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Abstr a ct
Ba ck g r ou n d
Chil dhood t uberculosis ( TB) has been neglect ed in t he fig ht ag ai nst TB. Despit e im p lem ent at ion of Direct ly Observ ed Treat m ent Short course ( DOTS) p rogram in pub lic and priv at e hospit als in I nd on esi a si nce 200 0, t he burden of chi ldh ood TB in hospit als w as largely unk now n . Th e g oals of t h is st udy w ere t o docum ent t he caseload and t y pes of ch ild hood TB i n t he 0- 4 an d 5- 1 4 y ear age grou ps di ag nosed in DOTS h osp it al s on Java I sland , I nd on esi a.
M e t h od s
Cross- sect ional st udy of TB cases record ed in i npat ient an d out pat i en t regist ers of 3 2 hospit als. Cases w ere an al yzed b y h osp it al charact erist ics, ag e g roup s, an d t yp es of TB. Th e n um b er of cases rep ort ed in t he out pat i en t u nit w as com pared w it h t hat record ed in t he TB regi st er.
Re su lt s
Of 5 ,877 TB cases in t he in pat i en t u nit and 1 5,69 4 in t h e out pat ient uni t , 1 1% ( 6 48) an d 27 % ( 4,1 73) respect iv el y w ere chil dren . Most of t he chil dhood TB cases w ere u nder fiv e y ears old ( 56% and 53% i n t he inp at ient and out pat ient clin ics resp ect iv ely ) . The prop ort ion of sm ear posit iv e TB w as t w i ce as hi gh i n t he inp at ient com pared t o t he ou t p at ient un it s ( 15 .6% v s 8.1% ) . Ex t ra- pu lm onary TB accou nt ed for 15 % an d 6% of TB cases in inp at ient and out pat ient clin ics resp ect iv ely. Am on g chi ldren recorded in hospit als only 1.6 % w ere rep ort ed t o t he Nat ional TB Program .
Con clu sion
I n response t o t he hig h casel oad and gross u nder- rep ort ing of ch ild hood TB cases, t h e Nat i on al TB Prog ram sh ou ld g iv e h igh er priorit y for chil dhood TB case m anagem ent in d esi gnat ed DOTS hospit als. I n ad dit ion, an i nt ernat ional gu idan ce on chi ldh ood TB recordin g and report in g and i m proved diagn ost ics and st and ardi zed classificat ion is requi red
Ba ck g ro un d
Chil dhood t uberculosis ( TB) has been neglect ed in t he gl ob al effort s t o con t rol TB, [1,2] because it is consid ered t o b e rarely cont ag ious and diffi cult t o d iagnose. I t is di fficul t t o con firm on bact eriologi cal ex am in at ion of spu t u m , not ab ly if only m i croscopy is avail ab le [3,4] .
Th e WHO est i m at ed t hat 11% of all n ew TB cases diagn osed i n 20 00 w ere chil dren [5] . Th e p roport i on is hi gher in h igh TB- burden coun t ries, reflect ing t h at chi ldh ood TB rep resent s act iv e TB t ran sm issi on w it hi n a com m un it y. A recent t uberculi n surv ey est i m at ed t hat 3.2% t o 6.8% of all chil dren in Cent ral Java Prov ince hav e TB in fect ion [6] . The proport ions est im at ed for low - an d m i ddl e- incom e count ries rang e from 15 % t o 4 0 % of al l TB cases, w h ile it accou nt ed on ly for 0.2 % t o 6% of not ified n ew sput um sm ear posit iv e ( SS+ ) cases from 22 h igh burden coun t ries [5,7] . How ev er, t h e n um b er of not i fied chi ldh ood TB cases m ay not reflect t h e t rue burden of chi ldh ood TB because of t he in ad eq uacy of exi st i ng surveil lance syst em s and p oorly docum ent ed dat a [8] . The WHO gui delin es h av e al ready requ est ed count ries t o rep ort chil d TB dat a in t w o age grou ps ( 0 - 4 and 5- 1 4 y ears ol d) , h ow ev er, v ery few cou nt ri es com p ly [9] .
Sim i lar t o ot her hig h bu rd en cou nt ri es, I ndonesia faces ch al lenges in cap t u ri ng ch ild hood TB cases t o be t reat ed u nder t h e Nat i on al TB Prog ram ( NTP) . Before t he int rod uct ion of a scoring chart as a st andardized app roach t o t he d i ag nosis of chil dhood TB in 2 007 , t h e d iagnosis of chi ldh ood TB Re se arch ar t icle
H igh ca se loa d of ch ildh ood tu be rcu losis in h ospita ls on Ja va I sla n d, I n don e sia : a cross
se ction a l stu dy
T risasi Lest a ri1*, Ari Pr o b an d ar i2, An n a- Ka rin H u r t ig3 an d Ad i U t a rin i1
BMC Publ ic Healt h 2 011 , 1 1: 78 4 d oi : 10 .118 6/ 1 471 - 24 58- 11- 784
Th e elect roni c version of t h is art icl e i s t h e com p let e one an d can be found on lin e at : ht t p: / / w w w.bi om ed cen t ral.com / 147 1- 2 458 / 11 / 78 4
Receiv ed: 1 March 20 11 Accep t ed: 11 Oct ob er 20 11 Pu bli shed: 11 Oct ob er 20 11
© 20 11 Lest ari et al ; li cen see BioMed Cent ral Lt d .
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Corresp on din g aut hor: Trisasi Lest ari
Depart m en t of Publ ic Healt h, Facul t y of Medici ne Univ ersi t as Gad j ah Mada, ( Jl Farm ak o, Sek ip Ut ara) , Yogy akart a, ( 5 528 1) , I ndonesia
Depart m en t of Publ ic Healt h, Facul t y of Medici ne Univ ersi t as Sebelas Maret , ( Jl . I r. Su t am i 36A) , Surak art a, ( 57 126 ) , I n donesia
Depart m en t of Publ ic Healt h and Clin ical Medi cine, Um eå Univ ersi t y, Um eå, ( SE- 9 01 8 5) , Sw ed en
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* t ri sasi lest ari@g m ail.com
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w as based on chest X- ray and/ or TB sign s an d sy m pt om s. The scorin g chart com p ri ses h ist ory of cont act w it h a sm ear spu t u m posit iv e case, posit iv e t ub ercul in sk in t est ( TST) , w eigh t , fev er, cou gh, l ym ph enl argem ent , bone an d j oin t enl argem ent s, and su ggest iv e ch est X- ray [10] . How ev er, t h e sensi t i vi t y and sp eci ficit y of t he I n donesian scori ng ch art have not been vali dat ed and t h e cost for TST t est i s st i ll h igh an d only av ailabl e at hospit als and ch est cli nics.
Despi t e im plem ent at i on of Direct l y Observed Treat m en t Sh ort - course ( DOTS) st rat eg y i n hospi t als si nce 200 0 [1 1] , t he bu rd en of ch ild hood TB i n t h ese hospi t als w as l argely un kn ow n. The goal s of t hi s st u dy w ere t o d ocu m ent t h e caseload an d t yp es of chi ldh ood TB in t h e 0 - 4 and 5- 1 4 y ear ag e g roup s diagn osed i n DOTS hospi t als on Jav a I sland , I nd on esi a.
M e t h od s
Th is is a cross- sect ional st ud y t hat w as part of a l arger research on assessm ent of t he im plem ent at i on of DOTS st rat egy in h osp it al s in Jav a I sland , I nd on esi a. The st udy w as condu ct ed from 1 Au gust 20 06 t o 31 May 20 07 i n all si x p rov inces of Java t o coll ect TB dat a from cases di ag nosed in 200 5 t o ensu re t hat all pat i en t s h ad com plet ed t h ei r t reat m ent .
I n 2 005 , a t ot al of 15 3 ( 3 1% ) h osp it al s on Java I sl an d w ere t rai ned in DOTS st rat egy by t he NTP an d t he hospit als w ere d esi gnat ed as DOTS hospit als. One hun dred an d one DOTS hospit als w ere select ed t h roug h qu ot a sam pli ng an d st rat i fied based on bed capacit y ( large an d sm all ) , ow nersh ip ( pub lic and priv at e) , and t each ing funct ion ( t eachin g and n on - t eachi ng) . Th ree hospit als decli ned t o p art icip at e for adm i nist rat iv e reason s. I ncl usion crit eri a for a su b- st ud y on caseload of ch ild hood TB w ere t h e av ai labil it y of a st and ardi zed hospit al m orbid it y report in inp at ient an d out pat i en t u nit s, and a TB regi st er for t he year 2 005 . On ly 32 h osp it al s m et t hese incl usion crit eri a and w ere select ed for t h e st ud y. These hospit al charat eri st i cs, i.e. bed capacit y, ow nership an d t eachi ng fu nct ion w ere n ot sig nifi can t l y d ifferent from t h e h osp it al popul at ion ( p 0.1 , 0.1 and 0.4 respectively, α = 5%).
A half- d ay m eet i ng w as cond uct ed in each provi nce t o exp lain t he st udy 's p urpose and prot ocol . On e represent at i ve from each h osp it al w as ap point ed as t h e cont act p erson resp on sibl e for con firm in g t he av ailabi lit y of d at a n eed ed . A t rained research assist an t w as t hen sent t o each hospit al for t hree d ay s t o coll ect TB dat a in 200 5.
Th e research assisst an t s coll ect ed dat a on: ( 1) Hospi t al p rofil es ( hospit al size, ow n ership an d t eachi ng st at u s) , w h ich w ere col lect ed from a sel f- adm i nist ered q uest i on naire; ( 2) Dat a on TB cases am ong ad ult s and ch ild ren w ere ob t ain ed from t he hospi t al m orbi dit y report for t h e i npat ient ( RL2A) an d t he ou t p at ient un it ( RL2B) an d ( 3 ) Dat a on TB cases regi st ered in t he DOTS program ( TB 03) .
RL2A and RL2 B are t h e n at ional st andardized form s cont ai nin g t he ag greg at ed dat a report in g hospi t al m orbi dit y, w hich are grou ped based on t he I nt ern at ional Code of Di sease version 10 ( I CD- 1 0) . I n t hese report s, TB is coded un der I CD- 10 A1 5.0 - A19.0 , an d classifi ed furt h er in t o ni ne grou p of d iseases, i.e. sm ear sp ut um p osi t i ve TB ( A15 .0) , ot her p ulm on ary TB ( A15.1 - A16 .2) , respirat ory t ract TB ( A16 .3- 9 ) , m eni ngi t i s TB ( A17.0 ) , ot her cen t ral nervous sy st em TB ( A17.1 - A17 .9) , b on e and j oi nt TB ( A18.0 ) , ly m p haden it is TB ( A1 8.2) , m il iary TB ( A19 ) and ot her TB ( A1 8.1, A18.3 , A18.8 ) . Wi t h in t he 'ot her p ulm on ary TB' grou p in t h e RL2 A an d RL2B form s ( A1 5. 1- A16.2 ) , bact eriologi cal ly, h ist ol og ically, or cul t u re con firm ed TB cases ( A1 5.1 t o A15.9 ) w ere com b ined w it h un con firm ed TB cases ( A1 6.1 t o A16.2 ) . Therefore, it w as not possibl e t o cal culat e all con firm ed TB cases from t h e h osp it al m orb idi t y rep ort . We t reat ed t hi s grou p as uncon fi rm ed cases because t h e cu rrent pract ice in diagn osi ng chil dhood TB in I ndonesia rarely used bact eriologi cal ly, h ist ol og ically or cu lt ure confi rm at ion. To si m pl ify ou r analy sis, w e fu rt her com bin ed 'ot h er pul m onary TB' ( A1 5.1 - A16.2 ) and ' ot her respi rat ory TB' ( A16 .3 - A1 6.9) grou ps in t o 'u nconfirm ed p ulm on ary TB" ( A15 .1 - A1 6.9) . We also com bin ed differen t g roup s of ex t ra- pu lm onary TB ( A1 7.0, A1 7.1 - A17.9 , A18.1 - 3, A1 8.8 , and A19.0 ) in t o one grou p of 'EPTB' ( A1 7.0 - A19.0 ) . Th erefore, w e have t hree groups of di sease classificat ion in t h is st udy, i.e. t u bercu losis of lun g, confirm ed b y sp ut um m icroscopy w i t h or w i t h ou t cult ure ( A15 .0) , u nconfirm ed p ulm on ary TB ( A15.1 - A16 .9) , and ex t ra- p ulm on ary TB ( A1 7.0 - A19 .0) . Due t o t he nat ure of t he ag greg at e dat a sou rces, it w as not possibl e t o verify t h e d iagnost ic m et hods in ind iv idu al cases and t o con firm t he diagn osi s of TB.
I n I ndonesia, hospi t als are m ai nly classifi ed accordin g t o t he nu m ber of b ed s av ailab l e, ow n ershi p, and t each ing cap aci t y. Large and sm al l, pu bli c an d priv at e, or t each ing an d non- t eachin g hospi t al feat u re un iqu e com p lexi t i es i n t he im p lem ent at ion of DOTS program . Th e ch i- sq uare t est and t w o- prop ort ion z- t est w ere used t o calcu lat e di fferences bet w een g roup s of ch ild hood TB i n di fferent t y pes of hospit als, t yp es of TB, an d age grou ps accordin g t o t he WHO recom m end at ion ( i.e. 0- 4 an d 5- 14 y ear- old ) . The find ing s are su m m arized separat ely for in pat i en t s and ou t p at ient s. We div id ed t h e n um b er of chil dhood TB cases in t h e TB reg ist er by t he t ot al num ber of ch i ldh ood TB cases recorded i n t he hospit al m orbid it y report in t h e i npat ient an d out pat i en t u nit t o obt ain t he proport ion of chi ldh ood TB t reat ed u n der t h e DOTS st rat egy. St at i st i cal an al yses w ere carri ed ou t usin g Ep i I n fo soft w are v ersion 3 .3.2 and Microsoft Ex cel.
Et hical app rov al w as ob t ain ed from t he Et hi cs Com m it t ee, Facult y of Med icin e, Un iv ersit as Gadj ah Mad a. Perm ission t o con duct t he st u dy w as receiv ed from each hospi t al.
Re su lt
Un d e r r e p or t in g of ch ild h ood TB t r e a t e d u n d e r t h e D OTS st r a t e g y
I n 2 005 , a t ot al of 4,8 21 ch ild ren ( 648 in t he in pat i en t u nit and 4 ,173 in t he out pat i en t u nit s) w ere diagn osed as TB pat i en t s i n 32 hospit als on Java I sl an d. How ev er, t here w as a larg e d iscrep an cy b et w een t he num ber of chi ldh ood TB cases b ei ng d iagnosed in t h e h osp it al an d t hose t hat w ere act u al ly report ed t o t h e NTP. Out of 3 2 hospi t als, onl y 1 1 hospi t als recorded ch ild hood TB i n t heir TB regist ry ( TB0 3 form ) . Overal l, only 75 ou t of 4 ,821 ( 1.6 % ) chi ldh ood TB cases i n hospi t als w ere act uall y recorded i n t he TB regist ers and report ed t o t h e NTP. The m aj orit y of cases report ed w ere 5 t o 14 y ears old ( 75% ) an d classifi ed as p ulm on ary cases ( 6 5% ) . Sp ut um sm ear ex am in at ion w as carri ed ou t i n 39 cases ( 5 2% ) , and 9 ( 23 % ) w ere p osi t i ve. Only one case receiv ed chi ld friend ly an t i TB form ul at ions, and t h e rest recei ved a st an dard ad ult reg im en.
Prop or t ion of ch ild h ood TB ca se s a m on g a ll TB ca se s
Chil dren con st i t u t ed 1 1% and 2 7% of al l TB cases in t h e i npat ient an d out pat i en t u nit s, resp ect iv ely. Tab le 1 show s t he casel oad of chi ldh ood TB by hospit al t yp e. I n in pat i en t u nit s, t he prop ort ion of chil dhood TB w as sign ificant ly h i gher in l arger an d t eachi ng h osp it al s ( p < 0.01 ) , bu t d id n ot differ sign ificant ly by hospi t al ow n ershi p. I n con t rast , am ong ou t p at ient un it s, t h e p roport i on of ch ild hood TB w as si gni ficant ly larg er ( p < 0.0 1) i n sm all and non- t each ing hospit als, as w ell as in pub lic h osp it al s.
Table 2 d escrib es caseload an d t yp es of chi ldh ood TB based on age grou ps in t h e i npat ient an d out pat i en t u nit s. The m aj orit y of ch ild hood TB cases in t he in pat i en t u nit w ere ch ild ren aged 0 - 4 y ears ( 5 6% ) . I n reg ards t o TB t y pes, m ost w ere classified as un con firm ed pu lm onary TB ( 6 9% ) . The prop ort ion of t h ose w i t h sput um sm ear or cu lt ure p osi t i ve TB an d EPTB w as eq ual, i.e. 16 % an d 15 % . Chil dren w it h sp ut um sm ear posit iv e TB con t rib ut ed up t o 5% of al l spu t u m sm ear p osi t i ve TB cases t reat ed i n t he inp at ient u n it an d 20 % of t hese chil dren ( 20 ou t of 10 1 cases) w ere less t h an fiv e y ears old. There w ere no differen ces i n t he dist ribu t i on of EPTB bet w een ag e g roup s ( p = 0.08 ) .
T ab le 2 . Typ es and prop ort ion of chil dhood TB in i npat ient an d out pat i en t u nit
Th e fi ndi ngs also show ed t hat t h e p roport i on of ch ild hood TB cases und er fiv e years old in t he out pat i en t u nit s w as sli ght ly hi gher t h an in t he inp at ient un it s ( 53 % in out pat ient uni t s, 5 6% in inp at ient un it s) . I n som e g en eral hospi t als, t he nu m ber of out pat ient chil dhood TB cases surpassed t h e n um b er of ad ult TB cases ( d at a not sh ow n) . The m aj ori t y of cases w ere cl assi fied as 'un con firm ed pu lm onary TB' ( 86% ) , fol low ed by sput um sm ear posit iv e TB ( 8% ) and EPTB ( 6% ) . The proport ion of chi ldren w i t h sput um sm ear posit iv e TB out of al l spu t u m sm ear p osi t i ve TB cases t reat ed at t h e out pat ient uni t w as 1 6% , t hree t im es hi gher t h an it s prop ort ion in t h e i npat ient uni t and m ore t han half ( 52% ) w ere below fi ve years of age.
Table 3 d escrib es t y pes of EPTB in t h ree m aj or groups accord ing t o I CD 10 classificat ion, i. e. TB of t he nervous sy st em ( A17 , 36% ) , TB of ot h er organs ( A18, 5 2% ) and m il iary TB ( A19 , 11.2 % ) . Tu bercu losis of t h e n erv ou s syst em in t h e i npat ient an d out pat i en t u nit w as dom i nat ed b y m enin git is TB ( 9 5% , dat a n ot show n ) and occurred eq ually at d ifferent age grou ps. Tu b ercu losis periph eral ly m p hadenopat h y w as t he m ost com m on t yp e of TB of ot her organs ( 6 4% ) and m ost l y occurred am on g older chil dren . Mil iary TB w as pred om inant am ong y oung chil dren ( 68 % ) .
T ab le 3 . Typ es of ext ra- pul m onary t uberculosis
Discu ssio n
Ou r st ud y i dent ified t w o m ain find ing s: first ly, t he hi gh p roport i on of ch ild ren d iag nosed w i t h TB i n all t y pes of h osp it al s t h roug hout Java isl an d; an d secon dly, gross u nder report i ng of chi ldh ood TB cases t reat ed in t he DOTS desig nat ed h osp it al t o t he NTP.
A key find ing report ed i n t his st ud y i s t h e fact t h at only 11 ou t of 32 t rained h osp it al s im p lem ent ing t h e DOTS st rat egy record ed chil dhood cases i n t h e st andardized TB reg ist er and report ed t hem t o t he NTP. Th e t ot al n um b er of regi st ered chil dhood TB cases w as only 1.6 % of all chil dhood TB cases t reat ed i n hospi t als, i ndi cat in g a poor di sease surveil lance syst em for ch ild hood TB i n t he cou nt ry. Th is ph en om en on is not uni que t o I nd on esi a, as w eak su rv eill an ce d at a for chi ldh ood TB in m any ot her cou nt ri es i s com m on du e t o diffi cult y in d iagnosis, and as a resu lt , lim it ed chil dhood TB ep idem i ol og ical st udi es h av e been con duct ed. Ev en in a w el l- resou rced coun t ry such as in t h e UK, an est im at ed 20% of all ch ild hood TB cases in 2 004 w ere not report ed t o t h e TB surv ei llance sy st em [12] . I n Sout h Africa, only 56 % of m en ing it is TB cases w ere report ed t o t he NTP [13] . This si t u at ion reflect s t he percei ved l ow priori t y of chil dhood TB in g en eral, and w eak int ern al lin kage w i t h pediat ri c uni t s i n t he
im p lem ent at ion of t he DOTS st rat egy in hospit als.
Con seq uent ly, NTP i s unl ik el y t o accu rat el y capt ure t h e b urden of chil dhood TB, im p ai ri ng accurat e pl an nin g and m an ag em en t , i nclu din g logi st i cs, i.e. t h e su ppl y of chi ld- fri en dly ant i TB drugs i n DOTS hospi t als. The fact t hat on ly on e report ed case recei ved ant i TB drug s from t he NTP m ay ill ust rat e t he li m it ed use of chil d- friend ly an t i TB d ru gs in hospit als, and t herefor e n on - st an dard ized TB drug form ul at ions are cont in uously prescrib ed .
Th e p roport i on of ch ild hood TB i n t he ou t p at ient un it w as t en t im es h igh er t han t he est im at ed proport ion of all t y pes of ch ild hood TB for t h e I nd on esi an popul at ion ( 27% v s 2.7 % ) . This fi ndi ng, h ow ev er, corresponds w el l w i t h t h e est im at ed chil dhood TB caseload in low and m idd le- in com e cou nt ri es, w hich rang ed from 1 5% t o 4 0% of al l TB cases [7] . I n Java I sl an d, hospi t als rem ain t o be t h e fi rst healt h provi der of choice. Hal f of households w it h previ ou s TB h ist ory survey ed in t he Nat ional TB Prev al en ce Su rv ey 2 00 4 chose h osp it al s for TB t reat m ent [1 4] . Furt her analy sis of chil dhood TB caseloads in differen t h osp it al charact erist ics su ggest t h at bu rd en of p ubl ic hospi t als w ere hig her com p ared t o p ri vat e h osp it al s. Cases referred t o h osp it al al so t end t o be m ore severe com p ared t o ot her h ealt h facil it ies, such as prim ary heal t h care. Th erefore it is m ore l ik el y t o det ect TB cases in h osp it al . Hence, our resul t cann ot be ext rap ol at ed t o t he general popul at ion d ue t o pot en t i al sel ect ion b ias.
Con sist en t w it h fin din gs from ot her st u dies,[1 5-1 9] m ore t h an half of chil dhood TB cases occurred i n t he ag e g roup of 0 - 4 y ears ( i .e. 5 6% in t h e inp at ient and 5 3% in t h e out pat ient uni t ) . Hi gh i ncid en ce of TB am on g chi ldren un der fi ve y ears of age in dicat es ong oi ng d isease t ransm ission i n t h e h ou seh ol d [2 0] . Thi s can be prev ent ed w it h t he provi sion of I soniazid Prophy lax is Therapy ( I PT) i n approxi m at ely 60 % of at - risk ind iv idu al s [21] . Accord ing t o t he WHO recom m endat ion, I PT should be giv en for si x m on t h s t o chi ldren aged less t han fiv e years w ho are household cont act s of i nfect i ou s cases [9,22] . I n I ndonesia, how ev er, con t act t racing an d provi sion of TB p roph yl ax is t o hig h- risk chi ldren are st ill rarel y i m pl em en t ed.
Con t rary t o t he usu al op ini on , t h e p robl em of ch ild hood TB also poses a serious pu bli c heal t h issue du e t o a h igh prop ort ion of SS+ TB seen i n chil dren in t hi s st u dy. These cases are as infect ious as sput um sm ear posit iv e ad ult TB cases and t hey can be t h e source of i nfect i on s for ot h er chil dren [20] . The WHO est im at ed t h at t he prop ort ion of chil dren w it h sp ut um sm ear posit iv e TB am ong all not i fied spu t u m sm ear p osi t i ve TB cases for I ndonesia ran ged from 0.2% t o 4.8% , w it h an est i m at ed p roport i on of 1 .1% [5] . I n ou r st ud y, t he prop ort ion in hospit als w as hi gher, u p t o 5% in t h e i npat ient uni t and 16% i n t he ou t p at ient un it . Th e p roport i on of sm ear posit iv e cases am on g chi ldh ood TB cases report ed t o t he NTP w as ev en hi gher ( 23 % or 9 out of 39 ch ild hood TB cases w it h sm ear sput um resul t ) . Anot h er st udy in hig h endem i c set t ing s fou nd a proport ion of 5.8 % of all chil dhood TB w ere sm ear p osi t i ve in t h e Ki lim an j aro regi on [15] , 5% i n Malaw i ,[19] 4.7 % in I ndi a [23] , an d 20 % in Thail an d [2 4] . Thi s find ing challeng es a com m on p ercept ion t hat y oung chil dren w it h TB are rarely con t agi ou s [25] . Hen ce, aw aren ess of TB sym pt om s an d cont act t racing for every sp ut um sm ear posit iv e cases, incl udi ng t hose in ch ild ren, i s need ed t o di ag nose ch ild hood TB earl ier and t o prevent close con t act s from d ev elopin g adv an ced disease.
Alt hough t h e p roport i on of sp ut um sm ear posit iv e ch ild hood TB cases in our st udy w as hi gh, i t w as n ot possib le t o confirm t he rel iabil it y of our find ing - in t erm s of diagn ost ic m et hods and resul t s - due t o t he nat ure of aggregat e dat a i n t he hospit al rep ort ing form s as our sou rce of inform at i on . Con t am i nat i on of env ironm ent al m y cobact eria is anot h er reason t hat m ay h av e i nflu en ced t h is fin din g, w h ich u nderscores t h e im p ort an ce of cul t u re or i m m u nological m et hods t o con firm chi ldh ood TB di ag nosis.
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I n t J Tu berc Lu ng Dis 2 002 , 6 :3 73- 374 . Pu bMed Ab st ract | Pu bli sher Ful l Tex t
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St op TB Part nersh ip Ch ild hood TB su bgroup:
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3 .
m ean s. How ev er, due t o t he nat ure of aggregrat e dat a, it is i m possib le t o separat e confi rm ed cases from unconfi rm ed cases. Classifi cat ion of TB cases w i t h ou t m en t i on of b act eri ol og ical or h ist ol og ical confirm at ion" g roup w it hi n t he I CD syst em w i ll g en erat e a hig h lev el of false posit iv es or ov erd iagnosis [26] . An exam i nat i on of t he di scordance bet w een num ber of cases regist ered w it h I CD- 9 diagn ost ic codes and t he act u al num ber of con firm ed TB cases show ed a low p osi t i ve predict iv e valu e ( 28.6 % ) com pared t o ot h er com m u nicabl e d iseases [2 7] . Av ailabi lit y of X- ray facili t i es i n hospit als also increased t he risk for overdiagn osi s, esp eci al ly w hen t he di ag nosis w as m ade solely on t h e b asi s of u ndefin ed radi ol og ic crit eria [2 8] . Fu rt herm ore, in I nd on esi an hospit als, t he I CD syst em is m ai nly used for bil lin g pu rp oses, w h ere accu racy of sp eci fic di ag nosis classifi cat ion i s oft en neglect ed . Th e p ossi bil it y of overdiagn osi s can not b e i gnored in t hi s st u dy since it m i ght pu t ch ild ren at hig her risk for m ed icat i on error [2 9] and ad verse d ru g effect s [8] . This i ssue im p lies t he need for furt her research t o confi rm t h e d iagnosis of chi ld h ood TB in hospit als by v al idat ing chil dhood TB sign s an d sy m pt om s w i t h laborat ory an d rad iological fi ndi ngs as w ell as i m provi ng I CD- 10 cl assi ficat i on for chi ldh ood TB. Desp it e t h ese li m it at i on s, t h e result from t h is st udy in dicat es a hi gh caseload of ch ild ren d iagnosed as TB i n DOTS desig nat ed h osp it al s in I ndonesia.
A t ot al of 3 65 cases ( 7.5 % of all chil dhood TB cases) w ere record ed und er I CD 10 A17. 0 - A19 .0, i.e. EPTB. Th e p roport i on of EPTB in chil dren in t h is st udy w as low com p ared t o t en- y ear cohort s in t h e US and ru ral sout heast Et h iopia w h ich sh ow ed t h at EPTB accoun t ed for 21% and 33% of all chil dhood TB, respect iv el y [30,3 1] . Usi ng t hese prop ort ions t o est im at e t he t ru e b urden of pul m onary TB am on g chi ldren , a 7.5% p roport i on of EPTB am ong al l chi ldh ood TB cases su ggest s a p ossi bil it y of over diagn osi s of p ulm on ary chil dhood TB in h osp it al s. Accordi ng t o t h e I CD- 10, diagn osi s of t y pical ch ild hood TB b y observat ion of int ra- t h oracic ly m p h nodes on chest X- ray w as n ot classifi ed as EPTB, bu t as resp irat ory TB. Th is classificat ion low ers t h e p roport i on of ch ild ren w it h EPTB an d m ay ex pl ai n t he discrepancy w it h fi ndi ngs from ot h er st udi es. How ever, t he I CD- 1 0 syst em does not all ow clear classifi cat ion of in t ra- t horacic d isease ent it ies, w hi ch are t he t y pi cal t y pes of TB encoun t ered in ch ild ren. The chest X- ray rem ains t he m ost im p ort an t d iagnost ic t ool for chil dhood TB in l im i t ed resou rce set t in gs, t herefore im plem ent at i on of t he proposed radi ol og ical classifi cat ion of chi ldh ood i nt ra- t horaci c TB i s a p ot ent ial w ay t o im pr ov e t h e cl assi ficat i on of ch ild hood TB [32] . How ev er, t h is fin din g cou ld also refl ect v ariat ions associ at ed w i t h t y pes of chil dhood TB in a hi gh- burden set t i ng. Furt her st ud y i s need ed t o confirm t hi s hy pot h esi s.
Th e p rogression t o d isease and t he risk of d ev elopin g di ssem inat ed form s of TB incl ud i ng m ili ary TB and TB of t he nerv ous sy st em are h igh est in chil dren . Th erefore chil dren w it h d issem in at ed form s of TB need special at t ent ion [7,33,34] . I n k eep ing w it h t he above fin din g of a l ow er rat io of EPTB t o PTB cases t han ex pect ed, m ili ary TB cases in our st udy w ere sl igh t l y l ess com m on ( 0.8 % , 41 out of 482 1 cases) t h an t h at has been report ed i n t he lit erat ure ( 1- 2 % ) [3 5] . The m aj ori t y ( 6 8% ) occurred am on g y ou nger chil dren , in k eep ing w it h ot her fi ndi ngs w here m ore t han 7 0% of m ili ary TB cases occu rred in chil dren ag ed 0- 4 years [17,3 6] . BCG v acci nat i on has been kn ow n t o h av e t h e g reat est effect in p rev en t i ng sev ere dissem i nat ed d isease in youn g chi ldren [3 7] . I n t his st ud y, it w as not possibl e t o ret ri ev e t h e h ist ory of BCG im m un izat i on am on g chi ldren. I n general, cov erage of BCG im m un izat i on in I ndonesia in creased from 7 8% in 200 0 t o 8 9% in 200 5 [3 8] .
Co nclu sio n s
Th e h igh caseload of chil dhood TB in t hese design at ed DOTS hospi t als n ecessit at es in creased at t en t i on w it hi n t he NTP. Pub lic h osp it al s should be giv en priorit y i n t he im p lem ent at ion of im prov ed chi ldh ood TB case m an ag em en t . Record ing an d rep ort ing of all chil dhood TB cases di ag nosed in hospit als shoul d t herefore be great ly im prov ed t hrou gh a rev ised i nt ernat ional di sease classificat ion sy st em i n ord er t o p rov ide accurat e inform at i on for pl an nin g and m an ag em en t of chi ldh ood TB cont rol p rogram .
List o f a b br e v ia t io ns u se d
BCG: Baci llu s Cal m et t e- Guéri n; DOTS: Di rect ly Ob serv ed Treat m ent Short course; EPTB: Ex t ra pul m onary t uberculosis; I CD- 10 : I n t ernat i on al Classificat ion of Di sease version 10 ; I CD- 9 : I n t ernat i on al Classificat ion of Di sease version 9; I PT: I son iazid Prop hy laxi s Th erapy ; NTP: Nat i on al Tub ercul osi s Program ; PTB: Pu lm onary t ub ercul osi s; TST: Tuberculi n Sk in Test ; UK: Unit ed Kin gdom .
Co m pe t in g in t e re st s
Th e aut hors declare t hat t hey have no com pet ing int erest s.
Aut h or s' co nt ribu t io ns
TL cont ribu t ed t o t h e i nit ial concept , desig n, dat a coll ect ion, coord inat ion and w ri t i ng of t he m anuscrip t . AP and AU cont ribu t ed t o t h e i nit ial con cep t , d esi gn and dat a collect ion. TL, AP, AKH an d AU cont ri but ed t o t he in t erpret at i on of d at a. All aut hors com m ent ed on t h e m an uscript and gave approval for final su bm i ssion.
Ack n ow le d ge m e n t s
We t hank t h e h osp it al s inv olv ed , t h e Nat i on al TB Prog ram i n I n donesia, an d t he field st aff for t heir m et i culous fi el dw ork. We al so t hank Ann a Ralp h, Hans L. Ri ed er, Tari Turner, Yodi Mahendradhat a, and Pat ri ck Vau ghan, for t h ei r crit ical revi ew s of t he m anu scri pt an d useful com m ent s. Th e p roj ect w as supp ort ed by t h e Su b Direct orat e of Tu bercu losis, Mi nist ry of Healt h Repu bli c of I ndonesia and fu nded b y t he Dep art m ent for I n t ernat i on al Dev el op m ent , UK Gov ernm en t , t hrough WHO I ndonesia, proj ect no. I NO TUB 0 02 XW 06 EC0. P01. A0 1.
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Pre - pu b lica tion h isto ry
Th e p re- p ubl icat i on hist ory for t hi s paper can b e accessed here:
