The acceptability and feasibility of chemical prophylaxis for schoolchildren and adolescents with latent tuberculosis infection in Shanghai, China: A qualitative study

Low uptake of isoniazid window prophylaxis in patients exposed to a health-care worker with pulmonary tuberculosis in a paediatric ward

AIM

A nurse on a paediatric multidisciplinary ward was diagnosed with smear-positive pulmonary tuberculosis. Children <2 years old, immunocompromised, or >40 h of contact (n = 173) were contact-traced.

METHODS

Children received clinical review, chest X-ray, tuberculin skin test (TST; <5 years old) and/or an interferon-gamma release assay (Quantiferon TB-Gold, ≥5 years old). Infants <6 months old or children <5 years old screened <2 months from exposure were recommended isoniazid window prophylaxis (WP) until a repeat TST at 6 months old or 8-10 weeks after the last exposure to the index case, respectively. Empiric treatment for latent tuberculosis infection (LTBI) was individually considered for immunocompromised patients.

RESULTS

Of 173 children (135 immunocompetent, 38 immunocompromised), two were uncontactable, seven refused screening and two immunocompromised children excluded. Eight of 126 immunocompetent children were diagnosed with LTBI (initial TST positive n = 7, TST conversion n = 1); seven started isoniazid. Thirty-two of 36 immunocompetent children were recommended WP; 15 accepted (one non-compliant after 1 month). Six of seven immunocompromised children accepted empiric LTBI treatment due to severe immunosuppression/initial indeterminate Quantiferon TB-Gold result. Of 15 immunocompromised children offered WP, only five accepted.

CONCLUSIONS

There was high acceptance of screening but low uptake of isoniazid WP in high-risk children exposed to pulmonary tuberculosis. Perception of exposure risk and chemoprophylaxis should be explored further.

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.

Changes in the epidemic of pulmonary tuberculosis in Shanghai from 1992 to 2016

OBJECTIVE

To estimate whether WHO's End TB Strategy targets can be achieved by analysing the incidence trend of pulmonary tuberculosis in Shanghai during 1992-2016.

METHOD

The age-adjusted annual incidence of tuberculosis (TB) was calculated based on data from the national TB registration system. Linear regression was applied to analyse the trend of the epidemic, together with the statistical indicator of annual percent change (APC).

RESULTS

The overall age-standardised rate decreased from 34.8/100 000 in 1992 to 21.2/100 000 in 2016, or by 2.15% (t = -13.258, P < 0.05) annually. After rapidly declining between 1999 and 2003 (-5.4% p.a.), the epidemic remained at a stable level with a lower annual declining rate (-1.1% p.a). In 2035, the estimated incidence will be 17.2/100 000 based on the APC in 2004-2016. There were two peaks in average incidence of the total population, 30.9/100 000 in the 20-24 age group and 66.4/100 000 in the 70-74 age group. Overall, the ratio of new to retreated cases continually rose and eventually reached 8.36:1 in 2016. The constituent ratio of smear-positive cases ranged from 35.9% to 47.8% without rising or decreasing trend (P = 0.065).

CONCLUSION

The epidemic of TB in Shanghai has steadily declined during last two decades. A new strategy should be developed to rapidly reduce the incidence rate to achieve the WHO Goals in 2035.