Can we reach the tipping point for childhood TB?

Shobha Shukla *

An estimated 1 million annual cases of children with TB (although the actual number could be much higher); 210,000 annual deaths from childhood TB - a mortality rate of 21%! More shockingly, 96% of these deaths occur in children who do not receive any TB treatment. A treatable and preventable disease that is not being treated, and certainly not being prevented. A scary situation indeed!

Dr Jeffrey R Starke, an internationally recognized expert in paediatric TB, raised the important issue of TB in children during the opening of the 48th Union World Conference on Lung Health, in Guadalajara, Mexico. Dr Starke is Professor of Paediatrics at Baylor College of Medicine, Houston, Texas in USA. Incidentally, Houston has one of the highest rates of TB in children in the USA. Shobha Shukla, Managing Editor of CNS (Citizen News Service) was in exclusive conversation with Dr Starke.

Here are some excerpts from the interview:

Why has childhood TB been historically neglected?

Dr Jeffrey R Starke: "Firstly, childhood TB is fundamentally different from adult TB. Most children who develop the disease, do so rapidly, within weeks or a few months of acquiring the infection. So time is critical. The again, children with TB are almost never contagious - a dead-end in terms of transmission. They have a much smaller burden of TB bacteria in them as compared to adults. Children also do not tend to cough as much as adults - they do not bring up sputum from their lungs - so they do not spread the infection in the air.

As a result, over-burdened and under-resourced TB programmes consider children to be less important than adults to address the overall burden of disease. There seemed to be a perception amongst policy makers that treating adults with TB was enough - if all the contagious adult TB is eliminated, no more children would get infected."

What has been the progress in controlling TB in children since 2011, when the WHO first started gathering data on it?

Dr Jeffrey R Starke: "Many things have changed since then. Prior to that we just did not know the extent of TB in children. Now we have some estimates and the numbers keep on increasing. There is also a broader recognition that childhood TB is a major cause of mortality and morbidity in many countries. A Roadmap for Childhood TB was published in 2013 by WHO and partners, that presents a set of guiding principles on how childhood TB needs to be approached. However, unlike WHO End TB Strategy, it is not a strategic plan with timelines in terms of when certain goals must be accomplished. Then again, through the efforts of TB Alliance (Global Alliance for TB Drug Development) and partners, new child-friendly drug formulations have been developed, making treatment of childhood TB easier.

Another thing that has changed is the recognition that we need to find children with TB, because many of these kids are being missed out from being diagnosed. As children have very few TB bacteria, it is much harder to confirm TB in children than it is in adults, and clinical diagnosis becomes difficult with the current tools we have. So a large number of childhood TB cases are never correctly diagnosed, and are mistaken for pneumonia, complications of malnutrition or bacterial meningitis. High burden countries have now started to do contact tracing and look for children with TB or those who have been recently exposed to the disease, so that they can be treated."

What are the main action points to be taken to control TB in children?

Dr Jeffrey R Starke: "The tide can turn when DOTS is being offered in a community. When an adult patient is being treated in the public health system under DOTS on a regular basis, a very small increment in human resources and medications is required to ensure that the children in that person’s environment also get evaluated and treated for TB. The WHO End TB Strategy says that we need to do patient-centred care. But what we really need to be doing is family-centred care. We need to look at patients of TB as members of a household, and figure out not only what the patient needs but also what the other members of the family need, especially the young children.

Data has shown that a vast majority of children who died of TB never got any TB treatment. In other words, they were not diagnosed. So it is imperative to form alliances with child health programmes, nutrition programmes, and HIV programmes where children missed for TB might be found and evaluated properly for TB. The key question to ask, when a child is sick, is - 'Has this child been around anybody who has TB?'

If the answer is 'Yes', it changes everything. For instance, if a child looks like that she/ he has pneumonia- has fever and is breathing hard- and if we know that the child was recently exposed to someone with TB, it increases the likelihood that the child might be suffering from TB and not pneumonia. Child health programmes must work side by side with TB programmes at local levels, so that we can find these kids with TB and put them on treatment.

The real tragedy of childhood TB is that it is preventable in most cases with very minimal effort and expense - by simply recognising the children who live in households with adults with active TB, and providing them testing and medication to prevent them from developing active disease.

Yes, we do need better diagnostic tests that would easily determine the germs in them or determine their response to the germs. These would be immunologically based tests. But we also need to do rightly what we have now with us.

We have to adequately address childhood TB – both disease and infection, treatment and prevention - if we are to 'bend the curve' to eliminate the disease. It will take a paradigm shift to include children in all aspects of TB elimination, and to put as much emphasis on prevention, as there should be on treating the disease once it occurs in them.

Most importantly, it would require the political will within the TB and child health communities, and governments, to devote the necessary resources and energy to reach our goal of TB elimination. We need better funding and integration of healthcare systems for effective and sustainable TB service delivery to children and adolescents.

Children have the same right as adults to benefit from TB care and research! It is time that we put these words into action, as the elimination of TB depends on it."