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Diagnosis, Challenges and Management
Dr Mir Anwar MBBS,DCH,MPH(USA)
Richmond Hospital,KZN, South Africa
Paediatric Tuberculosis in HIV Era
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3rd SA TB Conference Durban 2012
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OverviewDiagnosis of TB in HIV +ve Children
Challenges
Management of Disease
New Developments
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HIV And TB Statistics2010 data
8.8 million new TB cases Globally.1.1 million Death (excluding HIV).~1.1 million new HIV associated TB cases82% living in Sub Saharan-Africa350, 000 death
Opportunistic infection20-37 times greater when HIV +ive
http://www.who.int/hiv/topics/tb/en/http://www.who.int/mediacentre/factsheets/fs104/en/
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Facts and FiguresDeaths Worldwide
HIV: 6000/day TB: 5000/day
South Africa TB cases : 4th in the world Children: 16% of all TB cases HIV/TB children : 25-60%
http://www.who.int/tb/challenges/hiv/facts/en/index.html
http://www.pedaids.org/What-We-re-Doing/Foundation-Blog/March-2011/A-Talk-on-Pediatric-Tuberculosis-and-HIV
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DiagnosisRecognizing symptomsContact history Sputum cultureChest X-rayMantoux testGastric washGeneXpert test- The New Era
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SymptomsCoughing >2 weeks Chest painWeakness or fatigueWeight Loss> 10%Fever/ChillNight Sweat
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Recognizing SymptomsProbable TB
+ive tuberculin skin test>Suggestive chest radiography. ie
Lymphadenopathy, pericardial effusion etc.
>CT Scan ,ie Chest, Abdomen, brain Suggestive histological appearance on
biopsy material- FNAFavourable response to TB-specific therapy
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Smear –ive TB is too confusing How do we understand it?Cough for more then 14 days.Chest pain more then 14 daysWeight loss >10%Failure to gain weight despite ARTMinimal or No Sputum production
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Cont’dLymphadenopathy i.e. X-raySevere anemia, Hb < 7gmSigns of extra pulmonary TBMilliary pattern on chest x-rayIf severe shortness of breath, we will
consider PCP first.
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Baby born to Mother with TBIf Baby has no TB signs or symptoms Start with Isoniazide 10mg/kg/day for 6
months.Once IPT completed, BCG can be given if
asymptomatic and HIV- uninfected.TST can be done on child after 3 months of
IPT.If TST negative and mother smear negative ,
stop INH & give BCG.
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Baby Born to a Mother with TBIf haveing TB signs/Symptoms in InfantSubmission of gastric aspirates and blood for
TB culture DSTCXRAbdominal sonar ( as the liver is often the
primary site in congenital TB).IF TB Diagnosed.Start Regimen 3 of TB treatment.Start Fast track for ART if baby is HIV-
infected.
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Statistics of Smear Negative TB1980-1990
33-50% HIV +ve PTB patient were smear –veKenya (2003)
64% HIV +ve patient with proven TB were AFB smear –ive
South Africa (2008)26% of patient entering ART had active PTB87% were AFB smear –ve even with
fluorescent microscopy test.
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Cont’dSmear –ive have high mortality rate even
with proper TB treatment
HIV +ive patient have less TB organism in sputum even with low CD4 count.
Limited lab tech and high sample load- smear +ve missed
Ref- TB in ERA of HIV by Jon Fielder
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ChallengesFailure to recognizing symptoms
Resource shortage
Lack in education
Adverse drug interaction
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WHO Global TB Report
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Interpreting Mantoux testNon-reactive Reactive
Had BCG < 15mm > 15mm
No BCG < 10mm > 10mm
HIV +ve < 4mm > 4mm
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Extra Pulmonary TB in ChildrenPeripheral LymphadenitisBones and Joints ,spinal TBPlural Effusion.TB PericarditisAbdominal TBTB MeningitisIn the late stage HIV TB can be anywhere in
the body.
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Objective Of TB TreatmentTo cure the patient
To prevent death
To prevent relapse
To prevent development of drug resistance
To reduce transmission
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Treatment WHO Guidelineshould betreated with a four-drug regimen (RHZE)
for 2 months followed by a two-drugregimen (RH) for 4 months total 6
months.TBM with HIV needs 9 to 12 months
regime.
at the following dosages
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Children in High HIV Settingisoniazid (H)
10 mg/kg (range 10–15mg/kg)maximum dose 300 mg/day
rifampicin (R) 15 mg/kg (range 10–20 mg/kg) maximum dose 600 mg/day
pyrazinamide (Z) 35 mg/kg (30–40 mg/kg)
ethambutol (E) 20 mg/kg (15-25 mg/kg)
http://whqlibdoc.who.int/publications/2010/9789241500449_eng.pdf
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MonitoringSymptom assessment
Adherence and reviewing treatment
Adverse events- LFT’s, haematology
rashes, IRISRegular follow-ups
Non-response to drugs- MDR TB
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How should we manage a child who deteriorates in TB treatment.Is the drug dose is correct?Is the child taking the drug as prescribed?
(good adherence, including DOT)Is the child HIV infected?Is the child severely malnourished?Is there is a reason to suspect MDR TB?Has child develops IRIS?Is there another reason for child illness other
than TB, ie Malignancy?
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GeneXpert TestGeneXpert MTB/RIF test
PCR based analysis.Endorsed by WHO in Dec 2010 for adults
Research being conducted in SA since 2008.
http://www.ajol.info/index.php/cme/article/viewFile/72026/60969
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AdvantagesProvides results in ~90 min
Minimal biohazard
Operation requires little technical training
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“If a minister can do it, it can’t be that hard," Health Minister Aaron Moatsoaled. http://www.aidsmap.com/GeneXpert-to-be-rolled-out-as-first-line-diagnostic-for-TB-in-South-Africa/page/1746803/
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Can GeneXpert be used for children?Yes according to WHO ?
if able to produce sputum or if an induced sputum is obtained
Gastric Aspiration fluid, Biopsy serous fluid.Mark Nichol @ U of Cape Town
More effective Vs smear microscopyWorks better in HIV +ve children
http://www.nhls.ac.za/assets/files/GeneXpert%20brochure.pdfhttp://sciencespeaksblog.org/2011/10/26/how-well-does-the-genexpert-rapid-tb-diagnostic-perform-among-children/#ixzz1zzsazJvB
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DisadvantagesCost-
$16 for cartridge/ per test.
Requires uninterrupted electric supply
Requires calibration
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Summary- TB in Era of HIVTB is surging in much of Africa because of
the HIV epidemic.The TB rates are usually higher than what is
reported in the public health system.TB is the number one cause of death in HIV-
infected patients in Africa.TB has usually spread through out the body
by the time of death.The patterns of TB diseases are changing.TB is a multisystem disease.
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Recommendations Good Record-keeping
Group nutrition counselling
HIV/TB awareness education
Fundraising
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Concluding RemarksHIV/AIDS is the major threat to TB control
TB/HIV rates directly proportional to each other.
Overcoming challenges
OUR CHILDREN ARE OUR FUTURE
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THANK YOU