Clinical standards for drug-susceptible TB in children and adolescents.

BACKGROUND: These clinical standards aim to provide guidance for diagnosis, treatment, and management of drug-susceptible TB in children and adolescents.METHODS: Fifty-two global experts in paediatric TB participated in a Delphi consensus process. After eight rounds of revisions, 51/52 (98%) participants endorsed the final document.RESULTS: Eight standards were identified: Standard 1, Age and developmental stage are critical considerations in the assessment and management of TB; Standard 2, Children and adolescents with symptoms and signs of TB disease should undergo prompt evaluation, and diagnosis and treatment initiation should not depend on microbiological confirmation; Standard 3, Treatment initiation is particularly urgent in children and adolescents with presumptive TB meningitis and disseminated (miliary) TB; Standard 4, Children and adolescents should be treated with an appropriate weight-based regimen; Standard 5, Treating TB infection (TBI) is important to prevent disease; Standard 6, Children and adolescents should receive home-based/community-based treatment support whenever possible; Standard 7, Children, adolescents, and their families should be provided age-appropriate support to optimise engagement in care and clinical outcomes; and Standard 8, Case reporting and contact tracing should be conducted for each child and adolescent.CONCLUSION: These consensus-based clinical standards, which should be adapted to local contexts, will improve the care of children and adolescents affected by TB.

Monitoring and evaluation of HIV screening and testing of hospitalized infants and their mothers.

SETTING: Improved HIV monitoring and evaluation (M&E) is urgently needed to help close gaps in inpatient infant provider-initiated testing and counseling (PITC) and pediatric case identification. A revised reporting system was piloted on the Breastfeeding Ward at Hospital Central de Maputo in Maputo, Mozambique. OBJECTIVE: To demonstrate how a simplified reporting system designed for pediatric inpatient ward registers can be used to easily calculate key PITC indicators, including testing coverage, HIV status, linkage to antiretroviral therapy, maternal testing, and point-of-care nucleic acid testing. DESIGN: This was a retrospective review of PITC data documented in the ward discharge register for all inpatient infants with charts closed from January 1 to June 30, 2020. RESULTS: At chart closure, 97.7% of infants (477/488) had known serostatus: 76.3% were not exposed (364/477), 15.3% were exposed (73/477), 1.9% definitively non-infected (9/477), and 6.5% infected (31/477). There was a 26.9% positivity rate (14/52) for infant point-of-care nucleic acid testing. Of all HIV-infected infants, 80.6% (25/31) were linked to antiretroviral therapy by the time of discharge. Preferred maternal testing was done in 80.5% of eligible mothers (276/343), with 3.0% newly positive (8/276). CONCLUSION: This straightforward PITC reporting system enabled simple calculation of key indicators needed for standard M&E, contributed to quality improvement efforts to increase testing coverage, and could be easily adapted for use in other settings.

CONTEXTE: Une amélioration du suivi et de l'évaluation du VIH est urgemment nécessaire afin d'aider à combler les lacunes en matière de conseil et de dépistage à l'initiative du soignant (PITC) chez l'enfant hospitalisé et d'identification des cas pédiatriques. Une nouvelle version du système de notification des cas a été testée dans l'unité dédiée à l'allaitement maternel de l'hôpital central de Maputo, Mozambique. OBJECTIF: Démontrer comment un système simplifié de notification des cas conçu pour les registres des unités hospitalières pédiatriques peut être utilisé afin de facilement calculer les indicateurs PITC clés, dont la couverture du dépistage, le statut VIH, le lien avec le traitement antirétroviral, le dépistage maternel et le test d'amplification des acides nucléiques au point de services. MÉTHODE: Il s'agissait d'une revue rétrospective des données PITC documentées dans le registre des sorties de l'unité pour tous les enfants hospitalisés dont les dossiers ont été clôturés entre le 1er janvier et le 30 juin 2020. RÉSULTATS: Au moment de la clôture de leur dossier, 97,7% des enfants (477/488) avaient un statut sérologique connu : 76,3% n'avaient pas été exposés au VIH (364/477), 15,3% avaient été exposés (73/477), 1,9% étaient définitivement non infectés (9/477) et 6,5% étaient infectés (31/477). Le taux de positivité aux tests d'amplification des acides nucléiques réalisés au point de services pédiatriques était de 26,9% (14/52). Parmi tous les enfants infectés par le VIH, 80,6% (25/31) étaient reliés à un traitement antirétroviral d'ici à leur sortie de l'hôpital. Le test préféré de dépistage maternel a été réalisé chez 80,5% des mères éligibles (276/343), dont 3,0% ont reçu un résultat positif (8/276). CONCLUSION: Ce système de notification PITC simplifié a permis de facilement calculer les indicateurs clés nécessaires à un M&E standard, tout en contribuant aux efforts d'amélioration qualitative visant à accroître la couverture du dépistage. Il pourrait aisément être adapté à une utilisation dans d'autres contextes.

Clinical and operational factors associated with low pediatric inpatient HIV testing coverage in Mozambique.

SETTING: Eleven pediatric wards in Maputo Province, Mozambique. OBJECTIVE: 1) To determine provider-initiated testing and counseling (PITC) coverage, the rate of human immunodeficiency virus (HIV) positivity, and the clinical and facility-level variables associated with PITC; and 2) to assess the care cascade for HIV-exposed and -infected children. DESIGN: This was a cross-sectional, retrospective review of inpatient charts, selected via systematic randomization, of patients aged 0-4 years, admitted between July and December 2015. RESULTS: Among the 800 patients included, the median age was 23 months and median duration of hospitalization was 3 days. HIV testing was ordered in 46.0% of eligible patients (known HIV-infected at admission excluded), with results documented for 35.7%, of whom 8.3% were positive. The patient hospitalization diagnoses with the highest PITC rates were malnutrition (73.8%), sepsis (71.4%) and tuberculosis (58.3%), with positivity rates of respectively 16.1%, 20.0%, and 28.6%. Longer hospitalization, weekday admission, and PITC training for staff were significantly associated with better PITC performance. Antiretroviral treatment was initiated during hospitalization for 29.6% of eligible patients. CONCLUSION: PITC coverage was low, with high HIV positivity rates, highlighting missed opportunities for diagnosis and linkage to treatment. Strengthened routine testing on wards with consideration of inpatient ART initiation are needed to help achieve pediatric 90-90-90 goals.

Risk factors for mortality in Malawian children with human immunodeficiency virus and tuberculosis co-infection.

SETTING: A large urban pediatric human immunodeficiency virus (HIV) clinic in Lilongwe, Malawi. OBJECTIVE: To identify demographic and clinical risk factors for mortality in children co-infected with HIV and tuberculosis (TB). DESIGN: A retrospective cohort study of HIV-infected children (aged <18 years) enrolled between October 2004 and October 2010 with at least one current or historical TB diagnosis. Descriptive statistics and logistic regression analyses were performed to determine factors associated with mortality. RESULTS: A total of 1561 patients met the inclusion criteria, representing 32% of patients ever enrolled. Median age at TB diagnosis was 3.8 years (interquartile range 1.5-7.4); 60.9% had severe immune suppression and 47.6% of those with available data had some degree of acute malnutrition at TB diagnosis. Of the 1113 patients with known outcomes, 225 (20.2%) died. Children with TB-HIV co-infection not initiated on antiretroviral therapy (ART) at any time were 8.8 times more likely to die compared to those initiated on ART 0-2 months after initiation of anti-tuberculosis treatment (adjusted OR 8.83, 95%CI 4.42-17.63). Severe immunosuppression and World Health Organization Stage IV were also associated with mortality. CONCLUSIONS: Pediatric TB-HIV co-infection is common and mortality is high in this cohort of Malawian children. Prompt initiation of ART should be emphasized in this high-risk patient population.