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

Adherence to treatment for tuberculosis infection in children using a comprehensive care strategy: a prospective cohort study with a historical control group

Background

Low adherence to treatment for tuberculosis infection (TBI) in children threatens tuberculosis (TB) control goals. This research focuses on children with close contact to TB and TBI. This study evaluated adherence to treatment of TBI using a comprehensive care strategy (CCS) for close-contact children with pulmonary TB compared with standard of care (SOC).

Methods

A prospective cohort study with a historical control group was conducted on children under five, who were close contacts of patients with bacteriologically confirmed pulmonary TB in three Colombian cities (study registration number: NCT04331262). The CCS comprised clinical evaluations, rifampicin for four months, multidisciplinary care, and logistical support, while the SOC followed program regulations with isoniazid for nine months. The primary outcome was the proportion of children completing 100% treatment during follow-up, and the secondary outcome was treatment-related adverse events (AEs).

Findings

213 children in the SOC group and 86 children in the CCS group were analyzed. The treatment adherence in the SOC group was 40·8% (95% CI 34%; 48%), while in the CCS group it was 76·7% (95% CI 66%; 85%). Children exposed to CCS had 87% higher probability of adherence to TBI treatment compared to SOC (RR 1·87; 95% CI 1·52; 2·31). The incidence of AEs was lower in the CCS group (n = 3) than in those receiving SOC (n = 24).

Interpretation

The CCS increases adherence to treatment for TBI in children safely compared to SOC. Future cost-effectiveness studies will help implement this strategy in programmatic settings.

Funding

Colombian Ministry of Science, Technology and Innovation.

Optimizing the cascade of prevention to protect people from tuberculosis: A potential game changer for reducing global tuberculosis incidence

The provision of tuberculosis preventive treatment is one of the critical interventions to reduce tuberculosis incidence and ultimately eliminate the disease, yet we still miss appropriate tools for an impactful intervention and treatment coverage remains low. We used recent data, epidemiological estimates, and research findings to analyze the challenges of each step of the cascade of tuberculosis prevention that currently delay the strategy implementation. We addressed research gaps and implementation bottlenecks that withhold key actions in tuberculosis case finding, testing for tuberculosis infection, provision of preventive treatment with safer, shorter regimens and supporting people to complete their treatment. Empowering communities to generate demand for preventive therapy and other prevention services in a holistic manner and providing adequate financial support to sustain implementation are essential requirements. The adoption of an effective, universal monitoring and evaluation system is a prerequisite to provide general and granular insight, and to steer progress of the tuberculosis infection strategy at global and local level.

Missed opportunities in the prevention and diagnosis of pediatric tuberculosis: a scoping review

OBJECTIVES

Identify potential barriers, delays, and missed opportunities in the prevention and diagnosis of childhood TB.

METHODS

Scoping review according to the PRISMA extension. The definitions considered for the selection followed the acronym PCC where the population (P) is children under 18 years of age with TB disease, the concept (C) refers to missed opportunities for prevention and diagnosis, and context (C) is defined as a diagnosis of TB disease. The authors searched systematically in the databases; VHL/Lilacs, Medline via PubMed, Cochrane, Scopus, and Web of Science, without date or language limitation.

RESULTS

Seven studies were included. In developed countries, with low disease burden, the main shortcoming is the delay in diagnosing bacilliferous adults in contact with young children. This problem is concentrated in the portion of the population with socioeconomic vulnerability. In underdeveloped countries, with a high burden of disease, the biggest challenge is tracking children who come into contact with bacilliferous patients.

CONCLUSIONS

There are still many missed opportunities in the prevention and diagnosis of childhood TB. The positive legacy of the COVID-19 pandemic should be taken advantage of and the encouragement of scientific development in the management of infectious diseases should be taken.

Food Pantry Referral and Utilization in a Pediatric Primary Care Clinic

INTRODUCTION

This study aimed to characterize progression from screening for food insecurity risk to on-site food pantry referral to food pantry utilization in pediatric primary care.

METHODS

This retrospective study included 14,280 patients aged 0-21 years with ≥1 pediatric primary care visit from March 2018 to February 2020. Analyses were conducted in 2020-2022 using multivariable regression to examine patient-level demographic, clinical, and socioeconomic characteristics and systems-related factors associated with progression from screening positive for food insecurity risk to food pantry referral to completing ≥1 food pantry visit.

RESULTS

Of patients screened for food insecurity risk, 31.9% screened positive; 18.5% of food-insecure patients received an on-site food pantry referral. Among patients referred, 28.9% visited the food pantry. In multivariable models, higher odds of referral were found for patients living near the clinic (AOR=1.28; 95% CI=1.03, 1.59), for each additional health-related social need reported (AOR=1.23; 95% CI=1.16, 1.29), and when the index clinic encounter occurred during food pantry open hours (AOR=1.62; 95% CI=1.30, 2.02). Higher odds of food pantry visitation were found for patients with a preferred language of Haitian Creole (AOR=2.16; 95% CI=1.37, 3.39), for patients of Hispanic race/ethnicity (AOR=3.67; 95% CI=1.14, 11.78), when the index encounter occurred during food pantry open hours (AOR=1.96; 95% CI=1.25, 3.07), for patients with a clinician letter referral (AOR=6.74; 95% CI=3.94, 11.54), or for patients with a referral due to a screening-identified food emergency (AOR=2.27; 95% CI=1.30, 3.96).

CONCLUSIONS

There was substantial attrition along the pathway from screening positive for food insecurity risk to food pantry referral and utilization as well as patient-level characteristics and systems-related factors associated with successful referrals and utilization.

Pediatric Tuberculosis Infection Care Facilitators and Barriers: A Qualitative Study

BACKGROUND

A total of 700 000 US children and adolescents are estimated to have latent tuberculosis (TB) infection. Identifying facilitators and barriers to engaging in TB infection care is critical to preventing pediatric TB disease. We explored families' and clinicians' perspectives on pediatric TB infection diagnosis and care.

METHODS

We conducted individual interviews and small group discussions with primary care and subspecialty clinicians, and individual interviews with caregivers of children diagnosed with TB infection. We sought to elicit facilitators and barriers to TB infection care engagement. We used applied thematic analysis to elucidate themes relating to care engagement, and organized themes using a cascade-grounded pediatric TB infection care engagement framework.

RESULTS

We enrolled 19 caregivers and 24 clinicians. Key themes pertaining to facilitators and barriers to care emerged that variably affected engagement at different steps of care. Clinic and health system themes included the application of risk identification strategies and communication of risk; care ecosystem accessibility; programs to reduce cost-related barriers; and medication adherence support. Patient- and family-level themes included TB knowledge and beliefs; trust in clinicians, tests, and medical institutions; behavioral skills; child development and parenting; and family resources.

CONCLUSIONS

Risk identification, education techniques, trust, family resources, TB stigma, and care ecosystem accessibility enabled or impeded care cascade engagement. Our results delineate an integrated pediatric TB infection care engagement framework that can inform multilevel interventions to improve retention in the pediatric TB infection care cascade.

Epidemiology of latent tuberculosis infection in Japan-born and foreign-born children in Japan

Objective

This study aims to compare the epidemiology of notifications of latent tuberculosis infection (LTBI) among Japan-born and foreign-born children in Japan between 2010 and 2020, and to assess the language used during LTBI case interviews with parents or caregivers of foreign-born children with LTBI during 2019.

Methods

Our study consisted of two parts: (1) an analysis of national data from the Japan Tuberculosis Surveillance (JTBS) system on the epidemiology of LTBI among Japan-born and foreign-born children in Japan, and (2) a survey of staff at public health centres that had registered at least one foreign-born child aged ≤ 14 years with LTBI. Data were extracted from the JTBS system for all children aged ≤ 14 years who were newly notified as having LTBI between 2010 and 2020, and analysed to determine trends, characteristics and treatment outcomes. Staff at relevant public health centres completed a self-administered survey.

Results

A total of 7160 Japan-born and 320 foreign-born children were notified as having LTBI between 2010 and 2020. Compared with Japan-born children, foreign-born children notified as having LTBI were more likely to be older, have their mother or sibling as their source of infection and have LTBI detected via a routine school health check. At case interviews, the use of language interpretation services was limited, even when both parents were non-Japanese. No interview was directly conducted with children themselves, not even with school-aged children.

Discussion

Foreign-born children and their parents may be unfamiliar with the system of testing for TB infection and the diagnosis of LTBI in Japan in school settings. Public health centres are required to provide education to patients and their families and care that takes into account cultural and linguistic differences. However, the provision of language support during case interviews may need strengthening.

Multicenter Analysis of Attrition from the Pediatric Tuberculosis Infection Care Cascade in Boston

OBJECTIVE

To characterize losses from the pediatric tuberculosis (TB) infection care cascade to identify ways to improve TB infection care delivery.

STUDY DESIGN

We conducted a retrospective cohort study of children (age <18 years) screened for TB within 2 Boston-area health systems between January 2017 and May 2019. Patients who received a tuberculin skin test (TST) and/or an interferon gamma release assay (IGRA) were included.

RESULTS

We included 13 353 tests among 11 622 patients; 93.9% of the tests were completed. Of 199 patients with positive tests for whom TB infection evaluation was clinically appropriate, 59.3% completed treatment or were recommended to not start treatment. Age 12-17 years (vs < 5 years; aOR 1.59; 95% CI, 1.32-1.92), non-English/non-Spanish language preference (vs English; aOR, 1.34; 95% CI, 1.02-1.76), and receipt of an IGRA (vs TST, aOR, 30.82; 95% CI, 21.92-43.34) were associated with increased odds of testing completion. Odds of testing completion decreased as census tract social vulnerability index quartile increased (ie, social vulnerability worsened; most vulnerable quartile vs least vulnerable quartile, aOR, 0.77; 95% CI, 0.60-0.99). Odds of completing treatment after starting treatment were higher in females (vs males; aOR, 2.35; 95% CI, 1.14-4.85) and were lower in patients starting treatment in a primary care clinic (vs TB/infectious diseases clinic; aOR, 0.44; 95% CI, 0.27-0.71).

CONCLUSIONS

Among children with a high proportion of negative TB infection tests, completion of testing was high, but completion of evaluation and treatment was moderate. Transitions toward IGRA testing will improve testing completion; interventions addressing social determinants of health are important to improve treatment completion.

Isoniazid preventive therapy completion in children under 5 years old who are contacts of tuberculosis cases in Lima, Peru: study protocol for an open-label, cluster-randomized superiority trial

BACKGROUND

Children < 5 years old in contact with TB cases are at high risk for developing severe and fatal forms of TB. Contact investigation, BCG vaccination, and isoniazid preventive therapy (IPT) are the most effective strategies to prevent TB among children. However, the implementation of IPT faces challenges at several stages of the cascade of care of TB infection among children, particularly those less than 5 years old. In Peru, a large proportion of children do not complete IPT, which highlights the need to design effective interventions that enhance preventive therapy adherence and completion. Although the body of evidence for such interventions has grown, interventions in medium TB incidence settings are lacking. This study aims to test the effectiveness, acceptability, and feasibility of an intervention package to increase information and motivation to complete IPT among children < 5 who have been prescribed IPT.

METHODS

An open-label, cluster-randomized superiority trial will be conducted in two districts in South Lima, Peru. Thirty health facilities will be randomized as clusters, 10 to the intervention and 20 to control (standard of care). We aim to recruit 10 children from different households in each cluster. Participants will be caretakers of children aged < 5 years old who initiated IPT. The intervention consists of educational material, and short message services (SMS) reminders and motivators. The primary outcomes will be the proportion of children who picked up > 90% of the 24 weeks of IPT (22 pick-ups) and the proportion of children who picked up the 24 weeks of IPT. The standard of care is a weekly pick-up with monthly check-ups in a health facility. Feasibility and acceptability of the intervention will be assessed through an interview with the caretaker.

DISCUSSION

Unfavorable outcomes of TB in young children, high effectiveness of IPT, and low rates of IPT completion highlight the need to enhance adherence and completion of IPT among children < 5 years old. Testing of a context-adapted intervention is needed to improve IPT completion rates and therefore TB prevention in young children.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03881228. Registered on March 19, 2019.

Testing and Scaling Interventions to Improve the Tuberculosis Infection Care Cascade

Tuberculosis (TB) preventive therapy (TPT) is increasingly recognized as the key to eliminating tuberculosis globally and is particularly critical for children with TB infection or who are in close contact with individuals with infectious TB. But many barriers currently impede successful scale-up to provide TPT to those at high risk of TB disease. The cascade of care in TB infection (and the related contact management cascade) is a conceptual framework to evaluate and improve the care of persons who are potential candidates for TPT. This review summarizes recent literature on barriers and solutions in the TB infection care cascade, focusing on children in both high- and low-burden settings, and drawing from studies on children and adults. Identifying and closing gaps in the care cascade will require the implementation of tools that are new (e.g. computer-assisted radiography) and old (e.g. efficient contact tracing), and will be aided by innovative implementation study designs, quality improvement methods, and shared clinical practice with primary care providers.

Determinants of losses in the tuberculosis infection cascade of care among children and adolescent contacts of pulmonary tuberculosis cases: A Brazilian multi-centre longitudinal study

Background

Approximately 10% of the global tuberculosis (TB) burden is in children. Identification, diagnosis, and early treatment of Mycobacterium tuberculosis infection (TBI) is critical to prevent progression to TB in children. The risk of TB, including severe disease, is highest in children <5 years old. We evaluated the cascade of TBI care among child and adolescent TB contacts to identify factors associated with losses in the cascade.

Methods

Close contacts ≤ 18 years old of pulmonary TB patients enrolled between 2015 and 2019 in a multi-centre Brazilian cohort were followed for up to 24 months and classified according to age groups: <5 years, 5-9 years, 10-14 years and 15-18 years. Data on clinical investigation, radiographic examination, IGRA testing at baseline and 6 months, initiation and completion of TB preventive treatment (TPT) were collected. Multivariable regression analyses identified factors associated with TBI and losses in the cascade of care in children and adolescents.

Findings

Among 1795 TB contacts initially identified, 530 (29·5%) were ≤18 years old. Losses for all steps in the cascade were especially high in children <5 years old (88%) because at this age all contacts are recommended to initiate TPT. As a proportion of all children, completion of TPT was low (between 10% and 13%) in all age-groups. Furthermore, multivariable regression revealed that younger age of contacts and TB index cases who were female, had pulmonary cavities, and persistent cough were independently associated with losses in the cascade of care among persons ≤18 years old.

Interpretation

Losses in the TBI cascade were the highest among children <5 years, which was the group at highest risk for TB among the four age groups. The findings highlight the need to improve screening, initiation, and completion of TPT of young children who are close contacts of people with TB in Brazil.

Funding

National Institutes of Allergy and Infectious Diseases.

Child Contact Case Management-A Major Policy-Practice Gap in High-Burden Countries

The 2021 Global Tuberculosis (TB) report shows slow progress towards closing the pediatric TB detection gap and improving the TB preventive treatment (TPT) coverage among child and adolescent contacts. This review presents the current knowledge around contact case management (CCM) in low-resource settings, with a focus on child contacts, which represents a key priority population for CCM and TPT. Compelling evidence demonstrates that CCM interventions are a key gateway for both TB case finding and identification of those in need of TPT, and their yield and effectiveness should provide a strong rationale for prioritization by national TB programs. A growing body of evidence is now showing that innovative models of care focused on community-based and patient-centered approaches to household contact investigation can help narrow down the CCM implementation gaps that we are currently facing. The availability of shorter and child-friendly TPT regimens for child contacts provide an additional important opportunity to improve TPT acceptability and adherence. Prioritization of TB CCM implementation and adequate resource mobilization by ministries of health, donors and implementing agencies is needed to timely close the gap.

Challenges Perceived by Health Care Providers for Implementation of Contact Screening and Isoniazid Chemoprophylaxis in Karnataka, India

Background: In India, challenges in pediatric TB contact screening and chemoprophylaxis initiation are still underexplored. Elucidating these challenges will help in better implementation of the programme at the grass-roots level thereby helping in early detection of pediatric cases and timely initiation of preventive therapy. This study aimed at exploring the challenges faced by the health care provider in contact screening and chemoprophylaxis initiation implementation of the pediatric household contacts. Methods: A qualitative study was conducted in the districts of Bengaluru and Udupi and in-depth interviews of key participants were adopted to explore the challenges. Qualitative data analysis was done after developing transcripts by generating themes and codes. Results: The key challenges were identified as stigma towards the disease, migrant patients with changing address, difficulty in sample collection, anxiety among parents due to long duration of the prophylactic treatment and adherence to IPT is not well documented, inadequate transportation from rural areas, and the ongoing COVID-19 pandemic. Conclusions: It is important for the National TB programme to address these challenges efficiently and effectively. Innovative solutions, feasible engagements, and massive efforts are to be taken by the programme to improve contact screening and isoniazid chemoprophylaxis implementation.