Addressing the gaps: Childhood TB · 2017-03-28 · Addressing the gaps: Childhood TB 25 March 2017...
Transcript of Addressing the gaps: Childhood TB · 2017-03-28 · Addressing the gaps: Childhood TB 25 March 2017...
Addressing the gaps: Childhood TB
25 March 2017
Laura Brandt, MD, FAAP
Clinical Services Director
International Training and Education Center for Health
(I-TECH)
Overview
• Epidemiology of child TB
• Prevention gap, barriers
• Diagnosis gap, barriers
• Approach to diagnosis
• The way forward
World TB Day 2017
0
100
200
300
400
500
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
Rat
e (p
er 1
00,0
00)
Trends of Prevalence, Mortality and
Incidence in the African Region: 1990-2013
Source: Global Tuberculosis Report 2014
TB Prevalence TB Mortality
TB Incidence TB/HIV Incidence
4
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
2006 2007 2008 2009 2010 2011 2012
0-4 Years 5-14 years
5
TB cases: 0-4 years and 5-14 years African Region 2006 - 2012
Global Child TB Burden What % of total TB
cases in SSA are
children?
6%
10-12%
15-20%
>20%
• Estimated 1 million
children <15 yrs with
TB (2015)* o 1/3 notified
• 210,000 died*
• >7.5 million infected * o <7% receive prophylaxis
*WHO Global Tuberculosis
Report 2016
10%
Greatest burden
<2 years old
TB in children • A leading cause of morbidity and
mortality in children
• It is preventable and usually curable
• Proportion of child deaths due to TB
(compared to other infections)
increasing
• Cannot reduce childhood mortality
(MDG 4) without addressing child TB
Current TB disease prevention
policies in Namibia 1. BCG vaccination at birth, helps prevent
disseminated disease in very young: well
implemented?
2. Provide one course of isoniazid preventive therapy
(IPT) to all PLHIV: implemented somewhat
3. Provide (additional) IPT to all immuno-
compromised persons of any age following proven
close contact with an infectious TB case: poorly
implemented
4. Provide IPT to ALL children <5 years old following
proven close contact with an infectious TB case:
very poorly implemented
The Policy – Practice Gap
MoHSS Policy: IPT
GLs
TB prevented
in child with TB contact
X
Barriers to implementation of IPT in <5 year olds
• Perceived inability to rule out active TB
o Symptom-based screening safe and feasible
(CXR of little value in asymptomatic children)
• Perceived fear of creating drug resistance
o Risk of acquiring DR is low if screening adhered to
o No elevated risk of DR observed in studies
o Pauci-bacillary disease, rarely transmit infection,
risk to community irrelevant
• Poor adherence with prolonged IPT
o Good adherence is possible
o Short-course IPT with dual drug regimens under
investigation
Risk of TB disease after infection by age (pre-tx era)
Adapted from Marais B, et al. Int J Tuberc Lung Dis 2004,8:392-402
50%
20%
Age-sex distribution: new and relapse TB cases, Namibia, 2016
0
200
400
600
800
1000
1200
1400
0-04 5-15 15-24 25-34 35-44 45-54 55-64 65+
Nu
mb
er o
f C
ases
Age Groups
Male Female
12
NTLP report, 2017
The Diagnosis Gap
0
5
10
15
20
25
*Namibia 2016 **SSA est. %
Children <15 years: % of total TB burden
*NTLP 2016 report
**Seddon,JA, D.Shingadia.2014.Infect Drug Resist.7:153-165
We diagnose
<half!
≥20%
9.5%
Myths and Mis-perceptions
• TB is a disease of adolescents and
adults, not of small children
oNot true!
• Child TB not a public health problem
because it is usually non-infectious
oNot true! Child TB means there is ongoing
TB transmission in the community, and this
is a problem!
o Infected children of today are reservoirs
for tomorrow’s TB patients
Myths and Mis-perceptions (2)
• Very difficult to diagnose TB especially
in young children o Not true! It may be difficult to CONFIRM, but
one can usually make a diagnosis
The Policy – Practice Gap
MoHSS Paediatric TB
diagnosis and
treatment GLs
Child diagnosed with and cured of
TB
X
Where will we find the lost children with TB?
• In households of patients with TB
o Are we missing opportunities to prevent or diagnose?
• Presenting to primary health care with signs and
symptoms of common childhood illness, e.g. cough,
weight loss, and malnutrition
o Are we remembering to think of TB, ask the right questions
and examine for clues?
• Presenting ill to secondary and tertiary health care
o Are we remembering to think of TB, ask the right questions
and evaluate comprehensively?
Diagnosis can be
challenging
BUT
is diagnosis always
“difficult”?
Case: 18 month old boy • Presents to PHC clinic with cough
• On examination: T=38˚C, weight: 8.8 kg (WFA z-
score= -2), RR=36, lungs clear
What else do you want to know?
• When did cough start? persistent? worsening?
o “long time”, more than a week ago, not getting better
• Appetite?
o not eating well
• Previous weights?
o Growth chart shows a drop from 9.5 kg (-1 z-score) 3 months previously
Case: 18 month old boy(2) • Anyone at home or who looks after the child
diagnosed with TB?
• No
• Anyone at home or anyone who looks after child
coughing?
o Yes, father has been coughing some weeks but is too busy
to get it checked
• HIV status?
o Mother RT negative when pregnant, not tested since
Clinical diagnosis?
Key message: ask the right questions - probe for a contact, check growth
Approach to TB diagnosis in children
• Careful history o TB contact (incl. household member with a
chronic cough), progressive, unremitting cough, fever, reduced playfulness, activity and appetite; no response to antibiotics
• Clinical examination o including growth assessment,
lymphadenopathy, chest exam (normal, adventitious sounds, wheeze)
o <2 months: pneumonia (can be acute), sepsis, HSmegaly
Growth faltering
Weight loss
Compare current with previous
weights
TB lymphadenopathy • Commonest form of EPTB in children
• Often 2-10 years old
• Commonest LN site: cervical
• Visibly large (>2 x 2 cm)
o painless and asymmetrical
o often multiple, can be discreet or matted
• Persistent (>1 month), not responsive to antibiotics
• Sinus and discharge may develop
Approach to TB diagnosis in children (2)
• Supportive investigations
o TST - less important if a positive exposure history
• 48-88% sensitivity; if HIV+,18-60% sensitive
o Chest X-ray
o Investigations relevant for suspected PTB or EPTB
• Bacteriological confirmation whenever
possible
• HIV testing
o Consider or rule out other HIV-related diagnoses
o Allows dual management, better outcomes
CXR abnormalities suggestive of TB
• Enlarged hilar lymph nodes
• Opacification
• Miliary mottling
• Cavitation (esp. in older children)
• Pleural or pericardial effusion (esp. in older
children)
Freely available on-line, google: diagnostic atlas Gie
http://www.theunion.org/index.php/en/component/flexicontent/items/item/110-diagnostic-atlas-of-
intrathoracic-tuberculosis-in-children
Diagnostic atlas of intrathoracic tuberculosis in children: a guide for low-income countries
2003, Robert Gie, IUATLD
Features for TB diagnosis
• chronic symptoms
• malnutrition
• tuberculin skin test
• CXR findings
Impact of HIV
• less specific
• less specific
• less sensitive
• less specific
Adapted from IUATLD/WHO, Management of Child TB training
Impact of HIV on clinical diagnosis of TB
Definitive diagnosis • Xpert MTB/RIF (Circular 1/2017), LPA,
culture • Sputum
o Challenge: some children unable to expectorate: • gastric aspirate • induced sputum
o Challenge: paucibacillary disease results in lower sensitivity
• EPTB specimens o LN FNA, biopsy o CSF/ascitic fluid taps
Sputum induction with inhaled hypertonic saline • How does it work?
o Interstitial fluid moves into airways (osmosis)
o Stimulates cough reflex, helps mobilise secretions
• Process: (utilise infection precautions)
o Pre-treatment with an inhaled bronchodilator
o Nebulisation with hypertonic (5%) saline x 15
minutes
o Chest physiotherapy
o Sample collection (expectoration or NP/OP
suctioning)
Sputum induction with inhaled hypertonic saline (2) • Target group: unable to voluntarily
expectorate
o SA study* found sputum induction successful in
142/149 (95%) of children with median age 9
months old with pneumonia (youngest 1 month
old)
• Staff training essential
*Zar,HJ et al. 2000.Arch Dis Child;82:305–308
Treatment • “Same old” anti-TB treatment first line
medications, but increased dosage per kg
to account for increased metabolism in
children already in 2012 TB GL
• Second line medications lagging behind
adults. . . but under study
Current treatment regimen
Body
weight
Intensive phase - 2 months
Current [RHZ]
“Pediatric”
(R60/H30/Z150)
No. tablets /
sachets
Add.
H100
No.
tablets
E100
No.
tablets /
sachets
E400
No.
tablets
6.5-7.4 kg 1½ ½ 1½
7.5-9.9 kg 2 ½ 1½
10-12.9 kg 2½ ½ 2
13-14.9 kg 3 1 3
15-19.9 kg 4 1 3
20-24.9 kg 5 1 1
New treatment regimen
Body weight
Intensive phase - 2 months Continuation phase
New RHZ
Pediatric
(R75/H50/Z150)
No. tablets
E100
No. tablets
New RH Paediatric
(R75/H50)
No. tablets
4-7 kg 1 1 1
8-11 kg 2 2 2
12-15 kg 3 2 3
16-24 kg 4 4 or one
adult E400
4
When 25+ kg, use adult formulations
Building the momentum for change. . .
Way forward:
How can we close the gaps? • Trace and screen every child contact of every
index case
• Strengthen TB symptom screening of all HIV (+)
children
• Integrate TB training into MCH, primary health care
and other courses
• Integrate TB screening and diagnosis into child
health SOPs/guidelines/GP visits, e.g., growth
monitoring, evaluation of fever or respiratory
infections
• Do appropriate investigations (clinical, supportive,
definitive)
• Advocate for child-friendly medications
Key points • We have the GLs, let’s implement them - do
something about the child TB prevention and
diagnosis gaps!
• Prevention with IPT saves lives
o Trace every child contact of every index TB case
• Child TB is underdiagnosed leading to too many
preventable deaths
• Diagnosis is not always difficult
o Always think of TB in primary care when child presents with
faltering growth, any cough, fever, lymphadenopathy
o Try to confirm diagnosis but not required to start TB treatment
o Use sputum induction method liberally
Thank you!