Contextual dimensions of pediatric tuberculosis imaging: radiation exposure, access, and system capacity in high- and low-resource settings

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Abstract Background Pediatric tuberculosis diagnosis relies heavily on imaging, yet access, equipment standards, and dose monitoring differ widely across health systems. Evidence describing how these contextual factors influence imaging use and radiation exposure in children remains scarce. Objective To describe pediatric tuberculosis imaging practices and estimated radiation doses across two distinct resource settings, Spain (hospital-based, high-resource) and Mozambique (primary care-based, low-resource), to inform strategies for safe, equitable, and context-appropriate imaging. Methods and materials A descriptive mixed-methods study combined retrospective data of children (<16 years) diagnosed with tuberculosis (Spain 2015–2021; Mozambique 2018–2021) with complementary surveys of imaging providers. In Spain, chest X-ray and computed tomography parameters were extracted from digital imaging and communications in medicine files to estimate organ-specific doses using the National Cancer Institute dosimetry systems for radiography and computed tomography. In Mozambique, dose estimates were based on standardized pediatric protocols and site survey parameters due to limited digital data. Surveys captured information on imaging access, guideline use, and professional training. Results Imaging data were available for 84 Spanish and 83 Mozambican children. In Spain, children underwent multiple chest X-rays (mean four per child) and computed tomographies (mean three per child), resulting in cumulative lung doses up to ~20 mGy cm 2 , remaining below diagnostic reference levels. In Mozambique, most children had one or two chest X-rays, with cumulative lung doses <0.05 mGy cm 2 . Survey findings indicated structured dose optimization and quality assurance practices in Spain, versus limited equipment and predominantly non-physician interpretation in Mozambique. Conclusion Context-appropriate improvements in pediatric imaging such as strengthened infrastructure, training, dose monitoring, and quality assurance are essential to ensure safe exposure and equitable, reliable tuberculosis diagnosis for children. Graphical abstract

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