Strategies to improve tuberculosis case finding in children

Preventing tuberculosis in children: A global health emergency

It is estimated that 20 million children are exposed to tuberculosis (TB) each year, making TB a global paediatric health emergency. TB preventative efforts have long been overlooked. With the view of achieving "TB elimination" in "our lifetime", this paper explores challenges and potential solutions in the TB prevention cascade, including identifying children who have been exposed to TB; detecting TB infection in these children; identifying those at highest risk of progressing to disease; implementing treatment of TB infection; and mobilizing multiple stakeholders support to successfully prevent TB.

Challenges and controversies in childhood tuberculosis

Children bear a substantial burden of suffering when it comes to tuberculosis. Ironically, they are often left out of the scientific and public health advances that have led to important improvements in tuberculosis diagnosis, treatment, and prevention over the past decade. This Series paper describes some of the challenges and controversies in paediatric tuberculosis, including the epidemiology and treatment of tuberculosis in children. Two areas in which substantial challenges and controversies exist (ie, diagnosis and prevention) are explored in more detail. This Series paper also offers possible solutions for including children in all efforts to end tuberculosis, with a focus on ensuring that the proper financial and human resources are in place to best serve children exposed to, infected with, and sick from all forms of tuberculosis.

Advances in the diagnosis, treatment, and prevention of tuberculosis in children

INTRODUCTION

Pediatric tuberculosis (TB) is a significant global health threat and is one of the top ten causes of death in children. There are a number of diagnostic, treatment, and preventive innovations that have been developed in the last decade for TB, however, these are out of reach for many children in the world. Areas covered: A comprehensive review of the literature on TB in children was done using PubMed and Ovid databases from 1 January 1996 up to 31 October 2018. Topic areas covered included diagnosis of TB, treatment of TB (including novel medications and regimens), prevention of DR-TB, and support to achieve the best possible outcomes. Each of these areas are explored in more detail in the paper. Expert commentary: There is great potential for radical changes in the way all forms of TB are diagnosed, treated and prevented in children. If there is continued advocacy and adequate funding and accountability, it could be possible to make great strides toward eliminating TB in children in the next ten years.

Tuberculosis in Infants and Children

One million children develop tuberculosis disease each year, and 210,000 die from complications of tuberculosis. Childhood tuberculosis is very different from adult tuberculosis in epidemiology, clinical and radiographic presentation, and treatment. This review highlights the many unique features of childhood tuberculosis, with special emphasis on very young children and adolescents, who are most likely to develop disease after infection has occurred.

Prediction of Under-Detection of Paediatric Tuberculosis in the Democratic Republic of Congo: Experience of Six Years in the South-Kivu Province

INTRODUCTION

In the field of tuberculosis (TB), and particularly in regard to paediatric TB (PedTB), clinical skills of health professionals play an important role in determining quality of care. In an era where novel diagnostic technologies and efficient treatment regimens are being made available for the poorest, we must not divert our attention from the importance of clinical skills, as this deliverable remains the cornerstone of individualized patient care and ultimately the best assurance for optimal use of resources. The aim of our work was to study the epidemiology of PedTB and the determinants of PedTB under-detection in the South-Kivu Province of the Democratic Republic of Congo (DRC), a setting with nearly no technical resources allowing to support the clinical diagnosis of PedTB, i.e. chest X-rays, rapid molecular tests or culture laboratories.

METHODS

We collected TB notification data from 2010 to 2015 and analysed the space-time variations in notification for the different forms of TB among the 113 health facilities (HF) the South-Kivu Province, a region with a low HIV incidence. The different forms of TB notified were: smear positive pulmonary TB (SS+PTB), smear negative pulmonary TB (SS-PTB) and extra-pulmonary TB (EPTB). We further analysed the distribution of these different forms of the disease per age group and explored the possibility to predict the detection of PedTB.

RESULTS

Significant differences were observed between HF in regard to the proportion of paediatric TB and the proportion of SS-TB among adults. We found a strong correlation between the proportion of PedTB and three major factors: the proportion of TB cases with no bacteriological confirmation (SS-TB) among adults, the number of TB cases notified by the HF and the fact that the HF was supported or not by Médecins Sans Frontières (MSF). The proportion of SS-TB among adults was found to be a valid indicator for predicting the level of detection of PedTB at the same HF.

CONCLUSION

Our observations strongly suggest that under-detection of PedTB is associated with insufficient clinical skills and technical resources at the HF level which similarly affects other forms of the disease, in particular SS-TB. We demonstrated that, in the specific context of South-Kivu, under-detection of PedTB can be predicted by a low SS-TB/SS+PTB ratio in the adult population. In the context of severely under-resourced settings, this ratio could be used to rapidly identify HF that should benefit in priority from deeper evaluation, and eventually targeted interventions.