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Advancing the diagnosis of child TB: The second edition of the Diagnostic CXR Atlas

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Despite substantial progress in the prevention and treatment of tuberculosis (TB) since the first edition of this publication in 2003, approximately 250,000 children are still dying from this curable disease every year. At the United Nations first-ever high-level meeting on TB in 2018, a global target was set to diagnose and treat 3.5 million children by 2022. However, annually fewer than half of the children estimated to develop TB are diagnosed and treated. It is clear that efforts to prevent deaths from TB and diagnose and treat TB in children must be urgently accelerated.

Chest x-rays (CXRs) are a critical component of the child TB diagnostic approach and yet, in many contexts, healthcare workers feel a pressing need to strengthen their ability to interpret CXR images. We have extensively revised the Diagnostic CXR Atlas for Tuberculosis in Children: A Guide to Chest X-ray Interpretation (the Atlas) with the aim of assisting non-specialist healthcare workers in high TB-burden settings to interpret CXRs from children investigated for TB.

The second edition of the Atlas has six sections. They describe the role of CXR in diagnosing children with TB, introduce an algorithmic approach to CXR evaluation in a child with symptoms and signs of TB, explain the features of a normal CXR in children and then present a comprehensive review of features that are highly specific and less specific for paediatric TB. The Atlas presents numerous CXR images with detailed annotations and summarises key messages to enhance its reader-friendliness.      

The Atlas was produced by Megan Palmer, James A. Seddon, Pierre Goussard, H. Simon Schaaf from Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Science at Stellenbosch University, Cape Town, South Africa, with support from The Union.

Megan Palmer, co-lead author, said: “The immediate beneficiaries of this Atlas are frontline healthcare professionals in low- and middle-income settings, in both public and private health facilities, where sick children seek care. They include medical, clinical and nursing officers, paramedical staff, child health specialists and focal points, TB and HIV focal people, TB and HIV coordinators, radiographers and X-ray technicians.”

The target audience of the Atlas also includes educators of these healthcare providers, supervisory level health officers, members of child TB working groups and national TB and child health programme managers and staff.

Megan added: “We hope that this Atlas will contribute to capacity and confidence building among healthcare workers when interpreting CXRs in children. We also hope that it will serve as a useful tool to assist healthcare workers in determining radiological TB disease severity on CXR and so support the implementation of the new WHO guidance on TB treatment shortening in children. We believe this Atlas is one way of ensuring that all children with TB will be appropriately diagnosed and initiated on the recommended treatment.”

The authors acknowledged Professor Robert Gie, who authored the first edition of this Atlas and mentored the authors of this second edition, within the Atlas: “He trained a generation of TB researchers on many aspects of the clinical management of childhood TB and on TB research. He was passionate about the reading of CXRs and taught hundreds of students, doctors and researchers how to read CXRs and, perhaps more importantly, how to think critically about what the identified CXR features might mean. Professor Gie felt strongly that we should be teaching people about ALL the CXR patterns that we see in children with TB, and not just the perfect pictures. We hope that this edition of the Atlas does him justice.”