Do not forget the children in the post 2015 agenda for health

Shobha Shukla, Citizen News Service – CNS 
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The vision for the post-2015 global End TB strategy for TB prevention, care and control is ‘a world free of TB’. The strategy aims to end the global TB epidemic, with targets to reduce TB deaths by 95% and to cut new cases by 90% between 2015 and 2035. This will require the current average annual decline of 2% in global TB incidence rates to accelerate to 10% per year by 2025.

Additional tools like an effective vaccine, better diagnostics and simpler treatment options will also be needed. The strategy also focuses on vulnerable groups, including children.

Burden of childhood TB

Addressing childhood TB should remain an important focus area of these efforts. The childhood TB Roadmap launched by the WHO in 2013 recognizes that any child dying from TB is one child too many. This roadmap shifts us from the ‘why’ to act towards the ‘how’ we can chart a course to accelerate progress against this deadly disease in children. It also focusses on increased visibility and advocacy on paediatric TB as well as on improved estimates of paediatric TB burden.

There are an estimated 550,000 cases of children with TB annually (some estimates put this figure at 650,000) and in 2013 there were 80,000 deaths among HIV-negative children with TB. TB is indeed a significant cause of illness and death among children.

Dr Steve Graham who is Professor of International Child Health at the University of Melbourne and Consultant in Child Lung Health at The International Union Agianst TB and Lung Disease led the development of WHO’s Roadmap for TB in children. While speaking to CNS he said that, “There is undoubtedly greater attention to childhood TB today than 5 years ago, and the post-2015 End TB Strategy provides an important opportunity to increase the momentum and address some of the current wide policy-practice gaps. Therefore, the Roadmap needs to inform the development of regional and national frameworks that link the TB control sector with the maternal and child health sector in order to move forward. This has already started happening in the Western Pacific and African region, with the recent engagement of UNICEF in childhood TB. Child health leaders, champions, practitioners and policy makers need to be more aware of, and engaged in the challenges of TB in children.”

Neglect of childhood TB

Yet, as Joanna Breistein of the Global Alliance for TB Drug Development (TB Alliance) points out, identifying and diagnosing TB in children is inadequate and leads to systematic under-reporting of the problem. While child survival from diseases like HIV and pneumonia is definitely improving, but those gains have not been realized for children with TB. Joanna insists that there is an urgent need for child appropriate treatments as the current 6 months to 2 years is a too long and difficult treatment, more so in the absence of simple and child-friendly appropriately dosed first-line TB drugs for children. Moreover, a gap of 7 years or more is projected between launch of adult treatments and availability of similar child formulations. 
  Joanna lists some priority actions for 2015 and beyond

• Find and treat: Leverage the opportunity/availability of simple treatments to improve diagnosis
• Integrate childhood TB activities in other child health sectors, particularly in maternal and child health programmes
• Stakeholders to rapidly adopt child-friendly formulations of first-line TB treatment in the correct WHO-recommended doses now coming to market
• Accelerate research for new, faster-acting treatments for children and also develop child-friendly forms of second-line treatments
• Increased advocacy to change the funding landscape for a better tomorrow.

Dr SoumyaSwaminathan, the Director General of Indian Council of Medical Research (ICMR), and an expert in the field of paediatric TB and HIV, spoke to CNS about her priorities for reducing incidence of paediatric TB in the post 2015 era. Stressing upon expanding access to high quality diagnostics, she said that the use of GeneXpert improves the diagnosis of paediatric TB as it not only confirms TB but also picks up drug resistance. She cited the evidence from a 2014 study done in India wherein out of 100000 children’s sputum specimen tested by GeneXpert, 600 odd tested positive for TB and out of these 600, about 10% were Rifampicin resistant. This came as a surprise to the paediatric community—they were not expecting such high rates of drug resistance in children.

“Expanding the access to good quality diagnosis and appropriate treatment for children can go a long way to reduce mortality which is one of the goals of the post 2015 agenda”, she said.

“Bringing down the incidence of TB in children will also involve expansion of contact tracing within the family of index TB cases; early detection of cases; identifying vulnerable children below 6 years and putting them on chemoprophylaxis, with IPT being the standard of care. For contacts of MDR-TB cases, we do not have an evidence base for prophylaxis. So for such cases, it will basically be contact screening and keeping them under close surveillance”.

Dr Swaminathan is also worried about the high incidence of TB among children with HIV, despite their being on anti retroviral treatment (ART). And a lot of this is being missed out, as procedures for screening such children for TB are not being adhered to. Here again Dr Swaminathan insists upon the need for not only good diagnostics, but also upon its availability at the ART centre itself.

“Having quality diagnostic facility available on site at ART centres and doing all investigations at one place only needs to pick up. Every time a child comes to an ART centre, screening for TB must be done. This involves training of the staff and also having diagnostic facilities available to ensure that as far as possible diagnostic tests are performed right there and the child is not made to go to another place for TB testing. Also the daily treatment regimen for children with TB (with or without HIV infection) is better than alternate day therapy and needs to be scaled up,” she said.

The connection between life and breath is fundamental, yet lung health is not high on the public health agenda. Let us hope that this will change beyond 2015. It is important to recognise the strong interconnections and linkages of specific lung health issues with other development issues.

We will have to make zero childhood TB deaths a reality through realization of the Childhood TB Roadmap as well as the End TB Strategy.

Shobha Shukla, Citizen News Service – CNS
August 19, 2015