Transcript HIV-infected

Module 10C - March 2010
Tuberculosis in Children:
Prevention
Project Partners
Funded by the Health Resources and Services Administration (HRSA)
Module Overview
 The child contact
 BCG vaccination
International Standards 18 and 19
Learning
Objectives
Upon completion of this session, participants
will be able to:
 Determine which child contacts should
receive Isoniazid Preventive Therapy (IPT)
 State the current Expanded Program on
Immunization recommendations regarding
BCG
 Name the factors that should be
considered when reviewing country policy
on BCG vaccination
TB Prevention:
The Child
Contact
ISTC Standard 18
All providers of care for patients with TB should
ensure that persons who are in close contact with
patients who have infectious TB are evaluated and
managed in line with international recommendations.
The determination of priorities for contact investigation
is based on the likelihood that a contact:
1.Has undiagnosed TB
2.Is at high risk of developing TB if infected
3.Is at risk of having severe TB if the disease develops
4.Is at high risk of having been infected by the index case
ISTC Standard 18 (2)
The highest priority contacts for evaluation are:
 Persons with
symptoms suggestive
of tuberculosis
 Children aged <5 years
 Contacts with known
or suspected immunocompromise, particularly HIV infection
 Contacts of patients with MDR/XDR tuberculosis
 Other close contacts are a lower priority group
Child Contact
 Children who are newly infected with M.
tuberculosis are at high risk for miliary
TB and possibly TB meningitis
• TB disease can develop within weeks unless
the child is given preventive therapy!
 Close contact screening and
management is recommended by most
NTPs, but it rarely happens in lowresource settings where the majority of
childhood TB occurs
Child Contact (2)
 Responsibility for conducting contact
tracing should be assigned to a health
care worker (ideally the one who registers
and/or also supervises treatment of the
source case)
 Could also provide isoniazid preventive
therapy (IPT) or treatment to the children
• More convenient for the household/family
• Facilitates compliance
ISTC Standard 19
Children <5 years of age and persons of any
age with HIV infection who are close
contacts of an infectious index patient and
who, after careful evaluation, do not have
active tuberculosis, should be treated for
presumed latent tuberculosis infection with
isoniazid.
Child Contact (3)
 All child contacts should be screened for
TB as soon as they are identified as a
contact
 Once screened and active TB ruled out,
children recommended for IPT should
then be registered separately and have
their own IPT card
High priority should be given to examining
contacts who are children or who are HIV
infected
Child Contact (4)
 The family of a child diagnosed with TB
must be examined to identify the source
case
 The source case is often someone in the
child’s close social network
 The investigation should also attempt to
identify others who may have been
infected by the source case
Recommendations for Management of
Child Contacts to Infectious PTB
1. Mantoux tuberculin skin test positive
children:
• If well, offer IPT for 6–9 months
• If unwell, further evaluate for TB disease
• Provide treatment for disease if tuberculosis
is evidenced
Recommendations for Management of
Child Contacts to Infectious PTB (2)
2. Mantoux tuberculin skin test negative
children:
• If well, offer IPT for 2 months then repeat TST
– If TST positive at 2 months, continue IPT for a total
of 6–9 months
– If negative at 2 months, discontinue IPT
• If unwell, further evaluate for TB disease
– Detailed history, physical exam and chest x-ray if
possible
– Treat for disease if TB is evidenced
Recommendations for Management of
Child Contacts to Infectious PTB (3)
3. When the Mantoux tuberculin skin test
is not possible:
• If well, educate the care giver to return with
the child should the child become ill
– Suggest a routine follow-up in 1 month
• If unwell, obtain a history and examination for
TB and include a chest X-ray if possible
– Treat for tuberculosis if evidenced
Approach to Contact Management when Chest
X-ray and Mantoux TST are Not Readily Available
Child Contact is Known to be HIV-Infected
1. Must rule out active TB disease first!
 if found to have TB disease, refer to the NTP
for registration and initiation of treatment
2. If the child contact is HIV-infected and
otherwise well:
 consider IPT for all ages, including those
aged 5 years and older
Suspected HIV Infection of Source
Case and Contact
 In HIV-endemic countries, the children of
a parent with smear-positive PTB may be
at risk for both TB and HIV infection
• Ask if HIV status of the source case and child
contact is known
• Consider HIV counseling and testing
Contacts of Infectious MDR-TB
 Clinical follow-up of close contacts for at
least 2 years
 If active TB disease develops, initiate an
MDR-TB regimen in consultation with an
expert in the management of MDR-TB
Management of a Baby Born to a
Mother Diagnosed with Infectious PTB
 Once a pregnant woman has been on
treatment for at least 2–3 weeks, she is
generally no longer infectious
 If a pregnant woman with TB has been on
treatment for TB for several weeks before
delivery, it is less likely that the baby will
become infected
 The risk is highest if a mother is
diagnosed at the time of delivery or
shortly thereafter
Management of a Baby Born to a Mother
Diagnosed with Infectious PTB (2)
 A breastfeeding infant of a mother with
smear-positive PTB has a high risk of TB
infection and of developing TB disease
• The infant should receive 6 months of IPT,
followed by BCG immunization; or
• Give 3 months IPT, then perform TST
– If TST -, stop INH and give BCG
– If TST +, continue INH another 3-6 months then
give BCG
(WHO/HTM/TB/2006.371)
TB Prevention
BCG VACCINATION
BCG Vaccine and Efficacy
 Bacille Calmette-Guérin (BCG) is a live
attenuated vaccine derived from
Mycobacterium bovis
 There is a wide range of reported BCG
efficacy in published studies to date (from
0-80%)
• It is generally accepted that BCG vaccination
provides protection against the more
severe types of TB
BCG: Risk in HIV-Infected
 HIV-infected children vaccinated with
BCG at birth, and who later developed
AIDS, were found to have an increased
risk of developing disseminated BCG
disease
 In 2007, WHO revised their BCG
vaccination guidelines to exclude children
known to be HIV-infected from receiving
BCG, even if asymptomatic
BCG: EPI Recommendations
 For the HIV-exposed infant:
• Defer BCG vaccination until HIV status is
known
 For the HIV-infected infant:
• BCG should not be given regardless of the
status of the baby (symptomatic or
asymptomatic)
BCG: Policy Considerations
 Factors to consider when deciding on
BCG vaccination policy most appropriate
for country implementation:
• HIV and TB prevalence in the country and
within sub-populations
• Access to and usage of PMTCT programs
• Capacity for earlier infant diagnosis of HIV
• Capacity for surveillance of BCG adverse
events
Summary: ISTC Standards*
Standard 18: All providers of care for patients with
TB should ensure that persons who are in close
contact with patients who have infectious TB are
evaluated and managed in line with international
recommendations.The highest priority contacts for
evaluation are:
 Persons with symptoms suggestive of tuberculosis
 Children aged <5 years
 Contacts with known or suspected immunocompromise,
particularly HIV infection
 Contacts of patients with MDR/XDR tuberculosis
 Other close contacts are a lower priority group
* Abbreviated versions
Summary: ISTC Standards* (2)
Standard 19: Children <5 years of age and
persons of any age with HIV infection who
are close contacts of an infectious index
patient and who, after careful evaluation, do
not have active tuberculosis, should be
treated for presumed latent tuberculosis
infection with isoniazid.
* Abbreviated versions
Summary
 TB infection in a child can progress
rapidly to TB disease; therefore, child
contacts should be promptly evaluated
 Once active disease ruled out, IPT should
be provided in child contacts as indicated
 The role of BCG vaccination as a TB
prevention strategy must be carefully
considered. Selective deferral of BCG
may be indicated in some country settings