childhood tuberculosis and community healthcare_kechi achebe_5.8.14

Thinking about childhood TB – where does it fit in our agenda?

Dr. Kechi Achebe Senior Director, HIV/AIDS

127780-46-Strategy framework-Jan09-BH-LIS v1 pp.ppt

Breakthrough for Children

Health & Nutrition: • No child under the age of

five dies from preventable causes and public attitudes will not tolerate high levels of child deaths

HIV and AIDS • The world no longer

tolerates children being affected or infected by HIV and AIDS.


Current Global Statistics • About half a million children become ill with tuberculosis (TB) and are

diagnosed every year

• 64,000 deaths among HIV negative children occur annually

• Actual extent of childhood TB is unknown

• Of the 8.6 million annual incident cases in the world, estimates suggest that up to 1 million cases (11 out of every 100) are in children 0-14 years of age. Most commonly it is between 1 and 4 years old

• In 2009, 10 million children were orphaned due to maternal TB

• As many as 32,000 children worldwide annually, become sick with multi-drug resistant TB (MDR-TB) 3


Current Global Statistics (2)

• Many cases missed – in Bangladesh, study by CWCH projects as many as 25,277 per year

of 0-14 year olds can be diagnosed with TB annually – Currently the NTP is diagnosing a mere 4,375 children a year

• TB in pregnancy, congenital TB, and perinatal TB are also under-

recognized

• no contact tracing

• •mis-diagnosis


MDR TB in Children • A child with TB is as likely as an adult with TB to have MDR-TB.

• Between 10,000 and 20,000 children in India are estimated to acquire

MDR-TB every year

• If TB drugs are not taken regularly as prescribed, TB bacteria can become resistant during treatment

• Drug resistant TB is much more difficult to treat, • It costs 100 times greater to treat MTB compared to TB! • Long treatment period lasts from 18 – 24 months. • There are many side effects of drugs which cause patient fatigue. • The cure rate is low and high rate of death.

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MDR TB in Children (2) • Children usually develop transmitted drug-resistant TB, but some may

acquire drug resistance due to inadequate treatment regimen, irregular supply of drugs or poor compliance

• The diagnosis of MDR-TB, which relies on a positive culture and drug sensitivity report, is a challenge.

• Clinical criteria are relied upon for diagnosis along with radiological support and Mantoux testing.

• Many children with bacteriologically/ histopathologically proven tuberculosis may have normal chest radiograph

• Insensitive diagnostic aids have led to delayed diagnosis / underdiagnosis / overdiagnosis. 6


The challenge for children • Children living in the same household with a pulmonary TB patient,

especially children under 5 are more susceptible – Children living with HIV – Children with malnutrition – Children living in poor living conditions and badly ventilated houses.

• The leading cause of death for children include pneumonia (up to 20%

may be TB), HIV/AIDS and Malnutrition (they all pose with the same features as TB)

• In most countries, the number of children being reported by the National Tuberculosis Program (NTP) is far below what is estimated.


The challenge for children (2) • Infants and young children are also more at risk of developing severe

disseminated disease (where TB spreads from the lungs to other parts of the body) associated with high mortality, such as TB meningitis and miliary TB.

• The diagnosis of TB in children is often missed or overlooked due to non-specific symptoms and other difficulties, such as obtaining sputum from young children.

• Childhood TB activities are rarely included in strategic plans or budgeted by Ministries of Health (MoH).

• Many patients with TB, including children, are diagnosed in the private sector and are not reported to the MoH.


How pulmonary TB presents in Children

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3 clinical features can diagnose childhood pulmonary TB

• 1. persistent non--‐remitting cough

• 2. documented failure to thrive (gain weight) in the previous three months • 3. reported fatigue (perceived decrease in playfulness, activity since onset

of coughing) Well characterized symptoms improve diagnostic accuracy • > 3 years: specificity: 98.9%; PPV: 85.1% • < 3 years: specificity: 82.6%; PPV: 88.6%

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Barriers to child TB detection • Lack of family centered contact tracing

• Lack of guidelines in the field about systematic screening and referral of

children suspected to have TB

• •Lack of trained personnel (doctors and paramedics) who can diagnose and treat children with TB according to WHO guidelines

• The number of patients reported depends on • the intensity of the epidemic, • the age structure of the population, • the alertness & knowledge of nurses and doctors in diagnosing childhood TB • the available diagnostic tools, • the extent of routine contact investigation and • the functioning of the administrative case reporting system.

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Missed Opportunities

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Community Integration

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VISION ZERO new HIV and TB infections

ZERO new infections due to vertical transmission ZERO preventable AIDS-related and TB deaths

ZERO HIV and TB discrimination


Our Theory of Change


Save the Children’s Contribution

• Increase case referral and detection rates of children with TB (suspected or actual) through current platforms in the health facilities or community

– OVC programs – CHWs providing visits – HIV programs – escpially pediatric and home based care

programs – Child Malnutrition programs – Prevention of Mother to Child HIV Transmission (PMTCT)

programs – iCCM platforms – Integrated Management of Childhood illnesses (IMCI) and

Community IMCI platforms – Family planning and maternal health programs

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Goal/Vision

• Conduct operational research and evaluate community based childhood TB programs to understand best practices in community-based childhood TB management.

• Increase case detection by 20% among referred children

• Ensure all newborn and children under 1 year are provided with BCG vaccine

• Ensure children under 5 years old or children with no TB or children having HIV and living in the same house with PTB patient are provided with ITP under instructions of Trained TB control workers.

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• By training CHW providing home visits to • Use child TB score chart (Keith Edwards) • Refer the child to the doctor when needed

• Providing guidelines and frameworks • Training health care workers to be able to make diagnosis at the

health facilities following referrals and to conduct health education sessions

• Integrate TB treatment adherence monitoring into current home visits protocol

• Providing posters and handbills on childhood TB and distributing to health facilities and CHWs

• Including Childhood TB as discussion points in PMTCT clinics, OVC child care committee meetings

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Resources (1) : Child TB Roadmap overview

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Resources (2): WHO/UNICEF training manuals for CHWs TB/HIV interventions

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Resources (3): Developed by CORE group TB and Community child health working groups

• Outlines the rationale for • developing community strategies for • childhood TB • • Suggests interventions addressing • – Risk assessment! • – Follow-up • – Contact tracing • – Treatment support • – Preventive services • • Identifies areas for pilot work/ • operational research

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Caring for the sick child in the community and potential TB-related actions

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Key Elements to Implement Community Child Health Services (Source: Reaching Communities for Child Health and Nutrition. Basics, CORE Group 2001)

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Thank you!

di ou mèsi

Merci

Asante Sana

Obrigado

! 谢谢 Salamat

¡Gracias

childhood tuberculosis and community healthcare_kechi achebe_5.8.14

Health & Medicine