You may engage in programs from a focused perspective & concentrate on certain program areasYour area of work may include specific TB programming, and likely does not include children. You may see childhood TB this way (more streamlined)
Or, you may view interventions more widely, and see spillage of one program area into another. You likely are not hearing much about TB in these broader programs. Regardless-- pediatric TB is still not being addressed adequately by either viewpoint but is a strong component of both of these approaches.
TB- caused by TB bacilliTransmitted to others by the respiratory route: coughing/ sneezing/ singingChildren: don’t transmit bacilli (for the most part)Do not have cavitary lesionsLow bacilliary burdenMajority of disease results from progression of primary infection rather than reactivation (might affect detectable immune responses) (Kampmann 2011)•More likely to be extrapulmonary and disseminated, particularly in infants (Kampmann 2011)
Tuberculosis in children differs from adults (Kampmann 2011- Stockholm Meeting)•Immune responses are Age-dependent: Following infection 40% < 2 yr, 25% 2-5 yr and 5-15% of older children will develop disease within 2 yearsDevelop disease RAPIDLY (weeks to months) after infection (Starke 2003)Deterioration in TB control impacts and hurts the youngest generation first (Nelson 2004)Disease can be crippling in children (Starke 2003)Spinal diseaseMeningitis & disseminated disease cause death
Sentinel eventHarbinger of future epidemics (Starke 2003)Marker of the effectiveness of public health control efforts (Getahun 2012)Child TB must by definition reflect recent infection (w/in the lifetime of the child) and in most cases occurs within a year following infection (Brent 2012)Serves as a window on current transmission dynamics within a community (Brent 2012)We invest in vaccines to prevent future disease--- maybe we should invest in Peds TB for the same reason?
Future reservoir of diseaseImpact the future global burden of disease (Starke 2003)Improvements in treating children had the largest impact on controlling disease in children (Heymann 2000)Once transmission has occurred, treating adults is not helpful (Heymann 2000)“Any efforts to reduce the long term trends of TB worldwide should consider the role played by infected and diseased children.” (Nelson 2004)“… literally millions of children would get sick while we are waiting to accomplish this.” (Starke 2003)
M.tb 2nd Most Common Pathogen identified in Children with CAP who Failed Empirical Antibiotic Therapy (McNally 2007)8-15% of children with acute pneumonia may have TBPrior to co-trimoxazole prophylaxis: in Zambia active TB was found in 25% of HIV+ and in 18% of HIV- children who died of pneumonia (Chintu 2002)TB control contributes to decline in <5 mortality (Atun 2010)Second leading cause of death (after respiratory illness) in children in a Kolkata slum (Kanungo 2010)
TB causes 6-15% of all maternal mortality (Getahun 2012)Although tuberculosis is reported to cause 6%–10% of all maternal mortality from both direct and indirect obstetric causes in low HIV prevalence settings, its contribution increases to 15% in high HIV prevalence settings((Getahun 2012)Newborns of women with TB are at high risk of contracting TB (STOP TB 2012)TB most common infectious cause of death in women from TB endemic countries (Marais 2012 Stockholm meeting)HIV/TB maternal co-infection is associated with increased risk of perinatal HIV transmission (Gupta 2011 JID)2.2-fold increased risk of death in HIV/TB infected women compared to HIV-infected only (Gupta 2007- CID)3.4-fold increased risk of death in infants born to HIV/TB infected mothers compared infant born to mothers with HIV aloneS. AFRICA: 107 pregnant women with TB (82 HIV+) -15% of neonates had M.Tb detected by culture (mostly gastric acid, CSF)
Malnutrition treatment guidelines need to emphasize diagnosis of HIV + TB in endemic areas (deMaayer 2011)TB treatment improves nutritional states (USAID 2008)Supplemental nutrition for TB programs could reduce incidence of active TB (USAID 2008)Wt gain common after TB Rx is initiated (USAID 2008)TB: a catabolic process wasting often before patient is diagnosed (USAID 2008) Malnourished people are more likely to become infected (USAID 2008)Tb worsens malnutrition (USAID 2008)Malnutrition weakens immunity (USAID 2008)Increased wasting results in increased mortality (USAID 2008)TB is found in 12-30% of cases of malnutrition (DOH 2007)May be case of failure to gain weight in upto 66% of cases (DOH 2007)
TB fuels poverty TB left 10 million children orphaned in 2010Strongest risk factor for childhood TB (USAID 2008)Assoc with poor nutritionOvercrowdingClose contact with infectious peopleThose treated for TB fall deeper into poverty Pay for food and transportation costs (Bond 2008)Death of 1 TB patient = 16x monthly income in Zambia (Bond 2008)Loss of family members (Bond 2008)Resources are consumed to treat ptMEN: can no longer work and contribute to the familyWOMEN: can no longer care for children Children malnourished more susceptible to TB
In children:Risk of active TB is 5x higher in HIV infected children (USAID 2008)HIV+ children were seen in a clinic in Ethiopia 5.6 times before they were diagnosed with TB (USAID 2008)41% of HIV infected will die of TB; compared to 7% of HIV negative children (USAID 2008)90% of deaths occur in the first 2 months of treatment (USAID 2008)Youngest children have highest mortality (USAID 2008)Children with HIV are also 20 times more likely to develop active TB than HIV-negative children and have a higher risk of dying of TB. (Results 2011)
Malnutrition + HIVFurther masks TBLess likely to be PPD positiveLess likely to obtain a microbiologic diagnosisHowever, more likely to have TBMore likely to die of TB
Burden of Disease: The true burden of TB in children is unknown because of the lack of child-friendly diagnostic tools and inadequate surveillance and reporting of childhood TB cases (Call to Action- Stockholm meeting 2011)R&D:BCG: vaccine but poor (Getahun 2012)Protects against meningitis & miliary TBOnly about 50% protection against pulmonary TBWanes after ~10 yrsThis is further compounded by drug stock outs and the lack of child-friendly formulations of drugs for TB treatment and prevention. ( CTA Stockholm 2011) Children are rarely included in clinical trials to evaluate new TB drugs, diagnostics or preventive strategies (CTA Stockholm 2011)Programs: Most public health programs have limited capacity to meet the demand for care and high-quality services for childhood TB (CTA Stockholm Meeting 2011)Due to inadequate case detection it is estimated that a large number of children suffering from TB are not appropriately treated (CTA Stockholm Meeting 2011)Diagnosis: (Ahmed 2011- Stockholm meeting)Manifestations non-specific Cannot produce sputum below 8-10 yr age Malnutrition usually results in a -ve skin test Cavitation, detected by x-ray, is rareDisease is paucibacillary
Contact tracing in children is easier than adults b/c they are not as mobileMonitoring therapy is also easier in children for the same reason.
Pediatric TB and Child Health Programming: WoefullyUnderdeveloped. Why, and What to Do? Devasena Gnanashanmugam, M.D. Consultant, CORE Group
Goals of this discussion • Overview of Childhood TB disease • How TB in children interfaces with other areas • Current challenges • Current recommended action • YOUR SUGGESTIONS
Focused Approach (“TB- centric”) Communicable HIV Diseases NCD Malaria Maternal Health Child Health TB Pediatric TB Environment Education NTDs Poverty Nutrition Other
Broad Approach Education Malnutritio n Pediatric TB Maternal health TB Child Health Infectious Disease Burden Poverty Global Health
Pediatric TB: How big is this problem? • AT LEAST 500,000 cases of TB in children each year (likely more) • AT LEAST 70,000 deaths each year • About 15% of global TB burden is due to disease in children (higher & lower in some regions) • Why don’t we have better data?
Primary pulmonary infection Clinical TB Exposure Successful Immune Response Child Well Adult Future pool of TB disease Immunity (live MTB) Primary pulmonary diseaseSpread by Late Reactivation oflymph/ blood pulmonary disease LowMiliary TB/ Meningitis/ other Higher bacterialextrapulmonary forms bacterial burden burden Adapted from Kampmann 2011
Child vs. Adult TBChildren Adults• Develop disease • Disease develops RAPIDLY (weeks to after years months) after infection • Adults less• Disease can be crippling vulnerable to in children severe forms• Deterioration in TB • Disease in adults control impacts the youngest generation will manifest later first in an epidemic What is the same: • INH preventive therapy (IPT) can be given to prevent disease those who are infected • Treatment is still many months of 4 (then 2) drugs
Childhood TB Neglected “Pediatric TB is a public health dead end.” – Sentinel event: reflects recent infection & transmission in the community – Window on transmission dynamics – Harbinger of future epidemics – Indicator of the effectiveness of control efforts
Childhood TB Neglected “Treating adults with TB is enough to control TB in children” – Future reservoir of disease predicts the future global TB burden – After transmission is over, treating adults is not helpful – Improving treatment in children largest impact on disease control in children – Reducing long term trends of global TB must account for disease in children – Millions of children would become sick while we wait for adult TB control
Child Survival & TB TB?Pneumonia• 8-15% of pneumonia may be TB• Autopsies: 18-25% pneumonia deathsMortality• 2nd leading cause of death in Kolkata slum• TB control decreases <5 yr mortality
TB is a leading infectious cause of TB causes death in women. 6-15% of all maternal mortality HIV/TB infected Maternal women are twice as likely to die thanHealth & TB HIV infected women without TBTB in pregnant Babies born to women HIV/TB infected increases HIV Newborns of women are more women with likely to die thantransmission to TB are at high the baby those of HIV women risk of without TB contracting TB
Malnutrition & TB• TB: 12-30% of cases of malnutrition• TB: a catabolic process wasting (before diagnosis) Malnutrition predisposes to• TB Rx results in weight gain & improves TB & makes TB worse nutritional states• Malnutrition treatment guidelines to emphasize Increased diagnosis of HIV + TB wasting results • Supplemental in increased nutrition improves mortality health in TB patients • SupplementalTB looks like malnutrition and nutrition for TB makes malnutrition worse programs could reduce incidence of active TB
TB fuels povertyChildren moresusceptible to Overcrowding Poor nutrition TB Strongest risk TB left 10 million factor for children orphaned childhood TB in 2010 Close contact with infectious people Loss of family WOMEN: unable to members care for Those treated for children TB fall deeper into Children no poverty longer educated MEN: can no longer work and Family cannot contribute to the Children need afford school family to work to fees/ uniforms assist families
Risk of active TB is 5- 20x higher in HIV infected children TB is more difficult to diagnose in HIV infected children Children withRisk of death due to TB is 5-6x more in HIV & TB HIV infected children. More than 1/3 HIV infected children will die of TB Youngest compared to <10% of HIV negative children children have highest mortality
Disaster Management Malnutrition TB Converging epidemics Less than 5 years HIV old
Where are we now? Science Policy Practice • Union Child • WHO guidance … Health Lung for NTPs • WHO Rapid Section Advice on • STOP TB Treatment of Childhood TB in children TB subgroup • UNION Desk • CDC guide • WHO TB website - National programs to integrate pediatric guidances- Research to develop moretools
R&D challenges and needsChallenges Needs• BCG vaccine is poor • Better vaccine• Diagnostic tests do • Child appropriate not detect disease diagnostics reliably in children• Pediatric drug • Child friendly formulations are drugs lacking • More clinical &• Children are not operational included in clinical research trials
What can we do now? “Simple changes in detection and treatment of children with TB exposure and infection could save millions of lives.” J. Starke • Perform contact investigation in all children exposed to TB • Provide IPT to those <5 yrs who meet criteria
Other items on the wish list • Provide more data on scale and scope of disease • Provide family centered care, including household focused case investigation • Integrate TB care within IMCI • Increase awareness building and advocacy to policy makers, practitioners, scholars & donors • More training & knowledge building on childhood TB • Integrate TB services into existing MCH programs • Increased community level programming
Programs that have worked • Indus Hospital, Pakistan (TB REACH/ STOP TB partnership grant) – Strengthened PPM – Approached CHWs & GPs to increase case detection – Used cash, training certificates, free diagnostic tests & free Rx as incentives – Used mobile technologies to increase case detection – Increased notification of children by 500% • Dhaka, Bangladesh (Damien Foundation) – Community based screening of pediatric TB – CHWs & other clinicians trained to detect S/S of TB & make referrals – Community awareness building – Logistical support – Increased case detection in children 3x baseline levels • MSF programs • OperationASHA http://www.coregroup.org/our-technical-work/working-groups/tuberculosis/pediatrictb
Practical Examples of Action Items • Create & disseminate community education materials about pediatric TB • Within MCH program, design and integrate educational materials and systems designed to help prevent mother-to-child transmission of TB • Adapt a pediatric TB screening tool to support community-level case finding and referral. • Within an IMCI, immunization or other child health effort, add education and linkages related to childhood TB. • Add household TB contact tracing component to community health portfolios • Advocate for government health service adoption of WHO guidelines regarding pediatric TB (This is especially important in high HIV settings) • Address the problem of TB and stigma, specifically in relation to children.