Barriers and facilitators to the uptake of tuberculosis diagnostic and treatment services by hard-to-reach populations in countries of low and medium tuberculosis incidence: a systematic review of qualitative literature

Summary Tuberculosis disproportionately affects hard-to-reach populations, such as homeless people, migrants, refugees, prisoners, or drug users. These people often face challenges in accessing quality health care. We did a systematic review of the qualitative literature to identify barriers and facilitators to the uptake of tuberculosis diagnostic and treatment services by people from hard-to-reach populations in all European Union (EU), European Economic Area, EU candidate, and Organisation for Economic Co-operation and Development countries. The 12 studies included in this review mainly focused on migrants. Views on perceived susceptibility to and severity of tuberculosis varied widely and included many misconceptions. Stigma and challenges regarding access to health care were identified as barriers to tuberculosis diagnosis and treatment uptake, whereas support from nurses, family, and friends was a facilitator for treatment adherence. Further studies are required to identify barriers and facilitators to the improved identification and management of tuberculosis in hard-to-reach populations to inform recommendations for more effective tuberculosis control programmes

Effectiveness of interventions for diagnosis and treatment of tuberculosis in hard-to-reach populations in countries of low and medium tuberculosis incidence: a systematic review

Tuberculosis is over-represented in hard-to-reach (underserved) populations in high-income countries of low tuberculosis incidence. The mainstay of tuberculosis care is early detection of active tuberculosis (case finding), contact tracing, and treatment completion. We did a systematic review with a scoping component of relevant studies published between 1990 and 2015 to update and extend previous National Institute for Health and Care Excellence (NICE) reviews on the effectiveness of interventions for identifying and managing tuberculosis in hard-to-reach populations. The analyses showed that tuberculosis screening by (mobile) chest radiography improved screening coverage and tuberculosis identification, reduced diagnostic delay, and was cost-effective among several hard-to-reach populations. Sputum culture for pre-migration screening and active referral to a tuberculosis clinic improved identification. Furthermore, monetary incentives improved tuberculosis identification and management among drug users and homeless people. Enhanced case management, good cooperation between services, and directly observed therapy improved treatment outcome and compliance. Strong conclusions cannot be drawn because of the heterogeneity of evidence with regard to study population, methodology, and quality

Chest ultrasound findings in children with suspected pulmonary tuberculosis

Introduction: Chest ultrasound is increasingly used for the diagnosis of pediatric lung disease but there are limited data for its use in pediatric pulmonary tuberculosis (PTB). Aim: To describe chest ultrasound findings in children with suspected PTB. Methods: Consecutive children, presenting with suspected PTB to a tertiary children's hospital in Cape Town between July 2014 and March 2016, were enrolled in this cohort study. Children were categorized into three groups based on microbiological and clinical features; confirmed PTB (microbiologically confirmed), unconfirmed PTB (clinical diagnosis only), and unlikely PTB (respiratory disease not due to PTB). A clinician, blinded to categorization, performed chest and mediastinal ultrasound for consolidation, pleural gaps, pleural effusions, B-lines or enlarged mediastinal lymph nodes at enrolment and 1, 3, and 6 months thereafter. Two readers interpreted the ultrasounds independently. Results: One hundred seventy children (median age 26.6 months) were enrolled; 40 (24%) confirmed PTB, 85 (50%) unconfirmed PTB, and 45 (26%) unlikely PTB. In children with confirmed PTB, pleural effusion was more common (30% vs 9% in unlikely PTB, P = 0.024), mediastinal lymph nodes were larger (median size 1.5 cm vs 1.0 cm in unlikely PTB, P = 0.027), resolution of consolidation occurred less commonly at 1-month follow-up (24% vs 67% unlikely TB, P = 0.014) and the proportional size reduction of a consolidation was lower (44% vs 80% in unlikely PTB, P = 0.009). Inter-reader agreement was perfect to moderate. Conclusion: Chest ultrasound identified abnormalities suggestive of PTB with a high inter-reader agreement. Consolidation showed slower resolution in children with confirmed PTB

Chest ultrasound for the diagnosis of paediatric pulmonary diseases: A systematic review and meta-analysis of diagnostic test accuracy

Background Chest ultrasound is an emerging imaging modality, for several paediatric pulmonary diseases. Sources of data MEDLINE and EMBASE (1946-47 to 10 March 2017) were searched to collect evidence on the diagnostic accuracy of chest ultrasound, compared to other imaging modalities, for the diagnosis of paediatric pulmonary diseases. Areas of agreement Eighteen pneumonia studies, comprising 2031 children, were included for meta-analysis; the summary estimate sensitivity was 95.0% (95%CI: 90.7-97.3%) and specificity was 96.1% (95%CI: 89.1-98.7%). Areas of controversy Other pulmonary diseases also yielded high sensitivity and specificity, but a meta-analysis could not be conducted due to a limited number of studies includable, and their heterogeneity. Growing points Chest ultrasound should be considered as a first-line imaging modality for children with suspected pneumonia. Areas timely for developing research Further research should focus on the diagnostic accuracy of chest ultrasound for the diagnosis of paediatric pulmonary diseases, other than pneumonia, comparing against a valid gold standard

Chest ultrasound compared to chest X-ray for pediatric pulmonary tuberculosis

Introduction: Chest ultrasound is increasingly used to radiologically diagnose childhood pneumonia, but there are limited data on its use for pulmonary tuberculosis (PTB). Aim: Compare chest ultrasound with a chest X-ray (CXR) findings. Methods: Children (up to 13 years) with suspected PTB were enrolled. Bedside chest ultrasound findings were compared to CXR. The analysis was stratified by PTB category: confirmed PTB (microbiologically confirmed), unconfirmed PTB (clinical diagnosis with negative microbiological tests), or unlikely PTB (other respiratory diseases with improvement without tuberculosis treatment). Results: One hundred fifty-nine children were enrolled (57% boys, median age 26.6 months [interquartile range 15.1-59.3]). Ultrasound detected abnormalities in 72% (n = 114), CXR in 56% (n = 89), P <.001. Pleural effusion was detected on ultrasound in 15% (n = 24) compared 9% (n = 14) on CXR, P =.004, more in confirmed PTB (33%, n = 12 vs 8%, n = 4 unlikely PTB, P =.013). Ultrasound detected enlarged mediastinal lymph nodes more commonly (22%, n = 25) than CXR (6%, n = 10, P =.001); the size of lymph nodes in the unlikely category (1.0 cm) was smaller than the other two PTB categories (1.4 and 1.5 cm, P =.001). Inter-reader agreement (kappa Cohen) was higher for ultrasound than CXR for several findings (consolidation 0.67 vs 0.47, pleural effusion 0.86 vs 0.56, enlarged lymph nodes 0.56 vs 0.27). Conclusion: Ultrasound detected abnormalities more frequently than CXR with the higher inter-reader agreement; ultrasound abnormalities were most common in children with confirmed PTB. Ultrasound is a promising modality for detecting abnormalities in PTB. Further studies should evaluate the diagnostic accuracy of ultrasound against a gold standard

Sonographic Findings of Abdominal Tuberculosis in Children With Pulmonary Tuberculosis

Ultrasound reports of 102 children with microbiologically confirmed or clinically diagnosed pulmonary tuberculosis (TB) showed that 23 of 37 (64%) and 23 of 65 (36%) had TB suggestive abdominal lymphadenopathy, and 16 of 37 (44%) and 8 of 65 (13%) had splenic microabscesses, respectively. Splenic microabscesses were associated with HIV infection (P = 0.041). These data suggest that pulmonary TB is often complicated by abdominal TB in childre

Utility of Point-of-care Ultrasound in Children With Pulmonary Tuberculosis

BACKGROUND: Point-of-care ultrasound (POCUS) detects extrapulmonary tuberculosis (EPTB) in HIV infected adults but has not been evaluated in children despite their higher risk of EPTB. This study's aims were to investigate feasibility of POCUS for EPTB in children, frequency of POCUS findings suggestive of EPTB and time to sonographic resolution of findings with treatment. METHODS: This prospective South African cohort study enrolled children with suspected pulmonary tuberculosis (PTB). POCUS for pleural, pericardial or ascitic effusion, abdominal lymphadenopathy or splenic or hepatic microabscesses was performed and repeated at 1, 3 and 6 months of tuberculosis (TB) treatment. Prevalence of POCUS findings and their association with HIV infection was investigated in children with confirmed PTB (microbiologically proven), unconfirmed PTB (clinically diagnosed) or unlikely TB (respiratory disease that improved during follow-up without TB treatment). RESULTS: Of 232 children [median age 37 months (interquartile range, 18-74)], 39 (17%) were HIV infected. Children with confirmed or unconfirmed PTB had a higher prevalence of POCUS findings than children with unlikely TB [18 of 58 (31%) and 36 of 119 (30%) vs. 8 of 55 (15%); P = 0.04 and P = 0.03, respectively]. Pleural effusion [n = 30 (13%)] or abdominal lymphadenopathy [n = 28 (12%)] were the most common findings; splenic microabscesses [n = 12 (5%)] were strongly associated with confirmed PTB. Children coinfected with HIV and TB were more likely than HIV-uninfected children with TB to have abdominal lymphadenopathy (37% vs. 10%; P < 0.001) or splenic microabscesses (23% vs. 3%; P < 0.001]. Most ultrasound findings were resolved by 3 months with appropriate TB treatment. CONCLUSIONS: POCUS for EPTB in children with PTB is feasible. The high prevalence of findings suggests that POCUS can contribute to timely diagnosis of childhood TB and to monitoring treatment response

Chest ultrasonography in patients with HIV: a case series and review of the literature

Pulmonary disease is common in HIV-infected patients. Diagnostic means, however, are often scarce in areas where most HIV patients are living. Chest ultrasonography has recently evolved as a highly sensitive and specific imaging tool for diagnosing chest conditions such as pneumothorax, pneumonia and pulmonary edema in critically ill patients. This article addresses the issue of imaging and differentiating common pulmonary conditions in HIV-infected patients by chest ultrasonography