肯尼亚 13 家政府医院入院儿童的结核病诊断实践和估计负担：两年常规临床数据分析。

Diagnostic practices and estimated burden of tuberculosis among children admitted to 13 government hospitals in Kenya: An analysis of two years' routine clinical data.

机构信息

KEMRI-Wellcome Trust Research Programme, Health Services Research Group, Nairobi, Kenya.

University of Nairobi, Department of Paediatrics and Child Health, Nairobi, Kenya.

出版信息

PLoS One. 2019 Sep 4;14(9):e0221145. doi: 10.1371/journal.pone.0221145. eCollection 2019.

BACKGROUND

True burden of tuberculosis (TB) in children is unknown. Hospitalised children are low-hanging fruit for TB case detection as they are within the system. We aimed to explore the process of recognition and investigation for childhood TB using a guideline-linked cascade of care.

METHODS

This was an observational study of 42,107 children admitted to 13 county hospitals in Kenya from 01Nov 15-31Oct 16, and 01Nov 17-31Oct 18. We estimated those that met each step of the cascade, those with an apparent (or "Working") TB diagnosis and modelled associations with TB tests amongst guideline-eligible children.

RESULTS

23,741/42,107 (56.4%) met step 1 of the cascade (≥2 signs and symptoms suggestive of TB). Step 2(further screening of history of TB contact/full respiratory exam) was documented in 14,873/23,741 (62.6%) who met Step 1. Step 3(chest x-ray or Mantoux test) was requested in 2,451/14,873 (16.5%) who met Step 2. Step 4(≥1 bacteriological test) was requested in 392/2,451 (15.9%) who met Step 3. Step 5("Working TB" diagnosis) was documented in 175/392 (44.6%) who met Step 4. Factors associated with request of TB tests in patients who met Step 1 included: i) older children [AOR 1.19(CI 1.09-1.31)]; ii) co-morbidities of HIV, malnutrition or pneumonia [AOR 3.81(CI 3.05-4.75), 2.98(CI 2.69-3.31) and 2.98(CI 2.60-3.40) respectively]; iii) sicker children, readmitted/referred [AOR 1.24(CI 1.08-1.42) and 1.15(CI 1.04-1.28) respectively]. "Working TB" diagnosis was made in 2.9%(1,202/42,107) of all admissions and 0.2%(89/42,107) were bacteriologically-confirmed.

CONCLUSIONS

More than half of all paediatric admissions had symptoms associated with TB and nearly two-thirds had more specific history documented. Only a few amongst them got TB tests requested. TB was diagnosed in 2.9% of all admissions but most were inadequately investigated. Major challenges remain in identifying and investigating TB in children in hospitals with access to Xpert MTB/RIF and a review is needed of existing guidelines.

背景

儿童结核病的真实负担尚不清楚。住院儿童是发现结核病病例的低挂果实，因为他们在系统内。我们旨在使用指南相关的级联护理来探索儿童结核病的识别和调查过程。

方法

这是对 2015 年 11 月 1 日至 31 日和 2017 年 11 月 1 日至 31 日期间在肯尼亚 13 个县医院住院的 42107 名儿童进行的观察性研究。我们估计了符合级联中每个步骤的患者、有明显（或“工作”）结核病诊断的患者，并对符合指南的儿童进行了与结核病检查相关的模型关联分析。

结果

23741/42107（56.4%）符合级联的第一步（≥2 种与结核病相关的症状和体征）。在符合第一步的患者中，有 14873/23741（62.6%）记录了第二步（有结核病接触史或全面呼吸系统检查的进一步筛查）。在符合第二步的患者中，有 2451/14873（16.5%）要求进行第三步（胸部 X 光或曼图试验）。在符合第三步的患者中，有 392/2451（15.9%）要求进行第四步（≥1 项细菌学检查）。在符合第四步的患者中，有 175/392（44.6%）记录了第五步（“工作性”结核病诊断）。在符合第一步的患者中，与结核病检查请求相关的因素包括：i）年龄较大的儿童[AOR 1.19（CI 1.09-1.31）]；ii）HIV、营养不良或肺炎合并症[AOR 3.81（CI 3.05-4.75）、2.98（CI 2.69-3.31）和 2.98（CI 2.60-3.40）]；iii）病情较重的儿童，再入院/转院[AOR 1.24（CI 1.08-1.42）和 1.15（CI 1.04-1.28）]。所有入院患者中，2.9%（1202/42107）被诊断为“工作性”结核病，其中 0.2%（89/42107）为细菌学确诊。

结论

超过一半的儿科住院患者有与结核病相关的症状，近三分之二的患者有更具体的病史记录。其中只有少数患者接受了结核病检查。所有住院患者中，2.9%被诊断为结核病，但大多数患者的检查不充分。在有条件进行 Xpert MTB/RIF 检测的医院中，识别和调查儿童结核病仍然存在很大的挑战，需要对现有的指南进行审查。