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Seminar-1.pptx
1. Welcome to seminar
Dr. Shewly Das
Assist. Registrar
&
Dr. Farjana Yasmin
DCH students of Dr. MR Khan
Shishu Hospital and ICH
Presented By-
2. Case Scenario
A 7 month old male child got admitted
to our hospital with the complaints of-
• Fever and cough for 2 months
• Respiratory distress for 7 days
• H/O taking broad spectrum
antibiotics for last 14 days.
On Examination-
• Baby was dyspneic, mildly pale
• Increased vocal fremitus &
resonance with bronchial breath
sound in rt upper & middle lobe of
lung
9. Global scenario
New cases- 10.6 million
Children-1.2 million
People died -About 1.6 million.
13th leading cause of death
Worldwide 230,000 children and
In South East Asia 99,040
children under 15 years died of
TB in 2019.
12% were children (<15 years.
Ref: WHO report 2021
10. TB in children-National Concern
Ref: Global TB report
2020
High burden TB countries-30
7th position .
Incidence : 221/lac
Mortality : 24/lac
MDR-TB : In new case- 0.7%
In re-treatment case- 11%
11. ▪ High burden TB countries-30
▪ 7th position .
▪ Incidence : 221/lac
▪ Mortality : 24/lac
▪ MDR-TB : In new case- 0.7%
In re-treatment case- 11%
Bangladesh TB scenario
Ref: Global TB report 2020
12.
13. • Total population- 164.69 million
• Child (<15 yr)-44.14 million (26.8%)
• Total TB cases : 361000
• Child TB : 43320 (12%)
• Highest in Dhaka division and the
lowest number from Barisal.
Ref: Global TB report 2020
Bangladesh Child TB Situation
14. Tuberculosis is an airborne infectious disease
Caused by Mycobacterium Tuberculosis species
Definition
15. M. Tuberculosis is a complex consists of
genetically related species, which includes-
•M. Tuberculosis
•M. Bovis
•M. Microti
•M. Africanum
•M. Canetti
16. Ziehl-Neelsen stain
non–spore-forming,
nonmotile,slightly curved Acid fast
rods
1-5 µm long
Obligate aerobe
Usually found in the well-aerated
upper lobes of the lungs
Slow generation time of 15-20
hours
Thick cell wall due to presence of
Mycolic acid
Virulence factor:
• Exported repetitive protein
• Cord factor
Characteristics of M. Tuberculosis
Culture-
• L-J media
• BACTEC media
18. Mode of
spread to other
part of body
Haematogenous
spread
Lymphatic
spread
Direct
extention
19. Close contact with TB person
Age < 5 years
Immunosuppressive condition-
Measles, HIV, Drugs
SAM
Overcrowding and low
socioeconomic condition
Risk factors for Childhood TB
21. Inhalation of TB bacilli
Entering into lung
M. TB resists phagocytosis by prevention of forming
phagolysosome and remain protected inside the macrophage
Multiplication of bacilli inside the macrophage
Pathogenesis
22. Activation of cell mediated immunity and formation of
granuloma
Leads to formation of primary foci or ghon foci
Draining of the bacilli into the hilar lymph node
Formation of primary/ghon complex
Continue…
27. • After entry to the terminal bronchiole the TB
bacilli multiply and
• Form sub pleural granulomatous lesion.
Primary Focus / Gohn focus-
• Ghon focus and hilar lymphadenopathy
together called primary or ghon complex.
Primary complex/ Ghon complex –
Definition
29. The histopathological hallmark of tuberculosis is
Granuloma. Granuloma is a focal collection of
inflammatory cells in which mononuclear cells
predominate. Macrophages predominate in the centre
attempting to phagocytose the mycobacteria. Activated
macrophages form epitheloid cells characterized by pale
eosinophillic cytoplasm. This is called Epitheloid cell
granuloma. Caseation necrosis is seen in the centre of
the granuloma.
29
32. TB bacilli in human body
TB Infection TB disease
• inhales droplet nuclei
• survive intracellularly within
the lung and associated
lymphoid tissue
• + TB Skin Test
• Not infectious
• No symptoms
• Bacteria- Dormant
• +/- TB Skin Test
• Infectious (possibly)
• Symptomatic (possibly)
• Bacteria- Multiplying
• CxR-Abnormal
Immunity compromised
Immunity not compromised
Difference between TB infection and
TB disease
33. Exposure
• significant contact (shared the air) with an adult or
adolescent with infectious tuberculosis
• but lacks proof of infection.
• an infected child <1yr old has a 40% chance of
developing TB disease within 9 months
d
34. Natural history of untreated TB
Time of
Infection
Manifestations
3-8 weeks Primary complex
Positive tuberculin skin test
3-6 months Meningeal, Miliary & Pleural disease
Due to hematogenous spread or direct
spread from en enlarging primary focus
Up to 3years Gastrointestinal, Bones ,joints and lymph
node disease.This stage lasts until primary
complex resolves.
Around 8 years Genitourinary tuberculosis
35. 35
Sequelae of
bronchial
complications
Stricture of bronchus
at site of erosion
Cylindrical
bronchiectasis in area
of old collapse
Wedge shadow:
contracture & fibrosis
of segmental lesion
Linear scar of fibrosis
following segmental
lesion
36. 36
Complications of
regional nodes
. Incomplete (ball-
valve) bronchial
obstruction,
emphysema of middle
& lower lobes
Complete bronchial
obstruction, collapse
of right lower lobe
Erosion of node into
bronchus & segmental
consolidation
. Rupture of node into
pericardium:
tuberculous pericardial
effusion
38. • Any person who has been exposed to an index
case.
Contact:
• Person of any age
• With new or recurrent TB in a specific
household
• In which others may have been exposed.
Index Case:
39. • A person who is not in the household
• Who shared an enclosed space with the index case
• For extended daytime periods
• During the 3 months before the start of the current
treatment episode.
Close contact:
• A person who shared the same enclosed
living space as the index case
• For one or more nights or for frequent or
extended daytime period
• During the 3 months before the start of current
treatment episode.
Household contact
40. • Presents with symptoms or signs suggestive of
TB.
Presumptive TB
• A biological specimen is positive by smear
microscopy or
• Culture positive or
• Xpert positive for M. tuberculosis.
Bacteriologically confirmed case
41. • Does not fulfill the criteria for
bacteriological confirmation or
smear not done but
• X-ray abnormalities or
• suggestive histology or
• extrapulmonary cases without
bacteriological confirmation
• Having S/S of TB confirmed by
physician.
• decided to have a full course of
anti-TB treatment
Clinically diagnosed TB case
43. Anatomical site of disease
History of previous treatment
Drug resistance
HIV status
Classification of TB
Bacteriologically confirmed or clinically diagnosed
TB cases are further classified according to -
44. According to anatomical sites of the
disease
Bacteriologically confirmed or clinically diagnosed cases of TB involving the
lungs or extra pulmonary sites should be classified as following
45. • Tuberculosis of the lungs and
tracheobronchial tree. Most common form of
TB and occurs in about 80% of cases.
➢ Pulmonary TB
• TB in any part of the body other than lungs-
such as bones, glands, pleura, lymph nodes,
spine, joints etc. It accounts for about 30% of
TB in children
➢Extra-pulmonary TB
According to anatomical sites of the
disease
,
46.
47. • A patient who has never received anti-TB drugs
or Received anti-TB drugs for < 1 month.
New case
• Patient who received 1 month or more of anti TB
drugs in the past.They are subclassified on the
basis of their most recent course of treatment.
Treatment after failure
Treatment after loss to follow up
Relapse
Treatment completed
Other previously treated
Previously Treated patient
According to treatment history
50. Symptom criteria for PTB
Persistent, non-remitting cough for >2 weeks not responding to
conventional antibiotics(amoxicillin, co-trimoxazole or
cephalosporins) and/or bronchodilators
and/or
Persistent documented fever (>38°C/100.4°F) >2 weeks after
common cases such as typhoid, malaria or pneumonia have
been excluded
and/or
Documented weight loss or not gaining weight during the past
3 months (especially if not responding to de-worming together
with food and/or micronutrient supplementation) or severe
malnutrition
and/or
Fatigue, reduced playfulness, decreased activity
51. S/S by Age Distribution
Clinical features Infants
(0-11)mo
Children
(1-9yr)
Adolescent
(10-19)yr
Symptom
Fever Common Uncommon Common
Night sweats Rare Rare Uncommon
Cough Common Common Common
Productive cough Rare Rare Common
Haemoptysis Never Rare Rare
Dyspnea Common Rare Rare
Signs
Crepitations Common Uncommon Rare
Wheezing Common Uncommon uncommon
Fremitus Rare Rare Uncommon
Dullness to percussion Rare Rare Uncommon
Decreased breath sound Common Rare Uncommon
57. • Raised red nodule at the
junction of the sclera and
cornea
• Surrounded by a red area of
conjunctivitis.
Phlyctenular conjunctivitis –
• Raised, tender, purple patches
on the skin.
Erythema nodosum –
Uncommon signs indicative of
recent TB infection
58. Congenital TB
Symptoms
At birth no symptoms except LBW.
Usually manifest at 2nd-3rd week of
life.
Nonspecific symptoms (respiratory
distress, pallor, fever, growth failure,
ear discharge, lethargy, irritability) born
to a mother suffering from
tuberculosis.
Newborn suffering from persistent
pneumonia or fever and
hepatosplenomegaly and peripheral
lymphadenopathy.
Transmission
It usually occurs in two
way-
1. Trans-placental through
umbilical vein causing
primary complex in liver
2. Aspiration/swallowing of
infected amniotic material
during birth process or in
utero
63. Challenges in Diagnosing TB in
Children
1.Symptoms are non-specific in young children.
2.Childhood TB is paucibacillary.
3.Difficulty in obtaining sputum.
4.MT or TST is often negative in malnourished
children.
5.X-rays are non specific and variable
interpretation.
64. How to diagnose a case of TB
Careful history
Clinical assessment
Investigations
• Mantoux test
• Chest X-ray and other radiological
evaluation
• Bacterial confirmation whenever possible
• Investigations relevant to suspected
PTB/EPTB
• HIV testing
65. • Severe respiratory distress
• Severe wheezing not responding to bronchodilator
• Headache,vomiting, irritability, drowsiness, neck
stiffness and convulsions
• Acutely ill with hepatosplenomegaly and ascites
• Breathlessness and peripheral oedema
• Acute angulation of the spine with/without
paraplegia
• Other co-morbidities e.g. severe anemia, severe
malnutrition
Danger signs requiring urgent
hospitalization
66. Clinical criteria :
The presence of 3 or more of the following features
suggests a diagnosis of TB:
Symptom criteria suggestive of TB
A history of recent close contact (within the past 12
months)
Physical signs highly suggestive of TB
A positive Mantoux test
Chest X-ray suggestive of TB
Special laboratory test- CSF, Histopathology
67. Diagnostic Tests-TST
It’s a delayed type of hypersensitivity reaction.
A Positive TST only indicates infection with M.Tuberculosis.
A negative MT does not exclude TB exposure, infection or disease.
Interpretation of MT should be done irrespective of previous BCG
vaccination
Dosage : 5 TU of tuberculin PPD
R/A: Intra-dermal
Site : Inner aspect of the left forearm.
Mechanism :T cells sensitized by prior infection are recruited to the
skin, where they release lymphokines that induce induration through
local vasodilation, edema, fibrin deposition, and recruitment of other
inflammatory cells to the area.
69. Mantoux TST
A TST should be regarded as “positive” as follows:
High-risk children: TST ≥5mm induration
Close contact to person with active PTB
HIV-infected children
Severely malnourished children, immunesuppression
Chest X-ray consistent with active or previously TB disease
All other children: TST ≥10mm
Children <4 yr old
Children with other medical conditions including Hodgkin disease, lymphoma, diabetes
mellitus, chronic renal failure or malnutrition(whether or not they have been BCG
vaccinated)
Increased exposure to tuberculosis disease
In children ≥4 yr old without any risk factors ≥15 mm
69
71. Diagnostic Tests-CXR
Commonest radiological presentation: Increased hilar
density.
Widened Mediastinum due to mediastinal lymphadenopathy.
Persistent opacity in the lung field
Less common radiological presentation:---*Compression of
the airway due to enlarged LN
segmental or lobar hyperinflation,
-collapse of a lung segment or lobe
*Miliary pattern of opacification
*Unilateral PE
75. Diagnostic Tests-Bacteriological
confirmation
Common ways of obtaining samples for smear
microscopy include the followings:
Expectoration
Sputum Induction
Gastric Aspiration
Nasopharyngeal aspirate
Bronchoalveolar lavage (BAL)
Fine Needle Aspiration Cytology (FNAC)
76. Smear microscopy by Z-N stain
Culture in L-J media and BACTEC
media
Xpert MTB/ RIF
Xpert MTB/ RIF Ultra
Line Probe Assay (LPA)
Bacteriological confirmation
83. Advantages Limitations
• Provide rapid result
in 2 hours versus 4-6
weeks by culture
• Specificity – high,
• Sensitivity-98%-99%
• Gives direction of
MDR
• Early detection of
EPTB
• Cannot
differentiate dead
and live bacteria.
Continue…
84. Diagnostic Tests-Bacteriological
confirmation
Topic Xpert MTB/Rif Xpert MTB/Rif Ultra
Cartridge and
Software
Conventional Updated cartridge and
improved software
DNA PCR
reaction chamber
25 μL 50 μL
Assay TAT 112 minute 65-87 minute
Limit of
detection
114-131 bacterial
CFU/mL
16 bacterial CFU/mL
Rif Resistance
Detection
Less detection of silent
Rif mutation
Improved differentiation
of certain silent Rif
mutation
85. Diagnostic Tests-Culture
Collection of specimens for culture
should be considered where facilities
are available.
TB culture is of particular value in
complicated cases or when there is a
concern regarding drug resistance.
Probability of obtaining a positive
TB culture improves when more
than one sample is taken; at least 2
samples.
86. IGRA (Interferon gamma release
assay)
86
T-SPOT & TBQuantiFERON-TB
Quantiferon TB Gold: detect IFN-γ
generation
most well-known
Uses specific MTB antigens to stimulate
primed patient's T cells
They release inflammatory protein:
interferon gamma
IGRA antigens are more specific to MTB
Not shared with NTM or BCG vaccine
T-SPOT: detects the number of
lymphocytes/monocytes producing IFN-γ.
87. Tuberculosis diagnosis research laboratory
• NTRL national institute of Diseases of Chest &
Hospital (NIDCH) Mohakhali, Dhaka.
• RTRL, Chest Disease Hospital, Rajshahi.
• Chest Disease Clinic, Shyamoli, Dhaka.
• RTRL, General Hospital Chittagong
• TB-Leprosy Project Hospitals, Netrokona,
Mymensingh & Tangail Damien Foundation
87
89. Line Probe Assay (LPA)
Polymerase Chain Reaction (PCR)
based technology used for detecting
the presence of putative resistance
genes.
The first line LPA (FL-LPA) can detect
resistance to rifampicin and isoniazid.
The second line LPA (SL-LPA) can
detect resistance to Fluroquinolones
and second line injectable drugs
within 1-2 days.
Only smear positive samples can be
subjected.
Smear negative samples need to be
inoculated on culture (Solid / Liquid)
and the growth subjected to DST on
90. Site Practical approach to dx
Peripheral lymph nodes Lymph node biopsy or FNAC
Miliary TB /disseminatedTB CXR,CSF study(to exclude
meningitis)
Tubercular meningitis CSF study(CT scan if available)
Tuberculoma of brain CT scan/MRI
Abdominal TB Abdominal ultrasound, Ascitic fluid
TB arthritis/Oste-
articularTB
X-ray,Joint fluid study or Synovial
biopsy
Pericardial TB CXR, Echocardiography,
Pericardial tap Pericardial biopsy,
Histopathology
TB, all forms MT and CXR
Sites and diagnostic approach for common
forms of EPTB in children
91. Diagnostic Tests-HIV testing
In areas with lower HIV prevalence like
Bangladesh, HIV counseling and testing is
indicated-
• For TB patients with symptoms and/or
signs of HIV-related condition
• In TB patients having a history
suggestive of high risk HIV-exposure.
94. Treatment of Tuberculosis in
children
Objectives of Anti-TB Treatment
1. To cure the Child from Tuberculosis
2. To prevent complications of disease progression
3. To reduce morbidity and mortality
4. To prevent relapse of TB
5. To render the patient non-infectious, break the
chain of transmission and decrease pool of infection.
6. To prevent the development of acquired drug
resistance.
95. Recommended treatment
regimens
Anti-TB treatment is divided into two phases:
• To achieve rapid killing of
actively multiplying bacilli and
• To prevent drug resistant.
1.
Intensive
phase
• To eliminate the remaining
bacterial population.
2.
Continuation
phase
97. First-line anti-TB drugs
Description Drug
Oral drugs
Isoniazid H
Rifampicin R
Ethambutol E
Pyrazinamide Z
Rifabutin Rfb
Rifapentine Rpt
Anti-Tubercular Drugs Classification
98. Second-line anti-TB drugs
Groups Drugs Abbreviation
Group A:
Include all three
medicines
Levofloxacin / Moxifloxacin Lfx/Mfx
Bedaquiline Bdq
Linezolid Lzd
Group B:
Add one /both
Clofazimine Cfz
Cycloserine OR Terizidone Cs/Trd
Group C:
Add to complete the
regimen and when
medicines from Groups
A and B cannot
be used
Ethambutol E
Delamanid Dlm
Pyrazinamide Z
Imipenem-cilastatin / meropenem Ipm–
Cln/Mpm
Amikacin (OR streptomycin) Am/(S)
Ethionamide / Prothionamide Eto/Pto
Continue…
99. Treatment regimens for children
in each TB diagnostic category
Status/ setting TB cases Regimen
IP CP
Low HIV
Prevalence
and Low INH
Resistance
● Smear negative pulmonary TB
● TB lymph node (intrathoracic
and peripheral)
2(HRZ) 4(HR
● Smear positive pulmonary TB
● Extensive pulmonary disease
Severe EPTB (except TBM and
Osteoarticular)
2(HRZE) 4(HR
Any status/
setting
● TB meningitis
● Osteoarticular TB
2(HRZE) 10(H
100. Recommended daily dosages of
1st line anti-TB drugs
Drug Daily dose and range (mg/kg
body weight)
Isoniazid (H) 10 (07-15) [maximum 300mg]
Rifampicin (R) 15 (10-20) [maximum 600mg]
Pyrazinamide (Z) 35 (30-40) [maximum 2000mg]
Ethambutol (E) 20 (15-25) [maximum 1200mg]
Regular weight-based dose adjustment is
important, particularly in young and/or
malnourished atleast after 1, 2, 3 months
consequitively (or at a lesser interval when
necessary) and at 6 month .
101. Fixed-dose-combinations (FDC)
for children
child-friendly (dispersible and flavoured)
FDC tablet New FDC Previous FDC
3 FDC R75, H50, Z150 R60, H30, Z150
2 FDC R75, H50 R60, H30
Children ≥ 8 years and/or ≥ 25 Kg are routinely
treated as adults regimen
*Child-friendly (dispersible and Mango
flavoured)
102. Weight
Bands
(Kg)
Number of Tablets
Intensive Phase Continuation
Phase
RHZ(mg) E(mg) RH(mg)
75/50/150 per tablet 100 per tablet 75/50 per tablet
2-3.9 ½ ½ ½
4-7 1 1 1
8-11 2 2 2
12-15 3 3 3
16-24 4 4 4
25+ Go to adult dosages and preparations
Weight Band Table For using Available FDCs
103. Anti-TB treatment-Pyridoxine
Dose: 12.5 mg/day for children 5 to11 years of
age and 25 mg/day for children ≥12 years.
Along with
isoniazid
•HIV infected children on HAART,severely
malnourished children,chronic liver disease
& liver failure
Recommend
• Not in general treatment initiation plan.
• If any child after treatment
• shows symptoms of neuropathy,
• then it is recommended to include
sev
ma
HA
fail
104. 1
• CNS TB including TB meningitis
2
• TB pericarditis
3
• Adrenal TB
Dose: Prednisolone- 2-4 mg/kg/day (max. 60mg) for 4 weeks- then
tapered over 1-2 weeks.
Indications for oral steroids
105. Follow up after Treatment
Phase of
Treatment
Sputum Smear
Exam. at
If Smear
Negative
If Smear Positive
Intensive
Phase (IP)
End of Month 2 Start Pt on
CP
Test on Xpert MTB/RIF.
• If Rif Sensitive, start Pt. on
CP
• If Rif Resistant, declare
Treatment Failure
and start DR TB management
protocol
Continuation
Phase (CP)
End of Month 5 Continue
CP
Declare Treatment Failure and
evaluate for
drug resistance. Manage
accordingly
End of Month 6 Declare
cure
106. Directly observed treatment, short
course (DOTS)
DOT means that an observer watches
the patient swallowing their drugs.
This ensures that a patient takes
Right anti-TB drugs,
In the right doses,
At the right interval and
Right period of time.
108. DRUG-RESISTANT TB
Features in the source
case :
Contact with a known case
of drug-resistant TB
Remains sputum smear-
positive after 3 months of
treatment
History of previously
treated TB
History of treatment
interruption.
Features of a child :
Contact with a
known case of drug-
resistant TB
Not responding to
the anti-TB
treatment regimen
Recurrence of TB
after adherence to
treatment
Drug resistant TB is a laboratory diagnosis (Based on drug
susceptibility test (DST) or Phenotypic/Genotypic test).
110. Drug resistant (DR) TB
Definations
Mono-
resistance
Refers to resistance to one first line anti-TB drug
only.
Poly resistance Refers to resistance to more than one first-line anti-
TB drug other than isoniazid and rifampicin
together
Rifampicin-
resistantTB(RR-
TB):
Refers to resistance to rifampicin detected using
phenotypic or genotypic methods.
Isoniazid-
resistant TB(Hr-
TB)
Refers to Mycobacterium tuberculosis strains in
which resistance to isoniazid and susceptibility to
rifampicin has been confirmed in vitro.
Active tuberculosis disease caused by MTB bacilli that are
resistant to one or more anti-TB medicines;
111. Drug resistant (DR) TB
Multidrug resistance(MDR) Refers to resistance to at least
isoniazid and rifampicin, the two
most potent anti-TB agents, with
or without resistance to other first
line drugs.
MDR TB with
Quinolon resistance
Refers to MDR TB with additional
resistance to moxifloxacin or
levofloxacin.
Extensive drugresistance (XDR) Refers to MDR TB with additional
resistance to moxifloxacin or
levofloxacin and to one of two
113. Treatment of child DR TB
The duration of treatment in children depends
upon the site and severity of disease.
Children with non-severe disease :
9 to 11months
Children with severe disease :
12-18 months
(depending on their clinical progress)
115. MDR/
RR-
TB
Sensitive to
2nd line Anti
TB drug
(STR)
IP
(4 - 6) Bdq(6 m)-Lfx-
Cfz-Z-E- Hhigh dose-E
CP 5 Lfx-Cfz-Z-E
Resistant to
2nd line Anti
TB drug
(LTR)
Quinolone
susceptible
IP 6(Bdq-Lzd-Lfx-Cfz-Z)
CP 14(Lzd-Lfx-Cfz-Z)
Quinolone
resistant
IP 6(Bdq-Dlm-Lzd-Cfz-Z-
Cs)
CP 14(Lzd-Cfz-Z-Cs)
Rifampicin resistance TB
Treatment Regimen:
<3 years (FLQ-R): Lzd-Cfz-
Add one of Dlm, PAS or Et
Additional drugs if needed
(FLQ-S): Lfx-Lzd-Cfz-Cs
Additional drugs if needed
Dlm, PAS and Eto
<6 years (FLQ-R): Lzd-Cfz-
Cs-Dlm; Additional drugs
needed PAS and Eto
(FLQ-S): Lfx-Lzd-Cfz-Cs
Additional drugs if needed
Dlm and PAS
>6 years (FQ-R): Bdq-Lzd-
Cfz-Cs Additional drugs if
needed Dlm and PAS
(FQ-S): Bdq-Lfx-Lzd-Cfz
Additional drugs if needed
Cs and Dlm
116. Grouping of medicines recommended for use in longer
MDR-TB regimens
Group A (include all 3 medicines) 1. Levofloxacin OR Moxifloxacin
2. Bedaquiline
3. Linezolid
Group B (include one or both medicines) 1. Clofazimine
2. Cycloserine OR Terizidone
Group C (add to complete the regimen
when drugs from group A and B cannot be
used)
1. Ethambutol
2. Delamanid
3. Pyrazinamide
4. Imipenem–Cilastatin OR
Meropenem
5. Amikacin (OR Streptomycin)
6. Ethionamide OR
Prothionamide
7. P-Aminosalicylic Acid
117. Follow up
2 weeks after the start of treatment
At the end of the intensive phase
Every 2 months until completion of treatment
Assessment:
Symptom assessment
Assessment of treatment adherence
Enquiry about any adverse events
Weight measurement
120. The most important questions to answer are
•Is the drug dosage correct?
•Is the child taking the drugs as prescribed ?
•Is the child HIV-infected?
•Is the child severely malnourished?
•Is there a reason to suspect drug-resistant TB?
•Is there another reason for the child’s illness
other than TB?
Causes of deterioration during TB Rx
121. • Completion of treatment course,
• No evidence of failure,
• Smear result negative at the end of treatment and at 5
month
Cured
• Full course treatment,
• No evidence of failure and
• No bacteriological evidence/documentation of cure
Treatment Completed
Treatment outcome of TB patients
122. • Whose treatment regimen needed to be
terminated or
• Permanently changed to a new regimen
Treatment failure
• Did not start treatment or
• Treatment was interrupted for 2
consecutive months or more.
Lost to follow up
Treatment outcome of TB patients
125. If the baby is
symptomatic
The baby needs to be
referred to hospital for
evaluation to exclude TB
If the baby is diagnosed
as TB, the baby should
receive a full course of
TB treatment.
If the baby is
asymptomatic
Withhold BCG at birth and
give BCG 3 month after
completion of 3RH therapy
If symptoms develop in
between, the baby needs to be
referred to hospital for
evaluation to exclude TB.
Mx of A baby born to a mother or
other close contact with TB
129. APPROACH TO CONTACT MANAGEMENT WHEN CHEST X-
RAY AND TST ARE NOT READILY AVAILABLE
130. The 4HR regimen had a higher completion
rate than the 9H regimen with comparable
safety in children & it is possible to prevents
progression to TB disease in more patient.
131. Treatment Options For LTBI
Regimen Age group Drugs Administration Dose
3HP >15 years (All
adult)
Isoniazid
300mg/Rifapentin
300mg
Weekly dose for
12 weeks/3
mont
3 tabs p
day
3HR <10 years age
Group
Rifampicin
75mg/Isoniazid
50mg
Daily dose for
90 days/3
months
5 tabs p
day
3HR >10 to <15
years child
Rifampicin
150mg/Isoniazid
75mg
Daily dose for
90 days/3
months
3 tabs p
day
INH-
300mg
All adult Isoniazid 300mg Daily dose for
180 days/6
1 tab pe
day
132. BCG means Bacillus-
Calmette –Guerin. It is a
live attenuated vaccine.
BCG is not fully
protective against TB
Give some protection
against severe forms of
TB:
▪73% in TB meningitis
▪77% in miliary TB
BCG Vaccination
133. TB infection control
• Early diagnosis and treatment of TB cases.
• Identify potential and known infectious
cases of TB.
• Provide health education about TB
transmission.
• Encourage proper cough hygiene.
• Ensure natural and/or cross ventilation and
sunlight.
134. TB infection control
• HCWs/ care givers should be screened out
if symptomatic.
• Personal protection of health care workers.
• Prompt recognition and treatment of TB
patients at community settings.
135. COVID-19 and its impact on TB
• COVID-19, typically affects the lungs and people
affected by it may show symptoms similar to TB.
• The lung damage and compromised immunity
caused by TB may render more vulnerable to get
severely ill with COVID-19.
• COVID-19 could potentially, derail all progress
made by the NTP .
• As a result 12% excess cases and up to 19%
additional deaths may take place between 2020-
2025.
137. Drugs classification
Previously
• There were 4
1st line drugs
• There was no
subgroup in 2nd line
drug
Now
• Rfb & Rpt are added
as 1st line drug
• 2nd line anti TB drugs
are subgroupd as A,
B & C
138. Sputum specimen
Now
2 sputum sample are
collected
“On the spot ”-1st
specimen
Early morning
sample- 2nd
specimen
Previously
At least 3 sputum
samples were
collected
At least one being
on early morning
specimen
139. Isoniazid Preventive Therapy (IPT)
Previously
6 months isoniazid
therapy used as IPT
Child < 5yrs
Immunocompromised
children
Baby born to infected
mother
Now
It is recommend
only for PLWHIV
140. Baby of infected mother
Previously
Asymptomatic
child of a mother
with active TB-
IPT for 6 months
Now
Asymptomatic
child of a mother
with active TB-
Isonizid &
Rifampicin for 3
months (3RH)
142. New term: severe disease
● Cavities
● Bilateral disease on chest radiography
● Extra pulmonary forms of disease other than
lymphadenopathy
● Advanced malnutrition
● Advanced immunosuppression
143. Registration/notification with
NTP:
Notification of TB patient has been made
mandatory by the Government of Bangladesh
in January 30, 2014 through a official order.
Recording and reporting of Child-TB patient
should be maintained according to 6th
edition DS-TB guideline
NTP has developed an App-based notification
through mobile of TB cases- Janao, with
support from ICDDR,B and USAID.
Editor's Notes
3rd cause brain tumors in children developing countries
1,which is essential for completion of treatment and recovery from TB.
