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Increased case detection in
infants and children
Robert Gie
Childhood TB Subgroup
Overview
• TB in pregnant woman
• Post partum TB and the infant
• TB in the HIV-infected infant
• Screening children exposed to an infectious
source case
• Barriers to the diagnosis of TB in children
Transitions of TB in pregnancy
Susceptible
Exposed
Infected
Pregnant
Diseased
Recognized
Diagnosed
Delivery
Infant
Diseased or infected
Diagnosed
Cured or prevented
Adapted from Don Enarson
Consequences of maternal TB
• Increased maternal mortality : 3 fold
• HIV infected mother have a 10 fold increase in
TB
• TB increases the probability of infant death by
2.2 to 6.4 fold
• Congenital TB mortality = 21-38%
Challenges:
• We have an opportunity to integrate maternal
and child health by;
– Integrating VCR and TB screening during pregnancy
– Screening mother and child in the postpartum period
• This will lead to an decrease in maternal and
infant mortality rates and increased HIV and TB
case finding
Source case’s: now 5 month old
daughter
03.12.03
The mother’s sister
The Grandmother’s
Questions raised?
• How do we integrate screening for TB into:
–
–
–
–
Antenatal care
PMTCT program
Post partum care
Nursery (kangaroo care)
• What should be included in the screening?
• How do we manage neonates exposed to an
infectious case of TB? ( and MDR exposure?)
What is the risks to HIV infected
infants?
Transition in TB
Susceptible
Exposed
Infected
Diseased
Infectious
Sick
Accessed care
Recognized
Diagnosed
Treated
Completed
Cured
Gratitude Don Enarson
The risk of developing TB in HIV
infected infants:
• HIV infected children have ;
– Increased risk of being exposed to TB
– Increased risk of developing disease (24 fold)
• All children suspected of having TB must be
tested for HIV in high prevalence communities
• At each health care visit each HIV-infected child
must be screened for TB
Barriers to diagnosis:
• Reasons why TB is not diagnosed:
– Lack of screening for disease
– “TB in children is difficult to diagnose”
– Dosage uncertainty and lack of child friendly drugs
– Lack of reporting and recording
Demystifying childhood TB
• Obstacles for children to be diagnosed:
– “Difficulty in making diagnosis”
– Lack of diagnostic tools
• Tuberculin skin test
• Chest radiography
• Difficulty in specimens collection and culture.
Difficulty in making the diagnosis.
• Is it true that the diagnosis of childhood TB
difficulty?
– History based screening.
– Value of history in making the diagnosis
Demystifying childhood TB
diagnosis
• Screening for children can effectively done by history
except in high risk groups (HIV infected and less than 2
years of age)
• The diagnosis of childhood TB in the majority of cases is
simply
• Diagnosis accuracy will be increased by the use of
– Tuberculin skin test
– Chest radiography
– Culture and sensitivity
• Simple tools are underused : Fine needle aspiration
TB drug dosages:
Recording and reporting
Summary
Increase the case finding in infants and children
• Integrate maternal and child health with increased VCR
and TB screening during
– Pre-natal clinics
– Post-natal clinics
– In nurseries
• Any infant and child suspected of TB must be tested for
HIV
• Screening children for TB can be successful using
symptoms
• The diagnosis of TB in children is in the majority is easy
especially in HIV non-infected children