title: Prediction of Under-Detection of Paediatric Tuberculosis in the Democratic Republic of Congo: Experience of Six Years in the South-Kivu Province.
abstract: BACKGROUND
  In the field of tuberculosis (TB), and particularly in regard to paediatric TB (PedTB), clinical skills of health professionals play an important role in determining quality of care. In an era where novel diagnostic technologies and efficient treatment regimens are being made available for the poorest, we must not divert our attention from the importance of clinical skills, as this deliverable remains the cornerstone of individualized patient care and ultimately the best assurance for optimal use of resources. The aim of our work was to study the epidemiology of PedTB and the determinants of PedTB under-detection in the South-Kivu Province of the Democratic Republic of Congo (DRC), a setting with nearly no technical resources allowing to support the clinical diagnosis of PedTB, i.e. chest X-rays, rapid molecular tests or culture laboratories.
  
  
  METHODS
  We collected TB notification data from 2010 to 2015 and analysed the space-time variations in notification for the different forms of TB among the 113 health facilities (HF) the South-Kivu Province, a region with a low HIV incidence. The different forms of TB notified were: smear positive pulmonary TB (SS+PTB), smear negative pulmonary TB (SS-PTB) and extra-pulmonary TB (EPTB). We further analysed the distribution of these different forms of the disease per age group and explored the possibility to predict the detection of PedTB.
  
  
  RESULTS
  Significant differences were observed between HF in regard to the proportion of paediatric TB and the proportion of SS-TB among adults. We found a strong correlation between the proportion of PedTB and three major factors: the proportion of TB cases with no bacteriological confirmation (SS-TB) among adults, the number of TB cases notified by the HF and the fact that the HF was supported or not by Médecins Sans Frontières (MSF). The proportion of SS-TB among adults was found to be a valid indicator for predicting the level of detection of PedTB at the same HF.
  
  
  CONCLUSIONS
  Our observations strongly suggest that under-detection of PedTB is associated with insufficient clinical skills and technical resources at the HF level which similarly affects other forms of the disease, in particular SS-TB. We demonstrated that, in the specific context of South-Kivu, under-detection of PedTB can be predicted by a low SS-TB/SS+PTB ratio in the adult population. In the context of severely under-resourced settings, this ratio could be used to rapidly identify HF that should benefit in priority from deeper evaluation, and eventually targeted interventions.
authors.affiliation: Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.|Cliniques Universitaires Saint-Luc, Brussels, Belgium.
authors.forename: Emmanuel
authors.identifier: http://orcid.org/0000-0001-8321-3770
authors.initials: E
authors.lastname: André
authors.affiliation: Hôpital Provincial Général de Référence de Bukavu, Bukavu, Democratic Republic of Congo.
authors.forename: Yvette
authors.initials: Y
authors.lastname: Lufungulo Bahati
authors.affiliation: Coordination Provinciale Lèpre et Tuberculose, Bukavu, Democratic Republic of Congo.
authors.forename: Eric
authors.initials: E
authors.lastname: Mulume Musafiri
authors.affiliation: Ambassadeurs de Lutte contre la Tuberculose, Bukavu, Democratic Republic of Congo.
authors.forename: Olivier
authors.initials: O
authors.lastname: Bahati Rusumba
authors.affiliation: Cliniques Universitaires Saint-Luc, Brussels, Belgium.
authors.forename: Dimitri
authors.initials: D
authors.lastname: Van der Linden
authors.affiliation: Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.
authors.forename: Francis
authors.identifier: http://orcid.org/0000-0002-5224-3712
authors.initials: F
authors.lastname: Zech
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D015023:Democratic Republic of the Congo / Q000453:epidemiology; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D015233:Models, Statistical; D025202:Molecular Diagnostic Techniques; D009169:Mycobacterium tuberculosis; D011159:Population Surveillance; D015203:Reproducibility of Results; D014376:Tuberculosis / Q000175:diagnosis* / Q000453:epidemiology*