Epidemiology of tuberculosis in young children in the United States

Clinical characteristic, common sites, and geographical distribution of pediatric tuberculosis patients in Southwest China

Background

The data report of a large sample, dynamic epidemiology, and characteristic analysis of pediatric tuberculosis (TB) in Southwest China is not clear. Herein, we conducted descriptive dynamic epidemiology, characteristic analysis and geographical distribution study of pediatric TB inpatients in Southwest China for more than 20 years.

Methods

Patients with pediatric TB were recruited from October 2002 to September 2022 in Southwest of China based on etiology or clinical confirmation. Extract hospitalization medical record information for each patient. The geographical distribution chart of cases is used to display the trend of case flow segmented every 5 years.

Results

Among 3,024 pediatric TB patients with an average age of 9.11 ± 4.39, 17.49% (529) had pulmonary tuberculosis (PTB), 9.06% (274) had extrapulmonary tuberculosis (EPTB), and 73.45% (2,221) had combined TB. The most common form of EPTB is disseminated TB (28.98%), followed by TB lymphadenitis (20.56%), pleural TB (19.72%), and TB meningitis (19.68%). Children aged 0-4 years had a high risk of TB meningitis and a severe symptoms, while children in the elderly age group had a high risk of pleural TB. In the past 20 years, hospitalized TB pediatric cases mainly came from Sichuan, Tibet, Qinghai, Yunnan and other places. The number of patients from ethnic minorities, especially Tibetans, showed an upward trend on a yearly basis (χ2 = 401.43, P < 0.001).

Conclusions

Public health investment and effective management in pediatric TB should be further strengthened.

Spatial Distribution and Temporal Trend of Childhood Tuberculosis in Brazil

Tuberculosis (TB) in children presents specificities in its diagnosis, which makes it prone to underreporting: therefore, the disease in this group is still a serious public health problem in several countries. We aimed to analyze the spatial distribution and temporal trend of childhood TB in Brazil. An ecological study with time series, spatial analysis, and description of cases in Brazil between 2010-2021 was conducted. A total of 1,054,263 TB cases were reported in the period, with 30,001 (2.8%) in children. The yearly average was 2,500 cases, with a trend toward an increase in the incidence rate in 2018 and 2019 and a decline in 2020. Children under 5 years old represented 38.2% of cases, 5.2% were indigenous, and 424 children (1.4%) died. Sputum culture was performed for 18.4% of pulmonary TB. The incidence rates were higher in municipalities in the north and midwest regions, with high occurrence locations (hot spots), especially on borders with other countries. There was a reduction in childhood TB in 2020, possibly related to the COVID-19 pandemic. Strategies are needed for the identification and monitoring of childhood TB, with reinforcement of professional training for assistance and control, especially in the most vulnerable locations and groups.

Treatment Outcomes of Childhood TB Patients in Four TB High Burden States of Malaysia: Results from a Multicenter Retrospective Cohort Study

Data regarding treatment outcomes among childhood TB patients are lacking in Malaysia. The present study aimed to evaluate the treatment outcomes and predictors of unsuccessful treatment outcomes among childhood TB patients in four TB high-burden states of Malaysia. This was a retrospective cohort study conducted at 13 healthcare centers in four states of Malaysia, namely, Sabah, Sarawak, Selangor, and Penang. During the study period, a total of 8932 TB patients were enrolled for treatment at the study sites, of whom 206 (2.31%) were children. The majority of the childhood TB patients were female (52.9%) and belonged to the age group of 6–10 years (42.7%). Pulmonary TB accounted for 70.9% of childhood TB. Among childhood PTB patients, 50% were sputum smear negative. One hundred and seventy-eight patients (86.4%) were successfully treated (87 were cured and 91 completed treatment). Among 28 (13.6%) patients with unsuccessful treatment outcomes, 13 (6.3%) died, 3 (1.5%) failed treatment, 9 (4.4%) defaulted, and 3 (1.5%) were transferred out. Multivariate analysis revealed that patients’ age (5–14 years) (OR = 0.279, p-value = 0.006) and male gender (OR = 0.390, p-value = 0.046) had a statistically significant negative association with unsuccessful treatment outcomes. The prevalence of childhood TB in the current study was comparable to the recently published national estimates. The study sites reached the WHO target of treatment success. Special attention to patients with identified risk factors can improve treatment outcomes.

Prevalence of latent tuberculosis among refugee children in Malaysia

Introduction

Tuberculosis remains one of the top 10 major causes of global mortality, imposing social-economic and medical challenges in Malaysia. Refugees sheltered in Malaysia are a high-risk population but basic health checks upon their arrival, including tuberculosis screening, are not practised. This study aimed to identify the prevalence and risk factors of tuberculosis and latent tuberculosis infection (LTBI) among refugee children in Malaysia.

Methods

A cross-sectional study was performed in three refugee schools in the Klang Valley, Malaysia, using tuberculin skin tests or interferon-γ release assays. Participants who tested positive were sent for further examination with chest radiography to confirm the tuberculosis diagnosis.

Results

From April 2018 to April 2019, we screened 430 refugee children with a median age of 13.0 years. Most of the children were born in Myanmar (n=274, 63.7%) and Pakistan (n=60, 14.0%). No children were diagnosed with active tuberculosis but 55 of the children (12.8%) were diagnosed with LTBI. Children with LTBI were generally older (OR 3.01, 95% CI 1.71-5.29; p<0.001) than those without LTBI infection. Sex, history of bacille Calmette-Guérin vaccination and country of birth were not associated with increased risk of LTBI.

Conclusion

The relatively high LTBI burden among refugee children in this study poses an indication of possible LTBI risk among this population nationwide, and thus would be an important group to target for preventive therapy. This provides a unique opportunity for researchers to further examine and implement well-structured preventive strategies in combating the endemic infectious disease in Malaysia.

Interferon-γ Release Assays in Children <15 Years of Age

OBJECTIVES

The tuberculin skin test (TST) has been preferred for screening young children for latent tuberculosis infection (LTBI) because of concerns that interferon-γ release assays (IGRAs) may be less sensitive in this high-risk population. In this study, we compared the predictive value of IGRAs to the TST for progression to tuberculosis disease in children, including those <5 years old.

METHODS

Children <15 years old at risk for LTBI or progression to disease were tested with TST, QuantiFERON-TB Gold In-Tube test (QFT-GIT), and T-SPOT.TB test (T-SPOT) and followed actively for 2 years, then with registry matches, to identify incident disease.

RESULTS

Of 3593 children enrolled September 2012 to April 2016, 92% were born outside the United States; 25% were <5 years old. Four children developed tuberculosis over a median 4.3 years of follow-up. Sensitivities for progression to disease for TST and IGRAs were low (50%-75%), with wide confidence intervals (CIs). Specificities for TST, QFT-GIT, and T-SPOT were 73.4% (95% CI: 71.9-74.8), 90.1% (95% CI: 89.1-91.1), and 92.9% (95% CI: 92.0-93.7), respectively. Positive and negative predictive values for TST, QFT-GIT, and T-SPOT were 0.2 (95% CI: 0.1-0.8), 0.9 (95% CI: 0.3-2.5), and 0.8 (95% CI: 0.2-2.9) and 99.9 (95% CI: 99.7-100), 100 (95% CI: 99.8-100), and 99.9 (95% CI: 99.8-100), respectively. Of 533 children with TST-positive, IGRA-negative results not treated for LTBI, including 54 children <2 years old, none developed disease.

CONCLUSIONS

Although both types of tests poorly predict disease progression, IGRAs are no less predictive than the TST and offer high specificity and negative predictive values. Results from this study support the use of IGRAs for children, especially those who are not born in the United States.

The impact of migration on tuberculosis in the United States

Due to greater exposure to Mycobacterium tuberculosis infection before migration, migrants moving to low-incidence settings can experience substantially higher tuberculosis (TB) rates than the native-born population. This review describes the impact of migration on TB epidemiology in the United States, and how the TB burden differs between US-born and non-US-born populations. The United States has a long history of receiving migrants from other parts of the world, and TB among non-US-born individuals now represents the majority of new TB cases. Based on an analysis of TB cases among individuals from the top 30 countries of origin in terms of non-US-born TB burden between 2003 and 2015, we describe how TB risks vary within the non-US-born population according to age, years since entry, entry year, and country of origin. Variation along each of these dimensions is associated with more than 10-fold differences in the risk of developing active TB, and this risk is also positively associated with TB incidence estimates for the country of origin and the composition of the migrant pool in the entry year. Approximately 87 000 lifetime TB cases are predicted for the non-US-born population resident in the United States in 2015, and 5800 lifetime cases for the population entering the United States in 2015.

Epidemiology of tuberculosis among children and adolescents in the USA, 2007-17: an analysis of national surveillance data

BACKGROUND

Understanding tuberculosis epidemiology among children and adolescents informs treatment and prevention efforts, and efforts to eliminate disparities in tuberculosis incidence and mortality. We sought to describe the epidemiology of children and adolescents with tuberculosis disease in the USA, including tuberculosis incidence rates by parental country of birth and for US territories and freely associated states, which have not been previously described.

METHODS

We analysed data for children aged younger than 15 years and adolescents aged 15-17 years with tuberculosis disease reported to the National Tuberculosis Surveillance System during 2007-17, and calculated tuberculosis incidence rates using population estimates from the US Census Bureau.

FINDINGS

During 2010-17, 6072 tuberculosis cases occurred among children and adolescents; of these, 5175 (85%) of 6072 occurred in the 50 US states or the District of Columbia and 897 (15%) of 6072 in US-affiliated islands. In US states, 3520 (68%) of 5175 cases occurred among US-born people overall, including 2977 (76%) of 3896 children and 543 (42%) of 1279 adolescents. The incidence rate among children and adolescents was 1·0 per 100 000 person-years during 2007-17 and declined 47·8% (95% CI -51·4 to -44·1) during this period. We observed disproportionately high tuberculosis rates among children and adolescents of all non-white racial or ethnic groups, people living in US-affiliated islands, and children born in or with parents from tuberculosis-endemic countries.

INTERPRETATION

Overall, tuberculosis incidence among children and adolescents in the USA is low and steadily declining, but additional efforts are needed to eliminate disparities in incidence and mortality.

FUNDING

US Centers for Disease Control and Prevention.

Tuberculosis Transmission in Danish Children: A Nationwide Register-based Study

BACKGROUND

Tuberculosis (TB) remains a major public health issue among children worldwide. Data on TB transmission in children living in low-incidence countries is limited.

METHODS

We studied TB transmission in ethnic Danish children younger than 15 years of age between 2000 and 2013. Identification of children with TB disease and information on demographics and TB contacts were retrieved from the national TB surveillance register and the International Reference Laboratory of Mycobacteriology.

RESULTS

In total, 88 children with TB disease were identified in the study period, corresponding to a mean annual incidence of 6.9 per 1,000,000 children younger than 15 years of age. The male to female ratio was 1.3. Median age was 5 years (interquartile range, 3-8.5). Seventy-three (83%) children had a known TB contact of which 60% was among household contacts with recent TB, predominantly parents. Sixty-six (75%) children were classified as part of epidemiologic clusters. Thirty-five (40%) children had culture verified TB of which information on genotypes was available for 34 (97%). Of these, 35% belonged to cluster C2/1112-15, the most prevalent cluster among adult Danes.

CONCLUSIONS

We found on-going TB transmission in Danish children within the households of a low TB incidence population. These findings emphasize the need for early diagnosis of TB in children, thorough contact tracing and increased focus on risk groups.

Interferon-Gamma Release Assay-Based Screening for Pediatric Latent Tuberculosis Infection in an Urban Primary Care Network

OBJECTIVE

To assess outcomes from a QuantiFERON-tuberculosis (TB) Gold (QFT)-based screening for pediatric latent TB infection (LTBI) in the Denver Health Community Health System (CHS), an urban primary-care network in the US.

STUDY DESIGN

We retrospectively analyzed all QFTs (n = 6685) performed on children aged 2-18 years between January 5, 2011, and August 18, 2014. Risk factors for positive testing in the CHS population were identified by logistic regression, and further assessed using a case-control comparison. Results from CHS were compared with higher-TB-risk populations (refugee and TB clinics) in our health system.

RESULTS

Positive QFT occurred in 79 of 3745 (2.1%) CHS patients. Positive rates increased with age (0.3% in age 2-5 years to 4.9% in age 13-18 years). Indeterminate results were uncommon (0.8%) including in children <5 (1.3%). Risk factors for positive tests in the CHS population included non-Medicaid insured/uninsured and non-English/Spanish preferred language. In the case-control analysis, birth/travel to/residence in a TB-endemic country was the only identified risk factor for positive testing (OR 5.2 [95% CI 1.04-25.5]). Rates of positive testing were lower in the CHS population than the refugee/TB clinic populations, including among children age 2-5.

DISCUSSION

QFT-based LTBI screening was successfully introduced in our pediatric primary-care health system, and supported our programmatic goals of identifying LTBI cases while limiting unnecessary LTBI treatment courses. Increasing positive rates with age, and higher rates in the refugee/TB populations compared with CHS, add indirect evidence of adequate test sensitivity, even among young children, for whom data on interferon-gamma release assay performance are limited.

Using Reports of Latent Tuberculosis Infection Among Young Children to Identify Tuberculosis Transmission in New York City, 2006-2012

The presence of latent tuberculosis infection (LTBI) in young children indicates recent tuberculosis (TB) transmission. We reviewed surveillance reports of children with LTBI to assess whether more follow-up is needed to prevent TB in this high-risk population. Data on all children under 5 years of age who were reported by health-care providers or laboratories to the New York City Department of Health during 2006-2012 were abstracted from the TB surveillance and case management system, and those with LTBI were identified. Potential source cases, defined as any infectious TB case diagnosed in the 2 years before a child was reported and whose residence was within 0.5 miles (0.8 km) of the child's residence, were identified. Neighborhood risk factors for TB transmission were examined. Among 3,511 reports of children under age 5 years, 1,722 (49%) had LTBI. The children were aged 2.9 years, on average, and most (64%) had been born in the United States. A potential source case was identified for 92% of the children; 27 children lived in the same building as a TB patient. Children with potential source cases were more likely to reside in neighborhoods with high TB incidence, poverty, and population density. The high proportion of children born in the United States and the young average age of the cases imply that undetected TB transmission occurred. Monitoring reports could be used to identify places where transmission occurred, and additional investigation is needed to prevent TB disease.

Interferon-γ Release Assay Performance for Tuberculosis in Childhood

BACKGROUND

Interferon-γ release assays (IGRAs) are important adjunctive tests for diagnosing tuberculosis (TB) disease in children.

METHODS

We analyzed California TB registry data for patients ≤18 years with laboratory-confirmed TB disease during 2010-2015 to identify case characteristics associated with test selection and performance and measure IGRA sensitivity.

RESULTS

In total, 778 cases of TB were reported; 360 were laboratory confirmed. Indeterminate IGRAs were associated with being <1 year old (prevalence rate ratio 9.23; 95% confidence interval 2.87 to 29.8) and having central nervous system disease (prevalence rate ratio 2.69; 95% confidence interval 1.06 to 6.86) on multivariable analysis. Ninety-five children had both an IGRA and tuberculin skin test (TST) performed. Among those, the sensitivity of IGRA in 5- to 18-year-olds was 96% (66 out of 69) vs 83% (57 out of 69) for TST (P = .01); IGRA sensitivity compared with TST in children ages 2 to 4 was 91% (10 out of 11) vs 91% (10 out of 11) (P > .99), and the sensitivity compared with TST in children aged <2 years was 80% (12 out of 15) vs 87% (13 out of 15) (P > .99).

CONCLUSIONS

This is the largest North American analysis of IGRA use and performance among children with TB disease. In children <5 years old, IGRA sensitivity is similar to TST, but sensitivity of both tests are reduced in children <2 years old. Indeterminate results are higher in children <1 year old and in central nervous system disease. In children ≥5 years old with laboratory-confirmed TB, IGRA has greater sensitivity than TST and should be considered the preferred immunodiagnostic test..

Towards the elimination of paediatric tuberculosis in high-income, immigrant-receiving countries: a 25-year conventional and molecular epidemiological case study

The epidemiology of tuberculosis (TB) in high-income countries is increasingly dictated by immigration. The influence of this trend on paediatric TB and TB elimination are not well defined.

We undertook a 25-year conventional and molecular epidemiologic study of paediatric TB in Alberta, one of four major immigrant-receiving provinces in Canada. All isolates of Mycobacterium tuberculosis were DNA fingerprinted using standard methodology.

Between 1990 and 2014, 176 children aged 0–14 years were diagnosed with TB. Foreign-born children or Canadian-born children of foreign-born parents accounted for an increasingly large proportion of total cases during the study period (from 32.1% to 89.5%). Of the 78 culture-positive cases, 35 (44.9%) had a putative source case identified by conventional epidemiology, with 34 (97.1%) having a concordant molecular profile. Of the remaining 43 culture-positive cases, molecular profiling identified spatially and temporally related sources in six cases (14.0%). These six children, along with four other children whose source cases were discovered through reverse-contact tracing, had a high morbidity and mortality.

The increasing burden of paediatric TB in both foreign-born children and Canadian-born children of foreign-born parents calls for more timely diagnosis of source cases and more targeted screening for latent TB infection.

Conventional and molecular epidemiology can inform paediatric TB elimination strategy in high-income countrieshttp://ow.ly/mwbn30iY1WF

Impact of nursing interventions on adherence to treatment with antituberculosis drugs in children and young people: A nonrandomized controlled trial

AIM

To evaluate the association of a new nursing intervention on the adherence to antituberculosis treatment in a paediatric cohort (<18 years).

BACKGROUND

Tuberculosis remains a public health problem worldwide. The risk of developing tuberculosis after primary infection and its severity are higher in children. Proper adherence to antituberculosis treatment is critical for disease control.

DESIGN

Nonrandomized controlled trial; Phase 1, retrospective (2011-2013), compared with Phase 2, prospective with intervention (2015-2016), in a referral centre for paediatric tuberculosis in Spain (NCT03230409).

METHODS

A total of 359 patients who received antituberculosis drugs after close contact with a smear-positive patient (primary chemoprophylaxis) or were treated for latent tuberculosis infection or tuberculosis disease were included, 261 in Phase 1 and 98 in Phase 2. In Phase 2, a new nurse-led intervention was implemented in all patients and included two educational steps (written information in the child's native language and follow-up telephone calls) and two monitoring steps (Eidus-Hamilton test and follow-up questionnaire) that were exclusively carried out by nurses.

RESULTS

Adherence to antituberculosis treatment increased from 74.7% in Phase 1% to 87.8% in Phase 2 (p = 0.014; Chi-square test), after the implementation of the nurse-led intervention. In Phase 2, nonadherence was only associated with being born abroad (28.6% vs. 7.8%; p = 0.019; Chi-square test) and with foreign origin families (27.3% vs. 0%; p < 0.0001; Chi-square test).

CONCLUSION

The nurse-led intervention was associated to an increase in adherence to antituberculosis treatment. Immigrant-related variables remained major risk factors for sub-optimal adherence in a low-endemic setting.

Childhood multidrug-resistant tuberculosis in the European Union and European Economic Area: an analysis of tuberculosis surveillance data from 2007 to 2015

Confirming tuberculosis (TB) in children and obtaining information on drug susceptibility is essential to ensure adequate treatment. We assessed whether there are gaps in diagnosis and treatment of multidrug-resistant (MDR) TB in children in the European Union and European Economic Area (EU/EEA), quantified the burden of MDR TB in children and characterised cases. Methods: We analysed surveillance data from 2007 to 2015 for paediatric cases younger than 15 years. Results: In that period, 26 EU/EEA countries reported 18,826 paediatric TB cases of whom 4,129 (21.9%) were laboratory-confirmed. Drug susceptibility testing results were available for 3,378 (17.9%), representing 81.8% of the confirmed cases. The majority (n = 2,967; 87.8%) had drug-sensitive TB, 249 (7.4%) mono-resistant TB, 64 (1.9%) poly-resistant TB, 90 (2.7%) MDR TB and eight (0.2%) had extensively drug-resistant (XDR) TB. MDR TB was more frequently reported among paediatric cases with foreign background (adjusted odds ratio (aOR) = 1.73; 95% confidence interval (95% CI): 1.12–2.67) or previous TB treatment (aOR: 6.42; 95% CI: 3.24–12.75). Successful treatment outcome was reported for 58 of 74 paediatric MDR TB cases with outcome reported from 2007 to 2013; only the group of 5–9 years-olds was significantly associated with unsuccessful treatment outcome (crude odds ratio (cOR) = 11.45; 95% CI: 1.24–106.04). Conclusions: The burden of MDR TB in children in the EU/EEA appears low, but may be underestimated owing to challenges in laboratory confirmation. Diagnostic improvements are needed for early detection and adequate treatment of MDR TB. Children previously treated for TB or of foreign origin may warrant higher attention.

Children with Cough and Fever: Up-to-date Imaging Evaluation and Management

Cough and fever in infants and children are frequent but nonspecific symptoms. Several usual differential diagnoses are under consideration and imaging is often necessary to help arrive at an accurate diagnosis and ensure proper management. A broad spectrum of underlying disorders may be present. Radiologists must remain cognizant of the potential for immune dysfunction and underlying structural abnormalities. A clear understanding of up-to-date imaging evaluation recommendations and characteristic imaging features can assist radiologists and clinicians in arriving at the most accurate diagnosis in a timely manner and help ensure proper management and necessary follow-up imaging assessment.

Pediatric Tuberculosis in Northern Sardinia

Background and Objectives

Migration flux is an increasing phenomenon in Italy, and it raises several public health issues and concerns in pediatric infectious diseases. This study investigated the clinical characteristics and outcomes of a pediatric population at high-risk for tuberculosis (TB) and the potential role of immigration as a risk factor.

Design

We performed an observational retrospective study of children referred to the only Pediatric Infectious Diseases Unit for Northern Sardinia over a 6-year-period (2009–2014). Main variables assessed included TB skin test (TST), confirmed by quantiFERON Gold in Tube test, thorax X-ray (TX), microbiological culture, direct microscopy for acid-fast bacilli and molecular assays.

Results

Of the 246 children (mean age = 5.8 ± 3.9 years) identified, 222 (90.2%) were native to Sardinia and 24 (9.8%) were immigrants. The majority of children (n=205; 83%) were TB-exposed but not infected based on a negative TST and TX. Among the TST positive group (n= 39; 16%), 19 (49%) had latent TB (TX negative), while 20 (51%) had active TB (TX positive). The percent of TST positive children was significantly higher in the immigrant than the native group (42.5% versus 14%, p<0.001). Clinical presentations included pulmonary involvement with hilar lymphadenopathy (72%), pleurisy (13,5%), lateral-cervical lymphadenopathy (9%), pneumonia with calcifications (4.5%) and disseminated TB (4.5%). One child had multidrug-resistant tuberculosis.

Conclusions

Pediatric TB represents a relevant and potentially worsening public health problem in Northern Sardinia. A strict surveillance system and appropriate treatment can prevent the most severe forms and reduce TB transmission.

Tuberculosis: Is the landscape changing?

Robert Heinrich Herman Koch, a German physician and microbiologist, received Nobel Prize in 1905 for identifying the specific causative agent of tuberculosis (TB). During his time it was believed that TB was an inherited disease. However he was convinced that the disease was caused by a bacterium and was infectious, tested his postulates using guinea pigs, and found the causative agent to be slow growing mycobacterium tuberculosis. TB is the second most common cause of death from infectious diseases after HIV/AIDS. Drug-resistant TB poses serious challenge to effective management of TB worldwide. Multidrug-resistant TB accounted for about half a million new cases and over 200,000 deaths in 2013. Whole-genome sequencing (first done in 1998) technologies have provided new insight into the mechanism of drug resistance. For the first time in 50 y, new anti TB drugs have been developed. The World Health Organization (WHO) has recently revised their treatment guidelines based on 32 studies. In United States, latent TB affects between 10 and 15 million people, 10% of whom may develop active TB disease. QuantiFERON TB Gold and T-SPOT.TB test are used for diagnosis. Further research will look into the importance of newly discovered gene mutations in causing drug resistance.

School-based Study to Identify and Treat Adolescent Students at Risk for Tuberculosis Infection

BACKGROUND

Screening for and treating tuberculosis (TB) infection in children and adolescents is an effective way of decreasing future TB cases. However, current approaches leave many children at risk for TB unidentified.

METHODS

We recruited adolescent students from 2 public high schools (a magnet and a low-income) in the Houston Independent School District. Compared with the magnet school, the student population at the low-income school was larger, primarily Hispanic and economically disadvantaged. Students were educated about TB, and parents completed a risk factor questionnaire. Students with TB risk factors were tested using 2 interferon gamma release assays (IGRAs). Those with a positive IGRA received a 12-dose regimen of weekly isoniazid/rifapentine (3HP) administered via direct observation at school.

RESULTS

Nine hundred twenty-five students received TB education; 73% of their parents submitted the TB questionnaire. Eighty-six percent of students (n = 415) with a TB risk factor identified on the study questionnaire agreed to IGRA testing. Sixteen students had at least one positive IGRA (1% [magnet], 4.1% [low-income]; P = 0.005). Recent student travel to a high-risk country (7) or contact with TB disease (2) were associated with IGRA positivity (P < 0.05). All students with a positive IGRA accepted, tolerated and completed 3HP treatment at school.

CONCLUSIONS

School-based TB education, screening, testing using IGRAs and administration of 3HP treatment is feasible to improve the identification and treatment of adolescent students at risk for TB.

Pediatric Tuberculosis in Italian Children: Epidemiological and Clinical Data from the Italian Register of Pediatric Tuberculosis

Tuberculosis (TB) is one of the leading causes of death worldwide. Over the last decades, TB has also emerged in the pediatric population. Epidemiologic data of childhood TB are still limited and there is an urgent need of more data on very large cohorts. A multicenter study was conducted in 27 pediatric hospitals, pediatric wards, and public health centers in Italy using a standardized form, covering the period of time between 1 January 2010 and 31 December 2012. Children with active TB, latent TB, and those recently exposed to TB or recently adopted/immigrated from a high TB incidence country were enrolled. Overall, 4234 children were included; 554 (13.1%) children had active TB, 594 (14.0%) latent TB and 3086 (72.9%) were uninfected. Among children with active TB, 481 (86.8%) patients had pulmonary TB. The treatment of active TB cases was known for 96.4% (n = 534) of the cases. Overall, 210 (39.3%) out of these 534 children were treated with three and 216 (40.4%) with four first-line drugs. Second-line drugs where used in 87 (16.3%) children with active TB. Drug-resistant strains of Mycobacterium tuberculosis were reported in 39 (7%) children. Improving the surveillance of childhood TB is important for public health care workers and pediatricians. A non-negligible proportion of children had drug-resistant TB and was treated with second-line drugs, most of which are off-label in the pediatric age. Future efforts should concentrate on improving active surveillance, diagnostic tools, and the availability of antitubercular pediatric formulations, also in low-endemic countries.

Managing tuberculosis infection in children in the USA: an update

The rate of tuberculosis (TB) disease has steadily declined in the last two decades in the USA, and over two-thirds of all cases now occur in foreign-born persons. Further declines in the incidence of TB will be most impacted by identifying and treating persons with TB infection. However, difficulties in accessing care, poor specificity of diagnostic tests and long courses of therapy historically have led to suboptimal screening of groups at high risk for infection, false-positive test results from cross-reaction with the bacille Calmette-Guérin vaccine and low treatment completion rates, respectively. This article reviews newer testing and treatment strategies for TB infection emphasizing risk and benefits of testing and treating.

Culture-positive Pediatric Tuberculosis in Toronto, Ontario: Sources of Infection and Relationship of Birthplace and Mycobacterial Lineage to Phenotype

BACKGROUND

Few data relate Mycobacterium tuberculosis (Mtb) lineage and disease phenotype in the pediatric population or examine the contribution of travel to the tuberculosis (TB)-endemic country in North America. We examined clinical, demographic and Mtb genotype data from patients with TB who were treated in Toronto between 2002 and 2012.

METHODS

Consecutive Mtb culture-positive, pediatric patients were included. Clinical data were collected from a prospectively populated clinical database. Mtb case isolate genotypes were identified using Mycobacterial Interspersed Repetitive Units-Variable Number Tandem Repeat (MIRU-VNTR) and spoligotyping and were categorized into phylogeographic lineages for analysis.

RESULTS

The 77 patients included 30.4% of all culture-positive pediatric TB cases in Ontario from 2002 to 2012. Seventy-six (99%) patients were first or second generation Canadians. Foreign-born patients were more likely to have extrathoracic disease [odds ratios (OR) = 3.0; 95% confidence interval (CI): 1.04-8.71; P < 0.05] and less likely to have a genotype match in the Public Health Ontario Laboratories database [OR = 0.32 (95% CI: 0.11-0.90); P < 0.05] than Canadian-born patients. For those without a known TB contact, Canadian-born patients were more likely to have travelled to a TB-endemic country [OR = 13.0 (95% CI: 2.5-78.5); P < 0.001]. Extrathoracic disease was less likely in patients infected with the East Asian Mtb lineage [OR = 0.1 (95% CI: 0.01-0.9); P < 0.05] and more likely in those infected with the Indo-Oceanic Mtb lineage [OR = 5.4 (95% CI: 1.5-19.2); P < 0.05].

CONCLUSIONS

Travel to TB-endemic countries likely plays an important part in the etiology of pediatric TB infection and disease, especially in Canadian-born children. Mtb lineage seems to contribute to disease phenotype in children as it has been described in adults.

Risk Factors for Central Nervous System Tuberculosis

OBJECTIVES

To describe the epidemiology and factors associated with pediatric central nervous system (CNS) tuberculosis (TB) in California from 1993 to 2011.

METHODS

We analyzed California TB registry data for persons aged ≤18 years, comparing CNS TB cases versus non-CNS TB cases reported from 1993 to 2011. Factors associated with CNS TB and TB deaths were identified by using multivariate logistic regression.

RESULTS

A total of 200 CNS TB cases were reported. Compared with non-CNS TB case patients, CNS TB case patients were more likely to be aged <5 years (72.0% vs 43.6%; odds ratio [OR]: 3.8 [95% confidence interval (CI): 2.4-5.9]), US-born (82.0% vs 58.2%; OR: 3.3 [CI: 2.3-4.7]), and Hispanic (75.0% vs 63.2%; OR: 1.7 [CI: 1.3-2.4]). Among US-born CNS TB case patients (during 2010-2011), 76.5% had a foreign-born parent. Tuberculin skin test results were negative in 38.2% of 170 CNS TB cases tested. In multivariate analysis, age <5 years (adjusted odds ratio [aOR]: 3.3 [CI: 2.0-5.4]), US birth (aOR: 1.8 [CI 1.2-2.7]), and Hispanic ethnicity (aOR: 1.5 [CI: 1.1-2.1]) were associated with an increased risk of developing CNS TB. For deaths, CNS TB (aOR: 3.8 [CI: 1.4-9.9]) and culture positivity (aOR: 6.2 [CI: 2.2-17.3]) were associated with increased risk of death, whereas tuberculin skin test positivity (aOR: 0.1 [CI: 0.04-0.2]) was associated with decreased risk.

CONCLUSIONS

Subsets of children are at increased risk for CNS TB in California and may benefit from additional prevention efforts.

Missed opportunities for tuberculosis screening in primary care

OBJECTIVE

To assess how frequently pediatric practitioners perform latent tuberculosis infection (LTBI) screening according to guidelines. We hypothesized that screening occurs less frequently among children whose parents do not speak English as the primary language.

STUDY DESIGN

We conducted a retrospective cohort study of patients attending well-child visits in an urban academic pediatric primary care clinic between April 1, 2012, and March 31, 2013. We assessed documentation of 3 LTBI screening components and tested the association between parent primary language and tuberculin skin test (TST) placement and documentation of results.

RESULTS

During the study period, 387 of 9143 children (4%) had no documentation of screening question responses. Among the other 8756 children, 831 (10%) were identified as at high risk for LTBI. Of these, 514 (62%) did not have documented TST placement in the appropriate time frame. Thirty-nine of 213 children (18%) who had a TST placed did not have documented results. Multivariable regression showed that parent language was not associated with TST placement or documentation of results, but non-Hispanic Black children were more likely to not have a documented test result (aOR, 2.12; 95% CI, 1.07-4.19; P=.03) when adjusting for age, sex, parent primary language, insurance status, day of the week, and study year of TST placement.

CONCLUSION

Parent primary language was not associated with LTBI testing. However, we found substantial gaps in TST placement and documentation of TST results among high-risk children, the latter of which was associated with race/ethnicity. Targeted quality improvement efforts should focus on developing processes to ensure complete screening in high-risk children.

Influence of nursing interventions on adherence to treatment with antituberculosis drugs in children and young people: research protocol

AIM

To evaluate the efficacy of nursing interventions on adherence to antituberculosis medication in a paediatric cohort (aged 0-18 years) and to identify the risk factors for non-compliance.

BACKGROUND

After primary infection, children have a higher risk of developing tuberculosis and the severity of the disease is worse in children. Adherence to treatment is essential to control both latent infection and tuberculosis disease.

DESIGN

Phase 1: retrospective descriptive analysis (n = 270) in children and young people receiving antituberculosis treatment. Phase 2: quasi-experimental, longitudinal, prospective study (n = 100). The results of the two phases will be compared.

METHODS

Phase 1: in children followed up during the period 2011-2013 (non-intervention group), the level of adherence and its associated epidemiological, sociocultural and clinical risk factors will be analysed. Phase 2: educational (written information in the child's mother tongue and follow-up telephone calls) and monitoring (Eidus-Hamilton test and follow-up questionnaire) nursing interventions will be implemented. The results of the two phases will be compared. The definitive Nurse-led Follow-up Programme will then be designed. This project was funded in October 2013.

DISCUSSION

The risk factors for poor adherence to antituberculosis therapy need to be identified to optimize treatment success in latent tuberculosis infection and disease in children and young people. Simultaneous application of several educational and monitoring methods in nurse-led follow-up shall improve adherence in children and adolescents in our setting. These results may also be applicable in other settings, where tuberculosis is more prevalent and directly observed treatment strategies are not available.

Imported transmissible diseases in minors coming to Spain from low-income areas

We prospectively studied the prevalence of imported transmissible diseases in 373 immigrant children and adolescents coming from Sub-Saharan Africa, North Africa and Latin America to Salamanca, Spain. The most frequent transmissible diseases in this group were latent tuberculosis (12.7%), chronic hepatitis B virus infection (4.2%), hepatitis C virus infection (2.3%), syphilis (1.5%) and human T-lymphotropic virus type 1 or 2 infections (1.4%). A total of 24.2% of patients had serologic profiles suggesting past hepatitis B virus infection. Anti-human immunodeficiency virus antibodies were not detected in any subject. Largely asymptomatic immigrant children show a high prevalence of communicable diseases. Thus, infectious disease screenings are highly advisable in immigrant children coming from low-income countries.