Nigerian Journal of
Paediatrics 2011;38(3):109-114
ORIGINAL
Nnaji G A
Ranking
of
diagnostic
features
of
Chukwu JN
childhood
pulmonary
tuberculosis
by
Ezechukwu CC
Ugochukwu EF
medical doctors in southeastern Nigeria
Ogbonnaya LU
Ogbuabor DC
Received: 28th February
2011
Abstract
Objective :
To rank
The study found that
the percentage
Accepted: 3rdAugust
2011
diagnostic features of
childhood
of doctors working in
DOTS clinics
pulmonary tuberculosis;
and to
who ranked weight loss
and failure
Nnaji GA
( )
determine the effect of
working in
to thrive (2) was
statistically and
Department of Family
Medicine,
tuberculosis Directly
Observed
significantly higher
than those of
Ezechukwu CC, Ugochukwu
EF
Treatment Short Course
(DOTS)
non-DOTS
respondents.
Department of
Paediatrics, Faculty facilities on the ranking of these
Conclusions: The
most important
of Medicine, College of
Health features by medical doctors.
symptoms/signs on which
medical
Sciences, Nnamdi
Azikiwe Methods : A cross
sectional
doctors based their
diagnosis of
University, Nnewi
Campus, descriptive study, using structured
childhood pulmonary
tuberculosis
Anambra State,
Nigeria;
questionnaires to
collect data from
include cough, weight
loss and
E-mail:godwsilln@yahoo.co.uk ;
medical doctors whose
daily
failure to thrive,
history of contact
Tel:
+2348033335694
routine included
attending to sick
with adult with smear
positive
Word Count: 3971
children in 34
selected
children
pulmonary tuberculosis,
and
outpatient clinics and
TB DOTS
radiographic
abnormalities
Chukwu JN, Ogbuabor
DC
centers in southeastern
Nigeria.
consistent with active
tuberculosis.
German Leprosy and
Tuberculosis Results : Approximately,
one
There was statistically
significant
Relief
Association,1Hill View, quarter (25.3% or 56 of 221) of
difference between the
ranking of
Enugu, Nigeria.
respondents worked in
Directly
weight loss and failure
to thrive by
Observed Treatment
Short course
doctors working in DOTS
clinics
Ogbonnaya LU
(DOTS) clinics, while
three
and their counterparts
in non DOTS
Department of Community
quarters (74.7% or 165 of 221)
clinics.
This study showed
a
Medicine, Ebonyi State
University, worked in non DOTS clinics.
decline in the
percentage of ranking
Abakaliki,
Nigeria.
Majority of the
respondents
in both DOTS and Non
DOTS
(69.7%) ranked chronic
persistent
respondents as they
moved from the
cough (1), 42.5 %
ranked weight
first to the
fifth.
loss and failure to
thrive (2),
another 27.7% ranked
weight loss
K E
Y
W O
R D S :
Childhood
and failure to thrive
(3), while
pulmonary tuberculosis,
Doctors,
17.6% and 21.7% ranked
History
Ranking, Diagnostic
features,
of contact with adult
index case
Directly observed
treatment short
and radiographic
abnormalities,
course (DOTS).
(4) and (5),
respectively.
Introduction
This has further
compounded the diagnostic
challenges of childhood
tuberculosis. Younger
Reduction of childhood
mortality is one of the
children are unable to
expectorate sputum for smear
Millennium Development
Goals (MDGs) by the
microscopic examination
and when they do it has
world community to be
achieved by the year 2015 .
1
been found to be
pauci-bacillary even in those who
have childhood
pulmonary tuberculosis
3
Morbidity and mortality
from childhood
. For
instance,
Zar
etal.
found that sputum
smear
tuberculosis have
increased due to the emergence of
microscopy was positive
in less than 10 to 15 % of
HIV/ TB co-morbidity
.
2
children
110
with probable
tuberculosis . Similarly, low culture
4
Than 3 years of age and
reported fatigue) could be
yields of 30 to 40%
have been reported in children
relied upon to make a
diagnosis of PTB in children ≥3
with probable
tuberculosis
4,5
.
while this was not
exactly the case with children < 3
years
17
. They observed that
the presence of a
Broncho-alveolar lavage
and nasopharyngeal
persistent, non
remitting cough together with
aspirates are
unavailable in resource poor TB
documented failure to
thrive still provided a fairly
endemic areas, are
expensive and give low yield . It
6
accurate
diagnosis.
is therefore difficult
to base child hood pulmonary
TB diagnosis on any
definitive reference or gold
They observed that the
use of well defined symptoms
standard
(bacteriological confirmation) .
7
as diagnostic tool,
even in resource limited settings,
may improve the chances
of diagnosing childhood
The diagnosis of
childhood tuberculosis in non-
pulmonary tuberculosis.
Fourie et al observed some
endemic areas is
usually based on the triad of history
clinical criteria
thought to be most relevant as
predictors of
tuberculosis in children . These criteria
18
of contact with an
adult index case, positive
tuberculin skin test
(TST), and suggestive signs on
include history of
contact with a case of tuberculosis,
chest radiograph. These
risk factors provide fairly
positive skin test,
persistent cough, low weight for
accurate diagnosis in
settings where exposure to
age, and unexplained/
prolonged fever. They noted
mycobacterium
tuberculosis is rare. However, in
that the criteria for
high prevalence setting include
endemic areas where
exposure to M.
tuberculosis is
case contact and skin
tests which were less important,
common; the accuracy of
the triad is reduced as
while low body weight,
prolonged fever and cough
exposure frequently
occurs outside the household , .
8 9
were more indicative of
tuberculosis.
Randomly selected
healthy children in endemic
areas were found to
have tested positive to TST .
10
This study, therefore,
intended to discover the
Thus limiting the
diagnostic value of TST, and
diagnostic features on
which medical doctors based
strengthening the
suggestion that clinical features
their diagnosis of
childhood PTB and how they
and chest radiograph
should be used for the diagnosis
ranked them in resource
poor and TB endemic
of tuberculosis in
children in endemic areas
11, 12
.
settings.
Various clinical
scoring systems have been
developed over the
years to improve the diagnosis of
childhood pulmonary
tuberculosis. However,
reviewers have
criticized them as being limited by a
lack of standard
symptom definitions and adequate
Subjects and Methods
validation
13,14
. World Health
Organisation (WHO)
recommended an approach
to diagnosis of
This cross sectional
descriptive study was conducted
tuberculosis in
children based on the use of a
among fully licensed
medical doctors whose practice
modified scoring system
for children under 15 years
routine included
providing clinical care services to
that includes chronic
cough (>2 weeks), fever, night
children in 34 selected
private and public health
sweats, failure to
thrive, anorexia, weight loss,
institutions in the
southeastern zone of Nigeria
(Abia, Anambra, Ebonyi,
Enugu, and Imo States).
history of contact with
adults with smear-positive
The 34 hospitals were
selected from over 181 health
pulmonary pulmonary
tuberculosis, no response to
facilities that
provided tuberculosis directly
standard broad-spectrum
antibiotic treatment, one or
observed treatment
short cut (TB-DOTS) services.
more sputum smear
positive for acid-fast bacilli,
culture positive
for Mycobacterium , and/or
The selected health
facilities were those that had
radiographic
abnormalities consistent with active TB
15
medical doctors in
their employment (e.g. teaching
.Ascore of ≥5 triggers
TB treatment initiation.
hospitals, specialist
hospitals, state general hospitals,
faith based or mission
hospitals and some private
According to Marais et
al, symptoms could offer
hospitals) and had both
children outpatient clinics
good diagnostic value
if they were well defined .
16
(Non DOTS clinics) and
TB -DOTS clinics, Two
They suggested that
pulmonary tuberculosis could
hundred and thirty
(230) consecutive doctors
be diagnosed in
HIV-uninfected children using a
working in the children
outpatient (Non DOTS
simple symptom-based
approach, particularly in
clinics) and TB- DOTS
clinics of the selected health
resource-limited
settings where current access to
facilities between
August and November 2011 and
antituberculosis
treatment was poor.
who consented were
recruited for the study and were
required to fill self
administered structured
In another study Marais
et al observed that 3 well-
questionnaire.
defined symptoms at
presentation (persistent, non
remitting cough of less
than 2 weeks' duration;
A list of WHO
recommended standard features of
objective weight loss
[documented failure to thrive]
tuberculosis was
provided and respondents were
of 3 months duration in
HIV-uninfected children less
111
asked to rank the
features as 1, 2, 3, 4, and 5 in
Respondents from
Anambra state were 36.7% or 81
descending order of
preference. Other questions
of 221, while 26.2% or
58 of 221 were from Abia
asked were number of
years of practice, area of
state, and 17.2% or 38
of 221 were from Imo state.
specialization, location
of practice, minimum
Others included 15.4%
or 34 of 221 from Enugu state
number of children
consulted in a typical day, and
and 4.5% or 10 of 221
were from Ebonyi state.
indication as to
working in a TB-DOTS centre. Two
Majority of the
respondents were in General practice
hundred and twenty
three completed questionnaires
(56% or 124 of 221),
while 37.1% or 82 of 221 were
were collected by five
trained research assistants and
in paediatrics and 6.8%
or 15 of 221 were in Family
the data were analysed
using SPSS for windows
practice.
version 15.
There is a male: female
sex-ratio of 3.4:1.0. The
Descriptive statistics
such as means, frequency
mean age of the males
(mean ± SD) 40.6 ± 10.43
distribution, and
standard deviation were used to
years, was
statistically significantly older than the
describe the findings.
The level of statistical
females 25.9 ± 8.2
years (t = 2.938, P = 0.004), while
significance was set at
p= 0.05 (95% confidence
80% of the females were
less than 40 years of age,
interval)
only 56% of the males
were in that category.
Approximately, one
quarter (25.3%) of respondents
worked in DOTS
facilities, while about three
quarters worked in non
DOTS clinics
Result
Table 1 shows that
chronic persistent cough was
ranked first by 69.7%,
followed by weight loss or
A total of 230
questionnaires were distributed to the
failure to thrive rated
second by 42.5%.
subject, and 223 were
returned. Two hundred and
twenty one
questionnaires were analyzed after
Acomparison of the
ranking of respondents in DOTS
rejecting two that were
found to be incomplete.
and non DOTS centers
showed the following;
Table 1: The distribution of Symptoms
of TB on a 5 level ranking scale by
the doctors
Diagnostic features
Ranking (n %)
1
2
3
4
5
Chronic cough
154(69.7)
26(11.8)
9(4.1)
9(4.1)
6(2.7)
Weight loss/failure to
thrive
27(12.2)
94(42.5)
60(27.1)
28(12.7)
17(7.7)
Fever
20 (9.0)
48(21.7)
33(14.9)
27(12.2)
15(6.8)
Radiographic
abnormalities
4(1.8)
8(3.6)
21(9.5)
24(10.9)
48(21.7)
consistent with active
TB
Hx of contact with
adults
3(1.4)
20(9.0)
46(20.8)
39(17.6)
25(11.3)
with smear positive
PTB
Night sweats
1(.5)
3(1.4)
10(4.5)
19(8.6)
16(17.2)
Sputum smear positive
for
3(1.4)
4(1.8)
6(2.7)
17(7.7)
13(5.9)
AFB
TB skin test
2(0.9)
-
2(0.96)
10(4.5)
14(6.3)
Others
7(3.2)
16 (7.3)
31 (14.2)
42 (19.1)
37 (16.8)
Total
221(100)
219(99.1)
218(98.6)
215(97.3)
192(86.9)
112
Table 2 : Ranking of five most important
diagnostic features by respondents in DOTS and Non DOTS
centers
TB/DOT
Ranking n (%)
1
2
3
4
5
Total
P-value
Cough
Yes
36 (64.3)
7 (12.5)
3 (5.4)
4 (7.1)
2 (3.6)
56
0.62
No
118 (71.5)
18 (10.9)
6 (3.6)
5 (3.0)
4 (2.4)
165
Weight loss/ failure to thrive
Yes
6 (10.7)
27 (48.2)
14 (25.0)
2 (3.6)
7 (12.5)
56
0.07
No
21 (7.86)
67 (40.6)
42 (25.5)
19 (11.5)
6 (3.6)
165
Fever
Yes
4 (7.1)
6 (10.7)
9 (16.1)
5 (8.9)
4 (7.1)
56
0.51
No
16 (9.7)
42 (25.5)
24 (14.6)
22 (13.3)
11 (6.7)
165
History of contact with adult TB cases
Yes
2 (3.6)
4 (7.1)
11 (19.6)
8 (14.3)
6 (10.7)
56
0.48
No
1 (0.6)
16 (9.7)
35 (21.2)
31 (18.8)
19 (11.5)
165
Radiographic abnormalities
Yes
0 (0.0)
2 (3.6)
6 (10.7)
6 (10.7)
11 (19.6)
56
0.82
No
4 (2.4)
6 (3.6)
15 (9.1)
18 (10.9)
37 (22.4)
165
First Ranking: Ahigher
percentage of
respondents in
non DOTS clinics ranked
chronic cough (71.5%) as
Modified scoring system
by WHO, however, this
first compared to
respondents in DOTS clinics
study went further to
rank the diagnostic features in
(64.3%). This
difference was not statistically
accordance with their
perceived preference in the
significant (p. value
> 0.05)
diagnosis of child hood
pulmonary TB. The possible
implication of these
findings was that such common
Second Ranking: Alower
percentage (40.6%)
of Non
symptoms as chest pain,
haemoptysis, dyspnoea,
DOTS respondents ranked
weight
breathlessness were not
perceived as prime
loss/ failure to thrive
second compared to the higher
symptoms in childhood
pulmonary tuberculosis by
percentage of
respondents in DOTS clinics (48.2%).
respondents. Although,
no study ranking symptoms
This difference was
statistically significant (p. value
could be found during
literature review, Fourie et
< 0.05)
al18 observed that five
clinical criteria including
history of contact with
a case of tuberculosis, positive
Third
Ranking:
Respondents from non
DOTS
skin test, persistent
cough, low body weight for age
(14.6%) clinics ranked
Fever as third compared to
and unexplained
/prolonged fever were most relevant
DOTS clinics
respondents (16.1%) . The difference
as predictors of
pulmonary TB in children.
was not statistically
significant (p. value > 0.05)
They found that low
body weight, prolonged fever
Fourth Ranking: History
of contact
with adults
with
and cough were more
indicative of tuberculosis in
smear positive
pulmonary tuberculosis was ranked
children. The findings
in this study were similar to
as fourth by
respondents, who worked in non DOTS
those of Fourier et al,
18 except that the positive
clinics (18.8%),
compared to those in DOTS clinics
tuberculin skin test
low rating was probably due to
(14.3%). The difference
was not statistically
perceived poor yield
caused by the presence of non-
significant (p. value
> 0.05)
tuberculous
mycobacteria species, routine BCG
vaccine to children and
poor reaction to tuberculo-
Fifth
Ranking:
Approximately, one
quarter of
protein in malnourished
children in this setting. The
respondents in non DOTS
clinics (22.4%) ranked
finding in this study
is relevant to the diagnosis of
Radiographic
abnormalities fifth compared with one
pulmonary tuberculosis
in resource poor and TB
fifth (19.6%) of
respondents in DOTS clinics. The
endemic setting where
the TB case finding has
difference was not
statistically significant (p. value >
become
problematic.
0.05)
The pattern of ranking
of symptoms by those
working in DOTS centre
was statistically significant
from those working in
non DOTS centre in the
Discussion
ranking of weight loss/
failure to thrive (p. value <
0.05). This pattern
tended to suggest that weight loss
The ranking of the
diagnostic features observed in
and failure to thrive
was rated higher in the diagnosis
this study agree with
the recommended approach of
of child hood pulmonary
tuberculosis
113
By doctors working in
DOTS clinics than their
Contributors
counterparts from the
non DOTS clinics. It is
probably because weight
loss and failure to thrive
Nnaji GA Research
Coordinator, development of the
have become a regular
feature observed by doctors in
research topic and
proposal, conducting
the DOTS clinics during
the diagnosis of childhood
literature review and
leading the report
pulmonary TB. Weight
gain was usually, seen to be
writing
the first indication of
recovery during treatment. This
Chukwu JN - Theoretical
conceptual phase
finding underlines the
perceived importance of
development, reviewing
the proposal
weight loss in the
diagnosis of childhood pulmonary
and the draft copy of
the manuscript,
tuberculosis and the
need for weight monitoring in
assisting in securing
funding.
detecting early
childhood pulmonary TB. Similar
Ezechukwu CC -Providing
technical advice,
observation was made by
Marais et al who found that
reviewing the draft
copy of the
the combination of
cough and weight loss was more
manuscript, Assisting
in the training of
significant than other
individual symptoms such as
Research
assistants.
dyspnoea, chest pain,
haemoptysis, anorexia,
Ugochukwu EF-
contribution to the discussion,
fatigue, fever, night
sweats .
19
reviewing and rewriting
of the report
and the manuscript for
consistency.
This study showed a
decline in the percentage of
Ogbonnaya L
Reviewing the
proposal,
ranking in both DOTS
and Non DOTS respondents
contributions to the
theoretical
conceptual phase of the
study
As they moved from the
first to the fifth. This decline
Ogbuabor DC -
contribution to the research
probably indicated that
there was a falling
conceptual theoretical
phase and review
confidence among the
doctors as the ranking moved
of the draft
report.
down from chronic
persistent cough to finding
Conflict of Interest: None
radiographic
abnormalities in the lung fields. The
No
restricting contract
implication is that the
first three features represented
the mostly rated
clinical approach to childhood
This research was
sponsored by German Leprosy &
pulmonary tuberculosis
and could be used to
Tuberculosis Relief
Association (GLRA) in
improve the clinical
case findings of childhood
collaboration with
Global Fund for AIDS/HIV,
pulmonary tuberculosis
if more doctors attending to
Tuberculosis and
Malaria (GFATM).
children are trained on
the use of this approach.
This study has shown
that the majority of doctors in
the study area used the
recommended diagnostic
approach in the
diagnosis of childhood pulmonary
TB. It has revealed the
need for improvement in the
Acknowledgement
diagnostic skills,
possibly through training and
regular workshops for
all doctors in the care of sick
We acknowledge
Professor E.A Bamgboye and the
children. The authors
believe that an improved case
staff of FOLBAM who did
data processing and
finding of child hood
tuberculosis would lead to
analysis.
better TB control in
the study areas.
Conclusion
The five most important
diagnostic features on
which medical doctors
based their diagnosis of
childhood pulmonary
tuberculosis include (in
descending order);
chronic persistent cough, weight
loss/ failure to
thrive, history of contact with adult
with smear positive
pulmonary tuberculosis, and
radiographic
abnormalities consistent with active
tuberculosis. The three
prime diagnostic features
were chronic persistent
cough, weight loss/failure
tothrive and fever. The
respondents working in TB-
DOTS and their
colleagues in the Non DOTS centers
differed significantly
in their rating of weight loss/
failure to
thrive.
114
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