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Childhood TB

An MSF Field Perspective

Dr Marianne Gale Medical Advisor – Paediatric TB&HIV

Médecins Sans Frontières

MSF - a brief overview

Founded in 1971

Emergency medical relief agency (NGO)

- Displacement

- Epidemics

- Neglect

Nobel Peace Prize in 1999

Range of medical activities eg:

• Emergency trauma services

• Maternal and child health

• Neglected diseases

• Tuberculosis and HIV

• Mental health

• Communicable disease outbreaks

TB/HIV CO-INFECTION IN

CHILDREN

Mathare, Kenya

Mathare, Kenya

Mathare, Kenya

Case – Mathare

6 month old boy

Mother HIV +, but no PMTCT

Child HIV + from 10 week PCR, but still not on ART (!)

Clinical notes:

Cough and stagnant weight recorded at each visit since 3 months of age

5 antibiotic courses prescribed

CXR - hilar lymphadenopathy?

Sputum collection impossible

TB treatment started at 6mo, followed by ART

TB HIV Co-infection

Main Issues Illustrated:

Prevention failed - PMTCT

Confusion over ‘complex’ protocols

High risk of TB exposure and severe disease

Failure of TB screening and alert to symptoms and signs

Lack of TB diagnostic tools

Lack of effective treatment options especially for co-infected children < 3years

Problematic TB drug formulations

DRUG RESISTANT TB IN

CHILDREN

Yerevan, Armenia

Yerevan, Armenia

Case – Armenia

2 month old boy

Both parents recently diagnosed with MDR TB and initiated on treatment

Initial assessment of child:

Asymptomatic

TST negative (BCG vaccinated)

CXR - possible hilar lymphadenopathy

Gastric aspirations – negative

Decision for close follow up

Case – Armenia

At 5 months of age

Reports of ‘sweating’

CXR repeated: hilar lymphadenopathy with infiltration

Gastric aspirations: negative

Decision to start empiric DR TB treatment

Child is so far doing well

DR TB in children

Main Issues Illustrated:

How to best manage contacts?

Prophylaxis?

Duration and nature of follow up?

Lack of adapted diagnostic tools

Problematic treatment

Little evidence – drug dosages? duration?

Adult formulations

Toxicities - short and long term safety?

Model of care adapted for children

TB IN SEVERELY

MALNOURISHED CHILDREN

Case study – Mali

4 year old girl

Admitted with severe acute malnutrition, pneumonia and

anaemia (Hb 4g/dl)

HIV – NEG

Malaria rapid test - NEG

No TB contact history

Case study – Mali

No response to IV ABx, O2, blood transfusion and therapeutic

feeding

Difficult access to quality CXR

Neither sputum nor gastric aspirates possible

TB treatment added empirically on day 10

Clinical course complicated by hepatitis and recurrent diarrhoea

Eventual good clinical response and recovery

TB and Malnutrition

Main Issues Illustrated:

‘Chicken and egg’ interaction

Overlapping signs and symptoms

Lack of adapted TB diagnostics

Severe clinical condition with complications - often too late

Lack of adapted treatment options

Barriers to addressing TB in children

Lack of

RECOGNITION

Lack of

DIAGNOSTIC TOOLS

Lack of adapted

TREATMENT OPTIONS

Lack of

PREVENTIVE STRATEGIES

Childhood TB

Challenges of the diagnostic ‘tools’

Sputum microscopy

Culture & DST

GeneXpert

X-ray

TST

Scores/algorithms

Samples collection difficult:

-Sputum induction

- Gastric aspiration

- FNAB

Access? Quality? Interpretation?

Logistics? Interpretation?

Lack of validation

Childhood TB

MSF Field Objectives

Improvement of case detection

Improvement of prevention strategies

Improvement of quality of care

Improving ‘integration’ in MCH and HIV services

Childhood TB

MSF Field Training

• 1 day course

• Can be adapted as needed according to context eg

prevalence

resources available

level of staff

Childhood TB

MSF/PIH Guidelines

Revised diagnostic approach

▪ No more score

▪ Emphasis on history + clinical signs & symptoms

▪ More guidance of specimen collection methods

Updated treatment recommendations

More details on DR TB

Childhood TB

MSF collaborations for improved drug options

• New fixed dose combination for 1st line drugs

• Better treatment options for young co-infected children

- Involvement with DNDi

• Standardized dosing and formulation issues of second

line drugs

Childhood TB

MSF collaborations for Drug Resistant TB

Aim to highlight need for inclusion of children in the

scale up of DR TB treatment

Union symposia: Lille (2011) and Kuala Lumpur (2012)

Collaboration with new Harvard/TRC(India) led network

on drug resistant TB in children

http://ghsm.hms.harvard.edu/sentinel/

Childhood TB

MSF collaborations for a Diagnostic Reference

Standard

• MSF launched in Dec 2009

• Consensus finally reached between multiple actors in July

2011 - NIH coordinated

• To be published on World TB day 2012 in JID

• Expected impact on quality of diagnostic research to allow the

inclusion of children, and more meaningful research outcomes

Childhood TB

MSF Advocacy

• Reports: ‘Out of the Dark’ (2011) http://www.msfaccess.org/content/out-dark-meeting-needs-of-children-with-TB

• Conference symposia

• Publications

Childhood TB

MSF Operational Research on Childhood TB

• Sites in Uganda, and Armenia

• Collaboration with Epicentre

• 4 child TB studies starting in 2012

Conclusion

Children carry a burden of TB disease - drug sensitive and drug resistant - that has long been underestimated

Child TB requires more attention at all levels

Much more research is needed: from diverse contexts

It is urgent to: Apply current recommendations and do the basics well

and

Prioritise new approaches to diagnosis and treatment

Thank you