Perspectives of TB survivors and policymakers on post-TB disability.

BACKGROUND: An international multistakeholder participatory workshop was hosted in the Gambia, West Africa, in November 2021. OBJECTIVES: To explore the experiences, challenges and recommendations of workshop participants on health and wellbeing after TB treatment. METHODS: An exploratory, descriptive, qualitative approach was used for data collection through facilitator-guided group discussions. Workshop participants included adolescent and adult TB survivors, and representatives of TB advocacy groups and the policy sector. Discussions were audio-recorded and transcribed verbatim, and the data were analysed using a deductive thematic approach. RESULTS: Overall, 38 participants (22 women) from six West African countries participated in the workshop, comprising 33 TB survivors and advocacy group representatives and 5 participants from the policy sector. Although some TB survivors noted improved ability to carry out physical activities, others continued to experience detrimental effects on their family life, social interactions, physical health and ongoing stigma. Policymakers emphasised the lack of data and clear guidelines on post-TB disability. CONCLUSIONS: Some TB survivors continue to suffer detrimental effects of the illness even after treatment completion. However, available data on post-TB disability is inadequate to support policy adoption. Therefore, there is an urgent need for increased advocacy, awareness and research to bridge knowledge gaps.

CONTEXTE: Un atelier participatif international multipartite a été organisé en Gambie, Afrique de l'Ouest, en novembre 2021. OBJECTIFS: Analyser les expériences, les défis et les recommandations des participants à l'atelier en matière de santé et de bien-être après un traitement antituberculeux. MÉTHODES: Une approche exploratoire, descriptive et qualitative a été utilisée pour le recueil des données par le biais de discussions de groupe encadrées par un animateur. Les participants à l'atelier étaient des adolescents et des adultes ayant survécu à une TB, ainsi que des représentants de groupes de plaidoyer de la TB et du secteur politique. Les discussions ont été enregistrées sur support audio et transcrites textuellement, et les données ont été analysées en utilisant une approche thématique déductive. RÉSULTATS: Au total, 38 participants (22 femmes) de six pays d'Afrique de l'Ouest ont participé à l'atelier, dont 33 représentants de groupes de plaidoyer ayant eux-mêmes survécu à une TB et 5 participants issus du secteur politique. Bien que certaines personnes ayant survécu à une TB aient constaté une amélioration de leur capacité à mener des activités physiques, d'autres ont continué à subir les effets néfastes sur leur vie familiale, leurs interactions sociales, leur santé physique et la stigmatisation permanente. Les responsables politiques ont souligné le manque de données et de directives claires sur le handicap post-TB. CONCLUSIONS: Certaines personnes ayant survécu à une TB continuent de subir les effets néfastes de la maladie, et ce même après la fin du traitement. Cependant, les données disponibles sur le handicap post-TB sont insuffisantes pour soutenir l'adoption de politiques. Il est donc urgent de renforcer le plaidoyer, la sensibilisation et la recherche pour combler les lacunes en matière de connaissances.

The socioeconomic impact of tuberculosis on children and adolescents: a scoping review and conceptual framework.

BACKGROUND: Tuberculosis (TB) has been repeatedly shown to have socioeconomic impacts in both individual-level and ecological studies; however, much less is known about this effect among children and adolescents and the extent to which being affected by TB during childhood and adolescence can have life-course implications. This paper describes the results of the development of a conceptual framework and scoping review to review the evidence on the short- and long-term socioeconomic impact of tuberculosis on children and adolescents. OBJECTIVES: To increase knowledge of the socioeconomic impact of TB on children and adolescents. METHODS: We developed a conceptual framework of the socioeconomic impact of TB on children and adolescents, and used scoping review methods to search for evidence supporting or disproving it. We searched four academic databases from 1 January 1990 to 6 April 2021 and conducted targeted searches of grey literature. We extracted data using a standard form and analysed data thematically. RESULTS: Thirty-six studies (29 qualitative, five quantitative and two mixed methods studies) were included in the review. Overall, the evidence supported the conceptual framework, suggesting a severe socioeconomic impact of TB on children and adolescents through all the postulated pathways. Effects ranged from impoverishment, stigma, and family separation, to effects on nutrition and missed education opportunities. TB did not seem to exert a different socioeconomic impact when directly or indirectly affecting children/adolescents, suggesting that TB can affect this group even when they are not affected by the disease. No study provided sufficient follow-up to observe the long-term socioeconomic effect of TB in this age group. CONCLUSION: The evidence gathered in this review reinforces our understanding of the impact of TB on children and adolescents and highlights the importance of considering effects during the entire life course. Both ad-hoc and sustainable social protection measures and strategies are essential to mitigate the socioeconomic consequences of TB among children and adolescents.

Diagnosis of paediatric TB using Xpert® MTB/RIF Ultra on fresh respiratory samples.

OBJECTIVE: To evaluate the diagnostic accuracy of Xpert® MTB/RIF Ultra (Ultra) on fresh respiratory samples for the diagnosis of pulmonary TB (PTB) in children.METHODS: Between July 2017 and December 2019, children with presumed TB were prospectively enrolled at clinical sites in three African countries. Children were assessed using history, physical examination and chest X-ray. Sputum or gastric aspirate samples were analysed using Ultra and culture. The diagnostic accuracy of Ultra was calculated against culture as the reference standard.RESULTS: In total, 547children were included. The median age was 4.7 years, 77 (14.1%) were HIV infected and 77 (14.1%) had bacteriologically confirmed TB. Ultra detected an additional 20 cases in the group of children with negative culture results. The sensitivity of Ultra was 66.3% (95% CI 47-82), and the specificity was 95.4% (95% CI 89-99) when assessed against culture as the reference standard.CONCLUSION: Despite the improved performance of Ultra as compared to Xpert as was previously reported, its sensitivity remains sub-optimal for the detection of TB in children. Ultra detected additional 20 cases which otherwise could not have been detected by culture alone, suggesting that the latter is an imperfect reference standard.

Isoniazid preventive therapy in child household contacts of adults with active TB in Bamako, Mali.

BACKGROUND AND OBJECTIVE: Isoniazid preventive therapy (IPT) is known to reduce the risk of developing active TB in about 59% in children aged ⩽15 years. We assessed adherence, completion and adverse events among children who were household contacts of a newly diagnosed adult with smear-positive TB in Bamako, Mali. METHODS: Children aged <15 years living in the same house with an adult smear-positive index case were enrolled in the study in the Bamako Region after consent was obtained from the parent or legal guardian. Adherence was assessed based on the number of tablets consumed during 6 months. RESULTS: A total of 260 children aged <15 years were identified as household contacts of 207 adult patients with smear-positive TB during the study period. Among all child contacts, 130/260 (50.0%) were aged 0-4 years and were eligible for IPT; 128/130 (98.5%) were started on IPT and 83/128 (64.8%) completed with good adherence at the end of the 6 months, and without any significant adverse events. CONCLUSION: We successfully implemented IPT with good acceptance, but low completion rate. The Mali National TB Program and partners should expand this strategy to reach more children in Bamako and the whole country and create greater awareness in the population.

CADRE ET OBJECTIF: Le traitement préventif par isoniazide (IPT) réduit le risque de développer une TB active chez environ 59% des enfants ⩽15 ans. Nous avons évalué l'observance, l'achèvement du traitement et les évènements indésirables chez des enfants qui étaient contacts domestiques d'un adulte ayant récemment reçu un diagnostic de TB à microscopie positive à Bamako, Mali. MÉTHODES: Les enfants âgés <15 ans vivant sous le même toit qu'un cas index adulte de TB à microscopie positive ont été inclus dans l'étude dans la région de Bamako, après obtention du consentement des parents ou du tuteur légal. L'observance a été évaluée en fonction du nombre de comprimés consommés au cours d'une période de 6 mois. RÉSULTATS: Au total, 260 enfants âgés <15 ans ont été identifiés comme contacts domestiques de 207 patients adultes atteints de TB à microscopie positive pendant la période d'étude. Parmi tous les contacts pédiatriques, 130/260 (50,0%) étaient âgés de 0­4 ans et étaient éligibles à l'IPT ; 128/130 (98,5%) ont été mis sous IPT et 83/128 (64,8%) ont achevé leur traitement avec une bonne observance à la fin de la période de 6 mois, sans évènement indésirable significatif. CONCLUSION: Nous avons mis en place l'ITP avec succès. L'acceptation était bonne mais le taux d'achèvement du traitement était faible. Le programme national de lutte contre la TB du Mali et ses partenaires devraient élargir cette stratégie afin d'inclure davantage d'enfants de Bamako et du pays, et d'accroître la sensibilisation de la population.

Post-tuberculosis lung health: perspectives from the First International Symposium.

ALTHOUGH CURABLE, TB frequently leaves the individual with chronic physical and psycho-social impairment, but these consequences have been largely neglected. The 1st International Post-Tuberculosis Symposium (Stellenbosch, South Africa) was held to discuss priorities and gaps in addressing this issue. A barrier to progress has been the varied terminology and nomenclature, so the Delphi process was used to achieve consensus on definitions. Lack of sufficient evidence hampered definitive recommendations in most domains, including prevention and treatment of post-TB lung disease (PTLD), but the discussions clarified the research needed. A consensus was reached on a toolkit for future PTLD measurement and on PTLD patterns to be considered. The importance of extra-pulmonary consequences and progressive impairment throughout the life-course was identified, including TB recurrence and increased mortality. Patient advocates emphasised the need to address the psychological and social impacts post TB and called for clinical guidance. More generally, there is an urgent need for increased awareness and research into post-TB complications.

Identifying children with tuberculosis among household contacts in The Gambia.

SETTING: Greater Banjul Area of the Gambia. OBJECTIVES: To identify co-prevalent tuberculosis (TB) among child contacts of adults with smear-positive TB. DESIGN: Child contacts aged <15 years in the immediate household and compound were prospectively enrolled and evaluated for TB disease using screening questionnaires and the tuberculin skin test (TST). Symptomatic and/or TST-positive (10 mm) contacts were further investigated. RESULTS: Of 4042 child contacts who underwent symptom screening and TST, 3339 (82.6%) were diagnosed as TB-exposed but not infected, 639 (15.8%) were latently infected and 64 (1.6%) had co-prevalent TB. Of the 64 TB cases, 50 (78.1%) were from within the immediate household of the index case, and 14 (21.9%) from within the same compound. Of the 27 asymptomatic but TST-positive children diagnosed with TB, 7 were microbiologically confirmed. The median age of the TB cases was 4.4 years (interquartile range 1.9-6.9); 53.1% were aged <5 years. Of the 4042 child contacts, 206 (5%) slept in the same bed as the index case; 28.1% of all TB cases occurred in this group. Symptom screening alone would have detected only 57.8% of the co-prevalent cases. CONCLUSION: In our community setting, if contact tracing is restricted to symptom screening and immediate households only, nearly half of all co-prevalent TB disease in child contacts would be missed.

Isoniazid preventive treatment among child contacts of adults with smear-positive tuberculosis in The Gambia.

Setting: Greater Banjul area of The Gambia. Objectives: To evaluate uptake, adherence and completion of treatment among tuberculosis (TB) exposed children in The Gambia when isoniazid preventive treatment (IPT) is delivered at home Design: Child (age <5 years) contacts of adults with smear-positive TB were prospectively enrolled. Following symptom screening, tuberculin skin testing and clinical evaluation where indicated, those without disease were placed on daily isoniazid, provided monthly at home. Adherence was assessed by pill counts and IsoScreen™ urine test. Results: Of 404 contacts aged <5 years, 368 (91.1%) were offered IPT. Of the 328 (89.4%) for whom consent was received and who commenced IPT, 18 (5.5%) dropped out and 310 (94.5%) remained on IPT to the end of the 6-month regimen. Altogether, 255/328 children (77.7%, 95%CI 73.2-82.2) completed all 6 months, with good adherence. The IsoScreen test was positive in 85.3% (435/510) of all tests among those defined as having good adherence by pill count and in 16% (8/50) of those defined as having poor adherence (P < 0.001). A cascade of care analysis showed an overall completion rate with good adherence of 61% for all child contacts. Conclusion: Home-delivered IPT among child contacts of adults with smear-positive TB in The Gambia achieved verifiable high uptake and adherence rates. System rather than patient factors are likely to determine the success of IPT at national level.

Contexte : Région du Grand Banjul en Gambie.Objectifs : Evaluer la couverture, l'adhésion et l'achèvement du traitement parmi des enfants exposés à la tuberculose (TB) en Gambie quand le traitement préventif par isoniazide (TPI) est donné à domicile.Schéma : Les enfants âgés de <5 ans, contacts d'adultes atteints de TB à frottis positif, ont été enrôlés de manière prospective. Après dépistage sur les symptômes, test cutané à la tuberculine et évaluation clinique quand cela était indiqué, les enfants non malades ont été mis sous isoniazide, fourni une fois par mois à domicile. L'adhésion a été évaluée par un comptage des comprimés et par un test urinaire IsoScreen™.Résultats : Sur 404 contacts âgés de <5 ans, 368 (91,1%) ont été invités à bénéficier du TPI, et 328 (89,4%) ont consenti et commencé le TPI. Sur ces 328 enfants, 18 (5,5%) ont abandonné et 310 (94,5%) sont restés sous TPI jusqu'à la fin du 6e mois. Au total, 255/328 enfants (77,7% ; IC95% 73,2­82,2) ont achevé les 6 mois de traitement avec une bonne adhésion. Le test IsoScreen a été positif chez 85,3% (435/510) de tous les tests parmi ceux définis comme ayant une bonne adhésion par le comptage des comprimés et chez 16% (8/50) de ceux définis comme ayant une adhésion médiocre (P < 0,001). L'analyse de la « cascade des soins ¼ a montré, pour tous les enfants contacts, un taux de bonne adhésion d'ensemble de 61%.Conclusion: L'administration à domicile du TPI à des enfants contacts d'adultes atteints de TB à frottis positif en Gambie a abouti à une bonne couverture et à un bon taux d'adhésion, tous deux vérifiables. Ce sont les facteurs de système plutôt que ceux liés au patient qui sont susceptibles de déterminer le succès du TPI au niveau national.

Marco de referencia: La zona del Gran Banjul en Gambia.Objetivos: Evaluar la aceptación del tratamiento preventivo con isoniazida (TPI), su cumplimiento y su compleción por parte de los niños expuestos en Gambia, cuando se suministra el tratamiento en los hogares.Método: Se incluyeron en el estudio de manera prospectiva los niños menores de 5 años de edad que eran contactos de un adulto con diagnóstico de tuberculosis (TB) y baciloscopia positiva. Luego de la detección sistemática a partir de los síntomas, se practicaron la prueba cutánea de la tuberculina y la evaluación clínica cuando estaban indicadas; en caso de ausencia de enfermedad activa se inició el tratamiento diario con isoniazida, la cual se suministraba en el hogar cada mes. Se evaluó el cumplimiento en función del recuento de los comprimidos y la prueba IsoScreen™ en muestras de orina.Resultados: En los 404 contactos menores de 5 años de edad, se ofreció el TPI a 368 niños (91,1%) y 328 lo aceptaron y comenzaron a recibirlo (89,4%). De este grupo, 18 niños abandonaron el tratamiento (5,5%) y 310 recibían aun el medicamento al final del 6 mes (94,5%). De los 328 niños, 255 terminaron los 6 meses de tratamiento, con un cumplimiento satisfactorio (77,7%; IC del 95% de 73,2 hasta 82,2). La prueba IsoScreen fue positiva en el 85,3% (435/510) de los casos definidos con cumplimiento adecuado según el recuento de comprimidos y en el 16% (8/50) de los casos cuyo cumplimiento se consideró deficiente (P < 0,001). El análisis de la trayectoria asistencial reveló que en todos los contactos la tasa global de compleción con cumplimiento satisfactorio fue 61%.Conclusión: El TPI suministrado en el hogar a los niños que son contactos de un adulto con diagnóstico de TB y baciloscopia positiva alcanza altas tasas de aceptación y de cumplimiento que se pueden verificar. Los factores que determinan el éxito del TPI a escala nacional dependen del sistema de salud y no del paciente.

Contribution of Xpert® MTB/RIF to the diagnosis of pulmonary tuberculosis among TB-exposed children in The Gambia.

SETTING: Greater Banjul Area, The Gambia. OBJECTIVE: To conduct a pragmatic evaluation of the Xpert(®) MTB/RIF assay in the diagnosis of tuberculosis (TB) among child contacts. DESIGN: In this prospective study, one induced sputum sample was obtained from TB contacts aged <15 years and tested using fluorescent microscopy, culture and Xpert. The diagnostic accuracy of the microbiological tests was evaluated against culture and 'all TB diagnosis and treatment' as separate reference standards. RESULTS: Using culture as a reference standard, Xpert was positive for Mycobacterium tuberculosis in 6/14 culture-positive and 6/473 culture-negative children, giving a sensitivity and specificity of respectively 42.9% (95%CI 17.7-71.1) and 98.7% (95%CI 97.2-99.5). With 'all TB diagnosis and treatment' as a composite reference standard, combined Xpert and culture tests were positive for M. tuberculosis in 20/62 children with TB disease (32.3%, 95%CI 20.9-45.3), which was comparable to the yield from microscopy, culture and Xpert combined (33.9%, 95%CI 22.3-47.0), but significantly higher than individual yields from each test. CONCLUSION: The sensitivity of Xpert is low in actively traced child contacts, but a combination of Xpert and mycobacterial culture has incremental benefits for the bacteriological confirmation of TB disease.

Foreign Body Aspiration and Tuberculosis: Possible Misdiagnosis

Childhood tuberculosis (TB) is common in developing countries whereas foreign body aspiration is relatively less frequently diagnosed. This report is of a child contact (same household) of a smear-positive index case who presented with suggestive clinical features; and was admitted as a case of pulmonary TB; but subsequently found to have an aspirated foreign body was accounting for his symptoms. Due to the similarity in the clinical features of a delayed clinical presentation of foreign body aspiration with pulmonary TB; clinicians attending to children with chronic respiratory pathology in a TB-endemic area should be mindful of the possibility of a foreign body in the airway and should always carefully review chest radiographs

Effect of age and vaccination with a pneumococcal conjugate vaccine on the density of pneumococcal nasopharyngeal carriage.

BACKGROUND: This study evaluated the impact of age and pneumococcal vaccination on the density of pneumococcal nasopharyngeal carriage. METHODS: A cluster-randomized trial was conducted in rural Gambia. In 11 villages (the vaccine group), all residents received 7-valent pneumococcal conjugate vaccine (PCV-7), while in another 10 villages (the control group), only children <30 months old or born during the study period received PCV-7. Cross-sectional surveys (CSSs) were conducted to collect nasopharyngeal swabs before vaccination (baseline CSS) and 4, 12, and 22 months after vaccination. Pneumococcal density was defined using a semiquantitative classification (range, 1-4) among colonized individuals. An age-trend analysis of density was conducted using data from the baseline CSS. Mean pneumococcal density was compared in CSSs conducted before and after vaccination. RESULTS: Mean bacterial density among colonized individuals in the baseline CSS was 2.57 for vaccine-type (VT) and non-vaccine-type (NVT) pneumococci; it decreased with age (P < .001 for VT and NVT). There was a decrease in the density of VT carriage following vaccination in individuals older than 5 years (from 2.44 to 1.88; P = .001) and in younger individuals (from 2.57 to 2.11; P = .070) in the vaccinated villages. Similar decreases in density were observed with NVT within vaccinated and control villages. No significant differences were found between vaccinated and control villages in the postvaccination comparisons for either VT or NVT. CONCLUSIONS: A high density of carriage among young subjects might partly explain why children are more efficient than adults in pneumococcal transmission. PCV-7 vaccination lowered the density of VT and of NVT pneumococcal carriage in the before-after vaccination analysis. CLINICAL TRIALS REGISTRATION: ISRCTN51695599.