Childhood TB: Introduction


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Childhood TB was written to enable healthcare workers to learn about the primary care of children with tuberculosis. It covers: introduction to TB infection, the clinical presentation, diagnosis, management and prevention of tuberculosis in children

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Childhood TB: Introduction

  1. 1. Childhood TBA learningprogramme forprofessionalsDeveloped by theDesmond Tutu Tuberculosis Centre
  2. 2. Childhood TBA learning programmefor professionalsDeveloped by theDesmond Tutu Tuberculosis
  3. 3. VERY IMPORTANTWe have taken every care to ensure that drugdosages and related medical advice in this bookare accurate. However, drug dosages can changeand are updated often, so always double-checkdosages and procedures against a reliable,up-to-date formulary and the given drug‘sdocumentation before administering it.Childhood TBA learning programme for professionalsUpdated: 17 August 2010First published by EBW Healthcare in 2010Text © Desmond Tutu Tuberculosis Centre 2010Getup © Electric Book Works 2010ISBN (print edition): 978-1-920218-46-1ISBN (PDF ebook edition): 978-1-920218-47-8All text in this book excluding the tests andanswers is published under the Creative CommonsAttribution Non-Commercial No DerivativesLicense. You can read up about this license at multiple-choice tests and answers in thispublication may not be reproduced, stored in aretrieval system, or transmitted in any form or byany means without the prior permission of ElectricBook Works, 87 Station Road, Observatory, CapeTown, 7925.Visit our websites at www.electricbookworks.comand
  4. 4. ContentsAcknowledgements 5 2 Clinical presentation of childhood tuberculosis 24Introduction 7 Early presentation of tuberculosis 24 The Desmond Tutu Tuberculosis Centre 7 Pulmonary tuberculosis 25 Aim of this Childhood TB course 7 Extrapulmonary tuberculosis 26 Self-help education 7 Enlarged tuberculous lymph nodes 26 Format of the Childhood TB Education Tuberculous meningitis 27 Programme 8 Abdominal tuberculosis 27 Study groups 9 Tuberculous bone and joint disease 28 The importance of a caring and Disseminated tuberculosis 28 questioning attitude 9 Scoring systems to identify tuberculosis 29 Copyright 9 Case study 1 29 Final assessment 9 Case study 2 29 Obtaining an exam code 10 Case study 3 30 books in the EBW Healthcare series 10 Case study 4 30 Managing your own course step by step 12 The five most important ‘take-home’ Using the book as a work manual 13 messages 31 Updating of the programme 13 Further information 14 3 Diagnosis of childhood tuberculosis 32 Comments and suggestions 14 Confirming the clinical diagnosis of tuberculosis 321 Introduction to childhood tuberculosis 15 Tuberculin skin tests 33 Tuberculous infection 15 Identifying TB bacilli in sputum 35 Pulmonary tuberculosis 18 Sputum smear examination 36 Extrapulmonary tuberculosis 20 Culture for TB bacilli 37 Case study 1 21 Chest X-ray 38 Case study 2 22 Fine needle aspiration of a lymph node 39 Case study 3 22 Lumbar puncture 39 The five most important ‘take-home’ Screening for HIV 39 messages 23 Case study 1 40 Case study 2 40
  5. 5. Case study 3 41 Case study 2 59 The five most important ‘take-home’ Case study 3 60 messages 41 The five most important ‘take-home’ messages 604 Management of childhoodtuberculosis 42 Tests 61 Planning the management of a child with Test 1: Introduction to childhood tuberculosis 42 tuberculosis 61 Treating tuberculosis 43 Test 2: Clinical presentation of childhood Good adherence 45 tuberculosis 63 Monitoring treatment 46 Test 3: Diagnosis of childhood Drug-resistant tuberculosis 47 tuberculosis 64 Good nutrition 49 Test 4: Management of childhood Treating tuberculosis and HIV co- tuberculosis 66 infection 49 Test 5: Preventing childhood tuberculosis 68 Case study 1 50 Case study 2 50 Answers 71 Case study 3 51 Test 1: Introduction to childhood The six most important ‘take-home’ tuberculosis 71 messages 51 Test 2: Clinical presentation of childhood tuberculosis 715 Preventing childhood tuberculosis 53 Test 3: Diagnosis of childhood Principles of prevention 53 tuberculosis 72 BCG immunisation 53 Test 4: Management of childhood Avoiding exposure to tb bacilli 55 tuberculosis 72 TB prophylaxis in children 56 Test 5: Preventing childhood tuberculosis 73 National tuberculosis programme 57 Writing the exam 73 Community involvement 58 Controlling the spread of hiv infection 58 Illustrations 74 Case study 1 59
  6. 6. AcknowledgementsThe aim of this book is to promote and improve for their innovative vision of presenting thethe care of all children with tuberculosis, text in both book and web-based format. Theespecially in under-resourced communities latter will be made available at no cost togetherin southern Africa. The learning material is with an invitation to contribute in the form ofpresented in a way which enables groups of comments which, after review, will be includedhealthcare workers to take responsibility for in the text. The question-and-answer layouttheir own continuing training. is adapted from that of the highly successful Perinatal Education Programme.We wish to gratefully acknowledge thecontributions of Prof N. Beyers, Prof S. Schaaf, The funding for this project was obtainedProf P. Jeena, Prof R. Green, Prof B. Marais from a United States Agency for Internationaland Dr A. Kutwa. When opinions differed Development (USAID) southern Africabetween contributing colleagues, the simplest grant (under the terms of Agreementmost practical choice was adopted. While every No.GHS-A-00-05-00019-00) to the Desmondeffort has been made to correct any errors in Tutu Tuberculosis Centre. The grant wasthe text, the final decision and responsibility administered by the Tuberculosis Controlwas ours alone. Assistance Programme (TBCAP) through the KNCV Tuberculosis Foundation. TheWe also wish to thank Dr Lindiwe Mvusi from views expressed in this publication do notthe South African National Department of necessarily reflect the views of the USAID orHealth and Ms Nellie Makhaye-Gqwaru of the United States Government. We also wishUSAID for their support and mobilisation of to acknowledge the generous funding fromresources toward this project. Eduhealthcare, a not-for-profit organisation,Where possible, we attempted to comply in writing this book.with the Guidance for the Managementof Childhood Tuberculosis (World HealthOrganisation WH/HTM/2006.371), South Prof David Woods and Prof Robert GieAfrican national tuberculosis programmeguidelines and provincial prevention,diagnostic and management protocols.Our sincere thanks go to the publishers fortheir willingness to support this project and
  7. 7. IntroductionTHE DESMOND TUTU Although the material was written to be used as a distance-learning course for healthcareTUBERCULOSIS CENTRE professionals in district and regional healthcare facilities, it is also used in theThe Desmond Tutu Tuberculosis Centre training of medical and nursing students.(DTTC) is attached to the Faculty of Health Childhood TB was written by South AfricanSciences, Stellenbosch University, South Africa. paediatricians with the contribution ofThe main focus of the DTTC is to improve colleagues in universities and health services.the health of vulnerable groups through This ensures a balanced, practical and up-influencing policy based on new knowledge to-date approach to common and importantcreated by research. The areas of research clinical problems.that the DTTC have actively been involved ininclude the epidemiology of tuberculosis (TB),childhood tuberculosis, multi-drug-resistanttuberculosis, HIV/TB interaction and SELF-HELP EDUCATIONoperational research to prevent the spread ofTB and HIV in southern African communities. If high-quality care is to be provided to allIn addition, the DTTC is actively involved children with tuberculosis, training at allin the education of healthcare workers and levels of healthcare workers is members to improve the awareness Unfortunately this is often only achieved inand early diagnosis of TB and HIV. the large centralised tertiary-care hospitals and not in the rural secondary- or primary- care centres. The providers of primary care inAIM OF THIS CHILDHOOD rural areas usually have the least continuing education as they are furthest away from theTB COURSE training hospitals in urban centres. It is not possible to send teachers to all these rural areasThe aim of this Childhood TB course is to for long periods of time while staff shortagesimprove the care of children with TB in and domestic reasons make it impractical toall communities, especially in poor peri- transfer large numbers of doctors and nursesurban and rural districts of southern Africa.
  8. 8. 8 CHILDHOOD TBfrom primary- and secondary-care centres to to the question. This method helps learning.centralised tertiary hospitals for training. Simplified flow diagrams are also used, where necessary, to indicate the correct approach toIdeally all medical and nursing staff should diagnosing or managing a particular problem.have regular training to improve and update Copies of these flow diagrams may be of valuetheir theoretical knowledge and practical skills. in the labour ward or nursery.One way of meeting these needs in continuingeducation is with a self-help outreach Different forms of text are used to identifyeducational programme. This decentralised particular sections of the Programme.method allows healthcare workers to takeresponsibility for their own learning and Each question is written in bold,professional growth. They can study at a time like this, and is identified with theand place that suits them. Participants in the number of the chapter, followed by theprogramme can also study at their own pace. number of the question, e.g. 5-23.The education programme should be cheapand, if possible, not require a tutor. Important practical lessons are emphasised by placing them in a box like this.FORMAT OF THE NOTE Additional, non-essential information isCHILDHOOD TB provided for interest and given in notes like this. These facts are not used in the case studies orEDUCATION PROGRAMME included in the multiple-choice questions.Throughout this programme the participant 3. Case problemstakes full responsibility for his or her ownprogress. This method teaches participants to A number of clinical presentations in storybecome self-reliant and confident. form are given at the end of each chapter so that the participant can apply his or her newly1. The objectives learned knowledge to solve some common clinical problems. This exercise also gives theAt the start of each chapter the learning participant an opportunity to see the problemobjectives are clearly stated. They help the as it usually presents itself in the clinic orparticipant to identify and understand the hospital. A brief history and/or summary ofimportant lessons to be learned. the clinical examination is given, followed by a series of questions. The participant should2. Questions and answers attempt to answer each question before readingTheoretical knowledge is taught by a problem- the correct answer. The knowledge presentedsolving method which encourages the in the cases is the same as that covered earlierparticipant to actively participate in the learning in the chapter. The cases, therefore, serve toprocess. An important question is asked, or consolidate the participant’s knowledge.problem posed, followed by the correct answeror explanation. In this way, the participant 4. Multiple-choice questionsis led step by step through the definitions, An in-course assessment is made at thecauses, diagnosis, prevention, dangers and beginning and end of each chapter in themanagement of a particular problem. form of a test consisting of 20 multiple-choiceIt is suggested that the participant cover the questions. This helps participants manage theiranswer for a few minutes with a piece of paper own course and monitor their own progressor card while thinking about the correct reply by determining how much they know before starting a chapter, and how much they have
  9. 9. INTRODUCTION 9learned by the end of the chapter. The correct principles of peer tuition and co-operativeanswer to each question is provided at the end learning play a large part in the success of PEP.of the book. This exercise will help participantsdecide whether they have successfully learnedthe important facts in that chapter and will THE IMPORTANCEalso draw participants’ attention to the areaswhere their knowledge is inadequate. OF A CARING ANDIn the multiple-choice tests the participant QUESTIONING ATTITUDEis asked to choose the single, most correctanswer to each question or statement from A caring and questioning attitude isfour possible answers. A separate loose sheet encouraged. The welfare of the patient is ofshould be used to record the test answers the greatest importance, while an enquiringbefore (pre-test) and after (post-test) the mind is essential if participants are to continuechapter is studied. The list of correct answers improving their knowledge and skills. Thealso indicates which section should be participant is also taught to solve practicalrestudied for each incorrect post-test answer. problems and to form a simple, logical approach to common perinatal problems.5. Skills workshopsSome courses include skills workshops which COPYRIGHTenable the participants to learn the clinicalskills needed. The skills workshops, which To be most effective, the Perinatal Educationalare often illustrated with line drawings, list Programme course should be used underessential equipment and present step-by-step the supervision of a co-ordinator. Using partinstructions on how to perform each task. of the programme out of context will be ofParticipants should find a colleague with the limited value only, while changing part of thenecessary experience to assist them with a programme may even be detrimental to thehands-on demonstration of the particular skill. participant’s perinatal knowledge. Therefore,This enables participants to use local expertise copyright on all PEP materials means thatrather than be dependent on outside tuition. no portion of the programme can be altered. However, for teaching and management purposes only, parts or all of the programmeSTUDY GROUPS may be photocopied provided that recognition to the programme is acknowledged. If theIt is strongly advised that the courses are routine care in your clinic or hospital differsstudied by a group of participants and not by from that given in the programme, you shouldindividuals alone. Each group of five to ten discuss it with your staff.participants should be managed by a localco-ordinator who is usually a member of thegroup, if a formal trainer is not available. The FINAL ASSESSMENTlocal co-ordinator orders the books and thenarranges the time and venue of the group On completion of each book, participants canmeetings (usually once every three weeks). write a formal multiple-choice examinationAt the meeting the chapter just studied is to assess the amount of knowledge that theydiscussed and the post-tests, and pre-tests have acquired. All the exam questions will befor the next chapter, are done. The skills taken from the tests at the end of each chapter.workshops should also be demonstrated and The content of the skills workshops will notpractised at the meetings. In this way the be included in the examination. Credit forgroup manages all aspects of their course. The
  10. 10. 10 CHILDHOOD TBcompleting the course will only be given if antenatal card and partogram, measuring bloodthe final examination is successfully passed. pressure and proteinuria, and performingA separate examination is available for each and repairing an episiotomy. Maternal Carebook and successful examination candidates is aimed at professional healthcare workers inwill be able to print their own certificate which level 1 hospitals or clinics.states that they have successfully completedthat course. A mark of 80% is needed to pass Primary Maternal Carethe final examinations. Any official recognitionfor completing a PEP course will have to be This book addresses the needs of healthcarenegotiated with your local healthcare authority. workers who provide both antenatal andSouth African doctors can earn CPD points on postnatal care but do not conduct deliveries.the successful completion of an examination. The content of these chapters is largely taken from the relevant chapters in Maternal Care. It contains theory chapters and skills workshops. This book is ideal for staffOBTAINING AN EXAM CODE providing primary maternal care in level 1 district hospitals and clinics.To write the examination, a participant firsthas to purchased an exam code. To purchase Intrapartum Carean exam code, visit: This book was developed for doctors and advanced midwives who care for women whoAn exam code is a unique number for one deliver in district hospitals. The chapters wereparticipant and one course. An exam code developed from selected units in the Maternalenables participants to test their knowledge Care manual. Particular attention is given toand write the final examination online. the care of the mother, the management ofThe fee and how to pay for exam codes are labour, and monitoring the wellbeing of theexplained on the website. fetus. Improved care during labour, delivery, and the puerperium promises to reduce both the maternal and perinatal mortality rates,BOOKS IN THE especially in rural areas. Intrapartum Care was written to support and complement the nationalEBW HEALTHCARE SERIES protocol of intrapartum care in South Africa.Maternal Care Newborn CareThis book addresses all the common and Newborn Care was written for healthimportant problems that occur during professionals providing special care for infantspregnancy, labour and delivery, and the in regional hospitals. It covers resuscitationpuerperium. It includes booking for antenatal at birth, assessing infant size and gestationalcare, problems during the antenatal period, age, routine care and feeding of both normalmonitoring and managing the mother, fetus and high-risk infants, the prevention,and progress during labour, medical problems diagnosis and management of hypothermia,during pregnancy, problems during the three hypoglycaemia, jaundice, respiratory distress,stages of labour and the puerperium, family infection, trauma, bleeding, and congenitalplanning after pregnancy, and regionalised abnormalities, as well as communicationperinatal care. Skills workshops teach the with parents. Skills workshops addressgeneral examination, abdominal and vaginal resuscitation, size and gestational ageexamination in pregnancy and labour, measurement, history, examination andscreening for syphilis and HIV, use of an clinical notes, nasogastric feeds, intravenous
  11. 11. INTRODUCTION 11infusions, use of incubators, measuring Birth Defectsblood glucose concentration, insertion of This book was written for healthcarean umbilical catheter, phototherapy, apnoea workers who look after individuals withmonitors and oxygen therapy. birth defects, their families, and women who are at increased risk of giving birth to anPrimary Newborn Care infant with a birth defect. Special attentionThis book was written specifically for nurses is given to modes of inheritance, medicaland doctors who provide primary care genetic counselling, and birth defects duefor newborn infants in level 1 clinics and to chromosomal abnormalities, singlehospitals. Primary Newborn Care addresses the gene defects, teratogens and multifactorialcare of infants at birth, care of normal infants, inheritance. This book is being used in thecare of low-birth-weight infants, neonatal Genetics Education Programme which hasemergencies, and important problems in been developed to train healthcare workers innewborn infants. genetic counselling in South Africa.Mother and Baby Friendly Care Perinatal HIVWith the recent technological advances in The HIV epidemic is spreading at anmodern medicine, the caring and humane alarming pace through many developingaspects of looking after mothers and infants countries, increasing the maternal and infantare often forgotten. This book describes better, mortality rates, and adding to the financialgentler, kinder, more natural, evidence-based burden of providing health services to allways that care should be given to women communities. Nowhere is the devastatingduring pregnancy, labour, and delivery. It effect of this infection more obvious than inlooks at improved methods of providing the transmission of HIV from mothers toinfant care with an emphasis on kangaroo their infants. In order to decrease this risk, allmother care and exclusive breastfeeding. A healthcare workers dealing with HIV-positivenumber of medical and nursing colleagues in mothers and infants will need to receiveSouth Africa contributed to this book. additional training. Perinatal HIV was written to address this challenge.Saving Mothers and Babies This book enables midwives, nurses andSaving Mothers and Babies was developed in doctors to care for pregnant women andresponse to the high maternal and perinatal their infants in communities where HIVmortality rates found in most developing infection is present. Special emphasis has beencountries. Learning material used in the book is placed on the prevention of mother-to-infantbased on the results of the annual confidential transmission of HIV.enquiries into maternal deaths and the Saving Chapters have been written on HIV infection,Mothers and Saving Babies reports published in antenatal, intrapartum and infant care, andSouth Africa. It addresses the basic principles counselling. Colleagues from a number ofof mortality audit, maternal mortality, hospitals and universities in South Africaperinatal mortality, managing mortality were invited to review and comment on themeetings, and ways of reducing maternal and draft document in order to achieve a well-perinatal mortality rates. This book should balanced text. It is hoped that this trainingbe used together with the Perinatal Problem opportunity will help to stem the tide of HIVIdentification Programme (PPIP). infection in our children.
  12. 12. 12 CHILDHOOD TBChildhood HIV MANAGING YOUR OWNChildhood HIV enables nurses and doctors COURSE STEP BY STEPto care for children with HIV infection. Itcovers an introduction to HIV in children, the 1. Before you start each chapter, take the testclinical and immunological diagnosis of HIV for that chapter at the back of the book. Doinfection, management of children with and the test by yourself even if you are studyingwithout antiretroviral treatment, antiretroviral with a group of colleagues. Choose the bestdrugs, and infections and end-of-life care. answer for each multiple-choice question and note your answers on a piece of looseChildhood TB paper. This is called your ‘pre-test’ for thatTo help tackle the tuberculosis epidemic in chapter. There is an answer sheet that yousouthern Africa, Childhood TB was written to should use to mark your completed pre-enable healthcare workers to learn about the test. Record your pre-test mark.primary care of children with tuberculosis. The 2. Now work through the chapter. Read eachbook covers an introduction to TB infection, question and answer, and make sure youand the clinical presentation, diagnosis, understand it. Pay particular attentionmanagement and prevention of tuberculosis to the facts in grey boxes as these are thein children. Childhood TB was developed by main messages. Read the case studiespaediatricians with wide experience in the to check whether you have learned andcare of children with tuberculosis, through the understood the important information.auspices of the Desmond Tutu Tuberculosis 3. If you are part of a study group, useCentre at the University of Stellenbosch. this opportunity to discuss with your colleagues any difficulties you may haveChild Healthcare experienced. Talking about what you have read is a very important part of theChild Healthcare addresses all the common learning process. If the book includes skillsand important clinical problems in children, workshops, these should be conducted atincluding immunisation, growth and nutrition, the time of the group meetings. Invite anacute and chronic infections, parasites, and skin experienced colleague who can help youconditions, as well as the home and society. master the particular skill. 4. When you have learned all the knowledgeAdult HIV in that chapter, take the same test again. This second test is called your ‘post-test’.Adult HIV was developed by doctors and nurses Now mark the post-test and compare yourwith a particular interest in HIV infection. The pre-test and post-test marks. Your marksbook covers an introduction to HIV infection, should have improved considerably. In themanagement of HIV-infected adults, preparing answers section of the book, opposite eachpatients for antiretroviral treatment, the drugs correct answer, is the number of the sectionused in antiretroviral treatment, starting and where the question was taken from. Re-maintaining patients on antiretroviral treatment read and learn the sections for any post-testand an approach to opportunistic infections. answers you got incorrect. Now you areThe aim of the book is to enable healthcare ready to move on to the next chapter.workers at primary-care clinics to manage all 5. Repeat steps 1 to 4 for each chapter asaspects of HIV-related patient care. you work your way through the book. This enables you to obtain the knowledge, monitor your progress, and measure how much you are learning. Most people will take about two to four weeks per chapter.
  13. 13. INTRODUCTION 136. Once you are confident that you have USING THE BOOK AS mastered all the main lessons in the book, you can write the final examination online A WORK MANUAL at To write the final examination you will need to have It is hoped that as many participants as an exam code. This is a unique number possible will use these books as work manuals that entitles you to write the examination after they have completed the course. The for a course. If you don’t have one yet, you flow diagrams should be most useful in or your group can buy exam codes. The managing difficult problems and for planning fee and how to pay are described on the management. A further benefit of the books website. This exam code will only work is that they standardise the documentation once for one examination. and management of certain clinical problems.7. You will be able to write the examination, This is particularly useful when patients are consisting of 75 multiple-choice questions, referred within or between healthcare regions. on the website. You will only have a It is further hoped that all those who use these limited time to answer each question and books will enjoy learning about new and better you will not be able to go back and check methods of caring for mothers and newborn previous questions. Set aside an hour to infants. Every opportunity to share knowledge write the examination. When you write the with both patients and colleagues should be examination, do not use the book to look used. By doing this you will find your career up the correct answers. Remember, you are more fulfilling and you will help to improve your own teacher, so be strict with yourself! the perinatal care in your region.8. Your examination answers will automatically be marked as soon as you have completed the last question. If you UPDATING OF THE get 80% or better you have passed and will be able to print your own certificate which PROGRAMME states that you have successfully completed the course. However, if you have failed to Based on the comments and suggestions achieve 80%, you can purchase another made by participants and other authorities, exam code to write the examination again. the chapters and skills workshops of the programme will be regularly edited to makeTips them more appropriate to the needs of• Work through the course with a group of perinatal care and to keep the programme friends or colleagues. up to date with new ideas and developments.• One person in your group (your co- Everyone studying the programme is invited ordinator or ‘convenor’) should take to write to the editor-in-chief with suggestions responsibility for organising meetings to as to how the books could be improved. You discuss each chapter before you write the can also send your comments on parts of the post-test. books on the website• Set yourself targets, such as ‘two units a month’.• Keep your book with you to read whenever you have a chance.• Write the examination only when you feel ready.
  14. 14. FURTHER INFORMATION COMMENTS AND SUGGESTIONSFor further information on the Childhood TBEducation Programme please contact: The Childhood TB Education Programme has been produced by a team of TB specialists,By email after wide consultation with colleagues practise in both rural and urban settings, in an attempt to reach consensus on the care ofBy fax children with tuberculosis. The programme is designed so that it can be improved+27 088 021 44 88 336 and altered to keep pace with current developments in health care. Participants using this programme can make an importantBy phone contribution to its continual improvement+27 021 44 88 336 by reporting factual or language errors, by identifying sections that are difficult toOnline understand, and by suggesting improvements to the contents. Details of alternative or forms of management would be particularly appreciated. Please send any comments or suggestions to EBW Healthcare at any of the above contact details.