The forgotten victims of TB
To overcome the disease burden of tuberculosis, attention must be brought to the largely ignored incidence of TB in children.
Tuberculosis, a disease which claims over a million lives every year, is undoubtedly the modern-day plague that states are striving to combat. Despite being preventable and curable, childhood TB has received scant attention from academics, health service providers and policymakers. TB eradication programs, the world over, are hurdled by the scarcity of resources. With 10 million people contracting the diseases annually, efforts tend to be more focused on containing the epidemic. The primary focus of most programmes, thus, is on adult patients that have the highly contagious TB germs as opposed to paediatric TB patients, who are comparatively less contagious.
However, this trend seems to be gradually reversing. In 2012, the World Health Organisation (WHO) included an estimate for childhood TB in their Annual Report on TB. Furthermore, in 2013 the TB Alliance was awarded up to $16.7 million from UNITAID for developing child-friendly formulations for TB and launching a childhood TB elimination roadmap. Both, the Sustainable Development Goals and WHO's End TB strategy are striving to end TB and achieve zero childhood TB deaths. Despite the efforts, WHO estimated that one million children (0-14 years) contracted TB and 250,000 died from it in 2016, thus advocating the need for increased attention to paediatric TB.
Understanding the complexities of TB among children is crucial. Children contracting TB are exposed to a higher risk as compared to adults, in terms of progression from infection to disease. Moreover, they develop more severe symptoms that go beyond the pulmonary tract leading to a higher incidence of disability and death. Sociocultural, geographical and dietary factors also play a role in contraction. Children in low and middle-income countries, living in impoverished conditions and in close proximity are more susceptible. Prevalent health conditions that impair the immune system, like HIV, undernutrition etc further complicate cases of TB, causing much faster progression, particularly for children below the age of five. Moreover, studies show that children are more likely to contract the disease from a TB infected adult in their household, in the absence of timely preventive measures.
It is, thus, imperative to diagnose and cure childhood TB in our fight against the global health burden of the disease. By identifying and treating TB infected children, we can ensure that the latent Mycobacterium tuberculosis is killed and children are removed from the infected pool. A failure in our efforts to mitigate childhood TB amounts to a human rights violation and, also, gravely impacts the productivity of nations. Undoubtedly then, prevention and mitigation during childhood is likely to make elimination efforts far more effective.
Challenges to childhood TB
Paediatric TB displays different types of the disease other than pulmonary TB, making diagnosis difficult. Thus, methods used to diagnose TB in adults cannot be replicated for children. Studies show that extra-pulmonary TB occurs in 20-30 per cent children and a high percentage of children also develop meningitis and disseminated TB. Limited research and advocacy on these other types of TB aggravate the issue. Furthermore, since most TB programmes focus on fighting pulmonary TB, there is an absence of adequate awareness about the symptoms of the other types of TB.
Research shows that children are more prone to contracting TB through exposure to even limited Mycobacterium tuberculosis, which may otherwise not affect adults. Consequently, the microbiological tests often fail to test positive for a large number of cases. Thus, due to the non-specificity of symptoms, most cases of childhood TB are either under or over-diagnosed leading to complications in cohesive treatment. To add to the challenges, general physicians, often fail to report the diagnosed cases of childhood TB due to poor linkages with the healthcare mechanisms and inadequate legal deterrent systems.
Second, the standard treatment for TB involves a very long process, with side-effects like nausea, vomiting, diarrhoea, permanent loss of hearing (in some cases) and an abnormal thyroid function. In the absence of community-based treatment programs like DOTs, adequate awareness and family support, children often stop their medication mid-way, leading to antimicrobial resistance. Accordingly, the multi-drug resistant TB comes with challenges of its own, requiring more expensive medication and a much longer treatment duration. These problems are even more pronounced in low and middle-income countries like India, due to the limited capacities for TB diagnosis and treatment. Children suffering from MDR TB often have to be admitted to tertiary care centres. As a result, they are isolated from their homes, schools and families for a prolonged period. Thus, whether it is TB or MDR TB, the children suffering are negatively affected by the social stigma, discrimination, isolation and poor school attendance.
Third, fixed-dose combinations for TB or the adult formulations, when used to treat children often lead to under or over-dosing, unfavourable treatment outcomes and, children are highly likely to develop drug resistance.
Fourth, children belonging to families where an adult member is suffering from TB also bear the brunt of the disease. They are at constant risk of contracting the disease at home itself. Moreover, even if the preventive measures safeguard them from developing TB, they suffer the economic brunt of a lost parent. As per WHO estimates, around 10 million children become orphans due to the loss of a parent from TB. The sociocultural and economic impact of TB is much deeper for children, particularly those belonging to the marginalised and vulnerable sections.
The way forward
Statistics show that of the one million childhood TB cases worldwide, the detection rate is a mere 36 per cent. These figures are particularly alarming for India which suffers from among the highest incidence of TB. Thus, it is imperative to understand that childhood TB is different from adult TB and faces several unique challenges. Children suffer gravely in every aspect whether sociocultural, psychological, developmental, or economic.
International and National TB Programmes need to emphasise the widely prevalent paediatric TB and make investments in targeted research. Special focus on childhood TB must be laid in the Draft National Strategic Plan 2017-2025 for TB Elimination in India, Revised National TB Control Programme and other initiatives, in the context of India. A focused strategy ensuring diagnosis, treatment and assimilation into the society after completion of the treatment is the need of the hour. A lot needs to be done in terms of identifying children exposed to the risk of contracting TB and accordingly ensuring their access to prevention measures, quality diagnosis and treatment. The first point of contact for children suffering from TB is usually community and primary healthcare. Spreading awareness and improving community healthcare systems to cater to children would prove to be a good starting point. Moreover, childhood TB needs to be better interwoven into maternal and child health programs like Poshan Abhiyan, Integrated Child Protection Scheme, and Pradhan Mantri Matru Vandana Yojana.
In the recent years, childhood TB has started receiving global attention. International organisations are working towards strengthening childhood TB diagnosis as well as cure. World Health Organisation and UNICEF have issued a joint statement, encouraging all National TB Programmes to replace existing TB medicines with a version of child-friendly dispersible TB fixed-dose combinations that are more effective in treating childhood TB. This is a welcome step in strengthening the treatment of paediatric TB.
Primary, secondary and tertiary healthcare systems, community and government initiatives along with families must be engaged to tackle this problem. Efforts like the BCG vaccination to prevent TB in children have helped achieve positive results. Strategic investments for developing newer and more effective alternatives to protect children against TB are needed. This must be supplemented with the pooling of health resources as well as academic research to better understand and manage this epidemic among children. Sustained global, national and regional efforts aimed at strengthening diagnosis, treatment and care for childhood TB would arm us to fight the largest public health threat faced by the world today and save our children to live a better tomorrow.
(The author is a Young Professional in the Economic Advisory Council to the Prime Minister. The views expressed are strictly personal)