Children and TB: The struggle continues

Sam Banda Jnr, Malawi 
(First published in The Daily Times, Malawi on 28th March 2013): On Sunday March 24, the world came together to commemorate the World TB Day under the theme Stop TB in My Life Time. The World TB Day was designed to build public awareness about the global epidemic and reporter SAM BANDA JNR takes a closer look at the challenge the disease poses on children. TB is an airborne disease and second leading cause of death among infectious diseases worldwide after HIV and Aids. World Health Organisation (WHO) latest figures indicate that at least 500,000 children become ill with TB each year and that up to 70,000 do not survive.

"Though curable, TB kills at least 130,000 children each year, making it one of the top ten causes of death in children," says WHO in a statement. Despite this being the case, children with TB or pediatric TB have not been sufficiently looked at compared to adults. Children, today, still receive the same dosage as adults although they respond well to treatment.

Health experts in Malawi and Australia feel there is a need to adjust the dosage for children so that they have their own treatment but this is a process which is long overdue. With this said and done, some experts believe that child TB is widely under-reported and can represent as much as 40 percent of the TB caseload in some TB high-burden settings.

According to WHO reports on the disease, National tuberculosis programmes have historically not given child TB high priority because children are not a major source of infection and diagnosis can be difficult. Children have only been considered on the vaccine known as the Bacillus Calmette-Guérin (BCG) vaccine which is overdue and is said to have been in use since 1921.

The WHO recommends a BCG vaccination for babies and children up to two years old living in TB-endemic countries because it protects against military or disseminated TB and TB meningitis (affecting the brain or spinal cord). Malawi is not spared but National Tuberculosis Programme (NTP) Programme Manager James Mpunga says the country is doing all its best in fighting pediatric TB which is claiming lives of many children. Mpunga's worry is the numbers of children who are infected with drug-resistant forms of TB which require complex treatment, are increasing.

The struggle to prevent deaths among children has seen the Ministry of Health introducing newer technologies. One of them is GeneXpert which has capacity to diagnose the disease in HIV positive patients, an exercise that would be difficult using older diagnostic methods like microscopy. Mpunga says although the GeneXpert itself has some challenges in diagnosing TB especially in smear negative HIV positive children; it is a good development for NTP Malawi and other NTPs in the region.

"There have been advances in research in diagnosing TB through urine but this needs to be developed more before it can be used in high TB/HIV settings like Malawi," he says. Mpunga says that Paediatric cases of TB are managed according to NTP TB treatment guidelines as contained in the TB Manual. "The proportion of Paediatric TB cases is 15 percent of the total notified TB cases. As NTP we have updated treatment guidelines for children in our new TB manual to take care of advances that have been made in this field," he says. He adds that children present a few challenges in both diagnosis and treatment especially in settings like Malawi where HIV prevalence is high.

Causes of TB in children

Dr Steve Graham of the Department of Lung Health and Non-Communicable Diseases of the International Union Against Tuberculosis and Lung Disease (The Union), Australia told The Daily Times/ CNS in an exclusive interview that the risks that put children in danger of getting TB include close contact with a case of the disease, especially sputum smear positive TB.

"Being young especially infants and young children less than four years or adolescence, being immune suppressed – HIV or malnourished are the common causes," says Graham. He advises parents to take care of their children if they are to be protected from the disease.

"If the child has TB, the completion of treatment is important, if the child is exposed to TB in household, then seek advice about screening and possible need for preventive therapy," says Graham. Graham points out that children tolerate TB drugs very well better than adults and that there is low risk of toxicity but stresses that it is important that the treatment is fully completed even if the child seems better.

With the BCG vaccine long overdue, the health expert maintains that this vaccine is still relevant in terms of protecting children from TB. "It protects against severe and often fatal forms of TB in young children – TB meningitis and protects against leprosy," he says. Currently Kenya ranks 13th out of the UN WHO 22 high TB burden countries and have the fifth-highest in Africa.


According to Graham some of the symptoms of the disease in children include cough, fever, weight loss or poor weight gain. "The problem is that these symptoms are common due to the disease's low and middle income setting. But mothers are very good at keeping road to health cards with weight monitoring and weight faltering is a marker of child," he says.

What then needs to be done to address paediatric TB especially with a case in point where a child was said to have been immunized for TB at nine months and then six months later he developed swollen glands around the neck which was later said to be TB? "Better diagnostics are needed. The vaccine has limited effect especially against forms of TB such as the case in point i.e. TB of Lymph nodes. And vaccine research is happening but not yet developing anything better than BCG," explains Graham.

Malawi, however, is on a better position though as there are not high cases of TB in children but Mpunga says prevention of TB in children continues to be emphasized by the NTP, adding that all children aged 14 and below living with TB patients are advised to go for screening at their nearest facilities. Mpunga also said that it remains the ministry's policy to vaccinate all children with BCG at birth in order to prevent TB.

The NTP Programme Manager also notes that in Malawi looking at the statistics in TB case finding/notification rates, more men are reported than women. "Several explanations may be given. The first is that women and children are disadvantaged in terms of access to TB services probably through geographical and health system related factors. Others have argued that the fact that TB services currently are not integrated with Maternal and Child Health services in Malawi, opportunities for the health system to screen women are missed," he says.

Women, children connection

Mpunga says that in Malawi they have not quantified the burden of TB among pregnant women because there are no clear drivers. However, he says, other countries especially outside Africa, recently have demonstrated that this section of the population reports higher figures and that this has led to WHO advocating for incorporation of TB services in all health facilities. "Women may become pregnant without any challenges. TB is not transmitted through secretions like HIV and so the risk of transmitting the Mycobacterium to the unborn baby is negligible," he says.

Sam Banda Jnr, Malawi 
Citizen News Service - CNS
(First published in The Daily Times, Malawi on 28th March 2013)