Pediatric TB and child health programming_Gnanashanmuga_5.2.12m

Pediatric TB and Child Health Programming: Woefully Underdeveloped. Why, and What to

Do?

Devasena Gnanashanmugam, M.D.Consultant, CORE Group

Goals of this discussion

• Overview of Childhood TB disease• How TB in children interfaces with other areas• Current challenges• Current recommended action• YOUR SUGGESTIONS

Focused Approach (“TB- centric”)

NCD

Maternal Health

Child Health

Environment

Education

Communicable Diseases

HIV

TB

Malaria

NTDs

Pediatric TB

Poverty

Nutrition Other

Global Health

Infectious Disease Burden

TBChild Health

Pediatric TB

Broad Approach

Malnutrition

Maternal health

Poverty

Education

Pediatric TB: How big is this problem?

• AT LEAST 500,000 cases of TB in children each year (likely more)

• AT LEAST 70,000 deaths each year• About 15% of global TB burden is due to

disease in children (higher & lower in some regions)

• Why don’t we have better data?

Clinical TBPrimary pulmonary infection

Miliary TB/ Meningitis/ other extrapulmonary forms

Primary pulmonary disease

Child

Well Adult

Successful Immune Response

Immunity (live MTB)

Spread by lymph/ blood

Exposure

Adapted from Kampmann 2011

Low bacterial burden

Late Reactivation of pulmonary disease

Higher bacterial burden

Future pool of TB disease

Child vs. Adult TBAdults• Disease develops

after years• Adults less

vulnerable to severe forms

• Disease in adults will manifest later in an epidemic

Children• Develop disease RAPIDLY

(weeks to months) after infection

• Disease can be crippling in children

• Deterioration in TB control impacts the youngest generation first

What is the same:• INH preventive therapy (IPT) can be given to prevent disease those who are

infected• Treatment is still many months of 4 (then 2) drugs

Childhood TB Neglected

“Pediatric TB is a public health dead end.”– Sentinel event: reflects recent infection &

transmission in the community – Window on transmission dynamics– Harbinger of future epidemics – Indicator of the effectiveness of control efforts

Childhood TB Neglected

“Treating adults with TB is enough to control TB in children”– Future reservoir of disease predicts the future global

TB burden– After transmission is over, treating adults is not helpful– Improving treatment in children largest impact on

disease control in children– Reducing long term trends of global TB must account for

disease in children – Millions of children would become sick while we wait

for adult TB control

Child Survival & TB

Mortality• 2nd leading cause of

death in Kolkata slum

• TB control decreases <5 yr mortality

TB?

Pneumonia• 8-15% of pneumonia

may be TB• Autopsies: 18-25%

pneumonia deaths

TB causes 6-15% of all maternal mortality

TB is a leading infectious cause of death in women.

TB in pregnant women increases HIV transmission

to the baby

Newborns of women with TB are at high risk of contracting

TB

HIV/TB infected women are twice as likely to die than HIV

infected women without TB

Babies born to HIV/TB infected women are

more likely to die than those of HIV women

without TB

Maternal Health & TB

Malnutrition predisposes to TB & makes TB worse

TB looks like malnutrition and makes malnutrition worse

• TB: 12-30% of cases of malnutrition

• TB: a catabolic process wasting (before diagnosis)

• TB Rx results in weight gain & improves nutritional states

• Malnutrition treatment guidelines to emphasize diagnosis of HIV + TB • Supplemental

nutrition improves health in TB patients

• Supplemental nutrition for TB programs could reduce incidence of active TB

Increased wasting results

in increased mortality

Malnutrition & TB

TB fuels poverty

Strongest risk factor for

childhood TB

Those treated for TB fall deeper into

poverty

TB left 10 million children orphaned

in 2010

Children no longer educated

Loss of family members

Children more susceptible to

TB

Close contact with infectious people

Overcrowding Poor nutrition

MEN: can no longer work and contribute to the

family

WOMEN: unable to care for children

Family cannot afford school fees/ uniforms

Children need to work to assist families

Risk of active TB is 5- 20x higher in

HIV infected children

More than 1/3 HIV infected children will die of TB compared

to <10% of HIV negative children

Risk of death due to TB is 5-6x more in

HIV infected children.

Youngest children have

highest mortality

TB is more difficult to diagnose in HIV infected children

Children with HIV & TB

Disaster Management

Converging epidemics

HIV

Malnutrition TB

Less than 5 years

old

Science

• Union Child Health Lung Section

• STOP TB Childhood TB subgroup

• CDC• WHO TB

website

Policy

• WHO guidance for NTPs

• WHO Rapid Advice on Treatment of TB in children

• UNION Desk guide

Practice…

- National programs to integrate pediatric guidances

- Research to develop more tools

Where are we now?

R&D challenges and needs

Challenges• BCG vaccine is poor• Diagnostic tests do not

detect disease reliably in children

• Pediatric drug formulations are lacking

• Children are not included in clinical trials

Needs• Better vaccine• Child appropriate

diagnostics• Child friendly

drugs• More clinical &

operational research

What can we do now?

• Perform contact investigation in all children exposed to TB

• Provide IPT to those <5 yrs who meet criteria

“Simple changes in detection and treatment of children with TB exposure and infection could save millions of lives.” J. Starke

Other items on the wish list

• Provide more data on scale and scope of disease• Provide family centered care, including household

focused case investigation• Integrate TB care within IMCI• Increase awareness building and advocacy to policy

makers, practitioners, scholars & donors• More training & knowledge building on childhood TB• Integrate TB services into existing MCH programs• Increased community level programming

Programs that have worked

• Indus Hospital, Pakistan (TB REACH/ STOP TB partnership grant)– Strengthened PPM– Approached CHWs & GPs to increase case detection– Used cash, training certificates, free diagnostic tests & free Rx as incentives– Used mobile technologies to increase case detection– Increased notification of children by 500%

• Dhaka, Bangladesh (Damien Foundation)– Community based screening of pediatric TB– CHWs & other clinicians trained to detect S/S of TB & make referrals– Community awareness building– Logistical support– Increased case detection in children 3x baseline levels

• MSF programs

• OperationASHAhttp://www.coregroup.org/our-technical-work/working-groups/tuberculosis/pediatrictb

Practical Examples of Action Items • Create & disseminate community education materials about pediatric

TB• Within MCH program, design and integrate educational materials and

systems designed to help prevent mother-to-child transmission of TB • Adapt a pediatric TB screening tool to support community-level case

finding and referral. • Within an IMCI, immunization or other child health effort, add

education and linkages related to childhood TB. • Add household TB contact tracing component to community health

portfolios• Advocate for government health service adoption of WHO guidelines

regarding pediatric TB (This is especially important in high HIV settings)

• Address the problem of TB and stigma, specifically in relation to children.

Your suggestions & comments…