Child TB: global and regional update

Ninth TAG meeting and NTP Managers Meeting9-12th December 2014

Manila

Steve GrahamCentre for International Child Health, University of Melbourne

International Union Against Tuberculosis and Lung Disease(The Union)

Child TB sub-group, Stop TB Partnership

The Meeting on the Development of Child Tuberculosis Action Plans in the Western Pacific Region: HCMC, Viet Nam, March 2014

The objectives of the meeting were:•To share country experiences, lessons learnt and best practices;•To establish priorities and design activities for strengthening childhood TB initiatives in the Western Pacific Region; and•To form a task force to oversee the activities and progress.

The meeting was attended by 21 country participants from 8 countries (Cambodia, China, Fiji, Lao PDR, Mongolia, PNG, Philippines and Viet Nam). Each country team was composed of focal point from NTP, maternal and child health programme and paediatric association.

Also 17 observers participated the meeting from different technical agencies.

Priorities for strengthening childhood TB activities in the WPR

1. Improved political commitment and collaboration with different stakeholders (e.g. MCH, EPI; partners like UNICEF, World Vision; paediatric associations, private providers)2. Improved case detection3. Improved case management and logistical management4. Improved prevention (BCG, IPT, infection control)5. Improved recording, reporting and data analysis (including private sector)6. Improved awareness of community and capacity building of health care worker 7. Operational research

Formation of a Regional Child TB Task Force

Participants of the Meeting formed an informal taskforce called 'The Regional Childhood TB Taskforce' on the Development of Child TB Action Plans in the Western Pacific Region The Regional Childhood TB Taskforce will support members to finalise national action plans and convene a regional workshop (with partners).

•Chair: Steve Graham•Co-Chair: Dr James Amini (PNG); Dr Nguyen Thein Huong (Viet Nam)•Vice Chair: Dr Celine Garfin (Philippines); Dr Lin Zhou (China)•Members: All participants of the meeting•Secretariat: WPRO,WHO

Next meeting: Union APR conference, Sydney, August 2015

Objectives and activities of the taskforce

1. Increase awareness of the child TB disease burden in the Asia-Pacific region

2. Assist the development of pragmatic, contextualized national child TB action plans

3. Monitor & support implementation of these plans

4. Provide an education resource (training)

5. Facilitate collaboration/integration between programs for TB and maternal and child health

Child TB at the new millenium

Childhood tuberculosis: out of control? Donald PR. Curr Opin Pulm Med 2002

JR Starke

Putting child TB on the global public health agenda Child TB subgroup of Stop TB Partnership formed 2003

Children recognised as a vulnerable group in need of increased case-finding: 2009

International Child TB Meeting, Stockholm, 2011

Increasing recognition that TB is an increasingly important cause of morbidity and mortality in infants and young children globally

Pregnancy-related TB – maternal and infant outcomes

Orphans due to TB – estimated to be around 9 million globally

Catastrophic economic costs of TB – families living with TB

TB in adolescents – uncertain burden and specific management issues

TB in the context of maternal and child health

Millennium Development Goals

Innovative approaches

Community-based

Wider health sector

Preventive therapy

Operational research

Roadmap for Childhood TuberculosisLaunched Washington DC, October 1st 2013

Situational analysis a critical first step

“Know your epidemic”

TB in women – best estimate3,300,000 casesDeaths:330,000 HIV negative180,000 HIV positive

TB in children (0-14 yrs) actual reported 275,00015% smear-positive 54% smear-negative31% EPTB

Best estimates:550,000 cases and 80,000 deaths

Child TB working group and NTP

Hiatt T & Nishikori N. WPSAR 2014

Age and sex-specific notification rates of new smear-positive TB cases for the Western Pacific Region, 2012

Hiatt T & Nishikori N. WPSAR 2014

Age and sex-specific notification rates of new smear-positive TB cases for the Western Pacific Region, 2012

Risk of TB disease following infection by age

Adapted from Marais B, et al. Int J Tuberc Lung Dis 2004

Gap in surveillance

TB case notifications

known to the NTP

Under-reported

Under-diagnosed

Incident (new) TB cases

Gap

Poor recording and reporting

TB case notifications

known to the NTP

Under-reported

Under-diagnosed

Incident (new) TB cases

Gap

From under-diagnosis

TB case notifications

known to the NTP

Under-reported

Under-diagnosed

Incident (new) TB cases

Gap

to over-diagnosis

TB case notificationsknown to the NTP

Under-reported

Under-diagnosed

Incident (new) TB cases

Not TB cases

Only 1.6% of 4,821 cases in children were registered with NTP

Diagnosis of child TB in Java and level of care

TB cases Inpatient Outpatient Overall

Total TB cases 5,877 15,694 21,571

Child TB cases N=648 N=4173 N=4821

% of total burden 11% 27% 22%

< 5 years 56% 53% 53%

Smear positive disease 16% 8% 9%

EPTB 15% 6% 8%

Non-teaching hospital 73% 76% 75%

Private health facility 8% 7% 7%

Lestari T, et al. BMC Pub Health 2011

Burden of child TB in four provinces of PNG: 2005-6

Law I, et al. Poster – The Union Global Lung Health Conference 2008

Pulmonary TB

Smear positiveSmear negativeSmear not done

1208 (61%)

18 (1%)138 (7%)

1052 (53%)EPTB 769 (39%)

Total 1977

Child TB accounts for 30% of total TB burden

Pattern of EPTB disease in children in four provinces of PNG: 2005-6

EPTB cases N=1097

Lymphadenitis

Meningitis

Abdominal

Pleural effusion

Miliary

Spinal

Pericarditis

Bone disease

Not indicated/others

342 (31%)

257 (23%)

173 (16%)

94 (9%)

64 (6%)

41 (4%)

12 (1%)

15 (1%)

99 (9%)

EPTB represented 39% of childhood TB cases

NATIONAL TB PROGRAMPAPUA NEW GUINEA

MANUAL ON MANAGEMENT OF CHILDHOOD TUBERCULOSIS

Child TB working group and NTP

Rapid development of diagnostics

HistoryTuberculinSkin Test

1890

Chest X-ray

1896

Bacteriology

1882

Diagnostic yield for pulmonary TB comparing children to adults

Xpert cannot be used to rule out TB

Xpert needs research on implementation to inform optimal usage in children

South America

BrazilPeru

South Pacific

New CaledoniaCook IslandsTongaMarshall IslandsFederated States of MicronesiaSolomon IslandsVanuataFiji

Union – MSF Operational Research CoursesTOTAL: 212 participants

MANAGEMENT OF TB IN CHILDRENIN VIETNAM

Activities

12,750 posters 554,400 leaflets

Community awareness – and support health worker!

Community contact screening in Viet NamOct 2012-Dec 2013

Child contacts screened 4109

Eligible for IPT 1577

Numbers received IPT 979 (62%)

% completed to date 88% (n=153)

Children diagnosed with TB 345

Sputum smear positive 37 (11%)

Sputum smear negative PTB 157 (46%)

EPTB 151 (43%)

NATIONAL PLAN FOR THE MANAGEMENT OF TB

IN CHILDREN: 2015-2020

Goal: To strengthen detection, treatment and preventive therapy for Vietnamese children towards decreasing childhood TB morbidity and mortality in Vietnam.

Regional activities in 2014

• WHO WPRO, Regional taskforce, Viet Nam, March

• China National Child TB, Beijing, August

• Global consultation on child TB for high burden countries in EMRO, SEARO and WPRO, Indonesia, September

“ There are many contributions which the pediatrician can make to a TB control program.

First the negativism about tuberculosis so prevalent in pediatrics must be overcome…”

Edith Lincoln, 1961

Donald PR. Edith Lincoln, an American Pioneer of Childhood Tuberculosis. Pediatr Infect Dis J 2013