Epidemiology of tuberculosis and treatment outcomes among children in Pakistan: a 5 year retrospective study

Tuberculosis prevalence and demographic characteristics of population in Azad Jammu and Kashmir (Pakistan): A retrospective study

Tuberculosis (TB) remains a serious problem for public health and a leading cause of death after COVID-19 and superior to even HIV/AIDS. It is a social health issue and can cause stigma and economic loss as the person cannot perform professionally due to lethargy caused by disease. It is a retrospective study done on data from National TB program Muzaffarabad chapter. The details were noted on SPSS and analysis was done to find important demographic characteristics. The total number of patients was 3441; among which 48.76% were males. Most of them (81.11%) belonged to the Muzaffarabad division of Azad Jammu and Kahmir (AJK). The microbiologically or culture positive cases were 440. Rifampicin resistance was present in 147 cases, further categorized as high (n = 143), very high (n = 3), or true positive (n = 1) resistance. Muti drug resistance was found in 19 cases. The microscopy culture is more sensitive (AUC = 0.511) than MTB/RIF or serology (AUC = 0.502) according to ROC. The rate of positive smear results is not very satisfactory in the present study as it cannot detect dormant or latent cases. There is a need to establish more sensitive tests for detection of cases and more research to combat the disease.

The magnitude of unfavorable tuberculosis treatment outcomes and their relation with baseline undernutrition and sustained undernutrition among children receiving tuberculosis treatment in central Ethiopia

Background

One of the global key indicators for monitoring the implementation of the World Health Organization's End Tuberculosis (TB) Strategy is the treatment outcome rate.

Objective

This study aims to assess the magnitude of unfavorable treatment outcomes and estimate their relationship with baseline undernutrition and sustained undernutrition among children receiving TB treatment in central Ethiopia.

Methods

This retrospective cohort study included children treated for drug-susceptible TB between June 2014 and February 2022. The study comprised children aged 16 and younger who were treated in 32 randomly selected healthcare facilities. A log-binomial model was used to compute adjusted risk ratios (aRR) with 95% confidence intervals (CIs).

Results

Of 640 children, 42 (6.6%; 95% CI = 4.8-8.8%) had an unfavorable TB treatment outcomes, with 31 (73.8%; 95% CI = 58.0-86.1%) occurring during the continuation phase of TB treatment. We confirmed that baseline undernutrition (aRR = 2.68; 95% CI = 1.53-4.71), age less than 10 years (aRR = 2.69; 95% CI = 1.56-4.61), HIV infection (aRR = 2.62; 95% CI = 1.50-4.59), and relapsed TB (aRR = 3.19; 95% CI = 1.79-4.71) were independent predictors of unfavorable TB treatment outcomes. When we looked separately at children who had been on TB treatment for two months or more, we found that sustained undernutrition (aRR = 3.76; 95% CI = 1.90-7.43), age below ten years (aRR = 2.60; 95% CI = 1.31-5.15), and HIV infection (aRR = 2.26; 95% CI = 1.11-4.59) remained predictors of unfavorable outcomes, just as they had in the first two months. However, the effect of relapsed TB became insignificant (aRR = 2.81; 95% CI = 0.96-8.22) after the first two months TB treatment.

Conclusions

The magnitude of unfavorable TB treatment outcomes among children in central Ethiopia met the World Health Organization's 2025 milestone. Nearly three-quarters of unfavorable TB treatment outcomes occurred during the continuation phase of TB treatment. Baseline undernutrition, sustained undernutrition, younger age, HIV infection, and relapsed TB were found to be independent predictors of unfavorable TB treatment outcomes among children receiving TB treatment in central Ethiopia.

Growth and anemia among children with tuberculosis infection at different sites in Southwest China

Objectives

To explore the effects of tuberculosis (TB) infection at different sites on anthropometric indicators, malnutrition and anemia incidence in children in Southwest China.

Methods

From January 2012 to December 2021, a total of 368 children aged 1 month to 16 years were enrolled. According to the sites of TB infection, they were divided into three groups: tuberculous meningitis (T group), tuberculous meningitis complicated withpulmonary tuberculosis (TP group), and tuberculous meningitis complicated with pulmonary tuberculosis and abdominal tuberculosis (TPA group). Data on weight, height, nutritional risk, blood biochemical indicators and basic descriptions were collected within 48 h after admission.

Results

The body mass index-for-age z score (BAZ), height-for-age z score (HAZ), and concentrations of hemoglobin (Hb) and albumin (ALB) decreased in the following order: T group, TP group, and TPA group. The prevalence of malnutrition was the highest in the TPA group (69.5%, 82/118) and 10-to 16-year-old group (72.4%, 63/87). Children aged 0.5-2 years exhibited the highest anemia prevalence of 70.6% (48/68) among the four age groups.The TPA group had the highest incidence of anemia (70.5%, 67/95) compared to T group and TP group.Compared with the treatment group, the abandonment group had a lower BAZ, HAZ and levels of HB and ALB, a higher rate of severe malnutrition, and higher nutritional risk scores. Children who had a low BAZ [odds ratio (OR) = 1.98], nutritional risk (OR = 0.56) and anemia (OR = 1.02) were less likely to obtain treatment with their guardians' support.

Conclusions

Children with tuberculous meningitis were at risk for growth disorders and anemia, especially when complicated with pulmonary tuberculosis and abdominal tuberculosis. The prevalence of anemia and malnutrition was the highest among patients aged 1 month to 2 years and 10-16 years, respectively. Nutritional status was one of the causes of abandoning treatment.

Intramedullary Spinal Tuberculoma: An Uncommon Presentation of a Common Disorder

Intramedullary tuberculoma (IMT) is rare and usually indistinguishable from spinal cord tumors. Thus, the diagnosis of an IMT is challenging. Our case deals with an unusual presentation of a 55-year-old Asian man who had presented with lower limb weakness which was found to be caused by the dissemination of tuberculosis (TB) resulting in an IMT, a rare complication of tuberculosis. The patient also had a concurrent incidental hepatitis B infection. The treatment of IMT is anti-tuberculous medication. This case highlights the significance of the prompt diagnosis of an IMT, urgent intervention particularly in developing areas of the world where tuberculosis is still endemic, an increased probability of patients having an IMT, and their diagnoses being missed.

Age-specific Clinical Presentation and Risk Factors for Extrapulmonary Tuberculosis Disease in Children

BACKGROUND

Clinical presentation for extrapulmonary tuberculosis (EPTB) in children can be variable and nonspecific, leading to delayed diagnosis, disease and death. We describe the age-specific clinical presentation and identify risk factors for EPTB among children in Pakistan.

METHODS

In 2015-2016 in 4 facilities in Sindh, Pakistan, children were diagnosed with TB either through bacteriologic confirmation or clinical-radiologic criteria. EPTB comprised any form of TB disease that did not involve the lungs. Among children with TB disease, we report demographics, clinical characteristics and symptoms, family medical history and diagnostic test results for children with and without EPTB. We conduct age-specific regression analyses to identify factors associated with an EPTB diagnosis among children age 0-4, 5-9 and 10-14 years.

RESULTS

A total of 1163 children were diagnosed with TB disease, of which 157 (13.5%) had EPTB. Of those, 46 (29.3%) were 0-4, 53 (33.8%) were 5-9 and 58 (36.9%) were 10-14 years old. Of children with EPTB, the most frequently reported sites were lymph node (113, 72.4%) and abdominal (31, 19.9%). Weight loss was associated with an increased risk of EPTB in the 0-4-year-old (adjusted odds ratio: 2.80, 95% confidence interval: 1.05-7.47) and 10-14-year-old (adjusted odds ratio: 2.79, 95% confidence interval: 1.28-6.07) groups, and the presence of cough was associated with a decreased risk of EPTB.

CONCLUSIONS

This study provides new knowledge about age-specific clinical presentation and risk factors of EPTB in children in Pakistan. Our results can help to optimize clinical algorithms designed to achieve a timely diagnosis in children with EPTB along with improved treatment outcomes.

Tuberculosis in children with severe acute malnutrition

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.

Age-specific effectiveness of a tuberculosis screening intervention in children

Objective

To apply a cascade-of-care framework to evaluate the effectiveness—by age of the child—of an intensified tuberculosis patient-finding intervention.

Design

From a prospective screening program at four hospitals in Pakistan (2014–2016) we constructed a care cascade comprising six steps: screened, positive screen, evaluated, diagnosed, started treatment, and successful outcome. We evaluated the cascade by each year of age from 0 to 14 and report the age-specific mean proportion and standard deviation.

Results

On average across all ages, only 12.5% (standard deviation: 2.0%) of children with a positive screen were not evaluated. Among children who had a complete evaluation, the highest percentages of children diagnosed with tuberculosis were observed in children 0–4 (mean: 31.9%; standard deviation: 4.8%), followed by lower percentages in children 5–9 (mean: 22.4%; standard deviation: 2.2%), and 10–14 (mean: 26.0%; standard deviation:5.4%). Nearly all children diagnosed with tuberculosis initiated treatment, and an average of 93.3% (standard deviation: 3.3%) across all ages had successful treatment outcomes.

Conclusions

This intervention was highly effective across ages 0–14 years. Our study illustrates the utility of applying operational analyses of age-stratified cascades to identify age-specific gaps in pediatric tuberculosis care that can guide future, novel interventions to close these gaps.

Characteristics of paediatric patients with tuberculosis and associated determinants of treatment success in Malaysia using the MyTB version 2.1 database over five years

Background

Tuberculosis (TB) among children remains a significant public health problem in many parts of the world. The objective of this study was to describe the characteristics of TB patients and to determine the predictors of treatment success among children in Malaysia.

Methods

Secondary data from MyTB version 2.1, a national database, were analysed using R version 3.6.1. Descriptive analysis and multivariable logistic regression were conducted to identify treatment success and its determinants.

Results

In total, 3630 cases of TB cases were registered among children in Malaysia between 2013 and 2017. The overall treatment success rate was 87.1% in 2013 and plateaued between 90.1 and 91.4% from 2014 to 2017. TB treatment success was positively associated with being a Malaysian citizen (aOR = 3.43; 95% CI = 2.47, 4.75), being a child with BCG scars (aOR = 1.93; 95% CI = 1.39, 2.68), and being in the older age group (aOR = 1.06; 95% CI = 1.03, 1.09). Having HIV co-infection (aOR = 0.31; 95% CI = 0.16, 0.63), undergoing treatment in public hospitals (aOR = 0.38; 95% CI =0.25, 0.58), having chest X-ray findings of advanced lesion (aOR = 0.48; 95% CI = 0.33, 0.69), having EPTB (aOR = 0.58; 95% CI = 0.41, 0.82) and having sputum-positive PTB (aOR = 0.58; 95% CI = 0.43, 0.79) were negatively associated with TB treatment success among children.

Conclusions

The overall success rate of treatment among children with TB in Malaysia has achieved the target of 90% since 2014 and remained plateaued until 2017. The socio-demographic characteristics of children, place of treatment, and TB disease profile were associated with the likelihood of TB treatment success among children. The treatment success rate can be increased by strengthening contact tracing activities and promoting early identification targeting the youngest children and non-Malaysian children.

Increasing trends of lung cancer in Golestan province, Northern Iran (2004-2016)

INTRODUCTION

We aimed to present the time trends and geographical distribution of lung cancer in Golestan province, a high-risk area for pulmonary tuberculosis (TB) in Northern Iran (2004-2016).

METHODS

Data on incident primary lung cancers were obtained from the Golestan population-based cancer registry. The data were analyzed by CanReg-5 software to calculate the age-standardized incidence rates (ASRs). We used Joinpoint software for time trend analysis. Average annual percent changes were calculated. The contribution of population aging, population growth and risk to the overall changes in incidence of lung cancer were determined using partitioning analysis.

RESULTS

Overall, 1829 cases of lung cancer were registered by the GPCR during 2004-2016, of which 1274 (69.7%, ASR in 2016 = 21.3) were men and 555 (30.3%, ASR in 2016 = 11.4) were women. The results of Joinpoint regression suggested a significant increasing trend in incidence of lung cancer in Golestan province during 2004 and 2016 (AAPC = 3.74; p-value = 0.01) with more prominent increasing in rural population (AAPC = 4.93; p-value<0.01). The number of new cases of lung cancer increased by 131.6% (from 98 in 2004 to 227 in 2016), of which 34.1%, 22.3% and 75.3% were due to population size, population aging and risk, respectively. Hot points of lung cancer were found in western parts of the Golestan.

CONCLUSION

With high incidence rates and increasing trends of lung cancer, further studies are warranted to clarify the role of TB and other risk factors on its burden in this population.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Hydatid Cyst of Spleen Presenting with Vague Symptoms: A Diagnostic Conundrum

Hydatid cysts are caused by a tapeworm Echinococcus granulosus. They usually occur in the liver. When occurring in spleen they present with vague symptoms which make it difficult for the physicians to diagnose. We present a case of a 10-year-old male who presented with fever, abdominal pain, and burning micturition along with vomiting. Abdominal exam revealed no visceromegaly. Abdominal ultrasound (US) and computed tomography (CT) scan showed multiple hypoechoic and hypo-dense areas, respectively. Splenic abscess, abdominal tuberculosis (TB), pyelonephritis and malignancy were ruled out with appropriate investigations. The patient was not responding to triple therapy of antibiotics (ceftriaxone, metronidazole, and cloxacillin). A final diagnosis of hydatid cyst of spleen was made when serum echinococcus immunoglobulin G (IgG) antibodies were found to be positive. The patient was treated with albendazole and was discharged on improvement. It is vital to be vigilant and consider echinococcal hydatid cyst as a differential in the lesions of spleen, especially if the patient has a rural background.

Risk factors for unsuccessful tuberculosis treatment outcomes in children

OBJECTIVE

Pakistan has a high pediatric burden of tuberculosis, but few studies describe the treatment experience of children with tuberculosis in Pakistan. We sought to identify risk factors for unsuccessful treatment outcomes in children with drug-susceptible tuberculosis identified in eight hospitals in Karachi, Pakistan.

DESIGN

We conducted a retrospective cohort study among children (<15 years old) treated with first-line anti-tuberculosis drugs for presumed or confirmed drug-susceptible tuberculosis between 2016 and 2017. We assessed risk factors for experiencing an unsuccessful treatment outcome through multivariable logistic regression analysis.

RESULTS

In total, 1,665 children initiated tuberculosis treatment, including 916 (55.0%) identified through intensified case finding. Unsuccessful treatment outcomes were experienced by 197 (11.8%) children, comprising 27 (1.6%) deaths, 16 (1.0%) treatment failures, and 154 (9.3%) lost to follow-up. An additional 47 (2.8%) children had outcomes not evaluable. In multivariable analysis, children 0-4 years old (OR: 1.80, 95% CI: 1.07-3.04), males (OR: 1.48, 95% CI: 1.04, 2.11), and those with bacteriologic confirmation of disease (OR: 3.39, 95% CI: 1.98, 5.80) had increased odds of experiencing an unsuccessful treatment outcome.

CONCLUSION

Our findings suggest a need to deploy strategies to identify children earlier in the disease process and point to the need for interventions tailored for young children once treatment is initiated.

Contact screening and risk factors for TB among the household contact of children with active TB: a way to find source case and new TB cases

Background

Source case investigation, for children with tuberculosis (TB), is conducted to establish the source of infection and to minimize the extent of on-going transmission from infectious persons in the community. The aim of the study was to evaluate the secondary TB cases and to investigate the risk factors in developing TB among the household contacts (HHC) of children with active TB.

Methods

A prospective cross-sectional study was conducted where 443 caregivers, of 508 children with active TB receiving treatment, were interviewed using a structured questionnaire. Logistic regression analysis was used to examine the risk factors for TB.

Results

A total of 2397 family members at the median of 5 persons were recorded. Of these, 223 (9.3%) were screened on symptoms basis and 35 (15.7%) of these contacts were diagnosed with TB. Multivariate analysis revealed HHC with TB (OR = 15.288, 95% CI: 5.378–43.457), HHC with smoking (OR = 7.094, 95% CI: 2.128–23.648), and contact of > 18 h with TB individual (OR = 4.681, 95% CI: 1.198–18.294) as statistically significant risk factors of TB among the HHC.

Conclusion

With the current system of contact screening for TB, only 9.3% of all HHC were screened. The low rates of contacts screened are possibly a repercussion of the passive nature of the program, which mainly depend on distinctive clinical symptoms being experienced by the contacts. Strategies are required to certify adherence with contact screening among children with active TB and to critically consider the factors responsible for TB transmission.