Child Lung Health

8/14/2019 Child Lung Health

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Child lung health in resource-limited

settings

Steve Graham

Centre for International Child Health

University of Melbourne Department of PaediatricsRoyal Childrens Hospital

Melbourne

Child Lung HealthInternational Union Against Tuberculosis and Lung Disease

Paris


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Patient care focusResource richBenefitExpecting best possible

outcome

Often complicatedfrom 95% to 99.9%

Relevant to local prioritiesSocial determinants

Public health focusResource poorCostbest can be the enemy of the

good

Keep it simplefrom 85% to 95%

Relevant to local prioritiesSocial determinants

Balance and perspective


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Global mortality among children (< 5 years) has fallen by 40% in past 20 years

Estimates of 12.2 million child deaths from preventable causes in 1993 falling

to less than 7 million in 2011

Pattern of causes has changed slightly but pneumonia remains major single

cause


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Schell C, et al. Scand J Pub Health, 2007;35:288-97

Female illiteracy is a more important determinant of high child mortalitythan low income per capita, and both are more important than lowpublic expenditure on health


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Schell C, et al. Scand J Pub Health, 2007;35:288-97

Female illiteracy is a more important determinant of high child mortalitythan low income per capita, and both are more important than lowpublic expenditure on health


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Country Year Male FemaleAfghanistan 1998 46.0 16.0

Bangladesh 1998 63.1 48.1

India 1997 70.5 43.9

Nepal 1997 62.5 27.7

Pakistan 1997 55.3 29.1

Sri Lanka 1998 92 0 88 0

Female literacy and child mortality: examples from south Asia


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Most cases occur in SE Asia

Most deaths occur in sub-Saharan Africa (50%)

and SE Asia (20%)

Rudan I et al. Bull WHO 2008


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Risk factors for child pneumonia

Age

Poor immunisation coverage

Pertussis

Measles

Hib

Nutrition

Low birth weight

Malnutrition Not breast fed

Vitamin A deficiency

Zinc deficiency

Socioeconomic

Indoor air pollution

Crowding

Hygiene

Access to health services

Underlying disease

HIV

Cardiac

Neurological


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Risk factor Category Death/

numbers

Case-

fatality

rate

Test of

significance

66/477 14 %

Age < 6 months6-12 months

1-4 years

5 -14 years

47/175

16/110

3/153

0/39

27 %

15 %

2 %

0%

Chi-square for

trend

P


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Category Pathogen

Bacterial 45% Streptococcus pneumoniae 20%

Haemophilus influenzae type B 15%

Staphylococcus aureus 5%

Other Gram negatives 5%

Mixed 5-10%

Viral 40% RSV 15-20%Influenza A and B 5%

Parainfluenza 7-10%

adenovirus 2-4%

Causes of childhood pneumonia

Data from 14 lung aspiration studies Berman S. Rev Infect Dis 1991

Changing spectrum of aetiology /prevalence of specific causes

Poor diagnostic techniques

Did not investigate for tuberculosis

Limited data from HIV endemic setting


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Disease burden

Very severe pneumonia

Severe pneumonia

Non-severe pneumonia

WHO pneumonia case definitions


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Disease burden


Severe pneumonia

Non-severepneumonia

Cause of death

Lung aspiration studies in early 1980s identified that most fatal

cases were due to bacteriaespecially pneumococcus and Hib

Shann F, et al Lancet 1981


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Disease burden


Severe pneumonia

Non-severepneumonia

WHO case definitions

Presence of danger signs

Chest indrawing

Fast breathing


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Disease burden


Severe pneumonia

Non-severepneumonia

WHO case definitions

Parenteral antibiotics +/-oxygen

Antibiotics +/- hospitalise

Homeoral antibiotics


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Management of child pneumonia

Case-management strategy Focus on reducing mortality Reduce unnecessary antibiotic use

Antibiotics

Recent changes to recommendations: amoxicillin Availability

Community-based care and improved access

Hypoxia management

Implementation a major challenge Cost-effective


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Hypoxaemia in >16,000 child pneumonia cases in 21studies: median prevalence of 13.3% (IQR 9.3-37.5)

Varies widely between settings

11-20 million children admitted to hospitals withpneumonia each year

At least 15 to 27 million annual cases of hypoxaemicpneumonia presenting to hospitals

How common is the need for oxygen?

Subhi R, et al. Lancet Infect Dis 2009


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Clinical detection of

hypoxia can bedifficult

Oxygen saturation

SpO2

Percentage of children

(n=1116) detected

to have cyanosis

70-84% 44%

50-69% 81%


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Oxygen availability

Papua New Guinea: oxygen not available for 22% of1300 children in 5 hospitals1 of 20 hospitals had pulse oximetry

Sierra Leone: 40% of hospitals no oxygen

South Africa health clinics: 39% no oxygen

Lao: some central hospitals, few district hospitalshave oxygen

Wandi F, et al. Ann Trop Paediatr 2006; English M, et al. Lancet 2004; Kingham T P, et al. Arch Surg2009;


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2010: 17 provincial and district hospitals

Scaling up is possible


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Oxygen concentrators andthe role of bubble CPAP

f d d


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Causes of respiratory disease in autopsy studies in

African children

Causes ofpneumonia

HIV-infectedN=473

HIV-uninfectedN=338

TotalN=811

Bacterial 238 (50%) 132 (39%) 370 (46%)

PcP 145 (31%) 11 (3%) 156 (19%)

CMV 121 (26%) 7 (2%) 128 (16%)

Tuberculosis 50 (11%) 27 (8%) 77 (9%)

Co-infection 98 (21%) 5 (1.5%) 103 (13%)


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PcP is commonest cause of death in HIV-infected infants

Presents in early infancy: 2-6 months of age

PcP is often associated with CMV disease

PcP is preventable by cotrimoxazole prophylaxis in HIV exposed infants

Pneumocystis jirovecii pneumonia (PcP)


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Site and year Number in

study

HIV-infected (%) Case-fatality rate

HIV uninfected HIV infected

Zambia

Rural hospital 1995132 14 (11%) 14% 36%

Malawi

Urban hospital 1996150 93 (62%) 9% 30%

South Africa Urban hospital

1998250 151 (60%) 8% 20%


19981165 548 (47%) 2% 13%


1999-2001366 82 (22%) 0.7% 3.6%


2001-2358 242 (68%) 2.5% 21%

Mozambique

Rural hospital 2004-2006195 49 (25%) 2% 27%

MalawiUrban hospital 2006 264 134 (51%) 3% 13%

Overall in-hospital CFR was 16.8% in 1313 HIV-infected children compared to3.4% in 1567 HIV-uninfected children: OR 5.67 [95%CI 4.17-7.71]

HIV-related increased mortality is in infants: PcP major contributor

Treatment of severe and very severe pneumonia and HIV


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Chronic lung disease extremely common among adolescents withvertically-acquired HIV infection

Severely restrictive lung disease with marked exercise intolerance

Pulmonary hypertension common

Ferrand R, et al. CROI 2010


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Notification Rates of Sputum Smear-Positive Tuberculosis,by Age, Tanzania Mainland, 1984 and 1995

Age group (years)

0 15 25 35 45 55 65

Notifications

per100,000

0

50

100

150

200

Tanzania NTLP / IUATLD. Progress Report 1996;No. 36

1995

1984


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Childhood TB and TB control programmes

Public health approach: Proper identification andtreatment of infectious cases will prevent childhood TB

Child TB historically afforded alow priority by NTPs:

Diagnostic difficulties Usually not infectious Limited resources Lack of recording and reporting

But- this disregards the impact of TB on childhood

morbidity and mortality- relevant MDGs 4 and 5 as well as MDG 6- child TB reflects recent TB control


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Signed by more than 1000 individuals/organisations


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Estimated TB incidence rates, 2011

Global Tuberculosis Report 2012

Child TB is common wherever TB is commonbut how common?


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Donald PR. Curr Opin Pulm Med

2002

Reported: range 1%-40%

Important factors:

Incidence of TB

Demographics - age

Effectiveness of case-finding and

management

Prevalence of risk factors in children

BCG coverage


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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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Incidence by age when TB was first diagnosed

Age (years)

0 5 10 15 20 25 30 35 40

Averageannualcaserate(per

100,000)

0

100

200

300

400

Comstock GW, et al. Am J Epidemiol 1974;99:131-8

Diagnostic challenges


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Clinical challenges are the diagnostic

challenges

Young age

Acute severe pneumonia

HIV-infected

Malnourished

MDR TB


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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 contact

symptoms suggestive of TB

2. Clinical examination

includes growth assessment

3. Tuberculin skin test

4. Bacteriological confirmation whenever possible

5. Investigations relevant for suspected PTB orsuspected EPTB


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Recommended approach to diagnose TB in children

1. Careful historyincludes history of TB contact

symptoms suggestive of TB

2. Clinical examination

includes growth assessment

3. Tuberculin skin test

4. Bacteriological confirmation whenever possible

5. Investigations relevant for suspected PTB orsuspected EPTB

6. HIV testing routine

TST and culture are oftenunavailable. Neither is required fora decision to treat for TB in mostcases.

CXR is an important tool for

diagnosis of TB in children but

recognised limitations


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Revised National Guideline on Management of Tuberculosis in Children, 2012, Myanmar


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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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Bugs or biomarkers

Xpert MTB/RIF

from Boehme CC et al, NEJM 2010 from Tebruegge M, PhD student

Uni of Melbourne 2011


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Improving managementpoint of care diagnosis


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Studies of child contacts in Asian countries

Study Location No. of child

contacts

Proportion with

TB infection

Proportion 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 recorded

From Triasih R et al, J Trop Med 2011


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WHO 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 roles

1. Active case-finding

2. Preventive therapy for at-risk contacts without TB

The outcome of symptom based screening in Indonesian children


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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 4

TB DISEASE AT FOLLOW UP


Triasih R, Graham SM. Unpublished data

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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 4

TB DISEASE AT 12 MONTH FOLLOW UP


Triasih R, Graham SM. Unpublished data

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IPT No IPT


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Childh d TB d NTP


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Childhood TB and NTPsBest Practices in Tuberculosis Control

September 2010, Kigali, Rwanda

1. Develop and adapt child TB guidelines2. Operationalise child TB guidelines

3. Identify child TB champion

4. Focal person for child TB at NTPworking group

5. Training

provide child TB training and incorporate intoongoing training related to TB and TB/HIV

6. Incorporate child TB into annual plans and 5-year strategic plan

7. Incorporate child TB into budget

8. Include child TB data in routine reporting and reviews

9. Operational research to determine constraints and barriers

10.Research aimed to improve child TB and contact management


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Launched

1st October 2013

Washington D.C.

Prevention of disease and deaths


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Prevention of disease and deaths

Addressing social determinants

Expanded Program on Immunisation

Pneumococcal conjugate vaccine

HIV prevention and management Lower antenatal HIV prevalence

Prevention of Mother to Child Transmission

Cotrimoxazole preventive therapy

Early antiretroviral therapy

Improve management of hypoxia

Preventive therapy for TB contacts


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Thank you

Child Lung Health

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