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ART programs in low-resource settings in need of TB diagnostic tools
Antiretroviral therapy programs in low- and middle-income countries are still in need of tuberculosis diagnostic tools to help identify tuberculosis in children with HIV, according to recent study findings published in the Journal of the Pediatric Infectious Diseases Society.
Lukas Fenner, MD, MSc, of the Swiss Tropical and Public Health Institute in Basel, Switzerland, and colleagues evaluated 43 ART programs that treated patients in 23 countries to determine the types of TB screening and diagnosis practices among children who were HIV-positive. Nearly 26% of the programs treated children only, and 74.4% treated both adults and children. More than half of the sites were tertiary teaching or referral hospitals (55.8%) vs. secondary, district or provincial hospitals (14%), and primary health care centers or clinics (30.2%). Most sites were urban (79.1%), followed by peri-urban (16.3%) and rural (4.6%).
Lukas Fenner
All of the sites had sputum microscopy and chest radiograph available for the diagnosis of TB, followed by mycobacterial culture at 93%, gastric aspiration at 62.8%, tuberculin skin testing in 60.5%, induced sputum in 53.5% and Xpert MTB/RIF (Cepheid) in 37.2%. Of the programs with direct access to pediatric TB diagnostic tools, 79.1% had radiographs, 72.1% had access to sputum microscopy, 44.2% to tuberculin skin test, 20.9% to mycobacterial culture and 20.9% to Xpert MTB/RIF.
Forty-one sites used both contact history and weight loss as screening practices to rule out active TB. Other screening practices used were fever screening (88.4%); cough screening (83.7%); chest radiograph (79.1%); sputum microscopy (58.1%); gastric aspiration (34.9%); tuberculin skin test (34.9%); mycobacterial culture (27.9%); and induced sputum microscopy (14%).
Fourteen sites used a treatment regimen of 2 months on isoniazid, rifampicin and pyrazinamide, followed by 4 months on isoniazid and rifampicin, whereas 18 sites did not have specific regimens.
“Childhood TB diagnostic tools are still infrequently available or used in pediatric ART programs of low- and middle-income countries,” Fenner told Infectious Diseases in Children. “The scale-up of highly sensitive molecular diagnostics such as Xpert MTB/RIF, alone or in combination with additional diagnostics, needs to be reinforced, and may become a key element in ART programs caring for HIV-infected children in high TB prevalence settings.” — by Amber Cox
Lukas Fenner, MD, MSc, can be reached at lukas.fenner@unibas.ch.
Disclosure: See the study for a full list of disclosures.
Perspective
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This is an extremely important study that should be a “call-to-arms” for both the HIV and tuberculosis communities. Particularly in Africa, TB is often the most important disease, causing morbidity and death among HIV-infected children. Unfortunately, it often goes undiagnosed and unrecognized as the cause of pneumonia and malnutrition in both HIV-infected and HIV-non-infected children.
Childhood TB in general has been neglected and has fallen through the cracks between national TB programs (because the disease often is not microscopy- or culture-confirmed and children with TB are rarely infectious to others) and child health programs (because TB has never been made part of its core activities). As a result, resources to diagnose childhood TB often are not available at the very sites and programs, including clinics and programs for HIV care, where children with TB are most likely to go. In addition, in most high-burden countries, family contact tracing when an adult is diagnosed with pulmonary TB does not take place. The result is that opportunities to prevent TB in children are missed, drug resistance in childhood TB is not recognized, and the children who develop TB disease tend to present much later when they are sicker and more difficult to treat.
WHO has conservatively estimated that there are 74,000 annual deaths from TB among children without HIV; it has not produced an estimate for HIV-infected children who have a much greater risk of mortality.
Recognizing these and other problems, WHO, UNICEF and several other organizations in October 2013 published The Roadmap for Childhood Tuberculosis. This publication documents the current deficiencies in the centralized approach to childhood TB through national TB programs and presents 10 basic steps for improvement. One of the central themes of this document is the need to provide diagnostic and treatment services for TB at the sites where children already go, especially HIV care programs, malnutrition clinics and centers, and within existing child care programs such as Integrated Management of Childhood Illness. This study is documentation of the current lack of these diagnostic capabilities at most pediatric HIV care centers.
Given the paucibacillary nature of childhood TB and the difficulty obtaining a microbiologic confirmation of disease in many cases, it also will be crucial to create greater collaboration between national TB programs and HIV and child care centers to enhance contact tracing, which contributes significantly to accurate diagnosis of TB in children. Experts in pediatric HIV should be included in national and local TB control efforts, including the creation of appropriate guidelines for screening, diagnosis and treatment and allocation of resources. It does little good