Challenges in Pediatric Tuberculosis. Mimi Emig, MD Spectrum Health Kent County Health Department

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1 Challenges in Pediatric Tuberculosis Mimi Emig, MD Spectrum Health Kent County Health Department

2 Pediatric Tuberculosis: A Missed Public Health Opportunity Mimi Emig, MD Spectrum Health Kent County Health Department

3 TB in Children Epidemiology Transmission of TB to children Public health exposure investigation Management of TB exposed child Management of child with active TB

4 Why a Missed Opportunity? Most children with active disease acquired it from an untreated adolescent or adult Most children with TB acquired it within past 2 years TB develops more rapidly in children Many children do not finish their preventive treatment for LTBI

5 Public Health Challenges Improve screening for LTBI in high risk children Improve rates of completion of prophylaxis for LTBI in children Improve case finding in children

6 Active TB in Children Children <15 years old Represent 6 7% of TB cases each year in US More likely to have primary TB Children < 4 years old More likely to develop TB meningitis May develop active disease even before PPD +

7 Epidemiology of TB in US Increased risk in urban, low income, and nonwhite groups In children, increased risk in: Immigrants & children of immigrants International adoptees Comorbidities DM, CKD, anti TNF, etc

8 Transmission of TB to Children Most often from an adult or adolescent in the household Pre adolescent children rarely spread TB Primary TB is paucibacillary (fewer bacteria) Rarely do children have cavitary disease Ineffective cough to aerosolize Less often have cough with TB

9 Risk of Progression from LTBI to Active Case Children < 4 yo >10% chance of development of active TB May occur even early during preventive tx May occur after incomplete treatment for LTBI

10 Risk of TB after Exposure Disseminated or meningitis Pulmonary TB LTBI <1 yo 10 20% 30 40% 50% 1 2 yo 2 5% 10 20% 75 80% 2 5 yo 0.5% 5% 95% 5 10 yo <0.5% 2% 98% >10 yo <0.5% 10 20% 80 90%

11 Pulmonary TB Signs of TB in Children Wheezing Poor appetite Failure to gain weight TB meningitis Less acute onset than bacterial Seizures, focal neurologic changes

12 Case 1 8 mo old boy, born at EGA 25 weeks Always wheezes

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15 Case 1, cont d Gastric aspirate ( ) on smear; MTb on culture at 1 month incubation Treated with standard TB treatment Postobstructive pneumonia due to hilar LA Source case never found

16 TB in Adolescents Presents more like adult TB Cough Apical disease Pleural effusion

17 Case 2 17 yo man with 2 weeks cough Father had active TB when pt was 10 yo Patient never received screening / prophylaxis for LTBI

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19 Targetted Screening in Children Documented exposure to TB Immigrants and adoptees Comorbities that increase the risk of active TB DM Malnutrition Anti TNF tx Cancer HIV

20 Screening for LTBI in Children PPD >15mm = +? Should this be lower for children < 1 2yo Close contact of active case Age > 4yo: 5mm = + Age < 4yo: 0mm = + Ignore BCG

21 IGRA IGRA = interferon gamma release assay T spot test Quantiferon gold Can be used even with prior BCG Positive test = exposure to TB Can have false negative; not well studied in children <5yo

22 TB Exposure in Children PPD or IGRA Examination, CXR

23 TB Exposure in Children Age PPD or IGRA Exam and CXR Treatment < 4 yo + or Normal INH 10mg/kg/d < 4yo + or Abnormal 4 drug TB tx > 4yo Normal Repeat in 3 mos > 4yo + Normal INH 10mg/kg/d

24 Why give INH if PPD / IGRA negative? High risk of development of TB in young children Active TB may develop before the immunologic response develops

25 Case 3 18 mo old girl Born in US; parents & grandparents born in Vietnam Maternal GM with active TB Received 5 mos preventive INH; lost to f/u after grandmother completed DOT

26 Case 3, continued 1 year later, developed mastoiditis Required mastoidectomy Culture grew susceptible TB; same strain as GM Required treatment for active TB; multiple surgeries Persistent hearing loss right ear

27 The Case for DOT for LTBI Most cases in children have an adult case that is being treated via DOT Completion of prophylaxis dramatically decreases the risk of development of active TB Treatment with single drug less costly than treatment for active disease

28 Problems with DOT for LTBI 5d/week INH not studied for LTBI Source case likely will decrease to 2X/wk tx INH prophylaxis requires 9 mos Treatment of active TB case will be completed before LTBI prophylaxis completed for exposed child

29 Treatment Options for LTBI INH 10 mg/kg/d (300mg max. daily) for 9 mos INH mg/kg/d (900mg max.) for 72 doses Rifampin 10 15mg/kg/d (600 mg max.) for 6 mos

30 Case 4 15 mo grandchild of active TB case Source case immigrated from Sudan; child born in US Started on prophylactic INH Source case INH resistant changed to rifampin prophylaxis

31 Case 4, continued After 1 mo RIF, developed lethargy, vomiting, and fevers over 1 2 weeks Admitted CSF c/w TB meningitis changed to 4 drug regimen CT & MRI strokes from TB Required feeding tube, rehab

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33 Challenges of Pediatric TB Initial evaluation by pediatrician or family physician Inadequate training in interpretation of PPD Lack of awareness of signs & risk factors for TB Lower bacterial burden Contact investigation Completion of prophylaxis

34 Any time we have a TB case in a child, we should ask Where did this child get this from? Identify source case and treat Did we miss an opportunity to screen & treat this child for LTBI? Are there other children that were also exposed to the same source case?