Transcript Paediatric TB - Croydon Health Services NHS Trust

PAEDIATRIC TB
Jenny Handforth
June 2014
Overview
•Why is Paediatric TB important
•Epidemiology- know the patients
•Adult v child with TB - differences?
• Diagnostic challenges:
Why do you need to know about
Paediatric TB?
• 1 million cases estimated globally each year (11%)
• 25-40% of all cases are children in high burden countries
• 4-7% in low burden countries
• Higher risk of severe disease and death in young children
• Indicator of effectiveness of TB control programmes
Figure 1.1: Tuberculosis case reports and rates, UK,
2000-2012
10,000
15
14
9,000
13
8,000
12
Number of cases
10
6,000
9
8
5,000
7
4,000
6
5
3,000
Rate (per 100, 000)
11
7,000
4
2,000
3
2
1,000
1
0
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Year
Number of cases
Rate per 100,000
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
4
Tuberculosis in the UK: 2013 report
Figure 1.3. Three-year average tuberculosis
case rates by local area*, UK, 2010-2012
*England – Local authorities, Wales and Scotland – Health
Boards, NI – data not available
London
© Crown copyright and database rights 2013 Ordnance Survey 100016969
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections
(ESMI), Office for National Statistics (ONS)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
5
Tuberculosis in the UK: 2013 report
Figure 1.4: Tuberculosis case reports and rates by
region*, England, 2012
4,000
3,500
50
41.9
Number of cases
45
Rate (per100,000) and 95% CI
40
3,000
Number of cases
2,500
30
2,000
25
19.4
20
1,500
1,000
11.3
11.5
9.3
15
10.8
7.8
5.8
500
0
Region
* HPA region
CI – 95% confidence intervals
Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
Tuberculosis in the UK: 2013 report
10
5
0
6
6.4
Rate (per 100, 000)
35
Figure 1.6: Tuberculosis case reports by place of
birth and country, UK, 2012
Non UK-born
UK-born
100%
90%
2,020
Percentage of cases
80%
39
142
56
48
185
73
70%
60%
50%
40%
5,819
30%
20%
10%
0%
Country (% where place of birth known)
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
7
Tuberculosis in the UK: 2013 report
Figure 1.8: Non UK-born tuberculosis case reports
by time since entry to the UK to tuberculosis
diagnosis, UK, 2012
600
Number of cases
500
400
300
200
100
0
0
5
10
15
20
25
30
35
Years since entry to diagnosis
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
8
Tuberculosis in the UK: 2013 report
40
45
50+
Figure 1.10: Tuberculosis case reports and rates by
age group and place of birth, UK, 2012
1,200
140
1,100
Number of cases
900
100
800
700
80
600
60
500
Rate (per 100,000)
120
1,000
400
40
300
200
20
100
0
0
Age group (years)
UK-born
Non UK-born
Rate in UK-born
Rate in non UK-born
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
9
Tuberculosis in the UK: 2013 report
800
40
700
35
600
30
500
25
400
20
300
15
200
10
100
5
0
0
Rate (per 100,000)
Number of cases
Figure 1.11: Tuberculosis case reports and rates by
age group and sex, UK, 2012
Age group (years)
Male cases
Female cases
Rate in males
Rate in females
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
10
Tuberculosis in the UK: 2013 report
Figure 1.14: Child to adult ratio in notifications rate, UK,
2000-2012
Ratio: case notification rate children/adults
0.40
0.30
0.20
0.10
0.00
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
The child-to-adult ratio is the ratio of the case notification rate in children under 15 years of age,
to that in adults. A declining trend in the ratio suggests a decrease in ongoing transmission
(European Centre for Disease Prevention and Control).
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
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Tuberculosis in the UK: 2013 report
Questions that must be asked...
• Has this child been exposed to TB?
• Has the child been infected with TB?
• If yes does this child have Tb disease?
• Who has infected this child?
•
…and answered!
3 scenarios for investigating TB in children
1.
2.
3.
Screening healthy children
- screen for
TB risk factors
Known contact with infectious case
- usually
adult
Child with symptoms and/or signs of TB or abnormal
CXR
- high index of suspicion required
Pathogenesis of TB in childhood
•
•
•
No infection
•
heals
Exposure to bacilli
from adult
Dissemination to
lung apices,
meninges,bone
spine,nodes
Primary complex
•
progresses
•
Active disease
•
Dormant
TB disease (TB) or Latent TB (LTB)
• TB: active M. tuberculosis in some part of child’s body
• May be asymptomatic
• Abnormal CXR and/or abnormal clinical exam
• LTB: dormant M. tuberculosis
• Clinical exam normal
• X rays normal
• Diagnosis is made by
• History
• Clinical examination
• CXR/imaging/microbiology
Risk of Disease following primary infection
Marais BJ et al. Int J Tuberc Lung Dis 2004;8:392-402
Disseminated
TB
Pulmonary No disease comments
TB
<1
years
10-20%
30-40% 50%
High rates of
morbidity &
mortality
1-2
years
2-5%
10-20% 75-80%
High rates of
morbidity &
mortality
2-5
years
0.5%
5%
95%
5-10
years
<0.5%
2%
98%
>10
years
<0.5%
10-20% 80-90%
Safe school
years
Adult
disease
Table 1.2: Tuberculosis case reports by site of
disease, UK, 2012
Site of disease*
Number of cases
4,563
Percentage**
52.1
Extra-thoracic lymph nodes
1,872
21.4
Intra-thoracic lymph nodes
946
10.8
Other extra-pulmonary
619
7.1
Pleural
651
7.4
Gastrointestinal
471
5.4
Bone – spine
Cryptic ±
394
4.5
46
0.5
±
197
2.3
Bone – other
218
2.5
CNS – meningitis
187
2.1
Genitourinary
137
1.6
CNS – other
80
0.9
Laryngeal
16
0.2
Unknown extra-pulmonary
15
0.2
Pulmonary
Miliary
*With or without disease at another site
±For
**Percentage of cases with known sites of disease (8751)
Scotland cases, this includes both cryptic and miliary site
CNS - Central Nervous System
Total percentage exceeds 100% due to infections at more than one site
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
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Tuberculosis in the UK: 2013 report
Evaluation for TB
Medical history
Physical examination
Mantoux tuberculin skin test
IGRAs
Chest radiograph
Bacteriologic or histologic exam
Medical History
Symptoms of disease
History of TB exposure, infection, or disease
Past TB treatment
Demographic risk factors for TB
Medical conditions that increase risk for TB
disease
Systemic Symptoms of TB
Fever
Cough
Chills
Night sweats
Appetite loss
Weight loss
Tiredness
Testing for
TB Disease and Infection
Factors that May Affect the
Skin Test Reaction
Type of Reaction
False-positive
False-negative
Possible Cause
Nontuberculous mycobacteria
BCG vaccination
Anergy
Recent TB infection
Very young age (< 6 months old)
Live-virus vaccination
Overwhelming TB disease
Anergy
• Do not rule out diagnosis based on negative skin test
result
•
Consider anergy in persons with no reaction if
- HIV infected
- Overwhelming TB disease
- Severe or febrile illness
- Viral infections
- Live-virus vaccinations
- Immunosuppressive therapy.
•
Anergy skin testing no longer routinely recommended
Interferon Gamma Release Assays (IGRAs)
• Recommended in NICE guidelines
• Quantiferon-TB gold and T-spot.TB
• Incubate patients blood with M. tuberculosis
specific antigens (ESAT 6 & CFP-10)
• Measure production of gamma interferon
• More specific than TST
• Cannot distinguish between active and latent TB
• Expensive
• Technically difficulties with sampling
• Lack of data for children
Chest Radiograph
Abnormalities often seen in apical
or posterior segments of upper
lobe or superior segments of
lower lobe
In young children- can mimic
pneumonia/effusions
hilar lymphadenopathy
Arrow points to cavity in
patient's right upper lobe
.
May have unusual appearance in
HIV-positive persons
Cannot confirm diagnosis of TB
Specimen Collection
Obtain 3 sputum specimens for smear
examination and culture
Persons unable to cough up sputum, induce
sputum, bronchoscopy or gastric aspiration
Consider lymph node biopsy
Notoriously difficult to achieve in children
AFB smear
AFB (shown in red) are tubercle bacilli
Cultures
•
Use to confirm diagnosis of TB
•
Culture all specimens, even if smear negative
•
Results in 4 to 14 days when liquid medium
systems used
Colonies of M. tuberculosis growing on media
Treatment
• Doses weight adjusted
• TB disease
• Latent TB
• 6 months of isoniazid
• 3 months of isoniazid
& rifampicin
• Pyrazinamide and
ethambutol for first 2
months
• CNS- total 12 months
plus dexamethasone
at start
and rifampicin
• Or
• 6 months isoniazid
Things to consider
• Baseline LFTS
• Eye check up
• HIV testing
Young Children with TB
• Differ from Adults with TB:
• Signs/symptoms
• Generally not infectious
• Pattern of progression to disease
• Response to treatment
• Side effects
• Don’t forget parent!
Adolescents with TB
• Differ from young children:
• Signs/symptoms
• Delay in diagnosis
• Adherence issues
• Side effect profile
• May be infectious!
Monitoring Patients
Establish rapport with patient and emphasize
Benefits of treatment
Importance of adherence to treatment regimen
Possible adverse side effects of regimen
Establishment of optimal follow-up plan
Monitoring Patients (cont.)
At least monthly, evaluate for
Adherence to prescribed regimen
Signs and symptoms of active TB disease
Signs and symptoms of hepatitis
Preventing and Controlling TB
Three priority strategies:
Identify and treat all persons with TB disease
Identify contacts to persons with infectious
TB; evaluate and offer therapy
Test high-risk groups for LTBI; offer therapy
as appropriate
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Tuberculosis in the UK: 2013 report
Table 2.1: Number and proportion of tuberculosis
cases with drug resistance by age group, UK, 2012
Isoniazid
Resistant to any
Multi-drug
resistant
first line drug*
resistant
Age Group
Total**
n
%
n
%
n
%
0-14
10
9.7
10
9.7
7
6.8
103
15-44
240
7.2
264
7.9
65
2.0
3,333
45-65
77
7.6
78
7.7
8
0.8
1012
65+
24
3.4
27
3.8
1
0.1
703
*First line drugs - isoniazid, rifampicin, ethambutol and pyrazinamide**First line drugs – isoniazid, rifampicin, ethambutol and pyrazinamide
**Culture confirmed cases with drug susceptibility results for at least isoniazid and rifampicin
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
Tuberculosis in the UK: 2013 report
Table 4.1: Treatment outcome at 12 months for
tuberculosis cases, UK, 2011*
Treatment outcome
n
%
7,302
82.9
Died
434
4.9
Lost to follow-up
435
4.9
Still on treatment
289
3.3
88
1.0
257
2.9
100
Completed
Stopped
Not evaluated
Total
8,805
* Excludes MDR-TB and RMP-resistant TB cases. Not evaluated includes missing, unknown
and transferred out
Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI)
Data as at July 2013
Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England
37
NHS Evidence
Visit NHS Evidence
for the best available
evidence on
tuberculosis
diagnosis, treatment
and management
NHS Evidence
Tuberculosis
topic page
Find out more
• www.nice.org.uk/guidance/CG117
Take home messages
•
•
•
•
•
•
•
Think about TB
TB is a family disease
Ask about risk factors
TB contacts
BCG Hx
Travel history
IGRA can be useful, but a negative IGRA does not
exclude TB
• Liaise with TB nurses/doctors
• TB therapy requires a lot of support
• TB should be managed by specialists-discuss/refer
early
Questions?