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

International Union Against Tuberculosis and Lung Disease

(The Union)

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. »

Exposure

Infection

Disease

Outcome

Epidemiological spectrum

Arvid WallgrenEdith Lincoln

Risk of TB disease following infection by age

Adapted from Marais B, et al. Int J Tuberc Lung Dis 2004

NATIONAL TB PROGRAMPAPUA NEW GUINEA

MANUAL ON MANAGEMENT OF CHILDHOOD TUBERCULOSIS

“Know your epidemic”

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

Millennium Development Goals

“ 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

Framework for child TB and NTP

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

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

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

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

Bugs or biomarkers

Xpert MTB/RIF

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

Uni of Melbourne 2011

Diagnostic yield for pulmonary TB comparing children to adults and adolescents

Average age specific risk for disease development following primary infection (pre-BCG)

Adapted from Marais B, et al. Int J Tuberc Lung Dis 2004

Average age specific risk for disease development following primary infection (post-BCG)

High BCG coverage

Average age specific risk for disease development following primary infection: BCG and IPT

High BCG coverage

Contact screening and preventive therapy

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

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

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

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

12,750 posters 554,400 leaflets

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%)

“ 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

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

Thank you