Childhood tuberculosis a “hidden epidemic”

Globally, an estimated 200 children die from tuberculosis every day despite the availability of cheap drugs to prevent and treat this highly infectious condition, the UN World Health Organization (WHO) has said.

"We have made progress on TB: death rates are down 40 percent overall compared to 1990 and millions of lives have been saved. But unfortunately, to a large extent, children have been left behind, and childhood TB remains a hidden epidemic in most countries. It is time to act and address it everywhere," Dr Mario Raviglione, Director of the WHO Stop TB Department said in a statement.

Every year at least 500,000 babies and children become infected with TB worldwide, and according to WHO an estimated 70,000 die of it. The organization noted that most developing countries still use a diagnosis method developed 130 years ago - the patient coughs up a sample of sputum, which young children are generally unable to produce - and even if a child with active TB succeeds in providing a sample, it often contains no detectable bacteria.

Infants and young children are as much at risk of developing drug-resistant TB as adults, and are at particularly risk of developing "severe, often fatal forms of TB, such as TB-meningitis, which can leave them blind, deaf, paralysed or mentally disabled".

At a government clinic in Narok, a rural town west of the Kenyan capital, Nairobi, Lelempai Nkare waits to see the clinical officer in charge. Her one-year-old sits on her lap breastfeeding, occasionally interrupted by her mother's hacking cough.

Children ignored

Nkare, who is also HIV-positive, was diagnosed with tuberculosis three months ago and has made numerous visits to the clinic, always accompanied by her child. Despite the highly infectious nature of TB, the health workers have never suggested testing her daughter for the disease.

"I get my medicines here... When I see the doctor, he will tell me whether I am doing fine or not," Nkare told IRIN/PlusNews. "He didn't see my child and he just told me I should continue taking my medicine and I will get better."

The Kenya government has guidelines that require health workers to be vigilant and monitor children born to HIV-positive mothers, and for TB in TB-infected households, but lack of information and frequent drug shortages mean that health workers, particularly in rural areas, become discouraged from looking out for TB infection in children, putting them at risk of infection.

"We experience so many drug outages that at times the frustration stops us from even caring to look out at possible TB infection in children and infants," one Narok health worker who wished to remain anonymous told IRIN/PlusNews

According to WHO, when health programmes actively search for children infected with TB, they usually discover far more cases than expected; one study in Bangladesh found that after community members received special training in paediatric TB, the number of cases reported more than trebled.

Misinformation

Duncan Nkoitoi, TB programme coordinator for the Christian Missionary Fellowship, an NGO that runs community clinics in Narok, says many health workers are not informed that the Bacillus Calmette-Guérin (BCG) vaccine given to children soon after birth does not provide full protection against active forms of tuberculosis.

In fact, some research suggests that HIV-positive babies who receive the BCG are more likely to contract TB from the vaccine than was previously thought. More than 80 percent of Kenyan newborns are given BCG vaccination. 

''Before we can give prevention or treatment we have to find the children at risk of TB ... From now on let us agree: It is unconscionable to let a single child die of TB''

"Many health workers fail to realize that BCG, even though provided widely to children, doesn't often protect them against active form of TB, which they can very easily acquire from adults. So this creates the feeling among health workers that these children might be safe, but it is normally a false sense of safety," Nkoitoi said.

"There is a thin line between pneumonia and TB symptoms, not just for parents, but even for health workers. Parents complicate it even further by preferring traditional treatment methods like herbs," he commented.

Children account for 11 percent of new TB infections in Kenya each year. According to government records, more than 10,000 children were diagnosed with TB nationally in 2011, and about 20 percent of children infected with TB are also HIV-positive.

Government officials say controlling TB in children is difficult as a result of inadequate diagnosis and treatment, but prevention among adults will have a knock-on effect on paediatric TB infections.

Improvements necessary

"Diagnosis of TB in children remains difficult because earlier developers of diagnostic tools have treated children like small adults, but when the society is able to contain TB among adults, which is relatively easier, then children benefit because adults with TB infection are the most dangerous to children," Joseph Sitienei, head of National Leprosy and TB Control Programme at the Ministry of Health told IRIN/PlusNews.

"The guidelines are very clear on how health workers need to deal with children from TB-infected households, or those born to HIV-positive mothers. Monitoring should be done every time a health worker gets into contact with a child who stands a high chance of contracting TB. Unless this is done, many children will die from TB."

Sitienei said the government was deploying paediatricians to high-prevalence areas to help control TB in children and streamline drug distribution to government clinics. Kenya is hosting one of the sites of a large TB vaccine trial, which, if successful could contribute significantly to ending TB in both children and adults.

WHO advises that health centres examine all children who have been exposed to TB by someone living in their household, and treating them for TB immediately if they are very ill or living with HIV, even if a definitive diagnosis unavailable. Health workers should provide preventive treatment with the drug Isoniazid to all children at risk for TB but not ill with the disease, and all health workers who care for pregnant women, babies and children should be trained to check patients for TB risk, signs and symptoms, and refer them for TB preventive therapy or TB treatment as needed.

"Before we can give prevention or treatment we have to find the children at risk of TB, and this will only happen if governments, civil society and the private sector work together,” said Dr Lucica Ditiu, executive secretary of the Stop TB Partnership. “From now on let us agree: It is unconscionable to let a single child die of TB."

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