Pediatric multidrug-resistant tuberculosis gets more attention

Due to difficulties in establishing accurate diagnoses and lower priorities assigned by tuberculosis (TB) control programs, pediatric TB has been relatively neglected. Treatment delays lead to the progression of disease, increased risk of infectiousness, greater complications, and higher rates of morbidity and death.


“The key learnings identified from this study are that the time of initiation of diagnosis is large, reflecting the difficulty in diagnosing pediatric TB and the lack of consensus among practitioners.”
-Gulrez Shah Azhar, MBBS, MD, MPH, senior lecturer, Indian Institute of Public Health, Ahmedabad, India, and member of mdCurrent-India’s Editorial Advisory Board


Approximately 1.5% of 245,000 new smear positive TB cases in India are in patients aged 0 to 14 years, with pediatric cases making up[s2If !is_user_logged_in()]…

[/s2If][s2If is_user_logged_in()] 3% of the total new registered caseload, according to the Revised National Tuberculosis Control Programme (RNTCP) for Directly Observed Treatment (DOT).

Key Point: Clinicians who treat children should always screen them for tuberculosis and treat infected patients with the best available agents following current guidelines. Children’s caregivers should be encouraged to continue treatments unless serious side effects occur or the initially prescribed medications aren’t tolerated. These children must receive follow-up care that includes alternate treatments.

Investigators of a meta-analysis published recently in Lancet Infectious Disease reviewed 8 studies of TB treatment outcomes in children (n=315) who were cured and completed treatment. Among these studies, treatment success was 82%, while 6% died, 6% were lost to follow-up, and 39% experienced an adverse event. Nausea and vomiting were most common, but hearing loss, psychiatric effects, and hypothyroidism also occurred.

All of the patients included in the analysis were 16 years of age or younger and were treated for an average of 6 months to 34 months. There was much variability between the studies in the programs and patients. Examples included the time to appropriate treatment, which varied from 2 days to 46 months; the duration of treatment and follow-up, which ranged from 12 months to 37 months; and the average treatment duration, which ranged from 6 months to 34 months.

“The key learnings identified from this study are that the time of initiation of diagnosis is large, reflecting the difficulty in diagnosing pediatric TB and the lack of consensus among practitioners,” said Gulrez Shah Azhar, MBBS, MD, MPH, senior lecturer, Indian Institute of Public Health, Ahmedabad, India, in an exclusive interview with mdCurrent-India. “The time to appropriate treatment ranged up to [nearly] 4 years, again reflecting the difficulty in diagnosing pediatric TB. There was also a large variation in treatment duration, noting a lack of consensus among practitioners while the WHO recommends a duration of 18 months, but a shorter duration may be desirable.”

Azhar, who is a member of mdCurrent-India’s Editorial Advisory Board, also noted: “There was a high percentage of adverse events, so children need to be regularly screened so they do not discontinue treatments which we took so long to put them on.”

According to the World Health Organization’s 2006 guidance on the management of TB in children, standardized approaches based on the best available evidence are required to successfully manage these patients by engaging all pediatric care providers and then including these standardized approaches in national treatment programs (NTPs). Pediatric cases are not routinely recorded and researchers have said that these data are severely underreported, with a greater burden of disease known to occur in these younger, more vulnerable patients.

While pediatric multidrug-resistant TB has been undertreated, when children are treated, the clinical outcomes are at least as good as those reported for adults. Clinicians and public health organizations encourage clinicians to report pediatric outcomes to improve the knowledge base for care, especially as new drugs become available.

Sources:
Ettad D, Schaaf HS, Seddon JA, et al. Treatment outcomes for children with multidrug-resistant tuberculosis: a systematic review and meta-analysis. Lancet Infect Dis. 2012;12:449-456.

Karande S, Bavdekar SB. Children and multidrug-resistant tuberculosis in Mumbai (Bombay), India. Emerg Infect Dis [serial online]. November 2002. Available at http://wwwnc.cdc.gov/eid/article/8/11/02-0513.htm.

Formulation of guidelines for diagnosis and treatment of pediatric TB cases under RNTC. Indian J Tuberc. 2004;51:102-105. Available at: http://medind.nic.in/ibr/t04/i2/ibrt04i2p102.pdf.

Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children. Geneva, World Health Organization, 2006 (WHO/HTM/TB/2006.371). Available at: http://whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.371_eng.pdf.

Access the original journal information here:
http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2812%2970033-6/fulltext
Journal publishers are independent from mdCurrent-India and may require a subscription or charge a fee to download the full article.

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