TB in Pregnancy A Forgotten Risk

In collaboration with NTP

Millennium Development Goals

Goal 5 Improve maternal health Goal 6 Combat AIDS, malaria and other diseases
Target 5A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

Target 8: Have halted by 2015, and begun to reverse, the incidence of

malaria and other major diseases Indicators 23. Prevalence and death rates associated with TB 24. Proportion of TB cases detected and cured under DOTS

Percentages of Regional case notification rates

2009 :Case notifcation per 100,000 pop.
BA 6% GAR 14% ASHANTI 9%

UW 5% NORTH 4%

UE 8%

VOLTA 13%

EAST 14%

CENTRAL 14%

WEST 13%

Comparison of Male and Female TB patients in Ghana 2009

1,600
MALE FEMALE

1,400

1,200

1,000

800

600

400

200

0-14 15-24 25-34 35-44 45-54 55-64 65--

Treatment Outcome
Trend on Treatment Success vrs Adverse Outcome (19962008)
100.0 90.0 80.0 70.0 Percentages 60.0 50.0 40.0 30.0 20.0 10.0 0.0 45.8 31.9 50.6 71.7 72.6 76.1 84.1 84.5 54.2 111.2 49.4 44.7 28.3 15.9

15.5

49.7

44.0

39.5

33.1

27.4

23.9

55.3

50.3

56.0

60.5

66.9

Year Treatment Success Adverse Outcomes

The TB Burden
TB is endemic in Ghana 353/100,000 pop estimated to have TB with 88/100,000 estimated as smear positives TB affects the reproductively active age group: 1554 age group Male : Female ratio is 2:1 Women constitute up to 33% of cases notified Not much data accumulated in TB in pregnancy High mortality rate co-morbid patients

Diagnosing TB in Pregnancy
Cough >1 week Weight loss and maternal wasting Fever Sputum production Haemoptysis Exposure to TB patient

Diagnosis Sputum for AFB 2 samples AFB scanty or more

Treatment of TB
Same treatment as adult patients
2(HRZE) + 4(HR) + 6(Pyridoxine) 25mg daily

Streptomycin is contraindicated as it causes fetal hearing loss All other drugs are safe cross placenta but do not cause teratogenic effects

Complications
Untreated TB leads to
Maternal wasting and poor health Spontaneous abortions Perinatal mortality Small for gestational age & low birth weight Above are worsened by delay in diagnosis Infection of the new born during breast feeding

TB can cause infertility when ovaries affected

Complications
Congenital TB through haematogenous spread is rare!
Difficult to diagnose Not differentiable from other congenital infections Symptoms arise in 2 3 weeks Symptoms: hepato-splenomegaly, respiratory distress, fever, abnormal X-ray

Challenges to Identifying TB in Pregnancy

Lack of knowledge of the extent of the problem TB in pregnancy is often ignored with a focus on the pregnancy alone When identified termination of pregnancy is offered the mother instead of comprehensive treatment National data systems do not capture co-morbidities associated with TB Clinicians often lack capacity to manage the condition Delayed diagnosis often a diagnosis of exclusion Non implementation of active TB case finding Almost 60% of TB cases are not detected.

Strategies
Implementing the policy of active TB case finding for early detection focusing on: HOSPITAL BASED CASE DETECTION Contact tracing and investigations among index TB cases Active TB case finding among clinical risk groups Involving community service providers pharmacists, chemical sellers, traditional healers etc. Management of co-morbidities Implementing innovative approaches for TB case finding Extensive use of NGOs, community and civil society groups Improve supervision, M&E, data management & research.