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Management of MDR TB contacts

By Patrick Gomani | 12 May, 2015

Hello dear friends out there, I am Patrick Gomani working for TB CARE II Malawi. Of late we have successfully initiated a patient on second line TB treatment after Gene X-pert results RIF resistance positive. This patient was investigated after failing first line TB treatment 2RHZE/4RH. Now my question is how do I manage her under five child who has no signs and symptoms of active TB and got INH prophylaxis while her mother was on still on 1st line TB treatment.
Looking forward to your valuable comments to how best I can help this child now.

Replies

 

RAJNEESH TRIPATHI Replied at 12:14 AM, 13 May 2015

HI Dear Patric

The sputum of adults may be tested by Xpert if they are symptomatic and
able to produce sputum otherwise it may be induced by inhaling hypertonic
saline. For the children Gastric aspirate may be collected for Xpert and
proceed as sputum.

Masoud Dara, MD Moderator Replied at 2:42 AM, 13 May 2015

Dear Patrick,

The decision on whether to initiate prophylactic treatment with the second line drugs for an under five child is a very delicate one. One would need a reliable DST results of the index case (before start of treatment of the index case with second line medicine as most probably infection has occurred by then, although it can be also the case that the child was re/infected with the acquired resistance of the index case). Therefore a thorough anamnesis is a must. Longer the lapse between initiation of symptoms in the index case and tapered chemoprophylactic treatment, less chance of it doing any help to prevent development of active TB.

Irrespective of prophylactic treatment, one need to examine the child and other close contacts thoroughly and very closely observe the child with periodic examination, taking any failure to thrive or other symptoms and signs serious enough for a rule out of TB or MDR-TB.

Colleagues from several countries particularly South Africa have worked extensively on management and prophylactic treatment of children in close contact with MDR-TB patients and may wish to add.

Sunil Kapoor Replied at 9:05 AM, 13 May 2015

Please clarify who is on SLD and who is on 1st line drugs. If the child has no s/s then advice him/her to come for frequent clinical examination ( 2 weekly perhaps) and have a keep the high index of suspicion intact. Dr Sunil Kapoor 
Specialist in Respiratory medicine and TB, healthcare researcher, research evaluator, healthcare administrator,
MBBS (MAMC), DTCD (Patel Chest Institute), DPH&H (Delhi) , MCCP (USA),
MBA-healthcare administration (FMS), Director, Harrow Medical Center.

egh Eduardo Gotuzzo Replied at 9:14 AM, 13 May 2015

we have a few cases when father or mother have sputum positive and child
with less of 5 years: i recoemded to use fluorquinolone for 9 meses plus
pirazinamida if this strain is senitive to PYZ
of course we need to have a clinical trial for this important question
regards
eduardo Gotuzzo​

Gaël CLAQUIN Replied at 9:32 AM, 13 May 2015

Depending in which context you are intervening, there are a few options,
to carefully consider according to local guidelines, legislation,
context of your prescription and of your care.
See attachements

Let us know what is your perspective based on this if possible

Indrajit Kumar Replied at 11:34 AM, 13 May 2015

Respected Sir,
The requirement of Isonizaid would depend on status of the child's TB infection as ascertained by Mantoux test or IGRA. I will review literature on the minimum interval between initiating INH chemoprophylaxis and any residual effect of previous INH chemoprophylaxisThe requirement of Isonizaid would depend on status of the child's TB infection as ascertained by Mantoux test or IGRA. I will review literature on the minimum interval between initiating INH chemoprophylaxis and any residual effect of previous INH chemoprophylaxis
With Regards
Indrajit.

Yacine Mar Diop Replied at 11:36 AM, 13 May 2015

Dear all,

This is an important question: management of MDR TB contacts. We all have
this problem in our countries. There is no second line drug prophylaxis
known. And we have to be careful for using fluoroquinolones in this case.
We don't have studies that show us its efficacy.
But I think the most important is application of environmental measures for
infection control and chirurgical mask for the mother until conversion of
her cultures. Children may have frequently clinical TB screening (every
month) until after mother's treatment (Up two years).

Dr Yacine

Tom Yates Replied at 11:48 AM, 13 May 2015

I don't think there is a consensus and I agree with Eduardo that an RCT is
needed. James Seddon's prospective cohort study may help guide practice
whilst we wait for this trial -
http://cid.oxfordjournals.org/content/57/12/1676. I have copied the
abstract below. Note that the source cases here were known to have
ofloxacin sensitive disease.

Best wishes,
Tom

Preventive therapy for child contacts of multidrug-resistant tuberculosis:
a prospective cohort study

1. James A. Seddon
<http://cid.oxfordjournals.org/search?author1=James+A.+Seddon&sortspec=date&su...>
1 <http://cid.oxfordjournals.org/content/57/12/1676#aff-1>,3
<http://cid.oxfordjournals.org/content/57/12/1676#aff-3>,4
<http://cid.oxfordjournals.org/content/57/12/1676#aff-4>,
2. Anneke C. Hesseling
<http://cid.oxfordjournals.org/search?author1=Anneke+C.+Hesseling&sortspec=dat...>
1 <http://cid.oxfordjournals.org/content/57/12/1676#aff-1>,
3. Heather Finlayson
<http://cid.oxfordjournals.org/search?author1=Heather+Finlayson&sortspec=date&...>
2 <http://cid.oxfordjournals.org/content/57/12/1676#aff-2>,5
<http://cid.oxfordjournals.org/content/57/12/1676#aff-5>,
4. Katherine Fielding
<http://cid.oxfordjournals.org/search?author1=Katherine+Fielding&sortspec=date...>
6 <http://cid.oxfordjournals.org/content/57/12/1676#aff-6>,
5. Helen Cox
<http://cid.oxfordjournals.org/search?author1=Helen+Cox&sortspec=date&submit=S...>
7 <http://cid.oxfordjournals.org/content/57/12/1676#aff-7>,
6. Jennifer Hughes
<http://cid.oxfordjournals.org/search?author1=Jennifer+Hughes&sortspec=date&su...>
7 <http://cid.oxfordjournals.org/content/57/12/1676#aff-7>,
7. Peter Godfrey-Faussett
<http://cid.oxfordjournals.org/search?author1=Peter+Godfrey-Faussett&sortspec=...>
3 <http://cid.oxfordjournals.org/content/57/12/1676#aff-3>, and
8. H. Simon Schaaf
<http://cid.oxfordjournals.org/search?author1=H.+Simon+Schaaf&sortspec=date&su...>
1 <http://cid.oxfordjournals.org/content/57/12/1676#aff-1>,5
<http://cid.oxfordjournals.org/content/57/12/1676#aff-5>

Clin Infect Dis. (2013) 57 (12): 1676-1684.

*Background.* Evidence is limited to guide the management of children
exposed to multidrug-resistant (MDR) tuberculosis (TB). We aimed to study
the tolerability and toxicity of a standard preventive therapy regimen,
given to children exposed to infectious MDR-TB, and explore risk factors
for poor outcome.

*Methods.* Prospective cohort study: Western Cape, South Africa. Children
<5 years old, or HIV-positive children <15, were recruited from May 2010
through April 2011 if exposed to an ofloxacin-susceptible, MDR-TB source
case. Children were started on preventive therapy as per local guidance:
ofloxacin, ethambutol and high-dose isoniazid for six months. Standardized
measures of adherence and adverse events were recorded; poor outcome was
defined as incident TB or death from any cause.

*Results.* 186 children were included, median age 34 months (inter-quartile
range: 14-47). Of 179 children tested for HIV, 9 (5.0%) were positive.
Adherence was good in 141 (75.8%) children. Only 7 (3.7%) children
developed Grade 3 adverse events. One child (0.5%) died and six (3.2%)
developed incident TB during 219 patient years of observation time. Factors
associated with poor outcome were: age <1 year (rate ratio: 10.1; 95%CI:
1.65-105.8; p=0.009), HIV-positive status (rate ratio: 10.6; 95%CI:
1.01-64.9; p=0.049), exposure to multiple source cases (rate ratio: 6.75;
95%CI: 1.11-70.9; p=0.036) and poor adherence (rate ratio: 7.50; 95%CI:
1.23-78.7; p=0.026).

*Conclusions.* This three-drug preventive therapy regimen was well
tolerated and few children developed TB or died if adherent to therapy. The
provision of preventive therapy to vulnerable children following exposure
to MDR-TB should be considered.

Erica Lessem Replied at 12:07 PM, 13 May 2015

Hi all, just to note a couple RCTs are beginning to look at this--
VQUIN in Viet Nam (sponsored by the National Health and Medical
Research Council of Australia) and TB-CHAMP (sponsored by BMRC,
Wellcome Trust, DFID, South African MRC) will test 6 months
levofloxacin vs placebo for prevention of MDR-TB. The ACTG's PHOENIX
study will look at 6 months of levo vs. isoniazid for prevention of
MDR-TB. All will include children; PHOENIX and VQUIN will also include
adults. It will be several years before we have results, but looking
forward to an evidence base to guide these discussions!

In the meantime, results from a prospective observational study (not
an RCT) of preventive therapy with fluoroquinolones for MDR-TB in an
outbreak in Chuuk, Micronesia were hopeful and may also be of
interest:
Int J Tuberc Lung Dis. 2014 Aug;18(8):912-8. doi: 10.5588/ijtld.13.0028
Treatment for LTBI in contacts of MDR-TB patients, Federated States of
Micronesia, 2009-2012.
Bamrah S1, Brostrom R1, Dorina F2, Setik L2, Song R1, Kawamura LM3,
Heetderks A1, Mase S1.

Best,
Erica

Gaël CLAQUIN Replied at 10:05 AM, 14 May 2015

Dear all,
kindly find articles I wanted to share but which needed to be attached on the website.
One is cited by Tom Yates, the other a review also written by the same very experienced crew.
Enjoy the reading.

Gaël

Attached resources:

Erica Lessem Replied at 1:02 PM, 14 May 2015

Hi All,

A webinar is also being held shortly on this very topic! See details below;
open to all, but registration required


>>



On behalf of our Capacity Building Task Force, we are writing to invite you
to join a webinar, scheduled for *Tuesday, May 19th, 2015, at9am
EDT, 1pm GST.*



The speaker will be Dr. Farhana Amanullah. She will be discussing the
management of child contact of DR-TB patients. The webinar will address a
contact management program in Karachi, Pakistan and review the following
topics:


1) Household contacts of DR-TB patients are at high risk of infection and
progression to TB disease;
2) The risk is higher for children and immunocompromised individuals who
develop disease faster and can develop fatal forms of disease;
3) A community based program for prompt evaluation, monitoring and
preventive therapy for household members of DR-TB patients is necessary to
avert preventable cases of disease and preventable deaths.



Below is the information about how to register for the event, so that you
can connect via the internet on May 19th. If you have any questions about
registering or connecting for this webinar, please contact Ms. Evgenia
Markvardt at



We hope this and future webinars will be a productive space for our network
to connect and collaborate.



Best wishes,

Mercedes Becerra and Soumya Swaminathan



*You have been invited to the event "Managing child contacts of DR-TB
patients"*

[image: Description: Description: cid:3fd66a49617794fe]

*Managing child contacts of DR-TB patients*

The webinar will address a contact management program in Karachi, Pakistan
and review the following topics:
1) Household contacts of DR-TB patients are at high risk of infection and
progression to TB disease;
2) The risk is higher for children and immunocompromised individuals who
develop disease faster and can develop fatal forms of disease;
3) A community based program for prompt evaluation, monitoring and
preventive therapy for household members of DR-TB patients is necessary to
avert preventable cases of disease and preventable deaths.

[image: Description: Description: cid:image001.jpg@01D08E30.C9164A40]

*Farhana Amanullah MD, FAAP*

The Sentinel Project on Pediatric Drug-Resistant Tuberculosis is a global
partnership of researchers, caregivers, and advocates who share a vision of
a world where no child dies from this curable disease. Members collaborate
to raise the visibility of this vulnerable population of children, and to
share evidence and resources that can increase children's access to prompt
and effective treatment. For more information and to join this network,
please visitwww.sentinel-project.org

To know more, click
https://pih.adobeconnect.com/peds051915/event/speaker_info.html


*Event:* Managing child contacts of DR-TB patients
*When:* Tuesday 19 May 2015, 09:00 AM - 10:00 AM
*Time Zone:* (GMT-05:00) Eastern Time (US and Canada) (Please note that
Daylight Saving Time (+01:00 hr) is in effect during this time)

*To register now, please visit the following link:*

https://pih.adobeconnect.com/peds051915/event/registration.html

To know more about the event, please visit our website:

https://pih.adobeconnect.com/peds051915/event/event_info.html



*Thank you,The DR-TB Training Network and the Sentinel Project*

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