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More comprehensive pediatric TB classification methods needed
Wiseman CA. Pediatr Infect Dis J. 2012;doi:10.1097INF.0b013e318243e27b.
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An improved, standard disease classification system would have concrete benefits in the study, management and treatment of tuberculosis, according to a proposal from the Desmond Tutu TB Centre of Stellenbosch University in Cape Town, South Africa.
Catherine A. Wiseman, MD, and colleagues in the department of pediatric and child health have proposed a framework for a better pediatric classification system that “reflects the spectrum and severity of clinical disease.”
TB is conventionally classified as pulmonary TB and extrapulmonary TB, with extrapulmonary TB broadly including disseminated forms of TB. The ICD-10 classifies TB according to its location in the body and bacteriologic or histologic conformation.
In a recently published paper, Wiseman and colleagues said these methods are inadequate to describe the disease’s severity. Researchers conducted an online literature review of Medline/PubMed database articles, searched reference lists of articles manually and looked at relevant textbooks to construct a more comprehensive model using clinical data and bacteriologic, histopathologic and imaging data.
“Each individual disease entity was systematically considered,” and “based on the extent and the presence of complications, each entity was then classified as ‘severe’ or ‘nonsevere,’” according to the study findings.
Researchers used a cohort of infants with HIV, and those who also had culture-confirmed TB, to examine the systems of conventional classification and their own. They concluded that agreement between the two was “poor” and that their model was superior in comprehensively and accurately describing TB.
“This approach may serve as a valuable tool to categorize disease severity and allow for stratified management in research on diagnostics and evaluation of new TB strategies,” Wiseman and colleagues wrote. “Future work will aim to incorporate this approach into the ICD-10 system, and to apply this standard system to cohorts representing wide disease spectra and comorbidities in relation to clinical outcome.”
Disclosure: The researchers report no relevant financial disclosures.
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The upcoming conversion from the long-used ICD-9 to the new ICD-10 coding system will present significant and expensive challenges to hospitals, physician groups and health care. The educational efforts needed will be a challenge and will require substantial resources by all parties to implement this new and complicated coding system. Although this new exercise is a challenge, it is an opportunity for researchers involved in clinical and translational research to better categorize diseases as to subtypes, subcategories and even to system involvement and severity.
The historical research literature on pediatric tuberculosis has relied on simplistic clinical categories by system — pulmonary, extrapulmonary and disseminated disease. There have been subgroups within each group from cervical lymphadenitis to meningitis. The new TB classification system based upon severity that also allows for HIV-infected vs. non-infected cohorts by specific systems classification will allow for a much clearer comparison of pediatric TB. For future research, drug trials, epidemiology and even vaccine trials, a new classification system should allow for significant clarification and analysis. The authors are to be congratulated for taking on this challenging task.
Richard F. Jacobs, MD
Infectious Diseases in Children Chief Medical Editor
Disclosure: Dr. Jacobs reports no relevant financial disclosures.
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