Stop-TB eForum Resource Team
To JOIN the global Stop-TB eForum, send an email to: join-stop-TB@eforums.healthdev.org
******************************
BACKGROUND:
As you know, the global Stop-TB eForum is hosting an online consultation/ dialogue, on key issues impeding TB and HIV collaborative activities in local contexts, from 2nd July to 6th of August 2010. This is a period during which the XVIII International AIDS Conference (IAC) shall also be held in Vienna, Austria. This online consultation/ dialogue gives people dealing with TB and HIV an opportunity to SPEAK THEIR WORLD, and inform the issue-framework which the Key Correspondents team facilitated by the International HIV/AIDS Alliance shall use on-site at the XVIII IAC in Vienna. The issues flagged by the members shall also shape the coverage generated by citizen journalists of other networks like Citizen News Service (CNS).
MINI-SERIES I: TB and Children
*******************************
From 2nd to 9th of July 2010, members are encouraged to share their perspectives and experiences on issues related to TB in children.
WHAT ARE YOUR EXPERIENCES IN:
- diagnosing TB in children
- preventing TB in children
- TB infection control and children
- treating TB in children
- TB-HIV co-infection and children
Members comments are most welcome.
Stop-TB eForum Resource Team
Latest issues of CNS Weekly - Stop-TB News Monitors
Friday, July 2, 2010
Subscribe to:
Post Comments (Atom)
12 comments:
Factsheet on TB and Children
Stop-TB eForum Resource Team
**********************************
[Mods note: Please find below a factsheet on TB and children, in support of the ongoing mini-series on TB and Children online consultation (2nd-9th July 2010) on the Stop-TB eForum - the announcement of which is available online at: http://stoptb.citizen-news.org/2010/07/online-discussion-mini-series-tb-and.html .
This factsheet is from the WHO (South East Asia Regional Office - SEARO) website, and available online at: http://www.searo.who.int/en/Section10/Section2097/Section2106_10681.htm . Thanks]
***********************************
Source: WHO (South-East Asia Regional Office - SEARO)
Online at: http://www.searo.who.int/en/Section10/Section2097/Section2106_10681.htm
TB ALERT factsheet on TB and Children
Stop-TB eForum Resource Team
**********************************
[Mods note: Please find below another factsheet on TB and children (from TB ALERT), in support of the ongoing mini-series on TB and Children online consultation (2nd-9th July 2010) on the Stop-TB eForum - the announcement of which is available online at: http://stoptb.citizen-news.org/2010/07/online-discussion-mini-series-tb-and.html .
This factsheet is from TB ALERT, and available online at: http://www.tbalert.org/worldwide/children.php
***********************************
TB IS A MAJOR KILLER OF CHILDREN IN POOR COUNTRIES
Read about children at some of TB Alert's projects around the world:
----------------------------
Prevention is better than cure - Alfred's story
Online at: http://www.tbalert.org/projects/malawi/ChristmasAppeal08.php
A life saved in India - Raheena's story
Online at: http://www.tbalert.org/projects/india/raheenastory.php
Paediatric TB at Queen Elizabeth Hospital, Blantyre, Malawi here
Online at: http://www.tbalert.org/projects/malawi/casestudiesqech.php
Booklet produced in Malawi for children with TB:
Online at: http://www.tbalert.org/projects/malawi/tbkidsbooklet.php
TB ALERT Factsheet is online at: http://www.tbalert.org/worldwide/children.php
Comment: Online dialogue mini-series-1: TB and children (1)
Christine Akoru
*********************
In some developing countries, where people depend on relief food, because of harsh environmental conditions or internal displacement, small children under one year suffer from malnutrition or at times, severely acute malnutrition (SAM).
The type of relief food given is hard food (and children can't chew).
Children need substitution because breast milk only is not enough for their growth. So in this situation, mothers chew food for them and are fed through mouth to mouth, in this case, if a mother has TB, then the child gets it directly from the mother.
Christine Akoru
Email: cnakoru@yahoo.co.uk
Anonymous
*********************
TUBERCULOSIS GERM DOES NOT SPREAD THOUGH SHARING FOOD, OR KISSING, OR SHARING FOOD THROUGH KISSING
Dear Stop-TB members,
The tuberculosis germ does not spread though sharing food, or kissing, or sharing food through kissing as described by Christine Akoru.
For reference, please read:
http://www.hhs.gov/tb/
http://www.cdc.gov/tb/publications/pamphlets/TBgtfctsEng.pdf
The tuberculosis germ can spread from mother to infant if the mother coughs, sneezes, laughs, speaks, or sings and saliva or sputum is inhaled by her infant.
These children will certainly die if they are not given supplementary feeding in this loving way by their mothers. Please do not stop feeding them.
Undernourished children may also die orphans if their mother is not treated effectively for tuberculosis. Please make sure their mothers get effective treatment for tuberculosis.
Anonymous
Dear Stop-TB members,
I will like to add my comment in the ongoing online discussion on TB and children.
- Developing countries like India can definitely be proud of reducing severe forms of childhood TB like TB meningitis and fulminating miliary TB, a common site during our student days (1961-67). Students today hardly get to see these cases. Similarly Gibbus (spinal TB) in children has also become relatively rare.
- The challenge continues for diagnosing TB in children. We hardly have made any progress in last 50 years. The situation is worse in remote rural and tribal population
Keeping in mind the International Standards for TB Care (ISTC), I reviewed the situation in India under the revised national TB control programme (RNTCP) of government of India. These are a few observations needing immediate attention.
- International Standards for TB Care 1 & 2: Most children under 5 years do not produce sputum, get excluded for diagnosis. Children between 6-14 years may be subjected for sputum examination if having cough of two weeks are more. Even for them examining sputum twice is very uncommon, leave apart collecting early morning specimen
- International Standards for TB Care 3: Children with extra pulmonary TB (likely to be more than Pulmonary TB) collecting appropriate sample for microscopy as advised is hardly visible explicitly except in a few tertiary facilities in the country
- International Standards for TB Care 4 & 5: Radiographic suspects to meet criteria of 3 negative smears, lack of response to appropriate antibiotics and radiographic findings consistent with TB to be put on DOTS. This is rarely done or at least reported. The RNTCP reports of 2009 and 2010 do not mention anything about cases diagnosed using this criteria
Thanks
Dr K Suresh
Email: ksuresh@airtelmail.in
The other issues are:
---------------------
THE NATIONAL AIDS CONTROL PROGRAMME (NACP)/ RNTCP COORDINATION MECHANISM (TB/HIV PACKAGE) HAS BEEN STARTED ONLY IN 2008 AND COVERS ABOUT 18 STATES
- In persons with HIV infection diagnosis should be expedited. Not many ARTs in the countries are equipped with this facility, nor are the district TB centers refer sputum positive cases to HIV test adequately as the National AIDS Control Programme (NACP)/ RNTCP coordination mechanism (TB/HIV package) has been started only in 2008 and covers about 18 states. Though it is reported that 10.6 % of referrals (HIV positives) suspected to be TB have been confirmed to be TB and vice versa 12% of TB patients were confirmed as HIV positive in 2009. In 2009 the proportion of TB patients with known HIV status has increased from 34% to 62%. Unfortunately the RNTCP does not look into desegregated status for children in this category too.
- It is evident that desegregated data for children with TB, association of TB and HIV/AIDS is hardly reviewed with serious concern.
- It is reported that TB among children remains to be the same more or less since 1991, i) with no extra efforts or ii) new diagnostic tools being applied. It is unfortunate such comments are made. we also know that these figures may not include the children taken to private paediatricians whose involvement in RNTCP is poor.
My major concern is if such is the quality of joint reviews involving all technical expertise globally , out efforts to ameliorate the Childhood TB status and co-existence of TB-HIV co-infection in children (despite good efforts in HIV/AIDS diagnosis and management of HIV/AIDS in children) will not yield desired results.
Last but not the least the agencies whose mandate is Children (UNICEF, Save the Children etc) need to wake up and add activities for childhood TB along with HIV/AIDS in all their projects.
LET "STOP TB" NOT GET LIMITED TO SPUTUM POSITIVE ADULT TB & TB-HIV CO-INFECTION ONLY
CHILDREN ARE OUR FUTURE. THEY CAN NOT SPEAK FOR THEMSELVES. SOEMBODY NEED TO SPEAK FOR CHILDREN
The least resolution to be passed is requesting countries to collect and share desegregated data for children on TB, HIV/AIDS and their co-infection. Estimates are fine but let the countries put the actual data on website for public access.
LET THE ISSUE BE RAISED AT XVIII IAC in Vienna by International HIV/AIDS Alliance and Citizen News Service writers.
Thanks
Dr K Suresh
Email: ksuresh@airtelmail.in
Please find our experience on TB and children issue, from Namakkal, Tamil Nadu, India.
Buds of Christ through its rural initiative has been working with children in Namakkal district. Due to a huge population affected by HIV and AIDS, Buds of Christ has been focusing its work primarily among children from Tiruchengode taluk and few deserving children (mostly orphans) from other parts of Namakkal district.
With regard to TB and HIV following issues are highlighted to be discussed and planned for interventions
1) Children who are not on ARV, but HIV infected have chances for contracting TB, but these children are not followed up, reasons being their CD 4 is quite high. The case is more severe, when they are orphan children, as the care takers are not aware on the need for periodic monitoring of CD 4 testing and children suffer with other forms of TB (extra pulmonary infection)
Dileep (name changed), orphan, 15 years old, school drop out recently died of TB meningitis recently. His CD 4 was in the range of 430. Though he had complaints of headache and fever, his grandfather attributed it to be ordinary complaint and medicines over the medical counter were used to treat the symptoms.
2) Knowledge level of care takers (especially grandparents) is very poor. The issue is more complicated, when children below 10 years are under the care of grandparents. It is important that constant information need to be provided to care takers in ensuring better care.
Anita (name changed), 8 years old orphan looked after by her grandmother. She was affected by TB two years before, but as the symptoms reduced, she has been casual about treatment and even her grandmother did not take it seriously. Now she suffers with the repeat TB and care is neglected.
The above two instances reveal the need for:
--------------------------------------
- Periodic monitoring for opportunistic infections, especially TB is needed both children living with HIV and affected by HIV
- Children who are not on ART should also be monitored for opportunistic infections and regular follow up is essential
- Knowledge about extra –pulmonary TB has to be provided during periodic monitoring for children and care takers
- Diagnostic facilities for extra pulmonary TB at taluk level hospitals
- Children under the care of grandparents have to be followed–up by counselors as treatment process is quite casual among such children.
- CD 4 testing also has to be maintained, six months once to ensure children enjoy good health. In some cases, children who are not on ARV have not accessed the center for more than one year for CD 4 testing
- Children have also shared that going for CD 4 testing is quite pressuring, so support and child friendly processes has to be adopted.
- Close monitoring of children on ARV and infected with TB has to be done, as such children are quite neglected, especially when they show symptoms of seizures. One boy, 13 years old is on ARV and affected by TB second time. He now has fits on a frequent basis.
- Supportive counseling has to be provided to care takers and parents as they are also affected emotionally.
- NGO's and community based organizations also should be involved and partnership working with counselors at the hospital has to strengthen.
A generous man will prosper; he who refreshes others will himself be refreshed.
Jeyapaul Sundar Singh
Buds of CHRIST
Tiruchengode. Tamil Nadu. India
Email: budsofchrist@gmail.com
I will like to comment on the post by Christine (online at: ). It says: "Children need substitution because breast milk only is not enough for their growth. So in this situation, mothers chew food for them and are fed through mouth to mouth, in this case, if a mother has TB, then the child gets it directly from the mother".
I am sorry. I can't support this statement.
If the children swallow the bacilli with the food, the bacilli will not pass the lungs and therefore, lung infection is excluded.
Best regards
Muherman Harun, Indonesia
Email: mhjkt01@attglobal.net
Comment from Dr Shanta Ghatak
****************************
I will like to add my comment in the ongoing online discussion on TB and children:
1. DOTS and BCG had a definite role to play
2. Paediatric drug boxes according to the 4 weight bands are used sub optimally EVERYWHERE and is being MORE utilised for low weight adult population and INH prophylaxis is very much neglected for children below 6 years of age. Awareness in the paediatrician population as well as coming out with useful pictorials during the mothers' meetings will definitely help.
3. Children suspected with TB are clinically diagnosed by hundreds of private providers and are prescribed ATT syrups and other scored dispersible medications- it is just that these children are not being notified at all whereas ONE SMEAR POSITIVE INDEX CASE in the community does speak a lot about the ongoing epidemiology of the disease
4. Many never go to school and those that do go have no idea about TB , nor the community that they belong to.Even if they have been sensitised by RNTCP- great numbers don't follow the guidelines for various issues
5. Extra-pulmonary TB is not a grey area anymore, it is ignorance from the entire medical fraternity
6. International Standards for TB Care 4 & 5: Radiographic suspects to meet criteria of 2 now (earlier was 3), ISTC guidelines have been reframed and it is hardly possible to keep up with the continuous changes in guidelines and reports
7. It is unbelievable how enormous amount of data are generated every quarter by the Revised National TB Control Programme (RNTCP) and never seen, understood or acted upon
8. # 3 Is (IPT, infection control, Intensified case findings) is another area that shouldn't be ignored
9. In persons with HIV infection diagnosis should be expedited but HOW?? Who will diagnose? Not many ARTs in the countries are equipped with this facility, and numbers where such facility exists, is very low.
10. It is evident that desegregated data for children with TB, association of TB and HIV/AIDS is hardly reviewed with serious concern. LOOKING AT SPECIFIC DATA FROM NRHM AND RNTCP IS DISPROPORTIONATE
11. Efforts have been there to address TB in children but not prioritised – so TB among children remains the same over years.
12. National level targets are set but NRLs are unable to cope with the sudden influx of activities of DOTS Plus services and officers are unwilling to decentralise with technically competent sectors and highly valued NGOs
13. It is hard to digest the money private providers /NQPPs are making beforeletting the patients in for regular DOT services....before long it is proved to be very late
14. These issues have been raised earlier too, issues are at the forefront, issues warrant discussions and panel discussions, issues are discussed and highlighted in world forums across continents but multinationals and private providers keep on the ball rolling for the seminars and workshops without feeling the pinch EVER!!!
Dr Shanta Ghatak
Email:drshantaghatak@gmail.com
May I comment on the following statement by an anonymous post on the eForum, that "The tuberculosis germ can spread from mother to infant if the mother coughs, sneezes, laughs, speaks, or sings and saliva or sputum is inhaled by her infant".
My point of view is that, "TB infection is an air-borne infection from droplet nuclei containing 1 or two TB bacilli".
THE EXPLANATION: After a cough or sneeze, many droplets will be produced from patient's mouth/nose. The smallest droplets fail to fall on the ground. They remain floating in the air. These are the tiniest droplets, called the droplet nuclei. Only these droplets are capable to enter the lungs (avoiding contact with the bronchial/subbronchial mucosa, thus escaping attack from the bacilli killer: the macrophages).
These tiniest droplets may end up in the alveoli, causing infection. The droplets on the ground can't enter the nose/lungs of contacts and are non-contagious for good. Dust containing bacilli cannot enter the alveoli, nor can the bacilli as such enter the alveoli. To cause infection, the droplet nuclei must have the very particular physical characteristics that enable them to reach the alveoli without contacting the bronchial mucosa.
Saliva is the product of salivary glands in the mouth. It may occasionally have only very few bacilli as compared with the number of numerous TB bacilli which are present in sputum. Microscopists refuse if mere saliva is presented for examination (they won't be able to detect any bacilli).
In conclusion, the main source of TB infection is coughing or sneezing producing droplet nuclei containing TB bacilli rather than speaking, laughing or singing when mere saliva is produced.
Muherman Harun
Jakarta, Indonesia
Email: mhjkt01@attglobal.net
TB in children has become uncommon in high TB prevalence countries when routine BCG vaccination is routinely given to all new-born babies.
BCG vaccination very effectively prevents many deaths from military and or meningitis TB. Besides, it is also effective in reducing the incidence of extra pulmonary TB (e.g. exsudative pleuritis).
Why is childhood TB so difficult to detect? The child usually has no symptoms and remains quite well. There would be no reason for the parents to see their medical doctor. The 'disease' is self-limiting.
It will simply cure by itself. So that even in high TB prevalence countries, more than tens of millions tuberculin positive adults, never ever remember as having experienced childhood TB (unless falsely diagnosed and treated).
Theoretically, childhood TB can be detected if centrifugal contact examination of a sputum positive case is routinely carried out and the child not having received BCG at birth (which is rare in our country).
BCG also appears to mask the manifestation of primary or childhood TB on chest x-ray so that no childhood TB can be found. Or, perhaps there is no more childhood TB after successful BCG vaccination?
Which means that childhood TB is no more a public health or medical problem?
Children, who fail to thrive, who often cough and from time to time have sub febrile temperature, have less appetite, transpiration at night and show no response to antibiotics, are often falsely treated as childhood TB. False diagnoses are commonly made by pediatricians, chest physicians, not excluding those having the highest respectable position in medicine!
The unfortunate children are treated with anti TB drugs for over 6 months. Other cases are treated for another 6 or even 12 more months, as the chest x ray result from radiologists show that lungs are not yet entirely 'normal' and activity may still be suspected. (On retrospection, all of the chest x rays from the start of treatment, were in my opinion, just normal).
If the tuberculin test and or other serologic tests are used for supporting the diagnosis of Childhood TB, over-diagnosis may become rampant. The National Scoring System for the diagnosis of childhood TB also leads to misdiagnoses of primary lung TB in children. To 'prevent' spread of disease the physician may have all the household members carry out tuberculin tests, sputum smear examinations and chest x rays, without discrimination. Which is of course is of no avail as the child has no TB after all!
The children on anti TB drugs still have cough etc if triggered by certain food, cold drinks or temperature, exercise etc. When asthma treatment was given they eventually got better.
In conclusion: In countries where BCG vaccination is given at a national scale we have to be aware of the numerous (false-) diagnoses of pulmonary childhood TB. One may not ever find children with (lung) TB anymore. Except, in very exceptional cases, where the child has the common signs and symptoms of (adult) lung TB, with chest x ray showing lesions consistent with progressive pulmonary TB and producing sputum containing TB bacilli.
Dr Muherman Harun
Jakarta, Indonesia
Email: mhjkt@attglobal.net
ADDENDUM 1. Classical findings in childhood TB (Primo-TB in children):
--------------------------------------------
1. The presence of a source of infection (adult patient with pos
sputum)in the same house hold.
2. Child had no routine BCG vaccination
3. Child has no clear symptoms of TB (has a self-limiting disease)
4. Chest X ray shows Primary TB complex: enlarged hilar lymphnodes (with the peripheral infiltrate = Primary affect too small may not be visible on chest x ray).
Differential diagnosis: Adult TB (peripheral infiltrates with or without local pleura reaction, cavity); thymus (temporary visible due to allergy), pronounced normal hilar bloodvessels.
ADDENDUM 2. Preventing spread of infection:
--------------------------------------------
There is only one most effective way to instant and effective prevention i.e. immediate treatment of source of infection with proper anti-TB drugs. No need to wait 2 - 3 weeks for source to become non-infectious!
Welcoming your comments,
Dr Muherman Harun
Jakarta, Indonesia
Email: mhjkt@attglobal.net
Post a Comment