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Childhood TB: Preventing childhood tuberculosis


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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: Preventing childhood tuberculosis

  1. 1. 5 Preventing childhood tuberculosisBefore you begin this unit, please take the PRINCIPLES OFcorresponding test at the end of the book toassess your knowledge of the subject matter. PREVENTIONYou should redo the test after you’ve workedthrough the unit, to evaluate what you havelearned. 5-1 How can the risk of childhood tuberculosis be decreased? • BCG immunisation Objectives • Avoiding exposure to adults with tuberculosis • TB prophylaxis in children When you have completed this unit you • Reporting and effectively treating cases of should be able to: tuberculosis • List ways of preventing tuberculosis. • Educating the community about • Provide BCG immunisation. tuberculosis • Reduce the risk of exposure to TB bacilli. • Controlling the spread of HIV • Give TB prophylaxis when indicated. • Report a case of tuberculosis. BCG IMMUNISATION • Describe the aims of the national tuberculosis programme. 5-2 What is BCG? • Give ways of educating the community about tuberculosis. BCG (Bacille Calmette Guerin) is a freeze- dried live vaccine. It is made from a weakened • Understand the importance of reducing live (attenuated) form of Mycobacterium the spread of HIV if the tuberculosis bovis, the bacilli which causes tuberculosis in epidemic in South Africa is to be cattle and sometimes in children who drink controlled. milk that was not pasteurised. BCG is included in the expanded programme on immunisation (EPI) in children.
  2. 2. 54 CHILDHOOD TB NOTE In South Africa the Danish strain 5-6 Should some newborn of BCG is being used. Each year over infants not be given BCG? 100 million doses of BCG are given worldwide. BCG was first used in 1921. In South Africa BCG is currently given to all infants after birth. However, BCG can5-3 Why should children be cause serious adverse effects in HIV-infectedimmunised with BCG? infants. Due to the fact that the prevention of mother-to-child transmission programmeBCG does not prevent infection with TB is reasonably efficient in South Africa, anbacilli but reduces the risk of TB meningitis accurate diagnosis of HIV infection can beand disseminated TB in young children made at six weeks after delivery by PCR, andby 75%. Unfortunately it is less effective antiretroviral treatment is started early, it isin preventing pulmonary TB, especially in still recommended that all neonates be givenmalnourished children and children with HIV BCG at birth. Infants known to be infectedinfection. It also gives less protection in older with HIV should not be given BCG if this haschildren, adolescents and adults which makes not already been given at birth.reimmunisation at an older age unnecessary. 5-7 How is BCG given? BCG reduces the risk of disseminated tuberculosis BCG is given by intradermal injection over the and tuberculous meningitis in children. right upper arm as follows: • Add 1 ml of diluent into the vial containing5-4 How should BCG be stored and mixed? BCG. Gently turn the vial upside down atBCG vaccine should be stored in a refrigerator least five times until fully mixed. Do notbetween 2 and 8 °C and must not be frozen. shake.Keep it and the diluent on the middle shelf. • Draw up 0.05 ml of BCG vaccine inIt must also be kept out of direct sunlight. To a sterile syringe (a special syringe toprepare the vaccine for administration the vial accurately measure 0.05 ml).of diluent should be added to the vial of dried • Clean an area of skin over the right deltoidvaccine. Do not use alcohol or ether to clean muscle (upper arm) with soap and water,the top of the vial as it may kill the BCG. After not an alcohol swab.adding the diluent, the vaccine will last for • Stretch the skin over the right deltoidsix hours if kept in a refrigerator or cool box. muscle with your thumb and forefinger.After six hours the vaccine must be discarded Slowly insert the needle intradermallyas the bacilli may be dead. (bevel facing up). Insert the needle for less than 2 mm into the skin. The needle can be seen through the skin.5-5 When should BCG be given? • Inject the 0.05 ml of vaccine. A whealUsually BCG is given during the first few days (raised lump) indicates that the intradermalafter birth in well infants and on the day of injection has been given successfully. Thedischarge from hospital or clinic in infants who most common error is to inject the BCGhave been ill or are low birth weight. If there under the skin when no wheal will be any doubt about whether BCG was given With no wheal, start again at a different siteafter birth, it should be given at six weeks with and inject into the skin.the other routine immunisations. BCG is notusually given to children older than one yearand most clinics do not stock BCG. It is important that BCG is given correctly.
  3. 3. PREVENTING CHILDHOOD TUBERCULOSIS 555-8 What are the adverse effects AVOIDING EXPOSUREof BCG immunisation? TO TB BACILLIIn the majority of infants a raised noduledevelops at the site of the immunisation aftertwo to four weeks. A small crust may develop 5-9 When are children at high riskor it may ulcerate. The nodule will heal by of exposure to TB bacilli?itself and no dressing should be applied. Aftereight weeks the nodule starts to decrease in There is a high risk of infection when childrensize and by six months a small flat scar will come into contact with someone who hasform. The lymph nodes in the axilla on that untreated smear-positive tuberculosis. This isside may enlarge slightly, which is normal. usually an adult with a cavity on chest X-ray.BCG immunisation does not always leave a They have a chronic cough but are not awarescar in an infant. It is not necessary to repeat that they have pulmonary tuberculosis. Thethe BCG immunisation if no scar is seen. risk is the highest if the child lives in the same household (close contact). Children are also atThe most common adverse effects are risk if their caregivers or family members theylocal pain and ulceration at the site of the regularly visit have tuberculosis.immunisation and enlarged lymph nodes inthe axilla and sometimes the neck. This situation is far more common in poor families where there is overcrowding inSerious adverse effects in infants who are not inadequate, dark, poorly ventilated housing.HIV infected are very rare. However there is Children may also be exposed to largea high risk of serious adverse effects in HIV- numbers of TB bacilli in taxis, buses, clinics orinfected infants. They include: other confined spaces.• An abscess may form at the site of the BCG NOTE The concentration of TB bacilli in the air, immunisation. the closeness of contact and the time a person• Axillary and rarely cervical (neck) lymph is exposed to the contaminated air are major nodes may enlarge rapidly to more than factors in determining who will become infected. 3 cm. A lymph node abscess may form and TB bacilli are rapidly killed by direct sunlight. a sinus can develop.• Disseminated BCG which presents in a 5-10 How can exposure to TB similar way to disseminated tuberculosis. bacilli be prevented?• BCG IRIS (immune reconstitution • It is the public health responsibility of both inflammatory syndrome due to BCG) the healthcare services and the general can develop after beginning antiretroviral public to be aware of anyone who has the treatment. This presents with enlarged symptoms of tuberculosis, especially a axillary (arm pit) lymph nodes two to eight chronic cough (more than two weeks). weeks after starting antiretroviral treatment. They need to be investigated.All HIV-infected infants must be identified as • Improved living conditions with betterearly as possible and referred for investigation housing and good nutrition.and treatment. • Whenever someone is diagnosed with tuberculosis, the family and others living NOTE An adverse effect to BCG must be reported in the same house should be screened if an abscess larger than 10 mm forms at the site of immunisation or an axillary lymph for tuberculosis. This is usually done by node larger than 15 mm occurs. BCG adverse taking a good history and referring those events are reported to the EPI program. with symptoms for sputum examination. If the sputum examination is negative and symptoms persist then a chest X-ray must be taken. If there is one person with
  4. 4. 56 CHILDHOOD TB tuberculosis in the family, there is an • Patients with pulmonary tuberculosis are increased chance that there will be others. usually no longer infectious to others after taking their medication correctly for 14 or5-11 What is contact tracing? more days.This is the finding and screening of people (the 5-13 What investigations should be done‘contacts’) who have been exposed to someone on children exposed to infectious patients?with tuberculosis (the ‘source’). Both adult • Careful history and examination forand child contacts may have undiagnosed symptoms and signs of tuberculosistuberculosis and need treatment. • Mantoux skin testSome children will have TB infection only (a • Record and plot their weight on the Road-positive Mantoux skin test with no symptoms To-Health chart. Look for lack of weightor signs of disease). Infected children younger gain.than five years of age and children of any age • Screen for malnutritionwho also have HIV infection will benefit from • HIV screening test if indicatedTB prophylaxis. • If there is any suspicion that a child has tuberculosis then the child must beContact tracing of infectious people is a very investigated, which would include a chestimportant part of controlling the spread of X-ray, a sputum sample in older childrentuberculosis in a community. The most effective (above eight years) and gastric aspirate ifpublic health measure to control tuberculosis is possible in younger children, for smearthe identification and cure of infectious cases. and culture. Contact tracing is an essential part of controlling 5-14 How can health workers the spread of tuberculosis. avoid infection? Health workers are exposed to TB bacilli, NOTE While the family are encouraged to bring especially while examining patients with a exposed children and adults with symptoms to be screened at the clinic (passive contact cough or while collecting sputum samples. tracing), home visits to screen the family Masks should be worn by healthcare workers (active contact tracing) should be done, but when examining patients suspected of having is not commonly practised in South Africa. infectious tuberculosis and hands should be washed after the examination. Good5-12 How can infected patients ventilation in examination and procedureprevent the spread of tuberculosis? rooms is essential.• By starting anti-TB treatment as soon as possible and taking their medication regularly and correctly. TB PROPHYLAXIS• By teaching the correct cough behaviour IN CHILDREN to communities (cough etiquette). This requires adults to cough into a handkerchief and not onto other people. 5-15 What is TB prophylaxis in children? They should cover the nose when sneezing. Usually INH for six months is used for• Ensuring that public spaces are well- prophylaxis against tuberculosis in children. ventilated by opening windows. The treatment is given daily using the same• Meet out of doors if possible. daily dose as for short-course treatment• By practising infection control in all (10 mg/kg/day). healthcare facilities.
  5. 5. PREVENTING CHILDHOOD TUBERCULOSIS 575-16 Who should receive TB prophylaxis? NATIONAL TUBERCULOSISThe following children should be given PROGRAMMEprophylactic treatment:• Clinically well asymptomatic children under five years of age who have been 5-17 What is the aim of a national in close contact with someone who tuberculosis programme? has smear-positive pulmonary TB. The aim of a national tuberculosis programme These young children are at high risk of is to prevent the spread of tuberculosis developing tuberculosis themselves as they and to promote the accurate diagnosis have an immature immune system. and correct treatment of tuberculosis. This• Children under five years who have a should reduce the mortality and morbidity positive Mantoux skin test (10 mm or due to tuberculosis and reduce the risk of more), who are clinically well with no drug resistance. The national tuberculosis symptoms or signs of tuberculosis and have programme in South Africa (National TB not recently been treated for tuberculosis. Control Programme) was started in 1996 with They have been infected with TB bacilli and widespread implementation of the DOTS are at high risk of the infection progressing strategy. to tuberculosis. They are at particular risk of disseminated tuberculosis. 5-18 Do children with tuberculosis• HIV-infected children of any age who are need to reported? in contact with adults with smear-positive or culture-positive tuberculosis. They are Yes. All children who are treated for at an increased risk of tuberculosis because tuberculosis need to be recorded and reported they have a depressed immune system. to the local health (EPI) authority. Children are reported in two age groups, zero to four,Asymptomatic HIV-negative children of and five to 14 years of age.five years and older, who have been inclose contact with an adult with untreated 5-19 Why is it important for children withpulmonary TB, or have a positive Mantoux tuberculosis to be recorded and reported?test, are not given prophylaxis, as they areat far less risk of developing tuberculosis. It is important that children with tuberculosisHowever, they should be followed and are reported and recorded for two maininvestigated for tuberculosis if they develop reasons.any early symptoms or signs of TB. 1. To know how many children require treatment for tuberculosis to ensure Prophylactic treatment is given to well children sufficient child-friendly treatment courses. under five years of age, and HIV-infected children 2. The number of children with tuberculosis, of any age, who have been exposed to someone especially in the zero to four age group, with untreated tuberculosis. gives an indication of the amount of recently transmitted infection. An evaluation of this group of children gives an indication of the quality of the National TB Programme. 5-20 Do we need to record and report on children receiving prophylaxis? It is not required at present to register these children. However it would be an advantage
  6. 6. 58 CHILDHOOD TBif each clinic knew which children were • Through community organisations (tradereceiving prophylaxis, how many completed unions, church groups).the course of prophylaxis, and what the • At healthcare clinics (posters, informationoutcome of these children was. This would sheets, discussion groups, individualhelp with the planning of the service. counselling). • Using peer educators (previous TB5-21 What are the Millennium patients who have been trained asDevelopmental Goals? community workers).These are eight developmental goals set by the 5-24 What are tradional beliefsUnited Nations to improve the living conditions about tuberculosis?in the world’s poorest countries. Goal numbersix addresses important infectious diseases. In In most communities there are manySouth Africa these are HIV and TB infection. misunderstandings and incorrect beliefs aboutThe challenge is to reduce the incidence of tuberculosis.tuberculosis by half by 2015. • Tuberculosis is caused by bewitchment. • Tuberculosis is a punishment for some sin Reducing the incidence of tuberculosis is committed. included in the Millenium Developmental Goals. • Tuberculosis is an inherited condition. • Tuberculosis cannot be cured. NOTE The Stop TB strategy of the WHO in 2006 • BCG immunisation prevents all forms of spells out the steps needed to reach this goal. tuberculosis. These false beliefs often cause a lot of unnecessary suffering. They can only beCOMMUNITY corrected by community education.INVOLVEMENT CONTROLLING THE5-22 What community education is needed? SPREAD OF HIV INFECTIONIt is important that the community in all areasis aware of the following: 5-25 How would controlling the• Know that tuberculosis is a common and spread of HIV infection reduce the important disease in South Africa. prevalence of tuberculosis?• Know how tuberculosis is spread.• Know the presenting symptoms of In South Africa the HIV epidemic has greatly tuberculosis. increased the number of both adults and• Know that treatment takes many months children with tuberculosis. HIV infection and that adherence is very important. lowers the immunity and thereby increases the• Know that tuberculosis can be cured. risk of TB infection progressing to tuberculosis, especially extrapulmonary tuberculosis. A5-23 How can the community be educated greater number of adults with tuberculosisabout the dangers of tuberculosis? increases the chance that children in the family and community will be infected with TB bacilli.• Via the print (magazines, newspapers) In addition, more women with tuberculosis and electronic (radio, television, internet) increases the risk of vertical transmission to media. infants (mother-to-child transmission).• By inclusion in the school curriculum.
  7. 7. PREVENTING CHILDHOOD TUBERCULOSIS 59Reducing the spread of HIV and tuberculosis 6. What is BCG IRIS?in the community is, therefore, essential if the IRIS (immune reconstitution inflammatorynumber of children with tuberculosis is to be syndrome) due to BCG may present withdecreased. markedly enlarged axillary lymph nodes a few weeks after antiretroviral treatment is started. It is due to the recovery of the immune system.CASE STUDY 1A newborn infant is given BCG immunisation CASE STUDY 2before discharge home from a obstetric careclinic. A month later the mother notices An unemployed man is diagnosed witha lump at the site of the immunisation. pulmonary tuberculosis. He lives with hisOn examination, the nurse notices mildly family, including a four-year-old son, inenlarged axillary lymph nodes. The child is an overcrowded house. He is concernedgenerally well and thriving. that his son may be at risk of developing tuberculosis. Clinically the child is well and1. What is BCG? not malnourished.A weakened (attenuated) form of TB bacilli. 1. What should be the2. What are the benefits of management of this child?BCG immunisation? He should be screened for tuberculosis asIt induces an immune response which reduces he is a ‘contact’ and therefore at high risk ofthe risk that TB infection will progress to infection.tuberculosis, especially disseminated andmiliary tuberculosis in young children. 2. What investigations are needed?However it does not reduce the risk of TB A Mantoux skin test and a chest X-ray must beinfection. done. A sputum test must be done if the chest X-ray suggests tuberculosis.3. How is BCG immunisation given?By injection into the skin (intradermal) of the 3. Should this child be treatedright upper arm (deltoid area). It is important for tuberculosis?that BCG is stored and mixed correctly. BCG Only if there is good evidence to suggestimmunisation should be given directly after that he developed tuberculosis ( a positivebirth. Mantoux test and abnormal chest X-ray). If he appears well and his Mantoux skin test is4. Would you be worried about the negative or intermediate, he should be givenswelling at the immunisation site TB prophylaxis.and the enlarged lymph nodes.No, as this is a normal response to BCG. 4. What is TB prophylaxis? INH 10 mg/kg daily for six months.5. What could cause severeadverse effects to BCG? 5. What other children shouldHIV infection. These infants have a weakened receive TB prophylaxis?immune system which can result in local BCG In addition to well children under five yearsabscesses or even disseminated BCG. of age who have been in contact with an adult
  8. 8. 60 CHILDHOOD TBwith pulmonary tuberculosis, children with a documented. This will help with planningpositive Mantoux skin test and children with both prevention and treatment.HIV infection should receive INH prophylaxisif they are TB contacts. 5. What are the Millennium Development Goals?6. How can adults with tuberculosis These are a set of goals aimed at improvingreduce the risk of spreading the the living conditions of people in developinginfection to their children? countries. One of the goals in South AfricaBy practising correct cough behaviour (cough includes halving the prevalence of tuberculosisetiquette) and taking their medication correctly. by 2015. 6. Are traditional beliefs aboutCASE STUDY 3 tuberculosis helpful? Some traditional beliefs lead toTuberculosis is common in a small rural misunderstanding and suffering. For example,community. The headmaster of the primary in some communities people with tuberculosisschool wants to involve the whole community are believed to be bewitched or are beingin reducing the risk of children developing punished for some sin. It is important for thetuberculosis. community to understand the true cause of tuberculosis and know that it can be cured1. How can the community help reduce with early diagnosis and correct treatment.the prevalence of tuberculosis?Everyone must be educated abouttuberculosis and understand the cause, THE FIVE MOSTclinical presentation, how it is spread and IMPORTANT ‘TAKE-the importance of good adherence. Theyshould understand that BCG immunisation, HOME’ MESSAGESregular weight checks and good nutrition areimportant for children. 1. BCG immunisation reduces the risk of tuberculous meningitis and disseminated2. How can the community be tuberculosis in young children.educated about tuberculosis? 2. INH prophylaxis should be given to children who are under five years of age orVia the print media (books, newspapers) and HIV infected and have been exposed to anelectronic media (radio and TV) as well as adult with pulmonary tuberculosis or havecommunity organisations. a positive Mantoux skin test. 3. All cases of childhood tuberculosis must be3. What can be done at the school? recorded and reportedInclude tuberculosis in the school curriculum. 4. Community education about tuberculosisEducation about tuberculosis can also be given is important in the fight to control theto teacher and parent groups. spread of the disease. 5. Controlling the HIV epidemic is essential to reduce the incidence of tuberculosis.4. Why should children with tuberculosisbe recorded and reported?So that the prevalence and spread oftuberculosis in the community can be