CNS: A childhood free from tuberculosis (TB)

Tuberculosis (TB) is a major killer of children in poor countries. Over 250,000 children develop TB and every one minute two children die of TB worldwide. It has been estimated that as many as one third of the world's population is infected with TB, and an estimated 20-50% of children who live in households where an adult has active tuberculosis, become infected. "Also the power to resist TB infection is normally poor in the first 5 years of life, as the immune system is less developed. The resistance can be further reduced by malnutrition, HIV, other childhood infections and worm infestations – all too common in poor countries" said Professor (Dr) Surya Kant, from Pulmonary Medicine department at CSM Medical University (erstwhile King George's Medical College - KGMC). Good words of caution before the XVIII International AIDS Conference (IAC) opens in Vienna, Austria next week. Read more

So the risk to contract TB becomes particularly high in the developing world where family size is large, houses are crowded and more than half the population are children. Moreover, diagnosis is difficult in children, and often fatally delayed. TB can have devastating long term effects on children who can be left deaf, blind and/or totally paralysed from TB meningitis, even after it is cured.

Yet Paediatric TB does not have a high priority in many developing countries as fewer children than adults have the disease and children are not usually infectious, and often, limited resources mean that infectious cases have priority.

Although the TB vaccine, BCG, does limit some of the severe forms of tuberculosis, but by no means does it prevent them all. Thousands of such "immunised" children in the developing world still suffer from tuberculosis meningitis and other forms of disease. A vast number of children infected remain undiagnosed – creating a reservoir of future adult disease.

Hence there is need to prioritize diagnosis, prevention and treatment of TB as well as TB-HIV co-infection in children.

"Childhood TB is difficult to detect. The infected child usually has no external symptoms and remains quite well. There would be no reason for the parents to see their medical doctor. The 'disease' is self-limiting" said Dr Muherman Harun from Jakarta, Indonesia, in an online consultation hosted by the CNS Stop-TB Initiative, and the global Stop-TB eForum that was established by the Health & Development Networks (HDN) in early 2001.

Dr Muherman continues: "TB in children has become uncommon in high TB prevalence countries when routine BCG vaccination is routinely given to all new-born babies. BCG vaccination does prevent many deaths from miliary and/or meningitis TB, and also reduces the incidence of extra pulmonary TB. But BCG also appears to mask the manifestation of primary or childhood TB on chest X-ray so that no childhood TB can be found. Children, who fail to thrive, who often cough and from time to time have sub febrile temperature, have less appetite, transpiration at night and show no response to antibiotics, are often falsely treated as childhood TB. The unfortunate children are treated with anti-TB drugs for 6 to 12 months, or even more, as the chest X-ray result from radiologists show that lungs are not yet entirely 'normal.' (On retrospection, all of the chest x-rays from the start of treatment, were in my opinion, just normal)."

"So, in countries where BCG vaccination is given at a national scale we have to be aware of the numerous (false-) diagnoses of pulmonary childhood TB" said Dr Harun.

Dr K Suresh of India is committed to the cause of eradicating the scourge of TB. He feels that India can definitely be proud of reducing severe forms of childhood TB like TB meningitis and fulminating miliary TB, a common occurrence during the 1960s. Similarly spinal TB in children has also become relatively rare.

But, at the same time, the challenge for diagnosing TB in children continues —an area where hardly any progress has been made during the last 50 years. The situation is worse in remote rural and tribal population.

Dr Suresh made some pertinent observations about the situation in India under the Revised National TB Control Programme (RNTCP), keeping in mind the International Standards for TB Care (ISTC).

According to him, "Most children under 5 years do not produce sputum, so they get excluded for diagnosis. Children between 6-14 years may be subjected for sputum examination if having cough of two weeks are more. Even for them examining sputum twice is very uncommon, leave apart collecting early morning specimen. For children with extra pulmonary TB (likely to be more than Pulmonary TB), collecting appropriate sample for microscopy as advised is hardly visible explicitly except in a few tertiary facilities in the country. As per the International Standards for Tuberculosis (TB) Care (ISTC) norms, radiographic suspects should meet criteria of 3 negative smears, and cases showing lack of response to appropriate antibiotics, and radiographic findings consistent with TB should be put on DOTS. This seems to be rarely done in India. The RNTCP reports of 2009 and 2010 do not mention anything about cases diagnosed using this criterion."

Dr Suresh further adds: "The National AIDS Control Programme (NACP)/ RNTCP coordination mechanism (TB/HIV package) has been started in India only in 2008 and covers only about 18 states. In persons with HIV infection, diagnosis should be expedited. But not many ARTs in the countries are equipped with this facility, nor do the district TB centres refer sputum positive cases for HIV testing adequately. Though it is reported that 10.6 % of referrals (HIV positives) suspected to have TB have been confirmed to be tubercular and 12% of TB patients were confirmed as HIV positive in 2009. In 2009 the proportion of TB patients with known HIV status has increased from 34% to 62%. Unfortunately the RNTCP does not look into desegregated status for children in this category too."

Dr Suresh rued that desegregated data for children with TB, association of TB and HIV/AIDS is hardly reviewed with serious concern. He appealed to agencies whose mandate is Children (UNICEF, Save the Children etc) to wake up and add activities for childhood TB along with HIV/AIDS in all their projects, and join hands in all government efforts to ameliorate the Childhood TB status and co-existence of TB-HIV co-infection in children.

He hopes that 'Stop TB' campaign does not get limited to sputum positive adult TB-HIV co-infection alone. Children are our future. They cannot speak for themselves. Somebody needs to speak for them. An important step in this direction would be for countries to collect and share desegregated actual data (and not mere estimates) for children on TB, HIV/AIDS and their co-infections.