A Brief Overview of Mycobacterial Diseases in Children Table 4: Continued Mycobacterium tuberculosis Non-tuberculous Mycobacteria
and curative therapy in children: this may outcome. However, in a RCT surgical be improved by introducing shorter
drug therapy treatment of cervicofacial lymphadenitis Mycobacterium leprae
approval of child-friendly leprosy drug formulations is likely to improve adherence
combination drug regimens, education of was found to be superior to combination Improving adherence to both preventive and caretakers, and the intensification of DOTS strategy
Optimising the dose of TB drugs: several recent studies have documented suboptimal serum concentrations in children receiving standard mg/kg body weight dosages of first-line TB drugs. This has led to a WHO-revised recommendation for first-line agents
curative therapy in children: this may be improved by researching on shorter combination drug regimen, education of caretakers and the intensification of the DOTS strategy
Trials to evaluate the efficacy, optimal dosage and duration of steroid treatment against nerve-damage in children are
urgently needed: although different trials have been conducted in adults, there have hardly been any studies in children The role of novel immune modulatory medications against neuropathic complications needs to be evaluated in children: possible role of novel specific immune modulatory drugs on nerve damage in children with leprosy should be studied in multicentre studies
Evaluation of long-term effects of the use of high dose and prolonged steroid and thalidomide against ENL reactions: ENL is usually treated with prolonged high dose prednisone and if found ineffective, thalidomide. Studies are needed to systematically evaluate the long-term adverse effects of these drugs on respectively length growth,
immunosuppression and teratogenicity, in young children with ENL
Prevention
Improving epidemic control: the most effective means to prevent TB infection in children is early detection and cure of infectious adult cases to reduce transmission
Screening for disease: at least all high-risk close contacts of a TB index case should be screened for TB infection and if positive be put on preventive therapy to eradicate LTBI (future infectious pool)
Universal provision, implementation and monitoring of preventive chemotherapy to everyone with documented TB exposure: this will eradicate the pool of LTBI, prevent progression to disease and reactivation and achieve a low risk of re-infection
Identifying high-risk groups of children: children at high risk of infection and severe disease (infants and young children and immunocompromised children) in contact with a TB index case should be screened for disease and put on preventive therapy Vaccine development: novel, more
efficacious subunit vaccines against MTB than the present BCG vaccine are urgently needed. There are a few candidate vaccines undergoing different trial phases
Improving epidemic control: the most effective means to prevent M. leprae infection in children is early detection and cure of infectious cases to reduce transmission
Universal provision, implementation and monitoring of preventive chemotherapy to everyone with documented leprosy exposure: this will reduce progression to disease, thereby eliminating future pool of transmission. This is supported by studies that have shown that chemoprophylaxis lowers the incidence of leprosy in household contacts.* Community-based prospective studies are needed to evaluate the efficacy of chemotherapy in children
Vaccine development: there are indications that neonatal and post-exposure BCG vaccination given to contacts of infectious Leprosy patients may be protective against the development of leprosy. However, it is still uncertain how it works, the timing or degree of protection of BCG vaccination. Newer, subunit protein vaccines against M. leprae need to be developed, or modification of TB-specific vaccines to protect against leprosy is needed
*The current recommendation of the World Health Organization (WHO) Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy advises to examine household contacts of a leprosy in index patient for evidence of leprosy. If no evidence of leprosy is found, it advises to educate these contacts for early signs of leprosy disease. These contacts should be advised to return if these signs develop. This policy is not easily applicable to infants and young children, who, as with TB prevention, should receive chemoprophylaxis based on contact history. ARI = annual risk of infection; BCG = Bacille Calmette-Guerin; DOTS = directly observed treatment short course; ENL = erythema nodosum leprosum; IGRAs = interferon gamma release assays; IRIS = immune reconstitution inflammatory syndrome; LTBI = latent TB infection; MODS = microscopic observation drug susceptibility; MTB = Mycobacterium tuberculosis; NTM= non-tuberculous mycobacteria; PCR = polymerase chain reaction; RCT = randomised controlled trial; TB= tuberculosis; TST = tuberculin skin test.
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