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Tuberculosis in

Children and
Young Adults

DR JOYCE M KADUCU
Objectives

Overview global epidemiology


Review available surveillance data
and epidemiologic studies
Review TB and HIV association
Assess data limitations
Provide recommendations for future
data collection and research
Tuberculosis
A Global Emergency
One third of the worlds population is infected
TB kills 5,000 people a day 2-3 million each
year
HIV and TB co-infection is producing explosive
epidemics
Hundreds of thousands of children will become
TB orphans this year
MDR threatens global TB control
Background

Tuberculosis (TB) is increasing


among adults in many areas
TB is major cause of childhood
morbidity and mortality worldwide
Limited information on epidemiology
of TB in children
Childhood TB
Why neglected?
Not considered important in global program
or contributing to immediate transmission
Not regarded as public health risk
Difficult to diagnose
Why is it important?
Health problem in children
May later contribute to epidemic
Leading Infectious Disease
Causes of Death, 1998
Death in millions

4 3.5
Under age 5
3 2.3 2.2 Over age 5
2 1.5
1.1 0.9
1
0
I S a ir a s
A
R ID e TB l e
A rh l a s
i ar M
a e a
D M
WHO Report 2000
TB in Children
WHO estimate of TB in children
1.3 million annual cases
450,000 deaths
15% of TB in low-income countries
children vs. 6% in United States
Childhood TB as Sentinel Event
Indicates recent transmission in a
community
Rapid progression from infection to
disease
A deterioration in the control of TB thus
immediately hurts the youngest generation
(Rieder, 1997)
Children are future reservoir of disease
Rieder H. Anales Nestle, 1997
700
Male
600 Female
Per 100,000 population

500

400

300

200

100

0
<1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54
Age (years)
Effect of HIV?
Childhood TB diagnosed by:
Combination of :
Contact with infectious adult case
Symptoms and signs
Positive tuberculin skin test
Suspicious CXR
Bacteriological confirmation
Serology
Risk factors : infection to disease
HIV
Malnutrition
Recent exposure
Young age
Short incubation period
More severe
Highest risk
More difficult to diagnose
Host factors
Effect of HIV?
Risk of Progression to Disease
Age
43% in infants (children < 1year)
25% in children aged one to five years
15% in adolescents
10% in adults
Recent Infection
Malnutrition
Immunosuppression, particularly HIV
Miller, 1963
Challenges for Surveillance

Difficult diagnosis of childhood TB


Lack of standard case definition
Increased extrapulmonary disease
Low public health priority of
childhood TB
Active Case Finding of TB Meningitis

South Africa study among children


< 15 years
Only 56% of cases were registered
16% of all cases in register contained
errors
Incorrect diagnosis, double notification,
clerical error

Berman et al. Tubercle. 1992; 73: 349-55.


Extrapulmonary TB in Children

Proportion in a given country could


be used as measure of case
detection
25-44% of all childhood TB in Ugandan
study
43% of children in Ethiopian study
21.3% of childhood TB using US
surveillance data
TB and BCG Vaccination
Efficacy for adult pulmonary TB 0-
80% in randomized clinical trials
Best efficacy against serious
childhood disease
64% protection against TB meningitis
78% protection effect against
disseminated TB
BCG important for young children,
inadequate as single strategy
Colditz GA et al. JAMA 1994; 271: 698-702.
Relationship between TB and HIV
What about children?
800
(per 100 000 population)
Estimated TB incidence

600

400

200

0 0.1 0.2 0.3 0.4

HIV prevalence adults 15- 49 years


TB/HIV Coinfection in Children

11-64% of children with TB are coinfected


with HIV in published studies
1-12% of children with AIDS in autopsy
studies found to have TB
Other lung disease in children with HIV
common
Difficulty of confirming TB in HIV-infected
children may result in overdiagnosis and
overreporting
Clinical and immunopathological course of
HIV associated TB
Treatment questions
Difficult to evaluate true cure
Recommended same length of treatment as
adults
HIV & length of treatment??
Many uncertainties eg pharmakokinetics,
treatment of MDR-TB
Relapse/re-infection in HIV positive children
Mortality?
Conclusions
Data on trends in childhood TB are
limited
Consensus needed on common
definitions
Few epidemiologic studies in children
worldwide
Additional studies are needed
Childhood TB needs to become a priority