Article

Updated national guidelines for pediatric tuberculosis in India, 2012

From Central TB Division, Nirman Bhawan, *Department of Pediatrics, Lady Hardinge Medical College, Department of Pediatrics, Maulana Azad Medical College, and Director General Health Services
Indian pediatrics (Impact Factor: 1.04). 03/2013; 50(3):301-6. DOI: 10.1007/s13312-013-0085-1
Source: PubMed
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Available from: Sharath Burugina Nagaraja
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    • "In 2012, 81,482 pediatric cases were notified accounting for 7% of all notified TB cases [5]. While the exact burden of childhood TB globally is not known due to diagnostic difficulties, it is estimated that childhood TB constitutes about 10–20% of all TB, in high burden countries [6]–[7]. "
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    ABSTRACT: Diagnosis of pulmonary tuberculosis (PTB) in children is challenging due to difficulties in obtaining good quality sputum specimens as well as the paucibacillary nature of disease. Globally a large proportion of pediatric tuberculosis (TB) cases are diagnosed based only on clinical findings. Xpert MTB/RIF, a highly sensitive and specific rapid tool, offers a promising solution in addressing these challenges. This study presents the results from pediatric groups taking part in a large demonstration study wherein Xpert MTB/RIF testing replaced smear microscopy for all presumptive PTB cases in public health facilities across India.
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    • "In 2012, the National Tuberculosis Programme (NTP) in India, issued a new paediatric TB management guideline. This guideline included a new algorithm for suspecting and diagnosing TB in children [21]. As per this guideline, all malnourished children were eligible for TB evaluation. "
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    ABSTRACT: Severe acute malnutrition (SAM) is the most serious form of malnutrition affecting children under-five and is associated with many infectious diseases including Tuberculosis (TB). In India, nutritional rehabilitation centres (NRCs) have been recently established for the management of SAM including TB. The National TB Programme (NTP) in India has introduced a revised algorithm for diagnosing paediatric TB. We aimed to examine whether NRCs adhered to these guidelines in diagnosing TB among SAM children. A cross-sectional study involving review of records of all SAM children identified by health workers during 2012 in six tehsils (sub-districts) with NRCs (population: 1.8 million) of Karnataka, India. Of 1927 identified SAM children, 1632 (85%) reached NRCs. Of them, 1173 (72%) were evaluated for TB and 19(2%) were diagnosed as TB. Of 1173, diagnostic algorithm was followed in 460 (37%). Among remaining 763 not evaluated as per algorithm, tuberculin skin test alone was conducted in 307 (41%), chest radiography alone in 99 (13%) and no investigations in 337 (45%). The yield of TB was higher among children evaluated as per algorithm (4%) as compared to those who were not (0.3%) (OR: 15.3 [95%CI: 3.5-66.3]). Several operational challenges including non-availability of a full-time paediatrician, non-functioning X-ray machine due to frequent power cuts, use of tuberculin with suboptimal strength and difficulties in adhering to a complex diagnostic algorithm were observed. This study showed that TB screening in NRCs was sub-optimal in Karnataka. Some children did not reach the NRC, while many of those who did were either not or sub-optimally evaluated for TB. This study pointed to a number of operational issues that need to be addressed if this collaborative strategy is to identify more TB cases amongst malnourished children in India.
    Full-text · Article · Dec 2013 · PLoS ONE
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    • "Data Analysis. Children with suspected TB were classified into the TB diagnostic categories, definite TB (any clinical sample positive for M. tuberculosis by culture), probable TB (definition derived from international consensus guidelines [15] [17] [18]), no TB (negative mycobacterial cultures and documented resolution of symptoms without TB treatment), or possible TB (all other children), using an automatic computer algorithm and manually verified independently by the study PI. Noncontinuous variables were reported as frequencies and percentages and compared using Fisher's exact test. "
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    ABSTRACT: Background: India has one of the highest tuberculosis (TB) burdens globally. However, few studies have focused on TB in young children, a vulnerable population, where lack of early diagnosis results in poor outcomes. Methods: Young children (≤ 5 years) with suspected TB were prospectively enrolled at a tertiary hospital in Pune, India. Detailed clinical evaluation, HIV testing, mycobacterial cultures, and drug susceptibility testing were performed. Results: 223 children with suspected TB were enrolled. The median age was 31 months, 46% were female, 86% had received BCG, 57% were malnourished, and 10% were HIV positive. 12% had TB disease (definite or probable), 35% did not have TB, while TB could not be ruled out in 53%. Extrapulmonary disease was noted in 46%, which was predominantly meningeal. Tuberculin skin test (TST) was positive in 20% of children with TB. Four of 7 (57%) children with culture-confirmed TB harbored drug-resistant (DR) strains of whom 2 (50%) were multi-DR (MDR). In adjusted analyses, HIV infection, positive TST, and exposure to household smoke were found to be significantly associated with children with TB (P ≤ 0.04). Mortality (at 1 year) was 3 of 26 (12%) and 1 of 79 (1%), respectively, in children with TB and those without TB (P < 0.05). Conclusions: Diagnosis of TB is challenging in young children, with high rates of extra-pulmonary and meningeal disease. While the data on DR-TB are limited by the small sample size, they are however concerning, and additional studies are needed to more accurately define the prevalence of DR strains in this vulnerable population.
    Full-text · Article · Dec 2013
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