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Actions to improve TB care WHO and the Stop TB Partnership point to 3 key actions needed to improve TB care and prevent TB deaths in children Trained Health workers Detection and management of children with TB Contact tracing and IPT Detect active TB and latent TB Prevention Identifying and treating more children with TB New (and “old”) diagnostic tools Diferences between TB in children & adolescents
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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).