CNS: Childhood Tuberculosis: Act before it is too late

(Based on an interview given to CNS by Dr Soumya Swaminathan, at Chennai ART Symposium, 2012)

A significant proportion - about 15% to 20% - of all tuberculosis (TB) occurs in children in India, where paediatric TB is a serious, but under-recognized and neglected public health problem. "The reason is that, unlike in adults, children get forms of TB that are not infectious. Therefore less public health priority and importance is given to it. TB spreads through the air borne route. So children get it from adults through cough etc. The most important risk factors in children are malnutrition, poverty, environmental pollution, poor housing, overcrowding, indoor air pollution, passive smoking, and to a much smaller extent HIV infection also" said Dr Soumya Swaminathan, National Institute for Research in Tuberculosis, Chennai.

Dr Swaminathan was speaking to Citizen News Service (CNS) at the recently concluded Chennai ART Symposium (CART 2012). She has been working at the National Institute for Research in Tuberculosis, Chennai since 1992. She has been involved with clinical trials for new TB regimens, both for adults and children, has focused on HIV infected adults and children, especially its interaction with TB.

According to Dr Swaminathan, the two main challenges in dealing with childhood TB are by way of diagnosis and treatment. Timely and correct diagnosis is a challenge due to two reasons:
(i) young children cannot produce sputum whose examination is the cornerstone of TB diagnosis and
(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. So now work is being done on diagnostic criteria which will be very well laid out and can be followed internationally by researchers as well as clinicians.

The symptoms of the common form of TB of lungs (pulmonary TB), are fever and cough, which overlap with the symptoms of many other common infections in children - viral, bacterial and upper respiratory tract infections, asthma and wheezing. So there is often confusion in the mind of the parent as well as the doctor as to what type of fever and cough it is. Most often, parents bring the child to the doctor for repeated and persistent fever/ cough, or if the child is not gaining weight and not having a good appetite. The other common form of TB in children is the lymph node TB, in which case there may be an enlarged swelling in the neck or the armpit. Then there are serious forms of TB like TB meningitis, in young children specially. They may just be lethargic and have low grade fever, followed by headache and vomiting. But there is a lot of overlap with symptoms of other diseases.

Treatment depends upon correct diagnosis, so once correct diagnosis is made, half the challenge is over. As TB can very often mimic pneumonia, bacterial/viral infections, it is very important to follow a correct procedure for diagnosis. Once TB is suspected we need to do a chest X- Ray, and wherever possible try to make a bacteriological diagnosis—either by obtaining sputum in case of an older child, or by obtaining respiratory secretions in younger ones like a gastric lavage or induced sputum. If the X- Ray is suggestive of TB, then one should give a course of antibiotics, and watch the child for about 10 to 14 days. Most of the other bacterial infections, including pneumonia, will improve in this time. If the child still does not improve, only then can one consider TB as a likely diagnosis. Many doctors skip this step. They may, find a lesion in the X- Ray and start TB treatment. This is responsible for a lot of misdiagnosis and may also be dangerous for the child in the long.

There are treatment adherence and compliance problems in children with TB, especially because of the long duration of treatment (6 to 9 months) and also because they have to depend on others to take the drugs. They may refuse to take medicine or spit it out. Even in older children and adolescents, we can get issues of non compliance, especially if we do not have child friendly formulations—the taste may be bad or the pills too big to swallow. It depends a lot on the parents and caregivers, to ensure that treatment is completed. Unfortunately we have very few quality assured child friendly formulations. So, very often one ends up using adult formulations with reduced dosage. The Revised National TB Control Program now has pediatric boxes which are made keeping in mind different age and weight bands in children. Luckily, side effects in TB drugs for children are very less as compared to those in adults.

Childhood TB is difficult to control, because the infection is air borne, and the only way to prevent is to tackle adult TB more seriously. All family members of a TB patient, especially children, should be tested, and started on chemoprophylaxis. This way the burden of pediatric TB can be reduced. There are social and economic issues too, as most of the TB affected children come from poor socio economic background.

As for HIV-TB co infection in children, it is not too much in terms of overall population prevalence, but for the HIV infected child, TB is a huge problem, and very often difficult to diagnose. HIV- TB co infected children have very bad outcomes, if they are not properly diagnosed and treated in a good centre. In HIV positive children infected with TB, the challenges are bigger, because many of them are orphans, living either with grandparents or extended families or living in orphanages. Treatment compliance in these children is much worse, as there is no dedicated caregiver, and children are left to themselves to take their medicine.

Children are innocent victims of the TB epidemic. They have to deal with the disease as well as the stigma associated with it. 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 can they do to reduce the burden of TB. As it is an air borne infection, anybody can get it, but poor nutrition makes one more susceptible to it. We must incorporate nutrition and education program in the primary health care system, as primary care is very critical for overall health of the child. We also need to use community volunteers, social mobilization, and self help groups to motivate patients to complete TB treatment and not leave it in between.

As someone has rightly said - Many things can wait, but a child cannot. To her we cannot say tomorrow, for her name is today.

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 has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. Email: shobha@citizen-news.org, website: http://www.citizen-news.org)