The Contribution of Chest Radiography to the Clinical Management of Children Exposed to Tuberculosis.

Rationale: Although World Health Organization guidelines emphasize contact investigation for tuberculosis (TB)-exposed children, data that support chest radiography as a useful tool are lacking. Objectives: We evaluated the diagnostic and prognostic information of chest radiography in children exposed to TB and measured the efficacy of isoniazid preventive therapy (IPT) in those with relevant radiographic abnormalities. Methods: Between September 2009 and August 2012, we enrolled 4,468 TB-exposed children who were screened by tuberculin skin testing, symptom assessment, and chest radiography. Those negative for TB disease were followed for 1 year for the occurrence of new TB diagnoses. We assessed the protective efficacy of IPT in children with and without abnormal chest radiographs. Measurements and Main Results: Compared with asymptomatic children with normal chest films, asymptomatic children with abnormal radiographs were 25.1-fold more likely to have coprevalent TB (95% confidence interval [CI], 1.02-613.76) and 26.7-fold more likely to be diagnosed with incident TB disease during follow-up (95% CI, 10.44-68.30). Among the 29 symptom-negative and CXR-abnormal child contacts, 20% (3/15) of the isoniazid recipients developed incident TB, compared with 57% (8/14) of those who did not receive IPT (82% IPT efficacy). Conclusions: Our results strongly support the use of chest radiography as a routine screening tool for the evaluation of child TB contacts, which is readily available. Radiographic abnormalities not usually considered suggestive of TB may indicate incipient or subclinical disease, although TB preventive treatment is adequate in most cases.

Tubercular infection in children living with adults receiving Directly Observed Treatment Short Course (DOTS): a follow up study.

BACKGROUND: Children living with sputum smear-positive adult tuberculosis (TB) patients are vulnerable to acquire tubercular infection. Contact tracing is an important strategy to control tubercular infection in the community. This study was done to find out prevalence of tuberculosis and tubercular infection in children living with sputum smear-positive adult patients receiving DOTS at recruitment and to find out incidence of tubercular infection and disease in these children on follow up. METHOD: Children (< 15 years) living in contact with adults on DOTS were grouped as < 6 years and 6-14 years. They were further sub grouped as being - uninfected, infected, diseased and on prophylaxis and were followed at 3, 6 and 9 months. Tuberculin skin test (TST) and chest X-ray were done. RESULTS: At recruitment 152 children were enrolled and 21.1% (n = 32) had TB. On follow up, 4.3% (n = 5), 5.8% (n = 6) and 11.6% (n = 11) children developed TB after 3, 6 and 9 months respectively.9 children did not come for the last follow up so the overall prevalence of TB disease at 9 months was 37.7% (n = 54). Out of the 128 children with TST reading 23.4% (n = 30) child contacts were found to be infected already at recruitment. The incidence of TST conversion was 20.7% (n = 18), 26.9% (n = 18) and 16.3% (n = 7) respectively. The overall prevalence of tubercular infection in the children, who were in contact with TB patients for 9 months was 74.5% (n = 73). CONCLUSION: About half the children were either suffering from TB or tubercular infection on recruitment. During 9 months follow up 22 unaffected children developed disease and 43acquired infection.

Preventive therapy in children exposed to Mycobacterium tuberculosis: problems and solutions.

Young children living with a tuberculosis patient are at high risk of Mycobacterium tuberculosis infection and disease. WHO guidelines promote active screening and isoniazid (INH) preventive therapy (PT) for such children under 5 years, yet this well-established intervention is seldom used in endemic countries. We review the literature regarding barriers to implementation of PT and find that they are multifactorial, including difficulties in screening, poor adherence, fear of increasing INH resistance and poor acceptability among primary caregivers and healthcare workers. These barriers are largely resolvable, and proposed solutions such as the adoption of symptom-based screening and shorter drug regimens are discussed. Integrated multicomponent and site-specific solutions need to be developed and evaluated within a public health framework to overcome the policy-practice gap and provide functional PT programmes for children in endemic settings.

The Negative Impact of Adult Children's Marital Dissolution on Older Parents' Mental Health in South Korea.

OBJECTIVE: Little is known about whether and the extent children's marital dissolution deteriorates older parents' mental health. This study examines the association of children's marital dissolution with parents' mental health, and whether children's gender and intergenerational contact and support moderate such an association in South Korea, where family lives are strongly linked under the Confucian collectivistic legacy. METHODS: We apply fixed-effects models on 15,584 parent-child dyads nested in 5,673 older parents (45-97 years in Wave 1) participating in the four waves of the Korean Longitudinal Study of Aging (KLoSA), conducted from 2006 to 2012. RESULTS: In South Korea, a son's transition to marital dissolution is associated with higher levels of parents' depressive symptoms. Frequent parent-son contacts of at least once a week, living with a son, and increasing financial transfers from parents to a son tend to reduce the negative association of the son's marital dissolution with parents' depressive symptoms. DISCUSSION: The findings imply that a son's transition to marital dissolution, as a later-life stressor, is detrimental to parents' mental health in a patrilineal Asian cultural context. The study also highlights the importance of intergenerational bonding in mitigating the negative impact of children's marital dissolution upwardly transmitted to their older parents.

Inclusion of a specific prompt within the standard clinical pro forma used in assessment of patients referred to a child and adolescent sexual assault treatment service: A suggested safety-net to facilitate detection of other children at risk of child sexual abuse.

BACKGROUND: Evaluation of an index case of child abuse necessitates risk assessment of other children who could be vulnerable to abuse from the same perpetrator/s. OBJECTIVE: To determine the effectiveness of the addition of a prompt to the standard clinical pro forma used for the assessment of new referrals to a child and adolescent sexual assault treatment service in terms of impact upon detection of other at risk children. PARTICIPANTS AND SETTING: All referrals to a Child and Adolescent Sexual Assault Treatment Service, Galway, West Ireland. METHODS: Retrospective chart review of all children assessed between September 2016 and March 2017. Intervention initiated on September 1st, 2017. Prospective chart review of all children assessed between September 2017 and March 2018. Chart reviews established whether potential risk to siblings, and other close child contacts, of the index case had been adequately considered. RESULTS: Comparing pre and post intervention groups, documentation of children at risk significantly increased from 70% to 96% (p = 0.0124). Cases in which a letter was sent to social services regarding other "at risk" children also significantly increased from 50% to 92% (p = 0.0005). There was a change in the percentage of "at risk" children examined or planned for examination, from 66% to 84%, however that was not statistically significant (p = 0.80). CONCLUSIONS: Introduction of a simple prompt within the standard clinical pro forma had a significant positive impact upon clinicians' consideration of other "at risk" children. We suggest that other services consider including a similar section in their own pro forma documents.

Routine programmatic delivery of isoniazid preventive therapy to children in Cape Town, South Africa.

SETTING: Fourteen primary health care facilities in Cape Town, South Africa. OBJECTIVE: To determine the proportion and characteristics of infectious adult tuberculosis (TB) cases that identify children aged <5 years who qualify for isoniazid preventive therapy (IPT), and to determine the proportion of children who initiate and complete IPT. DESIGN: A retrospective clinical record review conducted as a stratified cluster survey. RESULTS: Of 1179 records of infectious adult cases, 33.3% had no documentation of contacts. Of the remaining 786 records, 525 contacts aged <5 years were identified, representing 0.7 child contacts per infectious adult case. Older age, male, human immunodeficiency virus (HIV) positive, smear-negative and retreatment TB cases were all associated with no documentation of contacts. Of the 525 child contacts identified, less than half were screened for TB, 141 initiated IPT and 19 completed it. CONCLUSION: Less than 67% of infectious TB case records had documentation of contacts. Younger, female, HIV-negative and new smear-positive TB cases were more likely to have had contacts identified. Less than 14% of children already initiated on IPT completed 6 months of treatment.