Parasitic infections: what do paediatricians need to know?

Parasitic infections and the medications used to treat them may be unfamiliar to many paediatricians. Parasitic infections, however, are not uncommonly seen in children in the UK. We summarise infections which are commonly seen, currently recommended treatment and practical guidance on formulations, adverse effects and treatment choice.

Resurgence of congenital syphilis: new strategies against an old foe.

Congenital syphilis is a major global cause of fetal loss, stillbirth, neonatal death, and congenital infection. In 2020, the global rate of congenital syphilis was 425 cases per 100 000 livebirths-substantially higher than WHO's elimination target of 50 cases per 100 000 livebirths. Case rates are rising in many high-income countries, but remain low compared with those in low-income and middle-income settings. This Review aims to summarise the current epidemiology and knowledge on transmission and treatment of syphilis in pregnancy, and proposes measures to reduce the rising incidence seen worldwide. We also describe emerging diagnostic and treatment tools to prevent vertical transmission and improve management of congenital syphilis. Finally, we outline a programme of public health priorities, which include research, clinical, and preventive strategies.

Infections in Asymptomatic Unaccompanied Asylum-seeking Children in London 2016-2022.

BACKGROUND: Unaccompanied asylum-seeking children are at increased risk of infections and experience barriers to healthcare access. There is a lack of evidence to underpin existing national and international guidance regarding asymptomatic infection screening in this population. We describe the results from routine infection screening of 1104 unaccompanied asylum-seeking children attending for testing at 3 London centers. METHODS: We performed a retrospective analysis of routinely collected data from all unaccompanied asylum-seeking children seen in 3 services in London, United Kingdom, between 2016 and 2022. RESULTS: A total of 1104 unaccompanied asylum-seeking children attended clinic; all accepted screening. The median age was 16 years (range 11-18 years) and 987 (89%) were male. 407 (37%) had at least 1 infection; 116 (11%) had multiple infections. Tuberculosis infection and schistosomiasis were common (found in 18% and 17%, respectively). Hepatitis B infection was identified with a prevalence of 3.9%. Giardia 7.7%, tapeworm 3.3% and Strongyloides 2.8% were also commonly identified. CONCLUSIONS: We report the largest known dataset to our knowledge of infection screening in asymptomatic unaccompanied asylum-seeking children in Europe to date. This data supports recommendations for routine asymptomatic screening in this high-risk cohort, based on the significant prevalence identified of infections of both personal and public health significance.

The forgotten people: Hepatitis B virus (HBV) infection as a priority for the inclusion health agenda.

Hepatitis B virus (HBV) infection represents a significant global health threat, accounting for 300 million chronic infections and up to 1 million deaths each year. HBV disproportionately affects people who are under-served by health systems due to social exclusion, and can further amplify inequities through its impact on physical and mental health, relationship with stigma and discrimination, and economic costs. The 'inclusion health' agenda focuses on excluded and vulnerable populations, who often experience barriers to accessing healthcare, and are under-represented by research, resources, interventions, advocacy, and policy. In this article, we assimilate evidence to establish HBV on the inclusion health agenda, and consider how this view can inform provision of better approaches to diagnosis, treatment, and prevention. We suggest approaches to redress the unmet need for HBV interventions among excluded populations as an imperative to progress the global goal for the elimination of viral hepatitis as a public health threat.

Beyond arrival: safeguarding unaccompanied asylum-seeking children in the UK.

Unaccompanied children (also called unaccompanied minors) are children who have been separated from both parents and other relatives and are not being cared for by an adult who, by law or custom, is responsible for doing so. From 2010 to 2020, unaccompanied minors accounted on average for 15.4% of the total number of first-time asylum applicants aged less than 18 years in the UK. These young people risk their lives and undergo traumatic journeys in search of a better life. However, when they arrive in the UK, they are vulnerable to significant ongoing traumatic experiences.In this review, we look at the reasons young people are forced to flee their countries, how they make their journey, and the risks and dangers they face along the way. We examine safety and victimisation risks faced by children and young people after arrival in the UK, which mechanisms and processes exist to safeguard these individuals, and examine the data available on outcomes of unaccompanied asylum-seeking child (UASC. Finally, we share two case examples that represent both the strengths and weaknesses of existing processes for UASC.

The importance of taking ART appropriately in children and adolescents with HIV-1 to reach the highest capacity of immune function later in life.

Current antiretroviral therapy (ART) guidelines recommend treating all children with HIV-1 infection. This has changed from the broader use of ART to treat children to improve morbidity and minimise mortality. However, prior to current recommendations, not everyone with HIV-1 received timely treatment. What happens to the paediatric immune system when HIV-1 replication is not appropriately supressed remains unclear. 11 samples from adolescents with HIV-1 on ART and uninfected controls in the UK, aged 12-25 years, were examined; overall, adolescents with CD4+ counts > 500/µl and a viral load < 50 copies/ml were compared with adolescents with CD4+ counts < 500/µl and a viral load > 50 copies/ml at time of sampling. Measurements of thymic output were combined with high throughput next generation sequencing and bioinformatics to systematically organize CD4+ and CD8+ T cell receptor (TCR) repertoires. TCR repertoire diversity, clonal expansions, TCR sequence sharing, and formation of TCR clusters in HIV-1 infected adolescents with successful HIV-1 suppression were compared to adolescents with ineffective HIV-1 suppression. Thymic output and CD4+ T cell numbers were decreased in HIV-1 infected adolescents with poor HIV-1 suppression. A strong homeostatic TCR response, driven by the decreased CD4+ T cell compartment and reduced thymic output was observed in the virally uncontrolled HIV-1-infected adolescents. Formation of abundant robust TCR clusters and structurally related TCRs were found in the adolescents with effective HIV-1 suppression. Numerous CD4+ T cell numbers in the virally controlled adolescents emphasize the importance of high thymic output and formation of robust TCR clusters in the maintenance of HIV-1 suppression. While the profound capacity for immune recovery in children may allow better opportunity to deal with immunological stress, when ART is taken appropriately, this study demonstrates new insights into the unique paediatric immune system and the immunological changes when HIV-1 replication is ongoing.

Screening for neglected tropical diseases and other infections in refugee and asylum-seeker populations in the United Kingdom.

Asylum-seekers and refugees have an increased burden of infections compared with the general population. This has been widely recognised by countries welcoming those fleeing conflict and persecution; however, there are no screening standardised guidelines and regulatory processes. Identification of certain neglected tropical diseases (NTDs) and other infections is important for the health and well-being of the individual in addition to public health and biosecurity. In the United Kingdom, screening for infections at port of entry or after arrival is not mandatory. Those on refugee resettlement programmes will have infection screening as part of their pre-entry health assessment, but no such system exists for those claiming asylum in the United Kingdom. In this article, we have reviewed published, peer-reviewed articles looking at the approaches to screening for NTDs and infectious diseases in the United Kingdom. In addition to this, we have reviewed the literature looking at the acceptability, barriers and facilitators of these screening practices. We found that there is a heterogeneous approach to screening practices in the United Kingdom and a paucity of data to support a single 'best practice' approach. Based on our findings, we have made recommendations and consideration for NTD screening strategies and highlighted important areas for future research.

Utility of Esophageal Ultrasound-guided Biopsy of Mediastinal Lymph Nodes in Diagnosis of Childhood Tuberculosis.

A 6-year-old boy with autistic spectrum disorder was diagnosed with tuberculosis infection following contact tracing of his mother who had isoniazid-resistant pulmonary tuberculosis. He progressed to develop mediastinal lymphadenopathy causing a persistent cough. He was too small to undergo endobronchial ultrasound-guided biopsy. As an alternative, he underwent esophageal endoscopic ultrasound-guided biopsy, leading to confirmation of the diagnosis. We believe this approach to diagnostic biopsy is underrecognized in pediatric practice, and highlight its utility with this case and a brief literature review.

Piloting a registry for paediatric sepsis: The PoRPoiSe study.

AIM: To develop a model for a paediatric sepsis registry for use in emergency care settings. A regional study, in the UK, was undertaken to identify the most basic registry components which are desirable and feasible using the concept of a minimum viable product. METHODS: Two-round survey of clinicians using a modified Delphi methodology in conjunction with a regional data collection project in three paediatric emergency departments across London. RESULTS: The survey identified 34 desirable information items to be included in a registry. Fifteen of 34 items are currently feasible from our experience of data collection. CONCLUSION: The development of a multi-centre paediatric sepsis registry sepsis may have several benefits but is currently extremely limited primarily because of technological fragmentation within our Health Service. Our findings have important implications for researchers wishing to plan sepsis surveillance programmes, locally and internationally.

Iron-deficiency anaemia: the perils of excessive milk-drinking.

Iron-deficiency anaemia is a widespread and largely preventable problem in the paediatric population, with numerous potential sequelae. We describe the case of a 2-year-old girl presenting with non-specific symptoms, who was found to be iron-deficient and anaemic, in the context of excessive cow's milk consumption. We explore the patient's diagnostic journey, including a neurological deterioration and the link between her iron deficiency and the final diagnosis.

Description and evaluation of a pathway for unaccompanied asylum-seeking children.

OBJECTIVE: (1) To describe a novel integrated pathway for unaccompanied asylum-seeking children (UASC).(2) To evaluate a population engaged with this service. DESIGN: Description of the integrated pathway (objective 1) and retrospective evaluation, using data from community paediatrics, infectious diseases (IDs) screening and a sexual health (SH) service (objective 2). SETTING: Unlinked data were collected from three services across three National Health Service (NHS) trusts in London. PATIENTS: All Camden UASC engaged with the service from 01 January 2016 to 30 March 2019. INTERVENTIONS: A multidisciplinary approach prioritising the health needs of UASC including a childre and adolescent mental health service (CAMHS) clinican and a health improvement practitioner. There are low thresholds for onward referral and universal asymptomatic screening of UASC for ID. MAIN OUTCOME MEASURES: Data on demographics, unmet health needs and known outcomes. RESULTS: Data were available for 101 UASC, 16% female, median age 16 years (range 14-17). Physical assault/abuse was reported in 67% and 13% disclosed sexual assault/abuse, including 38% of female UASC. Mental health symptoms were documented in 77%. IDs warranting treatment were identified in 41% including latent tuberculosis (25%) and schistosomiasis (13%). Interpreters were required for 97% and initial non-attendance rates at follow-up were 40% (ID) and 49% (SH). CONCLUSIONS: These data demonstrate high rates of historical physical and sexual assault/abuse, unmet physical, mental and emotional health needs among UASC and significant barriers to engaging with services. An integrated pathway has been successfully implemented and shown to deliver appropriate, joined-up care for UASC, consistent with current recommendations, with the potential to improve outcomes.

A Whole-child, whole-family approach to health assessments for asylum-seeking children.

In 2020, 21% of people who sought asylum in the UK were children. This population has complex interconnecting health and social needs. Assessment requires a holistic approach, with consideration of physical and mental health in addition to social and developmental well-being, within the whole family group. A trauma-informed life-cycle and intergenerational care approach is important. This article, aimed at all health professionals who may work with asylum-seeking families, outlines the best practice principles for undertaking health assessments in migrant children and young people.

SARS-CoV-2 testing and infection control strategies in European paediatric emergency departments during the first wave of the pandemic.

Between February and May 2020, during the first wave of the COVID-19 pandemic, paediatric emergency departments in 12 European countries were prospectively surveyed on their implementation of SARS-CoV-2 disease (COVID-19) testing and infection control strategies. All participating departments (23) implemented standardised case definitions, testing guidelines, early triage and infection control strategies early in the outbreak. Patient testing criteria initially focused on suspect cases and later began to include screening, mainly for hospital admissions. Long turnaround times for test results likely put additional strain on healthcare resources.Conclusion: Shortening turnaround times for SARS-CoV-2 tests should be a priority. Specific paediatric testing criteria are needed. What is Known: • WHO and public health authorities issued case definitions, testing and infection control recommendations for COVID-19 in January. • SARS-CoV-2 testing was made available across Europe in February. What is New: • Paediatric emergency departments implemented COVID-19-specific procedures rapidly, including case definitions, testing guidelines and early triage. • A third of surveyed departments waited more than 24 h for SARS-CoV-2 test to be reported, resulting in additional strain on resources.

Screening for infection in unaccompanied asylum-seeking children and young people.

We aimed to evaluate a screening programme for infection in unaccompanied asylum seeking children and young people against national guidance and to described the rates of identified infection in the cohort. The audit was conducted by retrospective case note review of routinely collected, anonymised patient data from all UASC referred between January 2016 and December 2018 in two paediatric infectious diseases clinics.There were 252 individuals from 19 countries included in the study, of these 88% were male, and the median age was 17 years (range 11-18). Individuals from Afghanistan, Eritrea and Albania constituted the majority of those seen. Median time between arriving in the UK and infection screening was 6 months (IQR 4-10 months, data available on 197 UASC). There were 94% (238/252) of cases tested for tuberculosis (TB), of whom 23% (55/238) were positive, including three young people with TB disease. Of those tested for hepatitis B, 4.8% (10/210) were positive, 0.5% (1/121) were positive for hepatitis C and of 252 tested, none were positive for HIV. Of the 163 individuals who were tested for schistosomiasis, 27 were positive (16%).The majority of patients were appropriately tested for infections with a high rate of identification of treatable asymptomatic infection. Infections were of both individual and public health significance. Our findings of clinically significant rates of treatable infections in UASC highlight the importance of infection screening for all in this vulnerable patient group.