Clinical perspectives on treatment of rifampicin-resistant/multidrug-resistant TB.

Rapid diagnostics, newer drugs, repurposed medications, and shorter regimens have radically altered the landscape for treating rifampicin-resistant TB (RR-TB) and multidrug-resistant TB (MDR-TB). There are multiple ongoing clinical trials aiming to build a robust evidence base to guide RR/MDR-TB treatment, and both observational studies and programmatic data have contributed to advancing the treatment field. In December 2019, the WHO issued their second 'Rapid Communication´ related to RR-TB management. This reiterated their prior recommendation that a majority of people with RR/MDR-TB receive all-oral treatment regimens, and now allow for specific shorter duration regimens to be used programmatically as well. Many TB programs need clinical advice as they seek to roll out such regimens in their specific setting. In this Perspective, we highlight our early experiences and lessons learned from working with National TB Programs, adult and pediatric clinicians and civil society, in optimizing treatment of RR/MDR-TB, using shorter, highly-effective, oral regimens for the majority of people with RR/MDR-TB.

Barriers and solutions to finding rifampicin-resistant tuberculosis cases in older children and adolescents.

Little is known about the barriers to post-exposure management of rifampicin-resistant tuberculosis (RR-TB) in older children and adolescents. We report on implementation lessons from a pilot programme targeting household-exposed individuals aged 6-18 years in Khayelitsha, South Africa. Barriers included misperceptions regarding risk of exposure, multiple research and implementation stakeholders, additional workload for an overburdened healthcare system, logistical issues faced by families, and insufficient human and financial resources. Solutions to these barriers are possible, but creativity and persistence are required. Our experience can guide others looking to roll-out care for children and adolescents exposed to RR-TB.

On connaît mal les entraves à la prise en charge post-exposition de la tuberculose résistante à la rifampicine (RR-TB) chez les enfants plus âgés et les adolescents. Nous rapportons les leçons de la mise en œuvre d'un programme pilote ciblant les individus exposés dans leurs foyers, âgés de 6­18 ans, à Khayelitsha, Afrique du Sud. Les obstacles ont inclus des perceptions erronées à propos du risque d'exposition, la multiplicité des partenaires de recherche et de mise en œuvre, la charge de travail supplémentaire pour un système de santé déjà surchargé, les problèmes logistiques auxquels sont confrontées les familles, et l'insuffisance des ressources humaines et financières. Il y a des solutions possibles à ces obstacles mais elles demandent de la créativité et de la détermination. Notre expérience peut guider ceux qui veulent lancer la prise en charge des enfants et des adolescents exposés à la RR-TB.

Se conoce poco sobre los factores que obstaculizan la atención después de la exposición a un caso de tuberculosis resistente a rifampicina (RR-TB) en los niños mayores y los adolescentes. En el presente artículo se describen las enseñanzas aprendidas durante la ejecución de un programa piloto dirigido a los contactos domiciliarios expuestos entre los 6 y los 18 años de edad, en Khayelitsha, Suráfrica. Entre los obstáculos observados se pueden citar las percepciones equivocadas sobre el riesgo de exposición, la multiplicidad de interesados directos en la investigación y la ejecución, la carga de trabajo adicional en un sistema de salud sobresaturado, los problemas organizativos afrontados por las familias y la insuficiencia de recursos humanos y de financiamiento. Las soluciones a estos problemas son posibles, pero exigen creatividad y persistencia. Esta experiencia puede orientar a otros equipos que intenten poner en marcha la atención de los niños y los adolescentes expuestos a la RR-TB.

'I didn't know so many people cared about me': support for patients who interrupt drug-resistant TB treatment.

SETTING: Early interventions for patients who interrupt their treatment for drug-resistant tuberculosis (DR-TB) are rarely reported and assessed. A novel, patient-centred intervention for patients at risk of loss to follow-up (LTFU) from DR-TB treatment was implemented in Khayelitsha, South Africa, in September 2013. OBJECTIVE: To explore the experiences and perceptions of patients, key support persons, health care workers (HCWs) and programme managers of a patient-centred model. DESIGN: This was a qualitative study consisting of 18 in-depth interviews with patients, key support persons, HCWs, key informants and one focus group discussion with HCWs, between July and September 2017. Data were coded and thematically analysed. RESULTS: The model was well perceived and viewed positively by patients, care providers and programme managers. 'Normalisation' and tolerance of occasional treatment interruptions, tracing, tailored management plans and peer support were perceived to be beneficial for retaining patients in care. Although the model was resource-demanding, health workers were convinced that it 'needs to be sustained,' and proposed solutions for its standardisation. CONCLUSION: An intervention based on early tracing of patients who interrupt treatment, peer-delivered counselling and individualised management plans by a multidisciplinary team was considered a beneficial and acceptable model to support patients at risk of LTFU from DR-TB treatment.

HIV testing and retention in care of infants born to HIV- infected women enrolled in 'Option B+', Thyolo, Malawi.

Prevention of mother-to-child transmission 'Option B+' originated in Malawi in 2011 to prevent new infections in infants exposed to the human immunodeficiency virus (HIV). We assessed 12-month programme retention and HIV testing uptake among infants born to HIV-infected mothers from September 2011 to June 2012 in Thyolo District Hospital. Of 513 infants, 368 (71.7%) remained in care at 12 months. Altogether, 412 (80.3%) underwent HIV DNA polymerase chain reaction testing, with 267 (52.0%) tested at 6-12 weeks, and 255 (49.7%) underwent rapid HIV testing, with 144 (28.1%) tested at 12 months. Eighty-eight (17.2%) infants had both tests as scheduled. Measures are needed to improve adherence to national testing protocols.

L'option B+ de la prévention de la transmission mère-enfant a débuté au Malawi en 2011 afin de prévenir de nouvelles infections chez les enfants exposés au virus de l'immunodéficience humaine (VIH). Nous avons évalué un programme de 12 mois de rétention et de réalisation du test VIH parmi les bébés nés de mères VIH-positives de septembre 2011 à juin 2012 à l'hôpital de district de Thyolo. Sur 513 nourrissons, 368 (71,7%) sont restés en soins pendant 12 mois. Au total, 412 bébés (80,3%) ont bénéficié d'une recherche de VIH par ADN-PCR ; 267 (52%) ont été testés entre 6 et 12 semaines et 255 (49,7%) ont eu un test rapide, dont 144 (28,1%) testés à 12 mois. Quatre-vingt-huit bébés (17,2%) ont eu deux tests comme prévu. Il est nécessaire d'améliorer l'adhésion aux protocoles nationaux de dépistage.

En el 2011 se puso en marcha en Malawi la estrategia Opción B+ de prevención de la transmisión maternoinfantil, con el fin de evitar nuevas infecciones por el virus de la inmunodeficiencia humana (VIH) en los lactantes expuestos. Se evaluó durante un período de 12 meses, entre septiembre del 2011 y junio del 2012, la fidelización al programa y la práctica de la prueba diagnóstica del VIH a los lactantes de madres infectadas por el VIH en el Hospital Distrital de Thyolo. De los 513 lactantes expuestos atendidos durante el período del estudio, 368 continuaban en el programa a los 12 meses (71,7%). En total, se practicó la prueba del VIH mediante la reacción en cadena de la polimerasa (PCR-ADN) a 412 lactantes (80,3%); en 267 niños la prueba se realizó entre las 6 y las 12 semanas de edad (52,0 %). La prueba serológica rápida del VIH se practicó en 255 lactantes (49,7%) y en 144 de estos casos a los 12 meses (28,1%). Ochenta y ocho niños recibieron ambas pruebas, en conformidad con las pautas del programa. Es preciso adoptar medidas encaminadas a mejorar el cumplimiento de los protocolos nacionales en materia de pruebas diagnósticas del VIH.

¿Está infradiagnosticada la “tinea pedis”en pediatría? Estudio en una población escolar de Barcelona / Is tinea pedis underdiagnosed in children? Study in Barcelona school children

La tiña de los pies es menos frecuente en el niño que en el adulto y raramente aparece antes de los 4 años. Para identificar la prevalencia de este tipo de tiñas entre escolares se planificó un estudio en 39 escuelas del distrito que es área de referencia del Hospital del Mar de Barcelona. Se examinaron 2.613 escolares de edades comprendidas entre los 3 y 15 años. Se detectaron 72 casos con cultivo positivo a dermatófitos, 3 padecían conjuntamente afectación ungueal. La prevalencia era del 2,75% y aumentaba con la edad: un 0,86% entre los 3 y 5 años, un 2,08% entre los 10 y 12 años, y un 7,04% entre los 13 y 15 años. Los agentes fueron Trichophyton mentagrophytes (48,6%), J: rubrum (40,27%), Epidermophyton mophyton floccosum(6,94%y) J:t onsurans( 4,16%). De los 72 casos de dermatofitosis, sólo 49 tenían lesiones clínicas evidentes. Sólo 19 de los 49 con manifestacionesc línicas tenían conocimiento de sus lesiones, y 8 habían realizado tratamiento antifúngico de forma irregular unos meses antes. Posibles razones del bajo nivel diagnóstico podrían estar en: a) el bajo interés familiar por las lesiones, al no haber sido verbalizadas, y ser valoradas como triviales; b) la consideración de situación propia de la edad y asociada a la actividad deportiva; c) reducida sintomatología subjetiva; d) falta de práctica exploratoria sistemática de zonas interdigitales de los pies; e) la falta de un correcto diagnóstico diferencial; f) bajo interés de los adolescentes en acudir a visitas pediátricas; y g) autodiagnóstico y automedicación

Tinea pedís is less common in children than in adults and rarely appears before the age of tour years. A cross-sectional study was performed to determine the prevalence of this type of tinea in schoolc hildren in BarcelonaS, pain. A total of 2,613s choocl hildrenw ith the agesf rom 3 to 15, from 39 schools located in the municipal district in the vicinity of the hospital, were examinedto identity the presence of dermatophytogis of the feet. Seventy-two had positive cultures for tínea pedis and dermatophytes, while in three, the nail was involved as well. The overall prevalence was 2.75%, and increased with age, being 0.86% in 3 to 5-year-olds, 2.08% in 10 to 12-year-old and 7.04% in 13 to 15-year-old. The fungi found were Tríchophyton mentagrophytes (48.6%),T rubrum( 40.27%)Epidermophyton floccosum (6.94%) and T. tonsurans(4.16%).Of these 72 children, 49 had interdigital lesions, only 19 of them were aware of their presence and 8 had received antifungal therapy previously, although not consistently. Although the incidence of tinea pedís is low in children, we think that it is underdiagnose. Possible reasons for this could be the limited interest in the lesions on the part of parents, who consider them trivial and do not mention them during physical examinations; the consideration that the condition is characteristic of the age group and is associated with sports and the generalized use of athletic foot wear, the lack of proper foot hygiene after doing sports; the fact that there are few subjective symptoms; the failure on the part of the pediatrician to systematically and carefully examine the interdigital skin of the feet of healthy children; the lack of an accurate differential diagnosis; the reluctance of adolescents to visit the pediatrician; self-diagnosis and self-medication