update diagnosis and treatment of childhood...
TRANSCRIPT
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 ?
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