P=0·006). Of the total, 148 (37·4 %) had at least one co-morbidity (pneumonia or diarrhoea), of which thirty-nine (26·4 %) had both. Cumulative rate of mortality during follow-up time was 9·5 (95 % CI 6·0, 15·1) per 10 000 child-days; SAM children with co-morbidities were ten times more likely to die than those without (hazard ratio=10·2; 95 % CI 3·4, 31·0). In multivariable analysis, co-morbidity (P=0·01), oedema (P=0·003), dehydration (P=0·02) and weight on admission (P=0·01) were associated with mortality. Both recovery and defaulter rates (57·8 and 36·1 %, respectively) did not meet SPHERE standards. CONCLUSIONS Children with SAM and co-morbidities are less likely to survive, presenting a significant barrier in improving child survival. The findings call for integrated OTP models that incorporate clinical algorithms and ensure prompt referral for SAM children with co-morbidity.
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23
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Chisti MJ, Shahid ASMSB, Shahunja KM, Banu S, Raqib R, Shahrin L, Islam SB, Sharifuzzaman, Saha H, Alam T, Rahman MW, Nuzhat S, Afroze F, Sarmin M, Ahmed T. Comparative Performance of Modified Kenneth Jones Criteria Scoring, World Health Organization Criteria, and Antibodies in Lymphocyte Supernatant for Diagnosing Tuberculosis in Severely Malnourished Children Presenting With Pneumonia. Front Pediatr 2019; 7:406. [PMID: 31632942 PMCID: PMC6781649 DOI: 10.3389/fped.2019.00406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 09/19/2019] [Indexed: 12/03/2022] Open
Abstract
Background: The diagnosis of childhood tuberculosis (TB) can be difficult in severely malnourished children. This is mainly due to the fact of our perceived notion that clinical signs of TB are often subtle in severely malnourished children and we may rely on laboratory investigation for the diagnosis. However, comparative data on the performance of clinical and laboratory diagnostics of TB in such population are also very limited. Objectives: To compare the performance of composite clinical criteria and a technique that measures antibodies in lymphocyte supernatant (ALS) for the diagnosis of TB in severely malnourished children with pneumonia. Methods: Severely malnourished children under five with radiological pneumonia admitted to the Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh were enrolled consecutively following informed consent. We collected venous blood for ALS, gastric lavage fluid and induced sputum for microscopy, mycobacterial culture, and real-time PCR by Xpert MTB/RIF. We compared the sensitivity, specificity, positive, and negative predictive values, and accuracy of modified Kenneth Jones criteria (MKJC) score, World Health Organization (WHO) criteria, and ALS in diagnosing TB in severely malnourished children with pneumonia for "Confirmed TB" and "All TB" ("Confirmed TB" plus "Probable TB") vs. "Not TB." Results: Compared to culture confirmed TB, the sensitivity, and specificity (95% CI) for MKJC were 60 (27-86) and 84 (79-87)% and for WHO criteria were 40 (14-73) and 84 (80-87)%, respectively. Compared to culture and/or Xpert MTB/RIF positive TB, the sensitivity and specificity (95% CI) for the criteria were 37 (20-58) and 84 (79-87)%; and 22 (9-43) and 83 (79-87)%, respectively. For both these comparisons, the sensitivity and specificity of ALS were 50 (14-86) and 60 (53-67)%, respectively. Conclusion: Our data suggest that WHO criteria and MKJC scoring mainly based on clinical criteria are more useful than ALS in diagnosing TB in young severely malnourished children with pneumonia. The results underscore the importance of using clinical criteria for the diagnosis of TB in severely malnourished children that may help to minimize the chance of over treatment with anti-TB in such population, especially in resource limited TB endemic settings.
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Affiliation(s)
- Mohammod Jobayer Chisti
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu S M S B Shahid
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - K M Shahunja
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sayera Banu
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Rubhana Raqib
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Lubaba Shahrin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shoeb Bin Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sharifuzzaman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Haimanti Saha
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmina Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Muhammad Waliur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sharika Nuzhat
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Farzana Afroze
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Monira Sarmin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Birungi FM, van Wyk B, Uwimana J, Ntaganira J, Graham SM. Xpert MTB/RIF assay did not improve diagnosis of pulmonary tuberculosis among child contacts in Rwanda. Pan Afr Med J 2018; 30:39. [PMID: 30167066 PMCID: PMC6110558 DOI: 10.11604/pamj.2018.30.39.12600] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 04/19/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction To report on the diagnostic yield using the Xpert MTB/RIF assay on gastric lavage samples from children (<15 years) who were household contacts of tuberculosis (TB) cases in Kigali, Rwanda. Methods A cross-sectional study was conducted among 216 child contacts of index cases with sputum smear-positive TB over a 7 month period, from 1st August 2015 to 29th February 2016. Child contacts with tuberculosis-related symptoms or abnormal chest X-ray had sputum collected by gastric lavage on two consecutive days and samples were examined by smear microscopy, Xpert MTB/RIF assay and solid culture. Results Of the 216 child contacts, 94 (44%) were less than 5 years of age. Most of them 84 (89%) were receiving isoniazid preventive therapy at the time of screening. Thirty seven out of 216 children had TB-related symptoms. Only 4 (10.8%) were clinically diagnosed with TB; and none had bacteriologically confirmed tuberculosis. Conclusion The use of Xpert MTB/RIF assay did not contribute to bacteriological confirmation of active TB in child contacts in this study. The low prevalence of tuberculosis in child contacts in this study may reflect the high coverage of preventive therapy in young (<5 years) child contacts. The low sensitivity of Xpert MTB/RIF assay in contacts may also suggest likely reflection of paucibacillary disease.
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Affiliation(s)
- Francine Mwayuma Birungi
- Department of Epidemiology and Biostatistics, School of Public Health of the College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.,Faculty of Community and Health Sciences, University of Western Cape, Cape Town, South Africa
| | - Brian van Wyk
- Faculty of Community and Health Sciences, University of Western Cape, Cape Town, South Africa
| | - Jeannine Uwimana
- Department of Epidemiology and Biostatistics, School of Public Health of the College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.,Faculty of Community and Health Sciences, University of Western Cape, Cape Town, South Africa
| | - Joseph Ntaganira
- Department of Epidemiology and Biostatistics, School of Public Health of the College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Stephen Michael Graham
- Centre for International Child Health, University of Melbourne Department of Paediatrics and Murdoch Children's, Research Institute, Royal Children's Hospital, Melbourne, Australia.,International Union Against Tuberculosis and Lung Disease, Paris, France
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25
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Abstract
BACKGROUND Mortality among children with presumptive tuberculosis (TB) empiric TB treatment can be high. We describe the predictors of death among children with presumptive TB, and the relation between treatment and mortality. METHODS A prospective cohort of children with presumptive TB who underwent clinical assessment, chest radiograph, tuberculin skin test and sputum bacterial tests for TB was followed up for 3 months. TB diagnosis was based on mycobacterial, clinical and radiologic findings. Predictors of deaths were determined using cox regression model. RESULTS Of 360 children included in the analysis, 31.4% were younger than 2 years; 31.6% were HIV infected and 11.3% were severely malnourished. One hundred forty (38.9%) were diagnosed with TB, 18 (13%) of whom were bacteriologically confirmed. At 3 months of follow up, 25 of 360 (6.9%) children had died: 15 of 140 (10.7%) were receiving TB treatment versus 10 of 220 (4.5%) were not receiving treatment (P = 0.025). Severely malnourished children [adjusted hazard ratio (aHR), 9.86; 95% confidence interval (CI): 3.11-31.23] and those with chest radiographs suggestive of TB (aHR, 4.20; 95% CI: 0.93-19.01) were more likely to die. Children receiving empiric TB treatment had an increased risk of death (aHR, 2.37; 95% CI: 1.01-5.55) compared with children without treatment after adjustment for age, sex, HIV status and Bacillus Calmette-Guérin (BCG) vaccination. CONCLUSIONS The high mortality in children receiving empirically TB treatment highlights the difficulty in diagnosing childhood TB, the increased likelihood of starting treatment in critically ill children and in children with chronic disease, and the possibility of misdiagnosis. It strengthens the need to invest further in early TB detection and diagnosing nonsevere illness.
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26
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Kabir S, Uddin MKM, Chisti MJ, Fannana T, Haque ME, Uddin MR, Banu S, Ahmed T. Role of PCR method using IS6110 primer in detecting Mycobacterium tuberculosis among the clinically diagnosed childhood tuberculosis patients at an urban hospital in Dhaka, Bangladesh. Int J Infect Dis 2018; 68:108-114. [PMID: 29391244 DOI: 10.1016/j.ijid.2018.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Better methods are needed for the accurate detection of child tuberculosis (TB). This study compared different laboratory tests and evaluated IS6110 PCR for the detection of Mycobacterium tuberculosis (MTB) among clinically diagnosed child TB patients. METHODS A total of 102 paediatric patients (<15 years old) with clinically diagnosed TB were enrolled in this study. The patients were admitted to the icddr,b hospital in Dhaka between 2003 and 2005. Sputum/gastric lavage samples were collected for smear microscopy, culture (solid/Lowenstein-Jensen medium and liquid/MGIT), and IS6110 PCR testing. The sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of smear microscopy and PCR were compared to the two culture methods. RESULTS Three patients were positive on smear microscopy (2.9%). MTB was detected by conventional culture in 15.7% (16/102), liquid culture in 14% (14/100), and IS6110 PCR in 61.8% (63/102). PCR detected an additional 45 patients who were undetected with the three other tests. Compared to conventional and liquid culture, respectively, smear microscopy showed sensitivity of 18.8% and 21.4%, specificity of 100% individually, PPV of 100% individually, and NPV of 86.9% and 88.7%, whereas PCR had sensitivity of 87.5% and 92.9%, specificity of 43% individually, PPV of 22.2% and 21%, and NPV of 94.9% and 97.4%. CONCLUSIONS PCR can be useful compared to smear microscopy and culture methods and is applicable as a rapid screening test for child TB. A larger scale study is required to determine its diagnostic efficacy in improving the detection of child TB in the presence and absence of severe malnutrition.
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Affiliation(s)
- Senjuti Kabir
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh.
| | | | | | - Tilka Fannana
- Department of Pharmacy, East West University, Dhaka, Bangladesh.
| | - Mohammad Enamul Haque
- Directorate of Infection Prevention and Control, Ministry of Health, Najran, Saudi Arabia.
| | - Muhammad Reaj Uddin
- Diagnostic Laboratory Services, Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh.
| | - Sayera Banu
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh.
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh.
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27
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Abstract
The global impact of childhood malnutrition is staggering. The synergism between malnutrition and infection contributes substantially to childhood morbidity and mortality. Anthropometric indicators of malnutrition are associated with the increased risk and severity of infections caused by many pathogens, including viruses, bacteria, protozoa, and helminths. Since childhood malnutrition commonly involves the inadequate intake of protein and calories, with superimposed micronutrient deficiencies, the causal factors involved in impaired host defense are usually not defined. This review focuses on literature related to impaired host defense and the risk of infection in primary childhood malnutrition. Particular attention is given to longitudinal and prospective cohort human studies and studies of experimental animal models that address causal, mechanistic relationships between malnutrition and host defense. Protein and micronutrient deficiencies impact the hematopoietic and lymphoid organs and compromise both innate and adaptive immune functions. Malnutrition-related changes in intestinal microbiota contribute to growth faltering and dysregulated inflammation and immune function. Although substantial progress has been made in understanding the malnutrition-infection synergism, critical gaps in our understanding remain. We highlight the need for mechanistic studies that can lead to targeted interventions to improve host defense and reduce the morbidity and mortality of infectious diseases in this vulnerable population.
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Bacteriological diagnosis of childhood TB: a prospective observational study. Sci Rep 2017; 7:11808. [PMID: 28924198 PMCID: PMC5603584 DOI: 10.1038/s41598-017-11969-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/01/2017] [Indexed: 12/18/2022] Open
Abstract
Childhood TB diagnosis is challenging. Studies in adults suggest Microscopic Observation Drug Susceptibility (MODS) culture or the Xpert MTB/RIF assay might be used to expand bacteriological diagnosis. However data from children are more limited. We prospectively compared MODS and Xpert MTB/RIF with standard microscopy and culture using the BD MGIT 960 system among 1442 Kenyan children with suspected TB. 97 specimens from 54 children were TB culture-positive: 91 (94%) by MGIT and 74 (76%) by MODS (p = 0.002). 72 (74%) culture-positive and 7 culture-negative specimens were Xpert MTB/RIF positive. Xpert MTB/RIF specificity was 100% (99.7–100%) among 1164 specimens from 892 children in whom TB was excluded, strongly suggesting all Xpert MTB/RIF positives are true positives. The sensitivity of MGIT, MODS and Xpert MTB/RIF was 88%, 71% and 76%, respectively, among all 104 true positive (culture and/or Xpert MTB/RIF positive) specimens. MGIT, MODS and Xpert MTB/RIF on the initial specimen identified 40/51 (78%), 33/51 (65%) and 33/51 (65%) culture-confirmed pulmonary TB cases, respectively; Xpert MTB/RIF detected 5 additional culture-negative cases. The high sensitivity and very high specificity of the Xpert MTB/RIF assay supports its inclusion in the reference standard for bacteriological diagnosis of childhood TB in research and clinical practice.
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29
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Patel LN, Detjen AK. Integration of childhood TB into guidelines for the management of acute malnutrition in high burden countries. Public Health Action 2017; 7:110-115. [PMID: 28695083 DOI: 10.5588/pha.17.0018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 04/01/2017] [Indexed: 11/10/2022] Open
Abstract
Introduction: Childhood tuberculosis (TB) and undernutrition are major global public health challenges. In 2015, although an estimated 1 million children aged <15 years developed TB, the majority of the cases remain undiagnosed, partly due to a lack of awareness and capacity by providers who serve as the first point of care for sick children. This calls for better integration of TB with child health and nutrition services. TB can cause or worsen undernutrition, and undernutrition increases the risk of TB. Methods: Guidelines for the management of acute malnutrition from 17 high TB burden countries were reviewed to gather information on TB symptom screening, exposure history, and treatment. Results: Seven (41%) countries recommend routine TB screening among children with acute malnutrition, and six (35%) recommend obtaining a TB exposure history. Conclusion: TB screening is not consistently included in guidelines for acute malnutrition in high TB burden countries. Routine TB risk assessment, especially history of TB exposure, among acutely malnourished children, combined with improved linkages with TB services, would help increase TB case finding and could impact outcomes. Operational research on how best to integrate services at different levels of the health care system is needed.
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Affiliation(s)
- L N Patel
- Vital Strategies, New York, New York, USA
| | - A K Detjen
- United Nations Children's Fund, New York, New York, USA
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30
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Munthali T, Chabala C, Chama E, Mugode R, Kapata N, Musonda P, Michelo C. Tuberculosis caseload in children with severe acute malnutrition related with high hospital based mortality in Lusaka, Zambia. BMC Res Notes 2017; 10:206. [PMID: 28606173 PMCID: PMC5468953 DOI: 10.1186/s13104-017-2529-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/02/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis and severe acute malnutrition (SAM) in children pose a major treatment and care challenge in high HIV burden countries in Africa. We investigated the prevalence of Tuberculosis notifications among hospitalised under-five children with severe acute malnutrition. A retrospective review of medical records for all children aged 0-59 months admitted to the University Teaching Hospital from 2009 to 2013 was performed. Descriptive statistics were employed to estimate TB caseload. Logistic regression was used to identify predictors of the TB caseload. RESULTS A total of (n = 9540) under-five children with SAM were admitted over the period reviewed. The median age was 16 months (IQR 11-24) and the proportion diagnosed with TB was 1.58% (95% CI 1.3, 1.8) representing 151 cases. Of these, only 37 (25%) were bacteriologically confirmed cases. The HIV seroprevalence of children with SAM and TB was 46.5%. Children with SAM and TB were 40% more likely to die than children with SAM and without TB. CONCLUSIONS Tuberculosis contributes to mortality among children with SAM in high TB and HIV prevalence settings. The under detection of cases and association of TB with HIV infection in malnutrition opens up opportunities to innovate integrative case finding approaches beyond just HIV counselling and testing within existing mother and child health service areas to include TB screening and prevention interventions, as these are critical primary care elements.
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Affiliation(s)
- Tendai Munthali
- School of Public Health, University of Zambia, P.O Box 50110, Lusaka, Zambia.
- Ministry of Health, P.O Box 30205, Lusaka, Zambia.
| | - Chishala Chabala
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
- School of Medicine, University of Zambia, Lusaka, Zambia
| | - Elson Chama
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Raider Mugode
- National Food and Nutrition Commission, Lusaka, Zambia
| | | | - Patrick Musonda
- School of Public Health, University of Zambia, P.O Box 50110, Lusaka, Zambia
| | - Charles Michelo
- School of Public Health, University of Zambia, P.O Box 50110, Lusaka, Zambia
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31
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Bacha JM, Ngo K, Clowes P, Draper HR, Ntinginya EN, DiNardo A, Mangu C, Sabi I, Mtafya B, Mandalakas AM. Why being an expert - despite xpert -remains crucial for children in high TB burden settings. BMC Infect Dis 2017; 17:123. [PMID: 28166728 PMCID: PMC5294844 DOI: 10.1186/s12879-017-2236-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 01/31/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As access to Xpert expands in high TB-burden settings, its performance against clinically diagnosed TB as a reference standard provides important insight as the majority of childhood TB is bacteriologically unconfirmed. We aim to describe the characteristics and outcomes of children with presumptive TB and TB disease, and assess performance of Xpert under programmatic conditions against a clinical diagnosis of TB as a reference standard. METHODS Retrospective review of children evaluated for presumptive TB in Mbeya, Tanzania. Baseline characteristics were compared by TB disease status and, for patients diagnosed with TB, by TB confirmation status using Wilcoxon rank sum test for continuous variables and the Chi-square test for categorical variables. Sensitivity and specificity were calculated to assess the performance of Xpert, smear, and culture against clinical TB. Kappa statistics were calculated to assess agreement between Xpert and smear to culture. RESULTS Among children (N = 455) evaluated for presumptive TB, 70.3% (320/455) had Xpert and 62.8% (286/455) had culture performed on sputa. 34.5% (157/455) were diagnosed with TB: 80.3% (126/157) pulmonary TB, 13.4% (21/157) bacteriologically confirmed, 53.5% (84/157) HIV positive, and 48.4% (76/157) inpatients. Compared to the reference standard of clinical diagnosis, sensitivity of Xpert was 8% (95% CI 4-15), smear 6% (95% CI 3-12) and culture 16% (95% CI 9-24), and did not differ based on patient disposition, nutrition or HIV status. CONCLUSION Despite access to Xpert, the majority of children with presumptive TB were treated based on clinical diagnosis. Reflecting the reality of clinical practice in resource limited settings, new diagnostics such as Xpert serve as important adjunctive tests but will not obviate the need for astute clinicians and comprehensive diagnostic algorithms.
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Affiliation(s)
- Jason M Bacha
- Baylor College of Medicine Children's Foundation - Tanzania, Centre of Excellence at Mbeya Zonal Referral Hospital, Mbeya, Tanzania. .,Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Katherine Ngo
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics Baylor College of Medicine, Houston, TX, 77030, USA
| | - Petra Clowes
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Heather R Draper
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics Baylor College of Medicine, Houston, TX, 77030, USA
| | - Elias N Ntinginya
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Andrew DiNardo
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics Baylor College of Medicine, Houston, TX, 77030, USA
| | - Chacha Mangu
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Issa Sabi
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Bariki Mtafya
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Global and Immigrant Health, Department of Pediatrics Baylor College of Medicine, Houston, TX, 77030, USA
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32
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Islam Z, Sanin KI, Ahmed T. Improving case detection of tuberculosis among children in Bangladesh: lessons learned through an implementation research. BMC Public Health 2017; 17:131. [PMID: 28129755 PMCID: PMC5273826 DOI: 10.1186/s12889-017-4062-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/24/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND According to the Bangladesh National Tuberculosis Control Program (NTP), the proportion of childhood tuberculosis (TB) among all reported cases is only 3%. This is considerably lower compared to other high-burden countries. One of our previous studies identified substantial gaps at the primary care level related to capacity of service providers, supply of required logistics and community awareness about childhood TB. Therefore, we conducted an implementation study with the objectives to address those gaps. METHODS This implementation research was designed with pre and post-test evaluation at selected primary care facilities in urban and rural areas. Three interventions were implemented: (1) Training on childhood TB management for all categories of service providers (2) mass awareness campaign among primary and secondary school students and their teachers, mothers of <5y children, religious and community leaders and (3) facilitation of logistics supply at the study facilities. Training was conducted following the national guideline. We developed posters, leaflets, flipcharts and organized folksongs and street dramas as awareness campaign strategy. Quarterly follow up meetings were held with the facility managers of the study clinics. Cross-sectional surveys were conducted at the baseline and end line alongside review of service statistics to compare the change in community awareness and case detection of childhood TB. RESULTS Awareness regarding childhood TB among all target audience increased significantly showing better understanding of child TB symptoms, transmission, duration and treatment option. Overall proportion of TB case detection among children increased in all three sites compared to baseline as well as NTP estimate with relatively higher proportion in urban site. Majority of the children were suffering from extra-pulmonary TB and there were more female TB cases than male. However, supply and maintenance of necessary diagnostics and child friendly TB drugs remained suboptimal. CONCLUSION Through implementation research, detection of childhood TB cases increased in all study facilities exceeding the NTP's estimate. Community awareness on childhood TB improved significantly across all study sites as well. The NTP should implement strategies to raise community awareness alongside increasing the capacity of service providers and ensuring availability of diagnostics and pediatric TB drugs at the primary care level.
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Affiliation(s)
- Ziaul Islam
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
| | - Kazi Istiaque Sanin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
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Chisti MJ, Salam MA, Shahid ASMSB, Shahunja KM, Das SK, Faruque ASG, Bardhan PK, Ahmed T. Diagnosis of Tuberculosis Following World Health Organization-Recommended Criteria in Severely Malnourished Children Presenting With Pneumonia. Glob Pediatr Health 2017; 4:2333794X16686871. [PMID: 28229100 PMCID: PMC5308428 DOI: 10.1177/2333794x16686871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 12/04/2016] [Indexed: 01/29/2023] Open
Abstract
Evidences on diagnosis of tuberculosis (TB) following the World Health Organization (WHO) criteria in children with severe acute malnutrition (SAM) are lacking. We sought to evaluate the WHO criteria for the diagnosis of TB in such children. In this prospective study, we enrolled SAM children aged <5 with radiological pneumonia. We collected induced sputum and gastric lavage for smear microscopy, mycobacterial culture, and Xpert MTB/RIF. Using the last 2 methods as the gold standard, we determined sensitivity, specificity, and positive and negative predictive values of WHO criteria (n = 388). However, Xpert MTB/RIF was performed on the last 214 children. Compared to mycobacterial culture-confirmed TB, sensitivity and specificity (95% confidence interval) of WHO criteria were 40 (14% to 73%) and 84 (80% to 87%), respectively. Compared to culture- and/or Xpert MTB/RIF-confirmed TB, the values were 22% (9% to 43%) and 83 (79% to 87%), respectively. Thus, the good specificity of the WHO criteria may help minimize overtreatment with anti-TB therapy in SAM children, especially in resource-limited settings.
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Affiliation(s)
- Mohammod Jobayer Chisti
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammed Abdus Salam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu S M S B Shahid
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - K M Shahunja
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sumon Kumar Das
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu Syed Golam Faruque
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Pradip Kumar Bardhan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Nguyen TKP, Tran TH, Roberts CL, Graham SM, Marais BJ. Child pneumonia - focus on the Western Pacific Region. Paediatr Respir Rev 2017; 21:102-110. [PMID: 27569107 PMCID: PMC7106312 DOI: 10.1016/j.prrv.2016.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/12/2016] [Indexed: 01/09/2023]
Abstract
Worldwide, pneumonia is the leading cause of death in infants and young children (aged <5 years). We provide an overview of the global pneumonia disease burden, as well as the aetiology and management practices in different parts of the world, with a specific focus on the WHO Western Pacific Region. In 2011, the Western Pacific region had an estimated 0.11 pneumonia episodes per child-year with 61,900 pneumonia-related deaths in children less than 5 years of age. The majority (>75%) of pneumonia deaths occurred in six countries; Cambodia, China, Laos, Papua New Guinea, the Philippines and Viet Nam. Historically Streptococcus pneumoniae and Haemophilus influenzae were the commonest causes of severe pneumonia and pneumonia-related deaths in young children, but this is changing with the introduction of highly effective conjugate vaccines and socio-economic development. The relative contribution of viruses and atypical bacteria appear to be increasing and traditional case management approaches may require revision to accommodate increased uptake of conjugated vaccines in the Western Pacific region. Careful consideration should be given to risk reduction strategies, enhanced vaccination coverage, improved management of hypoxaemia and antibiotic stewardship.
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MESH Headings
- Anti-Bacterial Agents/therapeutic use
- Asia, Southeastern/epidemiology
- Child
- Child, Preschool
- Asia, Eastern/epidemiology
- Global Health
- Haemophilus Infections/drug therapy
- Haemophilus Infections/epidemiology
- Haemophilus Infections/mortality
- Haemophilus Infections/prevention & control
- Haemophilus Vaccines/therapeutic use
- Haemophilus influenzae
- Humans
- Hypoxia/therapy
- Infant
- Influenza Vaccines/therapeutic use
- Influenza, Human/epidemiology
- Influenza, Human/mortality
- Influenza, Human/prevention & control
- Influenza, Human/therapy
- Pneumococcal Vaccines/therapeutic use
- Pneumonia/drug therapy
- Pneumonia/epidemiology
- Pneumonia/mortality
- Pneumonia/prevention & control
- Pneumonia, Mycoplasma/drug therapy
- Pneumonia, Mycoplasma/epidemiology
- Pneumonia, Mycoplasma/mortality
- Pneumonia, Pneumococcal/drug therapy
- Pneumonia, Pneumococcal/epidemiology
- Pneumonia, Pneumococcal/mortality
- Pneumonia, Pneumococcal/prevention & control
- Respiratory Syncytial Virus Infections/epidemiology
- Respiratory Syncytial Virus Infections/mortality
- Respiratory Syncytial Virus Infections/therapy
- Streptococcus pneumoniae
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/epidemiology
- Tuberculosis, Pulmonary/mortality
- World Health Organization
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Affiliation(s)
- T K P Nguyen
- Discipline of Paediatrics and Adolescent Medicine, The Children's Hospital at Westmead, The University of Sydney, Australia; Da Nang Hospital for Women and Children, Da Nang, Viet Nam.
| | - T H Tran
- Da Nang Hospital for Women and Children, Da Nang, Viet Nam
| | - C L Roberts
- Clinical and Population Perinatal Health Research, Kolling Institute, Northern Sydney Local Health District, Sydney, Australia; Sydney Medical School Northern, The University of Sydney, Australia
| | - S M Graham
- Centre for International Child Health, University of Melbourne and Murdoch Children's Research Institute, Australia
| | - B J Marais
- Discipline of Paediatrics and Adolescent Medicine, The Children's Hospital at Westmead, The University of Sydney, Australia
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35
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Risk factors for child pneumonia - focus on the Western Pacific Region. Paediatr Respir Rev 2017; 21:95-101. [PMID: 27515732 DOI: 10.1016/j.prrv.2016.07.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 07/07/2016] [Indexed: 02/03/2023]
Abstract
Pneumonia is a major cause of disease and death in infants and young children (aged <5 years) globally, as it is in the World Health Organization Western Pacific region. A better understanding of the underlying risk factors associated with child pneumonia is important, since pragmatic primary prevention strategies are likely to achieve major reductions in pneumonia-associated morbidity and mortality in children. This review focuses on risk factors with high relevance to the Western Pacific region, including a lack of exclusive breastfeeding, cigarette smoke and air pollution exposure, malnutrition and conditions of poverty, as well as common co-morbidities. Case management and vaccination coverage have been considered elsewhere.
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36
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Clinical risk factors, bacterial aetiology, and outcome of urinary tract infection in children hospitalized with diarrhoea in Bangladesh. Epidemiol Infect 2016; 145:1018-1024. [PMID: 28029092 DOI: 10.1017/s0950268816002971] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Urinary tract infection (UTI) is common in children aged <5 years with diarrhoea, but little is known about risk factors, aetiology and outcome of such children. We aimed to evaluate these knowledge gaps of UTI in children aged <5 years with diarrhoea. We enrolled all children aged <5 years with diarrhoea admitted to Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh, between May 2011 and April 2013, who had history of fever (⩾38 °C) and obtained a urine sample for culture. Diarrhoea with UTI (confirmed by culture) constituted cases (n = 26) and those without UTI constituted controls (n = 78). Threefold controls were randomly selected. The case-fatality rate was comparable in cases and controls (4% vs. 1%, P = 0·439). Escherichia coli (69%) and Klebsiella (15%) were the most commonly isolated pathogens. Persistent diarrhoea, pneumonia and prior antibiotics use were identified as risk factors for UTI in logistic regression analysis (P < 0·05 for all). Thus, children with diarrhoea presenting with persistent diarrhoea, pneumonia, and prior antibiotic use should be investigated for UTI for their prompt management that may reduce morbidity.
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Khattab M, Sakr MA, Fattah MA, Mousa Y, Soliman E, Breedy A, Fathi M, Gaber S, Altaweil A, Osman A, Hassouna A, Motawea I. Novel non-invasive biological predictive index for liver fibrosis in hepatitis C virus genotype 4 patients. World J Hepatol 2016; 8:1392-1401. [PMID: 27917265 PMCID: PMC5114475 DOI: 10.4254/wjh.v8.i32.1392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 09/09/2016] [Accepted: 10/09/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the diagnostic ability of a non-invasive biological marker to predict liver fibrosis in hepatitis C genotype 4 patients with high accuracy.
METHODS A cohort of 332 patients infected with hepatitis C genotype 4 was included in this cross-sectional study. Fasting plasma glucose, insulin, C-peptide, and angiotensin-converting enzyme serum levels were measured. Insulin resistance was mathematically calculated using the homeostasis model of insulin resistance (HOMA-IR).
RESULTS Fibrosis stages were distributed based on Metavir score as follows: F0 = 43, F1 = 136, F2 = 64, F3 = 45 and F4 = 44. Statistical analysis relied upon reclassification of fibrosis stages into mild fibrosis (F0-F) = 179, moderate fibrosis (F2) = 64, and advanced fibrosis (F3-F4) = 89. Univariate analysis indicated that age, log aspartate amino transaminase, log HOMA-IR and log platelet count were independent predictors of liver fibrosis stage (P < 0.0001). A stepwise multivariate discriminant functional analysis was used to drive a discriminative model for liver fibrosis. Our index used cut-off values of ≥ 0.86 and ≤ -0.31 to diagnose advanced and mild fibrosis, respectively, with receiving operating characteristics of 0.91 and 0.88, respectively. The sensitivity, specificity, positive predictive value, negative predictive value and positive likelihood ratio were: 73%, 91%, 75%, 90% and 8.0 respectively for advanced fibrosis, and 67%, 88%, 84%, 70% and 4.9, respectively, for mild fibrosis.
CONCLUSION Our predictive model is easily available and reproducible, and predicted liver fibrosis with acceptable accuracy.
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Impact of Diarrhea on the Clinical Presentation and Outcome of Severe Pneumonia in Bangladeshi Children. Pediatr Infect Dis J 2016; 35:1161-2. [PMID: 27314825 DOI: 10.1097/inf.0000000000001265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We compared clinical presentation and outcome of 225 children with severe pneumonia between those with and those without diarrhea. Having diarrhea was associated with metabolic acidosis (P < 0.001) and hypocalcemia (P = 0.002) on presentation, and with a fatal outcome: 20/113 (20%) died with diarrhea versus 3/112 (3%) without diarrhea. Diarrhea is an important comorbidity in Bangladeshi children with severe pneumonia requiring attention for improved case management.
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Factors Associated with Klebsiella Bacteremia and Its Outcome in Under-Five Children Admitted with Diarrhea. Int J Pediatr 2016; 2016:4760610. [PMID: 27651802 PMCID: PMC5019881 DOI: 10.1155/2016/4760610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 08/01/2016] [Indexed: 12/29/2022] Open
Abstract
Although Klebsiella bacteremia in children is perceived to be associated with fatal consequences, data are scarce on those children presenting with diarrhea. We evaluated the factors associated with Klebsiella bacteremia in such children. In this retrospective chart analysis, data of all diarrheal children was retrieved from electronic medical record system (named as SHEBA) of Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), from January 1, 2010, to December 31, 2012, who had their blood culture done. This was a study having a case-control design where comparison of clinical and laboratory characteristics was done among children with Klebsiella bacteremia (cases = 30) and those without any bacteraemia (controls = 90). Controls were selected randomly. The cases more often had fatal outcome (p < 0.001). In logistic regression analysis, after adjusting for potential confounders such as young age, severe dehydration, severe wasting, abnormal mentation, hypotension, and fast breathing, the cases were independently associated with hospital-acquired infection and positive stool growth (for all, p < 0.05). The study highlights the importance of obtaining blood cultures in hospitalized children under five years old with diarrheal illness in the presence of either hospital-acquired infection or positive stool culture to have better outcome.
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Brennhofer S, Reifsnider E, Bruening M. Malnutrition coupled with diarrheal and respiratory infections among children in Asia: A systematic review. Public Health Nurs 2016; 34:401-409. [PMID: 27354205 DOI: 10.1111/phn.12273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this systematic literature review was to assess the relationship between malnutrition and respiratory and diarrheal infections among children aged five and under living in Asian countries. DESIGN AND SAMPLE The design was adapted from the PRISMA method to include case-control, cross-sectional, ecological, and experimental studies. A review of electronic databases identified 144 articles of which 20 met the inclusion criteria. The inclusion criteria were studies of malnourished children under the age of five with respiratory and/or diarrheal infections, admitted to hospitals or residing in villages throughout countries in Asia, and published between 2005 and 2015. MEASURES Infection was defined as the presence of a respiratory or diarrheal illness. Malnutrition was predominantly measured by WHO standards. RESULTS Malnutrition is associated with respiratory and diarrheal infections. Children have higher rates of mortality when both malnourished and experiencing a respiratory infection. CONCLUSION Further research needs to examine the synergetic effect of diarrheal and respiratory infections in malnourished children and rates of mortality. Public health nurses (PHNs) play a critical role in the prevention and treatment of malnutrition and infections in community and national systems. Obtaining better data will allow PHNs to provide critical care in the most underserved areas throughout Asia.
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Affiliation(s)
- Stephanie Brennhofer
- School of Nutrition and Health Promotion, Arizona State University, Phoenix, Arizona
| | - Elizabeth Reifsnider
- College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona
| | - Meg Bruening
- School of Nutrition and Health Promotion, Arizona State University, Phoenix, Arizona
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Shahid ASMSB, Ahmed T, Shahunja KM, Kabir S, Chowdhury F, Faruque ASG, Das SK, Sarker MHR, Bardhan PK, Chisti MJ. Factors Associated with Streptococcal Bacteremia in Diarrheal Children under Five Years of Age and Their Outcome in an Urban Hospital in Bangladesh. PLoS One 2016; 11:e0154777. [PMID: 27135829 PMCID: PMC4852900 DOI: 10.1371/journal.pone.0154777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 04/19/2016] [Indexed: 11/25/2022] Open
Abstract
Background Although Streptococcal bacteremia is common in diarrheal children with high morbidity and mortality, no systematic data are available on Streptococcal bacteremia in diarrheal children. We sought to evaluate the factors associated with Streptococcal bacteremia in diarrheal children under five years of age and their outcome. Methods We used an unmatched case-control design to investigate the associated factors with Streptococcal bacteremia in all the diarrheal children under five years of age through electronic medical record system of Dhaka hospital of International Centre for Diarrhoeal Disease Research, Bangladesh. We had simultaneously used a retrospective cohort design to further evaluate the outcome of our study children. All the enrolled children had their blood culture done between January 2010 and December 2012. Comparison was made among the children with (cases = 26) and without Streptococcal bacteremia (controls = 78). Controls were selected randomly from hospitalized diarrheal children under five years of age. Results Cases had proportionately higher deaths compared to controls, but it was statistically insignificant (15% vs. 10%, p = 0.49). The cases more often presented with severe dehydration, fever, respiratory distress, severe sepsis, and abnormal mental status compared to the controls (for all p<0.05). In the logistic regression analysis, after adjusting for potential confounders, it has been found that Streptococcal bacteremia in diarrheal children under five years of age was independently associated with nutritional edema (OR: 5.86, 95% CI = 1.28–26.80), hypoxemia (OR: 19.39, 95% CI = 2.14–175.91), fever (OR: 4.44, 95% CI = 1.13–17.42), delayed capillary refill time (OR: 7.00, 95% CI = 1.36–35.93), and respiratory distress (OR: 2.69, 95% CI = 1.02–7.12). Conclusions and Significance The results of our analyses suggest that diarrheal children under five years of age presenting with nutritional edema, hypoxemia, fever, delayed capillary refill time, and respiratory distress may be at risk of Streptococcal bacteremia. It underscores the importance of identification of these simple clinical parameters for the prompt recognition and management in order to reduce the morbidity and death of such children especially in resource limited settings.
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Affiliation(s)
| | - Tahmeed Ahmed
- Nutrition & Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - K M Shahunja
- Nutrition & Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Senjuti Kabir
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Fahmida Chowdhury
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu Syeed Golam Faruque
- Nutrition & Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sumon Kumar Das
- Nutrition & Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Habibur Rahman Sarker
- Nutrition & Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Pradip Kumar Bardhan
- Nutrition & Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition & Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Abstract
BACKGROUND Chest radiography is increasingly used to diagnose pneumonia in low-income and middle-income countries. Few studies examined whether chest radiographic findings predict outcomes of children with clinically suspected pneumonia in these settings. METHODS This is a hospital-based, prospective cohort study of children 1-23 months of age meeting clinical criteria for pneumonia in Botswana. Chest radiographs were reviewed by 2 pediatric radiologists to generate a consensus interpretation using standardized World Health Organization criteria. We assessed whether final chest radiograph classification was associated with our primary outcome, treatment failure at 48 hours, and secondary outcomes. RESULTS From April 2012 to November 2014, we enrolled 249 children with evaluable chest radiographs. Median age was 6.1 months, and 58% were male. Chest radiograph classifications were primary endpoint pneumonia (35%), other infiltrate/abnormality (42%) or no significant pathology (22%). The prevalence of endpoint consolidation was higher in children with HIV infection (P = 0.0005), whereas endpoint pleural effusions were more frequent among children with moderate or severe malnutrition (P = 0.0003). Ninety-one (37%) children failed treatment, and 12 (4.8%) children died. Primary endpoint pneumonia was associated with an increased risk of treatment failure at 48 hours (P = 0.002), a requirement for more days of respiratory support (P = 0.002) and a longer length of stay (P = 0.0003) compared with no significant pathology. Primary endpoint pneumonia also predicted a higher risk of treatment failure than other infiltrate/abnormality (P = 0.004). CONCLUSIONS Chest radiograph provides useful prognostic information for children meeting clinical criteria for pneumonia in Botswana. These findings highlight the potential benefit of expanded global access to diagnostic radiology services.
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Detection Yield and Tolerability of String Test for Diagnosis of Childhood Intrathoracic Tuberculosis. Pediatr Infect Dis J 2016; 35:146-51. [PMID: 26517328 DOI: 10.1097/inf.0000000000000956] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Difficulty to obtain sputum in children complicates diagnosis of intrathoracic tuberculosis (TB). The intragastric string test (ST) used for retrieval of enteric pathogens might be an alternative specimen collection method but requires further evaluation of its utility in TB diagnosis. We conducted a cross-sectional study comparing the TB detection yield and the tolerability of ST and sputum induction (SI) in children. METHODS Two ST and SI procedures were performed in children (3-14 years of age) who were clinically suspected of having TB. The string was removed after a 2-hour gastric downtime, and SI was done after a maximum of 20 minutes nebulization with 5% saline solution. LED-fluorescence microscopy and mycobacterial cultures were performed on all specimens, and XpertMTB/RIF assay was performed on stored specimen sediments. Tolerability questionnaires were administered to parents of children. RESULTS Of 137 included children (median age: 8.1 years; 33.3% with HIV infection), 14 (10.2%) were diagnosed with TB, 10 (71.4%) by ST and 12 (85.7%) by SI. Among 105 children with both ST and SI performed, 5 (4.8%) versus 4 (3.8%) were smear positive using ST and SI, respectively (McNemar P = 1.00). Nine (8.6%) in each group had positive cultures (P = 1.00). Of 64 children tested with XpertMTB/RIF, 3 (4.7%) of the ST group versus 4 (6.3%) of the SI group were TB positive (P = 1.00). No adverse serious events were reported. ST could not be performed in 22 of 137 (16.1%) children because they were unable to swallow the capsule. CONCLUSIONS TB detection yield was comparable between ST and SI. The tolerability of ST in young children might be improved by the reduction of the size of the capsule.
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Chisti MJ, Ahmed T, Shahid ASMSB, Shahunja KM, Bardhan PK, Faruque ASG, Das SK, Salam MA. Sociodemographic, Epidemiological, and Clinical Risk Factors for Childhood Pulmonary Tuberculosis in Severely Malnourished Children Presenting With Pneumonia: Observation in an Urban Hospital in Bangladesh. Glob Pediatr Health 2015; 2:2333794X15594183. [PMID: 27335971 PMCID: PMC4784598 DOI: 10.1177/2333794x15594183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We aimed to evaluate sociodemographic, epidemiological, and clinical risk factors for pulmonary tuberculosis (PTB) in children presenting with severe acute malnutrition (SAM) and pneumonia. Children aged 0 to 59 months with SAM and radiologic pneumonia from April 2011 to July 2012 were studied in Bangladesh. Children with confirmed PTB (by culture and/or X-pert MTB/RIF) (cases = 27) and without PTB (controls = 81; randomly selected from 378 children) were compared. The cases more often had the history of contact with active PTB patient (P < .01) and exposure to cigarette smoke (P = .04) compared with the controls. In logistic regression analysis, after adjusting for potential confounders, the cases were independently associated with working mother (P = .05) and positive tuberculin skin test (TST; P = .02). Thus, pneumonia in SAM children is a common presentation of PTB and further highlights the importance of the use of simple TST and/or history of contact with active TB patients in diagnosing PTB in such children, especially in resource-limited settings.
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Affiliation(s)
| | - Tahmeed Ahmed
- International Centre for Diarhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abu S M S B Shahid
- International Centre for Diarhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - K M Shahunja
- International Centre for Diarhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Pradip Kumar Bardhan
- International Centre for Diarhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Sumon Kumar Das
- International Centre for Diarhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mohammed Abdus Salam
- International Centre for Diarhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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Validity of antibodies in lymphocyte supernatant in diagnosing tuberculosis in severely malnourished children presenting with pneumonia. PLoS One 2015; 10:e0126863. [PMID: 26020966 PMCID: PMC4447255 DOI: 10.1371/journal.pone.0126863] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 04/08/2015] [Indexed: 11/25/2022] Open
Abstract
Background The diagnosis of tuberculosis (TB) in young children can be challenging, especially in severely malnourished children. There is a critical need for improved diagnostics for children. Thus, we sought to evaluate the performance of a technique that measures antibodies in lymphocyte supernatant (ALS) for the diagnosis of TB in severely malnourished children presenting with suspected pneumonia. Methods Children less than 5 years with severe acute malnutrition and radiological features of pneumonia admitted to the Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh, were enrolled consecutively following informed written consent. In addition to clinical and radiological assessment, samples taken for TB diagnosis included gastric lavage fluid and induced sputum for microbiological confirmation. ALS was measured from venous blood, and results were evaluated in children classified as “confirmed”, “non-confirmed TB” or “not TB”. Results Among 224 children who had ALS analysis, 12 (5.4%) children had microbiologically “confirmed TB”, a further 41 (18%) had clinically diagnosed “non-confirmed TB” and the remaining 168 (75%) were considered not to have TB. ALS was positive in 89 (40%) and negative in 85 (39%) of children, with a large number (47 or 21%) reported as “borderline”. These proportions were similar between the three diagnostic groups. The sensitivity and specificity of ALS when comparing “Confirmed TB” to “Not TB” was only 67% (95% CI: 31–91%) and 51% (95% CI: 42–60%), respectively. Conclusions and Significance Our data suggest that ALS is not sufficiently accurate to improve the diagnosis of TB in children with severe malnutrition.
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Experience with Clinically Diagnosed Down Syndrome Children Admitted with Diarrhea in an Urban Hospital in Bangladesh. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2015; 2015:979404. [PMID: 27351021 PMCID: PMC4897277 DOI: 10.1155/2015/979404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 04/08/2015] [Accepted: 04/21/2015] [Indexed: 12/29/2022]
Abstract
There is lack of information in the medical literature on clinically diagnosed Down syndrome children presenting with diarrhea. Our aim was to describe our experience with Down syndrome patients admitted with diarrhea by evaluating the factors associated with Down syndrome presenting with diarrheal illness. In this retrospective chart analysis, we enrolled all the diarrheal children aged 0-59 months admitted to the Dhaka Hospital of the International Centre for Diarrheal Disease Research, Bangladesh (icddr, b), from March 2011 to February 2013. Down syndrome children with diarrhea constituted cases and randomly selected threefold diarrheal children without Down syndrome constituted controls. Among 8422 enrolled children 32 and 96 were the cases and the controls, respectively. Median age (months) of the cases and the controls was comparable (7.6 (4.0, 15.0) versus 9.0 (5.0, 16.8); p = 0.496). The cases more often presented with severe acute malnutrition, developmental delay, congenital heart disease, hypothyroidism, sepsis, hypocalcemia, developed hospital acquired infection (HAI) during hospitalization, and required prolonged stay at hospital compared to the controls (for all p < 0.05). Thus, diarrheal children with clinically diagnosed Down syndrome should be investigated for these simple clinical parameters for their prompt management that may prevent HAI and prolonged hospital stay.
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Venturini E, Remaschi G, Berti E, Montagnani C, Galli L, de Martino M, Chiappini E. What steps do we need to take to improve diagnosis of tuberculosis in children? Expert Rev Anti Infect Ther 2015; 13:907-22. [PMID: 25938981 DOI: 10.1586/14787210.2015.1040764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Tuberculosis still represents a big global public health challenge. The diagnosis of tuberculosis and the differentiation between active and latent tuberculosis remain difficult, particularly in childhood, because of the lack of a gold standard test for diagnosis. In the last decade, novel diagnostic assays have been developed. Among immunologic tests, new assays based on the measurement of different cytokines released by specific T cells in response to Mycobacterium tuberculosis antigens, other than INF-γ, have been investigated. Promising results rely on nucleic acid amplification techniques, also able to detect drugs resistance. Innovative research fields studied the modifications of CD27 expression in T cells as well as different host gene expression in response to M. tuberculosis. Further studies are needed to assess the diagnostic value and the accuracy of these new assays.
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Affiliation(s)
- Elisabetta Venturini
- Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
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Detjen AK, DiNardo AR, Leyden J, Steingart KR, Menzies D, Schiller I, Dendukuri N, Mandalakas AM. Xpert MTB/RIF assay for the diagnosis of pulmonary tuberculosis in children: a systematic review and meta-analysis. THE LANCET RESPIRATORY MEDICINE 2015; 3:451-61. [PMID: 25812968 DOI: 10.1016/s2213-2600(15)00095-8] [Citation(s) in RCA: 201] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 02/26/2015] [Accepted: 02/26/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND Microbiological confirmation of childhood tuberculosis is rare because of the difficulty of collection of specimens, low sensitivity of smear microscopy, and poor access to culture. We aimed to establish summary estimates for sensitivity and specificity of of the Xpert MTB/RIF assay compared with microscopy in the diagnosis of pulmonary tuberculosis in children. METHODS We searched for studies published up to Jan 6, 2015, that used Xpert in any setting in children with and without HIV infection. We systematically reviewed studies that compared the diagnostic accuracy of Xpert MTB/RIF (Xpert) with microscopy for detection of pulmonary tuberculosis and rifampicin resistance in children younger than 16 years against two reference standards-culture results and culture-negative children who were started on anti-tuberculosis therapy. We did meta-analyses using a bivariate random-effects model. FINDINGS We identified 15 studies including 4768 respiratory specimens in 3640 children investigated for pulmonary tuberculosis. Culture tests were positive for tuberculosis in 12% (420 of 3640) of all children assessed and Xpert was positive in 11% (406 of 3640). Compared with culture, the pooled sensitivities and specificities of Xpert for tuberculosis detection were 62% (95% credible interval 51-73) and 98% (97-99), respectively, with use of expectorated or induced sputum samples and 66% (51-81) and 98% (96-99), respectively, with use of samples from gastric lavage. Xpert sensitivity was 36-44% higher than was sensitivity for microscopy. Xpert sensitivity in culture-negative children started on antituberculosis therapy was 2% (1-3) for expectorated or induced sputum. Xpert's pooled sensitivity and specificity to detect rifampicin resistance was 86% (95% credible interval 53-98) and 98% (94-100), respectively. INTERPRETATION Compared with microscopy, Xpert offers better sensitivity for the diagnosis of pulmonary tuberculosis in children and its scale-up will improve access to tuberculosis diagnostics for children. Although Xpert helps to provide rapid confirmation of disease, its sensitivity remains suboptimum compared with culture tests. A negative Xpert result does not rule out tuberculosis. Good clinical acumen is still needed to decide when to start antituberculosis therapy and continued research for better diagnostics is crucial. FUNDING WHO, Global TB Program of Texas Children's Hospital.
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Affiliation(s)
- Anne K Detjen
- The International Union Against Tuberculosis And Lung Disease (The Union), New York, NY, USA.
| | - Andrew R DiNardo
- Infectious Diseases, Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA; The Global Tuberculosis Program, Texas Children's Hospital, Houston, TX, USA
| | - Jacinta Leyden
- Department of Bioengineering, Rice University, Houston, TX, USA; The Global Tuberculosis Program, Texas Children's Hospital, Houston, TX, USA
| | - Karen R Steingart
- Cochrane Infectious Diseases Group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Dick Menzies
- Respiratory and Epidemiology Clinical Research Unit, Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | - Ian Schiller
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada
| | - Nandini Dendukuri
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Houston, TX, USA; Retrovirology and Global Health, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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Oliwa JN, Karumbi JM, Marais BJ, Madhi SA, Graham SM. Tuberculosis as a cause or comorbidity of childhood pneumonia in tuberculosis-endemic areas: a systematic review. THE LANCET RESPIRATORY MEDICINE 2015; 3:235-43. [PMID: 25648115 DOI: 10.1016/s2213-2600(15)00028-4] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 11/19/2014] [Indexed: 11/30/2022]
Abstract
Pneumonia is a major cause of morbidity and mortality in infants and children worldwide, with most cases occurring in tuberculosis-endemic settings. Studies have emphasised the potential importance of Mycobacterium tuberculosis in acute severe pneumonia in children as a primary cause or underlying comorbidity, further emphasised by the changing aetiological range with rollout of bacterial conjugate vaccines in high mortality settings. We systematically reviewed clinical and autopsy studies done in tuberculosis-endemic settings that enrolled at least 100 children aged younger than 5 years with severe pneumonia, and that prospectively included a diagnostic approach to tuberculosis in all study participants. We noted substantial heterogeneity between studies in terms of study population and diagnostic methods. Of the 3644 patients who had culture of respiratory specimens for M tuberculosis undertaken, 275 (7·5%) were culture positive, and an acute presentation was common. Inpatient case-fatality rate for pneumonia associated with tuberculosis ranged from 4% to 21% in the four clinical studies that reported pathogen-related outcomes. Prospective studies are needed in high tuberculosis-burden settings to address whether tuberculosis is a cause or comorbidity of childhood acute severe pneumonia.
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Affiliation(s)
- Jacquie N Oliwa
- KEMRI Wellcome Trust Research Programme, Department of Public Health Research, Nairobi, Kenya.
| | - Jamlick M Karumbi
- KEMRI Wellcome Trust Research Programme, Department of Public Health Research, Nairobi, Kenya
| | - Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity and The Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology and National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen M Graham
- Centre for International Child Health, University of Melbourne Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC, Australia; International Union Against Tuberculosis and Lung Disease, Paris, France
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Post-discharge mortality in children with severe malnutrition and pneumonia in Bangladesh. PLoS One 2014; 9:e107663. [PMID: 25225798 PMCID: PMC4167196 DOI: 10.1371/journal.pone.0107663] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 08/12/2014] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND Post-discharge mortality among children with severe illness in resource-limited settings is under-recognized and there are limited data. We evaluated post-discharge mortality in a recently reported cohort of children with severe malnutrition and pneumonia, and identified characteristics associated with an increased risk of death. METHODS Young children (<5 years of age) with severe malnutrition (WHO criteria) and radiographic pneumonia on admission to Dhaka Hospital of icddr,b over a 15-month period were managed according to standard protocols. Those discharged were followed-up and survival status at 12 weeks post-discharge was determined. Verbal autopsy was requested from families of those that died. RESULTS Of 405 children hospitalized with severe malnutrition and pneumonia, 369 (median age, 10 months) were discharged alive with a follow-up plan. Of these, 32 (8.7%) died in the community within 3 months of discharge: median 22 (IQR 9-35) days from discharge to death. Most deaths were reportedly associated with acute onset of new respiratory or gastrointestinal symptoms. Those that died following discharge were significantly younger (median 6 [IQR 3,12] months) and more severely malnourished, on admission and on discharge, than those that survived. Bivariate analysis found that severe wasting on admission (OR 3.64, 95% CI 1.66-7.97) and age <12 months (OR 2.54, 95% CI 1.1-8.8) were significantly associated with post-discharge death. Of those that died in the community, none had attended a scheduled follow-up and care-seeking from a traditional healer was more common (p<0.001) compared to those who survived. CONCLUSION AND SIGNIFICANCE Post-discharge mortality was common in Bangladeshi children following inpatient care for severe malnutrition and pneumonia. The underlying contributing factors require a better understanding to inform the potential of interventions that could improve survival.
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