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    Beyond patient delay, navigating structural health system barriers to timely care and treatment in a high burden TB setting in Papua New Guinea
    Jops, P ; Cowan, J ; Kupul, M ; Trumb, RN ; Graham, SM ; Bauri, M ; Nindil, H ; Bell, S ; Keam, T ; Majumdar, S ; Pomat, W ; Marais, B ; Marks, GB ; Kaldor, J ; Vallely, A ; Kelly-Hanku, A (ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD, 2023-01-02)
    Tuberculosis (TB) is a major public health issue in Papua New Guinea, with incidence rates particularly high in the South Fly District of Western Province. We present three case studies, along with additional vignettes, that were derived from interviews and focus groups carried out between July 2019 and July 2020 of people living in rural areas of the remote South Fly District depicting their challenges accessing timely TB diagnosis and care; most services within the district are only offered offshore on Daru Island. The findings detail that rather than 'patient delay' attributed to poor health seeking behaviours and inadequate knowledge of TB symptoms, many people were actively trying to navigate structural barriers hindering access to and utilisation of limited local TB services. The findings highlight a fragile and fragmented health system, a lack of attention given to primary health services, and undue financial burdens placed on people living in rural and remote areas associated with costly transportation to access functioning health services. We conclude that a person-centred and effective decentralised model of TB care as outlined in health policies is imperative for equitable access to essential health care services in Papua New Guinea.
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    Literature Highlights.
    Trauer, JM ; Tiberi, S ; Graham, SM ; Blackbourn, HD (International Union Against Tuberculosis and Lung Disease, 2023-10-01)
    Literature Highlights is a digest of notable papers recently published in the leading respiratory journals, allowing our readers to stay up-to-date with research advances. Coverage in this issue includes time to smear and culture conversion during TB treatment; probability of diagnosing ventilator-associated pneumonia in intensive care and use of antimicrobials; optimising computer-aided chest X-ray to diagnose intra-thoracic TB in children; and clinical standards for asthma in low- and middle-income countries.
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    Effectiveness of a community-based approach for the investigation and management of children with household tuberculosis contact in Cameroon and Uganda: a cluster-randomised trial
    Bonnet, M ; Vasiliu, A ; Tchounga, BK ; Cuer, B ; Fielding, K ; Ssekyanzi, B ; Tchakounte Youngui, B ; Cohn, J ; Dodd, PJ ; Tiendrebeogo, G ; Tchendjou, P ; Simo, L ; Okello, RF ; Kuate Kuate, A ; Turyahabwe, S ; Atwine, D ; Graham, SM ; Casenghi, M ; Chauvet, S ; de Carvalho, E ; Ouedraogo, S ; Leguicher, G ; Tiam, A ; Oziemkowska, M ; Atieno Ayuo, E ; Mafirakureva, N ; Berset, M ; Lemaire, JF ; Sih, C ; Kana, R ; Youm, E ; Guedem Nekame, JL ; Manguele, PW ; Bindzi, P ; Ndongo, MLA ; Ndjang Kombou, D ; Tsigaing, PN ; Mbunka Awolu, M ; Seuleu Ndjamakou, LG ; Sitamze Kaptue, N ; Ngounou Moyo, DF ; Patouokoumche Ngouh, R ; Kouotou Mouliom, JS ; Abogo Abatsong, HA ; Essebe Ngangue, RC ; Djeumene, R ; Maguia Tatiane Kouam, LT ; Nono Djilo, LF ; Bakmano Raïssa, MJ ; Njikeh, KD ; Bissek, AC ; Arinaitwe, R ; Otai, D ; Kamanzi, H ; Natukunda, A ; Natukunda, E ; Kyarimpa, R ; Kyomuhendo, D ; Sanyu, S ; Ssemanya, J ; Nabbuto, J ; Lugoose, S ; Rachael, K ; Tebylwa Beryta, J ; Kitakule, F ; Atuhaire, S ; Kembabazi, M ; Abok, F ; Kakinda, M ; Odongo, D ; Ijjo, H ; Kyomugisha, C ; Aryatuhwera, J ; Ashaba, B ; Nuwamanya, P ; Arinaitwe, M ; Natukunda, P ; Muhangi, C ; Muhumuza, D ; Ndyeimuka, G ; Bagabe, J ; Tiboruhanga, J ; Tibaijuka, F ; Nahabwe, M (Elsevier, 2023-01-01)
    Background: Globally, the uptake of tuberculosis-preventive treatment (TPT) among children with household tuberculosis contact remains low, partly due to the necessity of bringing children to health facilities for investigations. This study aimed to evaluate the effect on TPT initiation and completion of community-based approaches to tuberculosis contact investigations in Cameroon and Uganda. Methods: We did a parallel, cluster-randomised, controlled trial across 20 clusters (consisting of 25 district hospitals and primary health centres) in Cameroon and Uganda, which were randomised (1:1) to receive a community-based approach (intervention group) or standard-of-care facility-based approach to contact screening and management (control group). The community-based approach consisted of symptom-based tuberculosis screening of all household contacts by community health workers at the household, with referral of symptomatic contacts to local facilities for investigations. Initiation of TPT (3-month course of rifampicin–isoniazid) was done by a nurse in the household, and home visits for TPT follow-up were done by community health workers. Index patients were people aged 15 years or older with bacteriologically confirmed, drug-susceptible, pulmonary tuberculosis diagnosed less than 1 month before inclusion and who declared at least one child or young adolescent (aged 0–14 years) household contact. The primary endpoint was the proportion of declared child contacts in the TPT target group (those aged <5 years irrespective of HIV status, and children aged 5–14 years living with HIV) who commenced and completed TPT, assessed in the modified intention-to-treat population (excluding enrolled index patients and their contacts who did not fit the eligibility criteria). Descriptive cascade of care assessment and generalised linear mixed modelling were used for comparison. This study is registered with ClinicalTrials.gov (NCT03832023). Findings: The study included nine clusters in the intervention group (after excluding one cluster that did not enrol any index patients for >2 months) and ten in the control group. Between Oct 14, 2019 and Jan 13, 2022, 2894 child contacts were declared by 899 index patients with bacteriologically confirmed tuberculosis. Among all child contacts declared, 1548 (81·9%) of 1889 in the intervention group and 475 (47·3%) of 1005 in the control group were screened for tuberculosis. 1400 (48·4%) child contacts were considered to be in the TPT target group: 941 (49·8%) of 1889 in the intervention group and 459 (45·7%) of 1005 in the control group. In the TPT target group, TPT was commenced and completed in 752 (79·9%) of 941 child contacts in the intervention group and 283 (61·7%) of 459 in the control group (odds ratio 3·06 [95% CI 1·24–7·53]). Interpretation: A community-based approach using community health workers can significantly increase contact investigation coverage and TPT completion among eligible child contacts in a tuberculosis-endemic setting.
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    The clinical presentation and detection of tuberculosis during pregnancy and in the postpartum period in low- and middle-income countries: A systematic review and meta-analysis.
    Simpson, G ; Philip, M ; Vogel, JP ; Scoullar, MJL ; Graham, SM ; Wilson, AN ; Iyer, VJ (Public Library of Science (PLoS), 2023)
    For women infected with Mycobacterium tuberculosis, pregnancy is associated with an increased risk of developing or worsening TB disease. TB in pregnancy increases the risk of adverse maternal and neonatal outcomes, however the detection of TB in pregnancy is challenging. We aimed to identify and summarise the findings of studies regarding the clinical presentation and diagnosis of TB during pregnancy and the postpartum period (within 6 months of birth) in low-and middle-income countries (LMICs). A systematic review was conducted searching Ovid MEDLINE, Embase, CINAHL and Global Index Medicus databases. We included any primary research study of women diagnosed with TB during pregnancy or the postpartum period in LMICs that described the clinical presentation or method of diagnosis. Meta-analysis was used to determine pooled prevalence of TB clinical features and health outcomes, as well as detection method yield. Eighty-seven studies of 2,965 women from 27 countries were included. 70.4% of women were from South Africa or India and 44.7% were known to be HIV positive. For 1,833 women where TB type was reported, pulmonary TB was most common (79.6%). Most studies did not report the prevalence of presenting clinical features. Where reported, the most common were sputum production (73%) and cough (68%). Having a recent TB contact was found in 45% of women. Only six studies screened for TB using diagnostic testing for asymptomatic antenatal women and included mainly HIV-positive women ‒ 58% of women with bacteriologically confirmed TB did not report symptoms and only two were in HIV-negative women. Chest X-ray had the highest screening yield; 60% abnormal results of 3036 women tested. Screening pregnant women for TB-related symptoms and risk factors is important but detection yields are limited. Chest radiography and bacteriological detection methods can improve this, but procedures for optimal utilisation remain uncertain in this at-risk population. Trial registration: Prospero registration number: CRD42020202493.
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    Development of treatment-decision algorithms for children evaluated for pulmonary tuberculosis: an individual participant data meta-analysis.
    Gunasekera, KS ; Marcy, O ; Muñoz, J ; Lopez-Varela, E ; Sekadde, MP ; Franke, MF ; Bonnet, M ; Ahmed, S ; Amanullah, F ; Anwar, A ; Augusto, O ; Aurilio, RB ; Banu, S ; Batool, I ; Brands, A ; Cain, KP ; Carratalá-Castro, L ; Caws, M ; Click, ES ; Cranmer, LM ; García-Basteiro, AL ; Hesseling, AC ; Huynh, J ; Kabir, S ; Lecca, L ; Mandalakas, A ; Mavhunga, F ; Myint, AA ; Myo, K ; Nampijja, D ; Nicol, MP ; Orikiriza, P ; Palmer, M ; Sant'Anna, CC ; Siddiqui, SA ; Smith, JP ; Song, R ; Thuong Thuong, NT ; Ung, V ; van der Zalm, MM ; Verkuijl, S ; Viney, K ; Walters, EG ; Warren, JL ; Zar, HJ ; Marais, BJ ; Graham, SM ; Debray, TPA ; Cohen, T ; Seddon, JA (Elsevier BV, 2023-05)
    BACKGROUND: Many children with pulmonary tuberculosis remain undiagnosed and untreated with related high morbidity and mortality. Recent advances in childhood tuberculosis algorithm development have incorporated prediction modelling, but studies so far have been small and localised, with limited generalisability. We aimed to evaluate the performance of currently used diagnostic algorithms and to use prediction modelling to develop evidence-based algorithms to assist in tuberculosis treatment decision making for children presenting to primary health-care centres. METHODS: For this meta-analysis, we identified individual participant data from a WHO public call for data on the management of tuberculosis in children and adolescents and referral from childhood tuberculosis experts. We included studies that prospectively recruited consecutive participants younger than 10 years attending health-care centres in countries with a high tuberculosis incidence for clinical evaluation of pulmonary tuberculosis. We collated individual participant data including clinical, bacteriological, and radiological information and a standardised reference classification of pulmonary tuberculosis. Using this dataset, we first retrospectively evaluated the performance of several existing treatment-decision algorithms. We then used the data to develop two multivariable prediction models that included features used in clinical evaluation of pulmonary tuberculosis-one with chest x-ray features and one without-and we investigated each model's generalisability using internal-external cross-validation. The parameter coefficient estimates of the two models were scaled into two scoring systems to classify tuberculosis with a prespecified sensitivity target. The two scoring systems were used to develop two pragmatic, treatment-decision algorithms for use in primary health-care settings. FINDINGS: Of 4718 children from 13 studies from 12 countries, 1811 (38·4%) were classified as having pulmonary tuberculosis: 541 (29·9%) bacteriologically confirmed and 1270 (70·1%) unconfirmed. Existing treatment-decision algorithms had highly variable diagnostic performance. The scoring system derived from the prediction model that included clinical features and features from chest x-ray had a combined sensitivity of 0·86 [95% CI 0·68-0·94] and specificity of 0·37 [0·15-0·66] against a composite reference standard. The scoring system derived from the model that included only clinical features had a combined sensitivity of 0·84 [95% CI 0·66-0·93] and specificity of 0·30 [0·13-0·56] against a composite reference standard. The scoring system from each model was placed after triage steps, including assessment of illness acuity and risk of poor tuberculosis-related outcomes, to develop treatment-decision algorithms. INTERPRETATION: We adopted an evidence-based approach to develop pragmatic algorithms to guide tuberculosis treatment decisions in children, irrespective of the resources locally available. This approach will empower health workers in primary health-care settings with high tuberculosis incidence and limited resources to initiate tuberculosis treatment in children to improve access to care and reduce tuberculosis-related mortality. These algorithms have been included in the operational handbook accompanying the latest WHO guidelines on the management of tuberculosis in children and adolescents. Future prospective evaluation of algorithms, including those developed in this work, is necessary to investigate clinical performance. FUNDING: WHO, US National Institutes of Health.
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    Antimicrobial stewardship in the era of the COVID-19 pandemic: A systematic review protocol on the opportunities and challenges for Sub-Saharan Africa.
    Njuma Libwea, J ; Ngwa, CH ; Ngomba, AV ; Wirsiy, FS ; Mpofu, L ; Ndongo, CB ; Koulla-Shiro, S ; Graham, S ; Djieuya, LPT ; Mandeng, N ; Mballa, GAE ; Sobh, E ; Nwaru, BI ; Ndombo, PK ; Epee, E (Ovid Technologies (Wolters Kluwer Health), 2023-05-12)
    BACKGROUND: Antimicrobial resistance (AMR) remains one of the leading threats to global public health and this may increase following COVID-19 pandemic. This is particularly the case in Africa where regulations on antimicrobial usage are weak. This protocol outlines the steps to undertake a systematic review to synthesize evidence on drivers of AMR and evaluate existing approaches to strengthening antimicrobial stewardship (AMS) programs in Sub-Saharan Africa (SSA). On the basis of the evidence generated from the evidence synthesis, the overarching goal of this work is to provide recommendations to support best practices in AMS implementation in SSA. METHODS: A systematic search will be conducted using the following databases: Global Health Library, PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus, Google Scholar, Global Health, Embase, African Journals Online Library, Web of Science, antimicrobial databases (WHO COVID-19, TrACSS, NDARO, and JPIAMR), and the Cochrane databases for systematic reviews. Studies will be included if they assess AMR and AMS in SSA from January 2000 to January 31, 2023. RESULTS: The primary outcomes will include the drivers of AMR and approaches to AMS implementation in SSA. The Preferred Reporting Items for Systematic Reviews and Meta-analyses will guide the reporting of this systematic review. CONCLUSIONS: The findings are expected to provide evidence on best practices and resource sharing for policy consideration to healthcare providers and other stakeholders both at the local and international levels. Additionally, the study seeks to establish drivers specific to AMR during the COVID-19 era in the SSA, for example, with the observed increasing trend of antimicrobial misuse during the first or second year of the pandemic may provide valuable insights for policy recommendation in preparedness and response measures to future pandemics. PROSPERO REGISTRATION NUMBER: CRD42022368853.
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    Clinical algorithm reduces antibiotic use among children presenting with respiratory symptoms to hospital in central Vietnam
    Nguyen, PT ; Nguyen, TT ; Huynh, LT ; Graham, SM ; Marais, BJ (BMC, 2023-07-25)
    OBJECTIVE: To assess the safety and utility of a pragmatic clinical algorithm to guide rational antibiotic use in children presenting with respiratory infection. METHODS: The effect of an algorithm to guide the management of young (< 5 years) children presenting with respiratory symptoms to the Da Nang Hospital for Women and Children, Vietnam, was evaluated in a before-after intervention analysis. The main outcome was reduction in antibiotic use, with monitoring of potential harm resulting from reduced antibiotic use. The intervention comprised a single training session of physicians in the use of an algorithm informed by local evidence; developed during a previous prospective observational study. The evaluation was performed one month after the training. RESULTS: Of the 1290 children evaluated before the intervention, 102 (7.9%) were admitted to hospital and 556/1188 (46.8%) were sent home with antibiotics. Due to COVID-19, only 166 children were evaluated after the intervention of whom 14 (8.4%) were admitted to hospital and 54/152 (35.5%) were sent home with antibiotics. Antibiotic use was reduced (from 46.8% to 35.5%; p = 0.009) after clinician training, but adequate comparison was compromised. The reduction was most pronounced in children with wheeze or runny nose and no fever, or a normal chest radiograph, where antibiotic use declined from 46.7% to 28.8% (p < 0.0001). The frequency of repeat presentation to hospital was similar between the two study periods (141/1188; 11.9% before and 10/152; 6.6% after; p = 0.10). No child represented with serious disease after being sent home without antibiotics. CONCLUSIONS: We observed a reduction in antibiotic use in young children with a respiratory infection after physician training in the use of a simple evidence-based management algorithm. However, the study was severely impacted by COVID-19 restrictions, requiring further evaluation to confirm the observed effect.
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    Clinical standards for drug-susceptible TB in children and adolescents.
    Chiang, SS ; Graham, SM ; Schaaf, HS ; Marais, BJ ; Sant'Anna, CC ; Sharma, S ; Starke, JR ; Triasih, R ; Achar, J ; Amanullah, F ; Armitage, LY ; Aurilio, RB ; Buck, WC ; Centis, R ; Chabala, C ; Cruz, AT ; Demers, A-M ; du Preez, K ; Enimil, A ; Furin, J ; Garcia-Prats, AJ ; Gonzalez, NE ; Hoddinott, G ; Isaakidis, P ; Jaganath, D ; Kabra, SK ; Kampmann, B ; Kay, A ; Kitai, I ; Lopez-Varela, E ; Maleche-Obimbo, E ; Malaspina, FM ; Velásquez, JN ; Nuttall, JJC ; Oliwa, JN ; Andrade, IO ; Perez-Velez, CM ; Rabie, H ; Seddon, JA ; Sekadde, MP ; Shen, A ; Skrahina, A ; Soriano-Arandes, A ; Steenhoff, AP ; Tebruegge, M ; Tovar, MA ; Tsogt, B ; van der Zalm, MM ; Welch, H ; Migliori, GB (International Union Against Tuberculosis and Lung Disease, 2023-08-01)
    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.
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    The unfinished agenda of communicable diseases among children and adolescents before the COVID-19 pandemic, 1990-2019: a systematic analysis of the Global Burden of Disease Study 2019
    Azzopardi, PS ; Kerr, JA ; Francis, KL ; Sawyer, SM ; Kennedy, EC ; Steer, AC ; Graham, SM ; Viner, RM ; Ward, JL ; Hennegan, J ; Pham, M ; Habito, CMD ; Kurji, J ; Cini, K ; Beeson, JG ; Brown, A ; Murray, CJL ; Abbasi-Kangevari, M ; Abolhassani, H ; Adekanmbi, V ; Agampodi, SB ; Ahmed, MB ; Ajami, M ; Akbarialiabad, H ; Akbarzadeh-Khiavi, M ; AL-Ahdal, TMA ; Ali, MM ; Samakkhah, SA ; Alimohamadi, Y ; Alipour, V ; Al-Jumaily, A ; Amiri, S ; Amirzade-Iranaq, MH ; Anoushiravani, A ; Anvari, D ; Arabloo, J ; Arab-Zozani, M ; Arkew, M ; Armocida, B ; Asadi-Pooya, AA ; Asemi, Z ; Asgary, S ; Athari, SS ; Azami, H ; Azangou-Khyavy, M ; Azizi, H ; Bagheri, N ; Bagherieh, S ; Barone-Adesi, F ; Barteit, S ; Basu, S ; Belete, MA ; Belo, L ; Berhie, AY ; Bijani, A ; Bikbov, B ; Burkart, K ; Carreras, G ; Charalampous, P ; Abebe, EC ; Cruz-Martins, N ; Dai, X ; Dandona, L ; Dandona, R ; Degualem, SM ; Demetriades, AK ; Demlash, AA ; Desta, AA ; Dianatinasab, M ; Doaei, S ; Dorostkar, F ; Effendi, DE ; Emami, A ; Bain, LE ; Eskandarieh, S ; Esmaeilzadeh, F ; Faramarzi, A ; Fatehizadeh, A ; Ferrara, P ; Fetensa, G ; Fischer, F ; Flor, LS ; Forouhari, A ; Foroutan, M ; Gaihre, S ; Galehdar, N ; Gallus, S ; Gautam, RK ; Gebrehiwot, M ; Gebremeskel, TG ; Getacher, L ; Getachew, ME ; Ghamari, S-H ; Nour, MG ; Goleij, P ; Golitaleb, M ; Gorini, G ; Gupta, VK ; Hashemian, M ; Hassankhani, H ; Heidari, M ; Heyi, DZ ; Isola, G ; Jaafari, J ; Javanmardi, F ; Jonas, JB ; Jozwiak, JJ ; Juerisson, M ; Kabir, A ; Kabir, Z ; Kalankesh, LR ; Kalhor, R ; Kauppila, JH ; Kaur, H ; Kayode, GA ; Keikavoosi-Arani, L ; Khammarnia, M ; AB Khan, M ; Khatab, K ; Kashani, HRK ; Kolahi, A-A ; Koohestani, HR ; Koyanagi, A ; Kumar, GA ; Kurmi, OP ; Kyu, HH ; La Vecchia, C ; Lallukka, T ; Lim, SS ; Loureiro, JA ; Mahjoub, S ; Mahmoudi, R ; Majeed, A ; Rad, EM ; Maleki, A ; Mansour-Ghanaei, F ; Marjani, A ; Mathioudakis, AG ; Mehri, F ; Mentis, A-FA ; Mestrovic, T ; Mirica, A ; Misganaw, A ; Mohammadian-Hafshejani, A ; Mohammed, H ; Mohammed, S ; Mokdad, AH ; Mokhtarzadehazar, P ; Monasta, L ; Moradi, M ; Moradzadeh, M ; Morovatdar, N ; Mueller, UO ; Mulita, F ; Mulu, GBB ; Muthupandian, S ; Naik, GR ; Nashwan, AJJ ; Nejadghaderi, SA ; Netsere, HB ; Noor, NM ; Noori, M ; Oancea, B ; Oguntade, AS ; Okati-Aliabad, H ; Otoiu, A ; Padron-Monedero, A ; Pakzad, R ; Pandey, A ; Pardhan, S ; Parikh, RR ; Patel, J ; Pensato, U ; Peprah, P ; Perico, N ; Poddighe, D ; Postma, MJ ; Rahim, F ; Rahimi-Movaghar, V ; Rahmani, S ; Rahmanian, V ; Rawaf, S ; Razeghian-Jahromi, I ; Regasa, MT ; Remuzzi, G ; Rezaeian, M ; Riad, A ; Romero-Rodriguez, E ; Ronfani, L ; Pramanik, KR ; Sabour, S ; Sadeghian, S ; Saeb, MR ; Safary, A ; Sahebkar, A ; Sahiledengle, B ; Samadzadeh, S ; Sarveazad, A ; Sethi, Y ; Shahabi, S ; Shahraki-Sanavi, F ; Shams-Beyranvand, M ; Sharafi, K ; Sharew, NT ; Sheikh, A ; Sheikhi, RA ; Shiri, R ; Socea, B ; Soltani-Zangbar, MS ; Tabares-Seisdedos, R ; Tabatabai, S ; Soodejani, MT ; Oliaee, RT ; Tiyuri, A ; Tovani-Palone, MR ; Tualeka, AR ; Valizadeh, R ; Van den Eynde, J ; Vasankari, TJ ; Vos, T ; Walde, MT ; Wang, Y ; Wei, F-L ; Westerman, R ; Yadav, V ; Yaya, S ; Zare, I ; Zhu, B ; Zoladl, M ; Zumla, A ; Hay, S ; Patton, GC (ELSEVIER SCIENCE INC, 2023-07-22)
    BACKGROUND: Communicable disease control has long been a focus of global health policy. There have been substantial reductions in the burden and mortality of communicable diseases among children younger than 5 years, but we know less about this burden in older children and adolescents, and it is unclear whether current programmes and policies remain aligned with targets for intervention. This knowledge is especially important for policy and programmes in the context of the COVID-19 pandemic. We aimed to use the Global Burden of Disease (GBD) Study 2019 to systematically characterise the burden of communicable diseases across childhood and adolescence. METHODS: In this systematic analysis of the GBD study from 1990 to 2019, all communicable diseases and their manifestations as modelled within GBD 2019 were included, categorised as 16 subgroups of common diseases or presentations. Data were reported for absolute count, prevalence, and incidence across measures of cause-specific mortality (deaths and years of life lost), disability (years lived with disability [YLDs]), and disease burden (disability-adjusted life-years [DALYs]) for children and adolescents aged 0-24 years. Data were reported across the Socio-demographic Index (SDI) and across time (1990-2019), and for 204 countries and territories. For HIV, we reported the mortality-to-incidence ratio (MIR) as a measure of health system performance. FINDINGS: In 2019, there were 3·0 million deaths and 30·0 million years of healthy life lost to disability (as measured by YLDs), corresponding to 288·4 million DALYs from communicable diseases among children and adolescents globally (57·3% of total communicable disease burden across all ages). Over time, there has been a shift in communicable disease burden from young children to older children and adolescents (largely driven by the considerable reductions in children younger than 5 years and slower progress elsewhere), although children younger than 5 years still accounted for most of the communicable disease burden in 2019. Disease burden and mortality were predominantly in low-SDI settings, with high and high-middle SDI settings also having an appreciable burden of communicable disease morbidity (4·0 million YLDs in 2019 alone). Three cause groups (enteric infections, lower-respiratory-tract infections, and malaria) accounted for 59·8% of the global communicable disease burden in children and adolescents, with tuberculosis and HIV both emerging as important causes during adolescence. HIV was the only cause for which disease burden increased over time, particularly in children and adolescents older than 5 years, and especially in females. Excess MIRs for HIV were observed for males aged 15-19 years in low-SDI settings. INTERPRETATION: Our analysis supports continued policy focus on enteric infections and lower-respiratory-tract infections, with orientation to children younger than 5 years in settings of low socioeconomic development. However, efforts should also be targeted to other conditions, particularly HIV, given its increased burden in older children and adolescents. Older children and adolescents also experience a large burden of communicable disease, further highlighting the need for efforts to extend beyond the first 5 years of life. Our analysis also identified substantial morbidity caused by communicable diseases affecting child and adolescent health across the world. FUNDING: The Australian National Health and Medical Research Council Centre for Research Excellence for Driving Investment in Global Adolescent Health and the Bill & Melinda Gates Foundation.
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    Prevalence, clinical presentation and factors associated with chronic lung disease among children and adolescents living with HIV in Kenya.
    Maleche-Obimbo, E ; Attia, E ; Were, F ; Jaoko, W ; Graham, SM ; Kose, J (Public Library of Science (PLoS), 2023-08-09)
    INTRODUCTION: Children and adolescents with HIV (CAHIV) may experience recurrent and severe respiratory disease and are at risk of residual lung sequelae, and long-term morbidity from chronically damaged lungs. With improved survival due to increased access to effective antiretroviral therapy there is an increasing population of CAHIV who require optimal life-long care. Chronic lung disease in CAHIV is an under-recognised problem in African settings. We sought to determine the prevalence, clinical presentation and factors associated with chronic lung disease (CLD) among CAHIV in Kenya. METHODS: CAHIV aged ≤19 years in care at a public hospital in Nairobi were enrolled into a longitudinal cohort study. Sociodemographic and clinical information were obtained through interview, medical record review, physical examination and six-minute walk test. CD4 counts and viral load were determined. Enrolment data was analysed to determine baseline sociodemographic and clinical characteristics. Prevalence of CLD defined as presence of ≥2 respiratory symptoms or signs at enrolment was computed. Logistic regression analysis was performed to evaluate for association between various factors and presence or absence of CLD. RESULTS: We enrolled 320 CAHIV of median age 13 (IQR 10-16) years, 80 (25%) were <10 years, 46% were female, 31% lived in a one-room house and 51% used polluting cooking fuel. Antiretroviral therapy (ART) was initiated after age five years in 56%, 43% had prior pneumonia or tuberculosis, 11% had low CD4 count and 79% were virologically suppressed. Common respiratory symptoms and signs were exertional breathlessness (40%), chronic cough (23%), chest problems in the preceding year (24%), tachypnoea (52%), finger clubbing (6%), exercise limitation (59%) and oxygen desaturation during exercise (7%). CLD was present in 82 (26%) participants, and adding the six-minute walk distance <70% of predicted (exercise limitation) identified an additional 28 (9%) CAHIV with CLD. CLD was more common among older teenagers (odds ratio (OR) 1.95), those who had prior TB or pneumonia (OR 2.04), delayed initiation of ART (OR 2.60), cotrimoxazole prophylaxis (OR 3.35) or TB preventive therapy (OR 2.81). CLD was associated with viraemia (OR 2.7), lower quality of life (OR 12.7), small houses (OR 2.05), caregiver having fewer years of education (OR 2.46), outdoor pollution exposure (OR 3.31) and lower use of polluting cooking fuel indoors (OR 0.26). Adjusted analysis revealed CLD to be associated with prior tuberculosis or pneumonia (adjusted OR (aOR) [95%CI] 2.15 [1.18-3.91]), small house (aOR 1.95 [1.02-3.73]), lower use of polluting cooking fuel (aOR 0.35 [0.13-0.94]) and negative impact on health-related quality of life (aOR 6.91 [3.66-13.03]). CONCLUSIONS: CLD is highly prevalent across the age spectrum of CAHIV, and most are symptomatic with cough or exertional breathlessness. CLD is associated with prior tuberculosis or pneumonia, socio-environmental factors, and lower quality of life. Structured interventions are needed to provide optimal care specific to their needs.