I was exposed to the plight of children with tuberculosis early in my 32 years of experience as a physician. I was a medical intern in a provincial hospital in Peru’s jungle region. I noticed Adrian, a severely malnourished 3-year-old child in the corner of the ward, feverish and breathing with great difficulty. His condition didn’t respond to pneumonia treatment, and a chest X-ray revealed liquid surrounding the right lung. My attending physician concluded that Adrian had severe malnutrition and pneumonia and decided to continue his antibiotic treatment.
Adrian died on the third day of my watch. An autopsy revealed the little boy had been afflicted with TB. That was likely why he died, not malnutrition or pneumonia. We later found out that Adrian was living with an uncle who had recently died “coughing blood.” My attending physician confessed that he had been so focused on managing the presumed pneumonia that he didn’t think about TB as an alternative diagnosis.
As a doctor, you don’t forget a death under your care and that is why the 47th Union World Conference on Lung Health that gets under way in Liverpool in the United Kingdom this week will be so vital. Pediatric tuberculosis will be an important and complex issue on the agenda. The conference follows the World Health Organization’s latest report on TB, which showed that the TB epidemic is larger than previously estimated. Fortunately, effective treatments and innovative practices abound.
According to the WHO, TB killed 170,000 children in 2015. That’s almost 10 percent of TB’s total death toll. In the same time period, 10.4 million people are estimated to have fallen ill with TB, of which 1 million were children. In settings with a high burden of TB, around 10 to 20 percent of all TB cases are expected to occur in children. Such settings are countries that also have high rates of mortality in children who are younger than 5, thus making it more likely for sick and malnourished children to also be infected with TB.
It is difficult to diagnose children with TB: Around 20 to 30 percent of TB in children lack a typical pulmonary manifestation; it can affect the lymph nodes, the meninges of the brain, or be disseminated throughout the body. TB can also accompany children with malnutrition, pneumonia, and HIV, thus “hiding” a tuberculosis diagnosis.
All too often, maternal, newborn and child health — or MNCH — providers fail to ask about household TB contacts as part of the medical assessment of a sick child, such as adults who are diagnosed with TB or who are coughing for more than 15 days.
To make matters worse, in cases when we do suspect TB may be the problem, we often don’t know what to do — should we refer the patients elsewhere, or try to treat it ourselves? Part of the problem is that MNCH practitioners are seldom trained and encouraged to think of TB as a childhood disease, and what to do when confronted with a potential case. Moreover, MNCH and TB practitioners usually have none or limited collaboration for patient consultation and referral.
4 ways to capitalize on existing MNCH services
I am — and believe we should all be — more optimistic about the future. Examples of good policies and field implementation exist throughout the world. Of course, challenges still remain on both, especially in the countries where the TB burden is the largest. But there are enough positive examples to learn from using “south-south” exchanges. As a global community of MNCH and TB practitioners, we need to facilitate a speedy learning of these best practices.
Here are a few ways that TB programs can capitalize on existing MNCH services.
1. Improve the identification of children infected or diseased with TB who are in contact with an index TB patient. Active case finding is one of the most efficient ways to control TB transmission among children and adults because new infections usually occur around existing patients. The experience of MNCH programs with community health workers and volunteers, home visits, and outreach activities could decisively enhance active case finding.
2. Call on existing community- and facility-based MNCH providers. These providers can administer TB prophylaxis (to children exposed to TB patients) or TB treatment (to those diagnosed with TB), as it is currently happening in Brazil, Ethiopia and Afghanistan.
3. Utilize community-based peer support groups. Given that both TB prophylaxis and treatment last six months and require continuous family and community support to complete, TB providers can adapt the existing experience of community-based peer support groups, which have increased the attendance of pregnant women to antenatal care and skilled birth delivery. Thus, like-minded community groups can support the adherence of TB patients to their six-month drug regimen, as has happened with the Cured TB Patients Councils in Afghanistan.
4. Engage existing community-based MNCH organizations. These include women’s groups, safe motherhood action groups, youth and adolescent peer groups, and others. They can disseminate appropriate messages and raise awareness of childhood TB and its relationship to malnutrition, pneumonia and HIV infection. We can apply tools such as the Community Action Cycle to build local capacity to explore root causes, identify and prioritize local health challenges, and work to plan actions.
The big picture
Childhood TB is gaining significant policy attention at the global and national levels. Key policies took center stage at a recent webinar moderated by UNICEF, Save the Children and Management Sciences for Health: the 2013 WHO guidelines for managing children with TB and the increasing number of national guidelines for TB control, which include separate chapters for the identification and case management of TB in children.
The discussion also highlighted successful examples of the field implementation of these international and national policies — fortunately showing increased cooperation between TB and MNCH practitioners.
Here are some success stories that give me hope:
• In Uganda, the TB program uses the existing MNCH-focused village health team members to improve the detection of household contacts who might have TB.
• In Ethiopia, a similar program resulted in 90 percent of registered household contacts being screened for TB, with about 11 percent being children under 5.
• In Afghanistan, when women aren’t allowed to leave their homes, community health workers collect sputum samples from children at home and bring them to the health facility for testing. And the country’s national MNCH and TB programs trained midwives and other health professionals on childhood TB detection.
• In Malawi, the novel inclusion of a single question on household TB exposure as part of the diagnosis of sick children led to the identification of children at risk for TB. They were then referred to a health facility for a final diagnosis, but many of them never reached the facility mainly because of lack of transport or financial means.
And now years after Adrian’s death, Peru is a world example of how TB can be effectively controlled. If the global health community can identify and collectively address TB with today’s innovations and collaborations, we can prevent these tragic childhood deaths.
Dr. Luis Tam is the global technical lead for maternal, newborn and child health at Management Sciences for Health, a global health NGO. With 32 years of global public health practice, he regards childhood TB as one of the most important technical topics yet to be addressed in the implementation of the global maternal, newborn, and child agenda.