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Paediatric Tuberculosis in HIV Era: Diagnosis, Challenges, Management

Learn about diagnosing TB in HIV+ children, challenges, management, and new developments in treating paediatric TB in the HIV era according to Dr. Mir Anwar at the 3rd SA TB Conference. Explore key facts, statistics, symptoms, recognitions, and treatment guidelines.

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Paediatric Tuberculosis in HIV Era: Diagnosis, Challenges, Management

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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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