Childhood tuberculosis

Childhood Tuberculosis

Paediatric Tuberculosis Dr. Meely PandaJunior ResidentCommunity Medicine

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CONTENTSINTRODUCTIONKEY RISK FACTORSDIAGNOSISDIAGNOSTIC ALGORITHMTREATMENTWHO GUIDELINES AND RECOMMENDATIONSDRUG RESISTANCECONTACT SCREENINGRESEARCH NEEDS

IntroductionIt is estimated that 1/3rd of the worlds population is infected with Mycobacterium tuberculosis.

Each year, about 9 million people develop TB, of whom about 1.5 million die.

WHO has estimated that around 10% of global tuberculosis case load occurs in children(0-14 years).

Of these childhood cases, 75% occur annually in 22 high-burden countries that together account for 80% of the worlds estimated incident cases.

WHO - World report on tuberculosis.3

IntroductionChildren are also susceptible to the dual epidemic of TB/HIV. HIV-infected children are at 20-times greater risk of TB disease than HIV-uninfected children and at much higher risk of TB-related death.

Most surveys conducted have focused on pulmonary TB and no significant population based studies on extrapulmonary TB are available.

Children can present with TB at any age, but the majority of cases present between 1 - 4 years.

Disease usually develops within 1 year of infection the younger, the earlier and the more disseminated.

Population covered under RNTCP = 254 Lakh(Haryana), 12102(India)No of smear positive cases diagnosed = 25161(H), 953032(I)Annual smear positive notification rate = 81(H), Total pt registered for treatment = 37913(H), 1515072(I)TOTAL drug centres = 463 all over india

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IntroductionPulmonary TB is primarily an adult disease in our country & it has been estimated that 0-19 yr old population contains 7% of total prevalent cases. PTB is usually smear negative.

However often childhood TB is accorded low priority by National TB Control programmes. Probable reasons include:

Diagnostic difficulties Rarely infectious Limited resources Misplaced faith in BCG Lack of data on treatment

Childhood TB prevalence indicatesCommunity prevalence of sputum smear positive pulmonary tuberculosis (PTB) Age-related prevalence of sputum smear positive PTB Prevalence of childhood risk factors for disease Stage of epidemic

Key risk factors

Household contact with a newly diagnosed smear-positive case

Age less than 5 years

HIV infection

Severe malnutrition.

Diagnosis of TB in childrenCareful history (including history of TB contact and symptoms consistent with TB)Clinical examination (including growth assessment)Tuberculin skin testingBacteriological confirmation whenever possibleInvestigations relevant for suspected pulmonary TB and suspected extrapulmonary TBHIV testing (in high HIV prevalence areas)

1. Careful history ContactClose contact is defined as living in the same household or in frequent contact with a source case (e.g. the childs caregiver) with sputum smear-positive pulmonary TB.

History of contact with a suspected or diagnosed case of active TB disease within the last 2 years. Source cases that are sputum smear-negative but culture-positive are also infectious, but to a much lesser degree.

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Careful history

All children aged 04 years and children aged 5 years and above who are symptomatic, who have been in close contact with a smear-positive TB case, must be screened for TB

When any child (38 C for 14 days, after common causes such as malaria or pneumonia have been excluded.

Weight loss or failure to thrive Loss of 5% of the highest weight recorded in the last 3 months.

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2. Clinical examinationNo specific signs clinically, which are suggestive of pulmonary TB.

Physical signs highly suggestive of extrapulmonary TB:Gibbus, non-painful enlarged cervical lymphadenopathy with fistula formation

Physical signs requiring investigation to exclude extrapulmonary TB:Meningitis not responding to antibiotic treatment, pleural effusion, pericardial effusion, distended abdomen with ascites, non-painful enlarged lymph nodes.

3. Tuberculin skin test

A positive TST occurs when a person is infected with M. tuberculosis, but does not necessarily indicate disease.

TST can be used as an adjunct in diagnosing TB in children with signs and symptoms of TB and when used in conjunction with other diagnostic tests.

Mantoux test is the recommended method done with 2 TU of tuberculin PPD RT23.

Results of TST A TST should be regarded as positive as follows:

tbcindia.nic.in14

Importance of the TSTUsed to screen children exposed to TB (e.g. from household contact with TB), though children can still receive chemoprophylaxis even if the TST is not available.Useful in HIV-infected children to identify those with dual TB/HIV infection & as an aid in diagnosis of TB, although fewer HIV-infected children will have a positive TST, as normal immune response is required to produce positive test.It is useful to repeat the TST in children once their nutritional status has improved or their severe illness has resolved, as they may be initially TST negative, but positive after 23 months on treatment. A negative TST never rules out TB in a child.

4. Bacteriological confirmation Bacteriological confirmation is especially important for children who have:suspected drug-resistant TBHIV infectioncomplicated or severe cases of diseasean uncertain diagnosis.

Appropriate specimens from the suspected sites of involvement should be obtained for microscopy and, where facilities and resources are available, for culture.

In addition to increasing the yield of confirmed TB cases, mycobacterial culture is the only way to differentiate M. tuberculosis from other non - tuberculous mycobacteria.

Samples for smear microscopya. ExpectorationSputum should always be obtained in adults and older children (10 years of age or older) who are pulmonary TB suspects.

Among younger children, especially children 6 years

In early 2004, in consultation with Indian Academy of Pediatrics, the recommendations were revised whereby ethambutol was included for treatment of pediatric cases even under 6 years of age.

Haryana is the first state in the country where paediatric Patient Wise Boxes for the treatment of children suffering from tuberculosis (TB) are given under Directly Observed Treatment, Short Course (DOTS) strategy.

The Programme had difficulty in administering the drugs to smaller children as the available formulations needed to be broken up to meet the patients individual weights. To overcome these problems, RNTCP in consultation with IAP, has taken steps to make pediatric drugs available in patient-wise boxes (PWBs) similar to those supplied for adult patients under RNTCP. With the availability of pediatric PWBs, all new pediatric patients diagnosed and registered for treatment under RNTCP, would be initiated on pediatric patient wise boxes. This will enable optimum dosage for the patients, without resorting to further breaking of the tablets, as per respective weight bands.

The new formulations to be used in RNTCP are:

For the purpose of treatment, the pediatric population is divided into four weight bands: Rifampicin 75 / 150 mgIsoniazid 75 / 150 mgEthambutol 200 / 400 mgPyrazinamide 250 / 500 mg6 10 kgs11 17 kgs18 25 kgs26 30 kgs

The anti TB drugs for pediatric patients are available in the form of 2 generic patient wise boxes i.e. Product Code 13 and Product Code 14. Product Code 15 and 16 are available for the prolongation of the intensive phase, if required and also to facilitate conversion of the boxes into Category II and for reconstitution, if required.

Product Code 13 Treatment box 24 Combi - packs in one pouch and 18 multi-blister calendar Combi - pack in another pouch.

Intensive phase H 75mg, R 75mg, Z 250mg, E 200mg2(HRZE)3 to be given under direct observation (thrice a week on alternate days for 2 months - 24 doses).

Continuation phase H 75mg, R 75mg4 (HR)3 blister being directly observed (thrice a week on alternate days : 18 X 3 = 54 doses) 6-10 Kg

Intensive phase drugs are packed as 1 packper dayContinuous phase drugs are packed as per week packs30

Product Code 13 (Yellow)

The intermittent therapy will remain the mainstay of treating pediatric patients. However,Among seriously ill admitted children or those with severe disseminated disease/ neurotuberculosis,the likelihood of vomiting or non-tolerance of oral drugs is high in the initial phase.Such, select group of seriously ill admitted patients should be given daily supervised therapyduring their stay in the hospital using daily drug dosages. After discharge they will be taken on31

Product Code 14 Treatment box 24 Combi-packs in one pouch 18 multi-blister calendar Combi-pack in another pouch

Intensive phase H 150mg, R 150mg, Z 500mg, E 400mg2(HRZE)3 given under direct observation (thrice a week on alternate days for 2 months 24 doses).

Continuation phase H 150mg, R 150mg 4 (HR)3 blister being directly observed (thrice a week on alternate days 18 weeks; 54 doses) 11-17 Kg

Product Code 14 (Orange)

Since, the number of tablets is too many to consume and younger patients have difficultyin swallowing tablets the DOT centers will be provided with pestle and mortars forcrushing the drugs. It will be the responsibility of the DOT provider to supervise theprocess of drug consumption by the child and in case any child vomits within half anhour of period of observation, fresh dosages for all the drugs vomited will be provided tothe caregiver.33

Product Code 15 Prolongation of intensive phase of pediatric cases

Each box containing 5 pouches and each pouch containing 12 blister Combi pack.

The pouch consists of H 75mg, R 75mg, Z 250mg, E 200mg1(HRZE)3 to be given under direct observation thrice a week on alternate days for 1 month -12 doses).6-10 kg & 18-25 kg

Product Code 15 (Purple)

Product Code 16

Prolongation of intensive phase of pediatric cases.

Each box containing 5 pouches and each pouch containing 12 blister Combi packs.

Prolongation Pouch consists ofH 150mg, R 150mg, Z 500mg, E 400mg1(HRZE)3 to be given under direct observation (thrice a week on alternate days for 1 month12 doses).11-17 kg, 18-25 kg & 26-30 kg

Product Code 16 (Grey)

Product Code (PC) 13 and 14

Prolongation of Intensive Phase CATEGORY 1 6 10 kg --- 1 box of PC 13 11 17 kg --- 1 box of PC 14 18 25 kg --- 1 box of PC 13 & 1 box of PC14. 26 30 kg --- 2 boxes of Product Code 14. 6 10 kg -- 1 box of PC 15 11 17 kg -- 1 box of PC 16 18 25 kg -- 1 box of PC 15 & 1 box of PC 16. 26 30 kg -- 2 boxes of Product Code 16.

Cat 1 Cat 22HRZE 2HRZES 1HRZE

4HR 5HRE

2HRZES Add inj. Streptomycin 1HRZE Add prolongation pouch for prolongation of IP for 1 month.5HRE _ For 4 month CP - add prolongation pouch after removing pyrizinamide. 1 Month CP Add Ethambutol tablets from supply of loose drugs.

CATEGORY 2

Use of Pediatric Patient Wise Boxes for under weight adult patients (< 30 Kgs):One adult patient