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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