Integration of TB into child health policies in Africa’s high-burden countries: a normative analysis

Integration of paediatric TB care into decentralised child health services has the potential to reduce the large proportion of childhood TB that remains undiagnosed. We performed a review of national guidelines and policies for TB and child health to evaluate the normative integration of paediatric TB into existing child health programmes in 15 high TB burden countries in Africa. While integration is addressed in 80% of the national strategic plans for TB, the child health strategies insufficiently address TB in their plans to reduce child mortality. Emphasis needs to be put on multi-sectoral collaboration among national health programmes.

A Perspective on the Success and Failure of BCG

TB continues to be one of the major public health threats. BCG is the only available vaccine against TB and confers significant protection against the childhood disease. However, the protective efficacy of BCG against adult pulmonary TB, which represents a larger burden of disease, is highly variable. It has been suggested that prior exposure to environmental mycobacteria (EMb) mitigates the anti-TB efficacy of BCG by blocking its duplication or masking its immunogenicity. However, its effectiveness against childhood TB and failure of repeated administration to provide additional benefit against pulmonary TB, suggest of some other mechanisms for the variable efficacy of BCG against the pulmonary disease. Importantly, TB is a heterogeneous disease occurring in different forms and having distinct mechanisms of pathogenesis. While inability of the immune system to contain the bacilli is responsible for TB pathogenesis in infants, an aggravated immune response to Mtb has been blamed for the development of adult pulmonary TB. Available data suggest that EMb play a key role in heightening the immune response against Mtb. In this article, differential efficacy of BCG against childhood and adult TB is explained by taking into account the heterogeneity of TB, mechanisms of TB pathogenesis, and the effect of EMb on anti-Mtb immunity. It is believed that a refined understanding of the success and failure of BCG will help in the development of effective anti-TB vaccines.

An Evaluation of Childhood Tuberculosis Program in Chegutu District, Zimbabwe, 2020: A Descriptive Cross-Sectional Study

Background Childhood tuberculosis (TB) is a major global public health concern contributing to significant child morbidity and mortality. A records review of the TB notification for Chegutu District Health Information System 2 (DHIS2) showed a low childhood TB case detection rate. For 2018 and 2019, childhood TB notifications were 4% and 7% respectively against the national 12% case detection rate. We evaluated the performance of the childhood TB program in Chegutu. Methods We conducted a descriptive cross-sectional study. Sixty-six health workers (HW) participated in the study. Interviewer-administered questionnaires and checklists were used to collect data on reasons for low TB case detection, HW childhood TB knowledge, program inputs, processes and outputs. Strengths, Weaknesses, Opportunities and Threats analysis was used to assess the childhood TB processes. We analyzed the data using Epi Info 7TM to generate frequencies, proportions and means. A Likert scale was used to assess health worker knowledge. Results The majority 51/66(77%) of HW were nurses and 51/66(67%) of respondents were females. Reasons for the low childhood TB case detection were lack of HW confidence in collecting gastric aspirates 55/66(83%) and HW’s negative attitudes towards gastric aspirate collection 23/66(35%). HW 24/66 (37%) had a fair childhood TB notification knowledge. The district had only one functional X-ray machine for 34 health facilities. Only 6/18 motorcycles were functional with inadequate fuel supply. No desk guide for the management of TB in children for HW (2018) was available in 34 health facilities. Ethambutol 400mg was out of stock and adult 800mg tablets were used. Funds allocated for motor vehicle and motorcycles service ($1612USD/year) were inadequate. The district failed to perform planned quarterly TB review meetings, contact tracing and childhood TB training due to funding and COVID-19 lockdown restrictions. Conclusion The childhood TB program failed to meet its targets due to inadequate inputs and suboptimal HW childhood TB knowledge. Case detection and notification can be improved through on-job training, mentorship, support and supervision and adequate resources.

Provision of Decentralized TB Care Services: A Detect–Treat–Prevent Strategy for Children and Adolescents Affected by TB

In this review, we discuss considerations and successful models for providing decentralized diagnosis, treatment, and prevention services for children and adolescents. Key approaches to building decentralized capacity for childhood TB diagnosis in primary care facilities include provider training and increased access to child-focused diagnostic tools and techniques. Treatment of TB disease should be managed close to where patients live; pediatric formulations of both first- and second-line drugs should be widely available; and any hospitalization should be for as brief a period as medically indicated. TB preventive treatment for child and adolescent contacts must be greatly expanded, which will require home visits to identify contacts, building capacity to rule out TB, and adoption of shorter preventive regimens. Decentralization of TB services should involve the private sector, with collaborations outside the TB program in order to reach children and adolescents where they first enter the health care system. The impact of decentralization will be maximized if programs are family-centered and designed around responding to the needs of children and adolescents affected by TB, as well as their families.

Knowledge, Attitude, and Practices Regarding Childhood Tuberculosis Detection and Management Among Health Care Providers in Cambodia: A Cross-Sectional Study

Background The World Health Organization (WHO) estimated that 29% of global tuberculosis (TB) and almost 47% of childhood TB cases were not reported to national TB programs in 2019. In Cambodia, most childhood TB cases were reported from health facilities supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria in 2019. This study aimed to compare the healthcare providers' KAP on childhood TB case detection in ODs with high and low childhood TB case detection in Cambodia. Methods We conducted a cross-sectional study between November and December 2020 among healthcare providers in 10 purposively selected operational districts (ODs) with high childhood TB case detection and 10 ODs with low childhood TB case detection. A total of 110 healthcare providers from referral hospitals and 220 from health centers were interviewed. We collected information on socio-demographic characteristics, training, and KAP on childhood TB. Pearson's Chi-square or Fisher's exact and Student's t-tests were performed to explore the differences in KAP of healthcare providers from ODs with low vs. high childhood TB detection. Results Of the 330 respondents, 193 were from ODs with high childhood TB case detection, and 66.67% were from health centers. A significantly higher proportion (46.11%) of respondents from ODs with high childhood TB case detection received training on childhood TB within the past two years than those from low childhood TB case detection ODs (34.31%) (p=0.03). Key knowledge on childhood TB was not significantly different among respondents from ODs with high and low childhood TB case detection. A significantly higher proportion of respondents from ODs with high childhood TB case detection had a good attitude (98.96% v.s. 97.08%, p=0.002) and performed good practices (58.55% v.s. 45.26%, p=0.02) on contact investigation in the community than those from low childhood TB case detection ODs. Conclusions Healthcare providers from ODs with high childhood TB detection had better attitudes and practices towards childhood TB. The attitudes and practices need to be improved among healthcare providers in ODs with low case detection. Further investment in training and experience sharing on childhood TB case detection among healthcare providers is needed to improve childhood TB case detection.

Mycobacterium Tuberculosis (Tuberculosis)

Tuberculosis (TB) is a major health threat caused by the intracellular bacterial pathogen Mycobacterium tuberculosis (Mtb). Globally, 10 million individuals fell ill of TB and 1.4 million died in 2019. The COVID-19 pandemic has severely impacted on TB notifications in 2020, thereby markedly increasing morbidity and mortality caused by TB. The lung is the most frequent site of disease manifestation, the site of pathogen entry and the source of dissemination. In the infected lung, granulomas are formed at the site of Mtb persistence which primarily consist of macrophages of different maturation stages and T lymphocytes. Solid granulomas contain Mtb, thus preventing outbreak of active disease. The individual is now latently infected. Once Mtb evades immune control, granulomas become necrotic and later caseous. Active TB disease has started. Diagnosis of TB is done by chest X-ray, microscopy, bacterial culture, molecular test, and immunologic test. TB can be cured by a combination of 3-4 specific drugs given over a period of 6-9 months. Increasing incidences of multi-drug and extensively drug-resistant Mtb render therapy difficult to impossible. The current vaccine, Bacille Calmette-Guérin (BCG) prevents extrapulmonary childhood TB but fails to protect against pulmonary TB in all age groups. New vaccines against TB are urgently needed. New candidates that have entered clinical trials are killed whole cell vaccines, recombinant live vaccines, Mtb antigen-adjuvant formulations or viral vectors expressing Mtb antigens.

Comprehensive approach to the tuberculosis indicators assessment of the children population in the Republic of Crimea

Introduction. Childhood tuberculosis (TB) control is relevant due to the peculiarities of its course in this age group, and the TB incidence in children is an important prognostic epidemiological indicator.Aim. Use of multivariate statistical analysis to estimate and predict childhood TB indicators in the Republic of Crimea (RC).Materials and methods. The official TB statistics in the Republic of Crimea for 2014-2018 are used. The calculated means of the indicators are checked for normality using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Pearson correlation analysis is applied to determine pair correlation relationships. Stepwise multiple regression analysis is carried out to determine group conditionality of the indicators, where coefficients, with which significant pairwise correlations are found, are selected as independent variables. Based on the results, multiple regression equations are made to predict the values of dependent variables. The data is processed using Statistica 10.0 software.Results. For childhood TB incidence, strong direct correlations are established with the incidence and prevalence of pulmonary TB among children. The paired correlation coefficient between the incidence of childhood TB and childhood lung TB and the detection of active TB patients in preventive examinations of children varied in the range of 0.63-0.72. For the prevalence of TB among children, strong direct correlations were found with the incidence of TB and pulmonary TB in children. Multiple correlation coefficients for the incidence and prevalence of childhood TB exceeded the values of paired correlation coefficients and were in the range of 0.93 to 0.98 (p<0.001), indicating greater significance of group conditionality of the indicators. Determination coefficients R2 were between 0.87 and 0.96. Multiple regression models were built for the childhood TB incidence, childhood lung TB incidence, childhood TB prevalence, childhood lung TB prevalence.Conclusion. The found strong direct pairwise correlations for childhood TB incidence and prevalence and childhood pulmonary TB incidence and prevalence can serve as prognostic criteria and reflect the quality of antituberculosis interventions. High values of paired correlation coefficient between childhood TB incidence and childhood pulmonary TB and detection of patients with active TB in preventive examinations of children are a criterion of quality of both TB services and primary care, which can prevent the spread of TB and improve the epidemic situation of TB in Crimea. The calculated multiple regression models for the studied indicators can serve the needs of practical forecasting in Healthcare.

The diagnostic value of urinary culture filtrate protein-10antigen in childhood tuberculosis

Introduction and Aim:Childhood tuberculosis (TB) remains a major problem worldwide.However, diagnosis of tuberculosis in children is often complicated by the difficulty in obtaining a proper sputum specimens and low sensitivity of the gold standard diagnostic test to confirm the presence of Mycobacterium tuberculosis(M.tb)in this age group. Recently, M.tbantigen detection in urinaryspecimenshas become a popular method. It is non-invasiveand handling of specimen is simple. It was reported that urinary CFP-10, a specific protein of M.tb, has emerged as a potential biomarker in the future. However, its diagnostic value as a new biomarker in childhood TB remains poorly understood.The aim of the study is to determine the diagnostic value of urinary CFP-10 in childhood TB. Methods: Seventy children with suspected pulmonary or extrapulmonary TB were enrolled. Tuberculosis was diagnosed by performingTuberculin skin test, chest x-ray, microscopic examination, and microbiological cultureobtainedfrom sputum or gastric lavage specimen. The level ofurinary CFP-10 antigen was analyzedbyELISA (Elabscience, China). Statistical analyseswereperformed using SPSS 21.0 and p-values of <0.05 were consideredstatistically significant. Results: The levels of urinary CFP-10 in subjects diagnosed with TB was higher than that of the non-TB subjects, 4.13(0.62) vs 0.43(0.14) pg/mL, p=0.005. The cut-off value forurinary CFP-10 level reached 0.39 pg/mL (sensitivity 65% and specificity 67%). This value became0.54 pg/mL (sensitivity 61% and specificity 62%)in microbiologically confirmed cases. Conclusion: The urinary CFP-10 level has moderate diagnostic value for diagnosing childhood TB.

Tracing the Children in Contact of Sputum Smear Negative Adults is the Need of the Hour to Achieve WHO “Stop TB Strategy”

Tuberculosis has been a public health issue affecting a large number of population world wide. 1According to 2019 report, approximately 10 million of people fell ill by the disease around the globe. A considerable proportion of TB affected cases is constituted by paediatric patients solely. The WHO estimates that about 1 million children endure the disease each year of which a significant figure harbours the latent form of infection. Since, the accurate diagnostic test to confirm the tuberculosis in children has not been unrolled, a positive history of contact is regarded as the foremost feature for authenticating the diagnosis in children. A large proportion of children with tuberculosis lives under the same roof with sputum smear positive adults, tracing out the childhood TB cases in sputum smear negative contacts is equally important and needs to be diagnosed timely. This category of children left undiagnosed acts as a pool for further transmission of the disease from where new TB cases arise. Therefore, the early diagnosis of children of this group is the need of the hour and a challenge to “STOP TB Strategy”.

Epidemiology of childhood tuberculosis after ceasing universal Bacillus Calmette–Guérin vaccination

Universal Bacillus Calmette–Guérin (BCG) vaccination is recommended in countries with high tuberculosis (TB) burden. Nevertheless, several countries have ceased universal BCG vaccination over the past 40 years, with scarce comparative epidemiological analyses regarding childhood TB after the policy change. We analysed data on childhood TB in countries that ceased universal BCG vaccination. Data sources included national/international databases, published papers, annual TB reports, and public health authority websites. Childhood TB notification rate increased in one of seven countries with available data. Pulmonary TB and TB lymphadenitis were the main causes of increasing childhood cases, while changes in severe forms of TB cases were minor. Maintaining high vaccine coverage for the target group was a common challenge after shifting selective vaccination. In some countries showing no increase in childhood TB after a BCG policy change, the majority of childhood TB cases were patients from abroad or those with overseas parents; these countries had changed immigration policies during the same period. Heterogeneity in childhood TB epidemiology was observed after ceasing universal BCG vaccination; several factors might obscure the influence of vaccination policy change. Lessons learned from these countries may aid in the development of better BCG vaccination strategies.