Mikkel Vestergaard Frandsen, the CEO and owner of Vestergaard Frandsen (a company focused on achieving the United Nation's Millennium Development Goals of eradicating extreme poverty, combating infectious disease and reducing global warming) opened his Inaugural Lecture at the just concluded 42nd World Conference on Lung Health, by showing a video clip of a 14 years old poor African girl who contracted TB in a poor and indoor pollution ridden home and died of it a few months ago. The clip was a telling commentary on the status of childhood TB in poor household settings. TB in children is still highly under diagnosed, under reported and under estimated.
According to Dr Anne Detjen, Technical Consultant, the International Union Against Tuberculosis and Lung Disease (The Union), and a noted Paediatrician: "It is estimated that globally 15% of the annual cases of TB are in children, with the majority of cases occurring in high TB burden countries. For example in many low incident countries of Central Europe it may be around 2 per 100, 000 whereas in South Africa, in the region around Cape Town, it may be as high as 40% of the annual tuberculosis cases."
She feels that, “Childhood tuberculosis has been neglected for a long time and, in terms of the global policy the focus has been on adult tuberculosis. The concept was that as children contract TB from adults, and children very rarely infect other people, so if we can manage and eliminate TB in adults then it will also be eliminated in children. The problem of childhood tuberculosis is beset with challenges. Diagnosing TB in children is not easy and many of the common tools used in diagnosis of TB in adults, like sputum microscopy, do not work in children. Also, presentation of the disease is less specific in children, and it is often confounded with other diseases. It is also often felt that TB is a rare disease in children and that the probability of the child having pneumonia is greater. However, it is now being increasingly recognized as an issue that has to be tackled seriously.”
“The main reason for children becoming sick with TB is poverty. Children living in poor circumstances, in very crowded houses with bad ventilation/improper air flow, and increased air pollution due to use of bio fuels become easy targets for the TB bacterium. Poor children are often malnourished which weakens their immune system, making them less equipped to fight off the disease. A child infected with TB has a very high risk of becoming sick with the disease, as compared to an adult. An adult infected with TB has about 10% life time risk of actually contracting it. In children this risk is much higher. In infants under one year of age this risk could be up to 40% (4 times more than in adults). The risk is high, not only of becoming ill, but also of getting very severe forms of tuberculosis such as TB meningitis and miliary TB. This is one of the reasons why preventive therapy is very important in children, especially in young children under 5 who are exposed to cases of infectious TB, so that they never actually contract the disease. There is one recommended regimen of preventive TB treatment in children and that is the antibiotic Isoniazid which is one of the main drugs to manage TB and this is given for duration of six months” said Dr Detjun.
She emphasizes upon the urgent need for new diagnostic tools for diagnosing TB faster in children, as well as the need for new drugs and new vaccines. She conceded that there have been many exciting developments in the field of diagnostics, and we now have the GenXpert which can diagnose TB and Drug Resistant TB in two hours. But these tools have been developed for the examination of the sputum and sputum is something which children can often not produce. Also the TB which children have is called pauci-bacilliary that is they are infected with fewer bacteria than adults. So the probability that the bacteria are being seen in the sputum is very low. Children also often have a form of TB where the TB bacteria do not come into the sputum. So sputum based diagnostic tools may not be very good for children. We need to have better non sputum based tools.
Then again, BCG, the currently used vaccine, is suboptimal and proven to protect only very young children from very severe forms of TB. As of now there are a lot of vaccines in the pipeline but none of them are near the implementation stage. Beyond this what we need is new drugs which are child friendly. Children have to be given different dosages, and sometimes dosages have to be adapted to the weight of the children, they often get individual pills (than the six drug combination), and size of the pill has to be small. Also, many of the drugs that we are using now have never been tested for children. So once a new drug is shown to be effective in adults, it needs to be found out in what dosage it can be given to a child. There are some very exciting new drugs in the pipeline. One of the other big challenges in TB is that even if the best new tests and the best new drugs are available, unless healthcare settings, in which they have to fit, are functional it will not be of any use. We have to make our existing healthcare systems functioning and work as best as we can with whatever tools we have, and then be ready to bring in new tools whenever they become available.”
Then again, BCG, the currently used vaccine, is suboptimal and proven to protect only very young children from very severe forms of TB. As of now there are a lot of vaccines in the pipeline but none of them are near the implementation stage. Beyond this what we need is new drugs which are child friendly. Children have to be given different dosages, and sometimes dosages have to be adapted to the weight of the children, they often get individual pills (than the six drug combination), and size of the pill has to be small. Also, many of the drugs that we are using now have never been tested for children. So once a new drug is shown to be effective in adults, it needs to be found out in what dosage it can be given to a child. There are some very exciting new drugs in the pipeline. One of the other big challenges in TB is that even if the best new tests and the best new drugs are available, unless healthcare settings, in which they have to fit, are functional it will not be of any use. We have to make our existing healthcare systems functioning and work as best as we can with whatever tools we have, and then be ready to bring in new tools whenever they become available.”
Dr Detjen stresses upon the importance of awareness at the community level. People have to know about TB, and they have to know that children are at great risk. So if there is an adult diagnosed with TB then it is the responsibility of the health centre and of the community to ensure that all the members in the household of the patient, especially the children, are screened for TB.
According to her, “There are often cultural restraints in people -- they may not want to bring very young babies to the health centre, as it feels safer at home. But these very young babies are at the highest risk of getting TB, and even if they do not have any symptoms they should be put on preventive therapy. Health centres have to include this in their program. If there is high incidence of HIV in the region, then children should be tested for HIV too. Keeping patients informed is very important. TB is not like pneumonia, where the child gets treatment for a few days and is well. Parents have to be informed by the doctor that TB treatment has to be taken for the entire period of six months, even though the patient may start feeling better after a while. Because then it would come back with a vengeance. Patients are partners and have the right to information, education and knowledge. The main thing is to raise awareness at community level, health care level, and global policy levels.”
Shobha Shukla - CNS
(The author is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She is currently writing from the 42nd Union World Conference on Lung Health, Lille, France. She has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. Email: shobha@citizen-news.org, website: http://www.citizen-news.org)
