1. Increased case detection in infants and children Robert Gie Childhood TB Subgroup

2. Overview TB in pregnant woman Post partum TB and the infant TB in the HIV-infected infant Screening children exposed to an infectious source case Barriers to the diagnosis of TB in children

3. Transitions of TB in pregnancy Susceptible Exposed Infected Pregnant Diseased Recognized Diagnosed Delivery Infant Diseased or infected Diagnosed Cured or prevented Adapted from Don Enarson

4. Consequences of maternal TB Increased maternal mortality : 3 fold HIV infected mother have a 10 fold increase in TB TB increases the probability of infant death by 2.2 to 6.4 fold Congenital TB mortality = 21-38%

11. Challenges: We have an opportunity to integrate maternal and child health by; –Integrating VCR and TB screening during pregnancy –Screening mother and child in the postpartum period This will lead to an decrease in maternal and infant mortality rates and increased HIV and TB case finding

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17. Source case’s: now 5 month old daughter 03.12.03

19. The mother’s sister

20. The Grandmother’s

21. Questions raised? How do we integrate screening for TB into: –Antenatal care –PMTCT program –Post partum care –Nursery (kangaroo care) What should be included in the screening? How do we manage neonates exposed to an infectious case of TB? ( and MDR exposure?)

22. What is the risks to HIV infected infants?

28. The risk of developing TB in HIV infected infants: HIV infected children have ; –Increased risk of being exposed to TB –Increased risk of developing disease (24 fold) All children suspected of having TB must be tested for HIV in high prevalence communities At each health care visit each HIV-infected child must be screened for TB

29. Barriers to diagnosis: Reasons why TB is not diagnosed: –Lack of screening for disease – “TB in children is difficult to diagnose” –Dosage uncertainty and lack of child friendly drugs –Lack of reporting and recording

33. Demystifying childhood TB Obstacles for children to be diagnosed: –“Difficulty in making diagnosis” –Lack of diagnostic tools Tuberculin skin test Chest radiography Difficulty in specimens collection and culture.

34. Difficulty in making the diagnosis. Is it true that the diagnosis of childhood TB difficulty? –History based screening. –Value of history in making the diagnosis

40. Demystifying childhood TB diagnosis Screening for children can effectively done by history except in high risk groups (HIV infected and less than 2 years of age) The diagnosis of childhood TB in the majority of cases is simply Diagnosis accuracy will be increased by the use of –Tuberculin skin test –Chest radiography –Culture and sensitivity Simple tools are underused : Fine needle aspiration

41. TB drug dosages:

43. Recording and reporting

44. Summary Increase the case finding in infants and children Integrate maternal and child health with increased VCR and TB screening during –Pre-natal clinics –Post-natal clinics –In nurseries Any infant and child suspected of TB must be tested for HIV Screening children for TB can be successful using symptoms The diagnosis of TB in children is in the majority is easy especially in HIV non-infected children