The roadmap to a TB free future for children

Carolyn Kavita Tauro, India 
(First published in Mangalorean News, India on 4th October 2013) 
On the morning of 1st October, 2013, the very first plan of its kind was launched toward the goal of zero deaths in childhood TB. The launch was jointly brought about by the World Health Organization (WHO), International Union Against Tuberculosis and Lung Disease (The Union), Stop TB Partnership, UNICEF and other partners, bringing out of the shadows this disease in children, which has been neglected so far.

The Roadmap for childhood tuberculosis brings forth ten steps toward reducing deaths to zero with a timeline ranging from short term deadlines in 2015 to long term ones in 2025. The actual burden of paediatric TB is not known due to diagnostic difficulties but has been assumed that 10% of total TB load is found in children. Although TB is a preventable and curable disease, it is one of the top 10 causes of childhood mortality and globally every day up to 200 children lose their lives to it. More than 500,000 children worldwide become ill with the disease every year and have to take long treatments - treatments that are not easy for a child to take every single day for a period of 6 months.

On the day of the launch of the ‘Roadmap for Childhood Tuberculosis Towards Zero Death’, I spoke with one of its co-authors Dr. Soumya Swaminathan, Director of National Institute for Research in Tuberculosis Chennai, India. She said that, “The main objective of the roadmap is to raise awareness on the problem of childhood tuberculosis which is a neglected disease and has been given a low public health priority. It is to bring together all stakeholders, in trying to prevent deaths due to TB i.e. zero deaths and to control childhood TB. We need to go beyond the TB community to achieve this”.

While the roadmap expresses that at country level, a significant transformation of political will and commitment toward efforts to address this issue has taken place, where and how can India put its first foot forward?

“Recognition and priority - we need to start talking about it in India. We need to give it more priority within the management of the disease and look actively for contact screening, implement chemoprophylaxis etc. We need to involve the child programmes like Integrated Maternal Neonatal and Childhood Illnesses (IMNCI), which already exist. So far these programmes only focus on pneumonia, diarrhoea and malnutrition. Even in these diseases the underlying cause of death and morbidity could very well be TB but this is not recognized”, said Dr. Swaminathan.

The roadmap mentions the historical neglect with the misperception of childhood TB as a low public health priority, assuming that children with TB are usually less infectious than adults. They have thus attained little attention from national TB control programmes that prioritize controlling transmission by detecting and treating cases with sputum smear-positive TB.

What more can be done apart from the national level of integration with child health programmes?

It is known that in India, more than half of all patients seek healthcare from private doctors. This is no different for TB, where the private doctor is usually the first doctor the patient meets, despite the government providing free treatment for TB. According to Dr. Swaminathan, “Paediatricians should be involved in the Revised National TB Control Program (RNTCP). They do not always have paediatricians in the government set up, so private paediatricians should also be involved as appropriate interpretation is required since diagnosis is difficult. At the same time, the following should be ensured in all private clinics: (i) A rational evidence based manner in which diagnosis is made, (ii) Rational treatment with an approved treatment regimen, (iii) Tracing from adult contact to child and also from child to adult, looking within family and surrounding areas for any contacts and (iv) Chemoprophylaxis must be given for a period 6 months to all children with contact history who are below six years of age”.

While paediatricians come across children who suffer and die of TB almost every day, what do they have to say about the roadmap?

Dr. Suhas Prabhu, Consulting Paediatrician at Hinduja Hospital in Mumbai suggests three routes which need to be travelled simultaneously to reach the goal of zero deaths. According to him, “It is important to (i) educate all care-givers, paediatricians and all general doctors to continuously think about TB as a diagnosis in children (high index of suspicion), aggressively try to make a diagnosis and a bacteriological diagnosis at that with possibly drug susceptibility by culture DST or molecular methods, and offer correct drug treatment for the same; (ii) Start screening programmes in hospitals and schools for detection of TB in children with the help of NGOs. Costs for this may need to be subsidized or offered through government health agencies; (iii) Integrate the DOTS program with other Maternal and Child Health programmes. Compliance to treatment should also be ensured by involving NGOs, school teachers and workers”.

According to the roadmap, some examples of activities taken on at the national level in some countries are: (i) Development of national guidelines for the management of TB in children (ii) Situation analyses and identification of national priorities for implementation (iii) Inclusion of childhood TB in reviews and monitoring missions led by national TB control programmes (iv)Development of national leadership in addressing childhood TB and development of working groups focusing on childhood TB (v) Implementation and evaluation of training activities relating to TB in children (vi) Development of clinical guides for managing childhood TB.

Once children are diagnosed with TB, they are not always reported to the national surveillance programmes of the country. This happens due to lack of collaboration and communication among individual paediatricians, paediatric hospitals/clinics and national TB programmes. Apart from this, children below 15 years are not included in most national TB prevalence surveys. This is important to measure the burden of TB so that governments can assess the impact of their actions and detect loopholes as to why many cases go undetected. Bringing childhood TB out of the shadows of neglect, urging research to address TB in children, integrating the search and management within national child health programmes and collaboration across health systems and communities are highlighted in the roadmap to deal with this disease which requires much attention.

Dr Swaminathan says, “India should push to put childhood TB to the upfront. It is time to raise its profile, for more advocacy and TB should be brought into the mainstream”.

Carolyn Kavita Tauro, Citizen News Service -  CNS
(First published in Mangalorean News, India on 4th October 2013)