Tuberculosis and perinatal period

1
Tuberculosis and perinatal period

• Kai Kliiman
• Tartu University Lung Clinic
• Estonian NTP
• 15 September 2006
• Tallinn

2
Tuberculosis

• Is a communicable disease caused by Mycobacterium
  tuberculosis
• It is spread primarily by tiny air bone particles
  (droplet nuclei) expelled when person with
  infectious TB disease (lung or throat TB) coughs,
  sneezes, speaks or sings
• Close contacts have highest risk of becoming
  infected

3
Distribution of tuberculosis in the world in 2003
Dye C. Lancet 2006 367 93840
4
Estimated TB incidence in the WHO European
region 2002
World Health Organization. Global tuberculosis
control surveillance, planning, financing. WHO
report 2004. Geneva WHO, 2004
5
Notification rate of TB in Baltic States and in
Finland 1990 2004
EuroTB, 2004
EuroTB, 2004
6
Trajectories of tuberculosis epidemic for nine
epidemiologically different regions of the world
High HIV incidence- 4 in adults aged 15-49
years in 2003
Dye C. Lancet 2006
7
TB and HIV

• HIV is strongest risk factor for development of
  TB if infected
• - risk of developing TB disease 7-10 each year
• the risk of developing TB rises with worsening
  immune status
• more common are disseminated and extra pulmonary
  diseases
• low cure rates
• high mortality rates

8
Opportunistic Infections in AIDS patients in
Developing Countries
9
TB in AIDS Patients Spain (1994-2002)
No of cases
7378
HAART
42
2329
29
10
Notified TB and HIV co infection in Estonia
(number of cases, proportion of all)
6,6
3,9
2,6
2,2
1
0,3
0,1
0,1
1998 1999 2000 2001 2002
2003 2004 2005
Estonian TB register 2006
Estonian TB register 2006
11
Bacille Calmette Guerin (BCG) vaccine

• is the most widely used vaccination
• was developed in the 1930's and it remains the
  only vaccination available against tuberculosis
  today
• does not ensure against exposure to and
  development of tuberculoses disease, but offers
  significant protection against serious and
  widespread invasion
• the WHO recommends that asymptomatic HIV-infected
  infants receive BCG vaccine at birth or shortly
  thereafter

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Infants may have acquired TB

• - by trans placental spread through the umbilical
  vein to the fetal liver
• - by aspiration or ingestion of infected amniotic
  fluid
• - via airborne inoculation from close contacts
  (family members or nursery personnel)
• About 50 of children born to mothers with active
  pulmonary TB develop the disease during first
  year of life if chemoprophylaxis or BCG vaccine
  is not given

13
Neonatal TB

• The clinical presentation nonspecific
• Multiple organ involvement
• Usually fever, lethargy, respiratory distress,
  hepatosplenomegaly, or failure to thrive may
  indicate TB in an infant with a history of TB
  exposure
• For diagnosis culture and smear of tracheal
  aspirates, urine, gastric washings for acid-fast
  bacilli, chest x-ray (miliary infiltrates).
  Biopsy of the liver, lymph nodes, or lung and
  pleura may be needed.
• Skin test results may be negative

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Pregnant women with active TB

• Duration of therapy- at least 6 mo, drug-
  resistant cases- to 18 mo
• Isoniazid (300 mg po), ethambutol (15 to 25 mg/kg
  po), and rifampin (600 mg po) in single daily
  doses- in recommended doses have not been shown
  to be teratogenic
• Streptomycin is potentially ototoxic
• The other antituberculous drugs should be avoided
  because of teratogenicity (ethionamide,
  fluoroquinolones) or lack of clinical experience
  during pregnancy

15
Asymptomatic infants of women with active TB (1)

• The infant usually should be separated from the
  mother until effective treatment is under way and
  her sputum become smear negative (usually 2 to 3
  weeks)
• Family contacts should be investigated for
  undiagnosed TB
• All anti TB-drugs are compatible with
  breastfeeding
• The infants skin test negative ? BCG vaccine ?
  start on a regimen of INH (5mg/kg) and send home
  at usual time

16
Asymptomatic infants of women with active TB (2)

• Skin testing should be performed at ages 3 and 6
  mo
• If the infant remains tuberculin negative, INH
  may be discontinued and the infant followed with
  skin tests at 12 mo with monthly or bimonthly
  clinical evaluations
• The infant has a positive skin test? exclude
  tuberculosis disease by a thorough examination
• INH should be continued for at least 6 mo
• HIV-infected children should be treated for 12 mo

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Newborns with active TB (1)

• Treatment with INH (10 to 15 mg/kg po), rifampin
  (10 to 20 mg/kg po), pyrazinamide 820 to 40 mg/kg
  po), and streptomycin (20 to 40 mg/kg im) in
  single daily doses given for 2 mo, followed by
  INH and rifampin for another 10 mo.
• Drug-resistance- instead of streptomycin may be
  used kanamycin or capreomycin

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Newborns with active TB (2)

• CNS is involved- the initial therapy should also
  include corticosteroids (prednisolone 1 mg/kg/day
  po for 6 to 8 wk, then gradually tapered),
  continue with INH and rifampin daily or twice
  weekly for another 10 mo.
• Not disseminated form, and CNS, bones and joints
  are not involved- 6-9 mo regimen