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Clinical Pediatric TB IntensiveJuly 18, 2019Houston, Texas

Tuberculosis Exposure in ChildrenKim Connelly Smith, MD, MPH

July 18, 2019

• No conflict of interests

• No relevant financial relationships with any commercial companies pertaining to this educational activity

KimConnellySmith,MD,MPHhas the following disclosures to make:

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KIM CONNELLY SMITH, MD, MPH

Tuberculosis Exposure in Children

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Tuberculosis Exposure in Children

Define TB exposure Poll text ksmith1 to 22333

Stages of TB

Risk of progression to disease

Timetable for tuberculosis

Contact Investigation

Evaluation of the exposed child Newborns and Infants Daycare School age

Follow up testing and treatment

Prevention of Tuberculosis in children

PEDIATRIC CASE

6 month old 1-2 week history of fever,

vomiting and sweating CXR abnormal

Developed respiratory failure, seizures, intubation

Altered mental status and an abnormal neurologic exam

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HOSPITAL COURSE

Dx: meningitis & miliary TB Family history

Father hospitalized 2 months prior with cavitary pneumonia

Sputum AFB smear negative No TB treatment started Not reported until culture

grew TB at 4 weeks

Health Department unable to locate family

Long term complications Hydrocephalus and VP shunt Developmental delay

Outcome

All family members including 3 siblings tested positive for TB

Mother had an abnormal CXR Treated as TB suspect

Siblings had normal CXR’s Treated for LTBI

Baby grew TB from tracheal aspirate and CSF

Baby treated with standard RIPE (12 months) and steroids for 2 months

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Tuberculosis: How does it spread?

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Tuberculosis Exposure - Defined

Close contact with a contagious adult or teen: Living in same household Or > 4 hours close contact Consider environmental factors (crowding, poor

ventilation, second hand smoke)

Contagious source case: Adult or teen with pulmonary TB disease AFB smear positive and cavitary disease are

considered the most contagious Endobronchial and laryngeal TB are rare but

contagious

Who’s NOT Contagious

Extrapulmonary TB disease (lymph node, bone, meningitis, renal, etc.)

Children <10 years of age with TB are usually not contagious Low bacterial load

Uncommon to see cavitary disease in children

98% AFB smear negative

Weak coughing force

Patients with Latent TB Infection are not contagious

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STAGES OF TUBERCULOSIS

Exposureto Contagious Adult with

Pulmonary Disease

Latent TB InfectionLTBI

Adult Active TB Disease

Child Active TB Disease

20-30%

5-10% Risk varies by age5-50%

Householdcontacts

RISK OF PROGRESSION TO DISEASEWITH NO TREATMENT

BY AGE INFECTED OR MEDICAL CONDITION

50%

24%

5%

15%

7%

30%

50%

0%

10%

20%

30%

40%

50%

60%

Birth-12months

1-3 years 4-11 years 12-18 years HealthyAdults

Diabetes HIV Infected

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*Feigin & Cherry, Text of Pedi ID

TTimetable of Tuberculosis

Contact Investigation - Time is of the Essence!

MMWR 2005; 54 (No. RR-15, 1-37)AAP [Tuberculosis] Red Book: 2018

TB disease should be reported when suspected Contact Investigation (CI)

Health Department visits home within 7 days Looking for:

Other cases of TB disease Infected individuals Young children exposed to TB

All household contacts should have TB skin test or IGRA blood test Positive reactors (>5mm) need CXR and screening for symptoms Children < 4 years of age need the following: (even if TST or blood test are negative)

Screening for symptoms of TB Physical exam for signs of TB disease 2 view CXR (even if no symptoms)

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Window Prophylaxis orTreatment for Presumed Infection

Window Period: It may take 8-10 weeks after infection for the TST or IGRA tests

to convert

Goal of Window Prophylaxis: Prevent progression to TB especially disseminated disease in high

risk groups during the window period Rifampin or Isoniazid usually prescribed

Repeat TB skin test or IGRA blood test 8-10 weeks later If positive (>5mm) continue full course treatment for LTBI If negative in immunocompetent patients Window treatment may be stopped as long as exposure has been

broken by separation or adequate treatment of the source case

Who Needs Window Prophylaxis?

AAP [Tuberculosis] Red Book: 2018

aidsinfo.nih.gov/guidelines/adult-and-adolescent-opportunistic-infection/325/mycobacterium-tuberculosis-infection-and-disease/2017

Exposed children < 4 years of age with Normal CXR

Normal physical examination

No symptoms of TB disease

Exposed HIV infected or immunocompromised patients Full treatment for presumed infection is usually recommended

regardless of TST/IGRA results

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TB EXPOSURE IN NEWBORNS

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Maternal TB disease or LTBI during pregnancy

Is mother contagious?

Exposure to contagious household TB contact:• Window prophylaxis

for baby• Okay to breastfeed

If no exposure to contagious household TB contacts:• No treatment needed

for baby• Okay to breastfeed

No Yes

Case Scenarios for Newborns

Mother or household member with Latent TB Infection (LTBI)

Newly diagnosed pulmonary TB disease

Treated pulmonary TB disease

Multidrug-resistant pulmonary TB disease

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NEW MOTHER WITH POSITIVE TST OR IGRA

Newborn infant in hospital nursery

Mother with 15 mm TST CXR: calcified

granuloma no active disease

Mother not on treatment1. What is mother’s

diagnosis?2. Do mother or baby need

isolation?3. May baby breastfeed

and room with mother?

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Baby Exposed to TB Disease

Newborn infant

Mother with TB disease

How do you determine the risk to the baby?

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BABY EXPOSED TO TB DISEASE

Mother AFB positive Mom just starting

treatment

Is mother contagious? What does the baby

need?

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Newborn Exposed to Contagious Pulmonary TB Disease Evaluate baby

2 view CXR and physical exam to rule out congenital TB

Start window prophylaxis once disease is ruled out If mother and baby are on therapy, baby may breastfeed

Some experts recommend a mask for mother and sleeping in separate rooms to reduce exposure

Mothers with TB mastitis (rare) should not breastfeed

If multidrug-resistant TB is suspected Separate mother and baby Consult a TB expert

Note:Trial in South African comparing Levofloxacin vs placebo for children exposed to MDR-TB Seddon et al. Trial (2018) 19:693 BMC

Mother with Treated Pulmonary TB

Check Maternal Drug susceptibilities AFB sputum smears Adherence to treatment (DOT)

Most adults become No longer contagious after 2-4 weeks of therapy AFB smear negative x 3

If the mother is On appropriate therapy and No longer contagious Baby does not need prophylaxis and may

breastfeed

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Daycare Exposure

Daycare Exposure

Index case, teacher assistant with AFB smear positive pulmonary disease and cough for 6 weeks

135 children < 4 years of age, plus adult staff members were exposed

Smith, KC. Southern Medical Journal93(9):877-880, 2000

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Daycare Exposure Management

Follow up:All children were offered on site

CXR’sHistory and physical examinationsWindow prophylaxis by DOPTFollow up TST’s

Skin test results Baseline: 1 adult and 3 children were positive Conversions: 4 adults and 3 children No TB disease found among children

TB Exposure in 5-10 Year Olds

Lower risk of progression to disease

For exposure TST or IGRA

CXR not needed unless TB test is positive or patient symptomatic

If TST/IGRA negative, follow up in 8-10 weeks

Window prophylaxis not indicated unless immunosuppressed

Treat for TB infection if TB test is positive once disease has been ruled out

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TB Exposure in 11-18 Year Olds

Infected teens have 15% risk of progression to TB disease if not treated

Testing for close contacts Usually household and/or classroom

Sometimes entire school offered testing

TST or IGRA

If negative, follow up TB testing in 8-10 weeks

Window prophylaxis not indicated unless immunosuppressed

Treat for TB infection if TB test is positive and disease has been ruled out

Summary - Pediatric TB Exposure

TB test may take 8-10 weeks after infection to turn positive (window period)

Young children are at higher risk of progression to disease Especially infants (50%) and children 1-4 years (25%)

Disseminated TB diseases such as miliary and TB meningitis: May develop as soon as 1 month after infection

Disseminated TB is more common in infants and children <2 years of age

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Prevention of TB in Children

Screen with TB Questionnaire Order PPD or IGRA if TBQ positive

Contact Investigation!

Window prophylaxis For children < 4 years with TB exposure

Treat latent TB infectionShorter course regimens preferred

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