The Quest for a Child-Friendly Tuberculosis Triage Test.
The Quest for a Child-Friendly Tuberculosis Triage Test.
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寻求适合儿童的结核病分类测试。
DOI：
10.1093/jpids/piac020
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发表时间：
2022
影响因子：
3.2
通讯作者：
Thomas,TaniaA
中科院分区：
文献类型：
--
作者：
Otoupalova,Eva;Mmbaga,BlandinaT;Thomas,TaniaA
缺乏对结核病儿童的诊断检测是结核病连续护理中最薄弱的环节之一。在全球范围内，确认结核病最广泛使用的检测方法包括获得呼吸道标本，用于结核分枝杆菌复合群的微生物检测。虽然仍然依赖于涂片显微镜检查，但已经做出了巨大努力来增加世界卫生组织（WHO）批准的快速分子方法（如GeneXpert MTB/RIF检测）的使用。使用此类检测作为一线检测的建议扩展到儿科人群;然而，重要的是要认识到限制其有用性的相关逻辑障碍和性能缺陷。在结核病高流行率的环境中，由于成本和基础设施的限制等原因，较低级别的卫生设施通常无法提供快速分子检测[1]。在可获得的情况下，微生物检测降低了儿童的产量，儿童疾病的特点是分枝杆菌负荷较低。此外，获得高质量的呼吸道样本进行测试可能需要半侵入性技术，这可能不是在所有临床环境中都可以管理的。世卫组织已通过一项战略，到2035年实现消除结核病的目标。2019冠状病毒病大流行导致结核病发现率大幅下降，导致结核病相关死亡率上升，这一雄心勃勃的目标因此偏离了轨道。我们现在比以往任何时候都更需要重新思考诊断策略，以抓住数百万未被发现的结核病患者。修订后的方法必须确保目标人群包括那些目前诊断服务不足的人群，即那些患有少杆菌病、肺外疾病和无法咳出痰的人群。结核病分诊试验是一种有希望的策略，可以提高病例发现率，特别是在高患病率环境中。分诊测试是非确证性测试，设计用于具有与TB和/或显著TB风险因素相容的症状的人中的多步骤算法中，以识别需要进一步诊断评估的人。特征应包括现场友好设计，满足对基础设施或技术实验室技能要求最低的较低级别医疗保健环境，通常包括低成本的即时护理平台，理想情况下使用非呼吸道标本。它们应该作为结核病的“排除”测试，具有高灵敏度（最佳90%-95%）和强阴性预测值，从而降低需要转诊和/或确认测试的人群比例[2]。一
The lack of diagnostic assays for children with tuberculosis (TB) represents one of the weakest links in the TB continuum of care. Globally, the most widely used tests to confirm TB involve obtaining a respiratory specimen for the microbiologic detection of Mycobacterium tuberculosis complex. While there is still reliance on smear microscopy, tremendous efforts have been made to increase usage of World Health Organization (WHO)-approved rapid molecular methods such as the GeneXpert MTB/RIF assay. Recommendations for using such assays as a first-line test extend to pediatric populations; however, it is important to recognize the associated logistic barriers and performance pitfalls that limit their usefulness. In settings with a high prevalence of TB, rapid molecular tests are not commonly available at lower-level health facilities due to cost and infrastructure limitations, among others [1]. When accessible, microbiologic assays have reduced yield among children, in whom disease is characterized by a lower mycobacterial load. Furthermore, obtaining a good quality respiratory specimen for testing could require semi-invasive techniques which may not be manageable in all clinical settings. The WHO has adopted a strategy to achieve TB elimination targets by 2035. The ambitious goals have been derailed by the COVID-19 pandemic as marked by substantial reductions in TB detection and a resultant increase in TB-related mortality. Now more than ever we must rethink the diagnostic strategy in order to capture the millions of people with TB who go undetected. A revised approach must ensure that the target population includes those who are underserved by current diagnostics, namely those with paucibacillary disease, extrapulmonary disease, and those who are unable to expectorate sputum.Triage tests for TB serve as a promising strategy to work toward improved case detection, especially in high prevalence settings. Triage tests are nonconfirmatory tests designed for use within a multi-step algorithm among people with symptoms compatible with TB and/or significant TB risk factors to identify those in need of further diagnostic evaluation. Characteristics should incorporate a field-friendly design, catering to lower-level healthcare settings with minimal requirements for infrastructure or technical laboratory skills, often including point-of-care platforms with low cost, and ideally using non-respiratory specimens. They should serve as a “rule out” test for TB with high sensitivity (optimally 90%-95%) and strong negative predictive value, thereby decreasing the proportion of people requiring referral and/or confirmatory testing [2]. One