Underuse of effective measures to prevent and manage pediatric tuberculosis in the United States

A scoping review of paediatric latent tuberculosis infection care cascades: initial steps are lacking

BACKGROUND AND OBJECTIVES

Identifying and treating children with latent tuberculosis infection (TB infection) is critical to prevent progression to TB disease and to eliminate TB globally. Diagnosis and treatment of TB infection requires completion of a sequence of steps, collectively termed the TB infection care cascade. There has been no systematic attempt to comprehensively summarise literature on the paediatric TB infection care cascade.

METHODS

We performed a scoping review of the paediatric TB infection care cascade. We systematically searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Cochrane and Embase databases. We reviewed articles and meeting abstracts that included children and adolescents ≤21 years old who were screened for or diagnosed with TB infection, and which described completion of at least one step of the cascade. We synthesised studies to identify facilitators and barriers to retention, interventions to mitigate attrition and knowledge gaps.

RESULTS

We identified 146 studies examining steps in the paediatric TB infection care cascade; 31 included children living in low-income and middle-income countries. Most literature described the final cascade step (treatment initiation to completion). Studies identified an array of patient and caregiver-related factors associated with completion of cascade steps. Few health systems factors were evaluated as potential predictors of completion, and few interventions to improve retention were specifically tested.

CONCLUSIONS

We identified strengths and gaps in the literature describing the paediatric TB infection care cascade. Future research should examine cascade steps upstream of treatment initiation and focus on identification and testing of at-risk paediatric patients. Additionally, future studies should focus on modifiable health systems factors associated with attrition and may benefit from use of behavioural theory and implementation science methods to improve retention.

Pediatric tuberculosis consultations across 5 CDC regional tuberculosis training and medical consultation Centers

BACKGROUND

The U.S. Centers for Disease Control and Prevention (CDC) funds five Regional Tuberculosis Training and Medical Consultation Centers (RTMCCs) that provide training and consultation for tuberculosis (TB) control and management. RTMCC utilization for assistance with diagnosis and management of TB in children has not been described. We analyzed pediatric TB consultations performed across all RTMCCs in terms of question type, provider type, and setting.

METHODS

The CDC medical consultation database was queried for consultations regarding patients ≤ 18 years provided between 1/1/13-4/22/15 by all RTMCCs (Curry International TB Center, Heartland National TB Center, Mayo Clinic Center for TB, New Jersey Medical School Global TB Institute, Southeastern National TB Center). Each query was categorized into multiple subject areas based on provider type, setting, consultation topic, and patient age.

RESULTS

The 5 RTMCCs received 1164 pediatric consultation requests, representing approximately 20% of all consultations performed by the centers during the study period. Providers requesting consults were primarily physicians (46.3%) or nurses (45.0%). The majority of pediatric consult requests were from state and local public health departments (679, 58.3%) followed by hospital providers (199, 17.1%); fewer requests came from clinicians in private practice (84, 7.2%) or academic institutions (40, 3.4%). Consults addressed 14 different topics, most commonly management of children with TB disease (19.1%), latent TB infection (LTBI) (18.2%), diagnosis or laboratory testing (18.7%), and pharmacology (9.2%).

DISCUSSION

Pediatric consultations accounted for approximately 20% of all consultations performed by RTMCCs during the study period. RTMCCs were utilized primarily by public health departments regarding management of TB disease, LTBI, and diagnosis or laboratory testing. The relative underutilization of the RTMCCs by clinicians in non-public health settings, who often manage children with TB exposure or infection, warrants further study. As US TB case rates decline and providers become less experienced with childhood TB, medical consultation support may become increasingly important.

Tuberculosis in children from diagnosis to decision to treat

SETTING

Confirmation of tuberculosis (TB) in children is difficult, so clinicians use different procedures when deciding to treat.

OBJECTIVE

Identify criteria to initiate and maintain TB treatment in children younger than 5 years-old, without diagnosis confirmation.

DESIGN

A web-based survey was distributed by email to the corresponding authors of journal articles on childhood TB. The observations were clustered into disjoint groups, and analyzed by Ward's method.

RESULTS

We sent out 260 questionnaires and received 64 (24.6%) responses. Forty-six respondents (71.9%) said that microbiological confirmation was not important for initiation of anti-TB treatment, and that the epidemiological context and signs/symptoms suggestive of disease were most important. Sixty-one respondents (95.3%) said that the decision to continue therapy was mainly dependent on clinical improvement. A cluster of older respondents (median age: 52 years-old) who were active at a hospital or primary health care centre placed the most value on immunological test results and chest X-rays. A cluster of younger respondents (median age: 38 years-old) who were less experienced in management of TB placed more value on Interferon Gamma Release Assay (IGRA) results and chest computed tomography (CT) scans. A cluster of respondents with more experience in treating TB and working at specialized TB centres placed greater value on the clinical results and specific radiological alterations ("tree-in-bud" pattern and pleural effusion).

CONCLUSION

TB management varied according to the age, work location and experience of the clinicians. It is necessary to establish standardized guidelines used for the diagnosis and decision to treat TB in children.

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.

Treatment of Latent Tuberculosis Infection

There are approximately 56 million people who harbor Mycobacterium tuberculosis that may progress to active tuberculosis (TB) at some point in their lives. Modeling studies suggest that if only 8% of these individuals with latent TB infection (LTBI) were treated annually, overall global incidence would be 14-fold lower by 2050 compared to incidence in 2013, even in the absence of additional TB control measures. This highlights the importance of identifying and treating latently infected individuals, and that this intervention must be scaled up to achieve the goals of the Global End TB Strategy. The efficacy of LTBI treatment is well established, and the most commonly used regimen is 9 months of daily self-administered isoniazid. However, its use has been hindered by limited provider awareness of the benefits, concern about potential side effects such as hepatotoxicity, and low rates of treatment completion. There is increasing evidence that shorter rifamycin-based regimens are as effective, better tolerated, and more likely to be completed compared to isoniazid. Such regimens include four months of daily self-administered rifampin monotherapy, three months of once weekly directly observed isoniazid-rifapentine, and three months of daily self-administered isoniazid-rifampin. The success of LTBI treatment to prevent additional TB disease relies upon choosing an appropriate regimen individualized to the patient, monitoring for potential adverse clinical events, and utilizing strategies to promote adherence. Safer, more cost-effective, and more easily completed regimens are needed and should be combined with interventions to better identify, engage, and retain high-risk individuals across the cascade from diagnosis through treatment completion of LTBI.

Can Intensified Tuberculosis Case Finding Efforts at Nutrition Rehabilitation Centers Lead to Pediatric Case Detection in Bihar, India?

Introduction

Seven district-level Nutritional Rehabilitation Centres (NRCs) in Bihar, India provide clinical and nutritional care for children with severe acute malnutrition (SAM).

Aim

To assess whether intensified case finding (ICF) strategies at NRCs can lead to pediatric case detection among SAM children and link them to TB treatment under the Revised National Tuberculosis Control Programme (RNTCP).

Materials and Methods

A retrospective cohort study was conducted that included medical record reviews of SAM children registered for TB screening and RNTCP care during July–December 2012.

Results

Among 440 SAM children screened, 39 (8.8%) were diagnosed with TB. Among these, 34 (87%) initiated TB treatment and 18 (53%) were registered with the RNTCP. Of 16 children not registered under the RNTCP, nine (56%) weighed below six kilograms—the current weight requirement for receiving drugs under RNTCP.

Conclusion

ICF approaches are feasible at NRCs; however, screening for TB entails diagnostic challenges, especially among SAM children. However, only half of the children diagnosed with TB were treated by the RNTCP. More effort is needed to link this vulnerable population to TB services in addition to introducing child-friendly drug formulations for covering children weighing less than six kilograms.

Evaluation of TB Case Finding through Systematic Contact Investigation, Chhattisgarh, India

Rationale. Contact investigation is an established tool for early case detection of tuberculosis (TB). In India, contact investigation is not often conducted, despite national policy, and the yield of contact investigation is not well described. Objective. To determine the yield of evaluating household contacts of sputum smear-positive TB cases in Rajnandgaon district, Chhattisgarh, India. Methods. Among 14 public health care facilities with sputum smear microscopy services, home visits were conducted to identify household contacts of all registered sputum smear-positive TB cases. We used a standardized protocol to screen for clinical symptoms suggestive of active TB with additional referral for chest radiograph and sputa collection. Results. From December 2010 to May 2011, 1,556 household contacts of 312 sputum smear-positive TB cases were identified, of which 148 (9.5%) were symptomatic. Among these, 109 (73.6%) were evaluated by sputum examination resulting in 11 cases (10.1%) of sputum smear-positive TB and 4 cases (3.6%) of smear-negative TB. Household visits contributed additional 63% TB cases compared to passive case detection alone. Conclusion. A standard procedure for conducting household contact investigation identified additional TB cases in the community and offered an opportunity to initiate isoniazid chemoprophylaxis among children.

Commentary: a targets framework: dismantling the invisibility trap for children with drug-resistant tuberculosis

Tuberculosis (TB) is an airborne infectious disease that is both preventable and curable, yet it kills more than a million people every year. Children are highly vulnerable, but often invisible casualties. Drug-resistant forms of TB are on the rise globally, and children are as vulnerable as adults but less likely to be counted as cases of drug-resistant disease if they become sick. Four factors make children with drug-resistant TB 'invisible': first, the nature of the disease in children; second, deficiencies in existing diagnostic tools; third, overreliance on these tools; and fourth, our collective failure to deploy one effective tool for finding and treating children - contact investigation. We describe a nascent science-advocacy network - the Sentinel Project on Pediatric Drug-Resistant Tuberculosis - whose goal is to end child deaths from this disease. Provisional annual targets, focused on children exposed at home to multidrug-resistant TB, to be updated every year, constitute a framework to focus attention and collective actions at the community, national, and global levels. The targets in two age groups, under 5 and 5-14 years old, tell us the number of: (i) children who require complete evaluation for TB disease and infection; (ii) children who require treatment for TB disease; and (iii) children who would benefit from preventive therapy.

Old and new approaches to diagnosing and treating latent tuberculosis in children in low-incidence countries

PURPOSE OF REVIEW

The primary purpose is to review guidance on the testing and treatment of latent tuberculosis infection (LTBI) in children. Most children and adults with LTBI have positive tuberculin skin test (TST) or interferon gamma release assay (IGRA) results, normal examinations, and normal chest radiographs. Diagnosis of and treatment completion for LTBI are critical to diminish future cases of tuberculosis (TB) disease.

RECENT FINDINGS

Children should be screened for TB risk factors, and only children with risk factors should be tested with either a TST or an IGRA. IGRAs measure interferon gamma production by lymphocytes after they are stimulated ex vivo by antigens that are primarily Mycobacterium tuberculosis-specific. The foundation of LTBI therapy in the United States has been 9 months of daily isoniazid, but shorter treatment regimens now exist, including a 12-dose regimen of weekly isoniazid and rifapentine. These shorter regimens are associated with higher completion rates.

SUMMARY

There are two distinct modalities for LTBI diagnosis and several treatment regimens that can prevent TB disease in infected children. The selection of treatment regimen should take several factors into consideration, including adherence, drug susceptibility results of the presumed source case (if known), safety, cost, and patient preference.

Improved outcomes found after implementing a systematic evaluation and program improvement process for tuberculosis

California's state and local tuberculosis (TB) programs collaborated to develop the Tuberculosis Indicators Project (TIP), a program evaluation and improvement process. In TIP, local and state staff review data, identify program gaps, implement plans to improve local TB program performance, and evaluate outcomes. After 10 years of project implementation, indicator performance changes and patient outcomes were measured. Eighty-seven percent of participating programs showed a performance increase in targeted indicators after three years compared with 57% of comparison groups. Statistically significant performance change was more common in the intervention local health departments (LHDs) than in comparison groups. The most notable performance changes were in the contact investigation and case management indicators. These results indicate that this systematic evaluation and program improvement project was associated with improved LHD TB control performance and may be useful to inform improvement projects in other public health programs.

Treatment of Latent Tuberculosis Infection in Children

Treatment of latent tuberculosis infection (LTBI) is an effective way of preventing future cases of tuberculosis disease. We review pediatric and adult studies of LTBI treatment (isoniazid and rifampin monotherapy, isoniazid plus rifampin, isoniazid plus rifapentine, and rifampin plus pyrazinamide). Based upon this review and our pediatric experience, we can offer recommendations for routine (isoniazid) and alternative courses of therapy.

Pediatric and adolescent tuberculosis in the United States, 2008-2010

OBJECTIVE

We examined heterogeneity among children and adolescents diagnosed with tuberculosis (TB) in the United States, and we investigated potential international TB exposure risk.

METHODS

We analyzed demographic and clinical characteristics by origin of birth for persons <18 years with verified case of incident TB disease reported to National TB Surveillance System from 2008 to 2010. We describe newly available data on parent or guardian countries of origin and history of having lived internationally for pediatric patients with TB (<15 years of age).

RESULTS

Of 2660 children and adolescents diagnosed with TB during 2008-2010, 822 (31%) were foreign-born; Mexico was the most frequently reported country of foreign birth. Over half (52%) of foreign-born patients diagnosed with TB were adolescents aged 13 to 17 years who had lived in the United States on average >3 years before TB diagnosis. Foreign-born pediatric patients with foreign-born parents were older (mean, 7.8 years) than foreign-born patients with US-born parents (4.2 years) or US-born patients (3.6 years). Among US-born pediatric patients, 66% had at least 1 foreign-born parent, which is >3 times the proportion in the general population. Only 25% of pediatric patients with TB diagnosed in the United States had no known international connection through family or residence history.

CONCLUSIONS

Three-quarters of pediatric patients with TB in the United States have potential TB exposures through foreign-born parents or residence outside the United States. Missed opportunities to prevent TB disease may occur if clinicians fail to assess all potential TB exposures during routine clinic visits.

Description of pediatric tuberculosis evaluated in a referral center in istanbul Turkey

PURPOSE

Diagnosis of tuberculosis (TB) in children is more challenging than in adults. This study aimed to describe demographical, clinical and laboratory findings of children diagnosed with tuberculosis in Turkey, including the issues of contact tracing, culture positivity and forms of the disease.

MATERIALS AND METHODS

Clinical and laboratory data of 51 children with a mean age of 8.0±4.6 years who were diagnosed with TB were retrospectively reviewed. Main diagnostic tools included tuberculin skin test, chest X-ray, sputum/gastric aspirate culture with sensitivity testing, and direct microscopy for acid-fast bacilli on available samples. Clinical characteristics and outcomes of the patients were examined.

RESULTS

Thirty-six (70.6%) children were diagnosed with intra-thoracic and 15 (29.4%) with extra-thoracic tuberculosis. Twenty-eight of the patients had a positive Bacillus Calmette-Guérin vaccine scar (28/51, 54.9%) and 23/51 (45.1%) had a positive tuberculin skin test. An adult TB contact was identified in 27 (52.9%) of the cases. On direct microscopy, acid-fast bacilli were found in nine (17.6%) patients and positive culture for Mycobacterium tuberculosis was found in 19 (37.3%). Drug resistance to isoniazid was detected in four (7.8%). One patient with nephrotic syndrome and miliary tuberculosis died during follow-up. All other patients responded well to the treatment.

CONCLUSION

Focusing on active contact tracing among all household contacts of tuberculous cases may be helpful in early identification and controlling childhood disease, even in regions with low disease prevalence. Adopting a suspicious and proactive approach in this particular age group is warranted.

Practices and policies of providers testing school-aged children for tuberculosis, Connecticut, 2008

This study identified current practices and policies related to testing school children for latent tuberculosis infection (LTBI) in Connecticut. A cross-sectional survey was mailed to a random sample of community pediatricians and family practitioners in Connecticut who provide health care services to children aged 4-18 years. The main outcome measure was adherence to national guidelines for tuberculosis (TB) testing of school-aged children. The response rate was 66.3% (345 of 520), 258 of whom provided services to children. Responses showed that 60% (152 of 252) of replying providers read the American Academy of Pediatrics (AAP) published guidelines, and 85% routinely assess children for TB risk before skin testing although only a minority (22%) use a written questionnaire. Of 153 responding providers, 130 (85%) report that schools require formal TB risk assessments at mandated school physical examinations or at school entry. Results also showed providers who read AAP-published guidelines and who are trained in the United States are more likely to follow the national guidelines for TB testing of children. The majority of health care providers reported following AAP-published guidelines for screening school-aged children for LTBI and TB disease; however, an important number of providers still do not follow recommended guidelines. Public health officials should make efforts to increase provider awareness of, and adherence to, guidelines. School districts also should take steps to ensure the appropriate level of testing of children for TB disease and LTBI.