Theme 1 (e-consultation): Getting to zero new TB infections in children by 2015

(CLICK HERE TO COMMENT!)
The theme 1 of the time-limited online consultation on childhood tuberculosis (TB) in lead up to the World TB Day is: "Getting to zero new TB infections in children by 2015." Have your say before 25th February 2012 - share with us what should be done more (or less of) to prevent new TB infections in children in your local settings. Your perspectives, opinions, voices are important for us and we do look forward to them.

GUIDING QUESTION
- What can be done more (or less of) at the family, community or your country level to prevent new TB infections in children?

This e-consultation on childhood TB is being facilitated by the Citizen News Service (CNS), a partner of the Stop TB Partnership, along with many other organizations and networks that have endorsed this initiative and joined as a partner (see the list below).

HOW CAN YOU HAVE YOUR SAY?
Join the new Stop-TB eForum by sending an email to: stop-tb-subscribe@yahoogroups.com and have your say by sending your comments to stop-tb@yahoogroups.com
Be a partner of this online consultation - to be a partner organization, send an email to: bobby@citizen-news.org
Email us your comments, perspectives and experiences at: stopTB@citizen-news.org
- Go online at CNS blog: www.citizen-news.org and publish your comments real time! 
Skype us and we will record your statement (skype id: bobbyramakant ). To schedule skype appointment, email: bobby@citizen-news.org
Tweet us! use #tag: #childhoodTB
- Have your say on our CNS Facebook page
Call us and record your statement! (+91-98390-73355)

TIMELINE for THEME 1
Responses to theme 1 are welcome till 25th February 2012, after which a summary report of Theme 1, will be compiled and released to mark World TB Day.

REFERENCE DOCUMENTS:
Call for Action for Childhood TB (launched in Stockholm in March 2011)
PARTNERS
International Union Against Tuberculosis and Lung Disease (The Union)
Irish Forum for Global Health (IFGH)
McGill TB Research Group
Treatment Action Group
International Council of Women living with HIV (ICW) Zimbabwe
Asian Harm Reduction Network (AHRN)
ACTION
TB Alert
International Treatment Preparedness Coalition-India (ITPC-India)
Global Health Strategies
PATH
Cambodian Health Committee (CHC)
L’Association de Lutte Contre la Pauvreté en abrégé (ALCP)
Positive Muslim Group, Myanmar
Life Foundation, Pakistan
The Good Neighbour Nigeria
University of Nairobi, Kenya
Medical Care Development Inputs (MCDI) Kenya
Kenya Consortium to Fight TB, Malaria and AIDS (KECOFATUMA)
Partnership for TB Care and Control, India
Karnataka Health Promotion Trust (KHPT)
National Coalition of PLHIV in India (NCPI+) 
PCI India
MAMTA Health Institute for Mother and Child
SNEHA
Institut Pasteur de Madagascar
Institute for Plantation Agricultural And Rural Workers (IPARW)
Advocates for Health International
Rural Youth Advocate for Health and Development in Nigeria (RYAN)
Citizens for Healthy Lucknow (CHL) initiative
Saaksham Foundation
TEST Foundation
PREPARE Foundation

JBS Foundation
Abhinav Bharat Foundation (ABF)
Asha Parivar
Samadhan
National Alliance of People's Movements (NAPM)
PRAYAS Health Group
Indian Society Against Smoking (ISAS)
Citizen News Service (CNS)

Looking forward to a meaningful dialogue,

Citizen News Service (CNS)
Email: stopTB@citizen-news.org

60 comments:

  1. shobha shukla13 February, 2012

    In an interview given recently to CNS, Dr Somya Swaminathan, MD in Pediatric TB, and a Scientist at the National Institute for research in Tuberculosis (ICMR), said that: “Pediatric TB is difficult to control, because the infection spreads through the air borne route, and children get it from adults. So the only way to prevent is to tackle adult TB more seriously. Contact to contact TB testing must be done. All family members of a TB patient, especially children, should be tested, and started on chemo prophylaxis. That way we can reduce the burden of pediatric TB. The general awareness level about TB is very poor, even amongst educated people. They do not know how it spreads, how it can be diagnosed and treated and what they can do to reduce the burden of TB. As it is an air borne infection, anybody can get it. The most important risk factor in children is malnutrition, as poor nutrition makes one more susceptible to it. Other social or environmental causes could be poor housing, overcrowded indoors, indoor air pollution, passive smoking, and to a much smaller extent HIV infection also, as in India HIV prevalence is fairly low.”

    ReplyDelete
  2. From: Daisy Dharmaraj
    Email: daisy.dharmaraj@gmail.com

    1. screening the communities for pulmonary TB and active case finding are crucial to reduce the infection.Regular medical camps are essential especially in places of high prevalence. Voluntary reporting does not work in many instances because the community has a greater faith in private practitioners
    2.The subcentres and anganwadis and similar village level institutions have to focus on health education on TB, using different media. Make TB the talk of the town.
    3. Surveillance for successful DOTS is absolutely essential. There is too much distortion of facts and figures.
    4. Ensure that the patient is cured and non infective. through community based monitoring
    5 Incentives to village level workers towards case finding and treatment completion will go a long way in control
    .6. operationl research to understand the gaps in service delivery and adherence to treatment is crucial

    Daisy Dharmaraj
    Associate Professor
    Department of Community Medicine
    ACS Medical College
    Director TEST Foundation
    Mobile: +91-9444444857
    Email: daisy.dharmaraj@gmail.com

    ReplyDelete
  3. Partnership for TB care and control in India14 February, 2012

    In Tamil Nadu, the PPTCT (Prevention of Parent to Child Transmission)Project is being performed well outcome because of a strong network among partner NGOs which is initiated by MEERA FOUNDATION in the name of TAPNET-Tamil Nadu AIDS Prevention Network. This network helps to track the migrated cases and defaulters. This network partners are work closely with Angan-wadi Centres to the aim of follow the antenatal mothers and spouses. There are successful outcomes

    Similar to this, I would like to suggest that the Angan-wadi workers can be collaborated primarily for preventing new TB infections among children. Through this channel we can reach the reproductive families in coming years. The AW Workers may be involved in TB control orientation with aim of reaching and targeting child headed families. If this idea is reliable, we can start with in a Block as a trial.

    Thanks,

    Raja Mohamed
    MEERA FOUNDATION

    ReplyDelete
  4. I wish the people who matter think of and set achievable goals. There are no ways to reach this unrealistic goal.Having said frankly what best can be done is:
    1) Every one concerned with this issue need to encourage and make an aggressive effort to identify all families with sputum positive cases and contact infants/children, especially as bed or room sharing partners in local areas.
    2) Put all the cases under treatment as per RNTCP guideline
    3)Get the infant/child with a pediatrician and follow his advise for prophylactic treatment

    ReplyDelete
  5. How to correctly diagnose and treat TB in children and achieve 'zero TB deaths' in children by 2015?

    Every one in TB or child care work know how difficult it is to diagnose TB among children. My suggestion include:
    1. A large scale campaign by GOI and states to Screen all children by age cohorts of under, 1 year 1-3 years (at home), 3-6 years (at Anganwadi centers) and 6-18 years ( in schools)in appropriate facilities,screening for non-thriving children with no apparent cause and subject them for specialist's examination and investigations.
    2) Once identified manage /treat such children free of cost
    3) Take up health promotion and health education activities through all media particularly TV channels.
    4) Make mandatory for all TV and cable channels to air at least 5-6 times a day showing local TB testing and managing facilities

    ReplyDelete
  6. 0 CHILDREN DYING FROM TB BY 2015 IS POSSIBLE IF…………………………………………..!!!!!!!!

    I like to start by sharing a real story which I experienced in one of my visits in the field last year. I'm sure many of you working in the field have similar stories to tell.
    During a monitoring visit for our PPM program I came across a referral slip made out by a pharmacy staff referring a 36 year old woman to the DOTS health center. Looking at the symptoms circled on the slip one could tell that this was certainly a pulmonary TB case; weight loss, fatigue, chest pain, fever, and cough with blood. We traced the referral to one of the district health centers where we found out that the woman had indeed gone for further evaluation, she was checked, diagnosed, given medication and send home. We were told by the health center staff that since the first visit she came back 2x, each time sicker than before, and was again send home, no TB. We decided to visit her at home where she lived with her husband, her in laws, 2 small children and one baby. We asked the district TB officer to join us so he could be able to follow-up later on. When we arrived in her small house we were taken up in her room, she was sitting on a straw mat on the floor, baby on the breast, glassy eyes, face flushed with fever. She repeated the same story that the health staff told us. She told us how disappointed, sad, and scared she felt, she said she was getting worse by the minute and no one could help her. She said she wanted to go back to the health center but they didn't have any more money and no transportation. Each time she coughed she hit on her chest to show us where it hurts.

    I will never forget the pain on her face, the shortness of her breath when she tried to tell us her story. I will never forget the fear I felt for the baby on her breast and her other 2 children and thinking that this woman unless treated immediately will soon die and leave these kids orphans. The end of the story is that the woman did have TB and the last we heard was that the district officer was trying to get the children tested.

    So what went wrong? why did this woman sought care 3x and still was send home with a bag of antibiotics and vitamins? This is a very common story and it's happening every day, many times a day around the world, especially in developing HTB countries.

    Hara Mihalea CHE, MPH
    hsrimau@path.org or hsrimau@gmail.com

    ReplyDelete
  7. I shared this story with you because I truly believe that once again we might not be able to reach our goal to Zero the numbers of children dying of TB in our lifetime, left alone by the year 2015, if we don't take some drastic steps to address the real problems that are preventing us from doing a good job. We can have the guidelines and country operational plans for TB in children, we can have the treatment algorithms however I strongly feel that these will not help much, especially in limited resource setting where stories such as this are real unless we start by:
    (1) Holding governments accountable for the health and well being of their populations, especially the children; health is a right not a luxury and not only for the few. Advocate governments for resource allocation that will increase the salaries of the health staff and will motivate them to perform their tasks in an appropriate manner; health staff in developing countries often do not get their salary for 3-6 months.
    (2) Strengthening the DOTS program. If we had a quality DOTS program the health staff would have been able to accurately diagnose and successfully treat the mom in the story. They would have being able to prevent TB and the needless suffering in her children.
    (3) Integrating TB into the primary health care and sensitizing all health care providers on TB. Once sensitized health staff be able to screen children and moms during immunization sessions, postnatal visits, RH visits or other consultations.
    (4) Most importantly recognizing the symptoms of TB in children, creating linkages and partnerships between communities, private providers and TB services
    (5) Intensifying case finding and contact tracing when TB is suspected to all family members, most importantly to children. The majority of the children get TB from a family member.
    (6)TB is a poverty disease, half of the children in the developing countries go without meals, they are malnutrition which makes them even more vulnerable to TB. Addressing the nutrition needs is of outmost importance.
    (7) TB in a child that already suffers with HIV/AIDS is a double heartbreak and so much more difficult to diagnose and treat.
    I might sound to you pessimistic, I am a little bit because TB is very political and things are moving very slowly; we cannot afford to move slowly anymore, we should not allow it. We need to step up and step up very fast. What we should all see at the end of 2015 is not just the numbers, the statistics showing fewer deaths, we should see children, happy and smiley faces, children free of TB. Where there is a will there is a way and collective voices will find the way.

    Hara Mihalea CHE, MPH
    hsrimau@path.org or hsrimau@gmail.com

    ReplyDelete
  8. From: Dr Alex Govender
    Email: AlexG@vwsa.co.za

    Get back to basics – as soon as someone is identified with TB, immediately do contact tracing and consider prophylactic treatment in children.

    From: Dr Alex Govender
    Email: AlexG@vwsa.co.za
    Volkswagen of South Africa (Pty) Ltd. (Reg No. 1946/023458/07)

    ReplyDelete
  9. From: Dr Aleyamma Thomas, TRC, Chennai, India
    Email: aleyammat@trcchennai.in

    My comments regarding the above subject,

    1. Strengthen and motivate the health system so as to increase the case detection.

    2. Treat all the TB cases irrespective of smear positivity.

    3. Strictly iimplement IPT

    4. Implement Infection control measures at all levels including home.,community & Hospital

    5. Improve nutrional status of children

    6. Proper health education to both ,health providers and the patients


    From: Dr Aleyamma Thomas, TRC, Chennai, India
    Email: aleyammat@trcchennai.in

    ReplyDelete
  10. From: Pylypchuk Volodymyr, Ukraine
    Email: pylypchuk@bk.ru

    I dont think you are able to have zero at any time soon for babies or not
    just read history
    we are in Ukraine and know that it is too optimistic to project figures

    From: Pylypchuk Volodymyr, Ukraine
    Email: pylypchuk@bk.ru

    ReplyDelete
  11. COMMENT FROM PAULA PERDIGAO, MOZAMBIQUE
    (Paula responds to comment of Hara Mihalea, PATH - Hara's comment is online at: http://www.citizen-news.org/2012/02/theme-1-e-consultation-how-to-get-to.html )

    I could not agree more with Hara. Sadly the true story she told us happens every day in my country too... and the solutions Hara said it all. Thanks a lot Hara. I only would like to reinforce training, retraining and supervision (support) to all health workers and community workers.

    Paula Perdigão
    TB consultant- Mozambique
    Email: paulazen@tropical.co.mz

    ReplyDelete
  12. Being the one connected to the reality existing at the grassroots level, I have an optimistic outlook on that. I see silver linings in as much as the things are changing for the better. The decade-long united efforts by all stake-holders are not going down the drain. We are moving in a right direction with better results today.

    1. With continued success achieved in the recent past, the Revised National Tuberculosis Program [RNTCP] this year has set equal/more than 90% Case Detection rate and similar rate for completed cure as a new target for the year ahead.

    2. The Indian Academy of Pediatrics [IAP] has come out with revised dosages and better diagnostic algorithms for children in a National consultative meet held jointly under the auspices of the WHO and RNTCP on 31 Jan and 1 Feb 2012 in New Delhi is a major gain for this neglected area of Pediatric TB and Pediatric HIV-TB.

    3. With due respect may I take liberty to differ radically from what has been suggested by Dr Aleyamma Thomas, TRC, Chennai, India especially point number 2. when it is advocated to 'Treat all the TB cases irrespective of smear positivity'. It is a sure recipe for creating resistance. Unless there is a sputum positive case, we cannot and must not start anti-tuberculosis therapy [ATT] for Pulmonary Tuberculosis. In Extra-pulmonary TB cases too the emphasis is on finding AFB positive specimen/granulomatous changes. This is in line with expert guidelines for treatment.

    4. Improving nutritional status is an extremely important intervention not only in disease-free population including children but also in patients on ATT.

    5. INH Prophylaxis with 10 mg/kg for 6 month is the revised IPT drug dosage protocol as recommended by the WHO very recently. This needs to be offered with reverse contact tracing. Contact definition for pediatric cases must be specifically followed in all cases.

    6. Early detection of cases goes a long way in prevention and control of the disease.

    7. To boost up and motivate the health system, proper incentives need to be offered in the shape of awards, monetary incentives, concessions in fare etc. in order to enhance rate of case detection, adherence and cure rate.

    8. Easier Fixed Drug Combinations for children in the form of dispersible tablets will do miracles.

    Dr ST WALI
    Consultant Pediatrician and PO [Pediatric Care] - HIV
    NEW DELHI
    Email: drstwali@gmail.com

    ReplyDelete
  13. ANONYMOUS COMMENT THAT WAS POSTED TO STOP-TB EFORUM

    Dear Moderator,

    I am inserting comments on one of the postings below.

    1. Strengthen and motivate the health system so as to increase the case
    detection.

    2. Treat all the TB cases irrespective of smear positivity. Comment: To
    eliminate TB we have to eliminate the source of infection. The source of
    infections are those excreting AFB in the sputum.

    3. Strictly implement IPT

    4. Implement Infection control measures at all levels including home, community & Hospital Comment: The best infection control measure is just one and only one: Treat the infectious patient with the proper Anti TB drugs. All other measures are ineffective or not practical.

    5. Improve nutritional status of children Comment: That is a big problem also not helpful.

    6. Proper health education to both ,health providers and the patients.

    Anonymus

    ReplyDelete
  14. Just like HIV, Stigma still is high against Tb. This has to be overcome.
    Rural medical practitioners and private practitioners need to be necessarily roped into this campaign..Another strategy that could be tried is to involve the mahila mandals in each village/slum as these are the nerve centres of the micro economy that keeps the families going, and are very active. women will use their knowledge and skills to save their own and the neighbours as well

    ReplyDelete
  15. About 20% of new TB cases in India are in children. This form of TB is called childhood TB or primary TB.

    Childhood TB or primary TB is entirely different in terms of management than post-primary or adulthood TB – this behaves differently in clinical presentation, difficulty in diagnosis and managing it.

    Main 4-5 important forms of childhood TB are: lymph node TB, pleural TB, CNS TB (form of TB meningitis), bone and joint TB, and renal TB. Sputum for AFB which is supposed to be the gold standard for diagnosis of TB does not work for the diagnosis of TB in children.

    The second challenge is that chest x-ray in children is hardly helpful in diagnosing TB. Usually a child’s x-ray is misleading in diagnosing TB in children. What happens is that any shadow in the x-ray of the child is considered as pulmonary TB. But that is not true. Even the calcified shadow may not be TB.

    Even the post complex or primary complex is regarded as active pulmonary TB in India which is a wrong practice. We have to educate the healthcare providers and the public at large that primary complex is not primary TB or childhood TB. Primary complex is simply an end product of any infection by Mycobacterium tuberculosis at the end of eight weeks of infection. So this is called primary complex and mind it, it is not primary TB.

    There is a lot of confusion in our paediatric doctor fraternity, general physicians – the usual dictum is that whenever any report comes with Mantoux test positive or radiology report of primary complex, usually it is considered as TB. And that is why primary TB or childhood TB in our country is over-diagnosed. Due to the over diagnosis of TB we may be missing out on very important diagnosis – for example, misdiagnosis of childhood TB is in some cases lymphoma, leukaemia, anaemia, simple non-reactive lymph adenopathy or reactive lymph adenopathy, etc

    Dr Surya Kant
    PRESIDENT, INDIAN CHEST SOCIETY (North Zone)
    Head of the Pulmonary Medicine Department
    Chhatrapati Shahuji Maharaj Medical University (erstwhile King George's Medical College - KGMC)

    ReplyDelete
  16. Dr.Alex Govender said it nicely, in short and simple words. "go back to basics" and I fully second this.

    The majority of the children get TB disease from a parent or a close relative, someone that the child spends most time with. In the settings I work in children are always being held, carried around and sleep on the same mat with a parent, a grandparent or/and a sibling. The longer the exposure the higher the risk for infection.

    Thus If we fail to appropriately diagnose and successfully treat the mom we certainly will fail to diagnose and treat the child. So YES we need to go back to basics and start doing a good job.

    Hara Mihalea CHE, MPH
    Email: hsrimau@path.org or hsrimau@gmail.com

    ReplyDelete
  17. It is a hard fact that TB in the paediatric population is overdiagnosed based on CXRs across all the institutions that cater to
    this unique and vulnerable segment of our society.

    It is another hard fact that all these children are put on ATDs ( so
    many many formulations are still around)

    And it is even more sad that these formulations have uncertain
    quantities of the drugs as per bioavailability standards.
    And blanket IPT is hard to find an audience with.

    Point is ARE WE REALLY PROMOTING DOTS?

    A lot needs to be answered to
    the future population riddled with resistance, failure , poverty and
    misery.

    Dr Shanta Ghatak Email: drshantaghatak@gmail.com

    ReplyDelete
  18. Getting to Zero new infections in children is difficult. As compared reducing TB related morbidity and mortality is easier.
    Prevention of infection is dependent on multiple external factors- Efficacy and coverage of adult TB control program being the most important. However lack of an effective vaccine, limitations and controversies about IPT, and malnutrition etc are factors which would need urgent attention to reach somewhat near the goal.

    ReplyDelete
  19. The most important risk factor for childhood TB or primary TB in India is malnutrition. According to the data, about 49% of children between 0-5 years of age are malnourished in this country. Malnutrition is single most strong risk factor for childhood TB. If we see the immunopathology of TB, TB disease occurs as a result of interaction between Mycobacterium tuberculosis load and body’s resistance or immunity. Body’s resistance or immunity is directly related to nutrition. That is why malnutrition is a very important risk factor in development of active TB disease in children.

    Dr Surya Kant
    PRESIDENT, INDIAN CHEST SOCIETY (North Zone)
    Head of the Pulmonary Medicine Department
    Chhatrapati Shahuji Maharaj Medical University (erstwhile King George's Medical College - KGMC)

    ReplyDelete
  20. (सिटिज़न न्यूज़ सर्विस के राहुल कुमार द्विवेदी ने 4 वर्षीय टीबी रोगी और उनके अभिभावकों से बात की - वो प्रस्तुत हैं)
    (Rahul Kumar Dwivedi from Citizen News Service (CNS) had interviewed parents of a 4 years old child with TB - below are the responses in Hindi. We are translating and soon English version will be published too)
    ******************************

    4 वर्षीय टीबी रोगी का नाम- जुगलकिशोर
    उम्र- 4 वर्ष
    पिता का नाम- शिवप्रसाद
    माता का नाम- राम दुलारी
    व्यवसाय- लेबर

    1- चार साल से बच्चे को खाँसी आती है। एक महीना पहले, जब लोहिया अस्पताल में दिखाया और एक्स-रे कराया और वहाँ पर टीका लगा तब पता चला कि टीबी है. डॉक्टर ने फेफड़े की टीबी बतायी है।

    2- सरकारी अस्पताल में पहले से ही दिखा रही थी और दवा ला रही थी। जब बच्चा छोटा था तभी से दवा ला रही हूँ। पर दवा से कुछ फायदा नहीं हुआ था। और डॉक्टर ने बाहर से दवा लेने को कहा था पर मेरे पास पैसे नहीं थे तो हम बाहर से दवा नहीं लाये। इस बार जब एक्स-रे कराया तो डॉक्टर ने दवा लिखा और बाहर से खरीदने को कहा पर हमने कहा कि मैं दवा बाहर से नहीं खरीद सकती हूँ फिर दवा वहीं से लिखी। हमने बच्चे को गैर-सरकारी अथवा बाहरी डॉक्टर को नहीं दिखाया था। वहीं के डॉक्टर ने बताया कि बच्चे को टीबी है। एक्स-रे भी सरकारी अस्पताल से ही कराया था। हर बार के एक्स-रे के लिए 30 रुपये देने पड़ते थे। एक बार एक्स-रे कराया तो बाहर से दवा लेने को लिखा था पर बाहर से दवा नहीं ले पाये तो दवा नहीं कराये। दोबारा एक लेडी डॉक्टर को दिखाया तो उन्होने फिर से एक्स-रे कराने को कहा और फिर 30 रुपये देकर एक्स-रे कराया। और 35 रुपये भर्ती करने के लिए लिया।

    3- बच्चे को खांसी बहुत आती थी। और सांस लेने में तकलीफ होती थी। खाँसी इतनी ज्यादा आती थी कि घंटों खाँसता रहता था। पीठ पर मालिस किया करते थे। करीब तीन साल से लगातार खाँसी आ रही है। टीबी एक महीना पहले पता चला है। डॉक्टर ने कहा कि दवा खरीद लोगी क्या पर हमने कहा कि मैं खरीद नहीं पाऊँगी तब उन्होने कहा कि ठीक है अभी के लिए दवा ले जाओ। 10 दिनों तक अस्पताल में भर्ती भी थे।

    4- डाट्स सेंटर पर दवा मुफ्त में मिली। कहा गया था कि दवा खरीद लो पर जब हमने कहा कि मैं दवा खरीद नहीं पाऊँगी तो उन्होने दिया। डॉक्टर ने बताया कि टीबी की दवा मुफ्त में दी जाती है हमें पहले से नहीं मालूम था।

    5- डॉक्टर ने पूंछा था कि क्या घर में पहले किसी को टीबी थी? बच्चे के पिता जी को टीबी थी। जिसकी दवा छः महीने तक चली थी और खाँसी अभी तक आती रहती है।

    6- डॉक्टर ने बच्चे की टीबी के उपचार के लिए छः महीने तक दवा लेने को कहा है।

    7- बच्चे में टीबी होने से किसी प्रकार का भेद-भाव नहीं हुआ।

    8- परिवार में और भी बच्चे हैं पर किसी का भी कोई परीक्षण नहीं कराया है। डाट्स सेंटर पर भी इस बारे में कुछ नहीं बताया।

    9- बच्चे के पिता बीड़ी पीते हैं। बच्चे में शूगर की बीमारी नहीं है।

    10- जब बच्चा पैदा हुआ था तो मैं अपने दूध के साथ-2 ऊपर का दूध भी पिलाती थी।

    11- टीबी होने से पहले बच्चा स्वस्थ था। पर बच्चे का वजन कम था और कमजोर था।

    12- खाना लकड़ी जला कर चूल्हे पर पकाते हैं

    13- जैसे पहले खेलता-कूदता था वैसे टीबी की दवा खाने के बाद भी है पर आज सर में दर्द की शिकायत कर रहा था। रोने पर खाँसी पहले भी आती थी और अब भी आती है।

    14- बच्चा घर में पैदा हुआ था और पैदा होने पर कोई टीका नहीं लगा था। पैदा होने की एक महीने बाद टीका लगा था। अस्पताल में लगवाया था पर टीका लगाने के बाद फूला नहीं था। डॉक्टर ने बताया था कि बीसीजी का टीका है। पर जब टीका पका नहीं तो 9 महीने बाद आँगनबाड़ी कार्यकत्रि ने बीसीजी का टीका यहीं पर दूसरी बार लगाया। तब भी हल्का ही पका था। इस बार जब तीसरी बार बीसीजी का टीका लगा तब अच्छी तरह से पका था।

    15- हमें टीबी के बारे में कुछ नहीं मालूम।

    16- डाट्स सेंटर पर भी टीबी की रोक थाम के लिए कोई उपाय नहीं बताया गया।

    ReplyDelete
  21. (सिटिज़न न्यूज़ सर्विस के राहुल कुमार द्विवेदी ने 14 वर्षीय टीबी रोगी और उनके अभिभावकों से बात की - वो प्रस्तुत हैं)
    (Rahul Kumar Dwivedi from Citizen News Service (CNS) had interviewed parents of a 14 years old youth with TB - below are the responses in Hindi. We are translating and soon English version will be published too)

    रोगी का नाम- आकाश
    उम्र- 14 वर्ष
    पिता का नाम- रामखिलावन
    माता का नाम- रामा
    व्यवसाय- होटल पर बैठते हैं

    1- एक साल तक बाहर इलाज करते रहे पर कुछ नहीं पता चला, बच्चे को बुखार होता रहा फिर बाद में एक जन ने बताया कि लोहोया अस्पताल में दिखाओ तो लोहिया में गए दिखाने के लिए। पाँच महीने पहले लोहोया अस्पताल में दिखाने के बाद पता चला कि बच्चे को टीबी है।

    2- फेफड़े की टीबी डॉक्टर ने बताया है। बच्चे को बुखार रहता था और खांसी भी आती थी।

    3- टीबी पता होने से पहले तीन-चार जगह बच्चे को दिखाया था। कई सारे गैर-सरकारी डॉक्टर को दिखाया पर लोहिया अस्पताल में सरकारी डॉक्टर को एक ही बार दिखाने जाना पड़ा।

    4- जब सरकारी डॉक्टर को दिखाने गये तो पैसे नहीं खर्च हुए। गैर-सरकारी डॉक्टर को दिखाने में पैसे लगते थे, पाँच दिनों के दवा में लगभग 500-1000 रुपये लग जाते थे और एक महीने में करीब 4000 से 5000 हजार का खर्च होता था। 100-100 रुपये का तो इंजेक्शन ही लिखते थे और जब इंजेक्शन लग जाता था तब कुछ समय के लिए फायदा हो जाता था और बाद में फिर वैसे ही तबीयत हो जाती थी।

    5- बच्चे की टीबी की बीमारी पता करने में पाँच से छः महीने लग गये पर बच्चे की तबीयत एक साल से खराब थी।

    6- डाट्स सेंटर पर मुफ्त में दावा दी गई थी। डॉक्टर ने बाहर से कोई दावा नहीं लिखी थी।

    7- टीबी की दावा मुफ्त में मिलती है यह मुझे मालूम था।

    8- टीबी की संक्रमण के बारे में हमे नहीं मालूम डाट्स सेंटर पर बच्चे के पिता जी दावा लेने जाते थे। बच्चे के पिता जी से डॉक्टर ने खान-पान के बारे में बताया था। हरी सब्जी, भर्ता, और रोटी, दाल खिलाने को कहा था। साफ-सफाई के बारे में डॉक्टर ने बताया था कि बच्चे को दूध, खाने-पीने की चीजें सफाई से देना। बच्चे को जूठा नहीं खिलाना।

    9- डॉक्टर ने कहा है कि छः महीने तक टीबी की दावा चलेगी।

    10- बच्चे को टीबी होने के बाद किसी ने भी कोई भेद-भाव नहीं किया।

    11- बच्चे को टीबी होने से पहले परिवार में किसी को भी टीबी नहीं थी।

    12- परिवार में अन्य बच्चों का टीबी के बारे में परीक्षण नहीं किया गया है। डाट्स सेंटर पर भी डॉक्टर ने यह नहीं बताया कि परिवार के अन्य सदस्यों का भी टीबी परीक्षण कराएं।

    13- परिवार में लोग तंबाकू का प्रयोग करते हैं। बड़ा वाला लड़का और लड़के के पिता जी तंबाकू और गुटका खाते हैं। और सिगरेट भी हैं। घर की अंदर भी सिगरेट पीते हैं।

    14- बच्चे को और कोई बीमारी नहीं है, हमे नहीं पता है, सिर्फ बुखार होता था।

    15- बच्चे की जीवन के पहले छः महीने तक सिर्फ माँ का ही दूध पिलाया था। कोई अन्य या ऊपर का दूध नहीं पिलाया था।

    16- टीबी होने से पहले बच्चा दिनभर घूमता रहता था और शाम को खाना नहीं खा पाता था।

    17- टीबी की दवा शुरू होने के बाद से अब ठीक है, वजन भी 30 किग्रा है। पहले 25 किग्रा था।

    18- खाना चूल्हे पर पकाया जाता है।

    19- टीबी की दवा जब से खाता है तब से गुस्सा बहुत करता है।

    20- हमारे किसी भी बच्चे को कोई भी टीका नहीं लगा है। एक बार टीका लगवाया था तो बच्चे को फोड़ा निकल आया था तो बच्चे के पिता जी ने टीका लगवाने से मना कर दिया था।

    21- टीबी से बचने के बारे में कुछ भी नहीं मालूम है।

    ReplyDelete
  22. The second important risk factor is passive smoking. Usually in society people are less aware that they should not smoke inside homes or are conscious enough not to smoke in presence of children. Passive smoking or second hand smoking is also an important risk factor for development of active TB disease in children.

    Dr Surya Kant
    PRESIDENT, INDIAN CHEST SOCIETY (North Zone)
    Head of the Pulmonary Medicine Department
    Chhatrapati Shahuji Maharaj Medical University (erstwhile King George's Medical College - KGMC)

    ReplyDelete
  23. Third important risk factor for childhood TB is related to modernization. Children are increasingly opting for the fast food. Fast food culture is basically decreasing the body immunity of the children and that is why we are seeing TB in children from higher socio-economic background whereas earlier TB was thought to be a disease of poor people or those from lower socio-economic background. Affluent family members of children with TB often ask me ‘Doctor, I am from a high socio-economic background and no one in our past seven generations had TB, how come my child developed TB?’ The answer is probably it is because of fast food culture as fast food causes free radical injury and thereby decreases the body’s immunity making the child prone to infections such as TB.

    Dr Surya Kant
    PRESIDENT, INDIAN CHEST SOCIETY (North Zone)
    Head of the Pulmonary Medicine Department
    Chhatrapati Shahuji Maharaj Medical University (erstwhile King George's Medical College - KGMC)

    ReplyDelete
  24. Usually one TB patient spreads TB to 10-15 other people in a year. But if the patient is living in an overcrowded environment then the spread of TB is more rampant. Overcrowding is another risk factor for spread of TB. Children living in urban slums where dwellings house a large number of people in small space can be at higher risk of TB.

    Dr Surya Kant
    PRESIDENT, INDIAN CHEST SOCIETY (North Zone)
    Head of the Pulmonary Medicine Department
    Chhatrapati Shahuji Maharaj Medical University (erstwhile King George's Medical College - KGMC)

    ReplyDelete
  25. Another important risk factor is that we have a large number of adult TB infections that can potentially be transmitted to children. First and foremost measure that can control childhood TB is to early diagnose and successfully treat the adult TB. So all adult TB cases must be treated effectively and priority should be given to those whose sputum is positive for AFB. If we can intervene in early diagnosing and successfully treating adult TB then a secondary outcome will be to effectively control childhood TB.

    We have to improve the hygiene, control passive smoking, educate our children that they should not blindly follow the fast food culture, and government of India should take measures to ensure that malnutrition doesn’t exist in our society.

    Dr Surya Kant
    PRESIDENT, INDIAN CHEST SOCIETY (North Zone)
    Head of the Pulmonary Medicine Department
    Chhatrapati Shahuji Maharaj Medical University (erstwhile King George's Medical College - KGMC)

    ReplyDelete
  26. The usual dictum is that when somebody goes to the hospital, children accompany. This practice should stop. All hospitals should be instructed to convey to their patients that whenever they visit the hospital children shouldn’t accompany unless needed – because hospitals are a very important source of spreading infections.

    At the household level we can do a lot to reduce risk of TB – stopping passive smoking is one of them. Exposure to biomass or cook-stove smoke is also a risk factor for developing active TB disease. In rural areas many people still use biomass fuel for cooking, and exposure of children to cook-stove smoke can up their TB risk. Practice of using biomass fuel should be replaced by other energy options which are not detrimental for one’s health or that of the society.

    Dr Surya Kant
    PRESIDENT, INDIAN CHEST SOCIETY (North Zone)
    Head of the Pulmonary Medicine Department
    Chhatrapati Shahuji Maharaj Medical University (erstwhile King George's Medical College - KGMC)

    ReplyDelete
  27. One of the fallouts of urbanization is construction of flats or apartments where often adequate sunlight is not coming in and proper ventilation is not there. I want to share very important information about tuberculosis that five minute exposure to sunlight kills the Mycobacterium tuberculosis, even the drug resistant forms of bacilli. So sunlight exposure inside the house and proper ventilation are very important factors in terms of reducing the risk of getting active TB disease. I don’t think that the housing policy of the government of India is taking care about these important public health recommendations.

    Dr Surya Kant
    PRESIDENT, INDIAN CHEST SOCIETY (North Zone)
    Head of the Pulmonary Medicine Department
    Chhatrapati Shahuji Maharaj Medical University (erstwhile King George's Medical College - KGMC)

    ReplyDelete
  28. In hospital settings, every precaution must be taken to ensure very effective standard treatment. Proper ventilation in wards should be ensured so that same air is not getting circulated and air conditioning should not be done of the wards. Proper and cross ventilation should be kept in mind. Proper sunlight should be coming in the wards. Proper sputum disposal should be done. Every patient who is AFB sputum positive should be counseled to use a mask. Whenever these patients who are AFB sputum positive talk or cough, they should cover their mouth with cotton or proper masks. Cough hygiene is important to be practiced.

    Dr Surya Kant
    PRESIDENT, INDIAN CHEST SOCIETY (North Zone)
    Head of the Pulmonary Medicine Department
    Chhatrapati Shahuji Maharaj Medical University (erstwhile King George's Medical College - KGMC)

    ReplyDelete
  29. More effectively we cure the adult TB more effectively we will prevent the childhood TB. Studies show that children with TB usually don’t infect the adults rather adults with TB infect children. It is only one way transmission of TB from adults to children.

    I don’t think IPT will work in a country like India because 50% population is host to Mycobacterium tuberculosis.

    BCG vaccine is part of universal immunization programme of India. I believe it should be continued because meta-analysis has shown that BCG vaccine cannot prevent the TB disease but can definitely reduce the seriousness of the disease and reduce mortality. So if at all the child develops TB it will not be of serious type and if proper care is provided timely TB shouldn’t be lethal for her in all probabilities.

    Dr Surya Kant
    PRESIDENT, INDIAN CHEST SOCIETY (North Zone)
    Head of the Pulmonary Medicine Department
    Chhatrapati Shahuji Maharaj Medical University (erstwhile King George's Medical College - KGMC)

    ReplyDelete
  30. You people are out of you're minds. And you're doctors??! The best solution to TB problem is GETTING THE GENERAL PUBLIC TO CARE. It doesn't even matter whether it's a child or an adult, TB anywhere is TB everywhere.

    Right now, the public don't give a damn about this disease, probably due to stigma but mostly due to poverty. Just trying to survive for one day is a challenge already and you're talking about hospital ventilation? apartment arrangements? REALLY??!!

    I don't care who you are or where you're from but we will never be able to stop TB until the public gets involve.

    Any thing less than this is not a solution. All of the above comments are just a bunch of hypocrisies. You're talking about the same thing over and over and over again. GET REAL!!

    ReplyDelete
  31. Dear Mark,
    thanks for your comments. I completely agree with the issues you have raised. The above comments are not hypocrisies - people who are managing TB are speaking their world. They are raising issues that have NOT been addressed despite so much of TB control effort since years.

    We have recorded patients' and community perspectives too - and are transcribing and translating (Hindi or Urdu to English) and soon we will see a lot more issues that affected communities have raised.

    warm regards,

    Bobby Ramakant - CNS
    bobby@citizen-news.org

    ReplyDelete
  32. With all due respect I cannot agree with Dr Wali when he says we should only treat smear positive pulmonary TB cases… Almost all cases of TB in children are paucibacilar so smear is negative…and also in TB/HIV patients only 40-50% cases are smear positive. If we treat only smear positive cases millions of patients will die …so it is a dangerous and bad clinical practice. As I use to say everybody can make a smear positive TB diagnosis (just order the smear in a good lab) the challenge is the smear negative cases and ETB. For this reason we urgently need a new a rapid, easy and cheap diagnostic test for TB that can be more sensitive than sputum smear…

    Paula Perdigão
    TB consultant - Mozambique
    Email: paulazen@tropical.co.mz

    ReplyDelete
  33. One of the causes of Childhood TB is congested and unhygenic residence, poor refuse management and dirty drainage in the neighbourhood and community.

    The government of Lagos state identified these infection control challenges and introduced measures to reduce these conditions to the barest minimum. Also the state government policy on free medical treatment for children under 5 have contributed in reducing childhood TB. Howeever clinical management of childhood TB still remains a challenge due to late detection of the disaese in children.

    TB education should be incorporated into post natal care for nursing mothers and children under 5 care givers. Maternal and child health programme should be comprehensive including educating mothers and motherless baby home care givers on signs and symptoms of TB in children.

    Chibuike Amaechi
    The Good Neighbour
    Lagos, Nigeria
    Email: good2neighbour@yahoo.com

    ReplyDelete
  34. Patients' Charter for TB Care, and childhood TB
    ----------------------

    Will improving efficiency and efficacy of TB control programmes in the healthcare facilities help the world meet the 2015 targets set by the Millennium Development Goals, the Global Plan to Stop TB, and the country programmes, or do we need a paradigm shift in the basic principles we do TB control? Experts have repeatedly emphasized that unless we control adulthood TB, children will continue to get TB. And unless we the change the way we do TB control, adulthood TB is unlikely to be controlled. The TB programme is still very medical despite advocacy, investment and the gold standard Patients' Charter for TB Care - which is sadly not implemented to the extent it should have been by the countries.

    PATIENTS' CHARTER FOR TB CARE
    -------------
    According to the World Health Organization (WHO), the Patients' Charter for TB Care, outlines the rights and responsibilities of people with TB. It empowers people with the disease and their communities through this knowledge. Initiated and developed by patients from around the world, the Patients' Charter makes the relationship with healthcare providers a mutually beneficial one.

    UNLESS WE TREAT ADULT TB, CHILDHOOD TB WILL CONTINUE TO RISE
    -------------
    In an interview given recently to Shobha Shukla - CNS, Dr Somya Swaminathan, MD in Paediatric TB, and a Scientist at the National Institute for research in Tuberculosis (Indian Council of Medical Research - ICMR), said that: "Pediatric TB is difficult to control, because the infection spreads through the air borne route, and children get it from adults. So the only way to prevent childhood TB is to tackle adult TB more seriously. Contact to contact TB testing must be done. All family members of a TB patient, especially children, should be tested, and started on chemo-prophylaxis. That way we can reduce the burden of paediatric TB. The general awareness level about TB is very poor, even amongst educated people. They do not know how it spreads, how it can be diagnosed and treated and what they can do to reduce the burden of TB. As it is an air borne infection, anybody can get it. The most important risk factor in children is malnutrition, as poor nutrition makes one more susceptible to it. Other social or environmental causes could be poor housing, overcrowded indoors, indoor air pollution, passive smoking, and to a much smaller extent HIV infection also, as in India HIV prevalence is fairly low.”

    President of Indian Chest Society (North Zone) and Professor and Head, Department of Pulmonary Medicine, King George's Medical College (now renamed as CSM Medical University) Dr Surya Kant said: "Another important risk factor is that we have a large number of adult TB infections that can potentially be transmitted to children. First and foremost measure that can control childhood TB is to early diagnose and successfully treat the adult TB. So all adult TB cases must be treated effectively and priority should be given to those whose sputum is positive for AFB. If we can intervene in early diagnosing and successfully treating adult TB then a secondary outcome will be to effectively control childhood TB."

    Dr Surya Kant emphasized: "More effectively we cure the adult TB more effectively we will prevent the childhood TB. Studies show that children with TB usually don’t infect the adults rather adults with TB infect children. It is only one way transmission of TB from adults to children."

    (Continued in next comment)

    Bobby Ramakant - CNS
    Email: bobby@citizen-news.org

    ReplyDelete
  35. (Continued from previous comment)

    PATIENTS' CHARTER CAN BE THE GAME-CHANGER
    --------------
    Unless people who are experiencing the disease (TB) or have successfully completed the treatment are engaged as EQUAL PARTNERS WITH DIGNITY, we will continue to see TB control dominated by the medical experts who are undoubtedly doing a great contribution to TB control, but that's clearly not enough. Engaging people who know the best can be the game changer. People who have completed TB treatment are best "community experts" to share with us the challenges they faced on daily basis when on TB treatment. These are the challenges which are the potential barriers for many people in benefiting from existing TB control services and should be addressed by the programme. The realities of their lives, on day-to-day basis, that continues to put them and their family members at risk of preventable infections such as TB, needs to be brought in, to increase the impact of TB programmes. The challenges people face in getting a proper confirmed TB diagnosis and tolerating the anti-TB treatment, must be recorded and documented - without which the programme will continue to miss a very important piece of the puzzle - and is unlikely to reach the ZERO mark by 2015 in terms of zero new TB infections and deaths.

    --------------
    Unless we implement the Patients' Charter optimally adulthood TB will continue to challenge us, and so will childhood TB.
    --------------

    As experts said if we can control adulthood TB, childhood TB will automatically taper off. Implementing the Patients' Charter, empowering communities, especially those who have completed TB treatment, to get engaged as equal partners with dignity in TB control, and ensuring the programme addresses the needs felt by the people can help us reach the unreached TB patients - adults and children both.

    Bobby Ramakant - CNS
    Email: bobby@citizen-news.org

    ReplyDelete
  36. Comment from Shobha Shukla - CNS
    --------------

    In an exclusive interview given to CNS during the 42nd Union World Conference on Lung Health in Lille, Dr Anne Detjen, Technical Consultant, at the International Union Against Tuberculosis and Lung Disease (The Union), and a noted Paediatrician, had said:

    "Childhood tuberculosis has been neglected for a long time and, in terms of the global policy the focus has been on adult tuberculosis. The problem of childhood tuberculosis is beset with challenges. Presentation of the disease is less specific in children, and it is often confounded with other diseases like pneumonia. 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. While an adult infected with TB has about 10% life time risk of actually contracting it, in children this risk is much higher and could be up to 40% in infants under one year of age. 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. 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."

    Shobha Shukla - CNS
    Email: Shobha@citizen-news.org

    ReplyDelete
  37. National programs should invest in contact tracing of all patients diagnosed with active TB. This will enable early identification of children and adults with TB infection or disease which can be treated to stop further transmission.

    ReplyDelete
  38. Claire Crepeau Pediatric TB Nurse McGill University, Canada22 February, 2012

    I would like to comment on Hara Mihalea's post. I agree with what she states as priorities to achieve zero childhood TB by 2015. I have worked in Childhood TB Control for 8 years as a clinical and research nurse and I have also been involved with TB training for nurses in developing countries. Something I would like to add is that for these goals to be successfully met, we need resource allocation to provide training on TB to nurses. This would include education and supervised training on case detection, DOTS, contact tracing, IPT etc. Nurses benefit from close proximity to the patient and are often the first contact person in the health care system.They may be the only health professional in some remote regions.The effect of this investment in human resources can go a long way. It is a way of strenghtening existing resources so that ultimately they become sustainable by partnering with the national TB programs (NTP)Excellent TB patient care can be implemented at the local level to achieve TB reduction globally by strengthening the existing HCW capacities at the ground level. This offers a feasible way to improve communication and to brainstorming for practical solutions to patient and system obstacles (including infection control). I have heard first hand reports from nurses working in Kenyan slums, as well as in Uganda and in the Philippines. These nurses have achieved successes in their work despite their limited resources.
    Certainly, I also agree with maximizing all opportunities for integrating TB into primary health care as well as sensitizing all health care providers on TB. Immunization sessions, postnatal visits, under 5 nutrition clinics and other consultations should be utilized as an opportunity. In these settings, nurses also have much to offer. They can teach community health workers and support personel to identify potential cases. In addition, these settings allow nurses to identify existing structures to assist in this work (ex traditional healers to refer coughing patients to TB services or former TB patients who are assisting via support groups or as community workers). Similarly, educating the public about TB is also a key component. We must strive to manage adult TB properly if we are to decrease childhood TB & also prevent MDR TB. Meanwhile, children are the reservoir of TB for the future, and they cannot be forgotten especially in screening. All health professionals need to partner their efforts to attain this goal with government support. Finally, as Dr Swaminathan, states the two main challenges in dealing with childhood TB are by way of diagnosis and treatment. Teaching on using a systematic approach to childhood TB diagnosis provides a framework in which all health care workers use scientific evidence in combination with available resources to make the best possible diagnosis while under difficult circumstances. Until a new diagnostic tool is available or a better vaccine, we will need to have a high level of suspicion in this most vulnerable group to prevent further morbidities & mortalities.

    ReplyDelete
  39. When do we involve the private practitioners? They see most of the children really all over India? Some meaningful strategy had been taken up in 2007 but then it fell through. Can we achieve anything at all without their compulsory participation?

    Some organisational effort /operational research activity must be made to assess the workability of the topic in hand . If it is found that 90% of the paediatric TB population are being treated in the private sector initially and extensively then NO efforts can match the burning need with our existing resource allocation.

    Paediatric TB drug boxes' utilisation and repackaging strategies have been very uphill task in terms of fund and man power . But we never had the takers for the lower weight bands in the paediatric population for whom the dosage schedule had been worked out for.

    So my opinion would be :
    1) To go all out for the private providers
    2) Notifications of suspects asap (in the paeditric age gruop)
    3) Drug formulations to kept under a tight control
    4) CSO partnerships must have the local private practitioners with them
    5) Accountability of the system for a consistent TB care for children

    Thanks
    Dr Shanta Ghatak
    Email: drshantaghatak@gmail.com

    ReplyDelete
  40. Anita Chan
    (Taiwan Centre for Disease Control)
    (commented on CNS Facebook page)

    It's crucial to have prophylaxis and latent TB infection treatment to stop TB disease in closed contact children of index adult TB cases first! Meanwhile, diagnosis of any adult TB patient (especially mother or care givers) is crucial for children health!


    Anita Chan
    (Taiwan Centre for Disease Control)
    (commented on CNS Facebook page)

    ReplyDelete
  41. From: Alberto Colorado(On twitter: @acTBistas )

    We need to advocate for Children Rights and Social Protection if we want to have Zero deaths related to Childhood TB

    From: Alberto Colorado(On twitter: @acTBistas )

    ReplyDelete
  42. Dear colleagues,

    May I share with you our views on the 'essentials' of the diagnosis of TB in Children? The main means of diagnosing TB in children is undoubtedly, chest X-ray.

    1. Children sometimes may have adulthood TB (post primary TB). Diagnosis is relatively simple. Symptoms are like in adulthood TB: few weeks cough, subfebrile, night sweat, chest pain and sometimes hemoptoe. Every doctor treating TB can easily recognize TB features on chest X-ray: infiltrates or patches usually in upper lung fields, sometimes with cavitation. If cavitation is present, sputum should easily reveal Acid fast bacilli (AFB). This child can expectorate! Treatment will instantly stop infection and cure the disease. Without treatment, the child will die within one or two years.

    2. Child may have miliary TB. After witnessing the miliary shadows in the lung(s) on chest X-ray, even once only, the doctor will remember this X-ray's characteristic feature. Symptoms: weight loss, loss of energy and activity, fever, cough. Without treatment the child may die. Fortunately, this is a rare development after BCG.

    3. Child may have meningitis TB. Symptoms include, longstanding headache, febrile and drowsiness. Very characteristic/diagnostic signs are neck or back stiffness. Without treatment the child may die or suffer from sequellae, like hydrocephalus, blindness, deafness or other neurological defects. This is also fortunately, a rare development after BCG. Chest X-ray may be normal, or miliary TB may be present.

    4. Child may have primary TB. Chest X-ray may show enlarged hilar lymph glands. The primary TB shows no symptoms. Unfortunately, increased bronchovascular markings are often overdiagnosed as enlarged hilar lymph glands. Despite outrageous misjudgment of a number of primary TB cases by our colleagues, we should also realize that there are how many millions of primary cases that go unnoticed and get spontaneously cured ...

    If occasionally, primary TB is developing progressively, then the disease may develop into miliary TB or meningitis TB. Fortunately, such developments become rare after successful BCG vaccination.

    In some cases, if body resistance is low, the primary disease will develop into post primary TB. This condition however, can not be prevented by BCG. But in this case the diagnosis should be relatively simple. After treatment, sputum AFB becomes negative and the disease causes no further infection.

    Who are the main killers of children with TB?

    The main killers are: miliary TB and/or meningitis TB. They are the rapid awesome killers. Unabated, they may kill within several weeks. Fortunately, BCG gives effective protection.

    The other is the mass killer: post primary TB, killing the children slow but sure. Without treatment the child may die within a year or two. These killings are not prevented by BCG.

    The Theme of the First World TB Day 1982 (now thirty years ago) remains
    valid:

    DEFEAT TB! NOW AND FOREVER!

    Dr Muherman Harun
    St.Carolus TB Program 1983
    Jakarta, Indonesia
    Email: muhermanharun@gmail.com

    ReplyDelete
  43. Important diagnostic factors
    *******************

    * Sputum examination of AFB is most successful if lung/bronchial tissue is affected or damaged as in post primary TB. However, in miliary and meningitis TB, the bacilli are spread through the bloodstream i.e. hematogenic spread, hence bacilli are usually not detectable in sputum. In primary TB, bacilli are spread through the lymphatic system (hilar lymph glands) and bloodstream. Therefore, AFB are usually absent in the sputum.

    This explains the difficulty to detect AFB in sputum. We never carried out the gastric lavage for AFB. Such procedure is too drastic and traumatic for too little yield or impact, if any.

    * The tuberculin test in under-fives is particularly useful in the diagnosis of TB (if BCG was not given) However, the higher the age of the patient, the lesser diagnostic value the tuberculin test will have. About the usefulness of the tuberculin test after BCG, there's an old saying which still stands true: "After BCG, the tuberculin reaction goes, as the wind blows!", in other words, the tuberculin test is no more a reliable diagnostic tool after BCG vaccination. There is up till now, no serological or PCR tests for the diagnosis of TB.

    * The presence of a house-hold contact who is expectorating TB bacilli, is an important factor, supporting the diagnosis of TB in children.

    * Lymphatic glands caused by TB can usually be seen in the neck. These enlarged glands may not be painful, and are presented in clusters. If there is discoloration (livid) and fluctuation or abscesses appear, TB diagnosis becomes clear and treatment can be given right away. The presence of TB glands in the neck becomes very helpful in the diagnosis of pulmonary TB. After only a few weeks of anti-TB treatment, the swollen lymph glands will soon reduce in size. This also supports the diagnosis of TB of the lung.

    (But there also are lymph glands in the neck of viral origin. If thoroughly examined, there will be so many small children with enlarged lymph glands in the neck, which are not TB. These glands are usually not directly visible and will come and go with the (febrile) condition of the child. This condition does not need further examination nor treatment. As the child becomes older, the enlarged glands will disappear spontaneously).

    Finally, "How to get to zero new TB infections in children by 2015?" I'd like to answer this STOP-TB question by emphasizing and reiterating the main and grand principle: "Focus on the main reservoir, sources of TB bacilli.

    They are the ones that cough, spreading the AFB into the air". Find, treat and cure them, no more and no less. Contact (centrifugal or centripetal) examination could be carried out on a limited and selective scale.

    The important risk factors i.e. "malnutrition, poverty, environmental pollution, poor housing, overcrowding, indoor air pollution, passive smoking, etc" may not have an important role to play in an effective TB control program. This was spectacularly shown from the historic WHO/ BMRC/ MRCI experiment of Madras in the fifties.

    If we only can persistently treat and diligently cure all of our TB patients who are infectious, eventually, there will be no more children getting infected! Hence, chase without delay retrieve any absconders who and wherever they are, at any cost! Provide patients the fullest treatment with the very best regimen available, so that the disease be completely cured and forever.

    The Theme of the First World TB Day 1982 (now thirty years ago) remains valid:

    DEFEAT TB! NOW AND FOREVER!

    Dr Muherman Harun
    St.Carolus TB Program 1983
    Jakarta, Indonesia
    Email: muhermanharun@gmail.com

    ReplyDelete
  44. willy mbawala24 February, 2012

    I would join and agree with most comments in the string. To me the whole issue looks too ambitious, but why not! Getting to Zero new TB infection in children by 2015 in Tanzania is like moving a mountain, it all need faith in what we are doing. The challenges are so vast in the sense that the resources to bring this into reality are simply inadequate. Financial and HR are so scarce given the fact that the knowledge and skills required in detecting TB in children are very limited and needs a considerable investment. The situation is so urgent that there should be no time to sit back or entertainment of such things as projects or pilots. In our national TB hospital, the only treatment centre for MDR-TB, one of the patients under treatment is a one year old child, together with her mother who is believed to be a source of infection. With this situation we should think beyond the circles, the issue is multifaceted and no single intervention is a miracle, rather holistic approach of the Stop TB strategy components.

    ReplyDelete
  45. Dear Citizen-news .org
    To prevent TB in children.
    1.Adults in the family with active TB should be diagnosed and treated properly as soon as possible. They must adhere to the TB medications and strictly follow the doctor's instruction .
    2.Adults in the family with active TB should practice infection control by wearing mask as long as they continue to cough and try to stay away from kids in the family.
    3.Children of the family with active TB should be seen by the pediatricians and should have tuberculin test to find out whether they have been infected recently. If the initial tuberculin test is negative, isoniazid should be given and tuberculin test should be repeated in 3 months.If the test remains negative ,isoniazid can be discontinued. If the initial tuberculin test is positive chest x-ray should be done and isoniazid prevention therapy should be given for a total duration of 6-9 months once the active TB has been ruled out.
    Yours sincerely,
    Manoon Leechawengwong,M.D.
    Drug-Resistant Tuberculosis Research Fund
    Thailand
    Email: manoonlee@yahoo.com

    ReplyDelete
  46. I entirely agree with Dr. Surya Kant.

    Unless we control adult TB and prevent the DR - M/X&XXDR TB from going out of hand, achieving zero TB in children is not possible.

    Dr. Kant has indeed provided an overview of the issues and difficulties towards achieving effective TB control.

    Dr. Yatin Dholakia
    Hon. Technical Adviser & Secretary
    The Maharashtra State Anti TB Association, Mumbai, India.

    ReplyDelete
  47. What is the rationale behind three days of AFB smear? What is the scientific evidence or basis of it? I know that statistical chances of AFB positivity are increased but why three consecutive days?

    Kindest regards

    --
    Dr. Naghman Bashir
    89, Doctor's Town,
    Lohi Bher
    Islamabad. PAKISTAN.
    Email: naghman@gmail.com

    ReplyDelete
  48. The challenges with Childhood TB are timely and correct diagnosis due to two reasons:

    (i) Young children cannot produce sputum whose examination is the cornerstone of TB diagnosis

    (ii) TB in children is pauci-bacilliary: there is more of tissue damage, but less of bacteria. Hence it is more difficult to isolate and examine those bacteria.

    Another reason is the shortage of laboratory facilities in India to do TB cultures. Many states still do not have reference labs for this purpose. So, diagnosis has to rely on clinical evidence and X- Rays which can often lead to a lot of confusion and mismanagement.

    Suggestion is to address these concerns taking the ground realities into consideration the following

    - All the paediatricians and treating physicians in government and private sectors should be provided with dissemination of information on
    1. Childhood TB diagnosis and treatment protocols &
    2. Importance to screen all the household contacts including children of the adult TB diagnosed cases and treat them appropriately with chemo prophylaxis

    - Advocate with the government to have child friendly paediatric TB formulations available

    - Conduct School health programme to enhance awareness on TB among children

    We need multi pronged efforts and a well coordinated public private partnership approach to work towards making “Getting to zero new TB infections in children by 2015” a reality in near future.

    Dr. Subbanna
    Director
    LEPRA India – Blue Peter Public Health and Research Centre
    Email: subbanna@leprahealthinaction.in

    ReplyDelete
  49. To get zero new infection in children requires the effort of both the community and healthcare workers. Not withstanding what has been alluded in the other comments including early diagnosis, prompt treatment of active TB, and practicing infection prevention and control in the healthcare and community settings are key to achieving the goal. The issues of public health education on cough hygiene, good nutrition, improved housing/ good ventilation and lighting need to enhanced.

    HIV/AIDS prevention activities need to be addressed.

    Kenya has had very encouraging results in case detection and good treatment outcome, which shows that with more push then it is possible to have zero new infection in children by 2015. We need sustainable resources for TB prevention and control activities globally.

    Samuel Misoi, MPH
    Head: Prevention & Health Promotion
    Division of Leprosy, TB and Lung Disease
    Ministry of Public Health & Sanitation,
    Nairobi, Kenya
    Tel-020-2713198
    Email: smisoi@nltp.co.ke

    ReplyDelete
  50. There are many other aspects one needs to consider for prevention of TB, and not only medicine driven initiatives.

    For example we all know that healthy and nourishing food is important, and when we have millions impoverished children in the world it may be difficult to accomplish effective prevention.

    Same way availability of definitive centers for proper diagnosis and treatment is essential strategy. Many villages in the developing and underdeveloped countries are not even connected and it may take few days to reach definitive medical center, and about seventy percent of population in these countries are living in villages.

    Proper and timely disinfection and management of excreta from known tuberculosis patients is important.

    In essence I venture to state that prevention of TB may be multi-pronged approach. Whole world aims to reach zero new TB infections but it may just remain a slogan unless multi-pronged approach and graduated targets are set in a realistic time frame.

    Dr Lalji Verma
    Email: lalji.lkv2007@gmail.com

    ReplyDelete
  51. Single drug prophylaxis and choice of RNTCP regimens may have aggravated the problem in some areas.

    Research needs are there for these retrospective studies to be taken up and of course no one can deny the legitamacy of infection control. But I strongly feel this is to be taken up very forcefully at all levels so that a general awareness is created about having well ventilated spaces so that M Tb doesnt survive.

    As far as my experience goes there is very very less awareness about Tb transmission .

    It can only achieve the proper perspective the proper people can be pooled in with proper allocation of resources - to let the mothers know and feel that what prevents their children from the infection...?

    Shanta Ghatak Email: drshantaghatak@gmail.com

    ReplyDelete
  52. Please see below my comments with regard to childhood TB.

    Community level:

    1. Strengthening community structures such as SHG, NYKs, community volunteer network, HIV networks, postman / postal department, schools etc.,
    2. Organise themselves into forums and advocate to ensure early diagnosis, treatment and care services for TB infected children.
    3. Messaging around and contact tracing.
    4. Reduce stigma and discrimination.

    Facility level:

    1. Ensure that the supply side is well established to ensure quality assured diagnosis and treatment.
    2. Partnership with other programs such as HIV and MCH.
    3. To create awareness about decentralized TB diagnosis and treatment which are free and easily accessible.
    4. To advocate with private sector to provide accepted standard of TB care.

    Regards
    Malim
    Email: malim@pciindia.org

    ReplyDelete
  53. (सिटिज़न न्यूज़ सर्विस के राहुल कुमार द्विवेदी ने डा. अभिषेक वर्मा, वरिष्ठ बाल रोग विशेषज्ञ से बच्चों मे टीबी पर बात की - वो प्रस्तुत हैं)
    (Rahul Kumar Dwivedi from Citizen News Service (CNS) had interviewed Dr. Abhishek Varma on Childhood TB - below are the responses in Hindi. We are translating and soon English version will be published too)

    मोस्टली जो बच्चों में होता है वह प्राइमरी काम्प्लेक्स के रूप में होता है प्राइमरी ट्युबरक्लोसिस होता है तो उसमें सिम्पटम बहुत कम मिलते हैं। हम लोगों को प्रीडिक्ट करना पड़ता है कि इस बच्चे को ऐसा हो गया है। नही तो हम देखते हैं बच्चे को भूख न लगना, और बच्चा सालिटेरी बैठा रहे इन्वायरनमेंट के साथ इन्टरैक्ट न करे या बच्चों के साथ खेलता घूमता न हो और कमजोर हो, वेट गेन न कर रहा हो। ऐसे बच्चों को फिर हम लोग इन्वेस्टीगेट करते हैं क्योंकि इन बच्चों में सम्भावना रहती है कि प्राइमरी काम्प्लेक्स हुआ या ट्युबरक्लोसिस हुआ हो। शरीर के किसी भी अंग में हो सकता है तो उनके लिये हम लोग इन्वेस्टीगेट कराते हैं। इनवेस्टीगेशन में एक बहुत बड़ी चीज़ है जो बहुत सारे डाक्टर्स करते हैं कि हाइलर सैडो अगर लंग में है तो उससे मान लेते हैं कि प्राइमरी ट्युबरक्लोसिस है। लेकिन ऐसा नही है। 99 प्रतिशत केसेस में होता है कि हाइलर सैडो ट्युबरक्लोसिस से भिन्न प्रकट होते है और अगर हिलार लिम्फ़नोड बड़े हों तो भी जरूरी नहीं है कि बच्चे में टीबी हों। अगर पैरालाइटिस हो रहा है या बच्चे में कमजोरी हो रही है वजन नही बढ़ रहा है तो जब तक ऐसे सिम्पटम न हो तब तक प्र्राइमरी काम्पलेक्स में ट्युबरक्लोसिस की दवा नही देनी चाहिये आमतौर से हम नही देते हैं और कुछ लोग देते हैं।

    डा.अभिषेक वर्मा
    वरिष्ठ बाल रोग विशेषज्ञ
    डा.राम मनोहर लोहिया संयुक्त चिकित्सालय,लखनऊ

    ReplyDelete
  54. Children who contract TB most often do so from the adults around them. In that respect, pediatric TB is actually a barometer of overall TB within a community or region. Therefore, in addition to interventions aimed at children, including the research and development of new tools, initiatives to improve TB control in adults will also lead to fewer new pediatric infections. The development of new pediatric-friendly TB drugs will help cure TB in children and help prevent them from spreading the disease. However, in terms of curtailing the sources of initial infection, the development of new and improved, simpler, and more efficient tools to prevent, diagnose, and treat TB in adults will help to reduce the reservoir of infections that subsequently trickle to children.

    Stopping childhood TB simply won’t happen without support from countries at every level. Governments should invest in and support the development of new and improved tools for children and adults, while community education about TB will help raise awareness about transmission and prevention practices that reduce the incidence of childhood TB infection.

    ReplyDelete
  55. Dear STOP TB/ CNS ,

    I know that I am late and the question on childhood TB is over . But I do not know whether somebody mentioned this from the time the discussion was on.

    Poverty, overcrowding in houses, particularly small houses with poor ventilation with proximity to an index adult case, are well know factors.
    This is a very common feature in urban slums of the mega cities in India and the world. Public Health and NTP planners need to factor this in, when striving towards achieving zero TB deaths. This would also call for people in governance to see the link between poverty and overcrowding, leading to poor ventilation and spread of air borne diseases like TB. Those in city governance like city planners need to keep these critical issues in mind.

    We should not be found in a situation where we are pouring all our efforts and funds into diagnostics, research, treatment and care, while ignoring the silent spread of TB through fine droplets in closed rooms where the the poor of this world huddle together.

    Dr. Vijaykumar Edward
    World Vision India

    Vijaykumar Edward MBBS, MD | Director – Health & HIV/AIDS | World Vision India | Phone No: 91-44-2480 7163 | Mobile 98402 00780 | Fax:
    91-44-24807242 | https://www.worldvisionindia.org
    Email: vijay_edward@wvi.org

    ReplyDelete
  56. Just preventing TB in terms of preventing infections is not enough, as you said a rights based approach is a vital must that can lo longer be ignored. Consider these facts:

    In child labor prone areas where children work in industries like metal and polishing works the first hazardous exposure to children are the respiratory diseases among which TB infections tops the list.

    In cities like Moradabad, Aligah etc every third person is diagnosed with some form of TB and 64% of deaths take place due to TB.

    This clearly indicates that treatment approach and follow ups are non existent and children are constantly being exposed to infections on a daily basis. With no intervention.

    Adding to that are the unhygienic living conditions, lack of proper nutrition and health care, worse is lack of screening of children for infections makes it a very volatile situation.

    On the flip side:

    We know through our jail visits that a big number of TB cases exist in the jails. It is a health situation that authorities are struggling with.

    Our worry is that a big number of children who are brought to homes and institutions for Care and Protection or simply for being in conflict with law, are brought into a situation where large number of children are kept in confinement together .

    The first infections they catch is TB. But none are regular screened or treated for it, Though there is a provision for doctors to visit these institutions for medical care of these children, most are not sensitized enough to screen the child for infections on regular intervals.

    Children when brought in also are not put through a medical examination and so never receive any treatment for any chronic infections they may be having including TB.

    In more worrying is that we have no statistics to ascertain how such homes are housing children with such chronic infections without treatment. Neither do we know whether the child was infected in the home or came with the infection. So as far as TB in children in these situations we are groping in the dark.

    This is a policy issue and must be addressed under the protection schemes being run by the government.

    rgds

    Anjali Singh
    Development Journalist/Child Rights Activist
    Director, Saaksham Foundation
    saakshamforchildrights@gmail.com

    ReplyDelete
  57. Getting to Zero -

    A week back the door bell rang and two ladies stood with vaccine boxes at my doorstep asking if there were children five years and below in the house as they wanted to give polio drops. Hearing a 'no' from me they went to the next door and then continued knocking on doors.

    India just completed a year without a single case of Polio and this is a great achievement indeed. World over India's Polio control is being quoted as a huge success story and rightly so. Yesterday’s front page news says 'WHO knocks India off polio list.' The prime minister said, 'The success of our efforts against the disease show that teamwork pays.' The Health Minister said, 'Till 2009, India accounted for half of the total number of polio cases being reported worldwide. Its a remarkable achievement for us to be taken off the list.' All of us as Indians need to be proud of this achievement.

    This got me thinking. So what is it that worked for Polio? A few that I think worked. There must be others that can be added to this.

    - There was high level commitment for eradicating Polio.

    - The Goal was ambitious bold eradication and not a weak marginal reduction in numbers.

    - Target was zero.

    - No effort was spared to achieve this. Resources, HR everything was mobilized to achieve this.

    - Polio was high on the agenda of politicians, policy makers and other high level decision makers.

    - Very popular ambassadors promoted Polio vaccination. You cannot step out of the house and not see a posters of the President, Chief minister, leading Bollywood stars actually administering the Polio drops, endorsing the campaign and urging parents to get their children vaccinated against polio.

    - Massive awareness campaign. Attractive branding. A designated 'Polio Sunday' when you could get polio drops for the children.
    An effort which involved all players and stakeholders. Not just on paper or as a rubber stamp.

    To this we could also add, no Global Fund. Only Rotary. A group of committed people funding continuously and consistently with their personal money pushed the levels of response for polio. While Global Fund millions poured into the country for AIDS, Malaria and TB the 'personal' was missing and money ruled not lives. It was easy money meant to fill coffers, for many organizations.

    TB is killing one child every 5 minutes! We do not see them affected but their ashes swirl all around us. How long will we use the usual argument that TB is different and continue to turn a blind eye. Now that polio is of the list can we turn our eyes to TB and eradicate it.

    I am asking for a band of dedicated people to join me to call for 100% commitment to make ‘Getting to ZERO’ a reality.

    Blessina Kumar
    TB/HIV Activist
    Public Health Consultant, India
    Community Representative and Vice Chair- Stop TB Partnership (WHO, Geneva)
    Email: blessi.k@gmail.com

    ReplyDelete
  58. A high index of suscipion of TB in a child is key to early diagnosis
    of childhood TB. Less than that then the TB diagnosis is difficult!

    I have found the triad of ; History of contact with an adult with TB,
    Positive mantoux test and Chest X Ray changes. The challenge is when
    there seems to be no history of contact with TB patient at household
    level, Mantoux test is quit expensive and requires at least two visits
    and the intepretation of the Tuberculin Skin Test is tricky in an
    immunisuppressed (where majority lay!) child and chest x ray
    interpretation comes with experience.

    Successful treatment requires adequate patient preparation for
    treatment and ongoing support counseling for both the patient and the familiy. But ofcourse there must be regular drug supply which is not
    the case for the 22 high TB burden Countries.

    Dr Charles Namisi, Uganda
    Email: charlespcn@gmail.com

    ReplyDelete
  59. Viva india for achieving such great thing (POLIO ERADICATION) it is not easy to succeed such a great challenge.I wish other countries can do the some, we need more Activists for this achievment.

    thanks

    fred zambia
    TALC

    Fred Mwansa

    ReplyDelete
  60. Dear Stop TB Partners

    I fully endorse Blessina`s comments. Unlike the hype and aggressive advertising created for the polio TB just remains in the realm of meetings seminars and symposiums. I attended recently an open Symposium on Social Determinants of Tuberculosis at LSHTM which was followed by a 2 day meeting of Laboratory researcher Economist and so many other eminent persons( I did not attend this exclusive meeting). This 2 day meeting is supposed to form a high level Commission to lay down a policy frame work for devising ways t
    o direct cash transfers to nutritional support and even toiletries. Examples were cited of the impact of these special efforts. Coming from India I was surprised that the enlightened speakers are totally unaware of the food security under public distribution scheme in India which guarantees assured food grains to each BPL family.

    I have also experienced how Global Fund has not made the impact it was supposed to make even after few Rounds. There is too much stress on training and capacity building. Of whom is my question?

    Now there is talk of bringing childhood TB to zero by 15. How? please consider to resolve the issue of access versus availability. I come from a remote village in the lower Himalayas and I see that people from that reason have to walk miles and miles to the nearest diagnostic facility if there is one or the personnel are present.

    To tackle the monster of TB we have to think of ground realities and not theoretical solutions as the case is today. Create partnership and trust civil society to be a part owner of the programme. Create penetrative awareness at local level and enable to demand services very near to people.

    Tilak S Chauhan
    F-216 Vaishali Garden Apts
    Nagarjuna nagar Tarnaka
    Secunderabad - 500017

    Landline: 27179781
    Mob: 9849107449

    Email: tilak_chauhan@hotmail.com

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