This file contains the presentation on behalf of ptbnet at the National Spanish TB meeting in Barcelona in December 2009

1. Tuberculosis
in
children
in
Europe
-­‐
the
ptbnet
Beate
Kampmann
FRCPCH
PhD
A/Professor
in
Paediatric
Infec;on
&
Immunity
Consultant
Paediatrician
Imperial
College
London,
UK
and
Ins;tute
of
Infec;ous
Diseases
and
Molecular
Medicine
University
of
Cape
Town,
RSA
XIII
Taller
Internacional
sobre
Tuberculosis
UITB-­‐2009,
Barcelona
1
de
Diciembre
2009

2. Presentation overview
Acknowledgement & Thanks
Childhood TB- special considerations
Childhood TB- epidemiology
Issues in Europe
The rationale for the ptbnet
Summary of European Practices
Outlook

3. Paediatric TB: special & Thanks
Acknowledgement considerations
• Significant
Morbidity
and
Mortality
1.4
million
cases
annually
(95%
developing
countries)
450,000
Deaths
es;mated
10-­‐15%
of
global
burden
related
to
childhood
TB
•
Different
clinical
spectrum
of
disease
5-­‐10%
<
2
yr
meningi;s
disseminated
disease
more
common
• Remains
a
diagnos;c
challenge
paucibacillary,
rarely
culture
confirmed
:
Sputum
smear
posi;ve
in
10.3%
(10-­‐14yr),
1.8%
(5-­‐9)
and1.6%
(<5)
Cultures
posi;ve
21%
(10-­‐14),
5%
(5-­‐9)
and
4.2%
(<5),
•
Co
infec;on
with
HIV-­‐
clinically
very
difficult
to
dis;nguish

4. Tuberculosis
in
children
differs
from
adults
Acknowledgement & Thanks
•
Immune
responses
are
Age-­‐dependent:
Following
infec;on
40%
<
2
yr,
25%
2-­‐5
yr
and
5-­‐15%
of
older
children
will
develop
disease
within
2
years
•
Majority
of
disease
results
from
progression
of
primary
infec;on
rather
than
reac;va;on
might
affect
detectable
immune
responses
•
More
likely
to
be
extrapulmonary
and
disseminated,
par;cularly
in
infants
Newton,
Kampmann
The
Lancet
Infec?ous
Diseases,
August
2008;
Vol
8:
498-­‐510

5. Paediatric TB: Diagnostic challenges Thanks low bacillary load
Acknowledgement & due to

6. Diagnostic approaches
Acknowledgement & Thanks
Microbiological
Immunological
Organism
Host
response
smear
culture
DNA
skin
test
an;gen-­‐specific
produc;on
of
IFNγ

7. Paediatric TB: Epidemiology
Acknowledgement & Thanks
•
of
the
9
million
annual
TB
cases,
about
1
million
(11%)
occur
in
children
(under
15
years
of
age).
•
reported
percentage
of
all
TB
cases
occurring
in
children
varies
(from
3%
to
more
than
25%)
• Children
can
present
with
TB
at
any
age,
but
the
most
common
age
is
between
1
and
4
years
•
Most
children
will
have
a
known
household
contact
•
Chemopropphylaxis
is
a
recommended
interven;on

8. Percentage of TB cases of foreign origin, 2006
Acknowledgement & Thanks
Not
included
or
not
repor;ng
to
EuroTB
0%
–
4%
5%
–
19%
20%
–
49%
>
49%
Andorra
Malta
Monaco
San
Marino
Trends
in
incidence
of
TB
in
children
under
15
years
by
ethnic
group
in
London,
2001-­‐2006

9. UK: Tuberculosis
rates
in
persons
born
abroad
by
age
Development
of
TB
in
immigrant
children
Sources:
Enhanced
Tuberculosis
Surveillance,
Labour
Force
Survey
popula?on
es?mates,
Abubakar
et
al
Arch.
Dis.
Child.
2008;93;1017-­‐1021;

10.
Children
with
TB
at
Imperial
HCT
Ethnicity
and
country
of
birth:
south asian Travel to TB endemic countries
29%
yes no dk
black african
afro-caribbean dk
black african caucasian 5%
47%
SE asian
mixed race
arab
no
south asian
arab
39%
5% no dk household visitor
mixed race
yes
4%
56%
visitor
SE asian
6% 6% afro-caribbean
caucasian 2%
no
7% Country of Birth
28%
dk UK
4%
38%
UK
household non-UK
62% non-UK
62%

11. Issues
for
children
with
TB
in
Europe
Acknowledgement & Thanks
•
Incidence
and
prevalence
vary
depending
on
countries
•
Data
on
childhood
TB
are
not
recorded
as
systema;cally-­‐
-­‐
no
age-­‐related
repor;ng
(0-­‐14)
•
Children
are
infected
from
adult
contacts,
but
the
contact
details
are
not
recorded
•
Clinical
prac;ce
for
preven;on
varies
from
country
to
country
•
Chemoprophylaxis
protocols
vary
•
Monitoring
varies
•
No
idea
about
MDR
prevalence
in
children
•
Treatment
/(MDR)
protocols
derived
from
adult
prac;ce

12. ECDC-­‐
reported
variables
Acknowledgement & Thanks
Total
No
of
cases
and
No;fica;on
rate/100
000
Sex
ra;o
Median
age
group-­‐
na;onals
and
non-­‐na;onals
New
(never
treated)
Foreign
born
Culture
posi;ve
pTB
HIV
posi;ve
TB
cases-­‐
not
stra;fied
for
children
TB
deaths
Drug
resistance
Treatment
outcome

13. 2
Key
recommendaCons:
A.
2
age
bands
to
be
reported:
0-­‐4,
5-­‐14
“Enumera;ng
children
with
TB
is
a
key
step
in
bringing
their
management
into
the
mainstream
of
the
Stop
TB
Strategy
as
part
of
rou;ne
NTP
ac;vi;es.”
B.
Dosage
adjustments
for
TB
therapy
“revised
recommended
dose
of
Ethambutol
is
now
20
mg/kg
(range
15–25
mg/kg)
daily.

14. what else can&we do?
Acknowledgement Thanks
to
improve
the
care
for
children
with
TB
in
Europe
by
crea;ng
a
network
of
pediatric
experts
in
TB
in
Europe
-­‐
to
more
accurately
describe
ac;ve
and
latent
TB
in
children
in
Europe
-­‐
to
iden;fy
differences
in
prac;ce
between
European
countries
-­‐
to
improve
clinical
management
and
research
in
childhood
TB
in
Europe
-­‐
to
develop
a
European
"expert
panel"
for
consulta;on
on
paediatric
TB
and
possibly
a
training
course
clinicians
-­‐
to
conduct
collaboraCve
research
epidemiologists
laboratory
scien;sts

15. •
founded
in
April
2009
•
to
date:
25
members
from
15
European
countries,
incl
Eastern
Europe
•
includes
clinicians,
epidemiologists
and
laboratory
scien;sts
www.ptbnet.org
Aims
•
enhance
the
understanding
of
the
pediatric
aspects
of
tuberculosis
•
facilitate
collaboraCve
research
studies
for
childhood
TB
in
Europe
•
provide
expert
opinion
through
excellence
in
science
and
teaching
•
establish
a
beler
evidence
base
for
diagnosis
and
treatment
of
TB
in
children

16. April
09
Agenda
1. PresentaCons
from
each
country:
Theme
1:
Data
capture
for
TB
in
your
country
Theme
2:
Prac;cal
Care
for
children
in
your
country/at
your
hospital
2.
Data
collecCon:
Discussion
of
shared
database
op;ons
3.
Discussion
of
mulCcentre
studies:
Defining
research
priori;es
and
possible
future
studies
4.
Conclusions
and
future
plans:
What
do
we
want
to
be/do
Possible
funding
streams-­‐
where
to
go

17. Acknowledgement & Thanks
Summary
of
ptbnet-­‐data:
Epidemiology
140
120
100
80
total
no
of
cases/100
000
60
percentage
of
ped.
cases
40
20
0
Na?onal
TB
guidelines
for
children
Yes:
8/11
(72%)
No:
2/11
(18%)
Proposed:
1/11
(9%)

18. Summary
of
ptbnet-­‐data:
Acknowledgement & Thanks
MDR
-­‐
TB
percentage
of
MDR
TB
18
16
14
12
10
8
6
percentage
of
MDR
TB
4
2
0
percentage
of
MDR
TB
Austria
Belgium
Greece
Holland
Italy
Lithuania
No
data
in
children
Romania
Spain
Turkey

19. Summary
of
ptbnet-­‐data:
PrevenCon
and
Treatment
•
Rou;ne
use
of
BCG:
7/11
•
Targeted
use
of
BCG:
2/11
•
No
BCG:
4/11
•
Chemoprophylaxis:
11/11,
but
ages
vary,
as
do
regimes
•
Treatment:
available
free
of
charge

20. Summary
of
ptbnet-­‐data:
TB
and
HIV
•
Few
data
available
on
prevalence
of
HIV
in
children
with
ac;ve
TB
•
Only
2/11
countries
rou;nely
test
TB
cases
for
HIV
•
HIV
results
generally
not
recorded
in
repor;ng
systems

21. Summary
of
ptbnet-­‐data:
Use
of
Interferon-­‐gamma
release
Assays
(IGRA)
•
IGRA
Recommended
in
8/11
countries
•
Widely
used
for
diagnosis
of
ac;ve
TB
•
Used
for
LTBI
screening
in
only
4
countries
•
QFG-­‐IT
preferred
test
(7/11
vs
3/11)
•
Data
in
different
age
groups
could
be
combined
to
comment
on
age-­‐related
performance

22. Future
plans
of
the
ptbnet
1.
Designated
database
Consensus
that
a
paediatric
database
is
highly
desirable
?
Use
exis;ng
plasorms
or
start
from
scratch
?
ECDC
informa;on-­‐
too
limited,
disease
only
?
Should
be
able
to
combine
with
adult
data
(contacts)
?
What
to
include
Needs
to
not
just
focus
on
TB
disease
but
include
exposure/infec;on/disease
Designated
funding
needs
to
be
idenCfied
to
move
this
project
forwards
substanCally
In
the
shorter
term,
we
will
invesCgate
exisCng
plaTorms
and
compile
the
data
fields
that
we
would
like
to
include
(potenCal
data
protecCon
issues
in
our
individual
countries)

23. Future
plans
of
the
ptbnet
2.
Defining
research
prioriCes
Immuno-­‐assays
in
children
Longitudinal
studies,
age
related,
MDR
monitoring,
site-­‐specific,
in
immunocompromised
PharmacokineCcs
New
and
old
TB
drugs
MDR
TB
Risk
factors,
management
(exposed
and
cases)
Members
with
exisCng
studies
will
liaise
to
share
data
and
compare
experience
and
recommendaCons
as
well
as
prepare
shared
data
for
joint
publicaCons
(f.ex.:
Bamford
et
al,
ptbnet
(UK),
Arch
Dis
Child
2009)
Protocol
sharing
in
labs/training

24. Where
from
here
Logo
website
www.ptbnet.org
Database
nego;a;ons
with
TBNET-­‐
in
process,
needs
to
be
intensified
Funding
opportuni;es
?
within
EU-­‐
FP7
calls
Descrip;ve
manuscript
of
childhood
TB
in
Europe
to
be
prepared
ptbnet
members
contribu;ng
to
TBNET
an;-­‐TNF
and
IGRA
consensus
statement
Expansion
of
the
group
to
include
clinician,
laboratory
and
epidemiologist
in
each
place
Close
collaboraCons
with
TBNET
(www.tb-­‐net.org)
Database
Website
space
MDR
study
Paediatric
aspects
of
other
studies

25. How
can
you
help?
•
Consider
TB
as
a
family
disease
and
set
up
your
clinics
in
this
way
•
Ensure
that
paediatric
informa;on
is
collected
specifically/iden;fiable
•
Collect
informa;on
on
contact
screening
•
Collect
informa;on
on
chemoprophylaxis
and
outcome
•
Join
paediatric
research
studies
-­‐
Diagnos;cs
-­‐
TB/HIV
coinfec;on-­‐
test
the
cases
also
in
children
-­‐
be
aware
of
drug
formula;ons
for
children
Join
the

26. Muchas
graçias
de
su
atençión
Hay
preguntas???
b.kampmann@imperial.ac.uk
www1.imperial.ac.uk/medicine/people/b.kampmann