PAEDIATRIC TB Jenny Handforth June 2014. Overview Why is Paediatric TB important Epidemiology- know...
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Transcript of PAEDIATRIC TB Jenny Handforth June 2014. Overview Why is Paediatric TB important Epidemiology- know...
PAEDIATRIC TBJenny Handforth
June 2014
Overview
•Why is Paediatric TB important
•Epidemiology- know the patients
•Adult v child with TB - differences?
• Diagnostic challenges:
Why do you need to know about Paediatric TB?
• 1 million cases estimated globally each year (11%)
• 25-40% of all cases are children in high burden countries
• 4-7% in low burden countries
• Higher risk of severe disease and death in young children
• Indicator of effectiveness of TB control programmes
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Figure 1.1: Tuberculosis case reports and rates, UK, 2000-2012
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
4 Tuberculosis in the UK: 2013 report
5 Tuberculosis in the UK: 2013 report
Figure 1.3. Three-year average tuberculosis case rates by local area*, UK, 2010-2012 *England – Local authorities, Wales and Scotland – Health
Boards, NI – data not available
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS)Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
© Crown copyright and database rights 2013 Ordnance Survey 100016969
London
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6 Tuberculosis in the UK: 2013 report
Figure 1.4: Tuberculosis case reports and rates by region*, England, 2012
* HPA regionCI – 95% confidence intervals Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS) Data as at July 2013 Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
Figure 1.6: Tuberculosis case reports by place of birth and country, UK, 2012
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
7 Tuberculosis in the UK: 2013 report
5,819
48 185 73
2,020
39 142 56
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Figure 1.8: Non UK-born tuberculosis case reports by time since entry to the UK to tuberculosis diagnosis, UK, 2012
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
8 Tuberculosis in the UK: 2013 report
Figure 1.10: Tuberculosis case reports and rates by age group and place of birth, UK, 2012
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
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9 Tuberculosis in the UK: 2013 report
Figure 1.11: Tuberculosis case reports and rates by age group and sex, UK, 2012
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10 Tuberculosis in the UK: 2013 report
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
Figure 1.14: Child to adult ratio in notifications rate, UK, 2000-2012
The child-to-adult ratio is the ratio of the case notification rate in children under 15 years of age, to that in adults. A declining trend in the ratio suggests a decrease in ongoing transmission (European Centre for Disease Prevention and Control).
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Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
11 Tuberculosis in the UK: 2013 report
Questions that must be asked...• Has this child been exposed to TB?
• Has the child been infected with TB?
• If yes does this child have Tb disease?
• Who has infected this child?
• …and answered!
3 scenarios for investigating TB in children1. Screening healthy children - screen for
TB risk factors
2. Known contact with infectious case - usually adult
3. Child with symptoms and/or signs of TB or abnormal CXR
- high index of suspicion required
Pathogenesis of TB in childhood
• Exposure to bacilli
from adult
• No infection • Primary complex
Dissemination to
lung apices,
meninges,bone
spine,nodes
• heals • progresses • Active disease• Dormant
TB disease (TB) or Latent TB (LTB)• TB: active M. tuberculosis in some part of child’s body
• May be asymptomatic• Abnormal CXR and/or abnormal clinical exam
• LTB: dormant M. tuberculosis• Clinical exam normal• X rays normal
• Diagnosis is made by• History• Clinical examination• CXR/imaging/microbiology
Risk of Disease following primary infectionMarais BJ et al. Int J Tuberc Lung Dis 2004;8:392-402
Disseminated TB
Pulmonary TB
No disease comments
< 1 years
10-20% 30-40% 50% High rates of morbidity & mortality
1-2 years
2-5% 10-20% 75-80% High rates of morbidity & mortality
2-5 years
0.5% 5% 95%
5-10 years
<0.5% 2% 98% Safe school years
>10 years
<0.5% 10-20% 80-90% Adult disease
Table 1.2: Tuberculosis case reports by site of disease, UK, 2012
Site of disease* Number of cases Percentage**
Pulmonary 4,563 52.1
Extra-thoracic lymph nodes 1,872 21.4
Intra-thoracic lymph nodes 946 10.8
Other extra-pulmonary 619 7.1
Pleural 651 7.4
Gastrointestinal 471 5.4
Bone – spine 394 4.5
Cryptic± 46 0.5
Miliary± 197 2.3
Bone – other 218 2.5
CNS – meningitis 187 2.1
Genitourinary 137 1.6
CNS – other 80 0.9
Laryngeal 16 0.2
Unknown extra-pulmonary 15 0.2
17 Tuberculosis in the UK: 2013 report
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
*With or without disease at another site **Percentage of cases with known sites of disease (8751)±For Scotland cases, this includes both cryptic and miliary site
CNS - Central Nervous System Total percentage exceeds 100% due to infections at more than one site
Evaluation for TB
Medical history
Physical examination
Mantoux tuberculin skin test
IGRAs
Chest radiograph
Bacteriologic or histologic exam
Medical History
Symptoms of disease
History of TB exposure, infection, or disease
Past TB treatment
Demographic risk factors for TB
Medical conditions that increase risk for TB disease
Systemic Symptoms of TB
Fever
Cough
Chills
Night sweats
Appetite loss
Weight loss
Tiredness
Testing for TB Disease and Infection
Factors that May Affect the Skin Test Reaction
Type of Reaction Possible CauseFalse-positive Nontuberculous mycobacteria BCG vaccination
AnergyFalse-negative Recent TB infection Very young age (< 6 months old) Live-virus vaccination Overwhelming TB disease
Anergy
•Do not rule out diagnosis based on negative skin test result
•Consider anergy in persons with no reaction if
- HIV infected
- Overwhelming TB disease
- Severe or febrile illness
- Viral infections
- Live-virus vaccinations
- Immunosuppressive therapy.
•Anergy skin testing no longer routinely recommended
Interferon Gamma Release Assays (IGRAs)• Recommended in NICE guidelines• Quantiferon-TB gold and T-spot.TB• Incubate patients blood with M. tuberculosis specific antigens (ESAT 6 & CFP-10)
• Measure production of gamma interferon • More specific than TST• Cannot distinguish between active and latent TB• Expensive• Technically difficulties with sampling• Lack of data for children
Chest Radiograph
Abnormalities often seen in apical
or posterior segments of upper lobe or superior segments of lower lobeIn young children- can mimic pneumonia/effusionshilar lymphadenopathy
May have unusual appearance in
HIV-positive persons Cannot confirm diagnosis of TB
.
Arrow points to cavity in patient's right upper lobe
Specimen Collection
Obtain 3 sputum specimens for smear examination and culture
Persons unable to cough up sputum, induce
sputum, bronchoscopy or gastric aspiration
Consider lymph node biopsy
Notoriously difficult to achieve in children
AFB smear
AFB (shown in red) are tubercle bacilli
Cultures
•Use to confirm diagnosis of TB
•Culture all specimens, even if smear negative
•Results in 4 to 14 days when liquid medium systems used
Colonies of M. tuberculosis growing on media
Treatment
• Doses weight adjusted• TB disease• 6 months of isoniazid & rifampicin
• Pyrazinamide and ethambutol for first 2 months
• CNS- total 12 months plus dexamethasone at start
• Latent TB• 3 months of isoniazid and rifampicin
• Or• 6 months isoniazid
Things to consider• Baseline LFTS• Eye check up• HIV testing
Young Children with TB• Differ from Adults with TB:• Signs/symptoms• Generally not infectious• Pattern of progression to disease • Response to treatment• Side effects• Don’t forget parent!
Adolescents with TB• Differ from young children:• Signs/symptoms• Delay in diagnosis• Adherence issues• Side effect profile• May be infectious!
Monitoring Patients
Establish rapport with patient and emphasize
Benefits of treatment
Importance of adherence to treatment regimen
Possible adverse side effects of regimen
Establishment of optimal follow-up plan
Monitoring Patients (cont.)
At least monthly, evaluate for
Adherence to prescribed regimen
Signs and symptoms of active TB disease
Signs and symptoms of hepatitis
Preventing and Controlling TB
Three priority strategies:
Identify and treat all persons with TB disease
Identify contacts to persons with infectious TB; evaluate and offer therapy
Test high-risk groups for LTBI; offer therapy as appropriate
Table 2.1: Number and proportion of tuberculosis cases with drug resistance by age group, UK, 2012
Tuberculosis in the UK: 2013 report 36
n % n % n %
0-14 10 9.7 10 9.7 7 6.8 103
15-44 240 7.2 264 7.9 65 2.0 3,333
45-65 77 7.6 78 7.7 8 0.8 1012
65+ 24 3.4 27 3.8 1 0.1 703
Age Group
Isoniazid Resistant to any Multi-drug
Total**resistant first line drug* resistant
*First line drugs - isoniazid, rifampicin, ethambutol and pyrazinamide**First line drugs – isoniazid, rifampicin, ethambutol and pyrazinamide**Culture confirmed cases with drug susceptibility results for at least isoniazid and rifampicin
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
Table 4.1: Treatment outcome at 12 months for tuberculosis cases, UK, 2011*
Tuberculosis in the UK: 2013 report 37
* Excludes MDR-TB and RMP-resistant TB cases. Not evaluated includes missing, unknown and transferred out
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
Treatment outcome n %
Completed 7,302 82.9
Died 434 4.9
Lost to follow-up 435 4.9
Still on treatment 289 3.3
Stopped 88 1.0
Not evaluated 257 2.9
Total 8,805 100
NHS Evidence
NHS Evidence Tuberculosis
topic page
Visit NHS Evidence for the best available
evidence on tuberculosis
diagnosis, treatment and management
Find out more
• www.nice.org.uk/guidance/CG117
Take home messages• Think about TB• TB is a family disease• Ask about risk factors• TB contacts• BCG Hx• Travel history• IGRA can be useful, but a negative IGRA does not exclude TB
• Liaise with TB nurses/doctors• TB therapy requires a lot of support• TB should be managed by specialists-discuss/refer early
Questions?