Original Article
Adolescent tuberculosis: A challenge and opportunity to prevent community transmission
Tuberculosis en el adolescente; reto y oportunidad de evitar el contagio a la comunidad
Adriana Margarita, Sílvia Simóa, Librada Rozasb, Àngela Deyà-Martíneza, Irene Barrabeigc, Amadéu Genéd, Clàudia Fortunya, Antoni Noguera-Juliana,
Corresponding author
a Unitat d’Infectologia, Servei de Pediatria, Hospital Sant Joan de Deú, Universitat de Barcelona, Barcelona, Spain
b Unitat de Referència de Tuberculosi en el Nen, Direcció d’Infermeria, Hospital Sant Joan de Deú, Universitat de Barcelona, Barcelona, Spain
d Servei de Microbiologia, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
c Unitat de Vigilància Epidemiològica, Regió Barcelona Sud, Agència de Salut Pública de Catalunya, L’Hospitalet de Llobregat, Barcelona, Spain
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reto y oportunidad de evitar el contagio a la comunidad" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">According to data from the Red Española de Estudio de la Tuberculosis Pediátrica (Spanish Network for the Study of Paediatric Tuberculosis)<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> which comprises 73 institutions that treat paediatric patients with tuberculosis (TB) in Spain, 43% of them treat patients aged more than 14 years. This Network is still open to the incorporation of new institutions and researchers (contact <a id="intr0010" class="elsevierStyleInterRef" href="mailto:infoptbred@gmail.com">infoptbred@gmail.com</a>), and has prospectively collected data for 340 paediatric patients with TB disease from January to December 2015, of who 65 (19.1%) were older than 12 years at the time of diagnosis. Pulmonary TB in adolescents is sometimes characterised by radiological evidence of cavitation in the upper lung and smear-positive sputum in what has been termed adult-type pulmonary TB (ATpTB).<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2,3</span></a> This study describes the characteristics of a large paediatric series of cases of TB disease, with particular emphasis on adolescent patients.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">We conducted a retrospective observational study between January 2007 and December 2012 of a paediatric series (up to 18 years of age) of cases of TB disease in the Hospital Sant Joan de Déu (Barcelona), the tertiary referral hospital for paediatric TB infection in the Barcelona Sud Health Area (population, 1,346,050 inhabitants; 16.5% aged less than 15 years). The study was approved by the Ethics Committee of the Hospital Sant Joan de Déu.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We identified TB cases by searching the hospital diagnosis records and the registry of notifiable diseases of the Department of Public Health. We collected demographic, clinical, radiologic, microbiologic, treatment and outcome data from patient medical records. We classified TB disease based on the scheme proposed by Wiseman et al,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> taking into account not only location (intrathoracic or extrathoracic), but also severity based on disease extent and the associated complications. In our centre, the induction phase (2 months) of anti-TB treatment comprised three drugs (isoniazid, rifampicin and pyrazinamide) until March 2009, after which ethambutol was added to the combination. Maintenance treatment consisted of two drugs (isoniazid and rifampicin) administered for 4 months in most patients (with the exception of those with meningeal or osteoarticular TB) for the entire period under study.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We stored and processed the data in a Microsoft Office Excel relational database. We summarised qualitative variables as proportions, and quantitative variables as median and interquartile range. We classified patients based on their age at diagnosis: 12 years or less, and older than 12 years. In the bivariate analysis, we studied the association of qualitative variables by means of the chi square test or Fisher's exact test (SPSS version 17.0); we defined statistical significance as a <span class="elsevierStyleItalic">P</span>-value of less than 0.05.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">We did a retrospective study of 124 cases of TB disease (male, 56.5%; median age [interquartile range] at diagnosis, 4.0 [2.4–9.6] years), out of which 19 (male, 36.8%) corresponded to patients aged more than 12 years at the time of diagnosis. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the main characteristics of both groups of patients (≤12 years and >12 years).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In patients born to immigrants (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>66), the predominant regions of origin were Morocco (43.1%) and Latin America (30.8%). The diagnosis was made following clinical or radiological suspicion in 58.9% of the cases; the index case was identified in 64 patients (51.6%), in 22 through the investigation of contacts of the secondary paediatric case. Five patients had significant comorbidities at the time of TB diagnosis: Down syndrome, acute lymphoblastic leukaemia under ongoing treatment, homozygous mutation of protein MyD88, cystic fibrosis and superinfection by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> of a synthetic prosthesis in the buttock. Primary TB infection was the predominant clinical and radiological presentation (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>95, 76.6%). Cultures were positive to <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> in only 37.9% of the patients, and in all cases, the isolated strain was sensitive to first-line antibiotics, but for one patient of Peruvian ancestry, who was infected by a strain with single-drug resistance to streptomycin. Fourteen patients (11.3%) also received corticosteroids, most of them on account of neurologic involvement (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6) or paradoxical reaction after initiation of anti-TB treatment (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6). Only two patients did not recover in full: one boy aged 4 years with Down syndrome and tuberculous meningitis that developed raised intracranial pressure and extensive brain lesions, who died; and a girl aged 9 years with no relevant medical history with tuberculous meningitis and residual visual field defects secondary to a hypothalamic chiasmatic tuberculoma, who remains in followup.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Compared to patients aged 12 years or less (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), TB disease in adolescents was more prevalent in women (63.2%) and immigrants (68.4%), and 21.1% had comorbidities at the time of diagnosis. Furthermore, the diagnosis was made following clinical or radiological suspicion in most cases, and cavitary pulmonary forms were most prevalent. On the other hand, the index case was identified in only 21.1% of these patients.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">The incidence of TB in Spain in 2013 was 11.9 cases per 100,000 inhabitants, 8.3% less than in 2012. The notified cases included 383 patients aged less than 14 years and 498 patients aged 15 to 24 years.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> In the Health Area of Barcelona Sud, the mean incidence of TB in individuals aged 12 years or less and individuals aged 12–18 years in the 2010–2014 period was 8.4 and 8.6 cases per 100,000 inhabitants, respectively. However, the incidence of sputum-smear positive TB in these same age groups was 0.4 and 3.5 cases per 100,000 inhabitants.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The main characteristics of this case series were similar to those described in recent studies in low-incidence TB countries of national<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> as well as international<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> scope. In our study, paediatric TB predominantly affected previously healthy preschoolers, with an immigrant background in 50–70% of cases, and was diagnosed in the context of a contact investigation or following clinical or radiological suspicion in similar proportions. Most patients had intrathoracic forms of disease that in most cases, fortunately, responded to first-line anti-TB agents and were cured with appropriate treatment.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> Children with TB are considered sentinel cases of community outbreaks; in our series, the diagnosis of TB in children allowed the subsequent identification of 22 (17.7%) contagious index cases.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In adolescents, TB can develop over one to three years following primary infection, or due to reactivation of childhood TB.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2,3,8</span></a> Recent studies of school outbreaks have demonstrated that primary TB infection can also manifest with upper lung involvement with consolidation, nodules and cavitation<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> in the form of disease known as ATpTB. Compared to young children, ATpTB in adolescents usually manifests with overt respiratory symptoms and detection of bacilli in sputum.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2,3</span></a> Although the number of adolescents with cavitary TB in our study was small, the differences between groups were significant; furthermore, the only patient with cavitary disease in the 12-and-under group was 10.9 years of age at the time of diagnosis. Our series demonstrates that contagious cavitary TB can occur in school-aged children and adolescents, which carries important repercussions at the public health level.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In our case series, two-third of adolescent patients had an immigrant background, which also explains the significant differences in the BCG vaccination status and the rate of identification of index cases in adolescents compared to younger children. The other key difference is that diagnosis in nearly all adolescents resulted from clinical or radiological suspicion. These two aspects are highly relevant to public health. First of all, it can be assumed that adolescents with ATpTB have already put their household and school contacts at risk of infection by the time of diagnosis, as has already been described in other studies conducted in low-incidence countries.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> Furthermore, the social networks of adolescents tend to be broader than those of children, so the number of contacts at risk of infection is also higher.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> Secondly, if we assume that some of these patients became infected in their countries of origin, the subsequent development of TB disease reveals flaws in the health screening system for new immigrants, as it failed to detect cases of latent TB.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Another common characteristic of TB in adolescents and adults is the higher prevalence of comorbidities at the time of diagnosis, which also carries a higher risk of TB-related morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> In our case series we did find significant differences in prevalence between the groups, but found no association between comorbidity and disease outcome. In Spain, TB of any location is the most prevalent AIDS-defining disease in the adult population along with <span class="elsevierStyleItalic">Pneumocystis jirovecii</span> pneumonia.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> In the absence of other risk factors, HIV antibody tests are not commonly requested in paediatric patients with TB; recently, de Pontual et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> reported a 13% rate of HIV coinfection, especially in adolescents of African origin or with extrapulmonary or severe forms of TB. Although concurrent HIV infection is rare, given the enormous improvements in outcome associated with its early diagnosis, it would be advisable to test TB patients of immigrant backgrounds or with severe forms of disease for HIV.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the absence of directly observed therapy, adolescence is one of the classic risk factors for poor adherence to anti-TB treatment.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> In our study, we did not have access to specific data on adherence to anti-TB treatment. Nevertheless, the TB cure percentages after completion of treatment exceeded 95% in both age groups, which demonstrates that adherence was adequate in adolescents, as has been reported recently by other case series.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">10,11,13,15</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">There are various limitations to our retrospective study. The low number of adolescent patients included in the study may have decreased the possibility of finding an existing association. In addition, a culture of respiratory secretions was not performed in all patients, either due to its low yield or because the drug sensitivity of the index-case strain was known. Both of these circumstances are more common in patients aged 12 years or less, which may have resulted in performance bias. The tuberculin skin test, which continues to be the main tool used in the diagnosis of TB in children, was negative in 13 out of 124 patients (10.5%). During the period under study, interferon-gamma release assays and molecular diagnostic tests, which have increased the probability of obtaining a certain diagnosis of TB in the paediatric age group in recent years, were not yet available in our hospital.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In conclusion, in low-incidence countries, TB in adolescents usually presents as ATpTB, is associated with comorbidities, and is often diagnosed late, which carries a higher risk of transmission to contacts of the patient. Early diagnosis and treatment monitoring, as well as community-based interventions to prevent the transmission of adolescent TB, are the joint responsibility of the health authorities and paediatricians, who should be aware of the particular characteristics of ATpTB.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres805104" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec803260" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres805103" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec803261" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-01-15" "fechaAceptado" => "2016-03-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec803260" "palabras" => array:5 [ 0 => "Adolescent" 1 => "<span class="elsevierStyleItalic">Adult-type</span> disease" 2 => "Paediatrics" 3 => "Transmission" 4 => "Tuberculosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec803261" "palabras" => array:5 [ 0 => "Adolescente" 1 => "Enfermedad <span class="elsevierStyleItalic">tipo adulto</span>" 2 => "Pediatría" 3 => "Contagio" 4 => "Tuberculosis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Adolescents may present with <span class="elsevierStyleItalic">adult-type</span> pulmonary tuberculosis (TB), including cavity disease in upper lobes and smear-positive sputum, which involves a significant transmission risk for social and family contacts.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective (2007–2012) observational study of a case series of TB was conducted in children and adolescents (<18 years) in a paediatric referral centre in Barcelona. Patients aged ≤12 and >12 years at diagnosis were compared.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The series consisted of 124 patients (56.5% males, median age: 4.0 years). In half of the cases, the patient was of immigrant origin and TB was diagnosed after clinical–radiological suspicion, intra-thoracic disease being the most common (91.9%). Cultures yielded positive results in one third of cases (37.9%) and isolates were sensitive to oral first-line anti-TB agents in 100%. Median (interquartile range) duration of treatment was 6 (6–9) months, directly observed therapy was needed in 10 patients, and there was a satisfactory outcome after treatment in 98.4%. Among adolescents, TB was more prevalent in females (63.2%) and immigrant patients (68.4%), comorbidity at diagnosis and lung cavity forms were more common, and the source case was identified only in 21.1% of the patients.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Adult-type</span> pulmonary TB is common among adolescents, may be associated with underlying medical conditions, and is often diagnosed late, posing a significant transmission risk to the community.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La tuberculosis (TB) en el adolescente puede presentar formas radiológicas cavitadas en los lóbulos superiores, con esputos bacilíferos, en lo que se ha llamado TB pulmonar <span class="elsevierStyleItalic">tipo adulto</span>, que implica un importante riesgo de contagio en el entorno social y familiar del paciente.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo (2007-2012) en una serie pediátrica (<<span class="elsevierStyleHsp" style=""></span>18 años) con TB en un hospital pediátrico de referencia en Barcelona. Se compara a los pacientes<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>12 y<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>12 años.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 124 pacientes (56,5% hombres, edad mediana: 4,0 años). En la mitad, la TB afectó a pacientes de origen inmigrante y se diagnosticó por sospecha clínico-radiológica. La TB intratorácica fue la forma clínica predominante (91,9%), los cultivos fueron positivos en un tercio de los casos (37,9%) y sensibles a los fármacos orales de primera línea en su totalidad. El tiempo mediano (rango intercuartil) de tratamiento fue de 6 (6-9) meses; solo 10 pacientes precisaron tratamiento directamente observado y la evolución fue satisfactoria en la mayoría (98,4%). Entre los adolescentes, la TB fue más prevalente en mujeres (63,2%) e inmigrantes (68,4%), la comorbilidad al diagnóstico y las formas pulmonares cavitadas fueron más comunes y se identificó el caso índice solo en el 21,1% de los pacientes.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En el adolescente, la TB pulmonar <span class="elsevierStyleItalic">tipo adulto</span> es común, y a menudo asocia comorbilidad y se diagnostica más tarde, implicando un mayor riesgo de contagio a la comunidad.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Margarit A, Simó S, Rozas L, Deyà-Martínez À, Barrabeig I, Gené A, et al. Tuberculosis en el adolescente; reto y oportunidad de evitar el contagio a la comunidad. An Pediatr (Barc). 2017;86:110–114.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Previous presentation: Partial results of this study were presented at the VII Congress of the Sociedad Española de Infectología Pediátrica (Spanish Society of Paediatric Infectious Diseases [SEIP]); March 2014; Santiago de Compostela, Spain.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">BCG, bacillus Calmette-Guérin; IQR, interquartile range; DOT, directly observed therapy; MTB, <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>; NS, not significant.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Results expressed as <span class="elsevierStyleItalic">n</span> (%) unless noted otherwise.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>124) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>12 years (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>105) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>12 years (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>19) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male sex</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 (56.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 (60.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (36.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.006 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age at diagnosis; median (IQR), in years</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.0 (2.4–9.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.5 (2.0–5.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.9 (13.8–16.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Immigrant patient</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 (31.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (24.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (68.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patient of immigrant descent born in Spain</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 (53.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 (50.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (68.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Presence of BCG vaccine scar</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (15.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (7.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (57.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Reason for diagnosis</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Clinical-radiological suspicion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 (58.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 (52.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (94.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.004 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Contact investigation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (34.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 (39.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (5.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Immigrant patient protocol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (7.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (8.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Comorbidity at diagnosis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (15.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.028 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Known index case</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 (51.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (57.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (21.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.004 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Induration of TB skin test; median (IQR), in mm</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (12–20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (16–20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (11–20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Positive tuberculin skin test</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">111 (89.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 (90.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (84.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Intrathoracic disease</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">114 (91.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97 (92.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (89.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cavitary TB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (15.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Extrathoracic disease</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (14.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (15.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (10.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Severe disease</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (8.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (8.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (5.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Required corticosteroid therapy</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (11.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (13.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Required DOT</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (8.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (8.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (5.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Total treatment duration; median (IQR), en months</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (6.0–9.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (6.0–6.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (6.0–9.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Cure outcome</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">122 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">103 (98.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1351110.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Includes immigrant patients.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">According to Wiseman et al.,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> severe intrathoracic disease includes expansile alveolar opacification, cavitation, empyema or pericarditis, while all forms of extrathoracic disease are severe except tuberculous adenitis or immune-mediated responses such as erythema nodosum.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Main demographic, clinical, radiologic, microbiological characteristics and treatment and outcome of TB disease in the overall case series and in the under-12 and over-12 years age groups.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Red Española de Estudio de la Tuberculosis Pediátrica (pTBred). 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Noguera-Julian" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jan.12656" "Revista" => array:6 [ "tituloSerie" => "J Adv Nurs" "fecha" => "2015" "volumen" => "71" "paginaInicial" => "2189" "paginaFinal" => "2199" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25818512" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0150" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adult-type pulmonary tuberculosis in children 10–14 years of age" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B.J. Marais" 1 => "R.P. Gie" 2 => "A.H. Hesseling" 3 => "N. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 18 | 12 | 30 |
| 2024 October | 77 | 38 | 115 |
| 2024 September | 70 | 32 | 102 |
| 2024 August | 82 | 63 | 145 |
| 2024 July | 70 | 27 | 97 |
| 2024 June | 78 | 28 | 106 |
| 2024 May | 72 | 30 | 102 |
| 2024 April | 94 | 32 | 126 |
| 2024 March | 77 | 46 | 123 |
| 2024 February | 90 | 39 | 129 |
| 2024 January | 85 | 24 | 109 |
| 2023 December | 77 | 28 | 105 |
| 2023 November | 68 | 39 | 107 |
| 2023 October | 80 | 33 | 113 |
| 2023 September | 97 | 24 | 121 |
| 2023 August | 77 | 27 | 104 |
| 2023 July | 103 | 27 | 130 |
| 2023 June | 112 | 37 | 149 |
| 2023 May | 102 | 40 | 142 |
| 2023 April | 79 | 26 | 105 |
| 2023 March | 120 | 31 | 151 |
| 2023 February | 94 | 34 | 128 |
| 2023 January | 82 | 38 | 120 |
| 2022 December | 109 | 43 | 152 |
| 2022 November | 105 | 39 | 144 |
| 2022 October | 103 | 69 | 172 |
| 2022 September | 84 | 43 | 127 |
| 2022 August | 112 | 63 | 175 |
| 2022 July | 87 | 37 | 124 |
| 2022 June | 69 | 42 | 111 |
| 2022 May | 64 | 39 | 103 |
| 2022 April | 103 | 53 | 156 |
| 2022 March | 98 | 65 | 163 |
| 2022 February | 106 | 38 | 144 |
| 2022 January | 111 | 26 | 137 |
| 2021 December | 101 | 45 | 146 |
| 2021 November | 107 | 53 | 160 |
| 2021 October | 175 | 126 | 301 |
| 2021 September | 75 | 66 | 141 |
| 2021 August | 65 | 60 | 125 |
| 2021 July | 90 | 58 | 148 |
| 2021 June | 88 | 61 | 149 |
| 2021 May | 117 | 81 | 198 |
| 2021 April | 204 | 103 | 307 |
| 2021 March | 122 | 57 | 179 |
| 2021 February | 67 | 21 | 88 |
| 2021 January | 99 | 41 | 140 |
| 2020 December | 112 | 45 | 157 |
| 2020 November | 70 | 31 | 101 |
| 2020 October | 88 | 33 | 121 |
| 2020 September | 61 | 32 | 93 |
| 2020 August | 68 | 22 | 90 |
| 2020 July | 52 | 29 | 81 |
| 2020 June | 72 | 21 | 93 |
| 2020 May | 74 | 44 | 118 |
| 2020 April | 38 | 24 | 62 |
| 2020 March | 67 | 30 | 97 |
| 2020 February | 78 | 28 | 106 |
| 2020 January | 66 | 29 | 95 |
| 2019 December | 63 | 24 | 87 |
| 2019 November | 62 | 26 | 88 |
| 2019 October | 70 | 21 | 91 |
| 2019 September | 63 | 21 | 84 |
| 2019 August | 55 | 20 | 75 |
| 2019 July | 52 | 35 | 87 |
| 2019 June | 53 | 28 | 81 |
| 2019 May | 82 | 34 | 116 |
| 2019 April | 74 | 24 | 98 |
| 2019 March | 55 | 23 | 78 |
| 2019 February | 39 | 25 | 64 |
| 2019 January | 39 | 43 | 82 |
| 2018 December | 36 | 28 | 64 |
| 2018 November | 74 | 25 | 99 |
| 2018 October | 73 | 22 | 95 |
| 2018 September | 48 | 11 | 59 |
| 2018 August | 3 | 0 | 3 |
| 2018 July | 1 | 0 | 1 |
| 2018 June | 3 | 0 | 3 |
| 2018 May | 6 | 0 | 6 |
| 2018 April | 15 | 0 | 15 |
| 2018 March | 23 | 0 | 23 |
| 2018 February | 13 | 0 | 13 |
| 2018 January | 16 | 0 | 16 |
| 2017 December | 15 | 0 | 15 |
| 2017 November | 17 | 0 | 17 |
| 2017 October | 13 | 0 | 13 |
| 2017 September | 22 | 0 | 22 |
| 2017 August | 12 | 0 | 12 |
| 2017 July | 25 | 2 | 27 |
| 2017 June | 31 | 18 | 49 |
| 2017 May | 34 | 24 | 58 |
| 2017 April | 110 | 96 | 206 |
| 2017 March | 35 | 20 | 55 |
| 2017 February | 10 | 15 | 25 |
| 2017 January | 0 | 13 | 13 |
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