1. Finding the most neglected:identifying and treating more children with TB
TB is a leading killer of children, yet they remain utterly neglected. TB is a top 10 cause of death in children.
Each year more than 500,000 children suffer from TB and 74,000 die.
Clemax Couto Sant´Anna, MD, PhD
NTCP Brazil, Advisory Committe

2. Actions to improve TB care WHO and the Stop TB Partnership point to 3 key actions needed to improve TB care and prevent TB deaths in children
Trained Health workers
Detection and management of children with TB
Contact tracing and IPT
Detect active TB and latent TB
Prevention
Identifying and treating more children with TB
New (and “old”) diagnostic tools
Diferences between TB in children & adolescents

3. PREVENTION: Tuberculin skin testing & IGRAS
TST
IGRAS
Easy training
Yes No
Can be used in serial tests (repeated tests) – PLWHA contacts, health professionals
Evidence of benefit of IPT among positive TST people ??
Needs 1 visit for result - lost cases
Lab is not necessary
“Indetermined” results
Indetermined (~2%) results; in a Brazil study : 27%
PNCT. MS- Brazil, 2014

4. PREVENTION: Tuberculin skin testing & IGRAS
Extent and Effects of Recurrent Shortages of Purified-Protein Derivative Tuberculin Skin Test Antigen Solutions — United States, 2013.
Weekly. December 13, 2013 / 62(49);
Tub
TST
IGRAS
Easy training
Yes No
Can be used in serial tests (repeated tests) – PLWHA contacts, health professionals
Evidence of benefit of IPT among positive TST people ??
Needs 1 visit for result - lost cases
Lab is not necessary
“Indetermined” results
Indetermined (~2%) results; in a Brazil study : 27%
IGRAs should not replace the TST in low-and middle-income countries for the diagnosis of LTBI in children or for the diagnostic work-up of children (irrespective of HIV status) suspected of TB disease in these settings
RECOMMENDATION 5. Guidance for NTP on the management of TB in children.WHO, 2014.

5. DIAGNOSIS: Specimen collection methods
Nasopharyngeal aspiration
Bronchoalveolar lavage
Sputum induction
Lynph node fine needle aspiration
Gastric aspiration
String test
Stool

6. WHO. Guidance for NTP on the management of TB in children, 2014
Guidance on approach to diagnosis of TB in children (WHO. Guidance, 2nd ed,2014)
Careful history (including history of TB contact and symptoms consistent with TB)
Clinical examination (including growth assessment)
Tuberculin skin testing
Chest X-ray (if avaliable)
Bacteriological confirmation whenever possible
Investigations relevant for suspected PTB and suspected EPTB
HIV testing
WHO. Guidance for NTP on the management of TB in children, 2014

7. Pulmonary TB in children and adolescents Diferences
Children - Primary TB
Clinical signs & sintoms, contact, X rays , TST.
Diagnostic Score
Adolescents - Adult type TB
Clinical and bacteriological (or molecular) assessment.
Xpert

8. Score system for diagnosis of pulmonary TB in children (and negative adolescents).MOH-Brazil

9. Scores for Childhood TB dianosis. Sistematic review, 2012
Scores and systems
Statistics
Kenneth Jones
S- 56%
Sp – 73% - 95 %
Ghidey & Habte
S – 100%
Keith Edwards
S – 62% - 88%
Sp – 25 – 97%
WHO (Tdjani et al)
S – 0%
Sp – 100%
IUATLD
S < 70%
Sp < 70%
MOH Brazil
(Pulmonary TB)
Cutt-off ≥ 30 points
S – 88,9 – 99,3%
Sp – ,5%
Cutt-off ≥ 40 points
S – %
Sp – %
Pearce EC et al. Aids Res Treat 2012; 4018

10. J. Pio - SMSDC . Rio de Janeiro, Brazil
Gene Xpert Diagnosis of paediatric TB in Community-based TB services Rio de Janeiro, Brazil. 2014
Period: Aug- Sept 2014
Children
Adolescents
Total
8/68 (11. 8 %)
(n/suspected cases)
1 (1.5%)
RMP resistance- ᴓ
7 (10.2%)
J. Pio - SMSDC . Rio de Janeiro, Brazil

13. Finding the most neglected: identifying and treating more children with TB
Integrating CTB into Community-based child health care
Inclusion of CTB in reviews and monitoring missions led by NTBCP
Development of national leadership in adrressing CTB and working groups focusing on CTB
Implementation and evaluation of training activities relating to CTB
Development of clinical guides/national guidlines for managing CTB
Situation analyses and identification of national priorities for implementation
ROADMAP FOR CHILDHOOD TB, 2013 (adapt).