Epidemiology of tuberculosis among US- and foreign-born children and adolescents in the United States, 1994-2007

Review of Pediatric Tuberculosis in the Aftermath of COVID-19

In 2014, the World Health Organization developed the End Tuberculosis Strategy with the goal of a 95% reduction in deaths from tuberculosis (TB) by 2035. The start of the COVID-19 pandemic and global lockdown has had a major impact on TB awareness, screening, diagnosis, and prompt initiation of treatment, inevitably leading to a significant setback. We explore pediatric tuberculosis through the lens of the COVID-19 era, investigating how COVID-19 has impacted pediatric TB cases in different regions of the world and what the implications are for management moving forward to mitigate these effects. Furthermore, in light of recent findings showing how exposed infants and children are at higher risk than we thought of contracting the disease, greater attention and resources are needed to prevent further downward trends.

Characteristics of Emergency Department Patient Visits Referred for Follow-Up Medical Care After Discharge, National Hospital Ambulatory Medicare Care Survey—United States, 2018

Objective

To describe characteristics of a nationally representative sample of patient visits that ended with a referral for follow-up medical care after discharge from hospital emergency department (ED) visits.

Methods

We used 2018 National Hospital Ambulatory Medical Care Survey data to identify patient characteristics associated with higher rates of visits with referrals for follow-up medical care after ED discharge from nonfederal short-stay and general hospitals throughout the United States. Referral included categories of all disposition variables that indicated referral to a source of care consistent with the patient’s clinical condition at ED discharge.

Results

Approximately 97 million of 130 million visits (29 700/100 000 US resident population) were referred for follow-up medical care during 2018. Visit referral rates were higher among females (33 100) than among males (26 300/100 000 population); higher among Black patients (61 700) than among White patients (25 600/100 000 population); highest in the South (33 200/100 000 population); and similar rates in Nonmetropolitan (29 900/100 000 population) and Metropolitan Statistical Areas (30 200/100 000 population). Visit referral rates were higher for patients with Medicaid/Children's Health Insurance Program (CHIP) (66 900) than those with Medicare (31 500) or private insurance (14 000/100 000 population). Abnormal clinical findings and injuries were the discharge diagnoses most often referred for follow-up medical care.

Conclusion

Higher visit referral rates were observed among female sex, non-Hispanic Black race, Medicaid/CHIP, abnormal clinical findings, and injuries. Future studies might reveal reasons that prompted higher referral rates among various patients’ characteristics.

Association between Birth Region and Time to Tuberculosis Diagnosis among Non-US-Born Persons in the United States

Approximately 90% of tuberculosis (TB) cases among non–US-born persons in the United States are attributable to progression of latent TB infection to TB disease. Using survival analysis, we investigated whether birthplace is associated with time to disease progression among non–US-born persons in whom TB disease developed. We derived a Cox regression model comparing differences in time to TB diagnosis after US entry among 19 birth regions, adjusting for sex, birth year, and age at entry. After adjusting for age at entry and birth year, the median time to TB diagnosis was lowest among persons from Middle Africa, 128 months (95% CI 116–146 months) for male persons and 121 months (95% CI 108–136 months) for female persons. We found time to TB diagnosis among non–US-born persons varied by birth region, which represents a prognostic indicator for progression of latent TB infection to TB disease.

Towards elimination of childhood and adolescent tuberculosis in the Netherlands: an epidemiological time-series analysis of national surveillance data

BACKGROUND

Tuberculosis (TB) in children and adolescents is a sentinel event for ongoing transmission. In the Netherlands, epidemiological characteristics of childhood and adolescent TB have not been fully evaluated. Therefore, we aimed to assess TB epidemiology within this population to provide guidance for TB elimination.

METHODS

A retrospective time-series analysis using national surveillance data from 1993-2018 was performed in children (aged <15 years) and adolescents (aged 15-19 years) with TB. Poisson regression models offset with log-population size were used to estimate notification rates and rate ratios. Trends in notification rates were estimated using average annual percentage changes (AAPC) based on the segmented linear regression analysis.

RESULTS

Among 3899 children and adolescents with TB notified during 1993-2018, 2418 (62%) were foreign-born (725 (41.3%) out of 1755 children and 1693 (78.9%) out of 2144 adolescents). The overall notification rate in children was 2.3 per 100 000 person-years, declining steadily during the study period (AAPC -10.9%, 95% CI -12.6--9.1). In adolescents, the overall notification rate was 8.4 per 100 000 person-years, strongly increasing during 1993-2001 and 2012-2018. Compared to Dutch-born children and adolescents, substantially higher notification rates were observed among African-born children and adolescents (116.8 and 316.6 per 100 000 person-years, respectively). Additionally, an increasing trend was observed in African-born adolescents (AAPC 18.5%, 95% CI 11.9-25.5). Among the foreign-born population, those from countries in the horn of Africa contributed most to the TB caseload.

CONCLUSION

TB notification rate among children was low and constantly declining across different demographic groups. However, heterogeneities were shown in adolescents, with an increasing trend in the foreign-born, particularly those from Africa.

Better Choice, Better Health? Social Integration and Health Inequality among International Migrants in Hangzhou, China

The aim of this study is to investigate the impact of social integration and socioeconomic status on immigrant health in China. Taking the framework of social determinants of health (SDH) as the theoretical starting point, this paper uses the Hangzhou sample of the 2018 Survey of Foreigners in China (SFRC2018) to explore two core factors affecting the health inequality of international migrants in China: the level of social integration following settlement, and socioeconomic status before and after coming to China. The results show that having a formal educational experience in China helped improve both the self-rated health status and self-assessed change in health of international migrants; that the socioeconomic status of an emigrant's home country affected self-rated health; and that the self-assessed change in health of immigrants from developing countries was significantly higher than those from developed countries. This study concludes that the health inequalities of immigrant populations in China must be understood in the context of China's specific healthcare system and treatment structure.

Epidemiology of tuberculosis among children and adolescents in the USA, 2007-17: an analysis of national surveillance data

BACKGROUND

Understanding tuberculosis epidemiology among children and adolescents informs treatment and prevention efforts, and efforts to eliminate disparities in tuberculosis incidence and mortality. We sought to describe the epidemiology of children and adolescents with tuberculosis disease in the USA, including tuberculosis incidence rates by parental country of birth and for US territories and freely associated states, which have not been previously described.

METHODS

We analysed data for children aged younger than 15 years and adolescents aged 15-17 years with tuberculosis disease reported to the National Tuberculosis Surveillance System during 2007-17, and calculated tuberculosis incidence rates using population estimates from the US Census Bureau.

FINDINGS

During 2010-17, 6072 tuberculosis cases occurred among children and adolescents; of these, 5175 (85%) of 6072 occurred in the 50 US states or the District of Columbia and 897 (15%) of 6072 in US-affiliated islands. In US states, 3520 (68%) of 5175 cases occurred among US-born people overall, including 2977 (76%) of 3896 children and 543 (42%) of 1279 adolescents. The incidence rate among children and adolescents was 1·0 per 100 000 person-years during 2007-17 and declined 47·8% (95% CI -51·4 to -44·1) during this period. We observed disproportionately high tuberculosis rates among children and adolescents of all non-white racial or ethnic groups, people living in US-affiliated islands, and children born in or with parents from tuberculosis-endemic countries.

INTERPRETATION

Overall, tuberculosis incidence among children and adolescents in the USA is low and steadily declining, but additional efforts are needed to eliminate disparities in incidence and mortality.

FUNDING

US Centers for Disease Control and Prevention.

Interferon-γ Release Assay Performance for Tuberculosis in Childhood

BACKGROUND

Interferon-γ release assays (IGRAs) are important adjunctive tests for diagnosing tuberculosis (TB) disease in children.

METHODS

We analyzed California TB registry data for patients ≤18 years with laboratory-confirmed TB disease during 2010-2015 to identify case characteristics associated with test selection and performance and measure IGRA sensitivity.

RESULTS

In total, 778 cases of TB were reported; 360 were laboratory confirmed. Indeterminate IGRAs were associated with being <1 year old (prevalence rate ratio 9.23; 95% confidence interval 2.87 to 29.8) and having central nervous system disease (prevalence rate ratio 2.69; 95% confidence interval 1.06 to 6.86) on multivariable analysis. Ninety-five children had both an IGRA and tuberculin skin test (TST) performed. Among those, the sensitivity of IGRA in 5- to 18-year-olds was 96% (66 out of 69) vs 83% (57 out of 69) for TST (P = .01); IGRA sensitivity compared with TST in children ages 2 to 4 was 91% (10 out of 11) vs 91% (10 out of 11) (P > .99), and the sensitivity compared with TST in children aged <2 years was 80% (12 out of 15) vs 87% (13 out of 15) (P > .99).

CONCLUSIONS

This is the largest North American analysis of IGRA use and performance among children with TB disease. In children <5 years old, IGRA sensitivity is similar to TST, but sensitivity of both tests are reduced in children <2 years old. Indeterminate results are higher in children <1 year old and in central nervous system disease. In children ≥5 years old with laboratory-confirmed TB, IGRA has greater sensitivity than TST and should be considered the preferred immunodiagnostic test..

Childhood multidrug-resistant tuberculosis in the European Union and European Economic Area: an analysis of tuberculosis surveillance data from 2007 to 2015

Confirming tuberculosis (TB) in children and obtaining information on drug susceptibility is essential to ensure adequate treatment. We assessed whether there are gaps in diagnosis and treatment of multidrug-resistant (MDR) TB in children in the European Union and European Economic Area (EU/EEA), quantified the burden of MDR TB in children and characterised cases. Methods: We analysed surveillance data from 2007 to 2015 for paediatric cases younger than 15 years. Results: In that period, 26 EU/EEA countries reported 18,826 paediatric TB cases of whom 4,129 (21.9%) were laboratory-confirmed. Drug susceptibility testing results were available for 3,378 (17.9%), representing 81.8% of the confirmed cases. The majority (n = 2,967; 87.8%) had drug-sensitive TB, 249 (7.4%) mono-resistant TB, 64 (1.9%) poly-resistant TB, 90 (2.7%) MDR TB and eight (0.2%) had extensively drug-resistant (XDR) TB. MDR TB was more frequently reported among paediatric cases with foreign background (adjusted odds ratio (aOR) = 1.73; 95% confidence interval (95% CI): 1.12–2.67) or previous TB treatment (aOR: 6.42; 95% CI: 3.24–12.75). Successful treatment outcome was reported for 58 of 74 paediatric MDR TB cases with outcome reported from 2007 to 2013; only the group of 5–9 years-olds was significantly associated with unsuccessful treatment outcome (crude odds ratio (cOR) = 11.45; 95% CI: 1.24–106.04). Conclusions: The burden of MDR TB in children in the EU/EEA appears low, but may be underestimated owing to challenges in laboratory confirmation. Diagnostic improvements are needed for early detection and adequate treatment of MDR TB. Children previously treated for TB or of foreign origin may warrant higher attention.

Factors Affecting Outcome of Tuberculosis in Children in Italy: An Ecological Study

INTRODUCTION

Tuberculosis is a major problem in children depending on their families for management and a re-emerging disease in low incidence countries, where foreign-born cases account for a large proportion of cases.

METHODS

We investigated socioeconomic features of families and their impact on management and outcome of children with tuberculosis disease seen at a tertiary care centre for paediatric infectious diseases in Italy.

RESULTS

Forty-nine Italian and 30 foreign-origin children were included. Children from foreign families had more complicated diseases (20 % vs 0 %; P = 0.002), harbored more drug resistant strains (20 % vs 2 %; P = 0.011), showed longer hospital stay (12 ± 13.1 vs 5.1 ± 6.5 days; P = 0.012) and higher proportion of missed medical visits (15.7 ± 16 vs 8.6 ± 9.6; P ≤ 0.042) than those from Italian families. Harboring drug resistant strains was an independent risk factor for complicated disease course (OR: 72.98; 95 %CI: 1.54-3468.58; P = 0.029), and this risk is higher in children from Eastern Europe (OR: 10.16; 95 %CI: 1.7-61.9; P = 0.012).

CONCLUSIONS

Children from immigrant families showed an increased risk of complicated course of tuberculosis due to a higher rate of resistant strains and raise problems in clinical management. Specific protocols are needed to support these populations ensuring easy access to health services and monitoring.

Increased adolescent knowledge and behavior following a one-time educational intervention about tuberculosis

OBJECTIVE

To evaluate the impact of a tuberculosis (TB) educational intervention (EI) on change in adolescent student knowledge and participation in a TB prevention program.

METHODS

From 2/2013-5/2015, students from 2 high schools in Houston, TX participated. The 25-min EI discussed TB bacteriology, epidemiology, symptoms, and indications for TB testing/treatment. Students completed pre- and post-quizzes. Immediately after the EI, students were invited to participate in voluntary TB risk-factor screening, testing and treatment. At 6 months, focus groups were conducted.

RESULTS

895 students attended the EI. 827 students (92%) completed the EI quizzes. Knowledge improved by 12% (pre: 70%; post: 82%, p<0.001); 78% shared their TB knowledge. Following the EI, 671/827 (81%) enrolled in a TB prevention program. Focus groups indicated that the EI stimulated student learning about TB and increased their willingness to participate.

CONCLUSION

A brief, one-time, TB EI is an effective method to encourage adolescents to learn about TB and motivate their uptake of TB risk-factor screening, testing and treatment. Similar EIs should accompany TB prevention programs targeting adolescents.

PRACTICE IMPLICATIONS

The study's procedures could be considered for incorporation into school-based TB prevention programs to improve the identification, testing and treatment of adolescents at risk for TB.

School-based Study to Identify and Treat Adolescent Students at Risk for Tuberculosis Infection

BACKGROUND

Screening for and treating tuberculosis (TB) infection in children and adolescents is an effective way of decreasing future TB cases. However, current approaches leave many children at risk for TB unidentified.

METHODS

We recruited adolescent students from 2 public high schools (a magnet and a low-income) in the Houston Independent School District. Compared with the magnet school, the student population at the low-income school was larger, primarily Hispanic and economically disadvantaged. Students were educated about TB, and parents completed a risk factor questionnaire. Students with TB risk factors were tested using 2 interferon gamma release assays (IGRAs). Those with a positive IGRA received a 12-dose regimen of weekly isoniazid/rifapentine (3HP) administered via direct observation at school.

RESULTS

Nine hundred twenty-five students received TB education; 73% of their parents submitted the TB questionnaire. Eighty-six percent of students (n = 415) with a TB risk factor identified on the study questionnaire agreed to IGRA testing. Sixteen students had at least one positive IGRA (1% [magnet], 4.1% [low-income]; P = 0.005). Recent student travel to a high-risk country (7) or contact with TB disease (2) were associated with IGRA positivity (P < 0.05). All students with a positive IGRA accepted, tolerated and completed 3HP treatment at school.

CONCLUSIONS

School-based TB education, screening, testing using IGRAs and administration of 3HP treatment is feasible to improve the identification and treatment of adolescent students at risk for TB.

How to manage children who have come into contact with patients affected by tuberculosis

Childhood tuberculosis (TB) indicates a recent infection, particularly in children aged < 5 years, and therefore is considered a sentinel event insofar as it highlights the presence of an undiagnosed or untreated source case. The risk of acquiring TB is directly proportional to the number of bacilli to which a subject is exposed and the environment in which the contact occurred. This document contains the recommendations of a group of Italian scientific societies for managing a child exposed to a case of TB based on an analysis of the risk factors for acquiring latent tuberculous infection (LTBI) and developing the disease, and the particular aspects TB transmission during the first years of life. The guidance includes a detailed description of the methods used to identify the index case, the tests that the exposed child should receive and the possibilities of preventive chemoprophylaxis depending on the patient's age and immune status, the chemotherapy and monitoring methods indicated in the case of LTBI, the management of a child who has come into contact with a case of multidrug-resistant or extensively drug-resistant TB, and the use of molecular typing in the analysis of epidemics. The group of experts identified risk factors for tuberculous infection and disease in pediatric age as well as gave recommendation on management of contacts of cases of TB according to their age, risk factors and exposure to multidrug-resistant or extensively drug-resistant TB.

Domestic impact of tuberculosis screening among new immigrants to Ontario, Canada

BACKGROUND

All Canadian immigrants undergo screening for tuberculosis (TB) before immigration, and selected immigrants must undergo postimmigration surveillance for the disease. We sought to quantify the domestic health impact of screening for TB in all new immigrants and to identify mechanisms to enhance effectiveness and efficiency of this screening.

METHODS

We linked preimmigration medical examination records from 944,375 immigrants who settled in Ontario between 2002 and 2011 to active TB reporting data in Ontario between 2002 and 2011. Using a retrospective cohort study design, we measured birth country-specific rates of active TB detected through preimmigration screening and postimmigration surveillance. We then quantified the proportion of active TB cases among residents of Ontario born abroad that were detected through postimmigration surveillance. Using Cox regression, we identified independent predictors of active TB postimmigration.

RESULTS

Immigrants from 6 countries accounted for 87.3% of active TB cases detected through preimmigration screening, and 10 countries accounted for 80.4% of cases detected through postimmigration surveillance. Immigrants from countries with a TB (all-sites) incidence rate of less than 30 cases per 100 000 persons resulted in pre- and postimmigration detection of 2.4 and 0.9 cases per 100 000 immigrants, respectively. Postimmigration surveillance detected 2.6% of active TB cases in Ontario residents born abroad, and TB was detected a median of 18 days earlier in those undergoing surveillance than in those who were not referred to surveillance or who did not comply. Predictors of active TB postimmigration included radiographic markers of old TB, birth country, immigration category, location of application for residency, immune status and age.

INTERPRETATION

Universal screening for TB in new immigrants has a modest impact on the domestic burden of active TB and is highly inefficient. Focusing preimmigration screening in countries with high incidence rates and revising criteria for postimmigration surveillance could increase the effectiveness and efficiency of screening.

Evaluation of QuantiFERON-TB gold in-tube and tuberculin skin tests among immigrant children being screened for latent tuberculosis infection

BACKGROUND

Centers for Disease Control and Prevention requirements for pre-immigration tuberculosis (TB) screening of children 2- to 14-years old permit a tuberculin skin test (TST) or an interferon-gamma release assay (IGRA). Few data are available on the performance of IGRAs versus TSTs in foreign-born children.

METHODS

We compared the performance of TST and QuantiFERON-TB (QFT) Gold In-Tube in children 2- to 14-years old applying to immigrate to the United States from Mexico, the Philippines and Vietnam, using diagnosis of TB in immigrating family members as a measure of potential exposure.

RESULTS

We enrolled 2520 children: 664 (26%) were TST+ and 142 (5.6%) were QFT+. One hundred and eleven (4.4%) were TST+/QFT+, 553 (21.9%) were TST+/QFT- and 31 (1.2%) were TST-/QFT+. Agreement between tests was poor (κ = 0.20). Although positive results of both tests were significantly associated with older age (relative risks [RR] TST+, 1.64; 95% confidence interval [CI]: 1.36-1.97; RR QFT+, 3.05; 95% CI: 1.72-5.38) and with the presence of TB in at least 1 immigrating family member (RR TST+, 1.40; 95% CI: 1.12-1.75; RR QFT+ 2.24; 95% CI: 1.18-4.28), QFT+ results were more strongly associated with both predictive variables.

CONCLUSIONS

The findings support the preferential use of QFT over TST for pre-immigration screening of foreign-born children 2 years of age and older and lend support to the preferential use of IGRAs in testing foreign-born children for latent TB infection.

Tuberculosis in children

Tuberculosis (TB) is a major, but often unrecognised, cause of disease and death in young children from countries with high TB incidence rates among adults. It is also relevant to paediatricians in low-incidence countries, such as Australia, because of increased international travel, immigration and refugee resettlement. This manuscript provides a brief overview of the global TB disease burden, the natural history of disease in children, and offers guidance on the prevention, diagnosis and treatment of TB in children.

Epidemiology and disease burden of tuberculosis in children: a global perspective

Our understanding of the tuberculosis (TB) epidemic in children is incomplete due to challenges in diagnosis and reporting. Children have also been largely excluded from research and advocacy. However, the tide appears to be turning and interest in pediatric TB is increasing. In this article, we explore the epidemiology of childhood TB by first reviewing the natural history of TB in children and the factors that impact on each of the stages from exposure to disease. We then discuss how these factors affect what we see at a country and regional level. Finally, we assess the burden of childhood TB globally.

The 10-year Trend of TB Rate in West Azerbaijan Province, Iran from 2001 to 2010

BACKGROUND

The present study aimed to explore some risk factors affected the mean of the number of tuberculosis (TB) in West Azerbaijan Province, Iran between 2001 and 2010.

METHODS

Our time series study analyzed the data of 2,560 TB patients as registered with TB Patients Care System in West Azerbaijan Province from early 2001 to 2010. A checklist was prepared for collecting the data and they were then analyzed in SPSS V.16 software.

RESULTS

The percentage of male and percentage of female were close to each other (52.2% against 47.8%, respectively). A significant increasing trend of TB rate was found over the years of 2001and 2010 with a pick at 2008 (P<0.001). A Poisson log-linear analysis showed that the most important risk factor of the trend of rate was the level of education so that people with primary level or with illiterate level had a statistically significant TB rate of 5.21 (4.66-5.81), adjusted for years. The next risk factor was type of TB and place of residency, i.e., pulmonary TB cases had higher rate than External pulmonary TB cases (RR=1.67; (1.54-1.80). The last factor with the lowest risk was BCG with RR=1.29 (1.20-1.40) for people who received BCG compared to the people who had not received it.

CONCLUSION

Although the co morbidity of AIDS and TB was not a major problem, it is necessary that special attention be paid to the way of implementing the TB control program based on the demographic risk factors of the study population.

Increasing incidence of tuberculosis in Tuscan youth, 1997 to 2011

Data from 484 children (median age: 6 years; 46.5% immigrants) hospitalized for tuberculosis in 31 Tuscan hospitals in 1997-2011 were analyzed. Incidence increased from 7.3 (95% confidence interval: 4.9-9.4) to 12.5 (95% confidence interval: 9.6-15.4) per 100,000 (P=0.009). Increases were particularly profound in children<5 years of age, reaching 13.3 (95% confidence interval: 7.8-18.9; P<0.0001 for 2011 vs.1997) per 100,000. Pediatric tuberculosis is a major issue in Tuscany.

Spectrum of Disease in Children Treated for Tuberculosis at a Tertiary Children's Hospital in Australia

BACKGROUND

Tuberculosis (TB) notification rates in Australia have plateaued at a low level, but the pediatric disease burden remains poorly described. Child cases provide a marker of recent transmission and present unique diagnostic challenges.

METHODS

We performed an audit of all children (<18 years of age) treated for TB at the Children's Hospital at Westmead, Sydney, Australia from January 2008 to December 2011. Demographics, clinical presentation, diagnostics, disease profile, treatment, and outcome were reviewed.

RESULTS

A total of 25 children were treated for TB: 15 had microbiologically confirmed TB; 7 were diagnosed on clinical grounds; and in 3, an alternate diagnosis was established (2 bacille Calmette-Guérin disease and 1 atypical mycobacterial infection). Of the 22 TB cases, 21 had a history of immigration or travel to a TB-endemic country and 4 reported recent contact with a TB source case within Australia. Isolated intrathoracic TB was documented in 16 (72%) cases. Symptoms on presentation included the following: lethargy, weakness, or malaise (75%); fever (73%); and cough (64%). Among the 15 children with microbiologically confirmed TB, 11 (73%) were positive by culture and 11 of 13 (85%) by polymerase chain reaction test. Tuberculin skin test was positive (≥10 mm) in 80% (16 of 20) of cases, and interferon-gamma release assay was positive in 87% (13 of 15) of cases. All children received directly observed therapy and recovered.

CONCLUSIONS

This series demonstrates the broad spectrum of disease with which pediatric TB cases present and the need for ongoing vigilance. A more comprehensive review of pediatric TB cases throughout Australia would be informative.

Adolescents with tuberculosis: a review of 145 cases

BACKGROUND

Adolescents comprise one-third of pediatric tuberculosis (TB) cases in the United States, but there are few specific data on the epidemiology and clinical course in this population.

METHODS

This was a retrospective review of adolescents (12-18 years old) seen at a Children's Tuberculosis Clinic in Houston, TX, from 1987 to 2012.

RESULTS

One hundred forty-five adolescents were identified; median age was 15.4 years: 50% female, 55% were Hispanic, 26% black, 13% Asian and 1% white; 54 were born abroad. Diagnoses were made after symptomatic presentation in 79%, during contact investigations in 14% and after screening tuberculin skin testing in the remainder. The most common symptoms were fever (63%), cough (60%) and weight loss (30%), but 21% were asymptomatic at diagnosis. Only 8% of adolescents with intrathoracic TB had hemoptysis. One hundred fourteen (78.6%) had isolated intrathoracic TB, 4 (2.8%) had intra- and extrathoracic TB and 27 (18.6%) had extrathoracic TB. The most common sites of extrathoracic TB were peripheral lymphadenopathy (10) and meningitis (6). The most common radiographic findings were infiltrates (34%), lymphadenopathy (27%), cavitary lesions (26%), pleural effusions (19%) and miliary disease (10%). Acid-fast bacillus smears and mycobacterial cultures were attempted for 97 of 118 adolescents with intrathoracic and 22 of 27 with extrathoracic disease, respectively, resulting in smear/culture positivity in 25% and 54% and 18% and 45%, respectively. Two patients died, 2 had relapse, 7 had significant sequelae and 92% recovered without complication. Seventy three percent of cases potentially were preventable.

CONCLUSIONS

The clinical, radiologic and microbiologic findings in adolescents with TB have features seen in both younger children and adults; most cases were preventable.

Diagnosis, treatment and prevention of tuberculosis in children

In Australia, tuberculosis notification rates have plateaued at a low level and disease is highly concentrated in immigrant communities where children may be affected. Many clinicians regard tuberculosis as an adult disease, hence it is rarely considered in the differential diagnosis of sick children. This paper provides a brief overview of the natural history of the disease in children to demonstrate the importance of taking a careful tuberculosis exposure history. It also provides guidance regarding the diagnosis, treatment and prevention of tuberculosis in children. The management of paediatric cases is not difficult if important differences with adult disease are carefully considered; these differences are discussed in detail.

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.

Integrating social epidemiology into immigrant health research: a cross-national framework

Scholarship on immigrant health has steadily increased over the past two decades. This line of inquiry is often approached as a "specialty" topic involving a discrete de-contextualized population, rather than a topic that is central for understanding patterns of population health within and between sending and receiving countries. Frequently immigrant health research employs theoretical frameworks (e.g., acculturation) that emphasize cultural explanations, while less commonly utilized is the "social determinants of health" framework, which emphasizes social and structural explanations. Drawing upon literature in the fields of economics, sociology of immigration, and social epidemiology, we present a conceptual framework for understanding immigrant health from a cross-national perspective. We discuss the theoretical foundations of this framework; the methodological challenges for undertaking research on immigration and health using this framework; examples of emerging research in this area; and directions for future research. Progress in immigrant health research and population health improvements can be achieved through an enhanced understanding of population health patterns in sending and receiving societies. Immigrant health research needs to be better integrated into social epidemiology. Concurrently, immigrant health research offers conceptual, empirical, and analytic opportunities to advance social epidemiological research. Together, scholarship in immigrant health and social epidemiology can make significant contributions toward one of their mutual and ultimate goals: to improve knowledge about population health.

Scaling up interventions to achieve global tuberculosis control: progress and new developments

Tuberculosis is still one of the most important causes of death worldwide. The 2010 Lancet tuberculosis series provided a comprehensive overview of global control efforts and challenges. In this update we review recent progress. With improved control efforts, the world and most regions are on track to achieve the Millennium Development Goal of decreasing tuberculosis incidence by 2015, and the Stop TB Partnership target of halving 1990 mortality rates by 2015; the exception is Africa. Despite these advances, full scale-up of tuberculosis and HIV collaborative activities remains challenging and emerging drug-resistant tuberculosis is a major threat. Recognition of the effect that non-communicable diseases--such as smoking-related lung disease, diet-related diabetes mellitus, and alcohol and drug misuse--have on individual vulnerability, as well as the contribution of poor living conditions to community vulnerability, shows the need for multidisciplinary approaches. Several new diagnostic tests are being introduced in endemic countries and for the first time in 40 years a coordinated portfolio of promising new tuberculosis drugs exists. However, none of these advances offer easy solutions. Achievement of international tuberculosis control targets and maintenance of these gains needs optimum national health policies and services, with ongoing investment into new approaches and strategies. Despite growing funding in recent years, a serious shortfall persists. International and national financial uncertainty places gains at serious risk. Perseverance and renewed commitment are needed to achieve global control of tuberculosis, and ultimately, its elimination.

Pediatric tuberculosis in Stockholm: a mirror to the world

BACKGROUND

Increasing international migration has changed the epidemiology of tuberculosis (TB) in Europe. Little is published on clinical manifestations and epidemiology in children in this new era.

METHODS

Clinical and laboratory data on all children with TB in Stockholm between 2000 and 2009 were entered into a database and retrospectively completed with information from case records. Population data, including parents' country of birth, were obtained from Statistics Sweden.

RESULTS

TB was diagnosed in 147 children <18 years of age (78 confirmed, 12 probable, 57 possible). Fifty-six children (38%) presented clinically, and 91 were identified by screening procedures. Ninety children (61%) were born in high-endemic countries and 38 in Sweden to parents from such countries. The incidence was 451/100,000 person years among children born in Somalia, 44 among those born in other high-endemic countries, and 13 among Swedish-born children with parents from high-endemic countries. All but 1 of the 19 Swedish-born children with Swedish parents belonged to a single outbreak. Median age was 12 years. Severe, adult-type TB was predominantly observed in adolescents, whereas young children presented mild, primary disease that was diagnosed at the time of screening. The 78 positive cultures were traced back to 67 strains. Resistance to any first-line drug was present in 25% of the strains, of which 4 were multidrug resistant.

CONCLUSIONS

Active TB in Stockholm is common in children born in high-endemic countries, especially Somalia. The most severe cases are seen in adolescents. The high prevalence of antimicrobial resistance is a cause for concern.

Childhood TB Surveillance: Bridging the Knowledge Gap to Inform Policy

Tuberculosis (TB) is a leading cause of death globally. Natural history studies show that young children are at particularly high risk of progression to active TB and severe, disseminated disease following infection. Despite this, high-quality regional and global surveillance data on the burden of childhood TB are lacking. We discuss the unique aspects of TB in children that make diagnosis and therefore surveillance challenging; the limitations of available surveillance data; other data which provide insights into the true burden of childhood TB. Improved surveillance is among the key research priorities identified for childhood TB, but progress to date has been slow. Recent advances in TB diagnostics, and standardized clinical diagnostic guidelines and case definitions, all provide opportunities for new strategies to improve surveillance. Better-quality data on the burden and trends of childhood TB will inform and improve both public health policy and clinical practice.