Child TB: global and regional update Ninth TAG meeting and NTP Managers Meeting 9-12th December 2014 Manila Steve Graham Centre for International Child Health, University of Melbourne International Union Against Tuberculosis and Lung Disease (The Union) Child TB sub-group, Stop TB Partnership

The objectives of the meeting were: The Meeting on the Development of Child Tuberculosis Action Plans in the Western Pacific Region: HCMC, Viet Nam, March 2014 The objectives of the meeting were: To share country experiences, lessons learnt and best practices; To establish priorities and design activities for strengthening childhood TB initiatives in the Western Pacific Region; and To form a task force to oversee the activities and progress. The meeting was attended by 21 country participants from 8 countries (Cambodia, China, Fiji, Lao PDR, Mongolia, PNG, Philippines and Viet Nam). Each country team was composed of focal point from NTP, maternal and child health programme and paediatric association. Also 17 observers participated the meeting from different technical agencies.

Priorities for strengthening childhood TB activities in the WPR 1. Improved political commitment and collaboration with different stakeholders (e.g. MCH, EPI; partners like UNICEF, World Vision; paediatric associations, private providers) 2. Improved case detection 3. Improved case management and logistical management 4. Improved prevention (BCG, IPT, infection control) 5. Improved recording, reporting and data analysis (including private sector) 6. Improved awareness of community and capacity building of health care worker 7. Operational research

Formation of a Regional Child TB Task Force Participants of the Meeting formed an informal taskforce called 'The Regional Childhood TB Taskforce' on the Development of Child TB Action Plans in the Western Pacific Region The Regional Childhood TB Taskforce will support members to finalise national action plans and convene a regional workshop (with partners).  Chair: Steve Graham Co-Chair: Dr James Amini (PNG); Dr Nguyen Thein Huong (Viet Nam) Vice Chair: Dr Celine Garfin (Philippines); Dr Lin Zhou (China) Members: All participants of the meeting Secretariat: WPRO,WHO Next meeting: Union APR conference, Sydney, August 2015  

Objectives and activities of the taskforce Increase awareness of the child TB disease burden in the Asia-Pacific region Assist the development of pragmatic, contextualized national child TB action plans Monitor & support implementation of these plans Provide an education resource (training) Facilitate collaboration/integration between programs for TB and maternal and child health

Child TB at the new millenium Childhood tuberculosis: out of control? Donald PR. Curr Opin Pulm Med 2002 JR Starke

Putting child TB on the global public health agenda Child TB subgroup of Stop TB Partnership formed 2003 Children recognised as a vulnerable group in need of increased case-finding: 2009 International Child TB Meeting, Stockholm, 2011

TB in the context of maternal and child health Increasing recognition that TB is an increasingly important cause of morbidity and mortality in infants and young children globally Pregnancy-related TB – maternal and infant outcomes Orphans due to TB – estimated to be around 9 million globally Catastrophic economic costs of TB – families living with TB TB in adolescents – uncertain burden and specific management issues

Millennium Development Goals

Innovative approaches Community-based Wider health sector Preventive therapy Operational research

Roadmap for Childhood Tuberculosis Launched Washington DC, October 1st 2013

Situational analysis a critical first step

“Know your epidemic” TB in women – best estimate 3,300,000 cases Deaths: 330,000 HIV negative 180,000 HIV positive TB in children (0-14 yrs) actual reported 275,000 15% smear-positive 54% smear-negative 31% EPTB Best estimates: 550,000 cases and 80,000 deaths

Child TB working group and NTP

Hiatt T & Nishikori N. WPSAR 2014 Age and sex-specific notification rates of new smear-positive TB cases for the Western Pacific Region, 2012 Hiatt T & Nishikori N. WPSAR 2014

Hiatt T & Nishikori N. WPSAR 2014 Age and sex-specific notification rates of new smear-positive TB cases for the Western Pacific Region, 2012 Hiatt T & Nishikori N. WPSAR 2014

Risk of TB disease following infection by age These data explain the rationale for using preventive therapy in infants and young children that have been infected with TB but do not yet have disease. The risk of developing disease following infection is age-related and is particularly high in children of less than 2 years. The observational studies also found that most children develop disease within one year following infection. The data are also from before BCG was used. As already noted, the major impact of BCG has been to reduce the size of the red bar. Adapted from Marais B, et al. Int J Tuberc Lung Dis 2004

Incident (new) TB cases Gap in surveillance Incident (new) TB cases Under-diagnosed Gap Under-reported TB case notifications known to the NTP

Poor recording and reporting Incident (new) TB cases Under-diagnosed Gap Under-reported TB case notifications known to the NTP

Incident (new) TB cases From under-diagnosis Incident (new) TB cases Under-diagnosed Gap Under-reported TB case notifications known to the NTP

Incident (new) TB cases to over-diagnosis Not TB cases TB case notifications known to the NTP Incident (new) TB cases Under-diagnosed Under-reported

Only 1.6% of 4,821 cases in children were registered with NTP

Diagnosis of child TB in Java and level of care TB cases Inpatient Outpatient Overall Total TB cases 5,877 15,694 21,571 Child TB cases N=648 N=4173 N=4821 % of total burden 11% 27% 22% < 5 years 56% 53% Smear positive disease 16% 8% 9% EPTB 15% 6% Non-teaching hospital 73% 76% 75% Private health facility 7% Lestari T, et al. BMC Pub Health 2011

Burden of child TB in four provinces of PNG: 2005-6 Law I, et al Burden of child TB in four provinces of PNG: 2005-6 Law I, et al. Poster – The Union Global Lung Health Conference 2008 Pulmonary TB Smear positive Smear negative Smear not done 1208 (61%) 18 (1%) 138 (7%) 1052 (53%) EPTB 769 (39%) Total 1977 Child TB accounts for 30% of total TB burden

Pattern of EPTB disease in children in four provinces of PNG: 2005-6 EPTB cases N=1097 Lymphadenitis Meningitis Abdominal Pleural effusion Miliary Spinal Pericarditis Bone disease Not indicated/others 342 (31%) 257 (23%) 173 (16%) 94 (9%) 64 (6%) 41 (4%) 12 (1%) 15 (1%) 99 (9%) EPTB represented 39% of childhood TB cases

NATIONAL TB PROGRAM PAPUA NEW GUINEA MANUAL ON MANAGEMENT OF CHILDHOOD TUBERCULOSIS

Child TB working group and NTP

Rapid development of diagnostics History Tuberculin Skin Test 1890 Chest X-ray 1896 Bacteriology 1882

Diagnostic yield for pulmonary TB comparing children to adults Xpert cannot be used to rule out TB Xpert needs research on implementation to inform optimal usage in children

Union – MSF Operational Research Courses TOTAL: 212 participants Europe Moldova Georgia Armenia Ukraine Azerbaijan Estonia Denmark Latvia Italy Belorussia Asia India Singapore Bangladesh China Pakistan Mongolia Afghanistan Uzbekistan Nepal Vietnam Bhutan Myanmar Sri Lanka Indonesia Timor Leste Cambodia South Pacific New Caledonia Cook Islands Tonga Marshall Islands Federated States of Micronesia Solomon Islands Vanuata Fiji South America Brazil Peru Africa Kenya Burundi South Africa Madagascar Ethiopia Lesotho Malawi Swaziland Zimbabwe Democratic Republic of the Congo Benin Sudan Somaliland Mozambique Rwanda Nigeria Uganda Somalia Ghana Sierra Leone Tanzania Liberia

MANAGEMENT OF TB IN CHILDREN IN VIETNAM

Activities 2011 - 2012 Establish childhood TB working group in NTP Political will and policy Develop the national guidelines on management of TB in children including child contact screening and diagnostic algorithms, treatment, forms and registers, M&E forms, monitoring checklist, etc… Develop and distribute IEC materials Q3 -2012 Training – provide child TB training for NTP staff at provincial, district and community level, and for pediatricians in 4 piloted provinces Provide Isoniazid, forms and registers with pilot implementation in 4 provinces 2013 - 2014 Incorporate child TB into annual plans and 5-year strategic plan Include child TB data in routine reporting and reviews GFATM funding for rolling out to additional provinces in 2015

Community awareness – and support health worker! 12,750 posters 554,400 leaflets

Community contact screening in Viet Nam Oct 2012-Dec 2013 Child contacts screened 4109 Eligible for IPT 1577 Numbers received IPT 979 (62%) % completed to date 88% (n=153) Children diagnosed with TB 345 Sputum smear positive 37 (11%) Sputum smear negative PTB 157 (46%) EPTB 151 (43%)

NATIONAL PLAN FOR THE MANAGEMENT OF TB IN CHILDREN: 2015-2020 Goal: To strengthen detection, treatment and preventive therapy for Vietnamese children towards decreasing childhood TB morbidity and mortality in Vietnam.

Regional activities in 2014 WHO WPRO, Regional taskforce, Viet Nam, March China National Child TB, Beijing, August Global consultation on child TB for high burden countries in EMRO, SEARO and WPRO, Indonesia, September

“ There are many contributions which the pediatrician can make to a TB control program. First the negativism about tuberculosis so prevalent in pediatrics must be overcome…” Edith Lincoln, 1961 Donald PR. Edith Lincoln, an American Pioneer of Childhood Tuberculosis. Pediatr Infect Dis J 2013