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PI DSPJ OURNAL Vol18,No.2 Jul y -December 2017 EDI TORI AL PEDI ATRI C I NFECTI OUS DI SEASE SOCI ETY OF THE PHI LI PPI NES SecondSt op Ar l eneDy Co,MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ORI GI NALARTI CLES Cl i ni calPr of i l eandTr eat mentOut comesofChi l dhood Ext r apul monar yTuber cul osi si naChi l dr en’ sMedi calCent er Mel odyO.Ki at ,MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315 AMet aAnal ysi sonGeneXper tUsi ngSt oolSampl esi nDi agnosi ng Pedi at r i cPul monar yTuber cul osi s Ot hel l aMar yAnnS.Cac ay or i n,MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1622 ARet r ospect i veSt udyonSensi t i vi t y,Speci f i ci t y,Negat i ve Pr edi ct i veVal ue,Posi t i vePr edi ct i veVal ueofTBPCRVer susTB Cul t ur ei nDi agnosi ngTuber cul osi si nFi l i pi noChi l dr enAged3 Mont hst o 18Year sataTer t i ar yCar eCent er J es anel B.Anc het a,MD,Rober tDenni sJ .Gar c i a,MD . . . . . . . . . . . . . . . . . . 2335 Associ at i onofFact or swi t hSuccessf ulTr eat mentOut comeof Chi l dhoodTuber cul osi si nBar angayCommonweal t h,Quez onCi t y: A2YearRet r ospect i veSt udy Chr i s t i neN.Pec s on,MD,AnaLi z aH.Dur an,MD. . . . . . . . . . . . . . . . . . . . . . . . . . . 3653 CASEREPORTS Pedi at r i cSel l aSupr asel l arTuber cul arAbscess:ACaseRepor tand Li t er at ur eRevi ew Vi r gi LeaCl audi neC.Es qui v el Aguas ,MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5461 Hansen’ sDi seasei nanAdol escent :ACaseRepor t Pat r i c i aCar l aN.As unc i on,MD,RhaneeLot aSal v ado,MD. . . . . . . . . . . . . 6268 Vol . 18 No. 2 Jul y -December 2017 Pediatric Infectious Diseases Society of the Philippines Journal Vol 18 No. 2 pp. 36-53 July-December 2017 Pecson CN and Duran AL. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City: A 2-Year Retrospective Study ORIGINAL ARTICLE Christine N. Pecson , MD* Ana Liza H. Duran, MD* *East Avenue Medical Center, Philippines Correspondence: Dr. Christine N. Pecson; Email: [email protected] The authors declare that the data presented are original material and has not been previously published, accepted or considered for publication elsewhere; that the manuscript has been approved by all authors, and all authors have met the requirements for authorship. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City, Philippines: A Two-Year Retrospective Study ABSTRACT Background: Tuberculosis remains a public health concern worldwide. Reports on the association of factors of childhood tuberculosis with treatment outcome are limited. Objectives: To determine the epidemiology and association of factors of childhood tuberculosis with successful treatment outcome in some of the barangays of Quezon City. Methodology: This is a retrospective cohort study done at Barangay Commonwealth Health Centers including children 0-14 years old with tuberculosis registered and treated from January 1, 2013 to July 15, 2015. Socio-demographic and clinical data were obtained. Patient profile data, treatment cards and medical records were the data sources. Results: A total of 267 new cases of childhood TB were analyzed. The treatment success rate was 98% (97% completed treatment, 1% cured). The rate of poor treatment outcome including default cases was 2%. There were no reported deaths or treatment failure. On univariate analysis, patients with weight gain (p=0.001) had an odds ratio of 8.085 (95% CI:1.310-49.900) to have a successful treatment outcome. On multivariate analysis, weight gain was significantly associated with treatment success (p=0.042; OR=12.5, 95% CI: 1.091, 143.244). None of the socio-economic and clinical factors studied was associated with successful treatment outcome. Conclusion: Weight gain is a factor of a successful treatment in childhood tuberculosis. Children who gained weight after treatment are more likely to have a successful treatment outcome. KEYWORDS: Childhood tuberculosis, treatment outcome, weight gain 36 Pediatric Infectious Diseases Society of the Philippines Journal Vol 18 No. 2 pp. 36-53 July-December 2017 Pecson CN and Duran AL. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City: A 2-Year Retrospective Study INTRODUCTION Tuberculosis (TB) continues to be a public health concern not only in the Philippines but throughout every region in the world. It ranks as the world’s second leading cause of death from a communicable disease.1 As stated in the Global Tuberculosis Report 2014 of the World Health Organization (WHO), an estimated 9.0 million people developed TB and 1.5 million died from the disease in 2013. Childhood TB contributes 6%, equivalent to 550,000 of the total new cases and 7%, equivalent to 80,000 of the total TB deaths from HIV-negative people in the same year. The Philippines remains one of the 22 highest TB-burden countries worldwide and has one of the highest problems of multidrug resistant TB.2 TB in children in our country forms part of the TB burden. The Philippine Health Statistics of 2010 of the Department of Health shows that TB in all forms tops the list of the leading cause of mortality among the immunizable diseases in 0-14 years old.3 TB is a significant cause of morbidity and mortality among children 4,5,6 and yet there are limited data on the epidemiology of childhood tuberculosis.6 Few studies from Asia have also been published.7 The World Health Organization has recently expressed the urgent need to address the lack of epidemiological data on pediatric tuberculosis in high-burden countries.6 A surveillance report on TB profile of the Philippines from 2003 to 2011 stated that 1% of the new cases were children 0 – 14 years old.2 The proportion of their treatment outcome and the factors associated with it, however, were not emphasized. In a study on the treatment outcomes of childhood TB in Thailand, 200 (72%) out of the 279 (2% of the national burden) cases completed treatment or were cured; 17(6%) died, 3(1%) failed, 39(14%) defaulted and 20(7%) transferred out.7 A 5-year retrospective study in Addis Ababa on TB revealed that the percentage of children with TB was 6.6%. Treatment outcomes were documented for 95.2% of children with treatment success rate of 85.5%. Mortality rate was 3.3% and defaulting was 3.8%.8 The data collected in a review of pediatric TB cases in Taiwan from 2002 to 2009 showed that a relatively small number of children ranging from 0.72% to 1.24% were diagnosed with TB.9 The nationwide study of TB in Malawi revealed that 11.9% were children from the 22,982 cases registered. Death rate was high at 17%. Forty five percent completed treatment; 13% defaulted and 21% with unknown outcome.10 The above studies showed that treatment outcomes and incidence of childhood TB vary from one country or region to another even amongst endemic areas. Grange, et al discussed the changing epidemiology of tuberculosis which may result from a complex interplay between social, political, economic, genetic, cultural and environmental factors and the possibility of natural selection of an immune population.11 As presented by Sivanandan, et al, the factors associated with treatment failure in childhood tuberculosis included AFB positivity at diagnosis, non-receipt of Bacille CalmetteGuerin (BCG) vaccination and 12 extrapulmonary tuberculosis (EPTB). The study done in Southern Ethiopia indicated that males, extremes of ages and patients on retreatment were those with poor outcome; smear negative patients had the lowest rate of successful treatment outcome.13 Marais, et al pointed out in an article that the determinants of the burden of childhood TB could be extrapolated from community exposure which includes 37 Pediatric Infectious Diseases Society of the Philippines Journal Vol 18 No. 2 pp. 36-53 July-December 2017 Pecson CN and Duran AL. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City: A 2-Year Retrospective Study number and duration of infectiousness and crowding; and community vulnerability which comprises immune compromise, immune stimulation and local defenses.14 Aside from crowding the other risk factors on childhood TB were identified as parental education and annual household income.6 Successful treatment outcome in children was higher in older age group,9,11,15 smear-positive and HIVnegative patients.11,16 Childhood TB is a neglected aspect of the TB epidemic because it is usually smear-negative and considered to contribute little to the propagation of the disease.17,18,19 However, pediatric cases are important because they provide valuable epidemiologic perspective since they reflect on-going transmission within communities.20 This study determined and investigated the successful treatment outcomes of TB in children and identified the factors affecting them. The results may serve as monitoring tool and may contribute in the modification of existing guidelines, strategies or policies in the management of TB in children to improve the outcome particularly in the community level. This study aimed to determine the association of factors of childhood tuberculosis with successful treatment outcome in Barangay Commonwealth, Quezon City from January 2013 to July 2015. We also determined the sociodemographic, anthropometric and clinical profile of childhood TB patients and the prevalence rates of childhood TB with successful and poor treatment outcomes. The association of socio-demographic, anthropometric and clinical characteristics of childhood TB with successful treatment outcome was studied. METHODOLOGY This is a retrospective cohort study that utilized odds ratio to determine association between various sociodemographic, anthropometric and clinical data and treatment outcome of children with TB. The study was conducted in three health centers of Barangay Commonwealth, the biggest barangay in terms of population size, accounting for 5.6 percent (120,569) of the total population of Quezon City, Philippines 21 and located in the second district of the city which is administratively divided into seven units.22 The three health centers namely: Commonwealth Health Center (HC), Dona Nicasia HC and National Government Center (NGC) HC are also designated Directly Observed Therapy Short Course (DOTS) facilities under the management and supervision of the Quezon City Health Department (QCHD). The patients included in the study were children aged zero to fourteen years old diagnosed with tuberculosis based on the NTP standard guidelines and treated from January 1, 2013 to July 15, 2015. Sample Size All cases of childhood tuberculosis equivalent to 267 were included in the study. Inclusion and Exclusion criteria Patients aged zero to fourteen years old diagnosed with tuberculosis and treated in the above-mentioned centers were included. All patients transferred out were excluded from the study because the outcomes of treatment were indeterminate. Operational Definition of terms (as defined in the Manual of Procedures of the National Tuberculosis Control Program 5th ed., 2014 DOH)23 38 Pediatric Infectious Diseases Society of the Philippines Journal Vol 18 No. 2 pp. 36-53 July-December 2017 Pecson CN and Duran AL. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City: A 2-Year Retrospective Study Children – individuals with age ranging from 0 to 14 years old. Treatment outcome – the condition of the patient after the prescribed treatment period: Completed treatment – anti-tuberculous drugs taken and completed during the prescribed course. Cured – the condition of the patient in which he/she has initially a smear -positive sputum microscopy that turned out to be negative in the last month of treatment and on at least one previous occasion in the continuation phase. Relapse patient – those previously treated patients for TB and declared cured or treatment completed at the end of the recent course of treatment and are now TB symptomatic with any one of the following: progressive deterioration or worsening of chest radiograph findings, smear positive or culture positive.24 Failed – an initially smear positive who remains or becomes smear positive on the 5th month of treatment or a newly diagnosed TB patient whose TB symptoms persisted and has failed to gain weight after six months of treatment.24 Defaulted – one who has interrupted treatment for two months; lost to follow up. Retreatment – previously treated case of TB who is started on a treatment regimen after previous treatment has failed or a patient treated for TB who returns to treatment having defaulted; or a patient who was previously declared cured or treatment completed and is diagnosed with bacteriologically positive T5.25 Successful treatment outcome – refers to patients considered as cured or completed treatment; good treatment outcome; treatment success. Poor treatment outcome – refers to patients considered to have defaulted, failed in the treatment and died during the treatment period; unsuccessful treatment. Smear positive PTB – PTB diagnosed through DSSM with two or more initial sputum smear examination for acid-fast bacilli; or one sputum smear examination positive for acid-fast bacilli plus chest radiograph abnormalities consistent with active TB as determined by a clinician; or one sputum smear examination positive for acid-fast bacilli plus sputum culture positive for M. tuberculosis; bacteriologically-confirmed case of TB.24 Smear negative PTB – PTB diagnosed through DSSM in 10-14 years old or younger with at least three smear-negative for acid-fast bacilli; and radiologic abnormalities consistent with active pulmonary TB; and no response to a course of broad spectrum antibiotics; and decision by a physician and/or TB Diagnostic Committee to treat the patient with a full course of anti-TB chemotherapy; or a negative DSSM or PTB diagnosed through other diagnostic tests other than DSSM in 0-9 years old who cannot expectorate with any three of the following: TB symptomatic, positive exposure to an adult TB patient, positive tuberculin skin test, abnormal chest radiograph suggestive of TB, laboratory findings suggestive or indicative of TB; clinically-diagnosed case of TB.24 Poverty threshold – the minimum income required for a family/individual to meet the basic food and non-food requirements which is PhP 8,778.00 monthly for a family of five.26,27 Directly observed treatment short course (DOTS) – a treatment strategy wherein a TB patient takes the anti-TB drugs in the presence of a caregiver whether he be a doctor, a nurse, a midwife, a community health worker or any volunteer who stands as treatment partner of the patient. 39 Pediatric Infectious Diseases Society of the Philippines Journal Vol 18 No. 2 pp. 36-53 July-December 2017 Pecson CN and Duran AL. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City: A 2-Year Retrospective Study Malnutrition – undernutrition in children which is manifested as underweight, wasted or stunted based on the Preventive Pediatric Health Care Handbook 201428 as follows: Wasted – children with body mass index (BMI) for age z-score of below -2 to below -3 and weight for length/ height z-score of below -2 to below -3. Stunted – children with height for age zscore below -2 and below -3. Underweight – children with weight for age z-score of below -2 to below -3. Data and information were extracted from the National Tuberculosis Program (NTP) TB registry, treatment cards and the health center patient profile and medical records. The following data were collected: socio-demographic such as age, sex, educational attainment of parents, employment status and occupation of parents, family income, and family size; anthropometric data: weight, BMI and height; and clinical information as to the classification of TB cases, category of patients, close TB contact, BCG vaccination, Tuberculin Skin Test (TST), chest radiograph findings, co-morbid conditions, exposure to cigarette smoke and treatment outcomes. Pre-treatment and post treatment weight were taken to determine the presence of weight gain, average weight gain and percentage of weight gain from baseline. Post treatment height was unavailable; hence, post treatment BMI was not calculated. The presence of malnutrition in every patient was determined by getting the height/length for age, BMI for age, weight for age, and weight for height/length. Zscores of the anthropometric record of each patient were taken using the WHO Zscore charts. Data from the treatment cards were rechecked in the TB registry. Missing information on the patient profile and medical records were verified by the community health workers who stood as treatment partners of the patients. Hence, the TB registration number, the names, addresses and telephone numbers were initially gathered for this purpose but disregarded in the final tally of data prior to analysis to ensure confidentiality. Data were listed in a data extraction form and saved using EXCEL Data from all evaluable subjects who satisfy the inclusion/exclusion criteria were included in the analysis. Missing values were not replaced or estimated during the statistical analysis of outcome variables. Summary statistics were presented in tables and reported as n (%). Column percentages were computed relative to total data excluding missing values. Checks for homogeneity of sample population was done. Yates’ chi-square test was used to compare proportions. Univariate analysis was performed to determine independent significant associations of sociodemographic, anthropometric and clinical characteristics with success of treatment outcome. Significant variables from the univariate analysis were included in the multivariate logistic regression analysis to determine significant associations considering effects of other independent characteristics. Odds-ratios and 95% confidence intervals were estimated. Statistical significance was based on p-values ≤ 0.05. Statistical Package for the Social Sciences version 20 (SPSS v20) was used in data processing and analysis. ETHICAL CONSIDERATIONS A waiver of consent for the conduct of this study was given by the East Avenue Medical Center Institutional Ethics Review Board (EAMC IERB). An approval from the QCHD was obtained prior to the initiation of the study. 40 Pediatric Infectious Diseases Society of the Philippines Journal Vol 18 No. 2 pp. 36-53 July-December 2017 Pecson CN and Duran AL. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City: A 2-Year Retrospective Study RESULTS A. Socio-demographic, Anthropometric and Clinical Profile Data from 267 eligible subjects were included in the analysis. Most of the children were 4 years or younger with majority of the parents either finished grade school or high school, most had both or either parent employed and belonged to families with 2-5 members Sociodemographic characteristics are summarized in Table 1. Table 1. Socio-demographic Profile of Children with TB in Barangay Commonwealth, Quezon City, 2013 – 2015 The median weights of cured patients before and after treatment were 37kg and 40kg, respectively. Patients who completed treatment and defaulted both had a median weight of 14kg prior to treatment. The median weight after treatment among those with complete treatment was 15kg. No weight change was seen among those who defaulted. The BMI of patients with successful treatment outcome and poor treatment outcome was comparable prior to treatment. Among those who completed treatment, 50 (50/262) were stunted (Z-score below 2 to Z-score below -3) and 64 (64/262) were wasted (Z-score below -2 to Z-score below -3). Among those with poor treatment outcome, only 1 (1/5) was wasted. All cured patients had gained weight with a median percentage of 7.53% from baseline. Eighty four percent among those who completed treatment gained weight of 5.71% from baseline. Two patients who defaulted had a weight gain of 4.16%. Anthropometric characteristics are summarized in Tables 2 and 3. Table 2. Anthropometric Profile of Children with TB in Barangay Commonwealth, Quezon City, 2013 – 2015 Table 3. Anthropometric Data After Treatment of Children with TB in Barangay Commonwealth, Quezon City, 2013 – 2015 41 Pediatric Infectious Diseases Society of the Philippines Journal Vol 18 No. 2 pp. 36-53 July-December 2017 Pecson CN and Duran AL. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City: A 2-Year Retrospective Study All children were new cases of childhood tuberculosis and classified as pulmonary TB. Of the 267 cases, two children had both pulmonary and extrapulmonary types of TB. One had scrofula and the other, TB peritonitis. There were no cases of extrapulmonary TB alone. Two hundred sixty-four (99%) are smear-negative or clinically diagnosed TB. Comparable results were seen in children exposed (126/262, successful treatment; 3/5, poor treatment) and not exposed (109/262, successful treatment; 2/5, poor treatment) to a known source case of TB. Majority received BCG vaccination and most of the children (163/262, successful treatment; 4/5, poor treatment) had a positive skin test or TST size of equal to or more than 10mm. Most common comorbidity reported was malnutrition (3/3, cured; 108/262, completed; 1/5, defaulted). Clinical characteristics are summarized in Table 4. Table 4. Clinical Profile of Children with TB in Barangay Commonwealth, Quezon City, 2013 – 2015 Successful Treatment Outcome Cured Completed n=3 n = 259 Poor Treatment Outcome Defaulted n=5 Total n = 267 p-value Category of Patients, n (%) New 3 (100%) 259 (100%) 5 (100%) 267 (100%) – Classification of TB, n (%) PTB Smear +/ BCª PTB Smear -/ CDªª 3 (100%) – 259 (100%) 5 (100%) 3 (1%) 264 (99%) – Close TB contact, n (%) Negative Positive 3 (100%) – 106 (41%) 126 (49%) 2 (40%) 3 (60%) 111 (42%) 129 (48%) 0.199 BCG Vaccination, n (%) Positive Negative 2 (67%) 1 (33%) 240 (95%) 11 (4%) 5 (100%) – 247 (95%) 12 (5%) 0.000* – 51 (24%) 163 (76%) 1 (20%) 4 (80%) 52 (24%) 167 (76%) 0.000* Chest X-ray, n (%) Without findings With findings 3 (100%) – 121 (47%) 138 (53%) 4 (80%) 1 (20%) 128 (48%) 139 (52%) 0.341 Cigarette smoke exposure, n (%) Yes No 3 (100%) 97 (40%) 147 (60%) 2 (40%) 3 (60%) 99 (39%) 153 (61%) 0.000* Comorbidity, n (%) Without With 3 (100%) 145 (56%) 114 (44%) 3 (60%) 2 (40%) 148 (55%) 119 (45%) 0.019* Malnutrition, n (%) Without With 3 (100%) 151 (58%) 108 (42%) 4 (80%) 1 (20%) 155 (58%) 112 (42%) 0.076 Asthma, n (%) Without With 3 (100%) – 240 (93%) 19 (7%) 5 (100%) – 248 (93%) 19 (7%) 0.000* Recurrent URTIªªª, n (%) Without With 3 (100%) – 237 (92%) 22 (8%) 5 (100%) – 245 (92%) 22 (8.2%) 0.000* Pneumonia, n (%) Without With 3 (100%) – 232 (90%) 27 (10%) 5 (100%) – 240 (90%) 27 (10%) 0.000* Acute tonsillopharyngitis, n (%) Without With 3 (100%) – 257 (99%) 2 (1%) 5 (100%) – 265 (99%) 2 (1%) 0.000* Tuberculin Skin Test size (mm), n (%) < 10 ≥ 10 42 Pediatric Infectious Diseases Society of the Philippines Journal Vol 18 No. 2 pp. 36-53 July-December 2017 Pecson CN and Duran AL. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City: A 2-Year Retrospective Study Successful Treatment Outcome Cured Completed n=3 n = 259 Poor Treatment Outcome Defaulted n=5 Total n = 267 p-value Scabies, n (%) Without With 3 (100%) – 257 (99%) 2 (1%) 5 (100%) – 265 (99%) 2 (1%) 0.000* Otitis, n (%) Without With 3 (100%) – 256 (99%) 3 (1%) 5 (100%) – 264 (99%) 3 (1%) 0.000* Parasitism, n (%) Without With 3 (100%) – 259 (100%) – 4 (80%) 1 (20%) 266 (99.6%) 1 (0.4%) 0.000* Hearing defect, n (%) Without With 3 (100%) – 258 (99.6%) 1 (0.4%) 5 (100%) – 266 (99.6%) 1 (0.4%) 0.000* Brain cyst, n (%) Without With 3 (100%) – 258 (99.6%) 1 (0.4%) 5 (100%) – 266 (99.6%) 1 (0.4%) 0.000* *Non-homogeneity of sample population: significant at 5% level—The total number of cases in some parameters was less than 267 due to missing data ªBacteriologically confirmed ªªªUpper Respiratory Tract Infection ªªClinically diagnosed B. Treatment Outcome Majority of children with tuberculosis in this study had a successful treatment outcome. Two hundred fiftynine (97%) completed treatment and three (1%) were cured. A negligible number had unsuccessful treatment outcome (5, 2%). All of those with poor outcome defaulted. There were no reported cases of death or treatment failure (Figure 1). Figure 1. Rates of Outcome of Treatment in 267 Children with Tuberculosis C. Factors Associated with Successful Treatment Outcome On univariate analysis (Table 5), the successful treatment outcome was 8.085fold (95% CI, 1.310-49.000) higher in 43 Pediatric Infectious Diseases Society of the Philippines Journal Vol 18 No. 2 pp. 36-53 July-December 2017 Pecson CN and Duran AL. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City: A 2-Year Retrospective Study children with weight gain (p=0.001). The percent weight increase (p=0.422) of patients with successful treatment outcome (5.73%) was not significant compared to the percent weight increase of those with poor treatment outcome (4.16%). The absence of comorbid conditions namely: acute tonsillopharyngitis (p=0.015), scabies (p=0.015), parasitism (p=0.019), hearing defect (p=0.000) and brain cyst (p=0.000) was a factor independently related with the treatment outcome among children with tuberculosis. On multivariate analysis (Table 5), the successful treatment outcome was 12.5-fold (95% CI, 1.091143.244) higher in patients with weight gain (p=0.042). Table 5. Univariate and Multivariate Association of Sociodemographic, Anthropometric and Clinical Characteristics with the Treatment Outcome of Childhood TB in Barangay Commonwealth, Quezon City, 2013 – 2015 Successful Treatment Outcome n = 262 Poor Treatment Outcome n=5 pvalue Odds Ratio (95% CI**) pvalue (Univariate Analysis) Odds Ratio (95% CI**) (Multivariate Analysis) Age in years, n (%) 0–4 5–9 10-14 152 (58%) 85 (32%) 25 (10%) 5 (100%) – 0.447 – – – Gender, n (%) Male Female 131 (50%) 131 (50%) 4 (80%) 1 (20%) 0.380 0.250 (0.028,2.267) – – Educational Attainment of Parents, n (%) Grade School/ High School Vocational/ College 160 (65%) 87 (35%) 5 (100%) – 0.224 – – – Employment of Parents, n (%) Employed Unemployed 241 (98%) 6 (2%) 5 (100%) – 0.259 – – – Family size, n (%) 2-5 members ≥6 members 177 (72%) 70 (28%) 3 (60%) 2 (40%) 0.944 1.686 (0.276,10.305) – – 130 (53%) 5 (100%) 0.101 – – – 116 (47%) – Weight (kg), median (range) Before treatment After treatment 14 (6-52) 15 (6-52) 14 (8-15) 14 (8-16) 0.307 0.160 – – – Weight gain, n (%) With Without 221 (84%) 41 (16%) 2 (40%) 3 (60%) 0.001* 8.085 (1.310,49.900) 0.042* 12.5 (1.091, 143.244) Weight gain in kg, median(range) 0.8 (0.10-7.80) 0.5 (0.3-0.7) 0.204 – – – % weight gain relative to baseline weight, median (range) 5.73 (0.30-35.21) 4.16 (3.664.67) 0.422 – – – Economic status, n (%) Below/equal to poverty threshold Above poverty threshold Height for age before treatment, n (%) 44 Pediatric Infectious Diseases Society of the Philippines Journal Vol 18 No. 2 pp. 36-53 July-December 2017 Pecson CN and Duran AL. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City: A 2-Year Retrospective Study Successful Treatment Outcome n = 262 Poor Treatment Outcome n=5 pvalue Odds Ratio (95% CI**) (Univariate Analysis) pvalue Odds Ratio (95% CI**) 6 (2%) 7 (3%) 2 (1%) 173 (66%) 22 (8%) 30 (12%) 20 (8%) 1 (20%) 4 (80%) – 0.243 – (Multivariate Analysis) – BMI (kg/m2), median (range) 14 (6-23) 15 (13-15) 0.569 – – – BMI for age before treatment, n (%) Z-score above 3 Z-score above 2 Z-score above 1 Z-score 0 Z-score below -1 Z-score below -2 Z-score below -3 2 (1%) 10 (4%) 22 (8%) 96 (37%) 68 (26%) 33 (13%) 31 (12%) 1 (20%) 3 (60%) 1 (20%) – 0.682 – – – Category of Patients, n (%) New 262 (100%) 5 (100%) – – – – Classification of TB, n (%) PTB Smear +/ BCª PTB Smear -/ CDªª 3 (1%) 259 (99%) 5 (100%) 0.057 – – – Close TB contact, n (%) Negative Positive 109 (46%) 126 (54%) 2 (40%) 3 (60%) 0.865 1.298 (0.213,7.909) – – BCG Vaccination Positive Negative 242 (95%) 12 (5%) 5 (100%) – 0.564 – – – Tuberculin Skin Test size (mm), n (%) < 10 ≥ 10 51 (24%) 163 (76%) 1 (20%) 4 (80%0 0.739 1.252 (0.137,11.452) – – Chest X-ray, n (%) Without findings With findings 124 (47%) 138 (53%) 4 (80%) 1 (20%) 0.319 0.225 (0.025,2.037) – – Cigarette smoke exposure, n (%) No Yes 150 (61%) 97 (39%) 3 (60%) 2 (40%) 0.668 1.031 (0.169,6.283) – – Co-morbid condition, n (%) Without With 145 (55%) 117 (45%) 3 (60%) 2 (40%) 0.805 0.826 (0.136,5.027) – – Malnutrition, n (%) Without With 198 (76%) 64 (24%) 4 (80%) 1 (20%) 0.749 0.790 (0.087,7.195) – – Asthma, n (%) Without With 243 (93%) 19 (7%) 5 (100%) – 0.879 – – – Recurrent URTIªªª, n (%) Without With 240 (92%) 22 (9%) 5 (100%) – 0.885 – – – Z-score above 3 Z-score above 2 Z-score above 1 Z-score 0 Z-score below -1 Z-score below -2 Z-score below -3 45 Pediatric Infectious Diseases Society of the Philippines Journal Vol 18 No. 2 pp. 36-53 July-December 2017 Pecson CN and Duran AL. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City: A 2-Year Retrospective Study Successful Treatment Outcome n = 262 Poor Treatment Outcome n=5 pvalue Odds Ratio (95% CI**) pvalue (Univariate Analysis) Odds Ratio (95% CI**) (Multivariate Analysis) Pneumonia, n (%) Without With 235 (89%) 27 (10%) 5 (100%) – 1.000 – – – Acute tonsillopharyngitis, n (%) Without With 260 (99%) 2 (1%) 5 (100%) – 0.015* – – – Scabies, n (%) Without With 260 (99%) 2 (1%) 5 (100%) – 0.015* – – – Otitis, n (%) Without With 259 (99%) 3 (1%) 5 (100%) – 0.057 – – – Parasitism, n (%) Without With 262 (100%) – 4 (80%) 1 (20%) 0.019* – – – Hearing defect, n (%) Without With 261 (99.6%) 1 (0.4%) 5 (100%) – 0.000* – – – Brain cyst, n (%) Without With 261 (99.6%) 1 (0.4%) 5 (100%) – 0.000* – – DISCUSSION Tuberculosis is an infection that leads to wasting caused by loss of appetite and body weight, nutrient malabsorption, micronutrient malabsorption and altered metabolism as a response to the infectious process in which a complex interaction between the host and the virulence of the organism modulates the overall metabolic response and the various degrees of tissue breakdown.29,30 The presence of weight gain after therapy indicates a satisfactory response to treatment.31,32 wherein the virulence of mycobacteria has been successfully targeted by the antituberculosis drugs. As seen in our study, weight gain has a significant association with successful treatment outcome based on univariate and multivariate analyses. Children with TB who gained weight after treatment have an 8.085-fold to 12.5-fold probability of having a successful treatment outcome. However, the median weight gain of 0.8kg or 5.73 % weight increase seen among those with successful treatment in this study is not significant compared to the 0.5kg weight gain or 4.16% weight increase among those with poor outcome. This study shows that the sociodemographic and clinical factors such as age, gender, educational attainment and employment of parents, family size, economic status, patient category, TB classification, TST size, chest x-ray, cigarette smoke exposure and co morbid conditions namely malnutrition, asthma, recurrent URTI and pneumonia have no significant association with successful treatment outcome. Several studies have demonstrated an association between age and gender and successful treatment outcome such as those done in Addis Ababa8 and southern region of Ethiopia.13,15 Fifty nine percent of patients in this study are children 0-4 years old. Age plays one of the most significant 46 Pediatric Infectious Diseases Society of the Philippines Journal Vol 18 No. 2 pp. 36-53 July-December 2017 Pecson CN and Duran AL. Association of Factors with Successful Treatment Outcome of Childhood Tuberculosis in Barangay Commonwealth, Quezon City: A 2-Year Retrospective Study roles in determining which children will progress to disease.18 Young children under 2-3 years of age in whom the immune system is still immature are likely susceptible to developing disease following the primary Mycobacterium tuberculosis infection.7,14 This study parallels the research done in Cape Town, South Africa where children
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