Paediatrics (RCH) - Research Publications
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ItemNo Preview AvailableDisease Spectrum and Management of Children Admitted with Acute Respiratory Infection in Viet Nam(Wiley, 2017-11-23)Background: Acute respiratory infection (ARI) is the most common reason for admission to paediatric wards in Viet Nam, being responsible for 39.9% of hospital admissions and 7.9% of hospital deaths in southern Viet Nam. However, few studies have explored the ARI disease spectrum observed in central Viet Nam or differences between primary (district), secondary (provincial) and tertiary (national) level hospitals. Aims: To assess the acute respiratory infection (ARI) disease spectrum, duration of hospitalisation and outcome in children hospitalised with an ARI in Viet Nam. Methods: We conducted a retrospective descriptive study of ARI admissions to primary (Hoa Vang District Hospital), secondary (Da Nang Hospital for Women and Children) and tertiary (National Hospital of Paediatrics in Ha Noi) level hospitals in Viet Nam over a 12-month period(01/09/2015 to 31/08/2016). Results: ARIs accounted for 27.9% (37,436 / 134,061) of all paediatric admissions; nearly half (47.6%) of all children admitted to Hoa Vang District Hospital. Most (64.6%) children hospitalised with an ARI were<2 years of age. Influenza/pneumonia accounted for 69.4% of admissions; tuberculosis for only 0.3%. Overall 284 (0.8%) children died; most deaths (269/284; 94.7%) occurred at the tertiary referral hospital. The average duration of hospitalization was 7.6 days (median 7 days). The average direct hospitalization cost per ARI admission was 157.5 USD in Da Nang Provincial Hospital. In total, 62.6% of admissions were covered by health insurance. Conclusions: ARI is a major cause of paediatric hospitalization in Viet Nam, characterized by prolonged hospitalization for relatively mild disease. There is huge potential to reduce unnecessary hospital admission and cost.
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ItemShorter treatment for minimal tuberculosis (TB) in children (SHINE): a study protocol for a randomised controlled trial.(Springer Science and Business Media LLC, 2018-04-19)BACKGROUND: Tuberculosis (TB) in children is frequently paucibacillary and non-severe forms of pulmonary TB are common. Evidence for tuberculosis treatment in children is largely extrapolated from adult studies. Trials in adults with smear-negative tuberculosis suggest that treatment can be effectively shortened from 6 to 4 months. New paediatric, fixed-dose combination anti-tuberculosis treatments have recently been introduced in many countries, making the implementation of World Health Organisation (WHO)-revised dosing recommendations feasible. The safety and efficacy of these higher drug doses has not been systematically assessed in large studies in children, and the pharmacokinetics across children representing the range of weights and ages should be confirmed. METHODS/DESIGN: SHINE is a multicentre, open-label, parallel-group, non-inferiority, randomised controlled, two-arm trial comparing a 4-month vs the standard 6-month regimen using revised WHO paediatric anti-tuberculosis drug doses. We aim to recruit 1200 African and Indian children aged below 16 years with non-severe TB, with or without HIV infection. The primary efficacy and safety endpoints are TB disease-free survival 72 weeks post randomisation and grade 3 or 4 adverse events. Nested pharmacokinetic studies will evaluate anti-tuberculosis drug concentrations, providing model-based predictions for optimal dosing, and measure antiretroviral exposures in order to describe the drug-drug interactions in a subset of HIV-infected children. Socioeconomic analyses will evaluate the cost-effectiveness of the intervention and social science studies will further explore the acceptability and palatability of these new paediatric drug formulations. DISCUSSION: Although recent trials of TB treatment-shortening in adults with sputum-positivity have not been successful, the question has never been addressed in children, who have mainly paucibacillary, non-severe smear-negative disease. SHINE should inform whether treatment-shortening of drug-susceptible TB in children, regardless of HIV status, is efficacious and safe. The trial will also fill existing gaps in knowledge on dosing and acceptability of new anti-tuberculosis formulations and commonly used HIV drugs in settings with a high burden of TB. A positive result from this trial could simplify and shorten treatment, improve adherence and be cost-saving for many children with TB. Recruitment to the SHINE trial begun in July 2016; results are expected in 2020. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number: ISRCTN63579542 , 14 October 2014. Pan African Clinical Trials Registry Number: PACTR201505001141379 , 14 May 2015. Clinical Trial Registry-India, registration number: CTRI/2017/07/009119, 27 July 2017.
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ItemRisk factors for child pneumonia - focus on the Western Pacific Region(ELSEVIER SCI LTD, 2017-01)Pneumonia is a major cause of disease and death in infants and young children (aged <5 years) globally, as it is in the World Health Organization Western Pacific region. A better understanding of the underlying risk factors associated with child pneumonia is important, since pragmatic primary prevention strategies are likely to achieve major reductions in pneumonia-associated morbidity and mortality in children. This review focuses on risk factors with high relevance to the Western Pacific region, including a lack of exclusive breastfeeding, cigarette smoke and air pollution exposure, malnutrition and conditions of poverty, as well as common co-morbidities. Case management and vaccination coverage have been considered elsewhere.
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ItemNew and Repurposed Drugs for Pediatric Multidrug-Resistant Tuberculosis Practice-based Recommendations(AMER THORACIC SOC, 2017-05-15)It is estimated that 33,000 children develop multidrug-resistant tuberculosis (MDR-TB) each year. In spite of these numbers, children and adolescents have limited access to the new and repurposed MDR-TB drugs. There is also little clinical guidance for the use of these drugs and for the shorter MDR-TB regimen in the pediatric population. This is despite the fact that these drugs and regimens are associated with improved interim outcomes and acceptable safety profiles in adults. This review fills a gap in the pediatric MDR-TB literature by providing practice-based recommendations for the use of the new (delamanid and bedaquiline) and repurposed (linezolid and clofazimine) MDR-TB drugs and the new shorter MDR-TB regimen in children and adolescents.
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ItemTuberculosis in adolescents and young adults: epidemiology and treatment outcomes in the Western Cape(INT UNION AGAINST TUBERCULOSIS LUNG DISEASE (I U A T L D), 2017-06)SETTING: Western Cape Province, South Africa. OBJECTIVES: To characterise tuberculosis (TB) epidemiology, disease presentation and treatment outcomes among adolescents (age 10-19 years) and young adults (age 20-24 years) in the Western Cape. DESIGN: A retrospective, cross-sectional review of routine patient-level data from the Electronic TB Register (ETR.Net) for 2013. Site of TB disease, human immunodeficiency virus (HIV) status and TB treatment outcomes were analysed by 5-year age groups (<5, 5-9, 10-14, 15-19, 20-24 and 25 years of age). TB notification rates were calculated using census data. RESULTS: Adolescents and young adults comprised 18.0% of all new TB notifications in 2013. The notification rate was 141 TB cases/100 000 person-years (py) among 10-14 year olds, 418/100 000 py among 15-19 year olds and 627/100 000 py among 20-24 year olds. HIV prevalence among TB patients was 10.9% in 10-14 year olds, 8.8% in 15-19 year olds and 27.2% in 20-24 year olds. Older adolescents (age 15-19 years) and young adults (age 20-24 years) with HIV co-infection had poor treatment outcomes: 15.6% discontinued treatment prematurely and 4.0% died. CONCLUSIONS: Young people in the Western Cape suffer a substantial burden of TB, and those with TB-HIV co-infection are at high risk of treatment discontinuation.
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ItemNo Preview AvailableChild pneumonia - focus on the Western Pacific Region(ELSEVIER SCI LTD, 2017-01)Worldwide, pneumonia is the leading cause of death in infants and young children (aged <5 years). We provide an overview of the global pneumonia disease burden, as well as the aetiology and management practices in different parts of the world, with a specific focus on the WHO Western Pacific Region. In 2011, the Western Pacific region had an estimated 0.11 pneumonia episodes per child-year with 61,900 pneumonia-related deaths in children less than 5 years of age. The majority (>75%) of pneumonia deaths occurred in six countries; Cambodia, China, Laos, Papua New Guinea, the Philippines and Viet Nam. Historically Streptococcus pneumoniae and Haemophilus influenzae were the commonest causes of severe pneumonia and pneumonia-related deaths in young children, but this is changing with the introduction of highly effective conjugate vaccines and socio-economic development. The relative contribution of viruses and atypical bacteria appear to be increasing and traditional case management approaches may require revision to accommodate increased uptake of conjugated vaccines in the Western Pacific region. Careful consideration should be given to risk reduction strategies, enhanced vaccination coverage, improved management of hypoxaemia and antibiotic stewardship.
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ItemPaediatric use of antibiotics in children with community acquired pneumonia: A survey from Da Nang, Vietnam(WILEY, 2019-11)AIM: To characterise paediatricians' antibiotic-prescribing behaviour when managing community acquired pneumonia. METHODS: We conducted a knowledge and attitudes survey of paediatric doctors practicing at a regional provincial hospital in central Vietnam over a 2-week period (from 12 December 2017 to 29 December 2017). RESULTS: Of 79 eligible paediatric doctors, 69 (87.3%) completed the questionnaire, of whom 65 (94.2%) thought that antibiotics were overused in Vietnam. Thirty-eight doctors (55.1%) indicated that they routinely hospitalised children with pneumonia to provide intravenous antibiotics. Most doctors reported discharging children with non-severe pneumonia after 5 days (76.9%) and those with severe pneumonia after 7-10 days (88.4%); older doctors generally continued intravenous antibiotics for longer. The two most important factors driving discharge decisions were clinical assessment (95.6%) and completion of the full course of intravenous antibiotics (80.0%). Antibiotic prescription was influenced by local guidelines (62.3%), drugs used before admission (50.0%) and the opinion of senior clinicians (37.7%). Most doctors believed antibiotic stewardship was necessary (98.6%) and that over-the-counter use of antibiotics should be restricted (97.1%). CONCLUSIONS: Paediatricians recognised an urgent need for more effective regulation and antibiotic stewardship in Vietnam. Routinely completing a full course of intravenous antibiotics leads to unnecessary and prolonged hospitalisation.
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ItemXpert MTB/RIF assay did not improve diagnosis of pulmonary tuberculosis among child contacts in Rwanda(AFRICAN FIELD EPIDEMIOLOGY NETWORK-AFENET, 2018-05-17)INTRODUCTION: To report on the diagnostic yield using the Xpert MTB/RIF assay on gastric lavage samples from children (<15 years) who were household contacts of tuberculosis (TB) cases in Kigali, Rwanda. METHODS: A cross-sectional study was conducted among 216 child contacts of index cases with sputum smear-positive TB over a 7 month period, from 1st August 2015 to 29th February 2016. Child contacts with tuberculosis-related symptoms or abnormal chest X-ray had sputum collected by gastric lavage on two consecutive days and samples were examined by smear microscopy, Xpert MTB/RIF assay and solid culture. RESULTS: Of the 216 child contacts, 94 (44%) were less than 5 years of age. Most of them 84 (89%) were receiving isoniazid preventive therapy at the time of screening. Thirty seven out of 216 children had TB-related symptoms. Only 4 (10.8%) were clinically diagnosed with TB; and none had bacteriologically confirmed tuberculosis. CONCLUSION: The use of Xpert MTB/RIF assay did not contribute to bacteriological confirmation of active TB in child contacts in this study. The low prevalence of tuberculosis in child contacts in this study may reflect the high coverage of preventive therapy in young (<5 years) child contacts. The low sensitivity of Xpert MTB/RIF assay in contacts may also suggest likely reflection of paucibacillary disease.
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ItemMultidrug-resistant tuberculosis in children and adolescents in the WHO European Region: Expert opinion.(World Health Organization, 2019)Historically, children and adolescents have not been a priority for national programmes for tuberculosis (TB) prevention and care in the WHO European Region. Owing to the low incidence in the Region and the non-specific clinical symptoms of TB infection and disease, children with TB or at risk thereof do not routinely enter health systems through classical TB programmes. Children and adolescents were often thought to play only a minor role in transmission of TB, and as a result TB prevention and care was focussed on adults. However, children and adolescents are significantly affected by the epidemic of multidrug-resistant TB (MDR-TB) as the Region carries 25% of the global MDR-TB burden. The estimated number of children with MDR-TB in the Region was 2120 in 2016, 16% of the total incident cases, and an estimated 14.1% of latently infected children carry MDR-TB organisms. Evidence-based guidance on how to manage children and adolescents infected with or having active MDR-TB is needed. The aim of this publication is to guide Member States in the WHO European Region to adequately address child and adolescent MDR-TB at the highest level and quality. It intends to update readers on recent scientific evidence, as well as providing region-specific clinical and public health recommendations on child and adolescent MDR-TB. Resources are provided for national TB programme managers and clinicians to encourage all involved in TB prevention and care to seek expert advice for difficult-to-treat cases from their colleagues in the Region. The specific aspects of MDR-TB in children and adolescents in the Region are also discussed. Most countries of the Region have a low incidence of childhood TB but carry a large burden of MDR-TB cases. Health-care providers involved in child health should be sensitized to TB and its clinical presentation. The regionwide epidemiology of MDR-TB among children and adolescents is summarized and it is underlined that accurate reporting and notification of child and adolescent TB cases is key to successful control of the disease. An overview of the key guideline documents currently published by WHO is given, with a particular focus on how they relate to the regional response to child and adolescent TB. The latest evidence-based and WHO recommendations on diagnosis and treatment of MDR-TB are provided, together with a summary on WHO’s position on TB vaccination. There is still a need to develop national TB guidance documents dedicated to child and adolescent TB in some Member States of the Region. All measures should be integrated into the Member States’ respective national TB programmes and other health services managing children with MDR-TB or at risk thereof to meet the End TB Strategy goals as well as the related objectives laid out in the Tuberculosis Action Plan for the WHO European Region 2016–2020.
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ItemManagement of tuberculosis: a guide to essential practice(International Union Against Tuberculosis and Lung Disease, 2019-10-01)
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