Diagnosis, Challenges and Management Dr Mir Anwar MBBS,DCH,MPH(USA) Richmond Hospital,KZN, South...

Diagnosis, Challenges and Management

Dr Mir Anwar MBBS,DCH,MPH(USA)

Richmond Hospital,KZN, South Africa

Paediatric Tuberculosis in HIV Era

3rd SA TB Conference Durban 2012

OverviewDiagnosis of TB in HIV +ve Children

Challenges

Management of Disease

New Developments

HIV And TB Statistics2010 data

8.8 million new TB cases Globally.1.1 million Death (excluding HIV).~1.1 million new HIV associated TB cases82% living in Sub Saharan-Africa350, 000 death

Opportunistic infection20-37 times greater when HIV +ive

http://www.who.int/hiv/topics/tb/en/http://www.who.int/mediacentre/factsheets/fs104/en/

Facts and FiguresDeaths Worldwide

HIV: 6000/day TB: 5000/day

South Africa TB cases : 4th in the world Children: 16% of all TB cases HIV/TB children : 25-60%

http://www.who.int/tb/challenges/hiv/facts/en/index.html

http://www.pedaids.org/What-We-re-Doing/Foundation-Blog/March-2011/A-Talk-on-Pediatric-Tuberculosis-and-HIV

DiagnosisRecognizing symptomsContact history Sputum cultureChest X-rayMantoux testGastric washGeneXpert test- The New Era

SymptomsCoughing >2 weeks Chest painWeakness or fatigueWeight Loss> 10%Fever/ChillNight Sweat

Recognizing SymptomsProbable TB

+ive tuberculin skin test>Suggestive chest radiography. ie

Lymphadenopathy, pericardial effusion etc.

>CT Scan ,ie Chest, Abdomen, brain Suggestive histological appearance on

biopsy material- FNAFavourable response to TB-specific therapy

Smear –ive TB is too confusing How do we understand it?Cough for more then 14 days.Chest pain more then 14 daysWeight loss >10%Failure to gain weight despite ARTMinimal or No Sputum production

Cont’dLymphadenopathy i.e. X-raySevere anemia, Hb < 7gmSigns of extra pulmonary TBMilliary pattern on chest x-rayIf severe shortness of breath, we will

consider PCP first.

Baby born to Mother with TBIf Baby has no TB signs or symptoms Start with Isoniazide 10mg/kg/day for 6

months.Once IPT completed, BCG can be given if

asymptomatic and HIV- uninfected.TST can be done on child after 3 months of

IPT.If TST negative and mother smear negative ,

stop INH & give BCG.

Baby Born to a Mother with TBIf haveing TB signs/Symptoms in InfantSubmission of gastric aspirates and blood for

TB culture DSTCXRAbdominal sonar ( as the liver is often the

primary site in congenital TB).IF TB Diagnosed.Start Regimen 3 of TB treatment.Start Fast track for ART if baby is HIV-

infected.

Statistics of Smear Negative TB1980-1990

33-50% HIV +ve PTB patient were smear –veKenya (2003)

64% HIV +ve patient with proven TB were AFB smear –ive

South Africa (2008)26% of patient entering ART had active PTB87% were AFB smear –ve even with

fluorescent microscopy test.

Cont’dSmear –ive have high mortality rate even

with proper TB treatment

HIV +ive patient have less TB organism in sputum even with low CD4 count.

Limited lab tech and high sample load- smear +ve missed

Ref- TB in ERA of HIV by Jon Fielder

ChallengesFailure to recognizing symptoms

Resource shortage

Lack in education

Adverse drug interaction

WHO Global TB Report

Interpreting Mantoux testNon-reactive Reactive

Had BCG < 15mm > 15mm

No BCG < 10mm > 10mm

HIV +ve < 4mm > 4mm

Extra Pulmonary TB in ChildrenPeripheral LymphadenitisBones and Joints ,spinal TBPlural Effusion.TB PericarditisAbdominal TBTB MeningitisIn the late stage HIV TB can be anywhere in

the body.

Objective Of TB TreatmentTo cure the patient

To prevent death

To prevent relapse

To prevent development of drug resistance

To reduce transmission

Treatment WHO Guidelineshould betreated with a four-drug regimen (RHZE)

for 2 months followed by a two-drugregimen (RH) for 4 months total 6

months.TBM with HIV needs 9 to 12 months

regime.

at the following dosages

Children in High HIV Settingisoniazid (H)

10 mg/kg (range 10–15mg/kg)maximum dose 300 mg/day

rifampicin (R) 15 mg/kg (range 10–20 mg/kg) maximum dose 600 mg/day

pyrazinamide (Z) 35 mg/kg (30–40 mg/kg)

ethambutol (E) 20 mg/kg (15-25 mg/kg)

http://whqlibdoc.who.int/publications/2010/9789241500449_eng.pdf

MonitoringSymptom assessment

Adherence and reviewing treatment

Adverse events- LFT’s, haematology

rashes, IRISRegular follow-ups

Non-response to drugs- MDR TB

How should we manage a child who deteriorates in TB treatment.Is the drug dose is correct?Is the child taking the drug as prescribed?

(good adherence, including DOT)Is the child HIV infected?Is the child severely malnourished?Is there is a reason to suspect MDR TB?Has child develops IRIS?Is there another reason for child illness other

than TB, ie Malignancy?

GeneXpert TestGeneXpert MTB/RIF test

PCR based analysis.Endorsed by WHO in Dec 2010 for adults

Research being conducted in SA since 2008.

http://www.ajol.info/index.php/cme/article/viewFile/72026/60969

AdvantagesProvides results in ~90 min

Minimal biohazard

Operation requires little technical training

“If a minister can do it, it can’t be that hard," Health Minister Aaron Moatsoaled. http://www.aidsmap.com/GeneXpert-to-be-rolled-out-as-first-line-diagnostic-for-TB-in-South-Africa/page/1746803/

Can GeneXpert be used for children?Yes according to WHO ?

if able to produce sputum or if an induced sputum is obtained

Gastric Aspiration fluid, Biopsy serous fluid.Mark Nichol @ U of Cape Town

More effective Vs smear microscopyWorks better in HIV +ve children

http://www.nhls.ac.za/assets/files/GeneXpert%20brochure.pdfhttp://sciencespeaksblog.org/2011/10/26/how-well-does-the-genexpert-rapid-tb-diagnostic-perform-among-children/#ixzz1zzsazJvB

DisadvantagesCost-

$16 for cartridge/ per test.

Requires uninterrupted electric supply

Requires calibration

Summary- TB in Era of HIVTB is surging in much of Africa because of

the HIV epidemic.The TB rates are usually higher than what is

reported in the public health system.TB is the number one cause of death in HIV-

infected patients in Africa.TB has usually spread through out the body

by the time of death.The patterns of TB diseases are changing.TB is a multisystem disease.

Recommendations Good Record-keeping

Group nutrition counselling

HIV/TB awareness education

Fundraising

Concluding RemarksHIV/AIDS is the major threat to TB control

TB/HIV rates directly proportional to each other.

Overcoming challenges

OUR CHILDREN ARE OUR FUTURE

THANK YOU