CNS: TB In Children: An Avoidable Problem

Tuberculosis (TB) is one of the most under-reported and under-rated chronic disease for children across the world. Although childhood TB has been receiving attention from global health experts, it still remains a major cause for illness and death of children. Yet TB is preventable, treatable and curable. Children generally contract this disease because they are in proximity to elders who are already affected by the TB bacterium, such as a nanny, the mother, the care-giver or other infected family members.

Children are the prime targets as their immune systems are not fully developed. Children with TB are often poor and live in vulnerable communities where there may be lack of access to health care. According to the Stop TB Partnership, new-born infants of women with TB are at increased risk of contracting TB. Children living with adults suffering from TB can become ill with the disease even if they are vaccinated with the BCG vaccine. TB among children is often overlooked due to non-specific symptoms and difficulties in diagnosis such as obtaining sputum from young children.

The World Health Organization (WHO)’s Global Tuberculosis Control Report, 2012 estimates that 490,000 children fall sick with TB every year and nearly 70,000 of them die. Experts, however, maintain that these are gross underestimates. TB preys on the most vulnerable children – the poor, the malnourished and those living with HIV. This leads to an unimaginable burden on children and their families. In a Papua New Guinea village, a two-year old orphan whose mother died of the disease, infecting the child, was taken up for adoption by a school teacher. But all stories do not end happily. Another adult patient, who later died of multidrug-resistant TB (MDR-TB), told me that he was ‘tormented by guilt’ because there are no resources to help them care for their children while they are being treated at a hospital or at home. In another case, a stock-out of anti-TB medication in southern Romania prevented one 14-year-old boy from leaving the Bucharest hospital so he could take his high school exams,” says a Ph.D. student of Medical Anthropology of the City University of New York.

The only TB vaccine that exists, namely the BCG (Bacille Calmette-Guerin), was invented in 1921. In most countries across the world, BCG is mandatorily given at (or soon after) birth to infants to protect them from the most severe forms of TB including TB meningitis. But few are aware that (a) BCG does not protect children from the most common form of TB – TB of the lungs and (b) the effect of the vaccine wears off as children grow in age. Besides, children with HIV cannot receive BCG because it can make them sick.

Scientists are working on developing new vaccines that address these drawbacks. A dozen new vaccine candidates are currently undergoing clinical studies. Results of a study of a preventable TB vaccine, that enrolled nearly 3000 infants in South Africa, were published very recently in 2013, and were disappointing because the vaccine did not significantly protect children against TB. Collaboration between the public and private sectors is urgently called for to ensure adequate investment to develop and deliver a new safe and effective TB vaccine soon.

Evaline Kibuchi, from the Kenya National Aids NGOs Consortium (an ACTION partner) says, “The Ministry of Health needs to increase contact tracing for adults with TB. It is the best way to find children who have been exposed and it is not happening enough.”

It goes without saying that the more cost effective way is to prevent the disease than to cure it. The most effective way to prevent childhood TB is to stop it from spreading. This can be done through what is known as the three I’s (i) Intensified case finding, (ii) Isonaizid Preventive Therapy or IPT and (iii) Infection Control.

Intensified Case Finding implies that when an adult member in the family is diagnosed with TB, all close contacts and family members, including children must be screened for TB. If symptomatic, they should be provided appropriate diagnosis and treatment. IPT prevents children from developing the active disease which is also important in case of children living with HIV. Children with HIV are 20 times more likely of developing TB than children with healthy immune systems. Infection Control covers high burden areas where children are more likely to be exposed to the TB bacteria, such as health care facilities, crèches, homes, schools and other community settings that need to be made TB-safe. This includes separation of patients who are coughing from those who are not; providing them with masks; opening windows and doors to establish natural ventilation-- all of which can prevent the spread of the disease. These methods, endorsed by the WHO, can prove to be very effective in reducing childhood TB.

It is also necessary to train health workers to address childhood TB and TB services need to be incorporated into the Integrated Management of Childhood Illnesses (IMCI) -- a broad-based childhood health strategy. It is also important to link TB services with maternal health care to prevent mother-to-child transmission of HIV and TB. All children living with HIV must be screened for TB regularly,, and vice versa during visits to the medical centre.

In order to end childhood TB, we must address poverty. Child health is directly linked to poverty---a major risk factor for TB which in turn, is a big driver of poverty. This functions like a vicious circle leading back to where it began. Children living in poverty are more likely to be undernourished, lack access to medical care and live in crowded homes with little ventilation and poor hygiene. Their parents are also likely to be ignorant about medical treatment, importance of hygiene and preventive and curative health strategies in daily life, which in turn makes such children more vulnerable to TB than others. Then again, people living in impoverished conditions often cook indoors which creates an environment of thick smoke for the child that weakens their lungs. A study in Bangladesh found that children who completed primary school were less likely to develop TB.

“Childhood TB is all about money – who does not have it, who wants it and who is unable to provide it,” says Jennifer Furin, Assistant Professor, TB Research Unit, Case Western Reserve University.