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
Reference
8. Schaaf HS, Michaelis IA,
1. UN Millennium Project.
15.WHO. Supporting the
Richardson M et al. Adult-to-
Who's got the power?
achievement of the
child transmission of
Transforming health systems
Millennium Development
tuberculosis: household or
for women and children.
Goals in Nigeria, WHO
community contact? Int J
Summary version of the
Annual Report, 2006.
Tuberc Lung Dis 2003; 7:
report of the Task Force on
426-431.
16. Marais BJ, Gie RP, Obihara
Child health and maternal
CC, Hesseling AC, Schaaf
health 2005. New York, USA.
9. Verver S, Warren RM, Munch
HS, Beyers N. Well defined
2. Geoghagen M, Farr JA,
Z et al. Proportion of
symptoms are of value in the
Hambleton I, Pierre R,
tuberculosis transmission that
diagnosis of childhood
Christie CD. Tuberculosis
takes place in households in a
pulmonary tuberculosis.
and HIV co-infections in
high-incidence area. Lancet
Arch Dis Child. 2005b; 90
Jamaican children. West
2004; 363: 212-214.
(11): 1162-5.
Indian Med J. 2004 Oct;
10. Obihara CC, Kimpen JL, Gie
17 Marais BJ, Gie RP,
.
53(5): 339-45
RP et al. Mycobacterium
Hesseling AC et al. A refined
3. Marais BJ, Gie RP, Hesseling
tuberculosis infection may
symptom-based approach to
AC, Beyers N. Adult-type
protect against allergy in a
diagnose pulmonary
pulmonary tuberculosis in
tuberculosis endemic area.
tuberculosis in children.
children aged 10-14 years.
Clin Exp Allergy 2006; 36:
Pediatrics. 2006; 118
Pediatr Infect Dis J 2005;
70-76.
(5):e1350-9.
24: 743-744.
11. Weismuller MM, Graham SM,
18. Fourie PB, Becker PJ,
4. Zar HJ, Hanslo D, Apolles P,
Claesens NJ, Meijnen S,
Festenstein F et al.
Swingler G, Hussey G.
Salaniponi FM, Harries AD.
Procedures for developing a
Induced sputum versus
Diagnosis of childhood
simple scoring method based
gastric lavage for
tuberculosis in Malawi: an
on unsophisticated criteria
microbiological confirmation
audit of hospital practice. Int J
for screening children for
confirmation of pulmonary
Tuberc Lung Dis 2002; 6:
tuberculosis. Int J Tuberc
tuberculosis in infants and
432-438.
Lung Dis. 1998 Feb; 2 (2):
young children: a
116-23.
12. Enarson PM, Enarson DA,
prospective study. Lancet
19 . Marais BJ, Obihara CC, Gie
Gie RP. Management of
2005; 365:130-134.
RP et al. The prevalence of
tuberculosis in children in
symptoms associated with
5. Starke JR. Pediatric
low-income countries. Int J
pulmonary tuberculosis in
tuberculosis: time for a new
Tuberc Lung Dis 2005; 9:
randomly selected children
approach. Tuberculosis
1299-1304.
2003; 83: 208-212.
from a high-burden
13. Hesseling AC, Schaaf HS,
community. Arch Dis Child
6. Singh M, Moosa NVA, Kumar
Gie RP, Starke JR, Beyers N.
2005; 90: 1166-1170.
L, Sharma M. Role of gastric
A critical review of
lavage and bronchoalveolar
diagnostic approaches used in
lavage in the bacteriological
the diagnosis of childhood
diagnosis of childhood
tuberculosis. Int J Tuberc
pulmonary tuberculosis.
Lung Dis 2002; 6: 1038-
Indian
Pediatrics
2000;
1045.
37:947-951.
14. Edwards DJ, Kitetele F, Van
7. Eamranond P, Jaramillo E.
Rie A. Agreement between
(2001) Tuberculosis in
clinical scoring systems used
children: reassessing the
for the diagnosis of pediatric
need for improved diagnosis
tuberculosis in the HIV era.
in global control strategies.
Int. J Tuberc Lung Dis. 2007;
Int J Tuberc Lung Dis;
11 (3): 263-9
5:594-603 .