Tuberculosis in Children: Prevention Module 10C - March 2010

Project Partners Funded by the Health Resources and Services Administration (HRSA)

Module Overview  The child contact  BCG vaccination International Standards 18 and 19

Learning Objectives Upon completion of this session, participants will be able to:  Determine which child contacts should receive Isoniazid Preventive Therapy (IPT)  State the current Expanded Program on Immunization recommendations regarding BCG  Name the factors that should be considered when reviewing country policy on BCG vaccination

TB Prevention: The Child Contact

ISTC Standard 18 All providers of care for patients with TB should ensure that persons who are in close contact with patients who have infectious TB are evaluated and managed in line with international recommendations. The determination of priorities for contact investigation is based on the likelihood that a contact: 1.Has undiagnosed TB 2.Is at high risk of developing TB if infected 3.Is at risk of having severe TB if the disease develops 4.Is at high risk of having been infected by the index case

ISTC Standard 18 (2) The highest priority contacts for evaluation are:  Persons with symptoms suggestive of tuberculosis  Children aged <5 years  Contacts with known or suspected immuno- compromise, particularly HIV infection  Contacts of patients with MDR/XDR tuberculosis  Other close contacts are a lower priority group

Child Contact  Children who are newly infected with M. tuberculosis are at high risk for miliary TB and possibly TB meningitis TB disease can develop within weeks unless the child is given preventive therapy!  Close contact screening and management is recommended by most NTPs, but it rarely happens in low- resource settings where the majority of childhood TB occurs

Child Contact (2)  Responsibility for conducting contact tracing should be assigned to a health care worker (ideally the one who registers and/or also supervises treatment of the source case)  Could also provide isoniazid preventive therapy (IPT) or treatment to the children More convenient for the household/family Facilitates compliance

ISTC Standard 19 Children <5 years of age and persons of any age with HIV infection who are close contacts of an infectious index patient and who, after careful evaluation, do not have active tuberculosis, should be treated for presumed latent tuberculosis infection with isoniazid.

Child Contact (3)  All child contacts should be screened for TB as soon as they are identified as a contact  Once screened and active TB ruled out, children recommended for IPT should then be registered separately and have their own IPT card  High priority should be given to examining contacts who are children or who are HIV infected

Child Contact (4)  The family of a child diagnosed with TB must be examined to identify the source case  The source case is often someone in the child’s close social network  The investigation should also attempt to identify others who may have been infected by the source case

Recommendations for Management of Child Contacts to Infectious PTB 1.Mantoux tuberculin skin test positive children: If well, offer IPT for 6–9 months If unwell, further evaluate for TB disease Provide treatment for disease if tuberculosis is evidenced

Recommendations for Management of Child Contacts to Infectious PTB (2) 2. Mantoux tuberculin skin test negative children: If well, offer IPT for 2 months then repeat TST – If TST positive at 2 months, continue IPT for a total of 6–9 months – If negative at 2 months, discontinue IPT If unwell, further evaluate for TB disease – Detailed history, physical exam and chest x-ray if possible – Treat for disease if TB is evidenced

Recommendations for Management of Child Contacts to Infectious PTB (3) 3. When the Mantoux tuberculin skin test is not possible: If well, educate the care giver to return with the child should the child become ill – Suggest a routine follow-up in 1 month If unwell, obtain a history and examination for TB and include a chest X-ray if possible – Treat for tuberculosis if evidenced

Approach to Contact Management when Chest X-ray and Mantoux TST are Not Readily Available

Child Contact is Known to be HIV-Infected 1.Must rule out active TB disease first!  if found to have TB disease, refer to the NTP for registration and initiation of treatment 2.If the child contact is HIV-infected and otherwise well:  consider IPT for all ages, including those aged 5 years and older

Suspected HIV Infection of Source Case and Contact  In HIV-endemic countries, the children of a parent with smear-positive PTB may be at risk for both TB and HIV infection Ask if HIV status of the source case and child contact is known Consider HIV counseling and testing

Contacts of Infectious MDR-TB  Clinical follow-up of close contacts for at least 2 years  If active TB disease develops, initiate an MDR-TB regimen in consultation with an expert in the management of MDR-TB

Management of a Baby Born to a Mother Diagnosed with Infectious PTB  Once a pregnant woman has been on treatment for at least 2–3 weeks, she is generally no longer infectious  If a pregnant woman with TB has been on treatment for TB for several weeks before delivery, it is less likely that the baby will become infected  The risk is highest if a mother is diagnosed at the time of delivery or shortly thereafter

Management of a Baby Born to a Mother Diagnosed with Infectious PTB (2)  A breastfeeding infant of a mother with smear-positive PTB has a high risk of TB infection and of developing TB disease The infant should receive 6 months of IPT, followed by BCG immunization; or Give 3 months IPT, then perform TST – If TST -, stop INH and give BCG – If TST +, continue INH another 3-6 months then give BCG (WHO/HTM/TB/ )

BCG VACCINATION TB Prevention

BCG Vaccine and Efficacy  Bacille Calmette-Guérin (BCG) is a live attenuated vaccine derived from Mycobacterium bovis  There is a wide range of reported BCG efficacy in published studies to date (from 0-80%) It is generally accepted that BCG vaccination provides protection against the more severe types of TB

BCG: Risk in HIV-Infected  HIV-infected children vaccinated with BCG at birth, and who later developed AIDS, were found to have an increased risk of developing disseminated BCG disease  In 2007, WHO revised their BCG vaccination guidelines to exclude children known to be HIV-infected from receiving BCG, even if asymptomatic

BCG: EPI Recommendations  For the HIV-exposed infant: Defer BCG vaccination until HIV status is known  For the HIV-infected infant: BCG should not be given regardless of the status of the baby (symptomatic or asymptomatic)

BCG: Policy Considerations  Factors to consider when deciding on BCG vaccination policy most appropriate for country implementation: HIV and TB prevalence in the country and within sub-populations Access to and usage of PMTCT programs Capacity for earlier infant diagnosis of HIV Capacity for surveillance of BCG adverse events

Summary: ISTC Standards* Standard 18: All providers of care for patients with TB should ensure that persons who are in close contact with patients who have infectious TB are evaluated and managed in line with international recommendations.The highest priority contacts for evaluation are:  Persons with symptoms suggestive of tuberculosis  Children aged <5 years  Contacts with known or suspected immunocompromise, particularly HIV infection  Contacts of patients with MDR/XDR tuberculosis  Other close contacts are a lower priority group * Abbreviated versions

Summary: ISTC Standards* (2) Standard 19: Children <5 years of age and persons of any age with HIV infection who are close contacts of an infectious index patient and who, after careful evaluation, do not have active tuberculosis, should be treated for presumed latent tuberculosis infection with isoniazid. * Abbreviated versions

Summary  TB infection in a child can progress rapidly to TB disease; therefore, child contacts should be promptly evaluated  Once active disease ruled out, IPT should be provided in child contacts as indicated  The role of BCG vaccination as a TB prevention strategy must be carefully considered. Selective deferral of BCG may be indicated in some country settings