Transcript Paediatric Tuberculosis and HIV

Paediatric Tuberculosis in HIV Era
Diagnosis, Challenges and Management
Dr Mir Anwar
MBBS,DCH,MPH(USA)
Richmond Hospital,KZN, South Africa
3rd SA TB Conference
Durban 2012
Overview
 Diagnosis of TB in HIV +ve Children
 Challenges
 Management of Disease
 New Developments
HIV And TB Statistics
 2010 data
8.8 million new TB cases Globally.
1.1 million Death (excluding HIV).
~1.1 million new HIV associated TB cases
82% living in Sub Saharan-Africa
350, 000 death
 Opportunistic infection
20-37 times greater when HIV +ive
http://www.who.int/hiv/topics/tb/en/
http://www.who.int/mediacentre/factsheets/fs104/en/
Facts and Figures
 Deaths Worldwide
 HIV:
6000/day
 TB: 5000/day
 South Africa
cases : 4th in the world
 Children: 16% of all TB cases
 HIV/TB children : 25-60%
 TB
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
Diagnosis
 Recognizing symptoms
 Contact history
 Sputum culture
 Chest X-ray
 Mantoux test
 Gastric wash
 GeneXpert test- The New Era
Symptoms
 Coughing >2 weeks
 Chest pain
 Weakness or fatigue
 Weight Loss> 10%
 Fever/Chill
 Night Sweat
Recognizing Symptoms
 Probable 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- FNA
Favourable 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 days
 Weight loss >10%
 Failure to gain weight despite ART
 Minimal or No Sputum production
Cont’d
 Lymphadenopathy i.e. X-ray
 Severe anemia, Hb < 7gm
 Signs of extra pulmonary TB
 Milliary pattern on chest x-ray
 If severe shortness of breath, we will
consider PCP first.
Baby born to Mother with TB
 If 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 TB
 If haveing TB signs/Symptoms in Infant
 Submission of gastric aspirates and blood for TB
culture DST
 CXR
 Abdominal 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 TB
 1980-1990
33-50% HIV +ve PTB patient were smear –ve
 Kenya (2003)
64% HIV +ve patient with proven TB were AFB
smear –ive
 South Africa (2008)
26% of patient entering ART had active PTB
87% were AFB smear –ve even with
fluorescent microscopy test.
Cont’d
 Smear –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
Challenges
 Failure to recognizing symptoms
 Resource shortage
 Lack in education
 Adverse drug interaction
WHO Global TB Report
Interpreting Mantoux test
Non-reactive
Reactive
Had BCG
< 15mm
> 15mm
No BCG
< 10mm
> 10mm
HIV +ve
< 4mm
> 4mm
Extra Pulmonary TB in Children
 Peripheral Lymphadenitis
 Bones and Joints ,spinal TB
 Plural Effusion.
 TB Pericarditis
 Abdominal TB
 TB Meningitis
 In the late stage HIV TB can be anywhere in the body.
Objective Of TB Treatment
 To cure the patient
 To prevent death
 To prevent relapse
 To prevent development of drug resistance
 To reduce transmission
Treatment WHO Guideline
 should be
 treated with a four-drug regimen (RHZE) for 2
months followed by a two-drug
 regimen (RH) for 4 months total 6 months.
 TBM with HIV needs 9 to 12 months regime.
 at the following dosages
Children in High HIV Setting
 isoniazid (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
Monitoring
 Symptom assessment
 Adherence and reviewing treatment
 Adverse events- LFT’s, haematology
rashes, IRIS
 Regular 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 Test
 GeneXpert 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
Advantages
 Provides 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 microscopy
Works better in HIV +ve children
http://www.nhls.ac.za/assets/files/GeneXpert%20brochure.pdf
http://sciencespeaksblog.org/2011/10/26/how-well-does-the-genexpert-rapid-tb-diagnostic-perform-among-children/#ixzz1zzsazJvB
Disadvantages
 Cost$16 for cartridge/ per test.
 Requires uninterrupted electric supply
 Requires calibration
Summary- TB in Era of HIV
 TB is surging in much of Africa because of the HIV
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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 Remarks
 HIV/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