PAEDIATRIC TB Jenny Handforth June 2014. Overview Why is Paediatric TB important Epidemiology- know...
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Transcript of PAEDIATRIC TB Jenny Handforth June 2014. Overview Why is Paediatric TB important Epidemiology- know...
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PAEDIATRIC TBJenny Handforth
June 2014
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Overview
•Why is Paediatric TB important
•Epidemiology- know the patients
•Adult v child with TB - differences?
• Diagnostic challenges:
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Why do you need to know about Paediatric TB?
• 1 million cases estimated globally each year (11%)
• 25-40% of all cases are children in high burden countries
• 4-7% in low burden countries
• Higher risk of severe disease and death in young children
• Indicator of effectiveness of TB control programmes
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Figure 1.1: Tuberculosis case reports and rates, UK, 2000-2012
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
4 Tuberculosis in the UK: 2013 report
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5 Tuberculosis in the UK: 2013 report
Figure 1.3. Three-year average tuberculosis case rates by local area*, UK, 2010-2012 *England – Local authorities, Wales and Scotland – Health
Boards, NI – data not available
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS)Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
© Crown copyright and database rights 2013 Ordnance Survey 100016969
London
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41.9
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6 Tuberculosis in the UK: 2013 report
Figure 1.4: Tuberculosis case reports and rates by region*, England, 2012
* HPA regionCI – 95% confidence intervals Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS) Data as at July 2013 Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
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Figure 1.6: Tuberculosis case reports by place of birth and country, UK, 2012
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
7 Tuberculosis in the UK: 2013 report
5,819
48 185 73
2,020
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Figure 1.8: Non UK-born tuberculosis case reports by time since entry to the UK to tuberculosis diagnosis, UK, 2012
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
8 Tuberculosis in the UK: 2013 report
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Figure 1.10: Tuberculosis case reports and rates by age group and place of birth, UK, 2012
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
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9 Tuberculosis in the UK: 2013 report
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Figure 1.11: Tuberculosis case reports and rates by age group and sex, UK, 2012
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10 Tuberculosis in the UK: 2013 report
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
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Figure 1.14: Child to adult ratio in notifications rate, UK, 2000-2012
The child-to-adult ratio is the ratio of the case notification rate in children under 15 years of age, to that in adults. A declining trend in the ratio suggests a decrease in ongoing transmission (European Centre for Disease Prevention and Control).
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Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
11 Tuberculosis in the UK: 2013 report
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Questions that must be asked...• Has this child been exposed to TB?
• Has the child been infected with TB?
• If yes does this child have Tb disease?
• Who has infected this child?
• …and answered!
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3 scenarios for investigating TB in children1. Screening healthy children - screen for
TB risk factors
2. Known contact with infectious case - usually adult
3. Child with symptoms and/or signs of TB or abnormal CXR
- high index of suspicion required
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Pathogenesis of TB in childhood
• Exposure to bacilli
from adult
• No infection • Primary complex
Dissemination to
lung apices,
meninges,bone
spine,nodes
• heals • progresses • Active disease• Dormant
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TB disease (TB) or Latent TB (LTB)• TB: active M. tuberculosis in some part of child’s body
• May be asymptomatic• Abnormal CXR and/or abnormal clinical exam
• LTB: dormant M. tuberculosis• Clinical exam normal• X rays normal
• Diagnosis is made by• History• Clinical examination• CXR/imaging/microbiology
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Risk of Disease following primary infectionMarais BJ et al. Int J Tuberc Lung Dis 2004;8:392-402
Disseminated TB
Pulmonary TB
No disease comments
< 1 years
10-20% 30-40% 50% High rates of morbidity & mortality
1-2 years
2-5% 10-20% 75-80% High rates of morbidity & mortality
2-5 years
0.5% 5% 95%
5-10 years
<0.5% 2% 98% Safe school years
>10 years
<0.5% 10-20% 80-90% Adult disease
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Table 1.2: Tuberculosis case reports by site of disease, UK, 2012
Site of disease* Number of cases Percentage**
Pulmonary 4,563 52.1
Extra-thoracic lymph nodes 1,872 21.4
Intra-thoracic lymph nodes 946 10.8
Other extra-pulmonary 619 7.1
Pleural 651 7.4
Gastrointestinal 471 5.4
Bone – spine 394 4.5
Cryptic± 46 0.5
Miliary± 197 2.3
Bone – other 218 2.5
CNS – meningitis 187 2.1
Genitourinary 137 1.6
CNS – other 80 0.9
Laryngeal 16 0.2
Unknown extra-pulmonary 15 0.2
17 Tuberculosis in the UK: 2013 report
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
*With or without disease at another site **Percentage of cases with known sites of disease (8751)±For Scotland cases, this includes both cryptic and miliary site
CNS - Central Nervous System Total percentage exceeds 100% due to infections at more than one site
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Evaluation for TB
Medical history
Physical examination
Mantoux tuberculin skin test
IGRAs
Chest radiograph
Bacteriologic or histologic exam
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Medical History
Symptoms of disease
History of TB exposure, infection, or disease
Past TB treatment
Demographic risk factors for TB
Medical conditions that increase risk for TB disease
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Systemic Symptoms of TB
Fever
Cough
Chills
Night sweats
Appetite loss
Weight loss
Tiredness
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Testing for TB Disease and Infection
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Factors that May Affect the Skin Test Reaction
Type of Reaction Possible CauseFalse-positive Nontuberculous mycobacteria BCG vaccination
AnergyFalse-negative Recent TB infection Very young age (< 6 months old) Live-virus vaccination Overwhelming TB disease
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Anergy
•Do not rule out diagnosis based on negative skin test result
•Consider anergy in persons with no reaction if
- HIV infected
- Overwhelming TB disease
- Severe or febrile illness
- Viral infections
- Live-virus vaccinations
- Immunosuppressive therapy.
•Anergy skin testing no longer routinely recommended
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Interferon Gamma Release Assays (IGRAs)• Recommended in NICE guidelines• Quantiferon-TB gold and T-spot.TB• Incubate patients blood with M. tuberculosis specific antigens (ESAT 6 & CFP-10)
• Measure production of gamma interferon • More specific than TST• Cannot distinguish between active and latent TB• Expensive• Technically difficulties with sampling• Lack of data for children
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Chest Radiograph
Abnormalities often seen in apical
or posterior segments of upper lobe or superior segments of lower lobeIn young children- can mimic pneumonia/effusionshilar lymphadenopathy
May have unusual appearance in
HIV-positive persons Cannot confirm diagnosis of TB
.
Arrow points to cavity in patient's right upper lobe
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Specimen Collection
Obtain 3 sputum specimens for smear examination and culture
Persons unable to cough up sputum, induce
sputum, bronchoscopy or gastric aspiration
Consider lymph node biopsy
Notoriously difficult to achieve in children
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AFB smear
AFB (shown in red) are tubercle bacilli
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Cultures
•Use to confirm diagnosis of TB
•Culture all specimens, even if smear negative
•Results in 4 to 14 days when liquid medium systems used
Colonies of M. tuberculosis growing on media
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Treatment
• Doses weight adjusted• TB disease• 6 months of isoniazid & rifampicin
• Pyrazinamide and ethambutol for first 2 months
• CNS- total 12 months plus dexamethasone at start
• Latent TB• 3 months of isoniazid and rifampicin
• Or• 6 months isoniazid
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Things to consider• Baseline LFTS• Eye check up• HIV testing
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Young Children with TB• Differ from Adults with TB:• Signs/symptoms• Generally not infectious• Pattern of progression to disease • Response to treatment• Side effects• Don’t forget parent!
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Adolescents with TB• Differ from young children:• Signs/symptoms• Delay in diagnosis• Adherence issues• Side effect profile• May be infectious!
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Monitoring Patients
Establish rapport with patient and emphasize
Benefits of treatment
Importance of adherence to treatment regimen
Possible adverse side effects of regimen
Establishment of optimal follow-up plan
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Monitoring Patients (cont.)
At least monthly, evaluate for
Adherence to prescribed regimen
Signs and symptoms of active TB disease
Signs and symptoms of hepatitis
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Preventing and Controlling TB
Three priority strategies:
Identify and treat all persons with TB disease
Identify contacts to persons with infectious TB; evaluate and offer therapy
Test high-risk groups for LTBI; offer therapy as appropriate
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Table 2.1: Number and proportion of tuberculosis cases with drug resistance by age group, UK, 2012
Tuberculosis in the UK: 2013 report 36
n % n % n %
0-14 10 9.7 10 9.7 7 6.8 103
15-44 240 7.2 264 7.9 65 2.0 3,333
45-65 77 7.6 78 7.7 8 0.8 1012
65+ 24 3.4 27 3.8 1 0.1 703
Age Group
Isoniazid Resistant to any Multi-drug
Total**resistant first line drug* resistant
*First line drugs - isoniazid, rifampicin, ethambutol and pyrazinamide**First line drugs – isoniazid, rifampicin, ethambutol and pyrazinamide**Culture confirmed cases with drug susceptibility results for at least isoniazid and rifampicin
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
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Table 4.1: Treatment outcome at 12 months for tuberculosis cases, UK, 2011*
Tuberculosis in the UK: 2013 report 37
* Excludes MDR-TB and RMP-resistant TB cases. Not evaluated includes missing, unknown and transferred out
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
Treatment outcome n %
Completed 7,302 82.9
Died 434 4.9
Lost to follow-up 435 4.9
Still on treatment 289 3.3
Stopped 88 1.0
Not evaluated 257 2.9
Total 8,805 100
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NHS Evidence
NHS Evidence Tuberculosis
topic page
Visit NHS Evidence for the best available
evidence on tuberculosis
diagnosis, treatment and management
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Find out more
• www.nice.org.uk/guidance/CG117
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Take home messages• Think about TB• TB is a family disease• Ask about risk factors• TB contacts• BCG Hx• Travel history• IGRA can be useful, but a negative IGRA does not exclude TB
• Liaise with TB nurses/doctors• TB therapy requires a lot of support• TB should be managed by specialists-discuss/refer early
Questions?