1. Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB Junia Cajazeiro, Atadjan Khamraev, Philip Du Cros, Tleubergen Abdrasuliev, Joan Argen, Robert Cannon;
MSF Scientific Days - New Delhi
28th May 2016
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

2. Background
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

3. Background Tuberculosis in children Diagnostic challenges Symptoms
Laboratorial confirmation  
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

4. Background Tuberculosis in children Diagnostic Tools Contact tracing
Sputum induction
Gastric aspirate  
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

5. Aim
Compare treatment regimens prescribed for patients with a positive laboratory diagnosis of TB and those with a negative lab diagnosis in the paediatric population in Karakalpakstan.
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

6. Methods
Retrospective analysis of routinely collected MSF/MoH programme data
Children and adolescents 18 years of age
Started on DS-TB or DR-TB treatment
in 2013 through 2015
This retrospective study met the criteria of the MSF Ethics Review Board for exemption from ethics review
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

7. Results
A total of 655 paediatric patients were started on TB treatment during in Karakalpakstan
Median (IQR) age was 13 (7-16)
332 (51%) were male
128 (20%) were less than 6 years old
457 (70%) patients did not have a lab confirmation of TB
198 (30%) had a lab diagnosis
452 (98.9%) from the 457 without lab confirmation were started on DS-TB therapy.
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

8. DS TB treatment outcomes in 2013-2014 for children – 355 patients
Good outcome: 247 (69.5%)
Death: 1 (0.3%)
Fail: 1 (0.3%)
Lost of follow up: 11 (3.1%)
Transferred to MDR treatment: 10 (2.8%)
Missing results: 85 (24%)
Good outcome: cured -15(4.2%) / Tx completed – 232(65.3%).
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

9. Results Lab diagnosis by Treatment category 452 81
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

10. Results 457 patients with negative lab results
1% - MDR treatment
198 patients with positive lab results
41% - MDR treatment
Odds ratio 63, p value< 0.001
Adult population in KK
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

11. Results 4% [5/128] < 6 years old had a lab diagnosis
Lab diagnosis by Age group
Odds ratio 14
(95% CI 6-45, p<0,001)
193
123
4% [5/128] < 6 years old had a lab diagnosis
37% [193/527] aged 6-18 years had a lab diagnosis
Odds Ratio: 14 [95%CI 6-45; p=0.0000] for children >6 years of age to have a lab diagnosis compared to those < 6
So it is a risk factor for not having a lab diagnosis being less than 6 years old.
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

12. Results Treatment category by treatment course
Of 655 patients, 44 (6.7%) had 2 courses of treatment during 2013 through For first treatment course 42 of 44 were started as DS. On second treatment course, 36 (81.8%) of the 44 patients were started on DR-TB therapy – all had a lab diagnosis. Of the 8 patients started on DS-TB treatment, only 1(12.5%) had a lab diagnosis.
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

13. Results First course DS-TB treatment starts and subsequent lab results
Of the 42 that started as DS treatment, 26 [62%] had drug sensitivity results. Of those patients started on DS treatment with drug sensitivity results, 21 (81%) were found to have DR-TB. Range 24 – 246 days from the first treatment to the diagnosis made. Average 96 days. Median 63 days. IQR 40 – 185 days. Total 4046 days. So, this is the delay from clinical diagnosis to lab diagnosis – delay to the right treatment – should we wait more for lab results?
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

14. Conclusion
DR-TB is being underdiagnosed in children, especially those of a younger age
Contact tracing is a critically important when there is a lack of lab diagnosis in children to try to identify the potential source of their infection to determine the likelihood of
drug-resistant TB
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

15. Lessons learned
Need for an increased suspicion of DR – TB in children in Uzbekistan
Need for increased efforts to get a lab diagnosis in children
Critical importance of contact tracing, especially in children without a lab diagnosis
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

16. Acknowledgements Ministry of Health Karakalpakstan – Uzbekistan
Nukus MSF Epidemiology Department, Karakalpakstan
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.

17. Thank you! Contact: juniamdc@gmail.com
Junia Cajazeiro, MSF OCA, Tuberculosis in children in Uzbekistan: Don’t forget drug-resistant TB.