Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.
Global Health Directorate, Indus Health Network, Karachi, Pakistan.
J Glob Health. 2021 Feb 11;11:04011. doi: 10.7189/jogh.11.04011.
Every year, about 239 000 children die from tuberculosis (TB), despite availability of highly effective regimens. Few studies have evaluated predictors for poor treatment outcomes in children treated for TB.
We assessed predictors of unsuccessful TB treatment outcomes in a prospective cohort of children diagnosed by an intensified TB patient-finding intervention at four facilities in Pakistan between 2014 and 2016. A case of TB disease was determined through either bacteriologic confirmation of disease or a clinical diagnosis. To estimate characteristics predictive of experiencing an unsuccessful treatment outcome, we used a multi-level model with a modified Poisson approach, accounting for clustering at the facility level. We report estimated relative risks (RR) and 95% confidence intervals (CI).
During the study period, 1404 children less than 15 years old were initiated on treatment for drug-susceptible TB. In total, 709 (50.5%) were 0-4, 406 (28.9%) were 5-9 years, and 289 (20.6%) were 10-14 years old; 614 (43.7%) were female; and of the 1377 children assessed for malnourishment, 1161 (84.3%) were malnourished. A total of 1322 (94.2%) children experienced a successful treatment outcome, 14 (1.0%) children transferred out to a different facility, and 68 (4.8%) children experienced an unsuccessful treatment outcome: 14 (1.0%) died, 20 (1.4%) failed treatment, and 34 (2.4%) were lost to follow-up. After adjustment for age group, sex, and malnutrition status, we identified increased risk of unsuccessful treatment outcome in children presenting with fever (RR = 2.56, 95% CI = 1.02-6.44; = 0.05) or an abdominal examination suggestive of TB disease (RR = 2.34, 95% CI = 1.20-4.58; = 0.01), and a decreased risk in children who initiated treatment at a rural facility (RR = 0.05, 95% CI = 0.00-0.74; = 0.03).
More than 94% of children experienced successful treatment outcomes. We identified individual-, facility-, and clinical-factors predictive of experiencing unsuccessful treatment outcomes. Children with fevers and abdominal findings suggestive of TB disease should be tested for TB and followed closely throughout treatment to ensure necessary support for successful completion of treatment.
尽管有高效的治疗方案，但每年仍有约 239000 名儿童死于结核病（TB）。很少有研究评估儿童结核病治疗结果不良的预测因素。
我们评估了 2014 年至 2016 年期间在巴基斯坦四个设施中通过强化结核病患者发现干预措施诊断的前瞻性队列中儿童治疗失败的预测因素。通过疾病的细菌学证实或临床诊断来确定结核病病例。为了估计经历治疗失败的特征预测因素，我们使用具有修正泊松方法的多水平模型，考虑设施水平的聚类。我们报告估计的相对风险（RR）和 95%置信区间（CI）。
在研究期间，1404 名年龄小于 15 岁的儿童开始接受耐多药结核病治疗。共有 709 名（50.5%）为 0-4 岁，406 名（28.9%）为 5-9 岁，289 名（20.6%）为 10-14 岁；614 名（43.7%）为女性；在对 1377 名营养不良儿童进行评估中，1161 名（84.3%）存在营养不良。共有 1322 名（94.2%）儿童经历了成功的治疗结果，14 名（1.0%）儿童转移到另一个设施，68 名（4.8%）儿童经历了治疗失败：14 名（1.0%）死亡，20 名（1.4%）治疗失败，34 名（2.4%）失访。在调整年龄组、性别和营养不良状况后，我们发现发热（RR=2.56，95%CI=1.02-6.44；=0.05）或腹部检查提示结核病（RR=2.34，95%CI=1.20-4.58；=0.01）的儿童出现治疗失败的风险增加，而在农村地区接受治疗的儿童的风险降低（RR=0.05，95%CI=0.00-0.74；=0.03）。
超过 94%的儿童经历了成功的治疗结果。我们确定了可预测治疗失败的个体、设施和临床因素。有发热和腹部结核病表现的儿童应进行结核病检查，并在整个治疗过程中密切随访，以确保获得成功完成治疗所需的支持。
