Transcript Perinatal tuberculosis - Eesti Perinatoloogia Selts

Tuberculosis and perinatal
period
Kai Kliiman
Tartu University Lung Clinic
Estonian NTP
15 September 2006
Tallinn
Tuberculosis
• Is a communicable disease caused by
Mycobacterium tuberculosis
• It is spread primarily by tiny air bone
particles (droplet nuclei) expelled when
person with infectious TB disease
(lung or throat TB) coughs, sneezes,
speaks or sings
• Close contacts have highest risk of
becoming infected
Distribution of tuberculosis in the
world in 2003
Dye C. Lancet 2006; 367: 938–40
Estimated TB incidence in the
WHO European region; 2002
World Health Organization. Global tuberculosis control: surveillance, planning, financing. WHO
report 2004. Geneva: WHO, 2004
TB case rate (per 100 000)
< 10
TB case 10-24
rate (per 100 000)
<25-49
10
50-99
10-24
100-149
25-49
> 150
50-99
100-149
> 150
Notification rate of TB in Baltic
States and in Finland 1990 – 2004
EuroTB, 2004
EuroTB, 2004
Trajectories of tuberculosis epidemic for
nine epidemiologically different regions of
the world
High HIV
incidence≥4% in adults
aged 15-49
years in 2003
Dye C. Lancet 2006
TB and HIV
• HIV is strongest risk factor for
development of TB if infected
- risk of developing TB disease 7-10%
each year
• the risk of developing TB rises with
worsening immune status
• more common are disseminated and
extra pulmonary diseases
• low cure rates
• high mortality rates
Opportunistic Infections in AIDS
patients in Developing Countries
Tuberculosis
Bacterial infections
P. carinii pneumonia
Wasting syndrome
Criptococcosis
Toxoplasmosis
MAC
Herpes Zoster
Pencilinosis
Chronic diarrhea
Candidiasis
CMV retinitis
Kaposi sarcoma
Vietnam
Camboya
India
25%
5%
2%
13%
-1%
3%
9%
4%
-----
39%
14%
8%
3%
30%
---------
39%
-1%
-2%
1%
-4%
-12%
9%
---
Uganda
25%
-13%
-9%
13%
---11%
14%
---
Botswana
31%
--29%
<5%
----20%
-<5%
10%
TB in AIDS Patients Spain (1994-2002)
No of cases
8000
7378
HAART
7000
6000
5000
4000
42%
2329
3000
2000
1000
29%
0
1994 1995 1996 1997 1998 1999 2000 2001 2002
AIDS
TB-AIDS
Notified TB and HIV co infection in Estonia
(number of cases, proportion of all)
35
6,6%
33
30
HIV+TB
25
3,9%
22
2,6%
20
17
15
13
1%
10
5
0
2,2%
7
0,1%
0,1%
1
1
1998
1998
1999
1999
0,3%
2
2000 2001
2001
2000
2002
2002
2003
2003
2004 2005
2005
2004
Estonian TB register 2006
Estonian TB register 2006
Bacille Calmette Guerin (BCG) vaccine
• is the most widely used vaccination
• was developed in the 1930's and it remains
the only vaccination available against
tuberculosis today
• does not ensure against exposure to and
development of tuberculoses disease, but
offers significant protection against
serious and widespread invasion
• the WHO recommends that asymptomatic
HIV-infected infants receive BCG vaccine at
birth or shortly thereafter
Infants may have acquired TB
- by trans placental spread through the
umbilical vein to the fetal liver
- by aspiration or ingestion of infected
amniotic fluid
- via airborne inoculation from close
contacts (family members or nursery
personnel)
About 50% of children born to mothers with
active pulmonary TB develop the disease
during first year of life if
chemoprophylaxis or BCG vaccine is not
given
Neonatal TB
• The clinical presentation nonspecific
• Multiple organ involvement
• Usually fever, lethargy, respiratory
distress, hepatosplenomegaly, or failure to
thrive may indicate TB in an infant with a
history of TB exposure
• For diagnosis: culture and smear of
tracheal aspirates, urine, gastric washings
for acid-fast bacilli, chest x-ray (miliary
infiltrates). Biopsy of the liver, lymph
nodes, or lung and pleura may be needed.
• Skin test results may be negative
Pregnant women with active TB
• Duration of therapy- at least 6 mo, drugresistant cases- to 18 mo
• Isoniazid (300 mg po), ethambutol (15 to 25
mg/kg po), and rifampin (600 mg po) in single
daily doses- in recommended doses have not
been shown to be teratogenic
• Streptomycin is potentially ototoxic
• The other antituberculous drugs should be
avoided because of teratogenicity
(ethionamide, fluoroquinolones) or lack of
clinical experience during pregnancy
Asymptomatic infants of women
with active TB (1)
• The infant usually should be separated
from the mother until effective treatment is
under way and her sputum become smear
negative (usually 2 to 3 weeks)
• Family contacts should be investigated for
undiagnosed TB
• All anti TB-drugs are compatible with
breastfeeding
The infant’s skin test negative  BCG
vaccine  start on a regimen of INH
(5mg/kg) and send home at usual time
Asymptomatic infants of women
with active TB (2)
• Skin testing should be performed at ages 3 and
6 mo
• If the infant remains tuberculin negative, INH
may be discontinued and the infant followed
with skin tests at 12 mo with monthly or
bimonthly clinical evaluations
The infant has a positive skin test exclude
tuberculosis disease by a thorough examination
• INH should be continued for at least 6 mo
• HIV-infected children should be treated for 12
mo
Newborns with active TB (1)
• Treatment with INH (10 to 15 mg/kg po),
rifampin (10 to 20 mg/kg po),
pyrazinamide 820 to 40 mg/kg po), and
streptomycin (20 to 40 mg/kg im) in
single daily doses given for 2 mo,
followed by INH and rifampin for another
10 mo.
• Drug-resistance- instead of
streptomycin may be used kanamycin or
capreomycin
Newborns with active TB (2)
• CNS is involved- the initial therapy
should also include corticosteroids
(prednisolone 1 mg/kg/day po for 6 to 8
wk, then gradually tapered), continue
with INH and rifampin daily or twice
weekly for another 10 mo.
• Not disseminated form, and CNS, bones
and joints are not involved- 6-9 mo
regimen