Children: still at risk for TB

Transcription

1 Children: still at risk for TB Ann M Loeffler, MD Randall Children s Hospital, Portland OR & Curry International TB Center San Francisco, CA June, 2014 No disclosures except - many of these slides come from CDC: Objectives: To promote the understanding that TB disease and LTBI in children help define the high risk populations in each community To review the changes in pediatric TB demographics over the past 20 years Why do kids get their own talk? They re so flippin cute June 19, 2014 RANDALL CHILDREN'S HOSPITAL 3 Page 1

2 Why else? They are disproportionately affected by TB > Higher case rates considering their overall risk of exposure > Infants and toddlers at particular risk 40% of exposed babies will develop disease 25% of exposed toddlers will develop disease > High rates of disseminated disease Among infants < 1 yr of age 8.2% had meningeal disease 4.7% had miliary disease 6/19/2014 RANDALL CHILDREN'S HOSPITAL 4 Why else? A new diagnosis of LTBI or TB disease in a young child reflects recent transmission Recent transmission is a public health opportunity 6/19/2014 RANDALL CHILDREN'S HOSPITAL TB Case Definition and Verification Incident case of disease Case verification categories: 1) Laboratory confirmed cases Positive culture or nucleic acid amplification test Positive AFB smear when culture not attainable 2) Clinical case definition Positive tuberculin skin test or positive interferon gamma release assay Signs and symptoms of TB disease Current treatment for TB disease Completed diagnostic evaluation 3) Provider diagnosis Diagnosed by health care provider Does not fulfill all criteria necessary to meet laboratory or clinical case definitions Page 2

3 US Pediatric TB Cases by Case Verification Criterion*, Provider Diagnosis 23% Laboratory Confirmed 26% Clinical Case 51% *Based on the public health surveillance definition for TB [MMWR 1997:46(No. RR-10):40-41] US Pediatric TB Cases by Case Verification Criterion by Age Group, Age < 1 23% n=1,992 Age % n=9,692 20% 26% 51% 54% Age 5 9 n=4,474 Age n=3,682 24% 16% 16% 37% 60% 46% Laboratory Confirmed Clinical Case Provider Diagnosis A tale of two cities - Late 1990 s San Francisco > HIGH rates of TB disease > Immigrants, particularly Asian > HIV infected > Homeless > Low relative rates of pediatric TB 20 Purple = Alameda Co. 15 Blue = San Francisco # Peds TB cases age 0-4 yrs Alameda County (Oakland / east bay) > Lower rates of TB disease > High numbers of pediatric TB 75% African American > Distrust of public health > Clusters of pediatric cases > Adult source cases identified after pediatric cases June 19, 2014 RANDALL CHILDREN'S HOSPITAL 9 Page 3

4 A tale of two cities Late 1990 s TB in 0 4 year olds Number of cases of pediatric TB Purple = Alameda Co. Blue = San Francisco Alameda 12.4 / 100,000 (all ages) San Francisco 20.4 / 100,000 (all ages) 6/19/2014 RANDALL CHILDREN'S HOSPITAL 10 San Francisco cluster total TB cases > Nine pediatric (<7 years of age) cases > Two adult cases Source case: Adult male with sputum smears positive for acid-fast bacilli (AFB) symptomatic more than one year All US-born children of Central-American parents All lived or received childcare in the Mission district How cases were detected: 5 (56%) cases detected by primary care provider routine TB screening 1 (11%) detected during hospitalization for respiratory illness 3 (33%) detected by contact investigation (after first group of children identified) 3 (33%) were symptomatic / 45% were culture positive 6/19/2014 RANDALL CHILDREN'S HOSPITAL Alameda County cluster Cambodian Toddler with delayed diagnosis TB disease Source case investigation revealed: > Mom had pleural TB > Family friend had 4+ smear positive TB > Three more children had active TB > Everyone else had LTBI > Subsequent secondary case in adult 6/19/2014 RANDALL CHILDREN'S HOSPITAL 12 Page 4

5 US TB Cases, All Ages, by Age Group, TB Cases 12,000 10,000 8,000 6,000 Total cases declined from 25K to 10K Peds decline: 1660 cases to 486 cases 4,000 2,000 0 Year < 15 yrs yrs yrs yrs 65+ yrs Percent of Pediatric TB Cases by Age Group, US Age (18.6%) Age < 1 (10.0%) Age 5 9 (22.5%) Age 1 4 (48.9%) TB Cases by reason for primary evaluation / age 2012 United States; n (%) Reason for evaluation < 1 yr 1-4 yrs 5-9 yrs yrs > 15 yrs Abnormal radiograph 13 (22) 46 (23) 18 (17) 17 (15) 1921 (21) Contact investigation 25 (43) 86 (43) 36 (34) 15 (13) 238 (3) Administ / incidental lab 1 (2) 6 (3) 13 (12) 8 (7) 161 (2) Immigration evaluation 0 6 (3) 5 (5) 9 (8) 1106 (12) Targeted testing 0 4 (2) 5 (5) 10 (9) 333 (4) TB symptoms 19 (33) 51 (26) 30 (28) 56 (49) 5579 (60) Totals /19/2014 RANDALL CHILDREN'S HOSPITAL 15 Page 5

6 Number of US Pediatric TB Cases by Race/Ethnicity, # of cases White, non-hispanic Hispanic Asian Year Black, non-hispanic American Indian/Alaskan Native Note: Unknown, multiple race/ethnicity, and Native Hawaiian and Other Pacific Islander not shown US Pediatric TB Case Rates by Race/Ethnicity, TB Case Rate per 100, Peds Asian case rate 3.7 Black case rate 1.5 Hispanic case rate Year White, non-hispanic Black, non-hispanic Hispanic Asian Note: Rates presented on a logarithmic scale. American Indian/Alaska Native and Native Hawaiian and Other Pacific Islander rate not shown because of small denominators Adult Cases per pediatric TB Case Hispanic Black White Asian For 2006, > for each 10 Hispanic cases, one was a Hispanic child > for each 40 Asian cases, one was an Asian child fewer Asian cases transmitted to a child > Completely unclear reasons? Hispanic children have ongoing exposure in Mexico, child care practices, household size? The gap narrowed a bit in /19/2014 RANDALL CHILDREN'S HOSPITAL 18 Page 6

7 TB Cases by Primary Reason for TB Evaluation < 15 yrs; US, 2012 n (%) Reason for evaluation ASIAN BLACK HISPANIC WHITE Abnormal chest radiograph Contact Investigation Adminstrative Testing / Incidental Lab Immigrant Medical Exam Targeted Testing TB Symptoms Total 25 (25) 22 (18) 32 (17) 12 (34) 20 (20) 41 (33) 75 (41) 8 (23) 6 (6) 2 (2) 9 (5) 2 (6) 20 (20) 7 (6) 0 1 (3) 5 (5) 4 (3) 6 (3) 2 (6) 25 (25) 48 (39) 63 (34) 10 (29) /19/2014 RANDALL CHILDREN'S HOSPITAL Technical Instructions Intended to increase TB case finding before immigration by > Culturing sputum of those with abnormal chest radiographs > Requiring drug susceptibility testing > Instituting directly observed therapy and (with exception) requiring COT before immigration Pediatrics required information > TB incidence in country of screening (< 20 or > 20 / 100,000) > Age of child > HIV Status (not required, but influences management if positive) > Signs or symptoms of TB disease > Information about TB contacts 6/19/2014 RANDALL CHILDREN'S HOSPITAL 20 Evaluation of Applicants < 15 Years of Age CDC Culture and DOT TB TI (2007 TB TI) <20/100,000 TB Incidence >20/100,000 < 15 years of age < 2 years of age > 2 years of age Medical history Physical examination If signs or symptoms of TB or pediatric applicant has known HIV TST or IGRA and Chest radiograph (2 view for < 10 years) and Collect 3 sputum specimens by cough, induction or gastric aspirate for smears and cultures Consider TB treatment if exam or CXR highly suggestive of TB; see p. 14, 2007 TB TI Drug susceptibility testing of positive cultures CXR always required if documented TB history, regardless of TST or IGRA result If smear or culture positive, applicant is Class A until treatment completed and post-tests negative Medical history / Physical examination / TST TST 10 mm or IGRA + Chest radiograph 2 view for < 10 years TB signs or symptoms or CXR suggestive of TB or HIV infected Three sputum smears and cultures for M. tb Consider TB treatment if exam or CXR highly suggestive of TB; see p. 14, 2007 TB TI Drug susceptibility testing of positive cultures Page 7

8 Number of Pediatric TB Cases with Foreign Birth by Birth Country*, by 6-Year Intervals, Country (n) Country (n) Country (n) Mexico (651) Mexico (515) Mexico (159) Philippines (154) Somalia (109) Ethiopia (86) Vietnam (94) Philippines (94) Philippines (78) Somalia (78) Haiti (70) Haiti (53) Russia (54) Vietnam (52) Somalia (53) Haiti (52) India (48) Myanmar (53) Other (639) Other (621) Other (474) Mexico, Philippines, Vietnam, India, China, Haiti, Korea were most frequent countries of origin for all age US foreign born TB patients * Ranked by counts Summary Despite sharp declines in pediatric TB cases in the US in the last 20 years, children continue to be at high risk, especially the youngest children Identification of a child with TST conversion or TB disease is a sentinel event in public health and can sometime lead to identification of additional cases of TB Microbiologic diagnosis of TB is difficult, especially in 1-9 year olds Children diagnosed with TB in the US have a relative paucity of clinical symptoms and are likely to be diagnosed during a contact investigation of a contagious case (especially Black and Hispanic children) 6/19/2014 RANDALL CHILDREN'S HOSPITAL 23 Summary The largest number of pediatric TB cases are in Hispanic children, but Asian children have the highest case rates Hispanic children have the highest number of TB cases per adult case Children are screened for TB during the immigration process based on their age, history of TB, symptoms, PE findings and case rate in country of origin (do not assume that a child has been comprehensively screened prior to immigration) 6/19/2014 RANDALL CHILDREN'S HOSPITAL 24 Page 8

9 Thank you! Page 9