Pediatric TB and child health programming_Gnanashanmuga_5.2.12m


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Pediatric TB and child health programming_Gnanashanmuga_5.2.12m

  1. 1. Pediatric TB and Child Health Programming: WoefullyUnderdeveloped. Why, and What to Do? Devasena Gnanashanmugam, M.D. Consultant, CORE Group
  2. 2. Goals of this discussion • Overview of Childhood TB disease • How TB in children interfaces with other areas • Current challenges • Current recommended action • YOUR SUGGESTIONS
  3. 3. Focused Approach (“TB- centric”) Communicable HIV Diseases NCD Malaria Maternal Health Child Health TB Pediatric TB Environment Education NTDs Poverty Nutrition Other
  4. 4. Broad Approach Education Malnutritio n Pediatric TB Maternal health TB Child Health Infectious Disease Burden Poverty Global Health
  5. 5. 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?
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. Disaster Management Malnutrition TB Converging epidemics Less than 5 years HIV old
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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.
  22. 22. Your suggestions & comments…