tb nurse case management :: pediatric tuberculosis ......aug 22, 2019 · 1 tb nurse case...
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TB Nurse Case ManagementAugust 20‐22, 2019San Antonio, Texas
PediatricTuberculosisLisa Y. Armitige, MD, PhD
August 22, 2019
• No conflict of interests
• No relevant financial relationships with any commercial companies pertaining to this educational activity
LisaY.Armitige,MD,PhDhas the following disclosures to make:
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EXCELLENCE EXPERTISE INNOVATION
Pediatric Tuberculosis
Lisa Y. Armitige, MD, PhDMedical Consultant
Heartland National TB Center
Associate Professor Internal Medicine/PediatricsUniversity of Texas HSC Tyler
Nope, still no conflicts
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Epidemiologyof Pediatric TB
US Pediatric Tuberculosis
Definition of pediatric tuberculosis (TB):• TB disease in a person <15 years old
In 2017:• 9,105 TB cases were reported among all age groups
• 429 (4.7%) were pediatric
Age group NPercentage of all
cases
0–1 years 53 0.6%
1–4 years 175 1.9%
5–9 years 93 1.0%
10–14 years 108 1.2%
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State Total cases < 5 y/o 5‐14 y/oTotal
Pediatric Cases
California 2057 39 38 77
Texas 1127 34 23 57
Minnesota 178 12 11 22
Georgia 294 13 9 23
New Jersey 284 10 8 18
US States with Most Pediatric TB Cases
U.S. TB Cases, All Ages, by Age Group, 1993–2017
0
5000
10000
15000
20000
25000
30000
Cases
<15 yrs 15–24 yrs 25–44 yrs 45–64 yrs 65+ yrs
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U.S. Pediatric TB Cases by Age Group, 1993–2017
0
200
400
600
800
1000
1200
1400
1600
1800Cases
N=22,037
Age <1 year Age 1–4 years Age 5–9 years Age 10–14 years
Number of U.S. Pediatric TB Cases among
U.S.‐Born and Non‐U.S.–Born* Children, 1993–2017
N=22,037
0
200
400
600
800
1000
1200
1400
1600
1800
Cases
Non‐U.S.–born U.S.‐born
*Non‐U.S.–born refers to persons born outside the United States or its territories or not born to a U.S. citizen
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Number of U.S. Pediatric TB Cases among U.S.‐Born Children by Parent/Guardian Status, 2010–2017
0
100
200
300
400
500
600
700
800
Cases
U.S.‐born with parents/guardians with unknown origin
U.S.‐born with Non‐U.S.–born parents/guardians*
U.S.‐born with U.S.‐born parents/guardians
Stages of TuberculosisExposure
to Contagious Adult with Pulmonary Disease
Latent TB InfectionLTBI
Adult
Active TB DiseaseChild
Active TB Disease
20-30%
5-10%Risk varies by age5-50%
Household contacts
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Percent Risk of Disease by Age
Age at Infection Risk of Active TB
Birth – 1 year* 43%
1 – 5 years* 24%
6 – 10 years* 2%
11 – 15 years* 16%
Healthy Adults 5‐10% lifetime risk
HIV Infected Adults+ 30‐50% lifetime
*Miller, Tuberculosis in Children Little Brown, Boston, 1963 +WHO, 2004
Risk of Progression to TB Disease by Age
Age @ primary infection
• Birth – 12 months
• 1 ‐ 2 years
Risk of Disease
Disease 50%
Pulmonary Dis 30‐40%
Miliary or TBM 10‐20%
Disease 20‐25%
Pulmonary Dis 75%
Miliary or TBM 2‐5%
Marais BJ. Int J Tuberc Lung Dis 2004;8:392-402
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Risk of Progression from TB Infection to Disease by Age
Peds in Review 2010;31:13
Differences In Adult and Pediatric TB
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Reactivation DiseaseAdults and older children
• Occurs years after infection
• Occasionally seen in teens
• Often cavitary disease
• High numbers of organisms (AFB +)
• Usually symptomatic and contagious
• Typical of childhood TB
• Usually not cavitary
• Classic x‐ray: – Lobar pulmonary infiltrates – Hilar lymphadenopathy or– Miliary infiltrates
• Low numbers of organisms - AFB smears negative in 95% of pedi cases- Culture negative in 60% of cases
• Most children <12 yrs not contagious
• Often asymptomatic (50%)
Primary DiseaseSmall children and immunosuppressed
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Adult TB Disease
Pulmonary
Extrapulmonary
78%Pulmonary
22%Extrapulmonary
CDC 2010
Adult Extrapulmonary TB Disease
Lymphatic
Pleural
GU
Other
Bone/Joint
Miliary
Meningeal
16%Pleural
40% Lymphatic
5%GU
18%Other
10% Bone/Joint
9%Miliary
5%Meningeal
CDC 2010
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Pediatric TB Disease
Pulmonary
Extrapulmonary
75%Pulmonary
25% Extrapulmonary
CDC
Percentage of TB Cases in Children with Any Extrapulmonary Involvement
by Age Group (Age <5), Summed and Averaged Over 2013–2017
7.5
11.2
1.5
0.7
76.1
Age <1, n=267
17.3
6.4
0.5
1.6
2.6
71.6
Age 1–4, n=987
Lymphatic
Bone and Joint
Meningeal Miliary
Other Pulmonary Only
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Percentage of TB Cases in Children with Any Extrapulmonary Involvement
by Age Group (Ages 5–14), Summed and Averaged Over 2013–2017
27.5
2.9
0.52.3
61.2
Age 5–9, n=443
21.4
2.6
0.6
2.8
14.6
58
Age 10–14, n=500
Lymphatic
Bone and Joint
Meningeal Miliary
Other Pulmonary Only
Diagnosing Tuberculosisin Children
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Adults – Mycobacterial‐based diagnosis• positive sputum AFB smear 60% ‐ 75%
• positive sputum culture 90%
• positive tuberculin skin test 80% [HIV < 50%]
Children• positive sputum/gastric AFB smear 10%
• positive sputum/gastric culture 10% ‐ 40%
• positive tuberculin skin test 50% ‐ 80%
How is tuberculosis diagnosed?
Gastric Aspirates
• Inpatient procedure
• Overnight fasting
• Lavage with NS if volume < 20cc
• Generally done qAM x3
• Inpatient costs
• AFB smear yield: minimal
• AFB Culture yield: 20‐30%
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• Gold Standard –
Positive TB Culture
OR, Clinical Diagnosis:
• Abnormal CXR, laboratory, or physical examination consistent with TB AND
1 or more of the following:– Positive TST/IGRA
– Contagious adult source case identified
– Clinical course consistent with TB disease, or
– Improvement on TB therapy
Diagnosis for TB in Children
• Can use IGRAs in immunocompetent children 2 y/o and older in all situations when a TST would be used
• Preferred test for children 2 years and older who have received a BCG vaccination
• Data shows IGRAs perform consistent well in children 2 years and older, some experts use down to 1 y/o
• Neither IGRAs nor the TST are perfect; always need clinical judgment!
IGRAs and the 2018 AAP “RED BOOK”
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Clinical Presentation of TB in children
Cough and/or respiratory distress
Pulmonary findings on examination
Lymphadenopathy or lymphadenitis
S/Sx of meningitis including seizures
Persistent fever (FUO)
Weight loss or failure to thrive
Unlike adults, up to 50% of children with TB disease have no symptoms
Common symptoms of TB disease in children
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Signs and Symptoms of Pulmonary TB
Peds in Review 2010;31:13
• Hilar or mediastinal adenopathy
• Segmental/lobar infiltrates
• Calcifications (seen in 75‐80% of children with pulmonary TB)
• Miliary disease
• Pleural effusions
15% of patients with TB disease will have normal CXRs
CXR Findings in Pediatric TB
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Intrathoracic Lymphadenopathy
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Cavitary Lesions
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W.C. 2005
• More difficult diagnosis
• Nonspecific signs and symptoms
• Fewer mycobacteria
• Fewer positive bacteriologic tests
• Increases risk of progression to disease
• Higher risk of extrapulmonary and TB meningitis
Unique Diagnostic Challenges of TB in Children
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Treating Tuberculosisin Children
Why treat exposed children?
• Very high rate of infection
• Takes up to 3 months for the skin test to turn positive
• U.S. studies – 10% to 20% of childhood TB cases can be prevented if children exposed in a household receive isoniazid
• WHO standards – children <5 years old in a TB household should be treated
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TB Prevention After Exposure
• Household contact with contagious person– Teen or adult with pulmonary TB disease– Usually > 4 hours of contact
• Initial TST negative– Window period for TST conversion– (8‐10 weeks)
• CXR and physical exam normal
• Window prophylaxis recommended:– For children < 5 yrs of age– Immunosuppressed patients– Patients on tumor necrosis factor‐alpha blockers or other biologic– May prevent progression to disease during window period
• Repeat TST 8‐10 wks after exposure
• May stop medication if 2nd TST negative < 5mm in immunocompetent patients
• Approved for children ≥ 2 years of age
• Dosing:INH:15 mg/kg rounded up to the nearest 50 or 100 mg20‐30 mg/kg rounded up ages 2‐11 y/omaximum 900 mg
RPT:10.0–14.0 kg 300 mg 14.1–25.0 kg 450 mg 25.1–32.0 kg 600 mg 32.1–49.9 kg 750 mg
≥ 50.0 kg 900 mg maximum
Treating TB infection ‐ 3HP
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• Rifampin x 4 months– 10‐20 mg/kg daily dose ages 2 years and older (max 600 mg)
– 20‐30 mg/kg daily • Infants and toddlers
• Immunosuppressed
• Disseminated disease, ESPECIALLY meningitis
• Isoniazid (INH) – 10‐15 mg/kg single daily dose
– 20‐30 mg/kg twice weekly given by DOT
– Duration: 9 months
Treating TB Infection
Pearls of wisdom for treating TB Infection in children
• Use INH suspension only in children ≤ 5 kg
• Compliance with 9 months of INH averages 50% ‐ be vigilant and skeptical, consider shorter course treatments
• Use DOPT for: recent contacts, infants, immune compromised
• When children aren’t tolerating treatment, the problem is more often with the parent than the child
• Routine LFTs only for: other liver toxic drugs, liver disease, signs or symptoms of hepatitis
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Directly observed therapy for tuberculosis
• means a dispassionate 3rd party is actually present when medications are taken with every dose
• “standard of care” in U.S. for treating tuberculosis disease
• desirable for high risk infections ‐ newborns and infants, household contacts, HIV ‐ infected or immune compromised
The Pediatric Infectious Disease Journal 2012 31: 2
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• Start 4‐drug therapy (a change from 2006 Red Book)
– INH, rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB); INH/RIF are the backbone of therapy
• Use PZA only during 1st 2 months for susceptible TB
– This is your ‘shortening agent’: consolidate from 9 to 6 months of therapy
• Stop EMB once culture results known, if have pan‐susceptible TB
– This is your insurance in case you have drug‐resistant TB
• Anticipate minimum 6 month therapy, may need to extend it to longer periods, especially for extensive, CNS or bone disease
• Can dose BIW or TIW after first 2 weeks of daily dosing
• Always administered by directly observed therapy (DOT)
Therapy for TB Disease
2018 Red Book
• 12 months RIPE therapy – higher dosing of rifampin
– Consider a fluoroquinolone
• Steroids for 1‐2 month with 2‐3 week taper – decreases CNS inflammation
• Symptoms may initially worsen followed by gradual improvement
• Possible complications– Seizures – Hydrocephalus – CNS tuberculoma, stroke, MR, CP– Mortality usually 100% if not diagnosed and treated
TB Meningitis Treatment and Clinical Course
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• Risk of drug toxicity very low
• Monitor clinical signs – regular clinical visits (4‐6 wks)
– patient education
– Weigh at least monthly and increase dose as needed
• Routine blood work not necessary unless– symptoms
– risk factors for toxicity
• Monitor and reinforce adherence
Monitoring Children on TB Treatment
Monitoring Children on TB Treatment
• When to follow up CXR’s for pulmonary TB– Beginning and end of therapy
– If clinical change
• Adequate nutrition
• Routine vitamin B6 not necessary except breast‐feeding, pregnant adolescents, poor diet
– Vitamin B6 doses 1‐2 mg/kg
• Completion of therapy certificate
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• Pulmonary– CXR takes months to improve
• Hilar lymphadenopathy– May take a year or more to regress on x‐ray
• Cervical lymphadenitis– Can get worse before improvement over months to years
• Meningitis– Inflammation increases initially with treatment– Steroids crucial for 1st month– Hospitalization recommended until clinically stable or improving
Expected Clinical Coursefor TB Disease in Children
• Older adolescents
• Children with certain findings on CXR
• Producing sputum
• Any draining skin lesions
When do we worry about contagiousness?
Infect Control Hosp Epidemiol 2011;32:188
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