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Diagnosis, Challenges and Management Dr Mir Anwar MBBS,DCH,MPH(USA)

Paediatric Tuberculosis in HIV Era. Diagnosis, Challenges and Management Dr Mir Anwar MBBS,DCH,MPH(USA) Richmond Hospital,KZN, South Africa. 3 rd SA TB Conference Durban 2012. Overview. Diagnosis of TB in HIV +ve Children Challenges Management of Disease New Developments.

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Diagnosis, Challenges and Management Dr Mir Anwar MBBS,DCH,MPH(USA)

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  1. Paediatric Tuberculosis in HIV Era Diagnosis, Challenges and Management Dr Mir Anwar MBBS,DCH,MPH(USA) Richmond Hospital,KZN, South Africa

  2. 3rd SA TB Conference Durban 2012

  3. Overview • Diagnosis of TB in HIV +ve Children • Challenges • Management of Disease • New Developments

  4. HIV And TB Statistics • 2010 data • 8.8 million new TB cases Globally. • 1.1 million Death (excluding HIV). • ~1.1 million new HIV associated TB cases • 82% living in Sub Saharan-Africa • 350, 000 death • Opportunistic infection • 20-37 times greater when HIV +ive http://www.who.int/hiv/topics/tb/en/ http://www.who.int/mediacentre/factsheets/fs104/en/

  5. Facts and Figures • Deaths Worldwide • HIV: 6000/day • TB: 5000/day • South Africa • TB cases : 4th in the world • Children: 16% of all TB cases • HIV/TB children : 25-60% http://www.who.int/tb/challenges/hiv/facts/en/index.html http://www.pedaids.org/What-We-re-Doing/Foundation-Blog/March-2011/A-Talk-on-Pediatric-Tuberculosis-and-HIV

  6. Diagnosis • Recognizing symptoms • Contact history • Sputum culture • Chest X-ray • Mantoux test • Gastric wash • GeneXpert test- The New Era

  7. Symptoms • Coughing >2 weeks • Chest pain • Weakness or fatigue • Weight Loss> 10% • Fever/Chill • Night Sweat

  8. Recognizing Symptoms • Probable TB • +ive tuberculin skin test >Suggestive chest radiography. ie Lymphadenopathy, pericardial effusion etc. >CT Scan ,ie Chest, Abdomen, brain • Suggestive histological appearance on biopsy material- FNA • Favourable response to TB-specific therapy

  9. Smear –ive TB is too confusing How do we understand it? • Cough for more then 14 days. • Chest pain more then 14 days • Weight loss >10% • Failure to gain weight despite ART • Minimal or No Sputum production

  10. Cont’d • Lymphadenopathy i.e. X-ray • Severe anemia, Hb < 7gm • Signs of extra pulmonary TB • Milliary pattern on chest x-ray • If severe shortness of breath, we will consider PCP first.

  11. Baby born to Mother with TB • If Baby has no TB signs or symptoms • Start with Isoniazide 10mg/kg/day for 6 months. • Once IPT completed, BCG can be given if asymptomatic and HIV- uninfected. • TST can be done on child after 3 months of IPT. • If TST negative and mother smear negative , stop INH & give BCG.

  12. Baby Born to a Mother with TB • If haveing TB signs/Symptoms in Infant • Submission of gastric aspirates and blood for TB culture DST • CXR • Abdominal sonar ( as the liver is often the primary site in congenital TB). • IF TB Diagnosed. • Start Regimen 3 of TB treatment. • Start Fast track for ART if baby is HIV- infected.

  13. Statistics of Smear Negative TB • 1980-1990 • 33-50% HIV +ve PTB patient were smear –ve • Kenya (2003) • 64% HIV +ve patient with proven TB were AFB smear –ive • South Africa (2008) • 26% of patient entering ART had active PTB • 87% were AFB smear –ve even with fluorescent microscopy test.

  14. Cont’d • Smear –ive have high mortality rate even with proper TB treatment • HIV +ive patient have less TB organism in sputum even with low CD4 count. • Limited lab tech and high sample load- smear +ve missed • Ref- TB in ERA of HIV by Jon Fielder

  15. Challenges • Failure to recognizing symptoms • Resource shortage • Lack in education • Adverse drug interaction

  16. WHO Global TB Report

  17. Interpreting Mantoux test

  18. Extra Pulmonary TB in Children • Peripheral Lymphadenitis • Bones and Joints ,spinal TB • Plural Effusion. • TB Pericarditis • Abdominal TB • TB Meningitis • In the late stage HIV TB can be anywhere in the body.

  19. Objective Of TB Treatment • To cure the patient • To prevent death • To prevent relapse • To prevent development of drug resistance • To reduce transmission

  20. Treatment WHO Guideline • should be • treated with a four-drug regimen (RHZE) for 2 months followed by a two-drug • regimen (RH) for 4 months total 6 months. • TBM with HIV needs 9 to 12 months regime. • at the following dosages

  21. Children in High HIV Setting • isoniazid (H) • 10 mg/kg (range 10–15mg/kg) maximum dose 300 mg/day • rifampicin (R) • 15 mg/kg (range 10–20 mg/kg) maximum dose 600 mg/day • pyrazinamide (Z) • 35 mg/kg (30–40 mg/kg) • ethambutol (E) • 20 mg/kg (15-25 mg/kg) http://whqlibdoc.who.int/publications/2010/9789241500449_eng.pdf

  22. Monitoring • Symptom assessment • Adherence and reviewing treatment • Adverse events- LFT’s, haematology rashes, IRIS • Regular follow-ups • Non-response to drugs- MDR TB

  23. How should we manage a child who deteriorates in TB treatment. • Is the drug dose is correct? • Is the child taking the drug as prescribed? (good adherence, including DOT) • Is the child HIV infected? • Is the child severely malnourished? • Is there is a reason to suspect MDR TB? • Has child develops IRIS? • Is there another reason for child illness other than TB, ie Malignancy?

  24. NEWDevelopments

  25. GeneXpert Test • GeneXpert MTB/RIF test • PCR based analysis. • Endorsed by WHO in Dec 2010 for adults • Research being conducted in SA since 2008. http://www.ajol.info/index.php/cme/article/viewFile/72026/60969

  26. Advantages • Provides results in ~90 min • Minimal biohazard • Operation requires little technical training

  27. “If a minister can do it, it can’t be that hard," Health Minister Aaron Moatsoaled.http://www.aidsmap.com/GeneXpert-to-be-rolled-out-as-first-line-diagnostic-for-TB-in-South-Africa/page/1746803/

  28. Can GeneXpert be used for children? • Yes according to WHO ? • if able to produce sputum or if an induced sputum is obtained Gastric Aspiration fluid, Biopsy serous fluid. • Mark Nichol @ U of Cape Town • More effective Vs smear microscopy • Works better in HIV +ve children http://www.nhls.ac.za/assets/files/GeneXpert%20brochure.pdf http://sciencespeaksblog.org/2011/10/26/how-well-does-the-genexpert-rapid-tb-diagnostic-perform-among-children/#ixzz1zzsazJvB

  29. Disadvantages • Cost- • $16 for cartridge/ per test. • Requires uninterrupted electric supply • Requires calibration

  30. Summary- TB in Era of HIV • TB is surging in much of Africa because of the HIV epidemic. • The TB rates are usually higher than what is reported in the public health system. • TB is the number one cause of death in HIV-infected patients in Africa. • TB has usually spread through out the body by the time of death. • The patterns of TB diseases are changing. • TB is a multisystem disease.

  31. Recommendations • Good Record-keeping • Group nutrition counselling • HIV/TB awareness education • Fundraising

  32. Concluding Remarks • HIV/AIDS is the major threat to TB control • TB/HIV rates directly proportional to each other. • Overcoming challenges OUR CHILDREN ARE OUR FUTURE

  33. THANK YOU

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