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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0007">Introduction</span><p id="para0005" class="elsevierStylePara elsevierViewall">Despite its ancient origins&#44; tuberculosis &#40;TB&#41; remains a major public health concern&#46; The pediatric population accounts for approximately 11 &#37; of the global disease burden&#44; implying that approximately 1&#46;1 million children suffer from TB every year&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a> In 2022&#44; 78&#44;057 new cases of TB were diagnosed in Brazil&#44; and 3&#46;5 &#37; &#40;2703&#41; occurred in children under 15 years of age&#44; proportions recorded in the historical series from 2012 to 2022&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a></p><p id="para0006" class="elsevierStylePara elsevierViewall">In 2022&#44; 78&#46;057 new cases of TB were diagnosed in Brazil&#44; with 3&#46;5 &#37; &#40;2703&#41; occurring in children under 15 years of age&#46; This proportion represents a historical number of cases between 2012 and 2022&#46; In the pediatric sample&#44; patients from 0 to 4 years correspond to 37&#46;5 &#37;&#59; from 5 to 10 years represent 22 &#37; and between 10 and 15 years correspond to 40&#46;5 &#37; of cases&#46; Adolescents from 15 to 18 years old are in another group&#44; and the incidence of cases is 6 &#37; of the general population&#46;</p><p id="para0007" class="elsevierStylePara elsevierViewall">Diagnosing TB in children is challenging because of several factors&#44; including the paucibacillary nature of the disease&#44; non-specific symptoms&#44; clinical similarity with other childhood diseases&#44; and difficulty in collecting samples for diagnosis&#46; As per a 2020 estimate&#44; 63 &#37; of children and adolescents under 15 years of age with TB were not notified or did not have access to diagnostic and treatment services&#59; the proportion is even higher &#40;72 &#37;&#41; for children under five&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a></p><p id="para0008" class="elsevierStylePara elsevierViewall">The global report of the World Health Organization &#40;WHO&#41;&#44; with data updated in 2022&#44; reinforces that the global goals defined by the &#8220;End TB&#8221; strategy for controlling the number of cases and deaths from the disease are far from being met&#46; A reduction in the numbers diagnosed&#44; in access to essential TB services&#44; and&#44; consequently&#44; an increase in the number of deaths was observed in the last two years&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> The coronavirus disease 2019 &#40;COVID-19&#41; pandemic had a negative impact on access to diagnosis and reduced investments and funds destined for essential TB services&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a></p><p id="para0009" class="elsevierStylePara elsevierViewall">In addition to TB disease&#44; it is important to identify infected children who have shown no symptoms&#46; <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> infection without the manifestation of active disease is called latent tuberculosis infection &#40;LTBI&#41;&#44; and treating children in this phase&#44; in addition to improving the prognosis and reducing individual morbidity and mortality&#44; also substantially reduces the community transmission of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0004"><span class="elsevierStyleSup">4-6</span></a> Most children were infected through recent household contacts&#44; in the last two years&#44; mainly parents and caregivers&#46; This reflects the fact that every child with TB should be considered a sentinel event and indicative of recent disease transmission&#46;</p><p id="para0010" class="elsevierStylePara elsevierViewall">There are well-established protocols for contact tracing and treatment of LTBI in children&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> In Brazil&#44; guidelines structure LTBI surveillance into five pillars&#58; &#40;1&#41; identification of people who are more likely to have LTBI or with higher risks of illness&#59; &#40;2&#41; identification of persons with LTBI&#59; &#40;3&#41; correct indication of treatment &#40;4&#41; notification and &#40;5&#41; monitoring of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0011" class="elsevierStylePara elsevierViewall">Despite several advances in recent decades&#44; many difficulties still need to be overcome in the diagnosis of LTBI as well as in the diagnosis of TB disease&#46; This scoping review aimed to systematically map the research conducted in this area and identify the potential barriers&#44; delays&#44; and missed opportunities for the prevention and diagnosis of childhood TB&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0008">Methods</span><p id="para0012" class="elsevierStylePara elsevierViewall">This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses &#40;PRISMA&#41; extension for scoping reviews &#40;2018&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a></p><p id="para0013" class="elsevierStylePara elsevierViewall">To achieve the proposed objective of the review&#44; the guiding question was&#58; What is the scientific evidence of missed opportunities in the prevention and diagnosis of TB in pediatric patients&#63;</p><p id="para0014" class="elsevierStylePara elsevierViewall">Following the acronym PCC&#44; the population &#40;P&#41; is composed of children and adolescents under 18 years of age with TB disease&#59; the concept &#40;C&#41; refers to missed opportunities such as contact with adults with TB and failure in LTBI investigation or treatment&#59; and the context &#40;C&#41; is defined as the diagnosis of TB disease&#46;</p><p id="para0015" class="elsevierStylePara elsevierViewall">The protocol was registered at <a href="https://www.protocols.io">https&#58;&#47;&#47;www&#46;protocols&#46;io</a> &#40;DOI&#58; dx&#46;doi&#46;org&#47;10&#46;17504&#47;protocols&#46;io&#46;x54v9dwwmg3e&#47;v1&#41;&#46;</p><p id="para0016" class="elsevierStylePara elsevierViewall">Systematic searches were undertaken between July 2022 and November 2022 in the databases VHL&#47;Lilacs&#44; Medline via PubMed&#44; Cochrane&#44; Scopus&#44; and Web of Science&#46; The following descriptors were used&#58; &#8220;tuberculosis&#8221;&#44; &#8220;missed opportunities&#8221; &#8220;diagnosis&#8221;&#44; &#8220;prevention&#8221;&#44; &#8220;case discovery&#8221;&#44; and &#8220;gap&#8221;&#46;</p><p id="para0017" class="elsevierStylePara elsevierViewall">The final quest in each base is presented below&#58;<ul class="elsevierStyleList" id="celist0001"><li class="elsevierStyleListItem" id="celistitem0001"><span class="elsevierStyleLabel">&#8226;</span><p id="para0018" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">VHL&#47;Lilacs</span>&#58; &#40;diagn&#243;stico OR diagnosis OR diagnostic OR &#34;Oportunidade Perdida&#34; OR &#34;Oportunidades Perdidas&#34; OR &#34;Missed Opportunity&#34; OR &#34;Missed Opportunities&#34;&#41; AND &#40;&#34;Preven&#231;&#227;o de Doen&#231;as&#34; OR &#34;Disease Prevention&#34; OR &#34;Prevenci&#243;n de Enfermedades&#34; OR &#34;Pr&#233;vention des Maladies&#34; OR preven&#231;&#227;o OR prevention&#41; AND &#40;tuberculose OR tuberculosis&#41; AND &#40;pediatria OR pediatrics OR pediatr&#237;a OR p&#233;diatrie OR crian&#231;a OR child OR ni&#241;o OR enfant&#41; AND &#40;db&#58;&#40;&#34;LILACS&#34; OR &#34;IBECS&#34; OR &#34;BINACIS&#34; OR &#34;CUMED&#34; OR &#34;BIGG&#34; OR &#34;WHOLIS&#34; OR &#34;MULTIMEDIA&#34; OR &#34;BDENF&#34; OR &#34;LIPECS&#34; OR &#34;SES-SP&#34; OR &#34;colecionaSUS&#34; OR &#34;PAHO&#34; OR &#34;SOF&#34; OR &#34;campusvirtualsp&#95;brasil&#34; OR &#34;PAHOIRIS&#34; OR &#34;SMS-SP&#34;&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0002"><span class="elsevierStyleLabel">&#8226;</span><p id="para0019" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Medline via PubMed &#47; Scopus &#47; Web of Science &#47; Cochrane</span>&#58; &#40;Diagnosis OR &#34;Missed Opportunity&#34; OR &#34;Missed Opportunities&#34;&#41; AND &#40;&#34;Disease Prevention&#34; OR Prevention&#41; AND &#40;Tuberculosis&#41; AND &#40;Pediatrics OR Child&#41;</p></li></ul></p><p id="para0020" class="elsevierStylePara elsevierViewall">The inclusion criteria were originally published observational studies that included children and adolescents &#40;0&#8211;18 years&#41; with TB disease that addressed missed opportunities in the prevention and diagnosis of the disease&#46; The searches were not restricted to any language or date of publication&#46;</p><p id="para0021" class="elsevierStylePara elsevierViewall">Case reports&#44; abstracts&#44; consensuses&#44; letters to the editor&#44; and review articles were excluded&#46; Articles that included adult populations or populations with LTBI were not considered&#46;</p><p id="para0022" class="elsevierStylePara elsevierViewall">Studies were selected after screening the title&#44; abstract&#44; or full text&#44; if necessary&#44; by two independent reviewers&#46; In cases of doubt or disagreement&#44; a third reviewer was consulted&#46;</p><p id="para0023" class="elsevierStylePara elsevierViewall">Thereafter&#44; the full text of all selected studies was read for data extraction&#46; The reviewers aimed to identify and establish the variables presented in the literature as missed opportunities for the diagnosis of TB&#46;</p><p id="para0024" class="elsevierStylePara elsevierViewall">For data summarization&#44; each article was tabulated in accordance with PRISMA guidelines&#58; author&#44; year&#44; number of studied populations included&#44; missed opportunities&#44; frequency of cases in each of the defined missed opportunities&#44; current statistics&#44; and conclusion&#46;</p></span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0009">Result</span><p id="para0025" class="elsevierStylePara elsevierViewall">A bibliographic review conducted from July 2022 to November 2022 identified 4617 studies&#46; After screening and analyzing the inclusion criteria&#44; seven articles published between 1992 and 2022 were selected &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0026" class="elsevierStylePara elsevierViewall">The seven studies summarized in <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a> cover the year of publication&#44; geographical location&#44; study design&#44; population&#44; and main findings&#46; As seen from the Table&#44; three studies were carried out in the United States&#44; two in South Africa&#44; and one each in Brazil and Germany&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><p id="para0027" class="elsevierStylePara elsevierViewall">The main missed opportunities identified in the studies were failures in screening the contacts of bacilliferous patients&#44; identifying symptomatic infected children in routine consultations&#44; and the institution of LTBI treatment&#46; Failure was also observed in the routine screening of risk groups for the development of active TB&#44; regardless of a known contact history&#44; as in the case of individuals living with HIV&#46;</p><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0010">Exposure to <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span></span><p id="para0028" class="elsevierStylePara elsevierViewall">The percentage of children with known contact with adults diagnosed with TB was largely diverse &#40;37 &#37; to 85 &#37;&#41;&#46; Among the three studies that reported this&#44; over 75 &#37; were classified as household contacts and most children were mainly with parents and caregivers&#46;</p><p id="para0029" class="elsevierStylePara elsevierViewall">The study by Carvalho et al&#46; addressed children diagnosed with TB in Rio de Janeiro&#44; Brazil&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> Among the 544 children&#44; 71 &#37; underwent follow-ups at a basic health unit and 29 &#37; at tertiary reference centers&#46; A high proportion of children &#40;68&#46;7 &#37;&#41; had previous contact with adults with TB&#46; Feiterna-Sperling et al&#46; evaluated 48 children diagnosed with TB treated at a tertiary hospital in Berlin&#59; in 91&#46;7 &#37; of the cases&#44; the child or at least one of the parents had left in another country&#46; In 77 &#37; of the cases&#44; the index case was a family member&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a></p><p id="para0030" class="elsevierStylePara elsevierViewall">The South African study by Du Preez et al&#46; &#40;2011&#41;&#44; which included 614 children with a confirmed microbiological diagnosis of TB&#44; reported 54&#46;2 &#37; previous contact with an adult with TB&#44; 83 &#37; of whom were family members&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> Another study by the same author in 2017 showed that 40 &#37; of the children had known prior contact with an adult with TB&#46;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a></p><p id="para0031" class="elsevierStylePara elsevierViewall">In the American study by Mehta&#44; the index case&#44; the source of childhood TB&#44; was identified in 78 &#37; of 109 cases&#46;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> Notably&#44; 21 &#37; of the childhood TB cases in the study population could have been avoided&#46; In the study by Lobato et al&#44; also undertaken in the USA&#44; the rate of children with previous known contact with an adult with TB was 37 &#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a> Among them&#44; 84 &#37; were household contacts&#44; and 44 &#37; had some risk factors associated with the disease&#44; such as alcohol&#47;drug abuse&#44; unemployment&#44; former street dwellers&#44; or health professionals&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0011">Contact tracing and screening</span><p id="para0032" class="elsevierStylePara elsevierViewall">As regards the investigation of children with known previous contacts&#44; the disease screening rate ranged from 35 &#37; in Brazil to 75 &#37; in Germany&#46; In the German study&#44; children diagnosed with TB disease were identified in two ways&#58; active search for contact tracing or triage &#40;81&#46;3 &#37;&#41; and passively through the patient&#39;s voluntary search for the health service to assess symptoms &#40;18&#46;7 &#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> In Germany&#44; the screening of risk groups for TB follows the WHO guidelines for countries with low disease burden&#44; and systematic screening is recommended for individuals living with HIV&#44; immunosuppressed patients or those with chronic diseases&#44; prisoners&#44; health professionals&#44; immigrants from countries with a high TB burden&#44; homeless people&#44; and illicit drug users&#46;</p><p id="para0033" class="elsevierStylePara elsevierViewall">Screening should be performed systematically by identifying symptoms &#40;cough&#44; fever&#44; weight loss&#44; and prostration&#41; and using chest radiography&#46; Confirmation of <span class="elsevierStyleItalic">M&#46; tuberculosis</span> infection can be performed using the tuberculin skin test &#40;TST&#41;&#44; or Interferon Gamma Release Assay &#40;IGRA&#41;&#46;</p><p id="para0034" class="elsevierStylePara elsevierViewall">The study by Mehta showed that of 109 cases of childhood TB&#44; 63 &#40;57&#46;8 &#37;&#41; were found through contact tracing&#44; 35 &#40;32&#46;1 &#37;&#41; were identified passively through the investigation of symptoms&#44; and 11 &#40;10&#46;1 &#37;&#41; were detected by routine screening&#46;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> In the study by Lobato et al&#44; only 26 &#37; of the 161 children were identified through contact tracing&#44; and 91 &#37; of the infected children referred for screening already had TB disease at the first assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a> It is estimated that 40 &#37; of TB disease cases could have been prevented&#46;</p><p id="para0035" class="elsevierStylePara elsevierViewall">In the report by Kimerling et al&#44; including an Alabama cohort&#44; based on contact tracing failure&#44; delay in the initial assessment&#44; or noncompliance with preventive therapy in eligible patients&#44; an identical rate of 21 &#37; of preventable cases was described&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0012">LTBI treatment</span><p id="para0036" class="elsevierStylePara elsevierViewall">Among the children with an indication for LTBI treatment&#44; 13&#46;9 &#37; in the US and 86 &#37; in South Africa did not receive the indicated preventive treatment&#46; In the Brazilian study&#44; previous treatment for LTBI was performed in only 17 &#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a></p><p id="para0037" class="elsevierStylePara elsevierViewall">In the 2011 South African study&#44; approximately 74 &#37; of children under five years of age eligible for chemoprophylaxis did not receive preventive treatment&#46; Among them&#44; 25 &#37; developed disseminated TB&#44; and 5&#46;1 &#37; died&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> In 2017&#44; another study undertaken by the same authors showed that only 14 &#37; of children eligible for preventive therapy received adequate treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a></p></span></span><span id="sec0007" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0013">Discussion</span><p id="para0038" class="elsevierStylePara elsevierViewall">Children are vulnerable to TB&#44; which is systematically neglected and must be prioritized&#46; To this end&#44; several steps need to be addressed&#58; tracing children who have been exposed to <span class="elsevierStyleItalic">M&#46; tuberculosis</span> &#40;contact tracing&#41;&#44; identifying those at greater risk of developing TB by screening risk groups&#44; detecting and treating LTBI in these children&#44; implementing LTBI treatment&#44; identifying sick children through routine screening &#40;childcare&#41;&#44; and developing and expanding public health strategies for appropriate fulfillment of these steps&#46;<a class="elsevierStyleCrossRef" href="#bib0016"><span class="elsevierStyleSup">16</span></a></p><p id="para0039" class="elsevierStylePara elsevierViewall">Carvalho et al&#46; demonstrated that despite the high rate of known previous contact with TB&#44; only 17 &#37; of children were diagnosed and treated for LTBI&#44; suggesting a failure in the identification and treatment of LTBI&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> A study carried out in eight countries with a high burden of the disease showed that contact tracing helped to detect new cases of TB disease in 12 &#37; of contacts and the prevalence of LTBI was 72 &#37;&#46;<span class="elsevierStyleSup">4</span> Therefore&#44; screening household contacts for TB is a high-yield and cost-effective strategy&#46;</p><p id="para0040" class="elsevierStylePara elsevierViewall">In European countries with a low disease burden&#44; contact tracing appears to occur more effectively&#46; In the study by Feiterna-Sperling carried out in Berlin&#44; Germany&#44; 81&#46;3 &#37; of the 48 children were identified through an active search by contact tracing or screening&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> Among them&#44; 83 &#37; did not receive treatment for LTBI because they already met the TB disease criteria at the time of the first assessment&#46;</p><p id="para0041" class="elsevierStylePara elsevierViewall">Although the average time between the diagnosis of the source case and the assessment of the child in contact occurs early&#44; with an average of approximately 18 days&#44; the time between the diagnosis of the source case and the onset of symptoms was on average 3 months&#46; With prolonged exposure and a high bacterial load associated with an increased risk of TB transmission&#44; the biggest challenge in this population is the timely identification of adult cases&#46; Even if it is not possible&#44; in most cases&#44; to detect TB in its latent infection phase&#44; the screening program allows the diagnosis of TB disease in its initial phase&#44; contributing to a better prognosis&#44; reduction of morbidity and mortality&#44; and interruption of the chain of TB transmission&#46;</p><p id="para0042" class="elsevierStylePara elsevierViewall">These challenges are greatest in underdeveloped countries with high TB burdens&#46; The shortage of financial resources hinders the availability of tests that detect <span class="elsevierStyleItalic">M&#46; tuberculosis</span> &#40;tuberculin skin test or IGRA&#41;&#44; leads to a shortage of trained professionals for contact tracing&#44; and even results in difficulty in conducting and interpreting imaging tests&#46;</p><p id="para0043" class="elsevierStylePara elsevierViewall">According to Du Preez et al&#44; in two studies carried out in South Africa with an interval of 6 years &#40;2011&#8211;2017&#41;&#44; the number of children eligible for TB preventive therapy who did not receive chemoprophylaxis remained above 70 &#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a> WHO has considered the identification and treatment of LTBI the cornerstone of efforts to eliminate TB by 2030&#46; It is estimated that &#62;80 &#37; of adults and children at risk of <span class="elsevierStyleItalic">M&#46; tuberculosis</span> infection do not complete the care cascade&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a> A scoping review was conducted in 2021 identifying the following barriers to the care of children evaluated and treated for LTBI&#59; failure to identify children at high risk for LTBI&#44; low availability of tests to diagnose the infection&#44; refusal of parents to perform the test&#44; or adherence to treatment due to the stigma of the disease or fear of adverse effects&#44; and loss to follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a></p><p id="para0044" class="elsevierStylePara elsevierViewall">The unavailability of tests that detect <span class="elsevierStyleItalic">M&#46; tuberculosis</span> is a reality in underdeveloped countries&#46; In the Brazilian study&#44; the tuberculin skin test was performed in 73 &#37; of the patients&#44; and the positivity was 79&#46;6 &#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> According to the WHO recommendation&#44; the test is not essential for the diagnosis of LTBI in high-risk situations&#44; and chemoprophylaxis should be administered to children in contact with TB patients even when the test is not available&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a> This guideline is based on the fact that preventive treatment is well tolerated in young children&#44; and due to the paucibacillary nature of the disease in the pediatric population&#44; the risk of inducing resistance to antituberculostatic drugs is minimal&#46; The situation is different in adolescents who generally have multi-bacillary disease&#44; requiring a better investigation to rule out TB disease before LTBI treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a></p><p id="para0045" class="elsevierStylePara elsevierViewall">Tuberculosis in adolescence is a topic that is rarely discussed&#46; In the present review&#44; Carvalho et al&#46; report 8&#46;3 &#37; of patients aged 10 to 15 years but do not perform any specific analysis for this subgroup&#46; Feiterna-Sperling reports 33 &#37; of patients aged between 10 and 15 years but also does not report any difference observed in relation to younger children&#46; The literature describes evolution and clinical manifestations like those seen in young adults&#46; The specific characteristics of this age group&#44; such as endocrine-metabolic changes and psychosocial issues&#44; are generally not valued&#46;</p><p id="para0046" class="elsevierStylePara elsevierViewall">A USA study conducted in 1992 identified 21 &#37; of TB disease cases in children in the studied population that could have been avoided considering failure or delay in contact tracing&#44; incomplete evaluation&#47;workup&#44; and loss of follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a></p><p id="para0047" class="elsevierStylePara elsevierViewall">Two North American studies conducted in 2000 were analyzed&#46; In one referring to the population of Alabama&#44; an identical rate of 21 &#37; of preventable cases was described&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> In the other 37 &#37; of the patients &#40;72&#46;8 &#37;&#41; had known prior contact with a TB carrier&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a> However&#44; due to failure to investigate the source cases&#44; delay in investigating contacts&#44; incomplete assessment due to the unavailability of tuberculin skin testing and radiological examination&#44; or inadequate&#47;missing treatment for LTBI&#44; it is estimated that 40 &#37; of TB cases could have been prevented&#46; Evaluating the time elapsed since the first study&#44; it was observed that the challenges encountered in the 11990s remain in force in coping with TB in children even today&#46;</p><p id="para0048" class="elsevierStylePara elsevierViewall">A systematic review and meta-analysis conducted in 2022 analyzed interventions in the TB care cascade&#46; Relatively simple interventions&#44; such as education&#44; counseling&#44; and incentives&#44; could substantially reduce the burden of the disease&#46; In practice&#44; this translates to updating clinical guidelines&#44; integrating care&#44; providing tools and resources to improve case detection&#44; training staff&#44; providing TB educational materials for patients&#44; and involving laypeople in service delivery&#46;<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> These measures sensitize health professionals and raise attention and strong suspicion for the diagnosis of TB in children in routine pediatric consultations&#44; which is essential for early diagnosis&#46;</p><p id="para0049" class="elsevierStylePara elsevierViewall">A 2023 systematic review estimated the number of children screened to detect a single case of TB disease &#40;NNS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a> Most studies have been conducted in countries with a high disease burden&#44; and mainly screening for symptoms was undertaken&#46; The estimated NNS in healthcare settings &#40;109&#41; was lower than the estimated NNS in the community &#40;1117&#41; and school settings &#40;464&#41;&#46; Screening in child health services&#44; such as outpatient clinics and wards&#44; is a potential opportunity to increase the diagnosis of childhood TB&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a></p><p id="para0050" class="elsevierStylePara elsevierViewall">The North American studies identified racial and economic barriers to TB care&#46; One study observed that all patients who presented with missed opportunities were black&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> while the other demonstrated that 44 &#37; of the source cases of childhood TB had social risk factors&#44; such as unemployment or substance abuse&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a> Despite being a disease present in all social spheres&#44; the negative impact of TB on those with greater socioeconomic vulnerability is undeniable&#44; considering overcrowding&#44; poor ventilation&#44; food insecurity &#40;malnutrition&#41;&#44; and indoor and outdoor air pollution&#46; Therefore&#44; increased attention and public health policies aimed at this population are required&#46;</p></span><span id="sec0008" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0014">Summary of evidence</span><p id="para0051" class="elsevierStylePara elsevierViewall">There are still many missed opportunities for preventing and diagnosing childhood TB&#46;</p><p id="para0052" class="elsevierStylePara elsevierViewall">In developed countries with a low disease burden&#44; the main shortcoming is the delay in diagnosing bacilliferous adults who are in contact with young children&#46; In this context&#44; the problem is mainly concentrated in the portion of the population with greater socioeconomic vulnerability&#44; which includes Afro-descendants and immigrants&#46;</p><p id="para0053" class="elsevierStylePara elsevierViewall">In underdeveloped countries with a high disease burden&#44; the greatest challenge is tracking children who are in contact with adults with TB&#46; Closing persistent gaps in LTBI management and the early diagnosis of TB are paramount&#46; The main difficulties encountered were notification of the index case&#44; identification of contacts and patients with LTBI&#44; recommendation and adherence to preventive treatment&#44; available workups&#44; high suspicion of professionals&#44; and early diagnosis&#46;</p><p id="para0054" class="elsevierStylePara elsevierViewall">To intervene in this process&#44; it is necessary to improve public health policies through financial investment&#44; the availability of new technologies&#44; professional training&#44; and the awareness of parents and guardians&#46; The positive legacy of the COVID-19 pandemic should take advantage of community mobilization&#44; and rapid scientific development in the management of infectious diseases should be encouraged&#46;</p></span><span id="sec0009" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0015">Limitations</span><p id="para0055" class="elsevierStylePara elsevierViewall">This study has some limitations&#46; A quality assessment of the articles was not performed because of the heterogeneity of the studies&#46;</p><p id="para0056" class="elsevierStylePara elsevierViewall">The time interval of publication of the included articles was long &#40;1992 to 2022&#41;&#46; Thus&#44; the data presented may have been influenced by the incidence of the disease and the heterogeneity of the protocols in force at different times&#46;</p><p id="para0057" class="elsevierStylePara elsevierViewall">Most articles did not present sophisticated statistical analyses and described only the percentage of missed opportunities&#46; It is necessary to conduct new original studies with greater methodological rigor so that it is possible to carry out a systematic review&#46;</p></span></span>"
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          "titulo" => "Introduction"
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              "identificador" => "sec0004"
              "titulo" => "Exposure to Mycobacterium tuberculosis"
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            1 => array:2 [
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              "titulo" => "Contact tracing and screening"
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              "titulo" => "LTBI treatment"
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        5 => array:2 [
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          "titulo" => "Discussion"
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        6 => array:2 [
          "identificador" => "sec0008"
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    "fechaRecibido" => "2023-06-17"
    "fechaAceptado" => "2023-10-15"
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            1 => "Missed opportunities"
            2 => "Diagnosis"
            3 => "Prevention"
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    "resumen" => array:1 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Objectives</span><p id="spara004" class="elsevierStyleSimplePara elsevierViewall">Identify potential barriers&#44; delays&#44; and missed opportunities in the prevention and diagnosis of childhood TB&#46;</p></span> <span id="abss0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Methods</span><p id="spara005" class="elsevierStyleSimplePara elsevierViewall">Scoping review according to the PRISMA extension&#46; The definitions considered for the selection followed the acronym PCC where the population &#40;P&#41; is children under 18 years of age with TB disease&#44; the concept &#40;C&#41; refers to missed opportunities for prevention and diagnosis&#44; and context &#40;C&#41; is defined as a diagnosis of TB disease&#46; The authors searched systematically in the databases&#59; VHL&#47;Lilacs&#44; Medline via PubMed&#44; Cochrane&#44; Scopus&#44; and Web of Science&#44; without date or language limitation&#46;</p></span> <span id="abss0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Results</span><p id="spara006" class="elsevierStyleSimplePara elsevierViewall">Seven studies were included&#46; In developed countries&#44; with low disease burden&#44; the main shortcoming is the delay in diagnosing bacilliferous adults in contact with young children&#46; This problem is concentrated in the portion of the population with socioeconomic vulnerability&#46; In underdeveloped countries&#44; with a high burden of disease&#44; the biggest challenge is tracking children who come into contact with bacilliferous patients&#46;</p></span> <span id="abss0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Conclusions</span><p id="spara007" class="elsevierStyleSimplePara elsevierViewall">There are still many missed opportunities in the prevention and diagnosis of childhood TB&#46; The positive legacy of the COVID-19 pandemic should be taken advantage of and the encouragement of scientific development in the management of infectious diseases should be taken&#46;</p></span>"
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          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Selection of studies evaluating the missed opportunities in the prevention and diagnosis of pediatric tuberculosis&#46; <span class="elsevierStyleBold">&#42; PCC</span> P &#40;population&#41; &#61; is composed of children and adolescents under 18 years of age with TB&#59; C &#40;concept&#41; &#61; refers to missed opportunities such as contact with adults with TB and failure in LTBI investigation or treatment&#59; C &#40;context&#41;&#58; is defined as the diagnosis of TB disease&#46;</p>"
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          "leyenda" => "<p id="spara003" class="elsevierStyleSimplePara elsevierViewall">TB&#44; Tuberculosis&#59; LTBI&#44; latent tuberculosis infection&#46;</p>"
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0003"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Type of study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0005"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0006"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Main findings&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">Mehta &#38; Bentley<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1992&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0009"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0010"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0011"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">109 children under 15 years diagnosed with TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0012"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0002"><li class="elsevierStyleListItem" id="celistitem0003"><span class="elsevierStyleLabel">&#8226;</span><p id="para0059" class="elsevierStylePara elsevierViewall">77&#46;9 &#37; TB contact &#40;85&#47;109&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0004"><span class="elsevierStyleLabel">&#8226;</span><p id="para0060" class="elsevierStylePara elsevierViewall">Contact tracing &#8211; 57&#46;8 &#37; &#40;63&#47;109&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0005"><span class="elsevierStyleLabel">&#8226;</span><p id="para0061" class="elsevierStylePara elsevierViewall">Screening - 10&#46;1 &#37; &#40;11&#47;109&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0006"><span class="elsevierStyleLabel">&#8226;</span><p id="para0062" class="elsevierStylePara elsevierViewall">LTBI treatment &#8211; 10 &#37; &#40;11&#47;109&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0013"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Kimerling et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0014"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0015"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0016"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0017"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">120 children under 15 years diagnosed with TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0018"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0003"><li class="elsevierStyleListItem" id="celistitem0007"><span class="elsevierStyleLabel">&#8226;</span><p id="para0063" class="elsevierStylePara elsevierViewall">21 &#37; preventable cases &#40;25&#47;120&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0008"><span class="elsevierStyleLabel">&#8226;</span><p id="para0064" class="elsevierStylePara elsevierViewall">16 &#37; did not receive adequate LTBI prophylaxis &#40;4&#47;25&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0009"><span class="elsevierStyleLabel">&#8226;</span><p id="para0065" class="elsevierStylePara elsevierViewall">Contact tracking failure &#8211; 48 &#37; &#40;12&#47;25&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0010"><span class="elsevierStyleLabel">&#8226;</span><p id="para0066" class="elsevierStylePara elsevierViewall">Delay in initial assessment &#8211; 16 &#37; &#40;4&#47;25&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0019"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Lobato et al&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0020"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0021"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0022"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0023"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">161 children under 5 years diagnosed with TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0024"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0004"><li class="elsevierStyleListItem" id="celistitem0011"><span class="elsevierStyleLabel">&#8226;</span><p id="para0067" class="elsevierStylePara elsevierViewall">TB contact &#8211; 37 &#37; &#40;59&#47;161&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0012"><span class="elsevierStyleLabel">&#8226;</span><p id="para0068" class="elsevierStylePara elsevierViewall">Contact Tracing &#8211; 26 &#37; &#40;43&#47;161&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0013"><span class="elsevierStyleLabel">&#8226;</span><p id="para0069" class="elsevierStylePara elsevierViewall">Household contacts - 84 &#37; &#40;36&#47;43&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0014"><span class="elsevierStyleLabel">&#8226;</span><p id="para0070" class="elsevierStylePara elsevierViewall">Eligible but did not receive LTBI treatment &#8211; 13&#46;9 &#37; &#40;6&#47;43&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0015"><span class="elsevierStyleLabel">&#8226;</span><p id="para0071" class="elsevierStylePara elsevierViewall">40 &#37; contact investigation failure &#40;17&#47;43&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0025"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Du Preez K et al&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0027"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">South Africa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0028"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0029"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">614 children under 14 years diagnosed with TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0030"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0005"><li class="elsevierStyleListItem" id="celistitem0016"><span class="elsevierStyleLabel">&#8226;</span><p id="para0072" class="elsevierStylePara elsevierViewall">Previous TB contact - 54&#46;2 &#37; &#40;333&#47;614&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0017"><span class="elsevierStyleLabel">&#8226;</span><p id="para0073" class="elsevierStylePara elsevierViewall">Household contacts - 83 &#37; &#40;280&#47;333&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0018"><span class="elsevierStyleLabel">&#8226;</span><p id="para0074" class="elsevierStylePara elsevierViewall">Eligible but did not undergo LTBI treatment - 74 &#37; &#40;146&#47;197&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0031"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">du Preez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0032"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0033"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">South Africa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0034"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0035"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">99 children under 13 years with TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0036"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0006"><li class="elsevierStyleListItem" id="celistitem0019"><span class="elsevierStyleLabel">&#8226;</span><p id="para0075" class="elsevierStylePara elsevierViewall">40&#37; TB contact &#40;38&#47;96&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0020"><span class="elsevierStyleLabel">&#8226;</span><p id="para0076" class="elsevierStylePara elsevierViewall">86 &#37; of children with indication did not receive LTBI prophylaxis&#40;31&#47;36&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0037"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Carvalho et al&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0038"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0039"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0040"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0041"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">544 children under 15 years treated for TB in five cities in Rio de Janeiro&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0042"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0007"><li class="elsevierStyleListItem" id="celistitem0021"><span class="elsevierStyleLabel">&#8226;</span><p id="para0077" class="elsevierStylePara elsevierViewall">Previous TB contact &#8211; 68&#46;7 &#37; &#40;222&#47;323&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0022"><span class="elsevierStyleLabel">&#8226;</span><p id="para0078" class="elsevierStylePara elsevierViewall">LTBI screening - 35 &#37; &#40;78&#47;223&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0023"><span class="elsevierStyleLabel">&#8226;</span><p id="para0079" class="elsevierStylePara elsevierViewall">LTBI treatment &#8211; 17 &#37; &#40;13&#47;78&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0043"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Feiterna-Sperling et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0044"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0045"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Germany&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0046"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective cohort&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0047"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">48 children under 15 years diagnosed and treated for TB at the pediatric TB outpatient clinic of a tertiary hospital in Berlin&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0048"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0008"><li class="elsevierStyleListItem" id="celistitem0024"><span class="elsevierStyleLabel">&#8226;</span><p id="para0080" class="elsevierStylePara elsevierViewall">Contact tracing - 75 &#37; &#40;36&#47;48&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0025"><span class="elsevierStyleLabel">&#8226;</span><p id="para0081" class="elsevierStylePara elsevierViewall">Screening &#8211; 6&#46;3 &#37; &#40;3&#47;36&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0026"><span class="elsevierStyleLabel">&#8226;</span><p id="para0082" class="elsevierStylePara elsevierViewall">LTBI treatment - 8&#46;3 &#37; &#40;3&#47;36&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0027"><span class="elsevierStyleLabel">&#8226;</span><p id="para0083" class="elsevierStylePara elsevierViewall">83&#46;3 &#37; did not receive LTBI as they already had TB disease</p></li><li class="elsevierStyleListItem" id="celistitem0028"><span class="elsevierStyleLabel">&#8226;</span><p id="para0084" class="elsevierStylePara elsevierViewall">Household contacts &#8211; 77 &#37; &#40;28&#47;36&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0029"><span class="elsevierStyleLabel">&#8226;</span><p id="para0085" class="elsevierStylePara elsevierViewall">Average contact time 3 months</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall">Characteristics of studies that evaluated missed opportunities in the prevention and diagnosis of pediatric TB&#44; scoping review&#46;</p>"
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                  "referenciaCompleta" => "World Health Organization &#40;WHO&#41;&#46; Global tuberculosis report 2021&#46; 14 October 2021 &#124; Report&#46; &#91;cited 5 February 2023&#93;&#46; Available from&#58; <a target="_blank" href="https://www.who.int/publications/i/item/9789240037021">https&#58;&#47;&#47;www&#46;who&#46;int&#47;publications&#47;i&#47;item&#47;9789240037021</a>"
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                    0 => array:2 [
                      "titulo" => "Boletim Epidemiol&#243;gico - Tuberculose"
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                      "WWW" => array:1 [
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                0 => array:1 [
                  "referenciaCompleta" => "World Health Organization &#40;WHO&#41;&#46; Global tuberculosis report 2022&#46; 27 October 2022 &#124; Global report&#46; &#91;cited 5 February 2023&#93;&#46; Available from&#58; <a target="_blank" href="https://www.who.int/publications/i/item/9789240061729">https&#58;&#47;&#47;www&#46;who&#46;int&#47;publications&#47;i&#47;item&#47;9789240061729</a>"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "WHO Consolidated Guidelines on tuberculosis&#46; Module 5&#58; Management of Tuberculosis in Children and Adolescents"
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                  "referenciaCompleta" => "WHO Team&#46; Global Tuberculosis Programme &#40;GTB&#41;&#46; WHO consolidated guidelines on tuberculosis&#46; Module 1&#58; prevention &#8211; tuberculosis preventive treatment&#46; 25 February 2020 &#124; Guideline &#91;cited 5 February 2023&#93;&#46; Available from&#58; <a target="_blank" href="https://www.who.int/publications/i/item/9789240001503">https&#58;&#47;&#47;www&#46;who&#46;int&#47;publications&#47;i&#47;item&#47;9789240001503</a>"
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                  "referenciaCompleta" => "Brasil&#46; Minist&#233;rio da Sa&#250;de&#46; Protocolo de vigil&#226;ncia da infec&#231;&#227;o latente pelo Mycobacterium tuberculosis no Brasil&#46; 2018&#46; Bras&#237;lia&#58; Secretaria de Vigil&#226;ncia em Sa&#250;de&#59; Departamento de Vigil&#226;ncia das Doen&#231;as Transmiss&#237;veis&#59; 2018&#46; &#91;cited 5 February 2023&#93;&#46; Available from&#58;<a target="_blank" href="https://bvsms.saude.gov.br/bvs/publicacoes/protocolo_vigilancia_infeccao_latente_mycobacterium_tuberculosis_brasil.pdf">https&#58;&#47;&#47;bvsms&#46;saude&#46;gov&#46;br&#47;bvs&#47;publicacoes&#47;protocolo&#95;vigilancia&#95;infeccao&#95;latente&#95;mycobacterium&#95;tuberculosis&#95;brasil&#46;pdf</a>"
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Review article
Missed opportunities in the prevention and diagnosis of pediatric tuberculosis: a scoping review
Daniela Otoni Russoa,b,
Corresponding author
dani.ot.russo@hotmail.com

Corresponding author.
, Ana Luisa Lodi Jimenezc, Lilian Martins Oliveira Diniza,b, Claudete Araújo Cardosod, Roberta Maia de Castro Romanellib
a Hospital Infantil João Paulo II, Departamento de Infectologia Pediátrica, Belo Horizonte, MG, Brazil
b Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
c Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG, Brazil
d Universidade Federal Fluminense, Faculdade de Medicina, Departamento Materno-Infantil, Niterói, RJ, Brazil
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          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Selection of studies evaluating the missed opportunities in the prevention and diagnosis of pediatric tuberculosis&#46; <span class="elsevierStyleBold">&#42; PCC</span> P &#40;population&#41; &#61; is composed of children and adolescents under 18 years of age with TB&#59; C &#40;concept&#41; &#61; refers to missed opportunities such as contact with adults with TB and failure in LTBI investigation or treatment&#59; C &#40;context&#41;&#58; is defined as the diagnosis of TB disease&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0007">Introduction</span><p id="para0005" class="elsevierStylePara elsevierViewall">Despite its ancient origins&#44; tuberculosis &#40;TB&#41; remains a major public health concern&#46; The pediatric population accounts for approximately 11 &#37; of the global disease burden&#44; implying that approximately 1&#46;1 million children suffer from TB every year&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a> In 2022&#44; 78&#44;057 new cases of TB were diagnosed in Brazil&#44; and 3&#46;5 &#37; &#40;2703&#41; occurred in children under 15 years of age&#44; proportions recorded in the historical series from 2012 to 2022&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a></p><p id="para0006" class="elsevierStylePara elsevierViewall">In 2022&#44; 78&#46;057 new cases of TB were diagnosed in Brazil&#44; with 3&#46;5 &#37; &#40;2703&#41; occurring in children under 15 years of age&#46; This proportion represents a historical number of cases between 2012 and 2022&#46; In the pediatric sample&#44; patients from 0 to 4 years correspond to 37&#46;5 &#37;&#59; from 5 to 10 years represent 22 &#37; and between 10 and 15 years correspond to 40&#46;5 &#37; of cases&#46; Adolescents from 15 to 18 years old are in another group&#44; and the incidence of cases is 6 &#37; of the general population&#46;</p><p id="para0007" class="elsevierStylePara elsevierViewall">Diagnosing TB in children is challenging because of several factors&#44; including the paucibacillary nature of the disease&#44; non-specific symptoms&#44; clinical similarity with other childhood diseases&#44; and difficulty in collecting samples for diagnosis&#46; As per a 2020 estimate&#44; 63 &#37; of children and adolescents under 15 years of age with TB were not notified or did not have access to diagnostic and treatment services&#59; the proportion is even higher &#40;72 &#37;&#41; for children under five&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a></p><p id="para0008" class="elsevierStylePara elsevierViewall">The global report of the World Health Organization &#40;WHO&#41;&#44; with data updated in 2022&#44; reinforces that the global goals defined by the &#8220;End TB&#8221; strategy for controlling the number of cases and deaths from the disease are far from being met&#46; A reduction in the numbers diagnosed&#44; in access to essential TB services&#44; and&#44; consequently&#44; an increase in the number of deaths was observed in the last two years&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> The coronavirus disease 2019 &#40;COVID-19&#41; pandemic had a negative impact on access to diagnosis and reduced investments and funds destined for essential TB services&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a></p><p id="para0009" class="elsevierStylePara elsevierViewall">In addition to TB disease&#44; it is important to identify infected children who have shown no symptoms&#46; <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> infection without the manifestation of active disease is called latent tuberculosis infection &#40;LTBI&#41;&#44; and treating children in this phase&#44; in addition to improving the prognosis and reducing individual morbidity and mortality&#44; also substantially reduces the community transmission of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0004"><span class="elsevierStyleSup">4-6</span></a> Most children were infected through recent household contacts&#44; in the last two years&#44; mainly parents and caregivers&#46; This reflects the fact that every child with TB should be considered a sentinel event and indicative of recent disease transmission&#46;</p><p id="para0010" class="elsevierStylePara elsevierViewall">There are well-established protocols for contact tracing and treatment of LTBI in children&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> In Brazil&#44; guidelines structure LTBI surveillance into five pillars&#58; &#40;1&#41; identification of people who are more likely to have LTBI or with higher risks of illness&#59; &#40;2&#41; identification of persons with LTBI&#59; &#40;3&#41; correct indication of treatment &#40;4&#41; notification and &#40;5&#41; monitoring of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0011" class="elsevierStylePara elsevierViewall">Despite several advances in recent decades&#44; many difficulties still need to be overcome in the diagnosis of LTBI as well as in the diagnosis of TB disease&#46; This scoping review aimed to systematically map the research conducted in this area and identify the potential barriers&#44; delays&#44; and missed opportunities for the prevention and diagnosis of childhood TB&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0008">Methods</span><p id="para0012" class="elsevierStylePara elsevierViewall">This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses &#40;PRISMA&#41; extension for scoping reviews &#40;2018&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a></p><p id="para0013" class="elsevierStylePara elsevierViewall">To achieve the proposed objective of the review&#44; the guiding question was&#58; What is the scientific evidence of missed opportunities in the prevention and diagnosis of TB in pediatric patients&#63;</p><p id="para0014" class="elsevierStylePara elsevierViewall">Following the acronym PCC&#44; the population &#40;P&#41; is composed of children and adolescents under 18 years of age with TB disease&#59; the concept &#40;C&#41; refers to missed opportunities such as contact with adults with TB and failure in LTBI investigation or treatment&#59; and the context &#40;C&#41; is defined as the diagnosis of TB disease&#46;</p><p id="para0015" class="elsevierStylePara elsevierViewall">The protocol was registered at <a href="https://www.protocols.io">https&#58;&#47;&#47;www&#46;protocols&#46;io</a> &#40;DOI&#58; dx&#46;doi&#46;org&#47;10&#46;17504&#47;protocols&#46;io&#46;x54v9dwwmg3e&#47;v1&#41;&#46;</p><p id="para0016" class="elsevierStylePara elsevierViewall">Systematic searches were undertaken between July 2022 and November 2022 in the databases VHL&#47;Lilacs&#44; Medline via PubMed&#44; Cochrane&#44; Scopus&#44; and Web of Science&#46; The following descriptors were used&#58; &#8220;tuberculosis&#8221;&#44; &#8220;missed opportunities&#8221; &#8220;diagnosis&#8221;&#44; &#8220;prevention&#8221;&#44; &#8220;case discovery&#8221;&#44; and &#8220;gap&#8221;&#46;</p><p id="para0017" class="elsevierStylePara elsevierViewall">The final quest in each base is presented below&#58;<ul class="elsevierStyleList" id="celist0001"><li class="elsevierStyleListItem" id="celistitem0001"><span class="elsevierStyleLabel">&#8226;</span><p id="para0018" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">VHL&#47;Lilacs</span>&#58; &#40;diagn&#243;stico OR diagnosis OR diagnostic OR &#34;Oportunidade Perdida&#34; OR &#34;Oportunidades Perdidas&#34; OR &#34;Missed Opportunity&#34; OR &#34;Missed Opportunities&#34;&#41; AND &#40;&#34;Preven&#231;&#227;o de Doen&#231;as&#34; OR &#34;Disease Prevention&#34; OR &#34;Prevenci&#243;n de Enfermedades&#34; OR &#34;Pr&#233;vention des Maladies&#34; OR preven&#231;&#227;o OR prevention&#41; AND &#40;tuberculose OR tuberculosis&#41; AND &#40;pediatria OR pediatrics OR pediatr&#237;a OR p&#233;diatrie OR crian&#231;a OR child OR ni&#241;o OR enfant&#41; AND &#40;db&#58;&#40;&#34;LILACS&#34; OR &#34;IBECS&#34; OR &#34;BINACIS&#34; OR &#34;CUMED&#34; OR &#34;BIGG&#34; OR &#34;WHOLIS&#34; OR &#34;MULTIMEDIA&#34; OR &#34;BDENF&#34; OR &#34;LIPECS&#34; OR &#34;SES-SP&#34; OR &#34;colecionaSUS&#34; OR &#34;PAHO&#34; OR &#34;SOF&#34; OR &#34;campusvirtualsp&#95;brasil&#34; OR &#34;PAHOIRIS&#34; OR &#34;SMS-SP&#34;&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0002"><span class="elsevierStyleLabel">&#8226;</span><p id="para0019" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Medline via PubMed &#47; Scopus &#47; Web of Science &#47; Cochrane</span>&#58; &#40;Diagnosis OR &#34;Missed Opportunity&#34; OR &#34;Missed Opportunities&#34;&#41; AND &#40;&#34;Disease Prevention&#34; OR Prevention&#41; AND &#40;Tuberculosis&#41; AND &#40;Pediatrics OR Child&#41;</p></li></ul></p><p id="para0020" class="elsevierStylePara elsevierViewall">The inclusion criteria were originally published observational studies that included children and adolescents &#40;0&#8211;18 years&#41; with TB disease that addressed missed opportunities in the prevention and diagnosis of the disease&#46; The searches were not restricted to any language or date of publication&#46;</p><p id="para0021" class="elsevierStylePara elsevierViewall">Case reports&#44; abstracts&#44; consensuses&#44; letters to the editor&#44; and review articles were excluded&#46; Articles that included adult populations or populations with LTBI were not considered&#46;</p><p id="para0022" class="elsevierStylePara elsevierViewall">Studies were selected after screening the title&#44; abstract&#44; or full text&#44; if necessary&#44; by two independent reviewers&#46; In cases of doubt or disagreement&#44; a third reviewer was consulted&#46;</p><p id="para0023" class="elsevierStylePara elsevierViewall">Thereafter&#44; the full text of all selected studies was read for data extraction&#46; The reviewers aimed to identify and establish the variables presented in the literature as missed opportunities for the diagnosis of TB&#46;</p><p id="para0024" class="elsevierStylePara elsevierViewall">For data summarization&#44; each article was tabulated in accordance with PRISMA guidelines&#58; author&#44; year&#44; number of studied populations included&#44; missed opportunities&#44; frequency of cases in each of the defined missed opportunities&#44; current statistics&#44; and conclusion&#46;</p></span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0009">Result</span><p id="para0025" class="elsevierStylePara elsevierViewall">A bibliographic review conducted from July 2022 to November 2022 identified 4617 studies&#46; After screening and analyzing the inclusion criteria&#44; seven articles published between 1992 and 2022 were selected &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0026" class="elsevierStylePara elsevierViewall">The seven studies summarized in <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a> cover the year of publication&#44; geographical location&#44; study design&#44; population&#44; and main findings&#46; As seen from the Table&#44; three studies were carried out in the United States&#44; two in South Africa&#44; and one each in Brazil and Germany&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><p id="para0027" class="elsevierStylePara elsevierViewall">The main missed opportunities identified in the studies were failures in screening the contacts of bacilliferous patients&#44; identifying symptomatic infected children in routine consultations&#44; and the institution of LTBI treatment&#46; Failure was also observed in the routine screening of risk groups for the development of active TB&#44; regardless of a known contact history&#44; as in the case of individuals living with HIV&#46;</p><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0010">Exposure to <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span></span><p id="para0028" class="elsevierStylePara elsevierViewall">The percentage of children with known contact with adults diagnosed with TB was largely diverse &#40;37 &#37; to 85 &#37;&#41;&#46; Among the three studies that reported this&#44; over 75 &#37; were classified as household contacts and most children were mainly with parents and caregivers&#46;</p><p id="para0029" class="elsevierStylePara elsevierViewall">The study by Carvalho et al&#46; addressed children diagnosed with TB in Rio de Janeiro&#44; Brazil&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> Among the 544 children&#44; 71 &#37; underwent follow-ups at a basic health unit and 29 &#37; at tertiary reference centers&#46; A high proportion of children &#40;68&#46;7 &#37;&#41; had previous contact with adults with TB&#46; Feiterna-Sperling et al&#46; evaluated 48 children diagnosed with TB treated at a tertiary hospital in Berlin&#59; in 91&#46;7 &#37; of the cases&#44; the child or at least one of the parents had left in another country&#46; In 77 &#37; of the cases&#44; the index case was a family member&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a></p><p id="para0030" class="elsevierStylePara elsevierViewall">The South African study by Du Preez et al&#46; &#40;2011&#41;&#44; which included 614 children with a confirmed microbiological diagnosis of TB&#44; reported 54&#46;2 &#37; previous contact with an adult with TB&#44; 83 &#37; of whom were family members&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> Another study by the same author in 2017 showed that 40 &#37; of the children had known prior contact with an adult with TB&#46;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a></p><p id="para0031" class="elsevierStylePara elsevierViewall">In the American study by Mehta&#44; the index case&#44; the source of childhood TB&#44; was identified in 78 &#37; of 109 cases&#46;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> Notably&#44; 21 &#37; of the childhood TB cases in the study population could have been avoided&#46; In the study by Lobato et al&#44; also undertaken in the USA&#44; the rate of children with previous known contact with an adult with TB was 37 &#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a> Among them&#44; 84 &#37; were household contacts&#44; and 44 &#37; had some risk factors associated with the disease&#44; such as alcohol&#47;drug abuse&#44; unemployment&#44; former street dwellers&#44; or health professionals&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0011">Contact tracing and screening</span><p id="para0032" class="elsevierStylePara elsevierViewall">As regards the investigation of children with known previous contacts&#44; the disease screening rate ranged from 35 &#37; in Brazil to 75 &#37; in Germany&#46; In the German study&#44; children diagnosed with TB disease were identified in two ways&#58; active search for contact tracing or triage &#40;81&#46;3 &#37;&#41; and passively through the patient&#39;s voluntary search for the health service to assess symptoms &#40;18&#46;7 &#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> In Germany&#44; the screening of risk groups for TB follows the WHO guidelines for countries with low disease burden&#44; and systematic screening is recommended for individuals living with HIV&#44; immunosuppressed patients or those with chronic diseases&#44; prisoners&#44; health professionals&#44; immigrants from countries with a high TB burden&#44; homeless people&#44; and illicit drug users&#46;</p><p id="para0033" class="elsevierStylePara elsevierViewall">Screening should be performed systematically by identifying symptoms &#40;cough&#44; fever&#44; weight loss&#44; and prostration&#41; and using chest radiography&#46; Confirmation of <span class="elsevierStyleItalic">M&#46; tuberculosis</span> infection can be performed using the tuberculin skin test &#40;TST&#41;&#44; or Interferon Gamma Release Assay &#40;IGRA&#41;&#46;</p><p id="para0034" class="elsevierStylePara elsevierViewall">The study by Mehta showed that of 109 cases of childhood TB&#44; 63 &#40;57&#46;8 &#37;&#41; were found through contact tracing&#44; 35 &#40;32&#46;1 &#37;&#41; were identified passively through the investigation of symptoms&#44; and 11 &#40;10&#46;1 &#37;&#41; were detected by routine screening&#46;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> In the study by Lobato et al&#44; only 26 &#37; of the 161 children were identified through contact tracing&#44; and 91 &#37; of the infected children referred for screening already had TB disease at the first assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a> It is estimated that 40 &#37; of TB disease cases could have been prevented&#46;</p><p id="para0035" class="elsevierStylePara elsevierViewall">In the report by Kimerling et al&#44; including an Alabama cohort&#44; based on contact tracing failure&#44; delay in the initial assessment&#44; or noncompliance with preventive therapy in eligible patients&#44; an identical rate of 21 &#37; of preventable cases was described&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0012">LTBI treatment</span><p id="para0036" class="elsevierStylePara elsevierViewall">Among the children with an indication for LTBI treatment&#44; 13&#46;9 &#37; in the US and 86 &#37; in South Africa did not receive the indicated preventive treatment&#46; In the Brazilian study&#44; previous treatment for LTBI was performed in only 17 &#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a></p><p id="para0037" class="elsevierStylePara elsevierViewall">In the 2011 South African study&#44; approximately 74 &#37; of children under five years of age eligible for chemoprophylaxis did not receive preventive treatment&#46; Among them&#44; 25 &#37; developed disseminated TB&#44; and 5&#46;1 &#37; died&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> In 2017&#44; another study undertaken by the same authors showed that only 14 &#37; of children eligible for preventive therapy received adequate treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a></p></span></span><span id="sec0007" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0013">Discussion</span><p id="para0038" class="elsevierStylePara elsevierViewall">Children are vulnerable to TB&#44; which is systematically neglected and must be prioritized&#46; To this end&#44; several steps need to be addressed&#58; tracing children who have been exposed to <span class="elsevierStyleItalic">M&#46; tuberculosis</span> &#40;contact tracing&#41;&#44; identifying those at greater risk of developing TB by screening risk groups&#44; detecting and treating LTBI in these children&#44; implementing LTBI treatment&#44; identifying sick children through routine screening &#40;childcare&#41;&#44; and developing and expanding public health strategies for appropriate fulfillment of these steps&#46;<a class="elsevierStyleCrossRef" href="#bib0016"><span class="elsevierStyleSup">16</span></a></p><p id="para0039" class="elsevierStylePara elsevierViewall">Carvalho et al&#46; demonstrated that despite the high rate of known previous contact with TB&#44; only 17 &#37; of children were diagnosed and treated for LTBI&#44; suggesting a failure in the identification and treatment of LTBI&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> A study carried out in eight countries with a high burden of the disease showed that contact tracing helped to detect new cases of TB disease in 12 &#37; of contacts and the prevalence of LTBI was 72 &#37;&#46;<span class="elsevierStyleSup">4</span> Therefore&#44; screening household contacts for TB is a high-yield and cost-effective strategy&#46;</p><p id="para0040" class="elsevierStylePara elsevierViewall">In European countries with a low disease burden&#44; contact tracing appears to occur more effectively&#46; In the study by Feiterna-Sperling carried out in Berlin&#44; Germany&#44; 81&#46;3 &#37; of the 48 children were identified through an active search by contact tracing or screening&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> Among them&#44; 83 &#37; did not receive treatment for LTBI because they already met the TB disease criteria at the time of the first assessment&#46;</p><p id="para0041" class="elsevierStylePara elsevierViewall">Although the average time between the diagnosis of the source case and the assessment of the child in contact occurs early&#44; with an average of approximately 18 days&#44; the time between the diagnosis of the source case and the onset of symptoms was on average 3 months&#46; With prolonged exposure and a high bacterial load associated with an increased risk of TB transmission&#44; the biggest challenge in this population is the timely identification of adult cases&#46; Even if it is not possible&#44; in most cases&#44; to detect TB in its latent infection phase&#44; the screening program allows the diagnosis of TB disease in its initial phase&#44; contributing to a better prognosis&#44; reduction of morbidity and mortality&#44; and interruption of the chain of TB transmission&#46;</p><p id="para0042" class="elsevierStylePara elsevierViewall">These challenges are greatest in underdeveloped countries with high TB burdens&#46; The shortage of financial resources hinders the availability of tests that detect <span class="elsevierStyleItalic">M&#46; tuberculosis</span> &#40;tuberculin skin test or IGRA&#41;&#44; leads to a shortage of trained professionals for contact tracing&#44; and even results in difficulty in conducting and interpreting imaging tests&#46;</p><p id="para0043" class="elsevierStylePara elsevierViewall">According to Du Preez et al&#44; in two studies carried out in South Africa with an interval of 6 years &#40;2011&#8211;2017&#41;&#44; the number of children eligible for TB preventive therapy who did not receive chemoprophylaxis remained above 70 &#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a> WHO has considered the identification and treatment of LTBI the cornerstone of efforts to eliminate TB by 2030&#46; It is estimated that &#62;80 &#37; of adults and children at risk of <span class="elsevierStyleItalic">M&#46; tuberculosis</span> infection do not complete the care cascade&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a> A scoping review was conducted in 2021 identifying the following barriers to the care of children evaluated and treated for LTBI&#59; failure to identify children at high risk for LTBI&#44; low availability of tests to diagnose the infection&#44; refusal of parents to perform the test&#44; or adherence to treatment due to the stigma of the disease or fear of adverse effects&#44; and loss to follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a></p><p id="para0044" class="elsevierStylePara elsevierViewall">The unavailability of tests that detect <span class="elsevierStyleItalic">M&#46; tuberculosis</span> is a reality in underdeveloped countries&#46; In the Brazilian study&#44; the tuberculin skin test was performed in 73 &#37; of the patients&#44; and the positivity was 79&#46;6 &#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> According to the WHO recommendation&#44; the test is not essential for the diagnosis of LTBI in high-risk situations&#44; and chemoprophylaxis should be administered to children in contact with TB patients even when the test is not available&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a> This guideline is based on the fact that preventive treatment is well tolerated in young children&#44; and due to the paucibacillary nature of the disease in the pediatric population&#44; the risk of inducing resistance to antituberculostatic drugs is minimal&#46; The situation is different in adolescents who generally have multi-bacillary disease&#44; requiring a better investigation to rule out TB disease before LTBI treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a></p><p id="para0045" class="elsevierStylePara elsevierViewall">Tuberculosis in adolescence is a topic that is rarely discussed&#46; In the present review&#44; Carvalho et al&#46; report 8&#46;3 &#37; of patients aged 10 to 15 years but do not perform any specific analysis for this subgroup&#46; Feiterna-Sperling reports 33 &#37; of patients aged between 10 and 15 years but also does not report any difference observed in relation to younger children&#46; The literature describes evolution and clinical manifestations like those seen in young adults&#46; The specific characteristics of this age group&#44; such as endocrine-metabolic changes and psychosocial issues&#44; are generally not valued&#46;</p><p id="para0046" class="elsevierStylePara elsevierViewall">A USA study conducted in 1992 identified 21 &#37; of TB disease cases in children in the studied population that could have been avoided considering failure or delay in contact tracing&#44; incomplete evaluation&#47;workup&#44; and loss of follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a></p><p id="para0047" class="elsevierStylePara elsevierViewall">Two North American studies conducted in 2000 were analyzed&#46; In one referring to the population of Alabama&#44; an identical rate of 21 &#37; of preventable cases was described&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> In the other 37 &#37; of the patients &#40;72&#46;8 &#37;&#41; had known prior contact with a TB carrier&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a> However&#44; due to failure to investigate the source cases&#44; delay in investigating contacts&#44; incomplete assessment due to the unavailability of tuberculin skin testing and radiological examination&#44; or inadequate&#47;missing treatment for LTBI&#44; it is estimated that 40 &#37; of TB cases could have been prevented&#46; Evaluating the time elapsed since the first study&#44; it was observed that the challenges encountered in the 11990s remain in force in coping with TB in children even today&#46;</p><p id="para0048" class="elsevierStylePara elsevierViewall">A systematic review and meta-analysis conducted in 2022 analyzed interventions in the TB care cascade&#46; Relatively simple interventions&#44; such as education&#44; counseling&#44; and incentives&#44; could substantially reduce the burden of the disease&#46; In practice&#44; this translates to updating clinical guidelines&#44; integrating care&#44; providing tools and resources to improve case detection&#44; training staff&#44; providing TB educational materials for patients&#44; and involving laypeople in service delivery&#46;<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> These measures sensitize health professionals and raise attention and strong suspicion for the diagnosis of TB in children in routine pediatric consultations&#44; which is essential for early diagnosis&#46;</p><p id="para0049" class="elsevierStylePara elsevierViewall">A 2023 systematic review estimated the number of children screened to detect a single case of TB disease &#40;NNS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a> Most studies have been conducted in countries with a high disease burden&#44; and mainly screening for symptoms was undertaken&#46; The estimated NNS in healthcare settings &#40;109&#41; was lower than the estimated NNS in the community &#40;1117&#41; and school settings &#40;464&#41;&#46; Screening in child health services&#44; such as outpatient clinics and wards&#44; is a potential opportunity to increase the diagnosis of childhood TB&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a></p><p id="para0050" class="elsevierStylePara elsevierViewall">The North American studies identified racial and economic barriers to TB care&#46; One study observed that all patients who presented with missed opportunities were black&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> while the other demonstrated that 44 &#37; of the source cases of childhood TB had social risk factors&#44; such as unemployment or substance abuse&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a> Despite being a disease present in all social spheres&#44; the negative impact of TB on those with greater socioeconomic vulnerability is undeniable&#44; considering overcrowding&#44; poor ventilation&#44; food insecurity &#40;malnutrition&#41;&#44; and indoor and outdoor air pollution&#46; Therefore&#44; increased attention and public health policies aimed at this population are required&#46;</p></span><span id="sec0008" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0014">Summary of evidence</span><p id="para0051" class="elsevierStylePara elsevierViewall">There are still many missed opportunities for preventing and diagnosing childhood TB&#46;</p><p id="para0052" class="elsevierStylePara elsevierViewall">In developed countries with a low disease burden&#44; the main shortcoming is the delay in diagnosing bacilliferous adults who are in contact with young children&#46; In this context&#44; the problem is mainly concentrated in the portion of the population with greater socioeconomic vulnerability&#44; which includes Afro-descendants and immigrants&#46;</p><p id="para0053" class="elsevierStylePara elsevierViewall">In underdeveloped countries with a high disease burden&#44; the greatest challenge is tracking children who are in contact with adults with TB&#46; Closing persistent gaps in LTBI management and the early diagnosis of TB are paramount&#46; The main difficulties encountered were notification of the index case&#44; identification of contacts and patients with LTBI&#44; recommendation and adherence to preventive treatment&#44; available workups&#44; high suspicion of professionals&#44; and early diagnosis&#46;</p><p id="para0054" class="elsevierStylePara elsevierViewall">To intervene in this process&#44; it is necessary to improve public health policies through financial investment&#44; the availability of new technologies&#44; professional training&#44; and the awareness of parents and guardians&#46; The positive legacy of the COVID-19 pandemic should take advantage of community mobilization&#44; and rapid scientific development in the management of infectious diseases should be encouraged&#46;</p></span><span id="sec0009" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0015">Limitations</span><p id="para0055" class="elsevierStylePara elsevierViewall">This study has some limitations&#46; A quality assessment of the articles was not performed because of the heterogeneity of the studies&#46;</p><p id="para0056" class="elsevierStylePara elsevierViewall">The time interval of publication of the included articles was long &#40;1992 to 2022&#41;&#46; Thus&#44; the data presented may have been influenced by the incidence of the disease and the heterogeneity of the protocols in force at different times&#46;</p><p id="para0057" class="elsevierStylePara elsevierViewall">Most articles did not present sophisticated statistical analyses and described only the percentage of missed opportunities&#46; It is necessary to conduct new original studies with greater methodological rigor so that it is possible to carry out a systematic review&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Result"
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              "identificador" => "sec0004"
              "titulo" => "Exposure to Mycobacterium tuberculosis"
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            1 => array:2 [
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              "titulo" => "Contact tracing and screening"
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            2 => array:2 [
              "identificador" => "sec0006"
              "titulo" => "LTBI treatment"
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        5 => array:2 [
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          "titulo" => "Discussion"
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    "fechaRecibido" => "2023-06-17"
    "fechaAceptado" => "2023-10-15"
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            1 => "Missed opportunities"
            2 => "Diagnosis"
            3 => "Prevention"
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    "resumen" => array:1 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Objectives</span><p id="spara004" class="elsevierStyleSimplePara elsevierViewall">Identify potential barriers&#44; delays&#44; and missed opportunities in the prevention and diagnosis of childhood TB&#46;</p></span> <span id="abss0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Methods</span><p id="spara005" class="elsevierStyleSimplePara elsevierViewall">Scoping review according to the PRISMA extension&#46; The definitions considered for the selection followed the acronym PCC where the population &#40;P&#41; is children under 18 years of age with TB disease&#44; the concept &#40;C&#41; refers to missed opportunities for prevention and diagnosis&#44; and context &#40;C&#41; is defined as a diagnosis of TB disease&#46; The authors searched systematically in the databases&#59; VHL&#47;Lilacs&#44; Medline via PubMed&#44; Cochrane&#44; Scopus&#44; and Web of Science&#44; without date or language limitation&#46;</p></span> <span id="abss0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Results</span><p id="spara006" class="elsevierStyleSimplePara elsevierViewall">Seven studies were included&#46; In developed countries&#44; with low disease burden&#44; the main shortcoming is the delay in diagnosing bacilliferous adults in contact with young children&#46; This problem is concentrated in the portion of the population with socioeconomic vulnerability&#46; In underdeveloped countries&#44; with a high burden of disease&#44; the biggest challenge is tracking children who come into contact with bacilliferous patients&#46;</p></span> <span id="abss0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Conclusions</span><p id="spara007" class="elsevierStyleSimplePara elsevierViewall">There are still many missed opportunities in the prevention and diagnosis of childhood TB&#46; The positive legacy of the COVID-19 pandemic should be taken advantage of and the encouragement of scientific development in the management of infectious diseases should be taken&#46;</p></span>"
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          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Selection of studies evaluating the missed opportunities in the prevention and diagnosis of pediatric tuberculosis&#46; <span class="elsevierStyleBold">&#42; PCC</span> P &#40;population&#41; &#61; is composed of children and adolescents under 18 years of age with TB&#59; C &#40;concept&#41; &#61; refers to missed opportunities such as contact with adults with TB and failure in LTBI investigation or treatment&#59; C &#40;context&#41;&#58; is defined as the diagnosis of TB disease&#46;</p>"
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          "leyenda" => "<p id="spara003" class="elsevierStyleSimplePara elsevierViewall">TB&#44; Tuberculosis&#59; LTBI&#44; latent tuberculosis infection&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0001"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0002"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0003"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0004"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Type of study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0005"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0006"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Main findings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0007"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Mehta &#38; Bentley<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0008"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1992&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0009"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0010"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0011"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">109 children under 15 years diagnosed with TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0012"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0002"><li class="elsevierStyleListItem" id="celistitem0003"><span class="elsevierStyleLabel">&#8226;</span><p id="para0059" class="elsevierStylePara elsevierViewall">77&#46;9 &#37; TB contact &#40;85&#47;109&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0004"><span class="elsevierStyleLabel">&#8226;</span><p id="para0060" class="elsevierStylePara elsevierViewall">Contact tracing &#8211; 57&#46;8 &#37; &#40;63&#47;109&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0005"><span class="elsevierStyleLabel">&#8226;</span><p id="para0061" class="elsevierStylePara elsevierViewall">Screening - 10&#46;1 &#37; &#40;11&#47;109&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0006"><span class="elsevierStyleLabel">&#8226;</span><p id="para0062" class="elsevierStylePara elsevierViewall">LTBI treatment &#8211; 10 &#37; &#40;11&#47;109&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0013"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Kimerling et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0014"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0015"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0016"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0017"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">120 children under 15 years diagnosed with TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0018"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0003"><li class="elsevierStyleListItem" id="celistitem0007"><span class="elsevierStyleLabel">&#8226;</span><p id="para0063" class="elsevierStylePara elsevierViewall">21 &#37; preventable cases &#40;25&#47;120&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0008"><span class="elsevierStyleLabel">&#8226;</span><p id="para0064" class="elsevierStylePara elsevierViewall">16 &#37; did not receive adequate LTBI prophylaxis &#40;4&#47;25&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0009"><span class="elsevierStyleLabel">&#8226;</span><p id="para0065" class="elsevierStylePara elsevierViewall">Contact tracking failure &#8211; 48 &#37; &#40;12&#47;25&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0010"><span class="elsevierStyleLabel">&#8226;</span><p id="para0066" class="elsevierStylePara elsevierViewall">Delay in initial assessment &#8211; 16 &#37; &#40;4&#47;25&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0019"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Lobato et al&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0020"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0021"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0022"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0023"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">161 children under 5 years diagnosed with TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0024"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0004"><li class="elsevierStyleListItem" id="celistitem0011"><span class="elsevierStyleLabel">&#8226;</span><p id="para0067" class="elsevierStylePara elsevierViewall">TB contact &#8211; 37 &#37; &#40;59&#47;161&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0012"><span class="elsevierStyleLabel">&#8226;</span><p id="para0068" class="elsevierStylePara elsevierViewall">Contact Tracing &#8211; 26 &#37; &#40;43&#47;161&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0013"><span class="elsevierStyleLabel">&#8226;</span><p id="para0069" class="elsevierStylePara elsevierViewall">Household contacts - 84 &#37; &#40;36&#47;43&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0014"><span class="elsevierStyleLabel">&#8226;</span><p id="para0070" class="elsevierStylePara elsevierViewall">Eligible but did not receive LTBI treatment &#8211; 13&#46;9 &#37; &#40;6&#47;43&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0015"><span class="elsevierStyleLabel">&#8226;</span><p id="para0071" class="elsevierStylePara elsevierViewall">40 &#37; contact investigation failure &#40;17&#47;43&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0025"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Du Preez K et al&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0027"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">South Africa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0028"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0029"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">614 children under 14 years diagnosed with TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0030"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0005"><li class="elsevierStyleListItem" id="celistitem0016"><span class="elsevierStyleLabel">&#8226;</span><p id="para0072" class="elsevierStylePara elsevierViewall">Previous TB contact - 54&#46;2 &#37; &#40;333&#47;614&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0017"><span class="elsevierStyleLabel">&#8226;</span><p id="para0073" class="elsevierStylePara elsevierViewall">Household contacts - 83 &#37; &#40;280&#47;333&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0018"><span class="elsevierStyleLabel">&#8226;</span><p id="para0074" class="elsevierStylePara elsevierViewall">Eligible but did not undergo LTBI treatment - 74 &#37; &#40;146&#47;197&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0031"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">du Preez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0032"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0033"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">South Africa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0034"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0035"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">99 children under 13 years with TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0036"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0006"><li class="elsevierStyleListItem" id="celistitem0019"><span class="elsevierStyleLabel">&#8226;</span><p id="para0075" class="elsevierStylePara elsevierViewall">40&#37; TB contact &#40;38&#47;96&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0020"><span class="elsevierStyleLabel">&#8226;</span><p id="para0076" class="elsevierStylePara elsevierViewall">86 &#37; of children with indication did not receive LTBI prophylaxis&#40;31&#47;36&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0037"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Carvalho et al&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0038"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0039"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0040"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0041"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">544 children under 15 years treated for TB in five cities in Rio de Janeiro&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0042"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0007"><li class="elsevierStyleListItem" id="celistitem0021"><span class="elsevierStyleLabel">&#8226;</span><p id="para0077" class="elsevierStylePara elsevierViewall">Previous TB contact &#8211; 68&#46;7 &#37; &#40;222&#47;323&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0022"><span class="elsevierStyleLabel">&#8226;</span><p id="para0078" class="elsevierStylePara elsevierViewall">LTBI screening - 35 &#37; &#40;78&#47;223&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0023"><span class="elsevierStyleLabel">&#8226;</span><p id="para0079" class="elsevierStylePara elsevierViewall">LTBI treatment &#8211; 17 &#37; &#40;13&#47;78&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0043"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Feiterna-Sperling et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0044"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0045"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Germany&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0046"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Retrospective cohort&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0047"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">48 children under 15 years diagnosed and treated for TB at the pediatric TB outpatient clinic of a tertiary hospital in Berlin&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0048"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><ul class="elsevierStyleList" id="celist0008"><li class="elsevierStyleListItem" id="celistitem0024"><span class="elsevierStyleLabel">&#8226;</span><p id="para0080" class="elsevierStylePara elsevierViewall">Contact tracing - 75 &#37; &#40;36&#47;48&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0025"><span class="elsevierStyleLabel">&#8226;</span><p id="para0081" class="elsevierStylePara elsevierViewall">Screening &#8211; 6&#46;3 &#37; &#40;3&#47;36&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0026"><span class="elsevierStyleLabel">&#8226;</span><p id="para0082" class="elsevierStylePara elsevierViewall">LTBI treatment - 8&#46;3 &#37; &#40;3&#47;36&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0027"><span class="elsevierStyleLabel">&#8226;</span><p id="para0083" class="elsevierStylePara elsevierViewall">83&#46;3 &#37; did not receive LTBI as they already had TB disease</p></li><li class="elsevierStyleListItem" id="celistitem0028"><span class="elsevierStyleLabel">&#8226;</span><p id="para0084" class="elsevierStylePara elsevierViewall">Household contacts &#8211; 77 &#37; &#40;28&#47;36&#41;</p></li><li class="elsevierStyleListItem" id="celistitem0029"><span class="elsevierStyleLabel">&#8226;</span><p id="para0085" class="elsevierStylePara elsevierViewall">Average contact time 3 months</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall">Characteristics of studies that evaluated missed opportunities in the prevention and diagnosis of pediatric TB&#44; scoping review&#46;</p>"
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                  "referenciaCompleta" => "World Health Organization &#40;WHO&#41;&#46; Global tuberculosis report 2021&#46; 14 October 2021 &#124; Report&#46; &#91;cited 5 February 2023&#93;&#46; Available from&#58; <a target="_blank" href="https://www.who.int/publications/i/item/9789240037021">https&#58;&#47;&#47;www&#46;who&#46;int&#47;publications&#47;i&#47;item&#47;9789240037021</a>"
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                  "referenciaCompleta" => "World Health Organization &#40;WHO&#41;&#46; Global tuberculosis report 2022&#46; 27 October 2022 &#124; Global report&#46; &#91;cited 5 February 2023&#93;&#46; Available from&#58; <a target="_blank" href="https://www.who.int/publications/i/item/9789240061729">https&#58;&#47;&#47;www&#46;who&#46;int&#47;publications&#47;i&#47;item&#47;9789240061729</a>"
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                      "titulo" => "WHO Consolidated Guidelines on tuberculosis&#46; Module 5&#58; Management of Tuberculosis in Children and Adolescents"
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                      "titulo" => "PRISMA Extension for Scoping Reviews &#40;PRISMA-ScR&#41;&#58; checklist and explanation"
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                          "etal" => true
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                            2 => "W&#46; Zarin"
                            3 => "K&#46;K&#46; O&#39;Brien"
                            4 => "H&#46; Colquhoun"
                            5 => "D&#46; Levac"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.7326/M18-0850"
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                      "titulo" => "Pediatric tuberculosis in the metropolitan area of Rio de Janeiro"
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                            0 => "A&#46;C&#46; Carvalho"
                            1 => "P&#46; da Silva Martins"
                            2 => "C&#46;A&#46; Cardoso"
                            3 => "A&#46;L&#46; Miceli"
                            4 => "T&#46; Martire"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ijid.2020.06.070"
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                        "tituloSerie" => "Int J Infect Dis"
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              "identificador" => "bib0010"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pilot study to identify missed opportunities for prevention of childhood tuberculosis"
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                          "etal" => false
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                            0 => "C&#46; Feiterna-Sperling"
                            1 => "J&#46; Thoulass"
                            2 => "R&#46; Kr&#252;ger"
                            3 => "W&#46; Haas"
                            4 => "B&#46; Hauer"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur J Pediatr"
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              "identificador" => "bib0011"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Opportunities for chemoprophylaxis in children with culture-confirmed tuberculosis"
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                          "etal" => false
                          "autores" => array:5 [
                            0 => "K&#46; Du Preez"
                            1 => "A&#46;C&#46; Hesseling"
                            2 => "A&#46;M&#46; Mandalakas"
                            3 => "B&#46;J&#46; Marais"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Burden&#44; spectrum and outcomes of children with tuberculosis diagnosed at a district-level hospital in South Africa"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
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                            1 => "L&#46; du Plessis"
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                            3 => "A&#46;C Hesseling"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5588/ijtld.17.0893"
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                        "tituloSerie" => "Int J Tuberc Lung Dis"
                        "fecha" => "2018"
                        "volumen" => "22"
                        "paginaInicial" => "1037"
                        "paginaFinal" => "1043"
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ISSN: 00217557
Original language: English
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