Professor Anneke Hesseling, Director of the Paediatric TB Research Program at the Desmond Tutu TB Centre at Stellenbosch University confirmed that there was an urgent need for advocacy efforts to focus on the lack of TB diagnostics and treatment that specifically benefit children.
Hesseling explained that although most children with TB of the lungs have symptoms such as cough, reduced playfulness, loss of weight and often have contact history of TB, it is hard to confirm the diagnosis of pulmonary (lung) TB in children as young children find it tough to produce sputum. Young children have few of the TB bacilli in their sputum meaning that their sputum often test negative for TB using conventional available methods.
In Cape Town, the average age of children with TB are two to three years ‘ the age group most vulnerable to getting TB disease following exposure to an adult, where disease can be the most severe and where the diagnosis most challenging. She added that between 20 and 25% of the children in Cape Town was also HIV positive, making diagnosis even tougher since HIV-infected children may have many other lung problems.
‘Diagnosis is a huge challenge and we often treat clinically relying on the symptoms and to a degree the x-ray,’ she said. Culture of the organism, the gold standard of diagnosis, is positive in around 1 of 3 children who show TB disease on their x-ray.
Hesseling said she is keen to see whether the much-publicized new commercial molecular test (Gene Xpert) would also benefit children. Although this test is rapid, it is likely to pick up fewer cases than culture will in children.
‘We need a rapid and accurate test for children that does not rely only on sputum,’ said Hesseling.
Dr Eric Goemaere of Medecins Sans Frontieres in South Africa agreed with Hesseling, adding that there was a massive problem in the treatment and diagnosis of especially drug-resistant TB in children.
He said it was only due to the dogged determination and commitment of a handful of doctors that some children were benefiting from DR-TB treatment.
‘There is no second-line (drug-resistant) TB treatment developed specifically for paediatrics, it does not exist. It’s an absolute black hole and nobody is going to develop a drug spontaneously,’ said Goemaere. Doctors treating children with drug-resistant TB have to use formulations of the medications developed for adults, which are not child-friendly.
He said the dosages for children with drug-resistant TB were largely experimental at this stage. Hesseling added that the side effects of these medications may be severe and that child-friendly formulations for TB drugs and newer effective drugs that will shorten the treatment of MDR-TB children are urgently needed. The treatment of MDR-TB may be up to 18 months in children and often requires long periods of hospitalisation.
Despite these challenges, good treatment outcomes can be achieved with careful individual treatment in the capable hands of experts.
Hesseling said that there was a huge missed opportunity to prevent TB in children using proven prevention strategies that are both effective and safe. ‘Many children are suffering because were are not implementing TB contact tracing (finding and testing family and friends who have come into contact with a diagnosed TB or DR-TB patient) effectively and ensuring that these contacts receive isoniazid as a prophylaxis following exposure,’ said Hesseling.
She said the focus of most TB programmes has mostly been on the case finding of smear positive adults (patients who have TB which shows up in their sputum and who are most likely to transmit to others) while in reality the children as also critically important.
Hesseling pointed out that TB in children was a ‘litmus test’ of how well a TB programme was functioning and an indication of ongoing transmission in the greater community and within the household. ‘TB is a family disease and children are an indication of what is happening in a family, a community, a city, a country and globally,’ said Hesseling.
In the Western Cape between 15 and 20% of the TB caseload is found in children.
‘We often see sad, preventable cases and many of these children are affected for life,’ she said.
A group of international experts, including Hesseling recently convened in Stockholm, Sweden, to highlight the importance of TB in children. A ‘Call to Action’ was developed as an appeal to the international community to focus on children with TB.
TB facts and figures
· 1,7-million people died from TB in 2009, including 380 000 people with HIV, equal to 4 700 deaths a day
· TB is among the three greatest causes of death among women aged 15 to 44
· There were 9,4-million new TB cases in 2009, including 1,1-million cases among people with HIV
· There were an estimated 440 000 new multi-drug resistant TB cases in 2008 and 150 000 deaths from MDR-TB
· Only around 7% of these cases have been diagnosed while less than 3% received appropriate treatment
· Extensively-drug resistant TB cases have been confirmed in 58 countries
· 340 066 new TB cases reported in 2009
· 49 825 of these were younger than 15
· Another 65 916 cases were presenting for retreatment
· The total TB cases of 2009 were 405 982