Update Diagnosis and Treatment of Childhood Tuberculosis

Update Diagnosis and Treatment of Childhood Tuberculosis

Retno Asih Setyoningrum

Buku Petunjuk Teknis TB Anak

Outline

• Why should we update the guideline ?

• The Updates:

– Diagnosis approach

– Treatment

– Isoniazid Preventive Therapy

– Multidrug-Resistant TB in children

Why should we update the

guideline ?

Tuberculosis : An old disease - new twists

• One third of the world’s population is infected

• TB kills 5,000 people a day – 2-3 million/year

• Hundreds of thousands of children will become TB orphans

The challenges in TB global control:

HIV and TB co-infection

Multi-drug resistance TB (MDR TB)

Lancet 2014; 383: 1572–79

Estimated number of child TBglobally

CHILD TUBERCULOSIS: INDONESIA SITUATION

9.017.317.3

15.211.7

11.29.19.19.1

8.98.6

8.28.1

7.16.76.7

6.66.4

6.35.85.7

5.35.2

5.04.74.64.6

4.43.8

3.62.1

1.91.7

1.41.2

IndonesiaPapua

Papua BaratJawa Barat

Bangka BelitungDKI Jakarta

BantenDIY

BengkuluKalimantan…

Jawa TengahSumaterra Barat

Kalimantan TimurKalimantan…

LampungMaluku

NTTMaluku Utara

Sumatera SelatanKep Riau

Jawa timurBali

Sulawesi TengahKalimantan Barat

JambiRiau

Sulawesi SelatanKalimantan Utara

Sumatera UtaraNTB

Sulawesi BaratGorontalo

Sulawesi UtaraSulawesi…

Aceh

*data per 30 May 2016

Proportion of childhood TB cases among all TB cases, 2015*

Recording and reporting

Diagnosis of TB in children

Confirmed:

Sputum smear (+)/Xpert MTB/RIF (+)/Culture (+)

Clinically:

1. TB symptoms

2. Evidence of infection: TST (+) OR close contact (+) OR IGRA (+)

3. CXR: suggestive of TB

Diagnosis: problems & challenges

In children often difficult because of:

– Challenges in obtaining respiratory specimens

– The paucibacillary nature of childhood TB

– Low yield of positive culture: 30 – 50%

– Lack of resources for sputum collection and microbiological tests

The Indonesia Scoring System

0 1 2 3

Contact No or not clear

- AFB (-) OR reported

AFB(+)

TST negative - - positive

Weight - W/A < 80% W/A < 60% -

Fever - > 2 weeks - -

Cough < 3 wks >3 wks - -

Lymphnodeenlargment

- multiple, >1cm,tenderness (-)

- -

Joint - edema - -

CXR normal sugestive - -

The Scoring system: Problems

• PPD solution and CXR machines are not available in all Puskesmas

• Lack of confidence among general physician to diagnose without TST and CXR

• Over-diagnosis and underdiagnosis

Update on the diagnosis approach

NEW APPROACH OF CHILD TB

DIAGNOSIS IN INDONESIA (1)

Bacteriology

confirmed TB

Anti TB treatment

One or more of these symptoms:

• Cough > 2 weeks

• Fever ≥ 2 weeks

• No weight gain or weight loss in the previous 2 months

• Malaise ≥ 2 weeks

The symptoms persist despite “adequate” treatmetn

Rapid molecular test

(Xpert mTB/RIF)

NegativePositiveSpecimen can’t be

collected

No access for TST and

CXR

Access for TST and

CXR available*)

No access for TST and

CXR

Access for TST and

CXR available*)

No/Unclear contact

to an adult

pulmonary TB

patient

Contact to an

adult pulmonary

TB patient

Observe symptoms

for 2 weeks

Not TB

Persist Improved

Clinical TB

Anti TB treatment

NEW APPROACH OF CHILD TB

DIAGNOSIS IN INDONESIA (2)

No access for TST and

CXRAccess for TST and CXR

available*)

Scoring System

Score ≥6 Score <6

TST

OR

Contact (+)

TST (-)

AND

Contact (-)

Observe symptoms for

2 wks

Not TB

Persists Improved

Clinical TB

Anti TB

treatment

NEW APPROACH OF CHILD TB

DIAGNOSIS IN INDONESIA (3)

Diagnosis Regimen Duration(months)

Pulmonary TB (mild) 2RHZ/RH 6

Pulmonary TB AFB (+) atauconfirmed bacteriologis

2RHZE/RH 6

TB-HIV 2RHZE/RH 6

Severe TB (milliary, meningitis, spondilitis)

2RHZE/RH 9-12

Treatment

Kombinasi Dosis Tetap (KDT)

Berat badan(kg)

2 bulanRHZ (75/50/150)

4 bulan(RH (75/50)

5 – 7 1 tablet 1 tablet

8 – 11 2 tablet 2 tablet

12 – 16 3 tablet 3 tablet

17 – 22 4 tablet 4 tablet

23 – 30 5 tablet 5 tablet

>30 OAT dewasa

Isoniazid Preventive Therapy

(IPT)

Contact investigation !

1.

2.

Investigate for infection/disease

Provide appropriate treatment: ATT or IPT

How to manage a child contact ?

WHO symptom based screening

More than 5 yearsLess than 5 years

Children in close contact with a case of sputum smear-positive TB

Well Symptomatic Symptomatic Well

Preventive therapy Evaluate for TB disease No treatment

If becomes symptomatic If becomes symptomatic

Management of child contact

Age HIV Outcome of

investigation

Management

Balita (+)/(-) LTBI IPT

Balita (+)/(-) Exposed only IPT

> 5 th (+) LTBI IPT

> 5 th (+) Exposed only IPT

> 5 th (-) LTBI observe

> 5 th (-) Exposed only observe

IPT: INH 10 mg/kg BW/day for 6 months

Mutli-drug Resistance TB

MDR TB in Indonesia

• The 8th of the 27 countries with hghest MDR-TB cases

• Number of cases in children:

– Yogyakarta: 2

– DKI: 6

– East Java: 3

– West Java: 4

– Medan : 1

– Papua: 1

– West Sumatra: 1

Criteria for suspected MDR-TB in children

• Previous TB treatment in the past 6-12 months

• Close contact with a person known to have MDR-TB

• Close contact with a person who has died from TB,

failed TB treatment, or is non- adherent to TB

treatment

• Failure to improve (including persistence of positive

smears or cultures, persistence of symptoms, and

failure to gain weigh) after 2-3 months of first-line TB

treatment, despite of good adherence.

Alur Diagnosis TB RO Pada AnakSUSPEK TB RO ANAK

PemeriksaanTCM TB

TB resisten rifampisin TB sensitif rifampisin MTB not detected

pengobatan TB MDR

standar

Lakukan biakan dan

uji kepekaan obat

Sesuaikan paduan

OAT berdasarkan

hasil uji kepekaan

obat

OAT RHZE Kondisi klinis stabil

tanpa ada

kegawatan

Kondisi klinis

tidak stabila)

atau ada

gejala TB

berat b)

Observasi gejala klinis

Gejala menetap

Pertimbangkan

pengobatan

secara empirisc)

Lakukan biakan

dan uji

kepekaan obat

General principles of treatment

•Composed of at least five drugs:• Four core second-line drugs • Plus pyrazinamide.

•All treatment is daily and under direct observation

•Counsel and support patients/parents at every visit regarding adverse effects and importance of adherence

•Management – at a specialized MDR-TB clinic

Conclusion

Find and diagnose the case properly

Treat and monitor properly, including latent TB infection

Notify to NTP

Many things we need can wait.

The Child cannot.

Right now is the time his

bones are being formed,

his blood is being made,

and his senses are being developed.

To him we cannot answer “Tomorrow”.

His name is “Today”.”

- Gabriela Mistral -

Are we doing enough ?

31