Tuberculosis Among Children in the Republic of the Marshall Islands

Transcription

1 Tuberculosis Among Children in the Republic of the Marshall Islands Sarah Labuda, MD, MPH Medical Consultant Meeting San Antonio, TX November 29-30, EXCELLENCE EXPERTISE INNOVATION Disclosures Sarah Labuda, MD, MPH has the following disclosures to make: No conflicts of interest No relevant financial relationships 2 1

2 Tuberculosis among Children in the Republic of the Marshall Islands Sarah Labuda, MD, MPH Arkansas Department of Health November 30, Objectives Review Tuberculosis epidemiology in the Republic of the Marshall Islands and its overall impact on TB epidemiology in the mainland US, using Arkansas as a case study Describe the algorithm for screening and treatment of pediatric TB infection and disease in the TB + Leprosy Free Majuro project, with comparison to WHO recommendations Discuss examples of presentations among children in Majuro screened for TB 4 2

3 Republic of Marshall Islands World s 8 th highest TB incidence (488/100,000 WHO 2017) BCG administered at birth (~80%) Low prevalence of HIV, high prevalence of diabetes 5 Republic of Marshall Islands and the US As of 2014, about 1/3 of the population of the Marshall Islands had relocated to the US ~10,000 persons of Marshallese origin reside in NW Arkansas Many missed opportunities for TB screening by healthcare providers in the Marshallese community 6 3

4 Cases Percentage Foreign -born 12/6/2018 Trends in TB Cases, Arkansas, TB Cases Percentage Foreign-born 0 Slide by Dr. Leonard Mukasa 7 Country of Origin Non-US Born Persons with TB in Arkansas, Year Total Non-US Born From Central and South America Total Non-US Born non-hispanic Marshall Islands Total Non-US Born Median 23% (range 16-49%) all foreign-born cases among persons from the Marshall Islands Slide by Dr. Leonard Mukasa 4

5 Cases 12/6/2018 TB Among Marshallese in Arkansas, (N = 186) Marshallese Outreach Team 30 ADH Plan for Mass Screening Zero Cases Dr. Joseph Bates Outreach Clinic Year RMI US-Born Slide by Dr. Leonard Mukasa 9 Mass Tuberculosis Screening in RMI 2017 mass TB disease screening in Ebeye Island Active TB rate of 846/100,000 Expanded local TB program capacity Did not include TB infection or children <10 years 10 5

6 Mass Tuberculosis Screening in RMI June 2018 October 2018 Majuro Atoll Mass TB disease screening for population of 27,000 Mass treatment of TB infection Increased support to local TB program Community Health Outreach Workers, single physician, and program nurse Included children birth-10 years 11 US Mainland Volunteers 12 6

7 Majuro TB Resources and Providers 13 Evidence for Tuberculosis Screening in Children Worldwide is Lacking World Health Organization manual for screening ONLY recommends screening those children known to be close contacts to an active case or with known HIV infection No studies assessing screening algorithms for children 5-15 years of age, OR those <5 years who are not close contacts to an active case or with known HIV infection 14 7

8 Pediatric Tuberculosis Screening Project in RMI First of its Kind Complicated by lack of guidance in a highly endemic setting with background of BCG in population Overtreating TB infection? Focused on exposure history, a few specific signs/symptoms, and lymph node examination Ann Loeffler, Jeff Starke, Ben Marais, Dick Brostrom developed protocol First of its kind for mass screening of TB infection AND disease in children

9 Tuberculosis Screening in RMI <5 years Screening history for exposure or symptoms Weight and lymph node exam CXR if any danger signs/symptoms Referral to treatment for TB infection or evaluation by panel 17 Tuberculosis Screening in RMI 5-10 years TST placed at screening site or in home Screening history for exposure or symptoms Weight and lymph node exam CXR if any danger signs/symptoms Referral to treatment for TB infection or evaluation by panel 18 9

10 Tuberculosis Screening in RMI >=10 years TST placed at screening site or in home Screening history for exposure or symptoms CXR Referral to treatment for TB infection or evaluation by panel 19 Tuberculosis Screening Project in RMI Findings considered high-risk and indicating referral for chest xray included Weight <5%ile Cough >2 weeks, hemoptysis, fatigue, unexplained weight loss, night sweats Any palpable lymph nodes other than shotty anterior cervical nodes Close contact with an active case Attempted sputum for GeneXpert -> if positive, sent for sputum x2 for smear and culture 20 10

11 21 Tuberculosis Treatment Determined by Expert Panel Review 22 For those with any concerning/borderline lymph nodes, we scheduled follow-up appointments with the TB clinic or Pediatric clinic in 1-2 weeks for re-exam 11

12 23 56, FEMALE 11 MM TST 04 AUG 18 1 OF

13 42, FEMALE 11 MM TST 19 MAR 16 5 OF , MALE 12 MM TST 08 AUG 18 1 OF

14 44, MALE 18 MM TST 01 FEB 16 5 OF 6 27 But in children, it can be more subtle In reviewing these cases, we had access to limited symptom screening information, the current chest xray, and old comparison films, if we were lucky! 28 14

15 18 YRS, FEMALE 10 MM TST 20 JULY OF YRS, FEMALE 10 MM TST 26 JUNE OF

16 18 YRS, FEMALE 10 MM TST 11 DEC OF 3 31 June 16, 2018 View 1 of 2 15yo Male June 2018 Old or new lesion? 32 16

17 15 yo Male June 2018 June 16, 2018 View 2 of 2 33 Same 15 yo Male April 2018 April 27,

18 Same 15 yo Male Feb 2018 Feb 19, YRS, MALE 15 MM TST 30 JULY OF

19 17 YRS, MALE 15 MM TST 6 APR OF YRS, MALE 15 MM TST 11 DEC OF

20 17 YRS, MALE 15 MM TST 11 SEP OF 4 There it is! 39 7 YRS, MALE 0 MM TST 31 JULY OF

21 5 YRS, MALE 0 MM TST 30 JULY OF YRS, MALE 0 MM TST 16 JULY OF

22 5 YRS, MALE 0 MM TST 21 APR OF MONTHS, MALE NO TST Fever, cough 27 JULY OF

23 10 MONTHS, MALE NO TST 27 JULY OF year old female 10mm TST None of the siblings were positive 46 23

24 47 One last case 2 week old male Mom with lower lobe infiltrate, effusion, and cough for weeks during pregnancy What do we do? 48 24

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26 Preliminary TB Infection Numbers Number completed screening Latent TB diagnosis (TST 10mm) Recommen ded for latent TB treatment Started latent TB treatment Leprosy (new cases) Diabetes (all cases) Diabetes (new cases) Pediatric (0-14) Adult (15+) 10,058 3,491 3,132 2, Total 15,419 3,812 3,601 3, Comment 25% of those screened had TST 10mm 6% not medically eligible for latent TB treatment 94% of eligible patients started latent TB treatment Leprosy rate 29.2 per 10,000 23% of those screened for diabetes had HbA1c % of those screened for diabetes had a new diagnosis 51 Limitations/Process Improvements Confusion for children <5 years without TST placement Not being brought in for screening Radio messaging, reinforced teaching with outreach nurses and CHOWs Partnered with immunization program to screen with vaccine administration 52 26

27 53 Limitations/Process Improvements Incomplete and inconsistent screening completion Reinforced teaching with screeners on appropriate form completion and referral of pediatric patients Inconsistent lymph node examination and general discomfort with pediatric patients Capacity building with local providers 54 27

28 Summary Mass screening in children is hard work Especially in children <10 years old, when there is little experience or evidence to work with Mass screening works We found LOTS of TB and linked the children to care May have been selection bias, because many of the youngest children were not brought in by parents (only sick ones?) 55 Summary Mass screening can prevent childhood TB cases from coming into the US Delayed diagnosis is often recognized in AR cases, including a pediatric death in 2014 There is a VERY high rate of TB in children <5 years old in Majuro Screening in this population when they seek medical care for any reason in the US is important 56 28

29 Implications for Screening in the Mainland US We have access to IGRAs and no baseline BCG exposure, so can streamline interpretation of screening Screen US-born and non-usborn Marshallese children Especially those <5 years 57 Thank you for your attention! Questions? 58 29