Increased case detection in infants and children

Robert Gie

Childhood TB Subgroup

Overview

• TB in pregnant woman

• Post partum TB and the infant

• TB in the HIV-infected infant

• Screening children exposed to an infectious source case

• Barriers to the diagnosis of TB in children

Transitions of TB in pregnancy

SusceptibleSusceptible

ExposedExposed

InfectedInfectedPregnantPregnant

DiseasedDiseased

RecognizedRecognizedDiagnosed Diagnosed

DeliveryDelivery

InfantInfant

Diseased or infectedDiseased or infected

DiagnosedDiagnosed

Cured or preventedCured or prevented

Adapted from Don Enarson

Consequences of maternal TB

• Increased maternal mortality : 3 fold

• HIV infected mother have a 10 fold increase in TB

• TB increases the probability of infant death by 2.2 to 6.4 fold

• Congenital TB mortality = 21-38%

Challenges:

• We have an opportunity to integrate maternal and child health by;– Integrating VCR and TB screening during pregnancy

– Screening mother and child in the postpartum period

• This will lead to an decrease in maternal and infant mortality rates and increased HIV and TB case finding

1 2 3

Source case’s: now 5 month old daughter

03.12.03

The mother’s sister

The Grandmother’s

Questions raised?

• How do we integrate screening for TB into:– Antenatal care– PMTCT program– Post partum care– Nursery (kangaroo care)

• What should be included in the screening?

• How do we manage neonates exposed to an infectious case of TB? ( and MDR exposure?)

What is the risks to HIV infected infants?

Transition in TBSusceptibleSusceptible

ExposedExposed

InfectedInfectedDiseasedDiseased

InfectiousInfectious

SickSickAccessed careAccessed care

RecognizedRecognized

DiagnosedDiagnosed

TreatedTreated

CompletedCompleted

CuredCured

Gratitude Don Enarson

The risk of developing TB in HIV infected infants:

• HIV infected children have ;

– Increased risk of being exposed to TB

– Increased risk of developing disease (24 fold)

• All children suspected of having TB must be tested for HIV in high prevalence communities

• At each health care visit each HIV-infected child must be screened for TB

Barriers to diagnosis:

• Reasons why TB is not diagnosed:

– Lack of screening for disease

– “TB in children is difficult to diagnose”

– Dosage uncertainty and lack of child friendly drugs

– Lack of reporting and recording

Demystifying childhood TB

• Obstacles for children to be diagnosed:

– “Difficulty in making diagnosis”– Lack of diagnostic tools

• Tuberculin skin test• Chest radiography• Difficulty in specimens collection and culture.

Difficulty in making the diagnosis.

• Is it true that the diagnosis of childhood TB difficulty?

– History based screening.

– Value of history in making the diagnosis

Demystifying childhood TB diagnosis

• Screening for children can effectively done by history except in high risk groups (HIV infected and less than 2 years of age)

• The diagnosis of childhood TB in the majority of cases is simply

• Diagnosis accuracy will be increased by the use of– Tuberculin skin test– Chest radiography– Culture and sensitivity

• Simple tools are underused : Fine needle aspiration

TB drug dosages:

Recording and reporting

Summary Increase the case finding in infants and children

• Integrate maternal and child health with increased VCR and TB screening during – Pre-natal clinics– Post-natal clinics – In nurseries

• Any infant and child suspected of TB must be tested for HIV

• Screening children for TB can be successful using symptoms

• The diagnosis of TB in children is in the majority is easy especially in HIV non-infected children