childhood tuberculosis and community healthcare_steve graham_5.8.14
TRANSCRIPT
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Managing child TB where the children are
Steve Graham
Centre for International Child HealthUniversity of Melbourne Department of Paediatrics
International Union Against Tuberculosis and Lung DiseaseParis
Chairman, child TB sub-groupStop TB Partnership, WHO
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International Union Against Tuberculosis and Lung Disease
(The Union)
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Léon Bernard, 1920, L’Union Internationale Contre la Tuberculose
« Il faut que les chercheurs puissent cerner complètement le problème afin de transmettre aux gouvernements l'information nécessaire. »
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Exposure
Infection
Disease
Outcome
Epidemiological spectrum
Arvid WallgrenEdith Lincoln
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Risk of TB disease following infection by age
Adapted from Marais B, et al. Int J Tuberc Lung Dis 2004
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NATIONAL TB PROGRAMPAPUA NEW GUINEA
MANUAL ON MANAGEMENT OF CHILDHOOD TUBERCULOSIS
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“Know your epidemic”
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Most child pneumonia cases occur in SE Asia
Most pneumonia-related child deaths occur in sub-Saharan Africa (50%) and SE Asia (20%)
Rudan I et al. Bull WHO 2008
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Millennium Development Goals
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“ There are many contributions which the pediatrician can make to a TB control program.
First the negativism about tuberculosis so prevalent in pediatrics must be overcome…”
Edith Lincoln, 1961
Donald PR. Edith Lincoln, an American Pioneer of Childhood Tuberculosis. Pediatr Infect Dis J 2013
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Framework for child TB and NTP
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Diagnosing Childhood Tuberculosis - What do we have?
History Tuberculin-Skin Test (1890)
Chest X-ray (1896)
Bacteriology(1882)
Indicator of infection with limitations
LowSensitivity
History Chest X-ray (1896)
LowSpecificity
High negative predictive valueOzuah (2001) JAMA
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Recommended approach to diagnose TB in childrenWHO Guidance for NTP on management of TB in children 2006
1. Careful historyincludes history of TB contactsymptoms suggestive of TB
2. Clinical examinationincludes growth assessment
3. Tuberculin skin test4. Bacteriological confirmation whenever possible5. Investigations relevant for suspected PTB or
suspected EPTB6. HIV testing
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Burden of child TB in PNG: 2005-6Law I, et al. Poster – The Union Global Lung Health Conference 2008
Pulmonary TBSmear positiveSmear negativeSmear not done
1208 (61%)18
1381052
EPTB 769 (39%)
Total 1977
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Diagnosis and level of care
TB cases Inpatient Outpatient Overall
Total TB cases 5,877 15,694 21,571
Child TB cases N=648 N=4173 N=4821
% of total burden 11% 27% 22%
< 5 years 56% 53% 53%
Smear positive disease 16% 8% 9%
EPTB 15% 6% 8%
Non-teaching hospital 73% 76% 75%
Private health facility 8% 7% 7%
Lestari T, et al. BMC Pub Health 2011
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Bugs or biomarkers
Xpert MTB/RIF
from Boehme CC et al, NEJM 2010 from Tebruegge M, PhD
Uni of Melbourne 2011
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Diagnostic yield for pulmonary TB comparing children to adults and adolescents
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Average age specific risk for disease development following primary infection (pre-BCG)
Adapted from Marais B, et al. Int J Tuberc Lung Dis 2004
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Average age specific risk for disease development following primary infection (post-BCG)
High BCG coverage
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Average age specific risk for disease development following primary infection: BCG and IPT
High BCG coverage
Contact screening and preventive therapy
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Studies of child contacts in Asian countriesStudy Location No. of child
contactsProportion with
TB infectionProportion with
TB disease
Andrew et al India 398 39 % 5.5 %Narain et al India 790 24 % NR
Kumar et al India 142 NR 3 %*Singh et al India 281 34 %* 3 %*Rathi et al Pakistan 151 27 % NR
Salazar et al Philippines 153 69 % 3 %Tornee et al Thailand 500 47 % NR
Nguyen et al Lao PDR 148 31 % NR
Okada et al Cambodia 217 24 %* 9 %*
* Data only for < 5 years; NR: not recordedFrom Triasih R et al, J Trop Med 2012
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WHO symptom based screeningWHO symptom based screening
More than 5 yearsLess than 5 years
Children in close contact with a case of sputum smear-positive TB
Well Symptomatic Symptomatic Well
Preventive therapy Evaluate for TB disease No treatment
If becomes symptomatic If becomes symptomatic
Note that contact screening has two important roles1.Active case-finding2.Preventive therapy for at-risk contacts without TB
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269All child contacts
108Children < 5 yrs
161Children > 5 yrs
37symptomatic
71well
61symptomatic
100well
999 12 149TB DISEASE AT BASELINE
00 0 4TB DISEASE AT 12 MONTH FOLLOW UP
The outcome of symptom based screening in Indonesian children The outcome of symptom based screening in Indonesian children
Triasih R, Graham SM. Unpublished data
28 49
IPT No IPT
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Viet Nam• Reported child TB <2% of total burden• Low numbers of TB cases referred or diagnosed• Variable uptake of IPT
• NTP ownership and political will – technical support• Child TB working group formed• Pilot of community-based contact management• Four provinces involved – 35 districts and 611 communal
health centres• Development of IEC
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12,750 posters 554,400 leaflets
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Community contact screening in Viet Nam
Child contacts screened since Q4 2012 4109
Eligible for IPT 1577
Numbers received IPT 979 (62%)
% completed to date 88% (n=153)
Children diagnosed with TB 345 (8%)
Sputum smear positive 37 (11%)
Sputum smear negative PTB 157 (46%)
EPTB 151 (43%)
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“ There are many contributions which the pediatrician can make to a TB control program.
First the negativism about tuberculosis so prevalent in pediatrics must be overcome…”
Edith Lincoln, 1961
Donald PR. Edith Lincoln, an American Pioneer of Childhood Tuberculosis. Pediatr Infect Dis J 2013
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World Health Assembly 2014 TB “elimination”
Innovative approaches
Community-based
Wider health sector
Preventive therapy
Operational research
Progress too slow
Funding gap
MDR/XDR TB
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Thank you