André Emmanuel, Lufungulo Bahati Yvette, Mulume Musafiri Eric, Bahati Rusumba Olivier, Van der Linden Dimitri, Zech Francis
Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.
Cliniques Universitaires Saint-Luc, Brussels, Belgium.
PLoS One. 2017 Jan 6;12(1):e0169014. doi: 10.1371/journal.pone.0169014. eCollection 2017.
In the field of tuberculosis (TB), and particularly in regard to paediatric TB (PedTB), clinical skills of health professionals play an important role in determining quality of care. In an era where novel diagnostic technologies and efficient treatment regimens are being made available for the poorest, we must not divert our attention from the importance of clinical skills, as this deliverable remains the cornerstone of individualized patient care and ultimately the best assurance for optimal use of resources. The aim of our work was to study the epidemiology of PedTB and the determinants of PedTB under-detection in the South-Kivu Province of the Democratic Republic of Congo (DRC), a setting with nearly no technical resources allowing to support the clinical diagnosis of PedTB, i.e. chest X-rays, rapid molecular tests or culture laboratories.
We collected TB notification data from 2010 to 2015 and analysed the space-time variations in notification for the different forms of TB among the 113 health facilities (HF) the South-Kivu Province, a region with a low HIV incidence. The different forms of TB notified were: smear positive pulmonary TB (SS+PTB), smear negative pulmonary TB (SS-PTB) and extra-pulmonary TB (EPTB). We further analysed the distribution of these different forms of the disease per age group and explored the possibility to predict the detection of PedTB.
Significant differences were observed between HF in regard to the proportion of paediatric TB and the proportion of SS-TB among adults. We found a strong correlation between the proportion of PedTB and three major factors: the proportion of TB cases with no bacteriological confirmation (SS-TB) among adults, the number of TB cases notified by the HF and the fact that the HF was supported or not by Médecins Sans Frontières (MSF). The proportion of SS-TB among adults was found to be a valid indicator for predicting the level of detection of PedTB at the same HF.
Our observations strongly suggest that under-detection of PedTB is associated with insufficient clinical skills and technical resources at the HF level which similarly affects other forms of the disease, in particular SS-TB. We demonstrated that, in the specific context of South-Kivu, under-detection of PedTB can be predicted by a low SS-TB/SS+PTB ratio in the adult population. In the context of severely under-resourced settings, this ratio could be used to rapidly identify HF that should benefit in priority from deeper evaluation, and eventually targeted interventions.
在结核病领域，尤其是在儿童结核病（PedTB）方面，卫生专业人员的临床技能在确定医疗质量中起着重要作用。在一个为最贫困人群提供新型诊断技术和高效治疗方案的时代，我们绝不能忽视临床技能的重要性，因为这一可交付成果仍然是个性化患者护理的基石，也是最终实现资源优化利用的最佳保障。我们工作的目的是研究刚果民主共和国（DRC）南基伍省儿童结核病的流行病学以及儿童结核病漏诊的决定因素，该地区几乎没有技术资源来支持儿童结核病的临床诊断，即胸部X光检查、快速分子检测或培养实验室。
我们收集了2010年至2015年的结核病通报数据，并分析了南基伍省113家卫生设施（HF）中不同形式结核病通报的时空变化，该地区艾滋病毒感染率较低。通报的不同形式的结核病有：涂片阳性肺结核（SS + PTB）、涂片阴性肺结核（SS - PTB）和肺外结核（EPTB）。我们进一步分析了这些不同形式疾病在各年龄组中的分布，并探讨了预测儿童结核病检出情况的可能性。
在儿童结核病比例和成人中涂片阴性结核病（SS - TB）比例方面，各卫生设施之间存在显著差异。我们发现儿童结核病比例与三个主要因素之间存在很强的相关性：成人中无细菌学确诊的结核病（SS - TB）病例比例、卫生设施通报的结核病病例数以及该卫生设施是否得到无国界医生组织（MSF）的支持。发现成人中SS - TB的比例是预测同一卫生设施儿童结核病检出水平的有效指标。
我们的观察结果强烈表明，儿童结核病的漏诊与卫生设施层面临床技能和技术资源不足有关，这同样影响到其他形式的疾病，特别是SS - TB。我们证明，在南基伍的特定背景下，成人人群中低SS - TB/SS + PTB比率可预测儿童结核病的漏诊情况。在资源严重不足的情况下，该比率可用于快速识别应优先受益于更深入评估并最终接受有针对性干预的卫生设施。
