Feasibility and utility of a combined nasogastric-tube-and-string-test device for bacteriologic confirmation of pulmonary tuberculosis in young children

For microbiological confirmation of pediatric pulmonary tuberculosis (PTB), gastric aspirates (GA) are often operationally unfeasible without hospitalization, and the encapsulated orogastric string test is not easily swallowed in young children. The Combined-NasoGastric-Tube-and-String-Test (CNGTST) enables dual collection of GA and string specimens. In a prospective cohort study in Kenya, we examined its feasibility in children under five with presumptive PTB and compared the bacteriological yield of string to GA. Paired GA and string samples were successfully collected in 95.6 % (281/294) of children. Mycobacterium tuberculosis was isolated from 7.0 % (38/541) of GA and 4.3 % (23/541) of string samples, diagnosing 8.2 % (23/281) of children using GA and 5.3 % (15/281) using string. The CNGTST was feasible in nearly all children. Yield from string was two-thirds that of GA despite a half-hour median dwelling time. In settings where the feasibility of hospitalisation for GA is uncertain, the string component can be used to confirm PTB.

Leptin levels in childhood tuberculosis and its correlation with body mass index, IFN-γ, and TNF-α in an Indonesian population

BACKGROUND

Leptin plays a key role in the regulation of energy and inflammation in tuberculosis (TB). However, its correlation in children with TB remains unclear. Therefore, this study aimed to evaluate the correlations between body mass index, IFN-γ, TNF-α, and leptin levels in children with TB.

METHODS

This was a cross-sectional study of children aged 2-14 years with TB. Sputum examination, chest radiography, and tuberculin skin test findings and clinical symptoms were considered for TB diagnosis. Data on body weight; height; mid-upper arm circumference (MUAC); body mass index (BMI); food intake; and IFN-γ, TNF-α, and leptin levels were collected and analyzed.

RESULTS

Of the 64 diagnosed TB subjects, 2 subjects had positive bacteriological results. The median age was 6 (2-14) years, body weight was 17.7 (9.45-55) kg, height was 114 ± 21.46 cm, and Z score BMI was -0.85 ± 1.14 kg/m2. Malnourished was observed in 17.2% of the subjects. The median calorie intake was 1448.5 (676-4674) kcal, carbohydrate intake was 182.5 (63-558) g, protein intake was 57.9 (15.8-191.0) g, and fat intake was 81.6 (23.6-594.1) g. The median leptin level was 1.2 (0.2-59) ng/mL, IFN-γ was 2.5 (0.9-161) pg/mL, and TNF-α was 13.0 (5.7-356) pg/mL. Correlations were observed between leptin and MUAC (r = 0.251, p = 0.02), Z score (r = 0.453, p = 0.00), and IFN-γ (r = 0.295, p = 0.018).

CONCLUSION

There were positive correlations between BMI and leptin levels, whereas IFN-γ and MUAC showed weak correlations.

Diagnostic Accuracy of Cartridge Based Nucleic Acid Amplification Test (CBNAAT) in Stool Samples in Pediatric Tuberculosis

OBJECTIVES

To find out the diagnostic accuracy of stool Cartridge-based nucleic acid amplification test (CBNAAT) as an alternate method as compared to CBNAAT in gastric aspirate (GA) samples in pediatric tuberculosis (TB).

METHODS

This cross-sectional study was performed at Department of Pediatrics of a tertiary care hospital. Children aged 0-18 y diagnosed as presumptive tuberculosis were consecutively enrolled. Gastric aspirate and corresponding stool sample was subjected to CBNAAT and its performance was compared in both samples using appropriate statistical tests.

RESULTS

Total 100 patients were enrolled in the study. Diagnostic accuracy of CBNAAT was 81% and 80% in gastric aspirate and stool sample respectively. On comparing gastric aspirate with corresponding stool sample there was 97% agreement, with Cohen's kappa value of 0.94. There was a statistically significant association observed between gastric aspirate CBNAAT and stool CBNAAT p <0.001 using chi square test. Sensitivity of gastric aspirate CBNAAT and stool CBNAAT was 75% and 73% respectively and specificity was 100% for both the samples compared against Composite Reference Standard (CRS).

CONCLUSIONS

The diagnostic accuracy of stool CBNAAT is comparable to GA CBNAAT in children and can be used as a good alternative to gastric aspirate for diagnosis of pulmonary and disseminated tuberculosis in children.

Effect of time, temperature and pH on Mycobacterium tuberculosis culture positivity of gastric aspirate: An experimental study

BACKGROUND

The culture of gastric aspirate (GA) has been used for bacteriological confirmation of pulmonary tuberculosis in children and patients who are unable to expectorate. Sodium bicarbonate neutralization of gastric aspirates is commonly recommended to increase culture positivity. We aim to study Mycobacterium tuberculosis (MTB) culture positivity of GA collected from confirmed case of pulmonary tuberculosis after storing it at different temperature, pH & time.

METHODS

GA specimens from 865 patients of either sex predominately non-expectorating children/adults with suspected pulmonary TB were collected. Gastric lavage was performed in the morning after an overnight fasting (at least 6hrs fasting). The GA specimens were tested by CBNAAT (GeneXpert) and AFB microscopy & those who were positive on CBNAAT were further processed with MTB culture on Growth Indicator Tube (MGIT™) culture. pH neutralized and non-neutralized CBNAAT positive GA specimens were culture within 2 hours of collection and 24 hours after storage at 4 °C & room temperature.

RESULTS

MTB was detected in 6.8% of collected GA specimens by CBNAAT. Culture positivity of neutralized GA specimens when processed within 2 hours of collection, was higher compared to paired non-neutralized GA specimens. Neutralized GA specimens had higher contamination rate than non-neutralized GA specimens. Storage of GA specimens at $Deg C had better culture yield than those stored at room temperature.

CONCLUSION

Early neutralization of acid in Gastric aspirate (GA) is essential for better culture positivity of M. tuberculosis (MTB). If there is a delay in processing GA, it should be kept at 4 °C after neutralization; however, positivity decreases with time.

A Prospective Observational Study of Hepatic Dysfunction in Children on Antitubercular Drugs

The frequency, risk factors, and prognosis of antitubercular drug-induced liver injury (TB-DILI) was assessed in this prospective observational study. All consecutive children < 18 y put on antitubercular therapy (ATT) for pulmonary or extrapulmonary tuberculosis between July 2019 and December 2020 were included. Liver function tests (LFTs) were done at baseline and at 2, 4, 6 wk, and then 2 monthly after initiation of therapy till completion of ATT regimen. A total of 81 children [14.27 ± 3.38 y, 34 (42%) males] were included. Out of the patients enrolled, 10 (12.3%) developed TB-DILI at a median of 8.5 (3-18) d of starting ATT. All patients were symptomatic with the most common symptoms being anorexia and nausea (80%). A higher baseline ALT was independently associated with DILI with adjusted OR 2.1 (95% CI 1.3-3.4), p = 0.01. Eight patients tolerated reintroduction of ATT in a sequential manner, 9-24 d after discontinuation.

Utility of RNTCP (NTEP) guidelines in microbiological confirmation of pediatric tuberculosis

OBJECTIVE

To estimate the proportion of microbiologically confirmed disease among children diagnosed with tuberculosis using RNTCP guidelines.

MATERIALS AND METHODS

Retrospective chart review of a cohort of 151 children (aged between 1 month and 18 years) diagnosed with Tuberculosis between December 2016 and June 2020 at a pediatric department of a tertiary care hospital. We collected information on AFB (Acid Fast Bacillus) smear and Cartridge Based Nucleic Acid Amplification Test (CB NAAT) results.

RESULTS

Out of 151 children with a diagnosis of Tuberculosis, 66 (44%) children were found to have microbiologically confirmed disease. Confirmatory rate was almost equal in children less than <5 and >5 years (48% vs 52%). Confirmatory rate did not differ between pulmonary and extra pulmonary samples (49% and 53%). Cartridge Based Nucleic Acid Amplification Test outperformed AFB by 10%, which was statistically significant (p = .000 by fisher exact test).

CONCLUSION

Although considered paucibacillary in nature, microbiological confirmation can be obtained in almost up to half of children with a diagnosis of TB by using RNTCP guidelines. Neither young age nor type of TB is a deterrent to bacteriologically confirm TB in children.

Feasibility of a randomized clinical trial evaluating a community intervention for household tuberculosis child contact management in Cameroon and Uganda

Background

One of the main barriers of the management of household tuberculosis child contacts is the necessity for parents to bring healthy children to the facility. We assessed the feasibility of a community intervention for tuberculosis (TB) household child contact management and the conditions for its evaluation in a cluster randomized controlled trial in Cameroon and Uganda.

Methods

We assessed three dimensions of feasibility using a mixed method approach: (1) recruitment capability using retrospective aggregated data from facility registers; (2) acceptability of the intervention using focus group discussions with TB patients and in-depth interviews with healthcare providers and community leaders; and (3) adaptation, integration, and resources of the intervention in existing TB services using a survey and discussions with stakeholders.

Results

Reaching the sample size is feasible in all clusters in 15 months with the condition of regrouping 2 facilities in the same cluster in Uganda due to decentralization of TB services. Community health worker (CHW) selection and training and simplified tools for contact screening, tolerability, and adherence of preventive therapy were key elements for the implementation of the community intervention. Healthcare providers and patients found the intervention of child contact investigations and TB preventive treatment management in the household acceptable in both countries due to its benefits (competing priorities, transport cost) as compared to facility-based management. TB stigma was present, but not a barrier for the community intervention. Visit schedule and team conduct were identified as key facilitators for the intervention.

Conclusions

This study shows that evaluating a community intervention for TB child contact management in a cluster randomized trial is feasible in Cameroon and Uganda.

Trial registration

Clini calTr ials. gov NCT03832023. Registered on February 6^th 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-00996-3.

Profile of pediatric TB patients registered under Faridabad District TB centre of Haryana

BACKGROUND

Against the backdrop of Tuberculosis (TB) elimination strategy within India, all ages have assumed importance including the burden of pediatric TB. The current study was carried out to study the profile of pediatric TB patients and factors associated with treatment outcome of these patients registered in Faridabad district of Haryana, India.

METHODS

This was a descriptive cross-sectional study. Record reviews of 1589 pediatric tuberculosis patients (≤14 years) registered under Revised National Tuberculosis Control Programme of Faridabad district was carried out using TB registers present at tuberculosis units. Socio-demographic data, clinical characteristics, treatment outcome and factors associated with treatment outcome were studied.

RESULTS AND CONCLUSIONS

Among 1589 pediatric TB patients with records available, 62% were females, majority (68%) belonged to age group 10-14 years, 93% were new cases, and 65% had extra-pulmonary TB. Among 554 pulmonary TB cases, 41% were sputum smear-positive. Majority (97%) patients reported successful treatment outcome (cured or treatment completed). In bivariable analysis, sex, category of TB treatment, sputum result, type of TB and past history of TB treatment were significantly associated with successful treatment outcome. On multivariable analysis, patients who were female, had higher bacillary load and previously treated, had significantly lesser odds for achieving successful treatment outcomes at the end of treatment.

Drug resistance pattern and mutation pattern in pediatric tuberculosis: Study from north India

BACKGROUND

The emergence of multidrug-resistant MDR-TB and extensively drug-resistant XDR-TB are serious threats to global TB control. Molecular tests like GenoType MTBDRplus has revolutionized MDR-TB diagnosis by rapid detection of resistance, leading to early and appropriate management of DR-TB. Information about common mutations imparting resistance to RIF and INH, helps in understanding the disease epidemiology in various regions. The study was conducted to determine the genetic mutation in drug resistant tuberculosis in children less than 12 years with pulmonary or extrapulmonary tuberculosis.

MATERIALS/METHODS

Retrospective analysis was done over a period of 54 months from January 2015 to June 2019 to study the resistance pattern and mutations present in DR-TB in children less than 12 years with suspected pulmonary or extrapulmonary tuberculosis using Hain's GenoType MTBDRplus VER 2.0.

RESULTS

Over a period of 54 months, samples from 3461 patients with suspected TB were received for MGIT culture, out of which, 347 were positive for Mycobacterium tuberculosis. 250 of these 347 isolated were tested for drug resistance by Hain's GenoType MTBDRplus VER 2.0.61.1% were sensitive to isoniazid and rifampicin while 15.2% were DR-TB (38 out of 250). Out of these 38, 22 were MDR TB, 13 were isoniazid monoresistant (34.2%) and 3 were rifampicin monoresistant. The most common genotypic resistance for rifampicin was absence of rpoB WT8 band and presence of rpoB MUT 3 band (88%). 84.6% of the INH monoresistant isolates showed high level isoniazid resistant. All these isolates showed presence of katG MUT 1 band. On comparing Hain's GenoType MTBDRplus VER 2.0 with Xpert MTB/Rif Assay, most common mutation for rifampicin resistance at S531L which can be detected by Xpert MTB/Rif Assay (probe E). However, two cases with rifampicin resistance had mutation in codon region 509-513 and 513-519 which could be missed by Xpert MTB/Rif Assay.

CONCLUSIONS

We cannot solely rely on Xpert MTB/Rif Assay for detection of drug resistance due to the risk of missing the isoniazid monoresistance. GenoType MTBDRplus has revolutionized MDR-TB diagnosis by substantially reducing turn around time and leading to early management of DR-TB cases.

Plasma chemokines as immune biomarkers for diagnosis of pediatric tuberculosis

Background

Diagnosing tuberculosis (TB) in children is challenging due to paucibacillary disease, and lack of ability for microbiologic confirmation. Hence, we measured the plasma chemokines as biomarkers for diagnosis of pediatric tuberculosis.

Methods

We conducted a prospective case control study using children with confirmed, unconfirmed and unlikely TB. Multiplex assay was performed to examine the plasma CC and CXC levels of chemokines.

Results

Baseline levels of CCL1, CCL3, CXCL1, CXCL2 and CXCL10 were significantly higher in active TB (confirmed TB and unconfirmed TB) in comparison to unlikely TB children. Receiver operating characteristics curve analysis revealed that CCL1, CXCL1 and CXCL10 could act as biomarkers distinguishing confirmed or unconfirmed TB from unlikely TB with the sensitivity and specificity of more than 80%. In addition, combiROC exhibited more than 90% sensitivity and specificity in distinguishing confirmed and unconfirmed TB from unlikely TB. Finally, classification and regression tree models also offered more than 90% sensitivity and specificity for CCL1 with a cutoff value of 28 pg/ml, which clearly classify active TB from unlikely TB. The levels of CCL1, CXCL1, CXCL2 and CXCL10 exhibited a significant reduction following anti-TB treatment.

Conclusion

Thus, a baseline chemokine signature of CCL1/CXCL1/CXCL10 could serve as an accurate biomarker for the diagnosis of pediatric tuberculosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06749-6.

Evaluation of a serum-based antigen test for tuberculosis in HIV-exposed infants: a diagnostic accuracy study

BACKGROUND

Non-sputum methods are urgently needed to improve tuberculosis diagnosis and treatment monitoring in children. This study evaluated the ability of a serum assay quantifying a species-specific peptide of the Mycobacterium tuberculosis CFP-10 virulence factor via nanotechnology and matrix-assisted laser desorption ionization time-of-flight mass spectrometry to diagnose tuberculosis in HIV-infected and HIV-uninfected infants.

METHODS

Serum CFP-10 peptide signal was blinded evaluated in cryopreserved sera of 519 BCG-immunized, HIV-exposed infants (284 HIV-infected, 235 HIV-uninfected) from a multi-center randomized placebo-controlled isoniazid prophylaxis trial conducted in southern Africa between 2004 and 2008, who were followed up to 192 weeks for Mtb infection and TB. Children were classified as confirmed, unconfirmed, or unlikely tuberculosis cases using 2015 NIH diagnostic criteria for pediatric TB.

RESULTS

In HIV-infected infants, CFP-10 signal had 100% sensitivity for confirmed TB (5/5, 95% CI, 47.8-100) and 83.7% sensitivity for unconfirmed TB (36/43, 95% CI 69.3-93.2), with 93.1% specificity (203/218, 95% CI 88.9-96.1). In HIV-uninfected infants, CFP-10 signal detected the single confirmed TB case and 75.0% of unconfirmed TB cases (15/20; 95% CI 50.9-91.3), with 96.2% specificity (177/184, 95% CI, 92.3-98.5). Serum CFP-10 achieved 77% diagnostic sensitivity for confirmed and unconfirmed TB (13/17, 95% CI, 50-93%) at ≤ 24 weeks pre-diagnosis, and both CFP-10-positivity and concentration declined following anti-TB therapy initiation.

CONCLUSIONS

Serum CFP-10 signal exhibited high diagnostic sensitivity and specificity for tuberculosis in HIV-infected and HIV-uninfected infants and potential utility for early TB detection and monitoring of anti-TB treatment responses.

Community intervention for child tuberculosis active contact investigation and management: study protocol for a parallel cluster randomized controlled trial

Background

There are major gaps in the management of pediatric tuberculosis (TB) contact investigation for rapid identification of active tuberculosis and initiation of preventive therapy. This study aims to evaluate the impact of a community-based intervention as compared to facility-based model for the management of children in contact with bacteriologically confirmed pulmonary TB adults in low-resource high-burden settings.

Methods/design

This multicenter parallel open-label cluster randomized controlled trial is composed of three phases: I, baseline phase in which retrospective data are collected, quality of data recording in facility registers is checked, and expected acceptability and feasibility of the intervention is assessed; II, intervention phase with enrolment of index cases and contact cases in either facility- or community-based models; and III, explanatory phase including endpoint data analysis, cost-effectiveness analysis, and post-intervention acceptability assessment by healthcare providers and beneficiaries. The study uses both quantitative and qualitative analysis methods. The community-based intervention includes identification and screening of all household contacts, referral of contacts with TB-suggestive symptoms to the facility for investigation, and household initiation of preventive therapy with follow-up of eligible child contacts by community healthcare workers, i.e., all young (< 5 years) child contacts or older (5–14 years) child contacts living with HIV, and with no evidence of TB disease. Twenty clusters representing TB diagnostic and treatment facilities with their catchment areas are randomized in a 1:1 ratio to either the community-based intervention arm or the facility-based standard of care arm in Cameroon and Uganda. Randomization was stratified by country and constrained on the number of index cases per cluster. The primary endpoint is the proportion of eligible child contacts who initiate and complete the preventive therapy. The sample size is of 1500 child contacts to identify a 10% difference between the arms with the assumption that 60% of children will complete the preventive therapy in the standard of care arm.

Discussion

This study will provide evidence of the impact of a community-based intervention on household child contact screening and management of TB preventive therapy in order to improve care and prevention of childhood TB in low-resource high-burden settings.

Trial registration

ClinicalTrials.gov NCT03832023. Registered on 6 February 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05124-9.

Tuberculosis among children and adolescents in Rio de Janeiro, Brazil - Focus on extrapulmonary disease

OBJECTIVE

To compare the socio-demographic, clinical, and diagnostic characteristics and treatment outcomes between extrapulmonary tuberculosis (EPTB) and pulmonary tuberculosis (PTB) in children and adolescents in Rio de Janeiro, a high TB-burdened Brazilian city.

METHODS

This retrospective study used data from patients with EPTB and PTB aged 0 - 18 years, notified on two national databases from 2014 to 2016.

RESULTS

Among the 1008 patients, 144 (14.2%) had EPTB. Patients with EPTB showed higher odds of hospital-based diagnosis (odds ratio (OR): 6.76 [95% confidence interval (95% CI): 4.62-9.90]; p < 0.001), no laboratory confirmation (OR: 4.9 2.14 [95% CI: 3.07 - 7.85]; p < 0.001), and being <14 years old (OR: 3.13 [95% CI: 2.18-4.49]) than those with PTB. A diagnosis without laboratory investigation was observed among 301/864 (34.8%) patients with PTB, 48/144 (33.3%) with EPTB, and among those aged under five years with EPTB (15/27 [55.6%]). TB deaths were more frequent in patients with EPTB (5/144 [3.5%]) than in those with PTB (4/864[0.5%]) (p = 0.001); 4/5 (80%) TB deaths were due to TB meningitis; 50% died within 14 days of diagnosis.

CONCLUSIONS

EPTB remains a clinical diagnostic challenge that needs to be addressed to fully benefit from the higher sensitivity laboratory investigations.

Use of resuscitation promoting factors to screen for tuberculosis infection in household-exposed children in The Gambia

BACKGROUND

Interferon-γ release assays (IGRA) with Resuscitation promoting factor (Rpf) proteins enhanced tuberculosis (TB) screening and diagnosis in adults but have not been evaluated in children. Children often develop paucibacillary TB and their immune response differs from that of adults, which together affect TB disease diagnostics and immunodiagnostics. We assessed the ability of Rpf to identify infection among household TB-exposed children in The Gambia and investigated their ability to discriminate Mycobacterium tuberculosis complex (MTBC) infection from active TB disease in children.

METHODS

Detailed clinical investigations were done on 93 household TB-exposed Gambian children and a tuberculin skin test (TST) was administered to asymptomatic children. Venous blood was collected for overnight stimulation with ESAT-6/CFP-10-fusion protein (EC), purified protein derivative and RpfA, B, C, D and E. Interferon gamma (IFN-γ) production was measured by ELISA in supernatants and corrected for the background level. Infection status was defined by IGRA with EC and TB disease by mycobacterial confirmation and/or clinical diagnosis. We compared IFN-γ levels between infected and uninfected children and between infected and TB diseased children using a binomial logistic regression model while correcting for age and sex. A Receiver Operating Characteristics analysis was done to find the best cut-off for IFN-γ level and calculate sensitivity and specificity.

RESULTS

Interferon gamma production was significantly higher in infected (IGRA+, n = 45) than in uninfected (IGRA-, n = 20) children after stimulation with RpfA, B, C, and D (P = 0.03; 0.007; 0.03 and 0.003, respectively). Using RpfB and D-specific IFN-γ cut-offs (33.9 pg/mL and 67.0 pg/mL), infection was classified with a sensitivity-specificity combination of 73-92% and 77-72% respectively, which was similar to and better than 65-75% for TST. Moreover, IFN-γ production was higher in infected than in TB diseased children (n = 28, 5 bacteriologically confirmed, 23 clinically diagnosed), following RpfB and D stimulation (P = 0.02 and 0.03, respectively).

CONCLUSION

RpfB and RpfD show promising results for childhood MTBC infection screening, and both performed similar to and better than the TST in our study population. Additionally, both antigens appear to discriminate between infection and disease in children and thus warrant further investigation as screening and diagnostic antigens for childhood TB.

Integrating childhood TB: applying the care delivery value chain to improve pediatric HIV/TB services in Togo, West Africa

The World Health Organization has prioritized integrating tuberculosis (TB) and human immunodeficiency virus (HIV) services. Diagnosis of HIV/TB coinfection in children remains a challenge worldwide for numerous reasons. The care delivery value chain (CDVC) is an effective tool that can be applied as a systemic framework for assessing health care delivery. Our objective was to apply the CDVC framework to improve pediatric HIV/TB care at an HIV center in northern Togo that serves over 130 children and 1000 adults living with HIV. Using the CDVC framework, gaps in HIV/TB care were identified, and services related to screening and diagnosis were prioritized to implement 3 distinct quality improvement cycles. Primary outcomes included percentage of children screened for TB by medical providers and percentage of diagnostic sample results received at the HIV clinic for children and adults. Improvements in the TB diagnostic process were observed, resulting in a change of sputum sample results received for both children and adults from 25% at baseline to >88% at 3 months. Given the relative low associated costs, this QI approach may be applicable and feasible in other settings to target screening and diagnosis of TB for children living with HIV worldwide.

Demographic profile, clinical and microbiological predictors of mortality amongst admitted pediatric TB patients in a tertiary referral tuberculosis hospital

BACKGROUND

Pediatric tuberculosis (TB) constitutes 8% of the total caseload of TB. Children are particularly vulnerable to dissemination of disease and mortality.

AIM

To determine mortality rate, elucidate type of TB, causes and predictors of mortality, if any, in admitted pediatric TB patients.

METHODS

Present retrospective study was conducted in a tertiary referral center over last 6½ year on children who died out of total TB admissions.

RESULTS

Out of total 1380 pediatric (<15 years of age) TB admissions, 74 children died, a mortality rate of 5.36%. Mean age was 11.4 years with highest mortality 47 (63.51%) in patients from 11 to 14 years age group. Significant majority 58 (78.38%) patients were females (p < 0.011). Range of hospital stay was 0-113 days with 7 (9.5%), 9 (12.16%) and 27 (36.48%) children dying on day of admission, next day and 3rd-7th day respectively, therefore a total of 43 (58.11%) died within first week of admission. Most 60 (81.08%) patients belonged to poor socio-economic status. History of contact was present in 12 (16.22%) cases while none had diabetes. 31 (41.89%) patients had sepsis and severe anemia (Hb ≤ 6 g %) was present in 6 (8.11%) patients at admission, out of which 4 died on the same day of admission, even before blood could be arranged. Most patients 68 (91.89%) had pulmonary TB with 25 children having concomitant extrapulmonary involvement, while 4 (5.41%) had meningeal TB and 2 (2.70%) had disseminated TB with HIV. Microbiological confirmation was achieved in 51 (68.92%) (48 PTB and 3 EPTB) cases while 23 (31.08%) were clinically diagnosed. Bilateral extensive fibro-cavitary disease with infiltrations was the commonest. Drug resistance was confirmed in 21 (28.38%) with 2, 5, 8, 5 and 1 patient diagnosed with mono H, RR, MDR, pre-XDR and XDR respectively but results of 9 patients were received posthumously. Treatment given was category 1, category 2 and regimens for drug resistant TB in 24 (32.43%), 29 (39.19%) and 21 (28.37%) cases respectively based on prior history of ATT and drug sensitivity. Adverse drug reactions were noted in 12 (16.21%) cases. Noted immediate causes of mortality were cardio-respiratory failure, sudden pneumothorax, massive hemoptysis, sepsis, extensive pulmonary disease and aspiration pneumonia. The pointers towards mortality include female gender, severe malnutrition, anemia, extensive disseminated disease and drug resistant TB. Ignorance, dependency of children on parents, poor adherence and late referrals into the system lead to delayed diagnosis and initiation of proper regimen based treatment.

CONCLUSION

Early referrals of non-responders and failures to centers equipped with programmatic management facilities are essential for proper, timely management of pediatric TB to reduce mortality.

The Roll-out of Child-friendly Fixed-dose Combination TB Formulations in High-TB-Burden Countries: A Case Study of STEP-TB

Childhood tuberculosis (TB) has hitherto been treated through estimation of pediatric doses through the crushing of adult pills, but the bitter taste of the pills and the inaccuracy of this dosing method presents a challenge for both patients and healthcare providers, leading to poor treatment outcomes. The TB Alliance therefore launched the Speeding Treatments to End Pediatric-Tuberculosis (STEP-TB) project to incentivize the introduction of pediatric Fixed-Dose Combinations (FDCs) of TB drugs. This case study describes the elements of this project, evaluates its impact, and highlights future challenges for pediatric TB treatment. The impact assessment incorporates both market impact as well as projected public health impact, evaluating the availability, affordability, and quality of the FDCs, and lastly providing a projection of lives saved as a result of scale-up of the FDCs to near-universal availability and utilization, based on a publicly available pediatric TB-specific model. STEP-TB resulted in the development of two child-friendly FDCs that were successfully brought to market and made available in 20 of the project’s 22 high-burden countries. On the basis of a country-specific projection of pediatric TB mortality in Kenya, scale-up to near-universal availability and utilization of the new FDCs could reduce pediatric TB-associated mortality by 2660 cases over the next 5 years. Future challenges include maintaining affordable prices for the FDCs and considering mechanisms to incentivize their introduction among high-risk groups in low-burden countries.

Rs1914663 of SFTPA 1 gene is associated with pediatric tuberculosis in Han Chinese population

Surfactant protein A (SP-A), a part of the innate immune system of the lung, performs a vital role in the host defense against Mycobacterium tuberculosis (MTB) infection. In order to investigate the relationship between SFTPA polymorphism variations and Tuberculosis (TB) in a Chinese pediatric group, we conducted a case-control study using single-nucleotide polymorphism (SNP) analysis. Significant difference of the allelic distribution of rs1914663 in SFTPA gene was observed between TB group and control group and, T allele of rs1914663 was associated with increased risk for TB (control vs.

TB, OR

1.42, 95% CI: 1.10-1.81, P=0.005). In addition, the TC+TT genotype of rs1914663 was higher in PTB and non-severe TB than that in controls. The haplotype comprising rs17881720-A and rs17879335-G was a resistance factor while the haplotype comprising rs1914663-T and rs1059225-G was found to be a susceptibility factor to TB. Using a case-control study, we identified a genetic polymorphism in the SFTPA that regulates host susceptibility to pediatric TB in the Han Chinese population.

Recommendations for treating children with drug-resistant tuberculosis

Tuberculosis (TB) is still one of the most difficult infectious diseases to treat, and the second most frequent cause of death due to infectious disease throughout the world. The number of cases of multidrug-resistant (MDR-TB) and extensively drug-resistant TB (XDR-TB), which are characterised by high mortality rates, is increasing. The therapeutic management of children with MDR- and XDR-TB is complicated by a lack of knowledge, and the fact that many potentially useful drugs are not registered for pediatric use and there are no formulations suitable for children in the first years of life. Furthermore, most of the available drugs are burdened by major adverse events that need to be taken into account, particularly in the case of prolonged therapy. This document describes the recommendations of a group of scientific societies on the therapeutic approach to pediatric MDR- and XDR-TB. On the basis of a systematic literature review and their personal clinical experience, the experts recommend that children with active TB caused by a drug-resistant strain of Mycobacterium tuberculosis should always be referred to a specialised centre because of the complexity of patient management, the paucity of pediatric data, and the high incidence of adverse events due to second-line anti-TB treatment.

Polymerase Chain Reaction targeting insertion sequence IS6110 for the diagnosis of pulmonary tuberculosis among Sudanese children and young adults

This study was carried out in Khartoum State during the period from January 2011 to December 2013 to improve the rate of detection of Mycobacterium tuberculosis (MTB) in children with symptoms of tuberculosis (TB) infection using different conventional and advanced diagnostic techniques. One hundred and ninety-seven specimens of gastric lavage and sputum were collected from different hospitals in Khartoum State, including Elbolok Hospital, Jafar Ibn Owf Hospital, Elasha'ab Teaching Hospital, Soba University Hospital and Academy Charity Hospital. All children participating in the study were subjected to the Mantoux test after obtaining appropriate consent injected by 5 tuberculin units of tuberculin purified protein derivative, and the results were recorded after three days. Specimens were decontaminated and inoculated on Lowenstein-Jensen media according to the modified Petroff's method. Two smears were prepared and stained by Ziehl-Neelsen stain and Auramine fluorescent dye; bacterial DNA was extracted from each specimen by using phenol chloroform method, and then the Polymerase Chain Reaction technique was adopted to detect Insertion Sequence IS6110 gene of MTB in these specimens. This study showed that the positive results for TST, ZN, Auramine, Culture and PCR were 86 (43.7%), 16 (8.1%), 22 (11.2%), 32 (16.2%) and 35(17.8%), respectively. The study concluded that the PCR technique is the most sensitive and specific technique for a quick identification of MTB in gastric lavage and sputum from children who are unable to expectorate a good quality sputum sample or who are diagnosed as negative using conventional diagnostic methods.