1 00:00:00,000 --> 00:00:12,000 Thanks for joining us again at the Canadian Breakpoint, a Canadian infectious diseases 2 00:00:12,000 --> 00:00:15,640 podcast by Canadian infectious diseases physicians. 3 00:00:15,640 --> 00:00:20,480 I'm Summer Stewart, here with Dr. Rupeena Purewal, pediatric infectious diseases specialist 4 00:00:20,480 --> 00:00:21,480 from Saskatoon. 5 00:00:21,480 --> 00:00:27,340 For this episode, we welcome Dr. Rachel Dwillo, pediatric infectious diseases specialist from 6 00:00:27,340 --> 00:00:31,600 Winnipeg to discuss the current landscape of tuberculosis in Canada. 7 00:00:31,600 --> 00:00:32,600 Dr. Purewal. 8 00:00:32,600 --> 00:00:38,800 All right, welcome everyone to another episode of our podcast at the Canadian Breakpoint. 9 00:00:38,800 --> 00:00:42,440 So today we have a very special guest with us, Dr. Dwillo. 10 00:00:42,440 --> 00:00:44,600 So I would like to welcome Dr. Dwillo. 11 00:00:44,600 --> 00:00:49,480 Dr. Dwillo is a fellow of the Canadian Royal College of Physicians and Surgeons in general 12 00:00:49,480 --> 00:00:53,880 pediatrics and pediatric infectious diseases. 13 00:00:53,880 --> 00:00:58,440 During her infectious disease fellowship training, she completed additional training in pediatric 14 00:00:58,440 --> 00:01:04,640 tuberculosis at the University of Stellenbosch in Cape Town, South Africa. 15 00:01:04,640 --> 00:01:10,560 She has worked extensively with TB effective populations in remote low resource settings. 16 00:01:10,560 --> 00:01:16,860 Her current roles at the university include clinical lead for pediatric TB services, medical 17 00:01:16,860 --> 00:01:22,480 lead for the Winnipeg Regional Health Authority TB program, and the TB consultant for the 18 00:01:22,480 --> 00:01:25,960 Kivilek region of Nunavut, Canada. 19 00:01:25,960 --> 00:01:30,400 She's the lead author of the pediatric chapter in the most recent edition of the Canadian 20 00:01:30,400 --> 00:01:32,400 TV standards. 21 00:01:32,400 --> 00:01:33,400 Welcome. 22 00:01:33,400 --> 00:01:36,120 Thanks so much for having me. 23 00:01:36,120 --> 00:01:38,240 I usually go by Dr. Rachel or Rachel. 24 00:01:38,240 --> 00:01:41,240 So Dr. Dwillo seems too formal. 25 00:01:41,240 --> 00:01:42,640 Totally fine. 26 00:01:42,640 --> 00:01:44,920 We'll go with Rachel or Dr. Rachel today. 27 00:01:44,920 --> 00:01:45,920 Yeah. 28 00:01:45,920 --> 00:01:46,920 Yeah. 29 00:01:46,920 --> 00:01:47,920 Perfect. 30 00:01:47,920 --> 00:01:48,920 All right. 31 00:01:48,920 --> 00:01:49,920 Well, a little bit of a disclaimer. 32 00:01:49,920 --> 00:01:53,040 Dr. Rachel was my attending physician and fellowship as well. 33 00:01:53,040 --> 00:01:56,960 So we've worked closely together. 34 00:01:56,960 --> 00:02:01,800 We've had some TB discussions, but I think things are a little bit different in Canada 35 00:02:01,800 --> 00:02:04,040 for sure and around the world. 36 00:02:04,040 --> 00:02:08,720 So why don't we start off by talking a little bit about the current situation of TB in Canada, 37 00:02:08,720 --> 00:02:14,420 just for our listeners to have an overview of what's changed, what are the outbreaks 38 00:02:14,420 --> 00:02:17,000 like and what's going on in your world? 39 00:02:17,000 --> 00:02:18,000 Yeah. 40 00:02:18,000 --> 00:02:23,440 So, you know, I come from a Manitoba and Nunavut perspective. 41 00:02:23,440 --> 00:02:29,920 So I don't know what's going on actively in other provinces over the last couple of years, 42 00:02:29,920 --> 00:02:36,200 but I can say certainly in the standards that the first chapter definitely does a nice job 43 00:02:36,200 --> 00:02:41,960 of describing the situation up until about 2000. 44 00:02:41,960 --> 00:02:49,320 And so Canada is really quite obviously the Canadian population on a general basis. 45 00:02:49,320 --> 00:02:53,900 It's considered a low incidence setting for TB. 46 00:02:53,900 --> 00:03:00,080 So we've been like fairly stagnant around five per 100,000 cases, the incidence rate. 47 00:03:00,080 --> 00:03:05,760 But again, you know, that doesn't describe the entire picture, as I'm sure you know, 48 00:03:05,760 --> 00:03:08,520 having spent some time here in Manitoba. 49 00:03:08,520 --> 00:03:13,960 And you know, there's it's heterogeneous across Canada as to who's affected. 50 00:03:13,960 --> 00:03:21,480 But the general population groups at highest risk that we've seen in terms of what our 51 00:03:21,480 --> 00:03:28,320 EPI data tells us is that this is a disease in Canada of those who are foreign born or 52 00:03:28,320 --> 00:03:33,400 have foreign born relatives or live in the houses of foreign born people. 53 00:03:33,400 --> 00:03:41,960 And specifically, as the data shows, higher risk from from the South Asia region, which 54 00:03:41,960 --> 00:03:43,440 makes sense. 55 00:03:43,440 --> 00:03:47,120 High burden countries there, as well as the African region. 56 00:03:47,120 --> 00:03:53,040 Again, also not surprising, I think, for anyone that's done any work in the areas, and then 57 00:03:53,040 --> 00:03:54,040 indigenous. 58 00:03:54,040 --> 00:03:59,640 And so indigenous includes both Inuit, First Nations and Métis. 59 00:03:59,640 --> 00:04:03,880 And so depending where you are on the country, you actually get a really different patient 60 00:04:03,880 --> 00:04:04,880 population. 61 00:04:04,880 --> 00:04:11,280 So my population is very different in terms of who is affected than say in Ontario or 62 00:04:11,280 --> 00:04:14,300 say in BC versus Nunavut. 63 00:04:14,300 --> 00:04:18,320 So again, it depends where you are in the country. 64 00:04:18,320 --> 00:04:25,000 I know, at least in Manitoba over the last couple of years COVID did. 65 00:04:25,000 --> 00:04:27,040 There was a decrease in case count. 66 00:04:27,040 --> 00:04:30,640 Definitely, while COVID was happening. 67 00:04:30,640 --> 00:04:33,280 As to the reason why, I don't know. 68 00:04:33,280 --> 00:04:36,840 I don't know if we actually know or have data on that. 69 00:04:36,840 --> 00:04:40,760 But this year, it's come back with a vengeance. 70 00:04:40,760 --> 00:04:43,880 We're getting late cases, we're having more cases. 71 00:04:43,880 --> 00:04:50,720 And there are concerns with certain communities that again, I won't name them, but they're 72 00:04:50,720 --> 00:04:52,760 definitely struggling right now. 73 00:04:52,760 --> 00:04:54,560 And I would say globally, that's been the case too. 74 00:04:54,560 --> 00:04:56,960 We saw cases go down. 75 00:04:56,960 --> 00:04:59,200 Cases go up from TB. 76 00:04:59,200 --> 00:05:02,880 So I think probably this is just a trend of what's happened with COVID and a lot of other 77 00:05:02,880 --> 00:05:04,160 diseases as well. 78 00:05:04,160 --> 00:05:05,160 I agree. 79 00:05:05,160 --> 00:05:06,160 Yeah. 80 00:05:06,160 --> 00:05:11,520 So I guess for timing wise, I mean, the new addition for Canadian TB standards came out 81 00:05:11,520 --> 00:05:12,920 just in May here. 82 00:05:12,920 --> 00:05:17,640 So I think timing wise, I think it's very pertinent information and actually reviewing 83 00:05:17,640 --> 00:05:22,760 the guidelines myself came across a lot of changes that I might not have been aware of 84 00:05:22,760 --> 00:05:23,960 previously. 85 00:05:23,960 --> 00:05:31,720 And so I think in general, just kind of discussion around like, was there a reasoning behind 86 00:05:31,720 --> 00:05:39,520 the new release or was it just time due for this to come out? 87 00:05:39,520 --> 00:05:40,880 I don't entirely know. 88 00:05:40,880 --> 00:05:43,440 I was a later addition to the group. 89 00:05:43,440 --> 00:05:48,200 I know they had tried to do it right around the time COVID started. 90 00:05:48,200 --> 00:05:53,960 I think, so it's Dick Menzies that leads the whole group. 91 00:05:53,960 --> 00:06:02,560 I think his goal was to update it every five years, but obviously I guess that didn't happen. 92 00:06:02,560 --> 00:06:05,640 It's a lot of work to do something like this. 93 00:06:05,640 --> 00:06:10,560 So I think it was just, it was on his plate, but on the back burner and then he had some 94 00:06:10,560 --> 00:06:14,200 time and it was time to pull the trigger on it. 95 00:06:14,200 --> 00:06:18,320 And again, there's been a lot of changes as I reflected there in terms of treatment and 96 00:06:18,320 --> 00:06:19,320 diagnostics. 97 00:06:19,320 --> 00:06:23,800 So again, it was very timely and probably overdue as well. 98 00:06:23,800 --> 00:06:24,800 Right. 99 00:06:24,800 --> 00:06:25,800 All right. 100 00:06:25,800 --> 00:06:29,840 So kind of, I guess, digging right into the guidelines, because most of our listeners, 101 00:06:29,840 --> 00:06:32,880 we've actually had a lot of requests for this episode. 102 00:06:32,880 --> 00:06:33,880 Yeah. 103 00:06:33,880 --> 00:06:37,320 And so I know which is good. 104 00:06:37,320 --> 00:06:39,480 I like it when people are interested in this. 105 00:06:39,480 --> 00:06:40,480 That's great. 106 00:06:40,480 --> 00:06:41,480 Yeah. 107 00:06:41,480 --> 00:06:45,320 I like it's because clinicians are seeing a lot of tuberculosis in their communities 108 00:06:45,320 --> 00:06:52,000 and our listeners are, they're international, but we do have a lot of listeners from North 109 00:06:52,000 --> 00:06:58,840 America and especially in smaller communities, we're going to see outbreaks, things like 110 00:06:58,840 --> 00:07:00,560 presentation, right? 111 00:07:00,560 --> 00:07:04,920 So maybe we can talk a little bit about, because I know in the guideline that was a recent 112 00:07:04,920 --> 00:07:11,760 addition, as well, kind of comparing how like children may present very different from kind 113 00:07:11,760 --> 00:07:16,280 of our typical adult presentation that we see of tuberculosis. 114 00:07:16,280 --> 00:07:19,260 So why don't we touch on a little bit about that and then you can give us an overall kind 115 00:07:19,260 --> 00:07:24,080 of overview as to an outsider from my standpoint, like what should I be looking in the guidelines 116 00:07:24,080 --> 00:07:25,880 and what are the new things? 117 00:07:25,880 --> 00:07:26,880 Yeah. 118 00:07:26,880 --> 00:07:31,280 So again, you know, those of us who've studied pediatrics, children aren't little adults, 119 00:07:31,280 --> 00:07:36,200 as we all know, and again, manifest things very differently. 120 00:07:36,200 --> 00:07:41,480 I think the younger of the child, so an infant is very different than say a teenager with 121 00:07:41,480 --> 00:07:42,720 TB. 122 00:07:42,720 --> 00:07:50,000 So I would say the more adult type symptoms, which are fever, weight loss, hemoptysis, 123 00:07:50,000 --> 00:07:57,600 prolonged cough, night sweats, you do see that in the more, I would say teen to preteen 124 00:07:57,600 --> 00:08:03,800 as to the age cutoff, like there's no hard minimum age for that. 125 00:08:03,800 --> 00:08:11,360 So but if you get when you get into the infants, the big thing is, I would say to focus on 126 00:08:11,360 --> 00:08:15,280 is the epi link or epi contact. 127 00:08:15,280 --> 00:08:22,040 So when I see an infant and I'm thinking about TB, like who do they live with? 128 00:08:22,040 --> 00:08:24,040 Who are they exposed to? 129 00:08:24,040 --> 00:08:28,480 Do they fall into one of the risk groups that we know has a higher incidence in Canada? 130 00:08:28,480 --> 00:08:36,800 So again, recently immigrated to Canada from a high burden country or one of our Indigenous 131 00:08:36,800 --> 00:08:42,880 populations again, not all are affected equally in Canada and definitely it depends which 132 00:08:42,880 --> 00:08:44,500 region you're from. 133 00:08:44,500 --> 00:08:51,400 So when I think of the epi link, then again, we also use the TST or the I-GRAA depending 134 00:08:51,400 --> 00:08:52,400 on the age. 135 00:08:52,400 --> 00:08:57,600 Again, it's not to diagnose TB disease. 136 00:08:57,600 --> 00:09:02,840 So TB, when you're sick with TB, it's for TB infection. 137 00:09:02,840 --> 00:09:10,480 So when we're using that in terms of making a diagnosis of active TB in somebody, again, 138 00:09:10,480 --> 00:09:17,720 it doesn't tell me about TB disease, it tells me about immune response to tuberculosis antigens. 139 00:09:17,720 --> 00:09:23,520 So then if my immune system or their immune system is responding, therefore that implies 140 00:09:23,520 --> 00:09:28,040 exposure, therefore that implies risk. 141 00:09:28,040 --> 00:09:30,320 And that's how I like to think about it. 142 00:09:30,320 --> 00:09:36,520 So once those two things are thought about, then you move on to like clinical signs and 143 00:09:36,520 --> 00:09:37,520 symptoms. 144 00:09:37,520 --> 00:09:43,880 And again, I see a lot of kids with just Hyalur disease or perihyalur disease, mediastinal 145 00:09:43,880 --> 00:09:45,120 disease I should say. 146 00:09:45,120 --> 00:09:49,920 So lymph nodes in the chest, which is very classic of pediatric TB. 147 00:09:49,920 --> 00:09:54,280 And actually a lot of times they're minimally symptomatic. 148 00:09:54,280 --> 00:09:58,360 But again, you have to think about other things that cause that. 149 00:09:58,360 --> 00:10:02,600 And so if you have that epi link, that to me is a diagnosis. 150 00:10:02,600 --> 00:10:06,320 I would say a child who's more sick. 151 00:10:06,320 --> 00:10:11,120 So you always ask about the TB symptoms, but you start getting into things like lethargy 152 00:10:11,120 --> 00:10:13,840 and irritability. 153 00:10:13,840 --> 00:10:19,640 And so weight loss or not interested in feeding, but not for short periods of time, for long 154 00:10:19,640 --> 00:10:22,000 periods of time, like weeks. 155 00:10:22,000 --> 00:10:25,840 And that's often what I hear when they're quite sick and you see the x-ray and you're 156 00:10:25,840 --> 00:10:26,840 like, whoa, okay. 157 00:10:26,840 --> 00:10:27,840 Yeah. 158 00:10:27,840 --> 00:10:28,840 Okay. 159 00:10:28,840 --> 00:10:29,840 Yeah. 160 00:10:29,840 --> 00:10:32,160 So definitely a different presentation there. 161 00:10:32,160 --> 00:10:37,160 And then in terms of, so obviously that's a little bit of touching on the clinical presentation 162 00:10:37,160 --> 00:10:39,740 now kind of walking through. 163 00:10:39,740 --> 00:10:44,080 You have that clinical presentation, talked a little bit about the TST and IGRA. 164 00:10:44,080 --> 00:10:49,280 I know in the recent guideline, it was mentioned kind of the age group cutoffs, because I get 165 00:10:49,280 --> 00:10:55,480 this a lot in my practice where everybody will ask, you know, like, what should I send 166 00:10:55,480 --> 00:10:56,480 both? 167 00:10:56,480 --> 00:11:03,880 Should I be sending TST and IGRA both or what should be really be telling experts out there? 168 00:11:03,880 --> 00:11:04,880 Yeah. 169 00:11:04,880 --> 00:11:14,720 So I would say amongst our group in our chapter, so the pediatric clinicians, lots and lots 170 00:11:14,720 --> 00:11:21,000 of discussion around the IGRA and the minimum age range. 171 00:11:21,000 --> 00:11:28,960 And so previous to this minimum age range, generally, you know, amongst my colleagues 172 00:11:28,960 --> 00:11:31,320 was five years. 173 00:11:31,320 --> 00:11:33,400 So five years and up for the IGRA. 174 00:11:33,400 --> 00:11:40,960 And the reason for that is the immune system hasn't adequately developed. 175 00:11:40,960 --> 00:11:45,200 And as to when it's adequately developed within the first five years, that's hard to say, 176 00:11:45,200 --> 00:11:49,740 but you know, a chance of a false negative. 177 00:11:49,740 --> 00:11:52,040 But there has been more evidence recently. 178 00:11:52,040 --> 00:11:56,120 And there's a really nice, I think it's a table in the chapter talking about some of 179 00:11:56,120 --> 00:12:04,800 the studies where they use some large cohorts and some like better evidence, I would say, 180 00:12:04,800 --> 00:12:15,240 I'm not sure if it's the best, best evidence, but that the IGRA can be used in lower age 181 00:12:15,240 --> 00:12:16,320 groups than five. 182 00:12:16,320 --> 00:12:22,100 So pushing it down to around two is where we're at with that. 183 00:12:22,100 --> 00:12:28,920 So I would say, you know, for sure down to age five, for sure down to age two, with some 184 00:12:28,920 --> 00:12:33,080 caveats again, if you're an abnormal immune system, maybe not. 185 00:12:33,080 --> 00:12:39,120 I don't think you necessarily need to do both, but I would say I would use it as well. 186 00:12:39,120 --> 00:12:42,640 Consider more strongly using it in those who are BCG vaccinated. 187 00:12:42,640 --> 00:12:47,360 Again, the TST obviously reacts to that. 188 00:12:47,360 --> 00:12:53,560 So again, that's really also an emphasis, so BCG vaccinated should try and get an IGRA. 189 00:12:53,560 --> 00:12:56,840 Not the end of the world if you have a TST, again, there's really good reasons to use 190 00:12:56,840 --> 00:12:59,040 a TST. 191 00:12:59,040 --> 00:13:03,700 Remote settings, because often IGRA is not even available outside of bigger centers. 192 00:13:03,700 --> 00:13:08,400 So again, you know, TST is just fine and a good contact history and symptom history is 193 00:13:08,400 --> 00:13:10,160 also what you need. 194 00:13:10,160 --> 00:13:11,160 Okay. 195 00:13:11,160 --> 00:13:13,880 And then just touching a little bit more on the workup. 196 00:13:13,880 --> 00:13:18,040 And then the real area I want to talk about is the management, because I think a lot of 197 00:13:18,040 --> 00:13:19,600 the updates are around there. 198 00:13:19,600 --> 00:13:25,440 So in terms of, so do you want to just walk us through maybe, so we have a patient who 199 00:13:25,440 --> 00:13:31,080 we're thinking we're suspecting TB, you know, we would do the initial workup. 200 00:13:31,080 --> 00:13:37,160 So let's say it was somebody that you had high suspicion from clinical findings. 201 00:13:37,160 --> 00:13:41,240 And so obviously as part of that, we talked about sending some of the diagnostic testing 202 00:13:41,240 --> 00:13:43,960 as well, like taking IGRA. 203 00:13:43,960 --> 00:13:49,520 And then what are some of the additional management criteria that we should be using? 204 00:13:49,520 --> 00:13:52,720 So obviously initially it's a chest x-ray as well. 205 00:13:52,720 --> 00:13:58,880 And really like TB clinicians who spend all their time doing TB are so anal about this 206 00:13:58,880 --> 00:14:04,180 and I am so anal about this, is it's a good quality chest x-ray. 207 00:14:04,180 --> 00:14:07,700 So you want to get the, that is one of your best tools. 208 00:14:07,700 --> 00:14:14,560 And so because you're looking at the media stinum, you really need to have a great straight 209 00:14:14,560 --> 00:14:23,120 on view, good inspiration, good penetration, any twisting or anything like that, again, 210 00:14:23,120 --> 00:14:24,680 really affects what you're seeing. 211 00:14:24,680 --> 00:14:31,400 And again, I've seen a kid who had a bad x-ray, bad quality as we would label it or how it's 212 00:14:31,400 --> 00:14:32,400 known. 213 00:14:32,400 --> 00:14:35,200 And then we brought them in, redid it. 214 00:14:35,200 --> 00:14:36,480 Clearly TB disease. 215 00:14:36,480 --> 00:14:42,800 So again, really want to emphasize the importance of that and the importance of a good one. 216 00:14:42,800 --> 00:14:45,200 So there's that. 217 00:14:45,200 --> 00:14:48,640 And again, because usually it's going to be pulmonary is the most common thing. 218 00:14:48,640 --> 00:14:50,360 So that's where you start. 219 00:14:50,360 --> 00:14:53,400 But again, you know, dictated on signs and symptoms. 220 00:14:53,400 --> 00:14:57,080 So certainly if there are signs and symptoms outside of the respiratory system, obviously 221 00:14:57,080 --> 00:14:59,680 imaging for that. 222 00:14:59,680 --> 00:15:02,040 And then sputum. 223 00:15:02,040 --> 00:15:06,440 But most of the time our kids can't cough on command like an adult. 224 00:15:06,440 --> 00:15:09,320 So we use different ways to do it. 225 00:15:09,320 --> 00:15:16,080 So I would say gastric are really popular around Manitoba and because we also blast 226 00:15:16,080 --> 00:15:17,080 mycosis here. 227 00:15:17,080 --> 00:15:19,600 So we use it for that. 228 00:15:19,600 --> 00:15:26,280 And so we send gastric aspirates after a period of being a fasting, I would say probably four 229 00:15:26,280 --> 00:15:28,560 hours or more. 230 00:15:28,560 --> 00:15:32,960 Fasting in the morning is ideal, but I wouldn't necessarily admit someone to hospital just 231 00:15:32,960 --> 00:15:39,240 to do it or a prolonged hospitalization just to do it. 232 00:15:39,240 --> 00:15:50,120 And so send those for AFB PCR if it's available at least once, which we also really want. 233 00:15:50,120 --> 00:15:52,640 We talk about that a little bit. 234 00:15:52,640 --> 00:15:55,520 And that's talked about as well in the adult chapters. 235 00:15:55,520 --> 00:16:02,320 And then obviously smears and cultures as well for AFB. 236 00:16:02,320 --> 00:16:08,720 And the gold standard again is usually an AFB culture or MTB complex on culture or, 237 00:16:08,720 --> 00:16:10,720 you know, PCR as well. 238 00:16:10,720 --> 00:16:16,640 Positive PCR with compatible symptoms is also very appropriate. 239 00:16:16,640 --> 00:16:22,080 We also do touch upon a technique used in more lower resource settings of getting sputum 240 00:16:22,080 --> 00:16:25,240 induction on even on young kids. 241 00:16:25,240 --> 00:16:33,240 And I think that probably relies on the experience of the nursing staff or the RT or whoever 242 00:16:33,240 --> 00:16:35,400 is going to do it. 243 00:16:35,400 --> 00:16:37,000 Because again, it has to be a good sample. 244 00:16:37,000 --> 00:16:38,600 So you can do it on babies. 245 00:16:38,600 --> 00:16:41,320 They do it in South Africa and India on babies. 246 00:16:41,320 --> 00:16:46,480 So again, it depends on what you have and what resources you have. 247 00:16:46,480 --> 00:16:47,760 But again, you can do it. 248 00:16:47,760 --> 00:16:51,800 So you know, if you have that and that's all you have, do it. 249 00:16:51,800 --> 00:16:55,240 Again, some sputum is better than none. 250 00:16:55,240 --> 00:17:02,920 But you know, a lot of this, a lot of pediatric TB is, again, as a lot of you may know, is 251 00:17:02,920 --> 00:17:04,320 a clinical diagnosis. 252 00:17:04,320 --> 00:17:08,880 Again, we're really unlikely to have a positive smear culture. 253 00:17:08,880 --> 00:17:12,000 So again, it's just a gestalt and epihistory. 254 00:17:12,000 --> 00:17:16,400 And again, other surrogates like the TST or IGRA to make the diagnosis. 255 00:17:16,400 --> 00:17:20,000 And I'm actually glad that you brought that up because there's a lot of times, I mean, 256 00:17:20,000 --> 00:17:23,880 obviously dealing with like being an infectious disease specialist myself, there's a lot of 257 00:17:23,880 --> 00:17:27,120 times when there's multiple things on your differential. 258 00:17:27,120 --> 00:17:33,360 And I think reminding kind of the listeners as well, but what I do in my clinical practice 259 00:17:33,360 --> 00:17:40,600 as well is to remind them that like a negative culture or a negative smear doesn't rule it 260 00:17:40,600 --> 00:17:41,600 out. 261 00:17:41,600 --> 00:17:42,600 Yes, definitely. 262 00:17:42,600 --> 00:17:44,640 And that's a huge thing because... 263 00:17:44,640 --> 00:17:49,640 Oh, and that's like, if you know, it's hard for sometimes I think that's challenging for 264 00:17:49,640 --> 00:17:54,720 people to wrap their head around even, you know, here in our hospital. 265 00:17:54,720 --> 00:17:55,720 Yeah. 266 00:17:55,720 --> 00:17:58,960 Serial, serial follow up is actually super useful too. 267 00:17:58,960 --> 00:18:06,260 So if again, you're not sure the kid's healthy, there's minimal disease or whatever is going 268 00:18:06,260 --> 00:18:10,160 on in the chest, a follow up four weeks later, that's okay. 269 00:18:10,160 --> 00:18:13,480 As long as they have a reliable caregiver. 270 00:18:13,480 --> 00:18:18,520 Sometimes when I'm really on the fence, because again, treating someone for TB and especially 271 00:18:18,520 --> 00:18:20,480 young children is a very big deal. 272 00:18:20,480 --> 00:18:23,240 It's a lot of investment and resources. 273 00:18:23,240 --> 00:18:29,400 And so really good short-term follow up again, can sometimes help clarify things with another 274 00:18:29,400 --> 00:18:31,240 X-ray. 275 00:18:31,240 --> 00:18:34,840 And again, if it's TB, it's going to be there. 276 00:18:34,840 --> 00:18:38,440 So yeah, that's the approach I use when I'm on the fence. 277 00:18:38,440 --> 00:18:39,440 That's good. 278 00:18:39,440 --> 00:18:40,440 Yeah. 279 00:18:40,440 --> 00:18:41,440 Serial follow ups. 280 00:18:41,440 --> 00:18:43,400 I think that's really important to kind of reiterate too. 281 00:18:43,400 --> 00:18:44,400 So, okay. 282 00:18:44,400 --> 00:18:48,560 So I think in terms of our listeners should have like a bit of a grasp on, you know, because 283 00:18:48,560 --> 00:18:50,280 there hasn't been too many changes around that. 284 00:18:50,280 --> 00:18:56,080 I know that there's in the guidelines, more comments on age groups and cutoffs and volumes 285 00:18:56,080 --> 00:18:57,080 and that type of thing. 286 00:18:57,080 --> 00:19:01,400 So I think that's something that we can all refresh our knowledge about. 287 00:19:01,400 --> 00:19:09,360 I think the area that was, I think, very, I guess, intriguing for me was where the guidelines 288 00:19:09,360 --> 00:19:18,560 kind of emphasize more talking about, first of all, just like drug susceptible TB. 289 00:19:18,560 --> 00:19:23,360 And so maybe we can talk a little bit about things that have changed in the pediatric 290 00:19:23,360 --> 00:19:27,740 world as well, but also in the adult world with LTBI. 291 00:19:27,740 --> 00:19:31,180 So TB infection management. 292 00:19:31,180 --> 00:19:34,640 So maybe what's the most common regimen you can touch on that? 293 00:19:34,640 --> 00:19:35,640 Yeah. 294 00:19:35,640 --> 00:19:40,040 You know, and so that's actually a really great point you brought up. 295 00:19:40,040 --> 00:19:48,240 I would say the most changes in terms of treatment in the standards is around TB infection and 296 00:19:48,240 --> 00:19:54,640 even the name TB infection is different from latent TB infection. 297 00:19:54,640 --> 00:19:58,480 Just because I think we, you know, could talk about this longer. 298 00:19:58,480 --> 00:20:04,200 But again, TB infection is actually like a broad spectrum of things that we don't understand. 299 00:20:04,200 --> 00:20:09,160 So again, that concept itself is changing. 300 00:20:09,160 --> 00:20:17,080 And so really, I mean, globally, I think lots of low and middle income countries are actually 301 00:20:17,080 --> 00:20:21,860 farther ahead than we are on because they have better drug access. 302 00:20:21,860 --> 00:20:26,160 That's just simply because again, there's a bigger market. 303 00:20:26,160 --> 00:20:33,520 But really what we're the focus in children and adults is the rifamysin-based regimens. 304 00:20:33,520 --> 00:20:40,400 So anything with a riff in it is better than INH itself. 305 00:20:40,400 --> 00:20:46,040 And purely better, it's not that it's like there's an efficacy difference. 306 00:20:46,040 --> 00:20:51,360 It's that in the real world, people are more likely to finish a shorter regimen and rifamysin-based 307 00:20:51,360 --> 00:20:58,280 regimens are definitely associated with less side effects than traditional kind of longer 308 00:20:58,280 --> 00:20:59,280 INH regimens. 309 00:20:59,280 --> 00:21:01,880 So people like that. 310 00:21:01,880 --> 00:21:08,520 So that gets us into the two ones that are spoken about, which is the 3-HP regimen. 311 00:21:08,520 --> 00:21:13,220 So that's the three months of high dose isoniazidine and rifapentine. 312 00:21:13,220 --> 00:21:16,020 So once a week, 12 weeks. 313 00:21:16,020 --> 00:21:24,520 And then there's the 4-R regimen, which is four months of daily rifampin, which again, 314 00:21:24,520 --> 00:21:30,320 because it's daily, it's considered reasonable to have that done self-administered. 315 00:21:30,320 --> 00:21:36,560 So again, in resource limited settings for whatever reason, there's no DOT worker to 316 00:21:36,560 --> 00:21:38,520 monitor intermittent therapy. 317 00:21:38,520 --> 00:21:42,280 So therapy that's not every day. 318 00:21:42,280 --> 00:21:48,840 Then 4-R or daily rifampin is totally acceptable and has better completion rates than INH or 319 00:21:48,840 --> 00:21:51,080 9-INH, nine months of isoniazid. 320 00:21:51,080 --> 00:21:53,960 3-HP is where it's at. 321 00:21:53,960 --> 00:21:58,400 So if you're over the age of two, and obviously there's no drug interactions or anything like 322 00:21:58,400 --> 00:22:04,920 that, again, that's also a limitation of using rifamycin based therapy is lots of drug-drug 323 00:22:04,920 --> 00:22:05,920 interactions. 324 00:22:05,920 --> 00:22:09,440 So you have to be careful with that. 325 00:22:09,440 --> 00:22:19,480 But again, that's 12 weeks of once a week is 12 doses total versus 4-R is 120 doses. 326 00:22:19,480 --> 00:22:25,880 So completion is great, but rifapentine is not available everywhere yet. 327 00:22:25,880 --> 00:22:31,480 It's considered special access by Health Canada, but we've been lucky here in Manitoba. 328 00:22:31,480 --> 00:22:34,240 And I know what the Nunavutab app had access to it. 329 00:22:34,240 --> 00:22:36,520 So I use it whenever it's appropriate. 330 00:22:36,520 --> 00:22:39,520 That's good to hear. 331 00:22:39,520 --> 00:22:40,520 Perfect. 332 00:22:40,520 --> 00:22:41,520 It's great. 333 00:22:41,520 --> 00:22:47,120 And then going into more, I guess, management of TB disease. 334 00:22:47,120 --> 00:22:52,200 So are there any recent updates in terms of management change? 335 00:22:52,200 --> 00:22:57,000 I know that there's definition changes or there's like addition of definitions for resistant 336 00:22:57,000 --> 00:22:58,000 TB. 337 00:22:58,000 --> 00:22:59,000 Yeah. 338 00:22:59,000 --> 00:23:00,000 Yeah. 339 00:23:00,000 --> 00:23:08,440 I would say the big thing to focus on because DRTB or drug-resistant TB is very small proportion. 340 00:23:08,440 --> 00:23:14,800 And I would say that encourage anyone again, who's dealing with someone who has the possibility 341 00:23:14,800 --> 00:23:20,280 of having that or has that to reach out to their tertiary care center, because it's very 342 00:23:20,280 --> 00:23:25,240 complex management, side effect wise, prolonged therapy. 343 00:23:25,240 --> 00:23:29,080 So again, I wouldn't do that on one's own. 344 00:23:29,080 --> 00:23:34,960 So in terms of drugs susceptible TB, obviously susceptible to all first line drugs, just 345 00:23:34,960 --> 00:23:39,880 isoniazid, rifampin, paracetamide, ethambutol. 346 00:23:39,880 --> 00:23:47,360 So really what is being spoken about mostly is the standard six month regimen, which again, 347 00:23:47,360 --> 00:23:50,760 hasn't really changed that much. 348 00:23:50,760 --> 00:23:58,520 So you have the two months of the four drugs and then four months of two drugs. 349 00:23:58,520 --> 00:24:05,480 And then again, what's being brought up is to being a little bit more, I guess, less 350 00:24:05,480 --> 00:24:11,160 paternalistic about DOT, so directly observed therapy. 351 00:24:11,160 --> 00:24:17,120 It's felt, I think in some jurisdictions to be really restrictive to people and maybe 352 00:24:17,120 --> 00:24:22,800 even bordering on infringement of their rights. 353 00:24:22,800 --> 00:24:29,640 And so, you know, I think people are trying to back away from that and think about it 354 00:24:29,640 --> 00:24:32,720 more as treatment support, actually. 355 00:24:32,720 --> 00:24:38,240 So people that are going to like, I know some families that want help, and I know some families 356 00:24:38,240 --> 00:24:39,360 that are just fine. 357 00:24:39,360 --> 00:24:45,080 So it has to be obviously a discussion and good follow up to make sure that those who 358 00:24:45,080 --> 00:24:48,720 can like give them a bit more freedom. 359 00:24:48,720 --> 00:24:54,920 And they do mention that daily therapy is preferred over intermittent. 360 00:24:54,920 --> 00:24:58,960 There is some discussion about that, at least in the adult disease chapter. 361 00:24:58,960 --> 00:25:05,840 But what's really exciting, and I forget if this was included or not, is there are studies 362 00:25:05,840 --> 00:25:10,360 out there like clinical trials looking at even shorter than six months now. 363 00:25:10,360 --> 00:25:15,960 So there's study 31, which is a rifapentine based treatment that looked at four months 364 00:25:15,960 --> 00:25:16,960 of treatment. 365 00:25:16,960 --> 00:25:21,760 And then there's the Shine trial in pediatrics that looked at four months as well for minimal 366 00:25:21,760 --> 00:25:22,760 disease. 367 00:25:22,760 --> 00:25:28,600 We're not there yet to prescribe it, you know, broadly, but it's, you know, people are working 368 00:25:28,600 --> 00:25:32,760 on this because again, we recognize that some people don't need six months, but we have 369 00:25:32,760 --> 00:25:35,560 to figure out who those are and what the right drugs are. 370 00:25:35,560 --> 00:25:36,560 Right. 371 00:25:36,560 --> 00:25:38,480 Yeah, no, that's fair. 372 00:25:38,480 --> 00:25:44,760 So I think yeah, most of these kind of conventional treatments or standard treatments that we've 373 00:25:44,760 --> 00:25:48,960 used for a long, long time haven't changed much. 374 00:25:48,960 --> 00:25:55,520 But there definitely was mention about kind of our second line agents or agents when we 375 00:25:55,520 --> 00:25:57,240 are dealing with drug resistance. 376 00:25:57,240 --> 00:26:03,600 Now, obviously, in terms of everything we talk about today, even if we are clinicians, 377 00:26:03,600 --> 00:26:07,720 it's not medical advice and it doesn't, you know, it's really for discussion purposes 378 00:26:07,720 --> 00:26:09,400 and knowledge purposes. 379 00:26:09,400 --> 00:26:13,600 But touching on kind of what availability. 380 00:26:13,600 --> 00:26:18,640 So I mean, some of them are very available, like for a point of loans, for instance, we 381 00:26:18,640 --> 00:26:20,000 all have access to those. 382 00:26:20,000 --> 00:26:24,320 Are there certain drugs that are a little bit more difficult to access for second line 383 00:26:24,320 --> 00:26:28,440 that we should be aware of that, you know, we should be thinking about ordering sooner? 384 00:26:28,440 --> 00:26:29,440 Yeah. 385 00:26:29,440 --> 00:26:32,320 So, you know, that gets really complicated. 386 00:26:32,320 --> 00:26:38,920 It's a complicated question here and again, I don't have any. 387 00:26:38,920 --> 00:26:43,560 I've only had my mono resistance in my practice here. 388 00:26:43,560 --> 00:26:46,500 Meaning I said, I said, or a famine or pure cinnamide. 389 00:26:46,500 --> 00:26:51,920 So we're not getting into the second line agents there really. 390 00:26:51,920 --> 00:26:58,640 But definitely, at least here, things like the laminated and bedaquiline or special access 391 00:26:58,640 --> 00:27:01,040 only, but they're great drugs. 392 00:27:01,040 --> 00:27:02,760 They're oral. 393 00:27:02,760 --> 00:27:04,020 It's unfortunate. 394 00:27:04,020 --> 00:27:08,000 The availability is is what it is. 395 00:27:08,000 --> 00:27:16,240 But I would say in terms of choosing regimens, go to WHO's great publication and update on 396 00:27:16,240 --> 00:27:20,760 what is considered good regimens based on the group the medications fall in. 397 00:27:20,760 --> 00:27:23,500 So that's group A, group B, group C. Right. 398 00:27:23,500 --> 00:27:26,680 And they do touch on that in the in the standards. 399 00:27:26,680 --> 00:27:32,560 And I would also say, I don't know if we can readily accomplish this yet. 400 00:27:32,560 --> 00:27:36,400 It depends probably on jurisdiction and drug availability is we are trying to get away 401 00:27:36,400 --> 00:27:40,400 from amino glycosides or injectable. 402 00:27:40,400 --> 00:27:46,120 That's really being pushed globally as all oral regimens for drug resistant TB. 403 00:27:46,120 --> 00:27:51,160 Because again, amino glycosides are super toxic and and, you know, people have hearing 404 00:27:51,160 --> 00:27:52,640 loss from them. 405 00:27:52,640 --> 00:27:56,360 And you know, it's a really tragic thing. 406 00:27:56,360 --> 00:27:58,600 And so again, that's really being discouraged globally. 407 00:27:58,600 --> 00:28:03,640 I think in some circumstances, we do have to use them because they work simply because 408 00:28:03,640 --> 00:28:07,960 we don't have access to all the other oral agents that other countries do. 409 00:28:07,960 --> 00:28:08,960 So yeah. 410 00:28:08,960 --> 00:28:14,680 So talking about your practice, then with like the mono resistant. 411 00:28:14,680 --> 00:28:21,880 So if you have a patient who's like isoniazid resistant, like obviously, we just talked 412 00:28:21,880 --> 00:28:27,360 about the regimen having those four drugs and then the duration. 413 00:28:27,360 --> 00:28:29,840 So what how does that change kind of? 414 00:28:29,840 --> 00:28:35,240 Yeah, so it changes agents and it changes like so you can't use isoniazid then and it 415 00:28:35,240 --> 00:28:36,660 also changes duration. 416 00:28:36,660 --> 00:28:40,560 But again, it depends on which drug you drop. 417 00:28:40,560 --> 00:28:45,760 And again, they do talk about I believe they talk about mono resistance and different treatment 418 00:28:45,760 --> 00:28:46,760 strategies. 419 00:28:46,760 --> 00:28:50,880 And that's definitely super widely available in the literature. 420 00:28:50,880 --> 00:28:55,480 And you know, often you have to go to nine months, even if it's pulmonary. 421 00:28:55,480 --> 00:29:00,880 Again, and also depends on how extensive the disease is as well. 422 00:29:00,880 --> 00:29:01,880 Right. 423 00:29:01,880 --> 00:29:03,600 Which again, more extensive, more prolonged. 424 00:29:03,600 --> 00:29:10,240 But again, there's lots of great resources out there for mono resistant TB like the Curry 425 00:29:10,240 --> 00:29:13,720 Center as well as a great resource from the US. 426 00:29:13,720 --> 00:29:18,800 They do really great education out of San Francisco and lots of their stuff's available 427 00:29:18,800 --> 00:29:19,800 online. 428 00:29:19,800 --> 00:29:21,360 That's really good. 429 00:29:21,360 --> 00:29:26,360 And then in terms of since you see TB and you manage these patients, what intervals 430 00:29:26,360 --> 00:29:31,000 are we looking at, for instance, like side effect monitoring and that type of thing? 431 00:29:31,000 --> 00:29:34,000 Maybe we can touch a little bit about that. 432 00:29:34,000 --> 00:29:35,000 Yeah. 433 00:29:35,000 --> 00:29:42,800 I mean, so I'm not going to be prescriptive myself about that. 434 00:29:42,800 --> 00:29:44,920 But I would say follow the standards. 435 00:29:44,920 --> 00:29:50,800 And I would say generally speaking, because I do a lot of remote medicine and things are 436 00:29:50,800 --> 00:29:53,240 simply just not available. 437 00:29:53,240 --> 00:29:55,440 I can't do it. 438 00:29:55,440 --> 00:30:04,760 But I would say children, teenagers really don't need a lot of blood work, if any at 439 00:30:04,760 --> 00:30:09,860 all after kind of the first bit, if they do not have side effects. 440 00:30:09,860 --> 00:30:17,120 It's a little bit different in adults with comorbidities on medications or hepatitis 441 00:30:17,120 --> 00:30:23,640 or whatever, where you're worried about liver toxicity, which is the big, big thing you 442 00:30:23,640 --> 00:30:28,200 worry about with three of the first line agents. 443 00:30:28,200 --> 00:30:31,880 So again, we really don't do a lot of blood work regularly. 444 00:30:31,880 --> 00:30:39,680 But I would say really it's important in terms of monitoring is just talking to the patient 445 00:30:39,680 --> 00:30:46,360 about side effects and talking to them about things like signs of early hepatitis, which 446 00:30:46,360 --> 00:30:49,840 again is the thing that's going to kill someone. 447 00:30:49,840 --> 00:30:55,400 And again, knowing which agents to pull off and how to pull things off and how to reintroduce 448 00:30:55,400 --> 00:31:01,080 things is, again, I touched on in lots of different resources. 449 00:31:01,080 --> 00:31:07,600 So I would say it's key to ask about side effects in early nausea, early vomiting that's 450 00:31:07,600 --> 00:31:13,040 persistent is hepatitis, until proven otherwise and jaundice, you've missed the boat. 451 00:31:13,040 --> 00:31:18,920 So I always get a little bit at least that was what was always emphasized to me when 452 00:31:18,920 --> 00:31:26,080 I was in Cape Town is any nausea and any vomiting that's again prolonged beyond 24 hours, you 453 00:31:26,080 --> 00:31:28,400 really need to think about hepatitis. 454 00:31:28,400 --> 00:31:29,400 So yeah, that's good. 455 00:31:29,400 --> 00:31:31,400 Yeah, good point there for sure. 456 00:31:31,400 --> 00:31:32,400 All right. 457 00:31:32,400 --> 00:31:37,720 So yeah, I think we've touched on a lot of kind of the key points in the guideline. 458 00:31:37,720 --> 00:31:41,400 I did see that there was some mention of I mean, you mentioned one of the trials, but 459 00:31:41,400 --> 00:31:42,720 future. 460 00:31:42,720 --> 00:31:46,920 So what is the future of TB prevention and treatment in Canada? 461 00:31:46,920 --> 00:31:53,360 Is there something that is coming soon or anything that you'd like for our audience 462 00:31:53,360 --> 00:31:54,800 to kind of be aware of? 463 00:31:54,800 --> 00:31:58,800 Yeah, so I would say the couple of things we didn't touch on, which are kind of are 464 00:31:58,800 --> 00:32:05,840 really kind of quite big, actually, which, you know, maybe those outside of our TB world 465 00:32:05,840 --> 00:32:07,560 don't don't think they're that big. 466 00:32:07,560 --> 00:32:11,600 But you know, they're things we've done for a long time that have changed. 467 00:32:11,600 --> 00:32:20,440 So not in the treatment for adult chapter, that there's no max to refampin anymore. 468 00:32:20,440 --> 00:32:24,480 Also, they make some BMI caveats in there. 469 00:32:24,480 --> 00:32:28,800 But again, we probably really under dose people on refampin. 470 00:32:28,800 --> 00:32:35,200 And so 600 daily shouldn't be the cutoff as to an absolute max. 471 00:32:35,200 --> 00:32:41,320 Don't know, but they've been doing some really interesting things published that, you know, 472 00:32:41,320 --> 00:32:47,320 with people with TB meningitis or extensive disease, like pushing it way beyond 10 milligrams 473 00:32:47,320 --> 00:32:52,680 per kilogram, and people really tolerating it fairly well. 474 00:32:52,680 --> 00:32:55,760 Based on, you know, monitoring blood levels and things like that. 475 00:32:55,760 --> 00:32:57,920 So that's a really big change. 476 00:32:57,920 --> 00:33:00,120 It's such an important drug. 477 00:33:00,120 --> 00:33:05,200 So again, I would say, maybe that's actually more on the horizon, maybe we'll see even 478 00:33:05,200 --> 00:33:08,160 greater dosing for that. 479 00:33:08,160 --> 00:33:12,520 And I would say the other thing that's really, I think, was really important in this that 480 00:33:12,520 --> 00:33:17,320 people talked a lot about was de isolation. 481 00:33:17,320 --> 00:33:22,120 And at least that's a hot topic, I know, in Alberta, as well as in Manitoba. 482 00:33:22,120 --> 00:33:23,120 Right. 483 00:33:23,120 --> 00:33:29,760 And not being so restrictive about keeping people in for two or three weeks. 484 00:33:29,760 --> 00:33:34,600 Again, we know that's horrible for people to go through, especially if they're from 485 00:33:34,600 --> 00:33:41,000 a remote community and have to be brought somewhere else, away from family members, 486 00:33:41,000 --> 00:33:45,080 you know, people who have jobs they need to go to. 487 00:33:45,080 --> 00:33:51,680 Because again, there's lots of evidence out there that once you're on a regimen that 488 00:33:51,680 --> 00:33:58,640 works for your TB, you're responding to it, you become non infectious actually, quite 489 00:33:58,640 --> 00:34:00,640 quickly. 490 00:34:00,640 --> 00:34:05,320 And so there's really nice review on that at the end of the standards. 491 00:34:05,320 --> 00:34:09,080 I'm not going to make any recommendations on de isolation, because that's definitely 492 00:34:09,080 --> 00:34:10,720 very controversial. 493 00:34:10,720 --> 00:34:11,720 Yes. 494 00:34:11,720 --> 00:34:17,400 But really controversial, but I would say give it some, you know, amongst public health 495 00:34:17,400 --> 00:34:23,200 authorities out there, you know, consider, consider being less restrictive about it based 496 00:34:23,200 --> 00:34:29,440 on smear status response, and responding and taking appropriate therapy. 497 00:34:29,440 --> 00:34:35,920 So again, if you have to be drug susceptible, and on that therapy to respond, if you're 498 00:34:35,920 --> 00:34:41,920 someone with drug resistant TB, you know, this is not this conversation probably doesn't 499 00:34:41,920 --> 00:34:42,920 apply. 500 00:34:42,920 --> 00:34:43,920 Right. 501 00:34:43,920 --> 00:34:48,080 And again, for drugs susceptible TB, certainly, I think we can look at that and hopefully 502 00:34:48,080 --> 00:34:51,520 make more progress on that in the future. 503 00:34:51,520 --> 00:34:57,280 And I would say on the horizon, maybe not for like, I would say in terms of like, look 504 00:34:57,280 --> 00:35:02,680 out for shorter course regimens, like as I mentioned before, I think definitely there's 505 00:35:02,680 --> 00:35:06,280 lots of work being done on it globally. 506 00:35:06,280 --> 00:35:09,600 So maybe maybe that's the future, but we'll have to see certainly. 507 00:35:09,600 --> 00:35:14,920 And again, I think it's probably what's going to happen is you're going to probably stratify, 508 00:35:14,920 --> 00:35:20,200 if I had to predict based on extent of disease will dictate length of treatment, how we do 509 00:35:20,200 --> 00:35:24,280 that, I don't know yet, but maybe a more stratified approach is what's coming. 510 00:35:24,280 --> 00:35:25,280 So 511 00:35:25,280 --> 00:35:26,280 Okay. 512 00:35:26,280 --> 00:35:30,880 And then currently, I guess, one of the things I wanted to ask just for my personal knowledge 513 00:35:30,880 --> 00:35:36,560 as well, is there a database that's like look like, you know, nationally that we're following 514 00:35:36,560 --> 00:35:42,440 or they're currently, are there Canadian trials that are currently on the way? 515 00:35:42,440 --> 00:35:43,440 Yeah, I'm not up on that. 516 00:35:43,440 --> 00:35:47,680 Well, I do know like Dick Menzies does a lot out of Montreal does a lot. 517 00:35:47,680 --> 00:35:49,660 His main interest is TB infections. 518 00:35:49,660 --> 00:35:51,520 So I imagine there's stuff going on there. 519 00:35:51,520 --> 00:35:54,360 He does a lot of global work as well. 520 00:35:54,360 --> 00:35:59,960 I know there were some rifapentine, rifampin, LCBI trials in the past. 521 00:35:59,960 --> 00:36:02,040 I don't know if there's anything ongoing now. 522 00:36:02,040 --> 00:36:05,040 But yeah, lots of stuff done. 523 00:36:05,040 --> 00:36:07,080 But again, we're a low burden setting. 524 00:36:07,080 --> 00:36:11,840 So it's our patient population is probably not a good bang for your buck. 525 00:36:11,840 --> 00:36:19,000 So but I know lots of these people are on India and other places in the world doing 526 00:36:19,000 --> 00:36:20,680 work on these types of things. 527 00:36:20,680 --> 00:36:22,440 Yeah, that's there. 528 00:36:22,440 --> 00:36:23,800 All right. 529 00:36:23,800 --> 00:36:24,800 Perfect. 530 00:36:24,800 --> 00:36:31,880 So before we kind of let the audience go here to is there anything else key in the guidelines 531 00:36:31,880 --> 00:36:37,840 that we should be looking at as clinicians or key take home points, something that you're 532 00:36:37,840 --> 00:36:42,240 dying to tell us that we should know for sure about TB? 533 00:36:42,240 --> 00:36:45,680 Yeah, what what if I had to say something? 534 00:36:45,680 --> 00:36:46,680 That's a good question. 535 00:36:46,680 --> 00:36:49,880 I actually hadn't like totally thought about it. 536 00:36:49,880 --> 00:36:52,640 That question specifically. 537 00:36:52,640 --> 00:36:59,440 Yeah, so I would say 538 00:36:59,440 --> 00:37:04,040 Well, pediatric TB always requires a high index of suspicion. 539 00:37:04,040 --> 00:37:06,360 And again, your history is crucial. 540 00:37:06,360 --> 00:37:13,720 And looking for signs outside of the classic adult signs are really what's key. 541 00:37:13,720 --> 00:37:23,560 And I would say for you know, I think a lot of people felt very strongly about is that 542 00:37:23,560 --> 00:37:30,720 TB is more than just TB disease, and the families we see is more than just the medical treatment. 543 00:37:30,720 --> 00:37:36,760 There's a lot of other social issues that go along with it. 544 00:37:36,760 --> 00:37:41,400 You know, housing and food insecurity and and things that have to be addressed. 545 00:37:41,400 --> 00:37:47,080 And you know, all of us would love to have a social worker as well. 546 00:37:47,080 --> 00:37:51,000 All of us would have loved to have better access to all of these drugs being used in 547 00:37:51,000 --> 00:37:52,400 other places in the world. 548 00:37:52,400 --> 00:38:01,120 So just an appeal to anyone who's listening, more money, more availability. 549 00:38:01,120 --> 00:38:05,440 And again, I think that's probably the state of TB in the world in general. 550 00:38:05,440 --> 00:38:07,200 It's a huge problem. 551 00:38:07,200 --> 00:38:12,120 Maybe not as much in Canada, but still requires a lot of time and a lot of money to if we 552 00:38:12,120 --> 00:38:13,240 want to eliminate it. 553 00:38:13,240 --> 00:38:17,080 So yeah, I think that's what I that's that's my message. 554 00:38:17,080 --> 00:38:18,080 That's really great. 555 00:38:18,080 --> 00:38:23,880 I mean, it's always nice to hear from somebody who's kind of managing TB daily, you know, 556 00:38:23,880 --> 00:38:30,360 like even though a lot of us listeners are clinicians or pharmacists and nurses that 557 00:38:30,360 --> 00:38:34,320 are seeing TB, you know, there's there's many angles to this. 558 00:38:34,320 --> 00:38:38,120 And yeah, it's it's definitely just beyond the physician and the nurse. 559 00:38:38,120 --> 00:38:45,120 There's people giving people meds in the community that do such grueling work and find patients 560 00:38:45,120 --> 00:38:50,720 who are hard to find and and, you know, public health, public health is also a key ally. 561 00:38:50,720 --> 00:38:52,960 Speak to them all the time. 562 00:38:52,960 --> 00:38:56,040 And again, you know, implementing our programs and things like that. 563 00:38:56,040 --> 00:39:02,800 So it's a vast network of people just beyond me that deal with the patients that I see. 564 00:39:02,800 --> 00:39:09,400 So, you know, very thankful again, as well, all the people who just really love to work 565 00:39:09,400 --> 00:39:15,520 in this in this area and do so much so for so so very little, actually. 566 00:39:15,520 --> 00:39:17,560 So I think it's also very helpful. 567 00:39:17,560 --> 00:39:22,920 I mean, we're really grateful for yourself as well, like authors like you that have been 568 00:39:22,920 --> 00:39:29,280 able to kind of change up guidelines, current guidelines and updates for us, because obviously 569 00:39:29,280 --> 00:39:34,560 if we're not seeing TB cases as often, we're not really familiar with the current practice. 570 00:39:34,560 --> 00:39:35,880 Yeah, exactly. 571 00:39:35,880 --> 00:39:36,880 It's all about. 572 00:39:36,880 --> 00:39:38,360 It's all about volume. 573 00:39:38,360 --> 00:39:44,960 As I say, like you just like anything in infectious diseases, once you see it 10 times, it looks 574 00:39:44,960 --> 00:39:45,960 like that. 575 00:39:45,960 --> 00:39:46,960 Yeah. 576 00:39:46,960 --> 00:39:47,960 But you know what? 577 00:39:47,960 --> 00:39:50,200 You know, I also want to put a shout out out there. 578 00:39:50,200 --> 00:39:53,600 That's very nice and generous of you for the thanks. 579 00:39:53,600 --> 00:39:57,360 But to Ian Katai and Dick Menzies as well. 580 00:39:57,360 --> 00:39:59,880 They're out there in the world. 581 00:39:59,880 --> 00:40:04,640 But we're very I was very fortunate to be given this opportunity. 582 00:40:04,640 --> 00:40:06,920 And it was a collaborative effort. 583 00:40:06,920 --> 00:40:09,080 I learned so much. 584 00:40:09,080 --> 00:40:11,400 And these are experts and wonderful people. 585 00:40:11,400 --> 00:40:16,880 So again, you know, always phone a friend if they know more than you. 586 00:40:16,880 --> 00:40:18,240 I do that for other things. 587 00:40:18,240 --> 00:40:20,200 So I'm always happy to provide advice as well. 588 00:40:20,200 --> 00:40:21,200 That's great. 589 00:40:21,200 --> 00:40:25,280 Yeah, yeah, there's been multiple times I've been in touch with you. 590 00:40:25,280 --> 00:40:26,280 So it's great. 591 00:40:26,280 --> 00:40:27,280 Anytime. 592 00:40:27,280 --> 00:40:29,840 I love to talk about it and other things too. 593 00:40:29,840 --> 00:40:31,440 But yeah, yeah. 594 00:40:31,440 --> 00:40:36,080 So I think reiterating that the TB standards are the reason I wanted to do this episode 595 00:40:36,080 --> 00:40:41,800 was just remind everyone that there are updated guidelines and those standards. 596 00:40:41,800 --> 00:40:45,920 And again, and again, it's meant to be an accessible document, right? 597 00:40:45,920 --> 00:40:49,000 It's not meant to be a super scientific thing. 598 00:40:49,000 --> 00:40:53,640 So again, that was the as I think we spoke about before, that was the main goal. 599 00:40:53,640 --> 00:40:59,500 It landed up being much larger because everything was so important to all of us. 600 00:40:59,500 --> 00:41:02,680 So I hope I hope it's useful to people I really do. 601 00:41:02,680 --> 00:41:06,120 And that people use it and give good care to these patients. 602 00:41:06,120 --> 00:41:07,120 Awesome. 603 00:41:07,120 --> 00:41:08,120 Yeah. 604 00:41:08,120 --> 00:41:10,560 And there's actually a lot of information about kind of drug resistant TB in there. 605 00:41:10,560 --> 00:41:15,760 I know some of our listeners had asked for some elaboration in there. 606 00:41:15,760 --> 00:41:20,760 But I think the guidelines actually after reviewing them are fairly straightforward 607 00:41:20,760 --> 00:41:23,880 there and then remembering that reach out to your experts. 608 00:41:23,880 --> 00:41:29,600 Yeah, I would say yeah, you know, even in places like South Africa, I'm on a group talking 609 00:41:29,600 --> 00:41:34,880 about some pregnancy and newborn stuff like, yeah, if you're on the community, this is 610 00:41:34,880 --> 00:41:37,200 you should not be managing that alone. 611 00:41:37,200 --> 00:41:38,800 It's complicated. 612 00:41:38,800 --> 00:41:40,860 It depends what's available. 613 00:41:40,860 --> 00:41:46,920 And there's usually someone within your network that that does this and you should reach out 614 00:41:46,920 --> 00:41:49,040 to them and not be afraid to. 615 00:41:49,040 --> 00:41:53,920 I know I know certainly that's at least the philosophy with the people I learned from. 616 00:41:53,920 --> 00:41:59,540 So again, you know, you're not alone out there. 617 00:41:59,540 --> 00:42:03,920 So again, and all of us again, it's all TB is a team and a collaborative effort. 618 00:42:03,920 --> 00:42:06,120 So none of us minds, I think. 619 00:42:06,120 --> 00:42:07,840 So I would reach out. 620 00:42:07,840 --> 00:42:08,840 Awesome. 621 00:42:08,840 --> 00:42:09,840 Perfect. 622 00:42:09,840 --> 00:42:14,040 Well, thank you so much, Dr. Rachel or Dr. Dwillow. 623 00:42:14,040 --> 00:42:15,040 Just Rachel. 624 00:42:15,040 --> 00:42:16,040 Yeah, no problem. 625 00:42:16,040 --> 00:42:18,040 Thanks for having me and listening. 626 00:42:18,040 --> 00:42:20,040 Yeah, it was awesome. 627 00:42:20,040 --> 00:42:21,040 All right. 628 00:42:21,040 --> 00:42:22,040 Thanks. 629 00:42:22,040 --> 00:42:23,040 Take care. 630 00:42:23,040 --> 00:42:24,960 Thank you, Dr. Dwillow for joining us. 631 00:42:24,960 --> 00:42:26,440 Have a topic suggestion? 632 00:42:26,440 --> 00:42:33,000 Email us at thecanadianbreakpoint at gmail.com and follow us on Twitter at CABbreakpoint. 633 00:42:33,000 --> 00:43:02,920 See you again soon at the Canadian Breakpoint.