Pediatric TB: issues related to current and future treatment options

Direct economic burden of patients with tuberculous meningitis in western China

OBJECTIVE

To estimate the direct economic burden of tuberculous meningitis (TBM) in China for the first time.

METHODS

Patients who were first diagnosed with TBM from December 2015 to December 2018 in Western China Hospital were enrolled. We retrospectively collected data on demographic and clinical features, resource utilization, costs, and long-term outcomes. The patients were followed up for 15-53 months. We performed a cost-of-illness study and analyzed the cost contributors with a generalized linear model.

RESULTS

In total, the cases of 154 TBM patients (95 males, 59 females, aged 14-82 years) were reviewed. The average total direct cost per person was USD (United States dollars) 9,484 (range 1,822-67,285), with a mean direct medical cost of USD 8,901 (range 1,189-67,049). The average inpatient cost and drug cost after discharge were USD 6,837 (range 845-52,921) and USD 1,967 (range 0-60,423), respectively. The mean direct nonmedical cost was USD 583 (range 33-3,817), which accounted for 6.2% of the total direct cost. The average length of stay (LOS) in hospital was 25.0 days (range 6-152). A total of 117 of the patients (76.0%) had good outcomes (mRS = 0-2). There was no significant difference in the costs, LOS, or outcomes between rural and urban patients. Contributors to total direct cost were definite TBM, fever, coma, seizures, multidrug resistance, hydrocephalus, and poor long-term outcome.

CONCLUSIONS

Although the accessibility of medical resources in remote and rural regions has significantly improved in China, the cost of TBM imposes a catastrophic burden on patients.

A treatment-support intervention evaluated in South African paediatric populations with HIV infection or tuberculous meningitis

OBJECTIVES

To evaluate a paediatric treatment-support intervention for home-based treatment of HIV infection or tuberculous meningitis (TBM).

METHODS

A randomised-controlled study comparing local standard care (controls) with standard care plus intervention (combining adherence education, reinforcement and monitoring) in children aged 0-14 years. We recorded adherence measures (self-report, pill-count, drug-assays for isoniazid and rifampicin in urine and pyrazinamide in saliva), difficulties administering medication and PedsQL™questionnaires for health-related quality-of-life (HRQoL) and family impact.

RESULTS

In the HIV group (6-months follow-up, n = 195), more children had above-median HRQoL-scores in the intervention group than in the control group (P = 0.009). Problems reported administering medication declined between baseline and follow-up for controls (P = 0.043). Disclosure of HIV status to the child increased between baseline and follow-up in both groups (intervention P < 0.001; control P = 0.031). In the TBM group (3-months follow-up, n = 43), all adherence measures remained high for both intervention and controls, except for rifampicin which declined between baseline and follow-up in the intervention group (P = 0.031). The intervention group maintained above median HRQoL-scores between baseline and follow-up, when the number of children with above-median HRQoL-scores decreased in the controls (P = 0.063). More children in the intervention group had above-median family impact-scores than controls (P = 0.040).

CONCLUSIONS

The low-cost, culturally friendly treatment-support intervention had beneficial effects on health-related quality of life, family impact, caregiver disclosure of HIV status to the child, increased caregiver reporting of medication non-adherence and caregiver reporting of difficulties administering medication. Treatment adherence was not significantly affected in either HIV or TBM group.

Drug-resistant tuberculosis: pediatric guidelines

Drug-resistant Mycobacterium tuberculosis (TB) infection represents a serious and growing problem. For patients infected or suspected of being infected with multidrug or extensively drug-resistant TB, several medications have to be given simultaneously for prolonged periods. Here, we review the literature on treatment and monitoring of adverse effects of pediatric drug-resistant TB therapy in a high resource, low TB burden setting.

Childhood tuberculosis: epidemiology and natural history of disease

Despite previous misperceptions that childhood tuberculosis (TB) is less relevant, since children tend to develop mild disease, contribute little to transmission and do not impact epidemic control, awareness is growing that TB is an important preventable cause of disease and death among children in TB endemic areas. At an operational level there remains an urgent need for feasible and implementable policies to guide management in resource limited settings. This manuscript reviews the epidemiology and natural history of TB in children in order to improve understanding of the various disease entities encountered and to provide the rationale for different management approaches.

Childhood tuberculosis: an emerging and previously neglected problem

Although awareness is growing, childhood tuberculosis (TB) remains a neglected disease in many resource-limited settings. In part this reflects operational difficulties, lack of visibility in official reports, as well as perceptions that children tend to develop mild disease, contribute little to disease transmission, and do not affect epidemic control. At an international level there is greater appreciation that children contribute significantly to the global TB disease burden and suffer severe TB-related morbidity and mortality, particularly in TB-endemic areas, where the disease often remains undiagnosed. However, this is not always the case at the national or local level and there remains an urgent need for feasible and implementable policies to guide clinical practice. Pediatric TB can be regarded as an emerging epidemic in areas where the adult epidemic remains out of control and Mycobacterium tuberculosis transmission is ongoing. This article reviews important concepts, challenges, and management principles related to childhood TB; it also summarizes the main priorities for future research.