child lung health
TRANSCRIPT
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Child lung health in resource-limited
settings
Steve Graham
Centre for International Child Health
University of Melbourne Department of PaediatricsRoyal Childrens Hospital
Melbourne
Child Lung HealthInternational Union Against Tuberculosis and Lung Disease
Paris
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Patient care focusResource richBenefitExpecting best possible
outcome
Often complicatedfrom 95% to 99.9%
Relevant to local prioritiesSocial determinants
Public health focusResource poorCostbest can be the enemy of the
good
Keep it simplefrom 85% to 95%
Relevant to local prioritiesSocial determinants
Balance and perspective
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Global mortality among children (< 5 years) has fallen by 40% in past 20 years
Estimates of 12.2 million child deaths from preventable causes in 1993 falling
to less than 7 million in 2011
Pattern of causes has changed slightly but pneumonia remains major single
cause
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Schell C, et al. Scand J Pub Health, 2007;35:288-97
Female illiteracy is a more important determinant of high child mortalitythan low income per capita, and both are more important than lowpublic expenditure on health
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Schell C, et al. Scand J Pub Health, 2007;35:288-97
Female illiteracy is a more important determinant of high child mortalitythan low income per capita, and both are more important than lowpublic expenditure on health
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Country Year Male FemaleAfghanistan 1998 46.0 16.0
Bangladesh 1998 63.1 48.1
India 1997 70.5 43.9
Nepal 1997 62.5 27.7
Pakistan 1997 55.3 29.1
Sri Lanka 1998 92 0 88 0
Female literacy and child mortality: examples from south Asia
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Most cases occur in SE Asia
Most deaths occur in sub-Saharan Africa (50%)
and SE Asia (20%)
Rudan I et al. Bull WHO 2008
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Risk factors for child pneumonia
Age
Poor immunisation coverage
Pertussis
Measles
Hib
Nutrition
Low birth weight
Malnutrition Not breast fed
Vitamin A deficiency
Zinc deficiency
Socioeconomic
Indoor air pollution
Crowding
Hygiene
Access to health services
Underlying disease
HIV
Cardiac
Neurological
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Risk factor Category Death/
numbers
Case-
fatality
rate
Test of
significance
66/477 14 %
Age < 6 months6-12 months
1-4 years
5 -14 years
47/175
16/110
3/153
0/39
27 %
15 %
2 %
0%
Chi-square for
trend
P
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Category Pathogen
Bacterial 45% Streptococcus pneumoniae 20%
Haemophilus influenzae type B 15%
Staphylococcus aureus 5%
Other Gram negatives 5%
Mixed 5-10%
Viral 40% RSV 15-20%Influenza A and B 5%
Parainfluenza 7-10%
adenovirus 2-4%
Causes of childhood pneumonia
Data from 14 lung aspiration studies Berman S. Rev Infect Dis 1991
Changing spectrum of aetiology /prevalence of specific causes
Poor diagnostic techniques
Did not investigate for tuberculosis
Limited data from HIV endemic setting
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Disease burden
Very severe pneumonia
Severe pneumonia
Non-severe pneumonia
WHO pneumonia case definitions
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Disease burden
Very severe pneumonia
Severe pneumonia
Non-severepneumonia
Cause of death
Lung aspiration studies in early 1980s identified that most fatal
cases were due to bacteriaespecially pneumococcus and Hib
Shann F, et al Lancet 1981
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Disease burden
Very severe pneumonia
Severe pneumonia
Non-severepneumonia
WHO case definitions
Presence of danger signs
Chest indrawing
Fast breathing
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Disease burden
Very severe pneumonia
Severe pneumonia
Non-severepneumonia
WHO case definitions
Parenteral antibiotics +/-oxygen
Antibiotics +/- hospitalise
Homeoral antibiotics
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Management of child pneumonia
Case-management strategy Focus on reducing mortality Reduce unnecessary antibiotic use
Antibiotics
Recent changes to recommendations: amoxicillin Availability
Community-based care and improved access
Hypoxia management
Implementation a major challenge Cost-effective
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Hypoxaemia in >16,000 child pneumonia cases in 21studies: median prevalence of 13.3% (IQR 9.3-37.5)
Varies widely between settings
11-20 million children admitted to hospitals withpneumonia each year
At least 15 to 27 million annual cases of hypoxaemicpneumonia presenting to hospitals
How common is the need for oxygen?
Subhi R, et al. Lancet Infect Dis 2009
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Clinical detection of
hypoxia can bedifficult
Oxygen saturation
SpO2
Percentage of children
(n=1116) detected
to have cyanosis
70-84% 44%
50-69% 81%
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Oxygen availability
Papua New Guinea: oxygen not available for 22% of1300 children in 5 hospitals1 of 20 hospitals had pulse oximetry
Sierra Leone: 40% of hospitals no oxygen
South Africa health clinics: 39% no oxygen
Lao: some central hospitals, few district hospitalshave oxygen
Wandi F, et al. Ann Trop Paediatr 2006; English M, et al. Lancet 2004; Kingham T P, et al. Arch Surg2009;
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2010: 17 provincial and district hospitals
Scaling up is possible
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Oxygen concentrators andthe role of bubble CPAP
f d d
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Causes of respiratory disease in autopsy studies in
African children
Causes ofpneumonia
HIV-infectedN=473
HIV-uninfectedN=338
TotalN=811
Bacterial 238 (50%) 132 (39%) 370 (46%)
PcP 145 (31%) 11 (3%) 156 (19%)
CMV 121 (26%) 7 (2%) 128 (16%)
Tuberculosis 50 (11%) 27 (8%) 77 (9%)
Co-infection 98 (21%) 5 (1.5%) 103 (13%)
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PcP is commonest cause of death in HIV-infected infants
Presents in early infancy: 2-6 months of age
PcP is often associated with CMV disease
PcP is preventable by cotrimoxazole prophylaxis in HIV exposed infants
Pneumocystis jirovecii pneumonia (PcP)
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Site and year Number in
study
HIV-infected (%) Case-fatality rate
HIV uninfected HIV infected
Zambia
Rural hospital 1995132 14 (11%) 14% 36%
Malawi
Urban hospital 1996150 93 (62%) 9% 30%
South Africa Urban hospital
1998250 151 (60%) 8% 20%
South Africa Urban hospital
19981165 548 (47%) 2% 13%
South Africa Urban hospital
1999-2001366 82 (22%) 0.7% 3.6%
South Africa Urban hospital
2001-2358 242 (68%) 2.5% 21%
Mozambique
Rural hospital 2004-2006195 49 (25%) 2% 27%
MalawiUrban hospital 2006 264 134 (51%) 3% 13%
Overall in-hospital CFR was 16.8% in 1313 HIV-infected children compared to3.4% in 1567 HIV-uninfected children: OR 5.67 [95%CI 4.17-7.71]
HIV-related increased mortality is in infants: PcP major contributor
Treatment of severe and very severe pneumonia and HIV
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Chronic lung disease extremely common among adolescents withvertically-acquired HIV infection
Severely restrictive lung disease with marked exercise intolerance
Pulmonary hypertension common
Ferrand R, et al. CROI 2010
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Notification Rates of Sputum Smear-Positive Tuberculosis,by Age, Tanzania Mainland, 1984 and 1995
Age group (years)
0 15 25 35 45 55 65
Notifications
per100,000
0
50
100
150
200
Tanzania NTLP / IUATLD. Progress Report 1996;No. 36
1995
1984
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Childhood TB and TB control programmes
Public health approach: Proper identification andtreatment of infectious cases will prevent childhood TB
Child TB historically afforded alow priority by NTPs:
Diagnostic difficulties Usually not infectious Limited resources Lack of recording and reporting
But- this disregards the impact of TB on childhood
morbidity and mortality- relevant MDGs 4 and 5 as well as MDG 6- child TB reflects recent TB control
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Signed by more than 1000 individuals/organisations
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Estimated TB incidence rates, 2011
Global Tuberculosis Report 2012
Child TB is common wherever TB is commonbut how common?
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Donald PR. Curr Opin Pulm Med
2002
Reported: range 1%-40%
Important factors:
Incidence of TB
Demographics - age
Effectiveness of case-finding and
management
Prevalence of risk factors in children
BCG coverage
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Risk of TB disease following infection by age
Adapted from Marais B, et al. Int J Tuberc Lung Dis 2004
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Incidence by age when TB was first diagnosed
Age (years)
0 5 10 15 20 25 30 35 40
Averageannualcaserate(per
100,000)
0
100
200
300
400
Comstock GW, et al. Am J Epidemiol 1974;99:131-8
Diagnostic challenges
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Clinical challenges are the diagnostic
challenges
Young age
Acute severe pneumonia
HIV-infected
Malnourished
MDR TB
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Recommended approach to diagnose TB in childrenWHO Guidance for NTP on management of TB in children 2006
1. Careful historyincludes history of TB contact
symptoms suggestive of TB
2. Clinical examination
includes growth assessment
3. Tuberculin skin test
4. Bacteriological confirmation whenever possible
5. Investigations relevant for suspected PTB orsuspected EPTB
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Recommended approach to diagnose TB in children
1. Careful historyincludes history of TB contact
symptoms suggestive of TB
2. Clinical examination
includes growth assessment
3. Tuberculin skin test
4. Bacteriological confirmation whenever possible
5. Investigations relevant for suspected PTB orsuspected EPTB
6. HIV testing routine
TST and culture are oftenunavailable. Neither is required fora decision to treat for TB in mostcases.
CXR is an important tool for
diagnosis of TB in children but
recognised limitations
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Revised National Guideline on Management of Tuberculosis in Children, 2012, Myanmar
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Risk of TB disease following infection by age
Adapted from Marais B, et al. Int J Tuberc Lung Dis 2004
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Bugs or biomarkers
Xpert MTB/RIF
from Boehme CC et al, NEJM 2010 from Tebruegge M, PhD student
Uni of Melbourne 2011
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Improving managementpoint of care diagnosis
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Studies of child contacts in Asian countries
Study Location No. of child
contacts
Proportion with
TB infection
Proportion with
TB disease
Andrew et al India 398 39 % 5.5 %
Narain et al India 790 24 % NR
Kumar et al India 142 NR 3 %*
Singh et al India 281 34 %* 3 %*Rathi et al Pakistan 151 27 % NR
Salazar et al Philippines 153 69 % 3 %
Tornee et al Thailand 500 47 % NR
Nguyen et al Lao PDR 148 31 % NR
Okada et al Cambodia 217 24 %* 9 %*
* Data only for < 5 years; NR: not recorded
From Triasih R et al, J Trop Med 2011
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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
Note that contact screening has two important roles
1. Active case-finding
2. Preventive therapy for at-risk contacts without TB
The outcome of symptom based screening in Indonesian children
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269All child contacts
108Children < 5 yrs
161Children > 5 yrs
37symptomatic
71well
61symptomatic
100well
999 12 149TB DISEASE AT BASELINE
00 0 4
TB DISEASE AT FOLLOW UP
The outcome of symptom based screening in Indonesian children
Triasih R, Graham SM. Unpublished data
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The outcome of symptom based screening in Indonesian children
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269All child contacts
108Children < 5 yrs
161Children > 5 yrs
37symptomatic
71well
61symptomatic
100well
999 12 149TB DISEASE AT BASELINE
00 0 4
TB DISEASE AT 12 MONTH FOLLOW UP
The outcome of symptom based screening in Indonesian children
Triasih R, Graham SM. Unpublished data
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IPT No IPT
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Childh d TB d NTP
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Childhood TB and NTPsBest Practices in Tuberculosis Control
September 2010, Kigali, Rwanda
1. Develop and adapt child TB guidelines2. Operationalise child TB guidelines
3. Identify child TB champion
4. Focal person for child TB at NTPworking group
5. Training
provide child TB training and incorporate intoongoing training related to TB and TB/HIV
6. Incorporate child TB into annual plans and 5-year strategic plan
7. Incorporate child TB into budget
8. Include child TB data in routine reporting and reviews
9. Operational research to determine constraints and barriers
10.Research aimed to improve child TB and contact management
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Launched
1st October 2013
Washington D.C.
Prevention of disease and deaths
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Prevention of disease and deaths
Addressing social determinants
Expanded Program on Immunisation
Pneumococcal conjugate vaccine
HIV prevention and management Lower antenatal HIV prevalence
Prevention of Mother to Child Transmission
Cotrimoxazole preventive therapy
Early antiretroviral therapy
Improve management of hypoxia
Preventive therapy for TB contacts
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Thank you