We need to stop children dying from tuberculosis
Every three minutes, a child dies from this preventable illness
Doctors Without Borders / Médecins Sans Frontières (MSF) welcomed the World Health Organization’s (WHO) “Roadmap towards ending TB in children and adolescents” released recently, and urged all countries with high TB burdens to prioritize adoption, implementation and scale up of the WHO’S consolidated guidelines on management of tuberculosis to reduce the number of children killed by this deadly yet curable disease. TB remains a major killer in children, causing the death of a child every three minutes.
Released in 2022, the WHO’S TB guidelines for children and adolescents recommend several key interventions to save more children from TB: using integrated treatment decision algorithms that allow many children to be diagnosed based on symptoms alone; using the Genexpert test on stool specimens which is easier to manage than having children cough up sputum (phlegm) samples; using a four-month treatment for nonsevere drug-susceptible TB instead of previous six-month regimens; and providing three-months of treatment to prevent TB in children who are exposed to someone with TB in their home. These recommendations however have not been sufficiently implemented in most high-tbburden countries.
“The WHO’S recommendations serve as a crucial tool to help health workers diagnose TB in children in all settings, even when there is limited access to laboratory tests and X-ray, but we’re still not seeing enough countries implementing them to save more children’s lives,” said Dr. Gabriella Ferlazzo, TB medical advisor for Doctors Without Borders Access Campaign. “We urge governments to adopt and start putting the WHO recommendations into practice so that more children are diagnosed and started on treatment right away, which also means training and support for staff to make this possible. Governments must leave no stone unturned to find every child with TB and treat them right away.”
Under-diagnosis of TB in children has led to under-treatment and high numbers of deaths. The diagnostic tests available for adults with TB are not adapted for use in children, as they lack the sensitivity to detect the low levels of TB bacteria that make children sick. This has resulted in the fact that even in the most resourced settings, it is only possible to confirm TB in a minority of children.
While sputum (phlegm) is the preferred specimen used to test TB in adults, most children are unable to cough up sputum on demand. WHO now recommends that children are tested on gastric, naso-pharingeal, or stool samples using the Genexpert Ultra test.
Trying to get gastric fluid samples from children can be invasive and is often not possible or very challenging in small or ill children, leaving stool testing as the only option in many settings, even if this option still poses practical difficulties, especially for outpatients. In the absence of accurate and accessible diagnostic tests to detect TB in children, health providers must ensure an early diagnosis based on signs and symptoms, as also recommended by WHO. There is an urgent need for more research and development to find better tests to diagnose TB in children.
“It’s baffling that only 40 percent of children with TB get the treatment they need to stay alive, because the right tools to test TB in kids still don’t exist,” said Dr Nasiba Maksumova, who works in the Doctors Without Borders TB project in Tajikistan. “We desperately need more effective TB tests for children that can be used in the most remote settings using samples that are easy to collect, like mouth swabs or finger-prick blood. More efforts are needed from researchers, donors, and pharmaceutical corporations to develop improved TB tests, and once developed, these must be available and affordable in all countries with high TB burdens. Children with TB can’t afford to wait any longer for the world to get its act together on this deadly disease.”
Apart from testing and treatment, implementing preventive treatment in children and adolescents who have been in close contact with people affected with TB in their family or in the community remains a major challenge.
In the Doctors Without Borders TB project in the Philippines, teams visit the households of confirmed TB cases and encourage their close contacts to get screened. From January to October of 2023, the teams found these households to have 104 children aged zero to four years old, and 246 contacts aged five to 14 years old. In the zero to four age bracket, while 57 out of 104 were found to be eligible for preventive treatment, only 46 initiated treatment, and of these, only 22 were able to complete treatment. In the five to 14 age group, 61 out of 246 children were found eligible, but only 53 initiated treatment, and only 31 completed treatment.
Shorter, three-month regimens to prevent TB have been recommended for many years for children, but their scale-up remains insufficient. Countries need to increase access to preventive treatments and start eligible children on these treatments to reduce the risk of this vulnerable population developing active TB.
“After decades of pressure and waiting, we finally have childfriendly formulations of drugs to prevent TB,” said Dr Kennedy Uadiale, who works in the Doctors Without Borders project in Sierra Leone. “Still, so few kids get preventive TB drugs because the screening process to identify them is so cumbersome. It’s time now for countries to fulfil commitments made in the UN Political Declaration on TB last month and save lives by reaching all children affected by TB.