3 Tuberculosis in children

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Contents

• Objectives
• Cause of TB
• Diagnosing TB
• Treating TB
• Case studies

Objectives

When you have completed this chapter you should be able to:

1. Understand the cause of tuberculosis (TB) and how it is spread.
2. Describe the clinical presentation of TB in children.
3. Understand how TB is diagnosed and treated.
4. Support families where a child with TB is being treated.
5. Describe how TB can be prevented.

Cause of TB

3-1 What is tuberculosis?

Tuberculosis is usually called TB. It is a chronic illness (disease) which can affect many parts of the body but most commonly affects the lungs. This is called pulmonary TB (TB of the lung).

3-2 What causes TB?

TB is an infection which is caused by bacteria (germs). These bacteria are usually called TB bacilli.

3-3 How is TB spread?

TB is an infectious disease which is spread from one person to another. The TB bacilli are usually spread through the air when a person with pulmonary TB talks, coughs, spits, laughs, shouts or sneezes. This sends a spray of very small drops from the lungs of the person into the air. Live TB bacilli in these drops can then be breathed into the lungs of another person and give them TB infection. The risk of spreading TB bacilli is higher if people do not cover their mouth when they cough. Spitting in public can also spread TB. Sunlight and fresh air kill TB bacilli.

TB is usually spread when someone with TB coughs.

3-4 Who usually spreads TB?

TB bacilli are usually spread from an adult with untreated pulmonary TB. Therefore a child with TB has almost always been in close contact with an adult who has TB. This may be in the home, bus, taxi, crèche, school, clinic, community hall or anywhere that people are inside and close together.

3-5 Do children or adolescents with HIV infection often get TB?

Yes. HIV infection damages a person’s immune system and makes them more likely to get many different serious infections such as TB.

3-6 Do all children infected with TB bacilli develop TB?

No. Most people who get infected with TB bacilli are able to control the infection and stop the TB bacilli from spreading in their body. This is called inactive TB. In some poor communities up to 50% of all adults have had TB infection at some time during their life but only a few develop TB. Most of these people were infected when they were children. Only about 10% of children with TB infection develop TB (the disease).

Patients with inactive TB are well and not infectious to others. However if they later become undernourished or have HIV their immune system will become weak and the TB bacilli may spread in their body to cause TB. This is called active TB which needs treatment.

Many children have TB infection but do not develop TB.

3-7 Which children are at greatest risk of becoming infected with TB bacilli?

• Young children under the age of 5 years are at greatest risk.
• Children who are undernourished and live in overcrowded and poorly ventilated homes.
• Children with HIV infection.
• Children who have not had BCG immunisation.

3-8 How common is childhood TB in South Africa?

It is common especially in poor communities with crowded living conditions. Each year about 1% of the general population develops TB. TB is the commonest infection to cause death especially in people who are HIV positive.

Diagnosing TB

3-9 What would make you suspect that a child has TB?

• Someone in the family with TB.
• Poor, overcrowded living conditions.
• A child with HIV infection.
• The child is losing weight or is malnourished.
• The child has a persistent cough for more than 2 weeks.
• The child has been unwell with a fever lasting more than 2 weeks.

A cough, fever and weight loss suggest TB.

3-10 What should you do if you think a child may have TB?

It is important to refer the child urgently to the nearest clinic so that tests can be done to decide whether the child has TB.

Usually the clinical examination is not helpful in making a diagnosis of TB. A number of tests are needed.

3-11 How is the diagnosis of TB made?

The history together with the tests are used to make the diagnosis. The clinical examination alone usually will not make the diagnosis.

3-12 What tests are done when a child is thought to have TB?

• A skin test (Mantoux skin test)
• Sputum test
• Chest X-ray

A skin test, sputum test and chest X-ray are used to diagnose TB.

3-13 What is a Mantoux skin test for TB?

A small amount of TB protein is injected into the skin of the left forearm. After 2 to 3 days the site of the injection is examined. If there is a red swollen area the test is positive. This indicates that the child has TB infection but not necessary TB disease. A negative skin test with no redness or swelling suggests that the child does not have TB infection. However some very malnourished children with an mid-upper arm circumference less than 11.5 cm may have a negative skin test even though they have TB.

3-14 What is a sputum test?

This is a test on sputum which is coughed up. It cannot be done on spit. Sometimes it is difficult to get a young child to cough up sputum for the test. Usually the sputum is collected at the clinic.

A number of different tests can be done to determine whether there are TB bacilli in the sputum. If TB bacilli are present the child has pulmonary TB. A sputum test is the most accurate way to confirm a diagnosis of TB.

The sputum test for TB usually used in South Africa is called the Xpert test. It takes a few hours for a result to be given.

3-15 How helpful is a chest X-ray?

It is very important in making a diagnosis of pulmonary TB.

Treating TB

3-16 Can TB in children be cured?

Yes. More than 90% of children with TB can be cured with the correct treatment.

Most children with TB can be cured.

3-17 Can children with TB be treated at home?

Most children with TB can be treated at home with regular visits to the clinic. Children with severe TB will be treated in hospital until they are clinically improving. Then the treatment can be completed at home.

3-18 How is TB treated?

There are 2 stages in the treatment of TB:

1. First 3 or 4 medicines (drugs) are taken together for 2 months. This is called the intensive phase of treatment.
2. This is followed by 2 medicines taken together for 4 months. This is called the continuation phase of treatment.

Treatment is taken for a total of 6 months.

TB is treated with a combination of drugs for 6 months.

3-19 Why is more than one medicine needed?

Because they are much more effective than 1 medicine alone. This is called multidrug treatment. The TB bacilli become resistant to 1 medicine if it is used alone.

3-20 What medicines are used to treat TB in children?

• For the 2-month intensive phase INH (isoniazid), RIF (rifampicin) and PZA (pyrizinamide) are used in young children. In children older than 8 years a fourth medicine called EMB (ethambutol) is added to the other 3 medicines.
• For the 4-month continuation phase only INH and RIF are used.

For seriously ill children other medicines may be added.

3-21 How are the medicines for treating TB taken?

They are all taken together by mouth once a day, usually after breakfast. The dose of each medicine is calculated by the child’s weight. RIF and INH may be combined into a single pill.

3-22 What side effects do TB medicines have?

Side effects (adverse effects) are uncommon in children. If a child on TB treatment has nausea and vomiting or develops jaundice they should urgently be referred to the clinic.

Some TB medicines cause dark urine which is not a problem.

3-23 What is good adherence?

This means that the medicines are taken correctly every day at the correct time. With good adherence most children will be cured. If adherence is poor the TB may not be cured and become resistant to the medicines used. This is serious as treating drug resistant TB is difficult and not always successful. Therefore it is very important to make sure that adherence is excellent. Drug resistant TB is called MDR TB or multiple drug resistant TB.

Good adherence to treatment is essential to cure TB.

3-24 How can a community health worker improve adherence?

• Explain to patients and parents or guardians what TB is and why it is important it is to take the medicine correctly every day.
• Clear instructions must be given about how to take the medicine correctly.
• It helps to write down the instructions.
• Get parents to keep a treatment diary or a calendar where it is recorded each day whether the medicine is given. This can be checked at each home visit or visit to the clinic.
• A daily pill box is very helpful.
• A cellphone can be used to send daily reminders.
• Use DOT.
• Assess the mid-upper arm circumference in children less than 5 years old and refer to the nearest clinic if less than 11.5 cm.

Community health workers can play an important role in managing a child with TB.

3-25 What is DOT?

DOT stands for directly observed treatment. It is a way of making sure that TB medicines are taken correctly every day. With DOT a responsible person in the community observes every daily dose of medicine being swallowed. In practice this is often done from Monday to Friday with the family taking responsibility over weekends. A community health worker can be responsible for DOT. It is an important role for community health workers to make sure that patients take their TB treatment correctly.

3-26 How do most children respond to correct treatment?

After a few weeks on treatment the child will start to feel well and begin to gain weight. It is very important that the treatment is given correctly for 6 months and not stopped when the child appears to be well again.

3-27 How often should the child go to the clinic?

Every 2 weeks for the first month and then once a month until the treatment is completed. If there are side effects the child should be taken to the clinic urgently. A sputum test may be repeated after 2 months on treatment to see whether the TB bacilli have disappeared.

3-28 Should all children with TB be screened for HIV infection?

Yes. All children with TB must be screened for HIV. If the HIV test is positive both TB and HIV must be treated. Often TB treatment is started immediately but the start of HIV treatment may be delayed for a few weeks as the TB and HIV medicines may cause problems if started together. The dose of TB medicines may need to be increased if the child is also getting HIV treatment.

3-29 What are the commonest causes of treatment failure?

• Not taking the medicine correctly (poor adherence)
• Stopping treatment too early
• Not collecting TB medicines from the clinic
• Undiagnosed HIV infection

3-30 Should the rest of the family be screened for TB?

Yes. If one member of a family is diagnosed with TB all the other members should be screened for TB. Children under 5 years of age or HIV infected children will be given prophylactic TB medicine to prevent them from also getting TB as they are at increased risk of becoming infected. Use the opportunity to encourage all adult members to have their HIV status determined.

3-31 How can the risk of getting TB infection be reduced?

• Give BCG immunisation to all babies
• Improve housing and living conditions
• Improve nutrition of children
• Identify and treat adults with TB
• Suspect TB in any child who coughs and fails to thrive
• Screen family members for TB if someone in the household is diagnosed with TB
• Teach cough hygiene
• Screen all people with HIV for TB

3-32 Is there a risk that the community health worker may get TB?

Unlike adults with pulmonary TB, children with TB are usually not very infectious. If the community health worker visits an adult with suspected TB use a mask, open the windows of the house to let fresh air in, ask the patient to cover their mouth with their arm or a handkerchief when they cough (good cough hygiene). Wash your hands when you leave. It is best to meet them outside where the risk of spreading TB is less.

Once a person is on the correct treatment for a few weeks they are probably no longer infectious to others.

Case study 1

When visiting a poor home to check that the children have completed all their immunisations, the mother mentions that her father is living with them. She says he has been unwell for the past 2 months and coughs a lot.

1. Why should you be worried about the grandfather’s health?

Because he may have pulmonary TB (tuberculosis of the lungs).

2. Could this be a danger to the children?

Yes as TB may be spread from person to person through the air when an adult with pulmonary TB coughs. This sends a spray of small drops which contain TB bacilli and can be breathed in by another person. The TB bacilli can then start TB infection in the lung.

3. Is TB infection common in South Africa?

Very common. In some poor communities 50% have had TB infection in the past. However most of these people do not develop TB (tuberculosis).

4. Why do all people with TB infection not develop TB?

Because they are able to prevent the TB bacilli from spreading in the lung. However, if months or years later their immune system becomes weak due to undernutrition or HIV the TB infection may spread to result in TB.

5. Which family members are at highest risk of developing TB?

The children, especially children under 5 years of age. Their immune system is weak as they are still young.

6. What routine health care gives some protection against TB?

BCG immunisation.

Case study 2

A mother brings her child to the clinic as he is losing weight and has had a cough for the past month. The nurse who speaks to the mother is worried that the child may have TB.

1. What tests should be done on this child?

A skin test, sputum test and chest X-ray.

2. What is the Mantoux skin test?

A small amount of TB protein is injected into the skin. If this results in a red, swollen area after 2 to 3 days it indicates that the child has TB infection. However a positive skin test does not always mean that the child has TB. Many children have TB infection but not TB.

3. What sputum test is usually done?

The Xpert test is usually done on a sample of sputum to determine whether TB bacilli are present. If they are then the person has pulmonary TB. Sometimes it is difficult to get sputum from a child.

4. Do all children with TB need to be treated in hospital?

No. Most can be treated at home with regular clinic visits.

5. Can TB be cured?

Yes. With the correct treatment most children and adults can be cured.

Case study 3

A 10-year-old child is started on TB treatment and the community health worker is asked to visit the home and support the family.

1. How is TB treated?

With 3 or 4 drugs every day for 2 months followed by 2 drugs every day for a further 4 months. The medicine is taken by mouth once a day usually after breakfast.

2. Why is good adherence so important when treating TB?

Because the TB will not be cured if too many doses of medicine are not given correctly. Therefore it is very important to support the family to make sure the treatment is given correctly every day.

3. What can help the parents to remember to give the TB medicine correctly?

Both the parents and the child should understand the importance of good adherence. They must have a good understanding of how to give the medicine correctly. Recording each day that the medicine is given in a treatment diary or on a calendar helps.

4. What is DOT?

DOT stands for directly observed treatment when a responsible person watches the medicine being swallowed every day. A community health worker can help with DOT.

5. How often should a child on TB treatment attend the clinic?

Usually every 2 weeks for the first month and then every month.

Case study 4

A child on TB treatment at home remains unwell and does not gain weight. When the community health worker visits the home the mother is often drunk. The mother is on treatment for HIV infection. She has 2 other children.

1. What is the commonest cause of TB treatment failing?

Poor adherence. Not taking the medicine correctly every day and stopping treatment too early are important causes of failing to cure TB. This mother may not be reliable and may not be taking her child to all the clinic visits. She may even have run out of medicine.

2. Why is the mother’s HIV history important?

Because her child may also have HIV. All people with TB must be screened for HIV.

3. Should the other children be screened for TB?

Yes. A careful history for failure to thrive and chronic cough is important. They should be sent to the clinic for TB tests. They should also be screened for HIV.

4. Is this community health worker at high risk of catching TB from this child?

Unlike adults, children with TB are usually not infectious as they do not cough up a lot of TB bacilli. Therefore she is not at high risk.