Neglecting childhood tuberculosis “a human rights violation”

On May 23, 2018, the International Union Against Tuberculosis and Lung Disease (the Union) issued a report, Silent Epidemic: A Call to Action Against Child Tuberculosis. Launched at the World Health Assembly, the report noted that an estimated 239 000 children aged younger than 15 years died from tuberculosis in 2015, 90% of whom were untreated. The authors say: “the continuing medical neglect of child TB, resulting in millions of avoidable deaths, constitutes a human rights violation”.

Several factors lie behind this neglect. Children who fall ill are usually taken to primary care facilities, or mother and child health services, which are often ill-equipped to diagnose and treat tuberculosis. Paediatric tuberculosis mimics other common childhood infections, such as pneumonia. Diagnosing children with tuberculosis is notoriously difficult anyway, since they mostly develop paucibacillary disease and cannot easily generate sputum. This also means they are less contagious than adults, which is another reason for their marginalisation. “From a public health perspective, children have not been considered a priority in tuberculosis control since they are not important transmitters of the disease”, explains Paula Fujiwara (The Union, Paris, France).

Children typically contract tuberculosis from close contact with an adult. “This is a family disease”, stresses Beate Kampmann (London School of Hygiene and Tropical Medicine, UK and MRC Unit, Serekunda, the Gambia). “If you diagnose tuberculosis in an adult, the question should immediately be asked ‘are there any children in the household?’”. But although national guidelines recommend prevention, in practice it is rarely prioritised. In 2016, just 13% of children who were eligible for preventive therapy with isoniazid received it. “Programmes are only rewarded for reporting the cases they have treated, rather than the cases they have prevented; that stops prevention from getting the traction it needs”, said Kampmann. The lack of resources dedicated specifically to paediatric tuberculosis compounds the problem.

There have been some important advances over the past few years. In 2013, WHO published its roadmap for childhood tuberculosis; it is working on the second edition. The Stop TB Partnership has named five priority actions it would like included in any political declaration emerging from the forthcoming UN High-Level Meeting on Tuberculosis, two of which directly mention children. Funding for child and adolescent tuberculosis is increasing and in 2015 WHO approved a child-friendly therapy for drug-sensitive disease.

“To reach children with tuberculosis, or at risk of tuberculosis, WHO and partners need to assist countries to implement contact investigation and to link screening, diagnosis, and treatment into other programmes”, Tereza Kasaeva (WHO, Geneva, Switzerland) told The Lancet Infectious Diseases. A childhood tuberculosis hub within the national programme can help develop a coordinated response.

“Diagnostics have been driven by adult tuberculosis presentation”, points out Kampmann. This led to a focus on microbiological diagnostics. “Given that children are not smear-positive, we have to look at the host response and think of what might be different in childhood tuberculosis compared with the adult disease”, she said. Fujiwara suggests investigating diagnostics that use bodily secretions other than sputum. All of which will require sustained investment.

Less than 10% of children with multidrug-resistant tuberculosis are thought to be detected and treated. For those who are, treatment regimens are extrapolated from adult disease. “Children have many fewer bacilli, so perhaps we do not have to give them injectable drugs for months on end”, said Kampmann. “But we cannot answer this question unless we put children in clinical trials.” The Union report makes the same recommendation. “Children are not included in research; that has to change”, stated Fujiwara.

The Union piloted the DETECT Child TB programme in Uganda in which community health-care workers are trained to recognise the symptoms of the disease and screen household contacts. The initiative resulted in a sharp increase in the detection and treatment of childhood tuberculosis, while the proportion of at-risk children on preventive therapy rose from less than 5% to 72%. Kampmann led a similar programme, Reach4Kids, in the Gambia. She and Fujiwara are confident that the model could be rolled out elsewhere.

“Primary care is the key; frontline health-care workers have to be aware of childhood tuberculosis; treatment decisions can then be based on clinical diagnoses”, said Kampmann. Both the treatment for drug-sensitive tuberculosis and preventive therapy are effective, cheap, and well tolerated by children. And while children may not be as contagious as adults, they will one day grow into adults. “Children are the future reservoir of disease; unless we address childhood tuberculosis effectively, we are prolonging the transmission chain”, concluded Kampmann.

Source: The Lancet Infectious Diseases