TB is a leading killer of children, yet they remain utterly neglected

Finding the most neglected:identifying and treating more children with TB

TB is a leading killer of children, yet they remain utterly neglected.TB is a top 10 cause of death in children. Each year more than 500,000 children suffer from TB and 74,000 die.

Clemax Couto Sant´Anna, MD, PhDNTCP Brazil, Advisory Committe

Actions to improve TB careWHO and the Stop TB Partnership point to 3 key actions needed to improve TB care and prevent

TB deaths in children

PREVENTION: Tuberculin skin testing & IGRAS

PNCT. MS- Brazil, 2014

TST IGRAS

Easy training Yes NoCan be used in serial tests (repeated tests) – PLWHA contacts, health professionals

Yes No

Evidence of benefit of IPT among positive TST people Yes ??Needs 1 visit for result - lost cases

No Yes

Lab is not necessary Yes No

“Indetermined” results No Indetermined (~2%) results; in a Brazil study : 27%

PREVENTION: Tuberculin skin testing & IGRAS

Tub TST IGRAS

Easy training Yes No

Can be used in serial tests (repeated tests) – PLWHA contacts, health professionals

YesNo

Evidence of benefit of IPT among positive TST people Yes

??

Needs 1 visit for result - lost cases No Yes

Lab is not necessary Yes No

“Indetermined” results No Indetermined (~2%) results; in a Brazil study : 27%

Extent and Effects of Recurrent Shortages of

Purified-Protein Derivative Tuberculin Skin Test

Antigen Solutions — United States, 2013.

Weekly. December 13, 2013 / 62(49);1014-1015

IGRAs should not replace the TST in low-and middle-

IGRAs should not replace the TST in low-and middle-income countries for the diagnosis of LTBI in children

income countries for the diagnosis of LTBI in children or for the diagnostic work-up of children (irrespective

or for the diagnostic work-up of children (irrespective of HIV status) suspected of TB disease in these settings

of HIV status) suspected of TB disease in these settings RECOMMENDATION 5. Guidance for NTP on the management of TB in

children.WHO, 2014.

DIAGNOSIS: Specimen collection methods

Guidance on approach to diagnosis of TB in children (WHO. Guidance, 2nd ed,2014)

• Careful history (including history of TB contact and symptoms consistent with TB)

• Clinical examination (including growth assessment)• Tuberculin skin testing• Chest X-ray (if avaliable)• Bacteriological confirmation whenever possible• Investigations relevant for suspected PTB and suspected

EPTB• HIV testing

WHO. Guidance for NTP on the management of TB in children, 2014

Pulmonary TB in children and adolescents Diferences

Score system for diagnosis of pulmonary TB in children (and negative adolescents).MOH-Brazil

Scores and systems StatisticsKenneth Jones S- 56%

Sp – 73% - 95 %Ghidey & Habte S- 51.6 – 100%Keith Edwards S – 62% - 88%

Sp – 25 – 97%WHO (Tdjani et al) S – 0%

Sp – 100%IUATLD S < 70%

Sp < 70%MOH Brazil(Pulmonary TB)

Cutt-off ≥ 30 points Cutt-off ≥ 30 points S – 88,9 – 99,3% S – 88,9 – 99,3% Sp – 70 - 86,5%Sp – 70 - 86,5%Cutt-off ≥ 40 points Cutt-off ≥ 40 points S – 40 - 58% S – 40 - 58% Sp – 85 - 98 % Sp – 85 - 98 %

Pearce EC et al. Aids Res Treat 2012; 4018

Scores for Childhood TB dianosis. Sistematic review, 2012

Gene XpertDiagnosis of paediatric TB in Community-based TB services

Rio de Janeiro, Brazil. 2014

J. Pio - SMSDC . Rio de Janeiro, Brazil

Children Adolescents

Total

8/68 (11. 8 %)

(n/suspected cases)

1 (1.5%)

RMP resistance- ᴓ

7 (10.2%)

Period: Aug- Sept 2014

Finding the most neglected: identifying and treating more children with TB

ROADMAP FOR CHILDHOOD TB, 2013 (adapt).