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Vasiliu A, Köhler N, Altpeter E, Ægisdóttir TR, Amerali M, de Oñate WA, Bakos Á, D'Amato S, Cirillo DM, van Crevel R, Davidaviciene E, Demuth I, Domínguez J, Duarte R, Günther G, Guthmann JP, Hatzianastasiou S, Holm LH, Herrador Z, Hribar U, Huberty C, Ibraim E, Jackson S, Jensenius M, Josefsdottir KS, Koch A, Korzeniewska-Kosela M, Kuksa L, Kunst H, Lienhardt C, Mahler B, Makek MJ, Muylle I, Normark J, Pace-Asciak A, Petrović G, Pieridou D, Russo G, Rzhepishevska O, Salzer HJF, Marques MS, Schmid D, Solovic I, Sukholytka M, Svetina P, Tyufekchieva M, Vasankari T, Viiklepp P, Villand K, Wallenfels J, Wesolowski S, Mandalakas AM, Martinez L, Zenner D, Lange C. Tuberculosis incidence in foreign-born people residing in European countries in 2020. Euro Surveill 2023; 28:2300051. [PMID: 37855907 PMCID: PMC10588305 DOI: 10.2807/1560-7917.es.2023.28.42.2300051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/12/2023] [Indexed: 10/20/2023] Open
Abstract
BackgroundEuropean-specific policies for tuberculosis (TB) elimination require identification of key populations that benefit from TB screening.AimWe aimed to identify groups of foreign-born individuals residing in European countries that benefit most from targeted TB prevention screening.MethodsThe Tuberculosis Network European Trials group collected, by cross-sectional survey, numbers of foreign-born TB patients residing in European Union (EU) countries, Iceland, Norway, Switzerland and the United Kingdom (UK) in 2020 from the 10 highest ranked countries of origin in terms of TB cases in each country of residence. Tuberculosis incidence rates (IRs) in countries of residence were compared with countries of origin.ResultsData on 9,116 foreign-born TB patients in 30 countries of residence were collected. Main countries of origin were Eritrea, India, Pakistan, Morocco, Romania and Somalia. Tuberculosis IRs were highest in patients of Eritrean and Somali origin in Greece and Malta (both > 1,000/100,000) and lowest among Ukrainian patients in Poland (3.6/100,000). They were mainly lower in countries of residence than countries of origin. However, IRs among Eritreans and Somalis in Greece and Malta were five times higher than in Eritrea and Somalia. Similarly, IRs among Eritreans in Germany, the Netherlands and the UK were four times higher than in Eritrea.ConclusionsCountry of origin TB IR is an insufficient indicator when targeting foreign-born populations for active case finding or TB prevention policies in the countries covered here. Elimination strategies should be informed by regularly collected country-specific data to address rapidly changing epidemiology and associated risks.
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Affiliation(s)
- Anca Vasiliu
- Baylor College of Medicine, Department of Pediatrics, Global and Immigrant Health, Global Tuberculosis Program, Houston, Texas, United States
| | - Niklas Köhler
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), TTU-TB, Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
| | - Ekkehardt Altpeter
- Swiss Federal Office of Public Health, Division of Communicable Diseases, Bern, Switzerland
| | - Tinna Rán Ægisdóttir
- The National University Hospital of Iceland, Pharmaceutical Services, Reykjavik, Iceland
| | - Marina Amerali
- Tuberculosis Control Office, Department of Respiratory Infections, Directorate for Epidemiological Surveillance & Intervention, National Public Health Organization (NPHO), Athens, Greece
| | - Wouter Arrazola de Oñate
- Belgian Lung and Tuberculosis Association, Brussels, Belgium
- Flemish Association of Respiratory Health and TB Control, Leuven, Belgium
| | - Ágnes Bakos
- Koranyi National Institute for Pulmonology, Budapest, Hungary
| | - Stefania D'Amato
- Prevention of Communicable Diseases and International Prophylaxis, General Direction of Health Prevention, Ministry of Health of Italy, Rome, Italy
| | - Daniela Maria Cirillo
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Edita Davidaviciene
- Vilnius University hospital Santaros Klinikos, Department of Tuberculosis State information system, Vilnius, Lithuania
| | | | - Jose Domínguez
- Institut d'Investigació Germans Trias i Pujol; Universitat Autònoma de Barcelona; CIBER Enfermedades Respiratorias; INNOVA4TB consortium Badalona, Barcelona, Spain
| | - Raquel Duarte
- ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto
- ISPUP - Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
- Centro Hospitalar de Vila Nova de Gaia/Espinho, Porto, Portugal
| | - Gunar Günther
- Department of Pulmonary Medicine and Allergology, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Department of Medical Sciences, School of Medicine, University of Namibia, Windhoek, Namibia
| | - Jean-Paul Guthmann
- Division of Infectious Diseases, Santé publique France, Saint-Maurice, France
| | - Sophia Hatzianastasiou
- Tuberculosis Control Office, Department of Respiratory Infections, Directorate for Epidemiological Surveillance & Intervention, National Public Health Organization (NPHO), Athens, Greece
| | - Louise Hedevang Holm
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Zaida Herrador
- Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain
| | - Urška Hribar
- Tuberculosis Register of the Republic of Slovenia, University Clinic Golnik, Golnik, Slovenia
| | | | - Elmira Ibraim
- Marius Nasta Institute of Pulmonology, Bucharest, Romania
| | - Sarah Jackson
- Infectious Diseases; Health Service Executive Health Protection Surveillance Centre, Dublin, Ireland
| | - Mogens Jensenius
- Department of Infectious Diseases, Oslo University Hospital, Ullevaal, Norway
| | | | - Anders Koch
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
- Department of Infectious Diseases, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Maria Korzeniewska-Kosela
- Department of Tuberculosis Epidemiology and Surveillance, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Liga Kuksa
- Riga East University Hospital, TB and Lung Disease Clinic, Riga, Latvia
| | - Heinke Kunst
- Blizard Institute, The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Christian Lienhardt
- Unité Unité Mixte Internationale 233 IRD - U1175 INSERM - Université de Montpellier, Institut de Recherche pour le Développement (IRD), Montpellier, France
- Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Beatrice Mahler
- Marius Nasta Institute of Pulmonology, Bucharest, Romania
- Department Cardio-thoracic, Pneumophtisiology II, University of Medicine and Pharmacy "Carol Davila" Bucharest, Romania
| | - Mateja Janković Makek
- University of Zagreb, School of Medicine Zagreb, Croatia
- University Hospital Centre Zagreb, Department for Lung diseases, Zagreb, Croatia
| | - Inge Muylle
- Division of Pneumology, Onze-Lieve-Vrouw Ziekenhuis (OLV) Aalst, Aalst, Belgium
| | - Johan Normark
- Department of Clinical Microbiology, Umeå University, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Sweden
| | - Analita Pace-Asciak
- Infectious Disease Prevention and Control Unit, Health Promotion and Disease Prevention Directorate, Superintendence of Public Health, Ministry for Health of Malta, La Valetta, Malta
| | - Goranka Petrović
- Respiratory Diseases and Travel Medicine Department with Vaccination Unit, Infectious Diseases Epidemiology ServiceDepartment, Croatian Institute of Public Health, Zagreb, Croatia
| | - Despo Pieridou
- Cyprus National Reference Laboratory for Mycobacteria, Microbiology Department, Nicosia General Hospital, Nicosia, Cyprus
| | - Giulia Russo
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Olena Rzhepishevska
- Department of Chemistry, Department of Clinical Microbiology, Umeå University, Sweden
| | - Helmut J F Salzer
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine 4- Pneumology, Kepler University Hospital, Linz, Austria
- Faculty of Medicine, Johannes-Kepler-University, Linz, Austria and Ignaz Semmelweis Institut, Interuniversity Institute for Infection Resarch, Vienna, Austria
| | | | - Daniela Schmid
- Unit for Infectious Diseases Diagnostics and Infectious Diseases Epidemiology, Centre for Pathophysiology, Infectious Diseases and Immunology, Medical University of Vienna, Vienna, Austria
| | - Ivan Solovic
- National Institute for TB, Lung Diseases and Thoracic Surgery, Vysne Hagy, Slovakia
- Catholic University Ruzomberok, Ruzomberok, Slovakia
| | - Mariya Sukholytka
- First Faculty of Medicine and Faculty Thomayer Hospital Prague, Czechia
| | - Petra Svetina
- National TB Program and Tuberculosis Registry of Republic of Slovenia, University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Mariya Tyufekchieva
- Health Promotion and Prevention Unit, Directorate Public Health Protection and Health Control, Ministry of Health of Bulgaria, Sofia, Bulgaria
| | - Tuula Vasankari
- University of Turku, Division of Medicine, Department of Pulmonary Diseases and Clinical Allergology, Turku, Finland
- Finnish Lung Health Association (Filha ry), Helsinki, Finland
| | - Piret Viiklepp
- Estonian Tuberculosis Register, Dept. of Registries, National Institute for Health Development, Tallinn, Estonia
| | - Kersti Villand
- Estonian Tuberculosis Register, Dept. of Registries, National Institute for Health Development, Tallinn, Estonia
| | - Jiri Wallenfels
- National TB Surveillance Unit, University Hospital Bulovka, Prague, Czechia
| | - Stefan Wesolowski
- Department of Tuberculosis Epidemiology and Surveillance, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Anna-Maria Mandalakas
- Baylor College of Medicine, Department of Pediatrics, Global and Immigrant Health, Global Tuberculosis Program, Houston, Texas, United States
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
| | - Leonardo Martinez
- Boston University, School of Public Health, Department of Epidemiology, Boston, Massachusetts, United States
| | - Dominik Zenner
- Global Public Health Unit, Wolfson Institute of Population Health Barts
- The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Christoph Lange
- Baylor College of Medicine, Department of Pediatrics, Global and Immigrant Health, Global Tuberculosis Program, Houston, Texas, United States
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), TTU-TB, Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
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Apis V, Landi M, Graham SM, Islam T, Amini J, Sabumi G, Mandalakas AM, Meae T, du Cros P, Shewade HD, Welch H. Outcomes in children treated for tuberculosis with the new dispersible fixed-dose combinations in Port Moresby. Public Health Action 2019; 9:S32-S37. [PMID: 31579647 DOI: 10.5588/pha.18.0062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 01/13/2019] [Indexed: 12/30/2022] Open
Abstract
Setting The new child-friendly fixed dose combinations (FDCs) were introduced at Port Moresby General Hospital, Papua New Guinea, in 2016 for the first-line treatment of children (aged <15 years) with tuberculosis (TB) who weighed <25 kg. Objective To describe the characteristics and outcomes for children treated with the new FDCs, and to identify risk factors for unfavourable treatment outcomes. Design This was a retrospective cohort study of all children treated for TB with the FDCs from August 2016 to August 2017. Results Of 713 children included, 488 (68%) were diagnosed with pulmonary TB. Only 6 (0.8%) TB cases were bacteriologically confirmed and human immunodeficiency virus (HIV) status was known in 50%. Treatment outcomes were favourable in 425 (60%) children. Of 288 children with unfavourable outcomes, there were 242 (84%) with loss to follow-up (LTFU) and 25 (8.4%) were known to have died. Children who were severely underweight (weight-for-age Z score <-3) on presentation were at greater risk of LTFU compared to children of normal weight on multivariable analysis (aRR 1.3, 95%CI 1.0-1.6, P < 0.05). Conclusion Alternative models of care to decrease LTFU during treatment are needed, including integration with nutritional support. Improving diagnosis through microbiological confirmation of TB and HIV are major challenges to be addressed.
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Affiliation(s)
- V Apis
- Port Moresby General Hospital, Port Moresby, Papua New Guinea (PNG)
| | - M Landi
- Port Moresby General Hospital, Port Moresby, Papua New Guinea (PNG).,School of Medicine and Health Science, University of Papua New Guinea, Port Moresby, PNG
| | - S M Graham
- The Burnet Institute, Melbourne, Victoria, Australia.,Centre for International Child Health, University of Melbourne and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - T Islam
- World Health Organization, Representative Office for PNG, Port Moresby, PNG
| | - J Amini
- National Department of Health, Port Moresby, PNG
| | - G Sabumi
- Health & HIV Implementation Services Provider, Abt JTA, Port Moresby, PNG
| | - A M Mandalakas
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - T Meae
- Port Moresby General Hospital, Port Moresby, Papua New Guinea (PNG)
| | - P du Cros
- The Burnet Institute, Melbourne, Victoria, Australia
| | - H D Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,The Union, South-East Asia Office, New Delhi, India
| | - H Welch
- Port Moresby General Hospital, Port Moresby, Papua New Guinea (PNG).,School of Medicine and Health Science, University of Papua New Guinea, Port Moresby, PNG.,Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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Wiseman CA, Mandalakas AM, Kirchner HL, Gie RP, Schaaf HS, Walters E, Hesseling AC. Novel application of NIH case definitions in a paediatric tuberculosis contact investigation study. Int J Tuberc Lung Dis 2016; 19:446-53. [PMID: 25860001 DOI: 10.5588/ijtld.14.0585] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND International (National Institutes of Health [NIH]) case definitions have been proposed for paediatric tuberculosis (TB) diagnostic studies. The relevance of these definitions for contact tracing studies is unknown. METHODS We developed case definitions for a community-based contact tracing diagnostic study. We compare disease certainty using protocol-defined and NIH case definitions and describe TB disease spectrum and severity. RESULTS There were 111 potential disease episodes in 109 (21% human immunodeficiency virus [HIV] infected) of 1093 children enrolled. Based on NIH definitions, there were 8 confirmed, 12 probable, 17 possible and 3 unlikely TB and 2 non-TB episodes. Using protocol case definitions, there were 23 episodes of confirmed, 36 probable, 27 possible and 0 unlikely TB and 21 non-TB. Of 111 potential episodes, 69 were unclassifiable using the NIH definition, while 4 were unclassifiable using the protocol definition. Agreement between definitions was 0.30 (95%CI 0.23-0.38). There were 62 episodes (72%) of non-severe and 24 (28%) of severe TB. CONCLUSIONS The NIH definition had limited applicability to household contact studies, despite the wide spectrum of disease observed. Further research is needed to develop case definitions relevant to different research settings, including contact investigation to capture the wide spectrum of paediatric TB in clinical research.
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Affiliation(s)
- C A Wiseman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - A M Mandalakas
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Section on Retrovirology and Global Health, Department of Paediatrics, Baylor College of Medicine, Houston, Texas, USA; The TB Initiative, Texas Children's Hospital, Houston, Texas, USA
| | - H L Kirchner
- Division of Medicine, Geisinger Clinic, Danville, Pennsylvania, USA
| | - R P Gie
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - H S Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - E Walters
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Carlucci JG, Jin L, Sanders JE, Mohapi EQ, Mandalakas AM. Development of tuberculosis infection control guidelines in a pediatric HIV clinic in sub-Saharan Africa. Public Health Action 2015; 5:2-5. [PMID: 26400595 DOI: 10.5588/pha.14.0101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 01/25/2015] [Indexed: 11/10/2022] Open
Abstract
SETTING A well-established pediatric human immunodeficiency virus (HIV) clinic in Lesotho with initial infection control (IC) measures prioritizing blood-borne disease. In line with international recommendations, services have been expanded to include the management of patients with tuberculosis (TB). The creation of comprehensive IC guidelines with an emphasis on TB has become a priority. OBJECTIVE To provide a model for developing and implementing IC guidelines in ambulatory care facilities in limited-resource settings with high HIV and TB prevalence. Activities: An IC plan that includes guidance covering both general IC measures and TB-specific guidelines was created by integrating local and international recommendations and emphasizing the importance of administrative measures, environmental controls, and disease-specific precautions. An interdisciplinary committee was established to oversee its implementation, monitoring, and evaluation. DISCUSSION Development and implementation of IC guidelines in resource-limited settings are feasible and should be a priority in high HIV and TB prevalence areas. Education should be the cornerstone of such endeavors. Many interventions can be implemented with minimal expertise and material resources. Administrative support and institutional investment are essential to the sustainability of an effective IC program.
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Affiliation(s)
- J G Carlucci
- Baylor College of Medicine Children's Foundation, Lesotho, Maseru, Lesotho ; Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - L Jin
- Baylor College of Medicine Children's Foundation, Lesotho, Maseru, Lesotho ; Princeton in Africa, Princeton, New Jersey, USA
| | - J E Sanders
- Baylor College of Medicine Children's Foundation, Lesotho, Maseru, Lesotho ; Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - E Q Mohapi
- Baylor College of Medicine Children's Foundation, Lesotho, Maseru, Lesotho ; Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - A M Mandalakas
- Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA ; Section on Retrovirology and Global Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA ; The Global TB Program, Texas Children's Hospital, Houston, Texas, USA
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Skinner D, Hesseling AC, Francis C, Mandalakas AM. It's hard work, but it's worth it: the task of keeping children adherent to isoniazid preventive therapy. Public Health Action 2015; 3:191-8. [PMID: 26393028 DOI: 10.5588/pha.13.0010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 05/20/2013] [Indexed: 11/10/2022] Open
Abstract
SETTING Isoniazid preventive therapy (IPT) offers children protection against tuberculosis (TB), but it has been difficult to implement, particularly in developing countries. OBJECTIVE To understand what encourages or inhibits children from adhering to IPT. DESIGN In-depth interviews were conducted with two parents of children adherent to IPT and two staff members from three primary health care clinics in high TB prevalence communities. Themes explored were knowledge and attitudes towards IPT, problems in accessing and adhering to treatment, and community responses. RESULTS Parents administering treatment valued it positively, realised their children's risk of TB, and were positive about the clinic. Nurses acknowledged that resistance to treatment remained, with some parents not wanting to acknowledge risk nor willing to make the effort for their children; there was also considerable misinformation about IPT. Clinic nurses acknowledged problems of staff shortages, lengthy waiting times and conflict between staff and community members. Adherence was affected by social problems, stigma about TB and its link to the human immunodeficiency virus, and the extended treatment period. CONCLUSION Parents who maintained adherence to the IPT regimen showed that it was possible even in very difficult circumstances. Further effort is required to improve some of the clinic services, correct misinformation, reduce stigma and provide support to parents.
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Affiliation(s)
- D Skinner
- Research on Health and Society, Faculty of Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, Cape Town, South Africa
| | - C Francis
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, Cape Town, South Africa
| | - A M Mandalakas
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, Cape Town, South Africa ; Section on Retrovirology and Global Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA ; The TB Initiative, Texas Children's Hospital, Houston, Texas, USA
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Abstract
In children, the effectiveness of preventive therapy (PT) for tuberculosis (TB) will always be dependent upon the care giver's behaviour, as this determines adherence. We briefly describe the knowledge, attitudes and intended behaviours in care givers of young children referred for PT in a resource-constrained setting with high TB rates. These early efforts describe one critical piece of the PT puzzle: uptake. More behavioural research is needed to understand how the many pieces of this puzzle should be assembled to improve PT usage in children.
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Affiliation(s)
- D Skinner
- Research on Health and Society, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
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Mandalakas AM, Kirchner HL, Lombard C, Walzl G, Grewal HMS, Gie RP, Hesseling AC. Well-quantified tuberculosis exposure is a reliable surrogate measure of tuberculosis infection. Int J Tuberc Lung Dis 2012; 16:1033-9. [PMID: 22692027 DOI: 10.5588/ijtld.12.0027] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Cape Town, South Africa. OBJECTIVE To develop a standardized, reliable measure of household tuberculosis (TB) exposure that considers child-specific risk factors. DESIGN We assessed TB exposure in 536 children. Children were considered Mycobacterium tuberculosis infected if two of three tests of infection were positive. Principal component analysis identified a discrete set of components that collectively described exposure and contributed to a composite contact score. Logistic regression assessed the odds of having M. tuberculosis infection given increasing contact score while controlling for age and past TB treatment. RESULTS Four components described 68% of data variance: 1) maternal TB and sleep proximity, 2) index case infectivity, 3) duration of exposure, and 4) exposure to multiple index cases. Components were derived from 10 binary questions that contributed to a contact score (range 1-10, median 5, 25th-75th interquartile range [IQR] 4-7). Among children aged 3 months to 6 years with household exposure, the odds of being M. tuberculosis-infected increased by 74% (OR 1.74, 95%CI 1.42-2.12) with each 1-point increase in the contact score. CONCLUSIONS Well-quantified TB exposure is a good surrogate measure of M. tuberculosis infection in child household contacts in a high-burden setting, and could guide targeted preventive treatment in children at highest risk of M. tuberculosis infection.
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Affiliation(s)
- A M Mandalakas
- Section on Retrovirology and Global Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas 77030, USA.
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Van Wyk SS, Mandalakas AM, Enarson DA, Gie RP, Beyers N, Hesseling AC. Tuberculosis contact investigation in a high-burden setting: house or household? Int J Tuberc Lung Dis 2012; 16:157-62. [PMID: 22236914 DOI: 10.5588/ijtld.11.0393] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING A high tuberculosis (TB) burden setting, South Africa. Two frequently used definitions for 'household' are 1) 'all dwellings on the same plot of land that share the same residential address'; and 2) 'a group of persons who live together in the same dwelling unit and who have the same eating arrangements'. OBJECTIVE To characterise a household and the outcome of investigations in household child contacts using definition 1 compared to definition 2 during a TB contact investigation. DESIGN Access to a household (definition 1) was gained via an adult TB case. Children were assessed for TB infection and disease. RESULTS Household enumeration indicated 25 members of three families living in a main house and a fourth family living in an adjacent structure. Three children were diagnosed with TB and two referred for isoniazid preventive therapy. Families living in the main house shared the main kitchen, while the yard house family used its own kitchen. This household would have been classified as two separate households if definition 2 had been used, and children with TB disease and infection would have been missed. CONCLUSION The definition of household in TB contact investigation should provide a framework that is broad enough to capture the majority of children at risk.
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Affiliation(s)
- S S Van Wyk
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa.
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Du Preez K, Hesseling AC, Mandalakas AM, Marais BJ, Schaaf HS. Opportunities for chemoprophylaxis in children with culture-confirmed tuberculosis. ACTA ACUST UNITED AC 2012; 31:301-10. [PMID: 22041464 DOI: 10.1179/1465328111y.0000000035] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Chemoprophylaxis is an effective strategy to prevent progression of tuberculosis (TB) in vulnerable children who have had contact with an infectious source of TB. However, many operational gaps prevent implementation of routine chemoprophylaxis in high-burden settings. The TB exposure status and disease spectrum in children diagnosed with culture-confirmed TB are described and missed opportunities for chemoprophylaxis are highlighted. METHODS All children <13 years of age diagnosed with culture-confirmed TB at a tertiary referral hospital between March 2003 and February 2007 were included. Clinical data were collected from retrospective review of files. TB was classified as pulmonary and extra-pulmonary; disseminated TB included miliary disease and TB meningitis. RESULTS During the study period, 614 children (327, 53·3% boys, median age 32 months) were diagnosed with culture-confirmed TB. Contact with an infectious adult source case was documented in 333 (54·2%), 237 (71·2%) of whom were <5 years of age, and 24 (7·2%) were HIV-infected and ≥5 years of age. Of those eligible for chemoprophylaxis, missed opportunities were identified in 156/221 (70·6%) children; 127 (81·4%) were <3 years of age, 39 (25%) had disseminated TB and 8 (5·1%) died. The TB source case was the mother or father in 74/156 (47·4%) children. CONCLUSION Opportunities for initiation of chemoprophylaxis in vulnerable children following TB exposure are often missed. Awareness should be increased among health-care workers and in the community at large regarding the importance of chemoprophylaxis in young and HIV-infected children. Health system strengthening is required to improve delivery of chemoprophylaxis to vulnerable children in close contact with newly diagnosed infectious TB cases.
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Affiliation(s)
- K Du Preez
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics & Child Health, Faculty of Health Sciences, Stellenbosch University, South Africa
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du Preez K, Mandalakas AM, Kirchner HL, Grewal HMS, Schaaf HS, van Wyk SS, Hesseling AC. Environmental tobacco smoke exposure increases Mycobacterium tuberculosis infection risk in children. Int J Tuberc Lung Dis 2012; 15:1490-6, i. [PMID: 22008762 DOI: 10.5588/ijtld.10.0759] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Data on the association between exposure to environmental tobacco smoke (ETS) and Mycobacterium tuberculosis infection in children are limited. OBJECTIVE To examine the dose-response effect of ETS exposure on the risk of M. tuberculosis infection in children in a high tuberculosis (TB) burden setting. METHODS This cross-sectional study included healthy South African children from impoverished urban communities. Data were collected on household ETS and M. tuberculosis exposure, demographics, socio-economic and anthropometric data, M. tuberculosis infection, human immunodeficiency virus and TB disease status. RESULTS Among 196 children (median age 6.8 years, range 0.3-15.9), 97 (49.5%) were M. tuberculosis - i nfected (tuberculin skin test [TST] ≥ 10 mm) and 128 (65.3%) reported ETS exposure; of these, 81/128 (63.3%) were exposed to ≥ 2 household smokers. The presence of ≥ 2 household smokers was associated with M. tuberculosis infection in univariate analysis, irrespective of TST cut-off point. In analysis adjusting for M. tuberculosis exposure, socio-economic status, age and previous TB treatment, ETS exposure remained associated with M. tuberculosis infection. In univariate and multivariate analysis, pack-years of exposure were associated with risk of TB infection. DISCUSSION Exposure to ETS is associated with M. tuberculosis infection in children after adjustment for multiple variables, with a dose-response relationship between the degree of ETS exposure and risk of infection. Public health interventions to reduce exposure to tobacco smoke among children in high TB burden settings are urgently needed.
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Affiliation(s)
- K du Preez
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, Western Cape, South Africa.
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Mandalakas AM, Detjen AK, Hesseling AC, Benedetti A, Menzies D. Interferon-gamma release assays and childhood tuberculosis: systematic review and meta-analysis. Int J Tuberc Lung Dis 2011; 15:1018-32. [PMID: 21669030 DOI: 10.5588/ijtld.10.0631] [Citation(s) in RCA: 170] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Children infected with Mycobacterium tuberculosis have significant risk of developing tuberculosis(TB) and can therefore benefit from preventive therapy. OBJECTIVE To assess the value of interferon-gamma release assays (IGRAs) and the tuberculin skin test (TST)in the diagnosis of TB infection and disease in children. METHODS Thirty-three studies were included, assessing commercial IGRAs (QuantiFERON®-TB [QFT] andT-SPOT.®TB) and TST. Reference standards for infection were incident TB or TB exposure. Test performance for disease diagnosis was evaluated in studies assessing children with confirmed and/or clinically diagnosed TB,compared to children where TB was excluded. RESULTS Two small studies measured incident TB in children tested with QFT and found weak positive predictive value. Association of test response with exposure-categorized dichotomously or as a gradient-was similar for all tests. The sensitivity and specificity of all tests were similar in diagnosing the disease. Stratified analysis suggested lower sensitivity for all tests in young or human immuno deficiency virus infected children. CONCLUSIONS Available data suggest that TST and IGRAs have similar accuracy for the detection of TB infection or the diagnosis of disease in children. Heterogeneous methodology limited the comparability of studies and the interpretation of results. A rigorous, standardized approach to evaluate TB diagnostic tests in children is needed.
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Affiliation(s)
- A M Mandalakas
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA.
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Hesseling AC, Marais BJ, Kirchner HL, Mandalakas AM, Brittle W, Victor TC, Warren RM, Schaaf HS. Mycobacterial genotype is associated with disease phenotype in children. Int J Tuberc Lung Dis 2010; 14:1252-1258. [PMID: 20843415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
OBJECTIVE To investigate the association between mycobacterial genotype and disease phenotype in children. METHODS We describe hospitalised children diagnosed with culture-confirmed tuberculosis (TB) in South Africa, a high TB burden setting. Disease phenotype was classified as intrathoracic or extrathoracic based on mycobacterial culture site. Mycobacterial genotyping was completed using spoligotyping. RESULTS We analysed 421 isolates from 392 children (median age 2 years, range 0.1-12). Intrathoracic disease was present in 294 (75%) children and extrathoracic disease in 98 (25%). The Beijing genotype was the most prevalent (32.9%), followed by the Latin American Mediterranean (LAM, 28.8%), and S genotypes (6.4%). Age was significantly associated with genotype. Children with the Beijing (OR = 2.36, 95%CI 1.21- 4.60) and S genotypes (OR = 3.47, 95%CI 1.26-9.56) were more likely to have extrathoracic disease compared to children infected with the LAM genotype, in analyses adjusted for age and drug resistance. CONCLUSIONS TB genotype and disease phenotype in children were associated. Beijing and S genotypes were more frequently cultured from extrathoracic cultures, indicating potential improved ability to disseminate. Strain-related phenotypes could explain different disease spectra in geographic settings where certain strains are successful. Studies of mycobacterial human interaction should consider host immune responses, clinical and epidemiological factors.
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Affiliation(s)
- A C Hesseling
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa.
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Van Wyk SS, Hamade H, Hesseling AC, Beyers N, Enarson DA, Mandalakas AM. Recording isoniazid preventive therapy delivery to children: operational challenges. Int J Tuberc Lung Dis 2010; 14:650-653. [PMID: 20392361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
Despite recommendations to provide isoniazid preventive therapy (IPT) to eligible children aged <5 years who are in close contact with an infectious tuberculosis (TB) case, IPT delivery in high-burden settings remains poor. To evaluate the current system supporting IPT delivery to children in an urban community, South Africa, we reviewed the recording practices of a local clinic regarding management of children exposed to a current adult TB case. No standardised IPT management tools existed. Only 21% of children eligible for IPT had documentation of IPT delivery. There is a need to implement systems that support IPT recommendations in high-burden settings.
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Affiliation(s)
- S S Van Wyk
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa.
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Hesseling AC, Mandalakas AM, Kirchner HL, Chegou NN, Marais BJ, Stanley K, Zhu X, Black G, Beyers N, Walzl G. Highly discordant T cell responses in individuals with recent exposure to household tuberculosis. Thorax 2008; 64:840-6. [PMID: 18682523 DOI: 10.1136/thx.2007.085340] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND There are limited data comparing interferon-gamma release assays (IGRAs) for the detection of Mycobacterium tuberculosis infection in highly endemic settings. METHODS A cross-sectional household contact study was conducted to measure the agreement of two IGRAs in relation to the tuberculin skin test (TST) to detect M tuberculosis infection and to assess the influence of M tuberculosis exposure and age. RESULTS In 82 individuals in household contact, 93% of children and 42% of adults had a high M tuberculosis contact score. The TST was positive in 78% of adults and 54% of children, the T-SPOT.TB was positive in 89% of children and 66% of adults and the QuantiFERON TB Gold (QTF) was positive in a similar proportion of adults and children (38.1% and 39.6%). In children there was poor agreement between the TST and T-SPOT.TB (kappa = -0.15) and the T-SPOT.TB and the QTF (kappa = -0.03), but good agreement between the TST and the QTF (kappa = 0.78) using 10 mm cut-off. In adults there was fair to moderate agreement between the TST and T-SPOT.TB (kappa = 0.38), the TST and QTF (kappa = 0.34) and T-SPOT.TB and QTF (kappa = -0.50). High levels of exposure to M tuberculosis were associated with at least a sevenfold odds of being T-SPOT.TB positive (95% CI 7.67 to 508.69) and a threefold odds of being QTF positive (95% CI 3.02 to 30.54). There was a significant difference in the magnitude of T-SPOT.TB early secretory antigenic target (ESAT)-6 and culture filtrate protein 10 kD (CFP-10) spot counts between adults and children. CONCLUSIONS The T-SPOT.TB may be more sensitive than the TST or QTF for detecting recent M tuberculosis infection in children. Differences between assays and the predictive utility of these findings for subsequent disease development should be prospectively assessed.
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Affiliation(s)
- A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, Tygerberg, 7505, South Africa.
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Mandalakas AM, Hesseling AC, Chegou NN, Kirchner HL, Zhu X, Marais BJ, Black GF, Beyers N, Walzl G. High level of discordant IGRA results in HIV-infected adults and children. Int J Tuberc Lung Dis 2008; 12:417-423. [PMID: 18371268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
SETTING Tygerberg district, Western Cape Province, South Africa. OBJECTIVE To measure the agreement of two interferon-gamma release assays (IGRAs) and the tuberculin skin test (TST) for the detection of Mycobacterium tuberculosis infection in human immunodeficiency virus (HIV) infected adults and children in a setting highly endemic for tuberculosis (TB). DESIGN Cross-sectional study. RESULTS In HIV-infected adults (n=20) and children (n=23), tests yielded discordant results, with 61% of individuals testing positive with T-SPOT.TB, 41% with TST and 28% with QuantiFERON TB Gold (QTF). In children, there was poor agreement between the TST and T-SPOT.TB (kappa [kappa]=-0.02), but moderate agreement between the TST and QTF (kappa=0.44). In adults, there was moderate agreement between the TST and T-SPOT.TB (kappa=0.43), and the TST and QTF (kappa = 0.46). In children and adults, there was fair agreement between the T-SPOT.TB and QTF (kappa=0.33). Twenty per cent of adults had >or=1 indeterminate IGRA results. CONCLUSIONS There is poor to moderate agreement between the TST and IGRAs in HIV-infected adults and children. T-SPOT.TB may have improved sensitivity for detection of M. tuberculosis infection in HIV-infected individuals compared to the QTF and the TST. In HIV-infected individuals, IGRA test properties are affected by test cut-off point and nil control responses.
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Affiliation(s)
- A M Mandalakas
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, USA.
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Mandalakas AM, Guay L, Musoke P, Carroll-Pankhurst C, Olness KN. Human immunodeficiency virus status and delayed-type hypersensitivity skin testing in Ugandan children. Pediatrics 1999; 103:E21. [PMID: 9925867 DOI: 10.1542/peds.103.2.e21] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In previous studies, delayed-type hypersensitivity (DTH) skin testing has been shown to be affected by several factors including nutritional status, intercurrent infection, host immune status, and previous exposure to the antigen being used. OBJECTIVE To determine the effect of human immunodeficiency virus type 1 (HIV-1) status on DTH skin testing in a cohort of HIV-1-infected and noninfected Ugandan children followed prospectively from birth. DESIGN Nested case-control study. SETTING Primary care clinic serving study participants at Mulago Hospital, Makerere University, Kampala, Uganda. PARTICIPANTS Thirty HIV-1-infected children and 30 age-matched, HIV-1-noninfected children. METHODS After completion of history and physical, each child underwent Mantoux skin testing with both Candida and purified protein derivative (PPD). Results of skin testing were read in 48 to 72 hours. Complete chart reviews were performed on all children. CD4 lymphocyte counts were obtained on all HIV-1-infected children at the time the skin testing was read. RESULTS The average age of participants was 67 months (range, 51-92 months). HIV-1-infected children (mean CD4 lymphocyte count, 1069 mL-1; range, 86-3378 mL-1), compared with noninfected, age-matched peers, developed significantly smaller PPD reaction size (mean, 1.18 mm +/- 4.3 vs 3.6 mm +/- 7.6, respectively). Candida responses were not different between the two groups of children. Among HIV-1-infected children, there was a larger Candida reaction size in children who had recently received chloroquine treatment. There was no significant correlation between Candida reactivity and PPD reactivity, progressive HIV-1 disease, or CD4 lymphocyte count. The six children diagnosed clinically with active tuberculosis had lower absolute CD4 lymphocyte counts than children without tuberculosis. Lack of reaction to PPD was associated with lower CD4 lymphocyte counts and progressive HIV-1 disease. CONCLUSIONS In HIV-1-infected Ugandan children, DTH skin testing was influenced by the choice of antigen selected, HIV-1 infection, and recent treatment with chloroquine. Based on these findings, we believe that further prospective, longitudinal investigation into the role of chloroquine in HIV-1-infected children is needed. We emphasize the limitations of DTH skin testing in HIV-infected children as an adjunct in the diagnosis of active tuberculosis.
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Affiliation(s)
- A M Mandalakas
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA
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