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Pediatric TB and child health programming_Gnanashanmuga_5.2.12m
1. Pediatric TB and Child Health
Programming: Woefully
Underdeveloped. Why, and What to
Do?
Devasena Gnanashanmugam, M.D.
Consultant, CORE Group
2. Goals of this discussion
• Overview of Childhood TB disease
• How TB in children interfaces with other areas
• Current challenges
• Current recommended action
• YOUR SUGGESTIONS
3. Focused Approach (“TB- centric”)
Communicable HIV
Diseases
NCD
Malaria
Maternal Health
Child Health TB Pediatric TB
Environment
Education NTDs
Poverty
Nutrition Other
4. Broad Approach
Education
Malnutritio
n
Pediatric
TB
Maternal
health
TB
Child Health
Infectious Disease
Burden
Poverty
Global Health
5. Pediatric TB: How big is this problem?
• AT LEAST 500,000 cases of TB in children each
year (likely more)
• AT LEAST 70,000 deaths each year
• About 15% of global TB burden is due to
disease in children (higher & lower in some
regions)
• Why don’t we have better data?
6. Primary pulmonary infection Clinical TB
Exposure
Successful Immune Response
Child
Well Adult
Future
pool of TB
disease Immunity (live MTB)
Primary pulmonary disease
Spread by
Late Reactivation of
lymph/ blood
pulmonary disease
Low
Miliary TB/ Meningitis/ other Higher
bacterial
extrapulmonary forms bacterial
burden
burden
Adapted from Kampmann 2011
7. Child vs. Adult TB
Children Adults
• Develop disease • Disease develops
RAPIDLY (weeks to after years
months) after infection
• Adults less
• Disease can be crippling vulnerable to
in children severe forms
• Deterioration in TB
• Disease in adults
control impacts the
youngest generation will manifest later
first in an epidemic
What is the same:
• INH preventive therapy (IPT) can be given to prevent disease those who are
infected
• Treatment is still many months of 4 (then 2) drugs
8. Childhood TB Neglected
“Pediatric TB is a public health dead end.”
– Sentinel event: reflects recent infection &
transmission in the community
– Window on transmission dynamics
– Harbinger of future epidemics
– Indicator of the effectiveness of control efforts
9. Childhood TB Neglected
“Treating adults with TB is enough to control TB in
children”
– Future reservoir of disease predicts the future
global TB burden
– After transmission is over, treating adults is not
helpful
– Improving treatment in children largest impact on
disease control in children
– Reducing long term trends of global TB must account
for disease in children
– Millions of children would become sick while we
wait for adult TB control
10. Child Survival & TB
TB?
Pneumonia
• 8-15% of pneumonia
may be TB
• Autopsies: 18-25%
pneumonia deaths
Mortality
• 2nd leading cause of
death in Kolkata
slum
• TB control
decreases <5 yr
mortality
11. TB is a leading
infectious cause of TB causes
death in women. 6-15% of all
maternal
mortality
HIV/TB infected
Maternal women are twice as
likely to die than
Health & TB HIV infected
women without TB
TB in pregnant Babies born to
women HIV/TB infected
increases HIV Newborns of women are more
women with likely to die than
transmission to TB are at high
the baby those of HIV women
risk of without TB
contracting TB
12. Malnutrition & TB
• TB: 12-30% of cases of
malnutrition
• TB: a catabolic process
wasting (before
diagnosis) Malnutrition predisposes to
• TB Rx results in weight
gain & improves TB & makes TB worse
nutritional states
• Malnutrition treatment
guidelines to emphasize Increased
diagnosis of HIV + TB wasting results
• Supplemental
in increased
nutrition improves
mortality
health in TB patients
• Supplemental
TB looks like malnutrition and nutrition for TB
makes malnutrition worse programs could
reduce incidence of
active TB
13. TB fuels poverty
Children more
susceptible to Overcrowding Poor nutrition
TB
Strongest risk
TB left 10 million factor for
children orphaned childhood TB
in 2010
Close contact with
infectious people
Loss of family WOMEN:
unable to
members care for
Those treated for
children
TB fall deeper into
Children no poverty
longer educated MEN: can no
longer work and
Family cannot contribute to the
Children need
afford school family
to work to
fees/ uniforms assist families
14. Risk of active TB
is 5- 20x higher
in HIV infected
children
TB is more
difficult to
diagnose in HIV
infected children
Children with
Risk of death due to
TB is 5-6x more in
HIV & TB
HIV infected
children.
More than 1/3 HIV
infected children
will die of TB Youngest
compared to <10%
of HIV negative children
children have highest
mortality
15. Disaster Management
Malnutrition TB
Converging
epidemics
Less than
5 years HIV
old
16. Where are we now?
Science Policy Practice
• Union Child • WHO guidance …
Health Lung for NTPs
• WHO Rapid
Section Advice on
• STOP TB Treatment of
Childhood TB in children
TB subgroup • UNION Desk
• CDC guide
• WHO TB
website - National programs to
integrate pediatric guidances
- Research to develop more
tools
17. R&D challenges and needs
Challenges Needs
• BCG vaccine is poor • Better vaccine
• Diagnostic tests do • Child appropriate
not detect disease diagnostics
reliably in children
• Pediatric drug • Child friendly
formulations are drugs
lacking • More clinical &
• Children are not operational
included in clinical research
trials
18. What can we do now?
“Simple changes in detection and treatment of
children with TB exposure and infection could save
millions of lives.” J. Starke
• Perform contact investigation in all children
exposed to TB
• Provide IPT to those <5 yrs who meet
criteria
19. Other items on the wish list
• Provide more data on scale and scope of disease
• Provide family centered care, including household
focused case investigation
• Integrate TB care within IMCI
• Increase awareness building and advocacy to
policy makers, practitioners, scholars & donors
• More training & knowledge building on childhood
TB
• Integrate TB services into existing MCH programs
• Increased community level programming
20. Programs that have worked
• Indus Hospital, Pakistan (TB REACH/ STOP TB partnership grant)
– Strengthened PPM
– Approached CHWs & GPs to increase case detection
– Used cash, training certificates, free diagnostic tests & free Rx as incentives
– Used mobile technologies to increase case detection
– Increased notification of children by 500%
• Dhaka, Bangladesh (Damien Foundation)
– Community based screening of pediatric TB
– CHWs & other clinicians trained to detect S/S of TB & make referrals
– Community awareness building
– Logistical support
– Increased case detection in children 3x baseline levels
• MSF programs
• OperationASHA
http://www.coregroup.org/our-technical-work/working-groups/tuberculosis/pediatrictb
21. Practical Examples of Action Items
• Create & disseminate community education materials about
pediatric TB
• Within MCH program, design and integrate educational materials
and systems designed to help prevent mother-to-child transmission
of TB
• Adapt a pediatric TB screening tool to support community-level
case finding and referral.
• Within an IMCI, immunization or other child health effort, add
education and linkages related to childhood TB.
• Add household TB contact tracing component to community health
portfolios
• Advocate for government health service adoption of WHO
guidelines regarding pediatric TB (This is especially important in
high HIV settings)
• Address the problem of TB and stigma, specifically in relation to
children.
You may engage in programs from a focused perspective & concentrate on certain program areasYour area of work may include specific TB programming, and likely does not include children. You may see childhood TB this way (more streamlined)
Or, you may view interventions more widely, and see spillage of one program area into another. You likely are not hearing much about TB in these broader programs. Regardless-- pediatric TB is still not being addressed adequately by either viewpoint but is a strong component of both of these approaches.
TB- caused by TB bacilliTransmitted to others by the respiratory route: coughing/ sneezing/ singingChildren: don’t transmit bacilli (for the most part)Do not have cavitary lesionsLow bacilliary burdenMajority of disease results from progression of primary infection rather than reactivation (might affect detectable immune responses) (Kampmann 2011)•More likely to be extrapulmonary and disseminated, particularly in infants (Kampmann 2011)
Tuberculosis in children differs from adults (Kampmann 2011- Stockholm Meeting)•Immune responses are Age-dependent: Following infection 40% < 2 yr, 25% 2-5 yr and 5-15% of older children will develop disease within 2 yearsDevelop disease RAPIDLY (weeks to months) after infection (Starke 2003)Deterioration in TB control impacts and hurts the youngest generation first (Nelson 2004)Disease can be crippling in children (Starke 2003)Spinal diseaseMeningitis & disseminated disease cause death
Sentinel eventHarbinger of future epidemics (Starke 2003)Marker of the effectiveness of public health control efforts (Getahun 2012)Child TB must by definition reflect recent infection (w/in the lifetime of the child) and in most cases occurs within a year following infection (Brent 2012)Serves as a window on current transmission dynamics within a community (Brent 2012)We invest in vaccines to prevent future disease--- maybe we should invest in Peds TB for the same reason?
Future reservoir of diseaseImpact the future global burden of disease (Starke 2003)Improvements in treating children had the largest impact on controlling disease in children (Heymann 2000)Once transmission has occurred, treating adults is not helpful (Heymann 2000)“Any efforts to reduce the long term trends of TB worldwide should consider the role played by infected and diseased children.” (Nelson 2004)“… literally millions of children would get sick while we are waiting to accomplish this.” (Starke 2003)
M.tb 2nd Most Common Pathogen identified in Children with CAP who Failed Empirical Antibiotic Therapy (McNally 2007)8-15% of children with acute pneumonia may have TBPrior to co-trimoxazole prophylaxis: in Zambia active TB was found in 25% of HIV+ and in 18% of HIV- children who died of pneumonia (Chintu 2002)TB control contributes to decline in <5 mortality (Atun 2010)Second leading cause of death (after respiratory illness) in children in a Kolkata slum (Kanungo 2010)
TB causes 6-15% of all maternal mortality (Getahun 2012)Although tuberculosis is reported to cause 6%–10% of all maternal mortality from both direct and indirect obstetric causes in low HIV prevalence settings, its contribution increases to 15% in high HIV prevalence settings((Getahun 2012)Newborns of women with TB are at high risk of contracting TB (STOP TB 2012)TB most common infectious cause of death in women from TB endemic countries (Marais 2012 Stockholm meeting)HIV/TB maternal co-infection is associated with increased risk of perinatal HIV transmission (Gupta 2011 JID)2.2-fold increased risk of death in HIV/TB infected women compared to HIV-infected only (Gupta 2007- CID)3.4-fold increased risk of death in infants born to HIV/TB infected mothers compared infant born to mothers with HIV aloneS. AFRICA: 107 pregnant women with TB (82 HIV+) -15% of neonates had M.Tb detected by culture (mostly gastric acid, CSF)
Malnutrition treatment guidelines need to emphasize diagnosis of HIV + TB in endemic areas (deMaayer 2011)TB treatment improves nutritional states (USAID 2008)Supplemental nutrition for TB programs could reduce incidence of active TB (USAID 2008)Wt gain common after TB Rx is initiated (USAID 2008)TB: a catabolic process wasting often before patient is diagnosed (USAID 2008) Malnourished people are more likely to become infected (USAID 2008)Tb worsens malnutrition (USAID 2008)Malnutrition weakens immunity (USAID 2008)Increased wasting results in increased mortality (USAID 2008)TB is found in 12-30% of cases of malnutrition (DOH 2007)May be case of failure to gain weight in upto 66% of cases (DOH 2007)
TB fuels poverty TB left 10 million children orphaned in 2010Strongest risk factor for childhood TB (USAID 2008)Assoc with poor nutritionOvercrowdingClose contact with infectious peopleThose treated for TB fall deeper into poverty Pay for food and transportation costs (Bond 2008)Death of 1 TB patient = 16x monthly income in Zambia (Bond 2008)Loss of family members (Bond 2008)Resources are consumed to treat ptMEN: can no longer work and contribute to the familyWOMEN: can no longer care for children Children malnourished more susceptible to TB
In children:Risk of active TB is 5x higher in HIV infected children (USAID 2008)HIV+ children were seen in a clinic in Ethiopia 5.6 times before they were diagnosed with TB (USAID 2008)41% of HIV infected will die of TB; compared to 7% of HIV negative children (USAID 2008)90% of deaths occur in the first 2 months of treatment (USAID 2008)Youngest children have highest mortality (USAID 2008)Children with HIV are also 20 times more likely to develop active TB than HIV-negative children and have a higher risk of dying of TB. (Results 2011)
Malnutrition + HIVFurther masks TBLess likely to be PPD positiveLess likely to obtain a microbiologic diagnosisHowever, more likely to have TBMore likely to die of TB
Burden of Disease: The true burden of TB in children is unknown because of the lack of child-friendly diagnostic tools and inadequate surveillance and reporting of childhood TB cases (Call to Action- Stockholm meeting 2011)R&D:BCG: vaccine but poor (Getahun 2012)Protects against meningitis & miliary TBOnly about 50% protection against pulmonary TBWanes after ~10 yrsThis is further compounded by drug stock outs and the lack of child-friendly formulations of drugs for TB treatment and prevention. ( CTA Stockholm 2011) Children are rarely included in clinical trials to evaluate new TB drugs, diagnostics or preventive strategies (CTA Stockholm 2011)Programs: Most public health programs have limited capacity to meet the demand for care and high-quality services for childhood TB (CTA Stockholm Meeting 2011)Due to inadequate case detection it is estimated that a large number of children suffering from TB are not appropriately treated (CTA Stockholm Meeting 2011)Diagnosis: (Ahmed 2011- Stockholm meeting)Manifestations non-specific Cannot produce sputum below 8-10 yr age Malnutrition usually results in a -ve skin test Cavitation, detected by x-ray, is rareDisease is paucibacillary
Contact tracing in children is easier than adults b/c they are not as mobileMonitoring therapy is also easier in children for the same reason.