Variation in initial health assessment of unaccompanied asylum-seeking children: a cross-sectional survey across England.

OBJECTIVE: To assess variation in current practice of initial health assessments (IHAs) for unaccompanied asylum-seeking children (UASC) across England. DESIGN: Cross-sectional survey. MAIN OUTCOMES MEASURES: Type of routine assessment carried out, threshold to specialist referrals and facilities available to complete IHA. RESULTS: Eighty-six health professionals responded across England; 47% had received training in UASC IHA and 33% in UASC mental health issues. The majority (80%) of IHAs were conducted with translator support and 7% of participants reported Child and Adolescent Mental Health Services (CAMHS) input. Around half of clinicians (53%) performed tuberculosis and bloodborne virus screening for all UASC, while other infectious diseases (IDs) screening was symptom and risk factor dependent. Overall, 14% of clinicians routinely comment on age assessment and 76% share the IHA report and health plan with UASC. The time allocated for assessment range between 30 and 90 min. CONCLUSION: There is significant variation in practice around UASC IHAs across England, notably around CAMHS input, time allocated, translation facilities and ID screening. The results suggest that, an increase in resources available for UASC teams, improved access to specialist services and further training on UASC health are all needed. Guidance that aims to set a best practice framework for UASC IHA delivery such as a 'one-stop shop' model would help to standardise UASC IHA across the country.

Pediatric Endobronchial Ultrasound-Transbronchial Needle Aspiration Under Conscious Sedation for Suspected Tuberculosis in London.

Tuberculosis (TB) is an important cause of childhood death and morbidity worldwide. The diagnosis in the pediatric population remains challenging due to the paucibacillary nature of the disease. Intrathoracic lymphadenopathy is one of the most common manifestations of primary disease but is often difficult to sample. A retrospective case review was performed of children (younger than 16 years) suspected with intrathoracic TB lymphadenopathy who underwent an endobronchial ultrasound (EBUS)-transbronchial needle aspiration (TBNA) between January 2010 and 2020 in a London TB center. Ten children between 11 years 4 months and 15 years 9 months, with weights ranging from 48 to 95 kg, underwent EBUS-TBNA. All procedures were performed under conscious sedation with no reported complications. Six of 10 cases showed granulomas on rapid onsite histologic evaluation. Nine of 10 cases were confirmed to have Mycobacterium tuberculosis. Seven of 10 cases were culture positive with a mean turn-around time of 13.7 days; of these, 4 of 7 were smear positive. Six of 7 culture positive cases were also TB polymerase chain reaction (PCR) positive. TB PCR identified 2 further cases where microscopy and culture remained negative. One case had multidrug-resistant TB identified on TB PCR allowing early initiation of correct drug therapy. In our cohort, we show EBUS-TBNA is a safe and effective way of investigating intrathoracic TB lymphadenitis in children and a high diagnostic rate can be achieved. In high-resource settings, we should approach childhood TB with a standardized diagnostic approach and utilize EBUS-TBNA as a diagnostic modality. Samples should be sent for culture but also for molecular assays to timely identify TB and drug-resistant disease.

Experience of a novel community testing programme for COVID-19 in London: Lessons learnt.

We describe the London community testing programme developed for COVID-19, audit its effectiveness and report patient acceptability and patient adherence to isolation guidance, based upon a survey conducted with participants.Any patients meeting the Public Health England (PHE) case definition for COVID-19 who did not require hospital admission were eligible for community testing. 2,053 patients with suspected COVID-19 were tested in the community between January and March 2020. Of those tested, 75 (3.6%) were positive. 88% of patients that completed a patient survey felt safe and 82% agreed that community testing was preferable to hospital admission. 97% were able to remain within their own home during the isolation period but just 41% were able to reliably isolate from other members of their household.The London community testing programme allowed widespread testing for COVID-19 while minimising patient transport, hospital admissions and staff exposures. Community testing was acceptable to patients and preferable to admission to hospital. Patients were able to reliably isolate in their home but not from household contacts. The authors believe in the importance, feasibility and acceptability of community testing for COVID-19 as a part of a package of interventions to mitigate a second wave of infection.

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.

Evaluating UK National Guidance for Screening of Children for Tuberculosis. A Prospective Multicenter Study.

RATIONALE: To identify infected contacts of tuberculosis (TB) cases, the UK National Institute for Health and Care Excellence (NICE) recommended the addition of IFN-γ release assays (IGRA) to the tuberculin skin test (TST) in its 2006 TB guidelines. Treatment for TB infection was no longer recommended for children who screened TST-positive but IGRA-negative. OBJECTIVES: We performed a cohort study to evaluate the risk of TB disease in this group. METHODS: Children exposed to an infectious case of TB in their household were recruited from 11 pediatric TB clinics. TST and IGRA were performed at baseline, with IGRA repeated at 8 weeks and TST repeated if initially negative. Children were treated according to 2006 NICE guidelines and followed for 24 months. MEASUREMENTS AND MAIN RESULTS: Of 431 recruited children, 392 completed the study. We diagnosed 48 (12.2%) cases of prevalent TB disease, 105 (26.8%) with TB infection, and 239 (60.9%) without TB infection or disease. Eighteen children aged 2 years and above had a positive TST but persistently negative IGRA. None received TB infection treatment and none developed TB disease. Ninety (26.1%) children qualified for TB infection treatment according to 2006 NICE guidelines. In contrast, 147 (42.7%) children would have qualified under revised NICE guidance, issued in 2016. CONCLUSIONS: In this low-prevalence setting we saw no incident cases of TB disease in children who were TST-positive but IGRA-negative and did not receive treatment for TB infection. Following the latest NICE guidance, significantly more children will require medication.

The impact of BCG vaccination on tuberculin skin test responses in children is age dependent: evidence to be considered when screening children for tuberculosis infection.

BACKGROUND: Following exposure to TB, contacts are screened to target preventive treatment at those at high risk of developing TB. The UK has recently revised its recommendations for screening and now advises a 5 mm tuberculin skin test (TST) cut-off irrespective of age or BCG status. We sought to evaluate the impact of BCG on TST responses in UK children exposed to TB and the performance of different TST cut-offs to predict interferon γ release assay (IGRA) positivity. METHODS: Children <15 years old were recruited from 11 sites in the UK between January 2011 and December 2014 if exposed in their home to a source case with sputum smear or culture positive TB. Demographic details were collected and TST and IGRA undertaken. The impact of BCG vaccination on TST positivity was evaluated in IGRA-negative children, as was the performance of different TST cut-offs to predict IGRA positivity. RESULTS: Of 422 children recruited (median age 69 months; IQR: 32-113 months), 300 (71%) had been vaccinated with BCG. BCG vaccination affected the TST response in IGRA-negative children less than 5 years old but not in older children. A 5 mm TST cut-off demonstrated good sensitivity and specificity in BCG-unvaccinated children, and an excellent negative predictive value but was associated with low specificity (62.7%; 95% CI 56.1% to 69.0%) in BCG-vaccinated children. For BCG-vaccinated children, a 10 mm cut-off provided a high negative predictive value (97.7%; 95% CI 94.2% to 99.4%) with the positive predictive value increasing with increasing age of the child. DISCUSSION: BCG vaccination had little impact on TST size in children over 5 years of age. The revised TST cut-off recommended in the recent revision to the UK TB guidelines demonstrates good sensitivity but is associated with impaired specificity in BCG-vaccinated children.