Childhood TB, the silent killer we must work hard to eliminate

One million children under the age of 15 develop tuberculosis (TB) and 239,000—nearly one in four—die annually. The staggering statistics were revealed by The International Union Against Tuberculosis and Lung Disease (The Union) in a report at the just concluded 71st World Health Assembly held in Geneva Switzerland.

The report, which was Christened“Silent Epidemic: A Call to Action Against Child Tuberculosis”, is now calling for urgent action to protect children from TB.

This massive toll of deaths among children results from systematic disregard for children’s rights to health yet most of these deaths are treatable and preventable with simple, cost-effective public health measures.

It is an open secret that health systems neglect children with TB because children are less contagious than adults—stopping the spread of TB is a priority—and because the standard tools used to diagnose TB work less well in children.

“Children with TB rarely die when they receive standard treatment for the disease, but 90 per cent of children sick with TB worldwide is left untreated,” said Dr. Paula I. Fujiwara, Scientific Director, The Union.

“This neglect can no longer be excused on grounds of economy or expediency. TB is preventable, treatable, curable. The continuing medical neglect of child TB, resulting in millions of avoidable deaths, constitutes a human rights violation by any reasonable measure.”

Ending the childhood TB requires local interventions that are sensitive to social and cultural context, to reach at-risk children using simple tools for active screening and diagnosis. Even in resource-limited areas, projects like DETECT Child TB, spearheaded by The Union, are demonstrating that medical professionals can be equipped with the knowledge and tools to diagnose and treat TB in children, with access to care provided at the community level.

“By following a simple process to screen, diagnose and treat children in households with adults suffering from TB, we have been able to make a tremendous impact in a short space of time,” said John Paul Dongo, Director of The Union’s Uganda office.

“In Uganda, where this intervention was implemented, diagnosis of Child TB cases more than doubled, with the proportion of child TB cases increasing from 7.4 per cent at baseline to 17 per cent, we have also achieved 82 per cent success in treating children diagnosed with TB, up from 65 per cent.”

“Screening households where an adult is diagnosed with TB to see if children have been exposed in the home must become the standard implemented everywhere. Where The Union has piloted this approach in Uganda, 72 per cent of at-risk children were able to receive preventive TB treatment, up from less than 5 per cent previously,” he added

In the long run, investment in research and development needs to deliver better diagnostics, treatments and an effective vaccine that prevents TB.

To be a success, the UN High-Level Meeting on TB in September 2018 needs to generate concrete action, where governments are held accountable for achieving time-bound targets, for investing in new research and delivering the care to which all children with TB have a fundamental right.

“The public health sector cannot end the TB epidemic alone, because TB is driven by economic and demographic factors as much as it’s driven by health factors,” said José Luis Castro, Executive Director of The Union.

“We are dealing with an airborne disease that is becoming increasingly resistant to the few antibiotics we have to treat it, and children are bearing some of the worst impacts. We simply cannot continue like this. Heads of State are the only leaders with the power and influence to mobilise resources to end the epidemic. They must act.”

According to the 2017 TB Prevalence survey in Kenya, out of the possible 22,000 paediatric TB cases, only 7,714 were diagnosed, representing 35 per cent of all cases. Out of the detected paediatric cases, 161 children succumbed to the infectious disease.

This means that more than half of paediatric tuberculosis cases go undetected in Kenya every year, indicating a gap in diagnostics.

According to the survey, the use of microscopy for diagnosis, which is a common method of running TB test in Kenya, misses more than 50 per cent of the cases. Gene X-pert, an innovative method forTB diagnosis is able to detect 78 per cent of cases making it a more reliable and efficient than microscopy. However, the method also presented 22 per cent diagnostics gap.

The use also revealed that 85,188 overall cases of TB were diagnosed in Kenya during the year.

Detecting TB in children is difficult because it presents as a  cough, fever, weight loss, being dull and inability to gain weight. It also mimics other common childhood diseases and you can only detect it by running recommended tests.

“The biggest challenge in terms of childhood TB is under diagnosis. Estimates have it that about 22,000 children fall sick from TB every year in Kenya. only about 7,000 were diagnosed and put on medication last year, this means that close to 65 per cent of those with TB is not diagnosed every year. This is worrying,” said Enock Masini, a TB expert at the WHO.

“This is an area that needs a lot of investment to increase access to modern diagnostic technologies to be able to tackle it,” he said.

Two years ago Kenya rolled out improved FDC medicines for the treatment of childhood TB nationally and also called for screening of all children with respiratory symptoms seeking care in health facilities for TB.

The government also recommended chest x-rays for everyone suspected to have TB and Gene X-Pert be the first diagnostic test for all presumed childhood TB cases.

Until this new formulation, the treatment regime for children comprised of numerous pills of many formulations which proved complex to use for both the healthcare workers and caregivers.  The tablets were also big and difficult for the children to swallow hence they had to be crushed and sometimes mixed with food. This resulted in inaccurate dosing and poor adherence.

While all these are steps in the right direction, the efforts seeking to fill the gap between diagnostics and treatment are yet to take off as planned. The main hindrance has been lack of knowledge and awareness in public health institutions regarding TB and lack of enough diagnostics technology. For instance, the country only has 154 Gene Xpert machines, which means most facilities lack the crucial technology to detect and arrest the disease.

“Personnel is the other thing that is wanting. How TB is confused with pneumonia means that we need to enhance the capacity of health care to be able to diagnose. There is an opportunity to combat TB spread in children especially those under five. This is because they get it from adults,” said Masini.

Currently, TB is the fourth leading killer in Kenya and its high prevalence is attributed to HIV, poor ventilation, overcrowding, and poor nutrition. Children exposed to infectious persons are more likely to develop TB. Younger children are more likely to develop severe forms of the disease.

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