Tuberculosis: five reasons to focus on children
Policies to fight TB overlook children's fate
International and national policies to fight TB have set as their principal aim to limit further transmission of the disease. Therefore, efforts undertaken to control the TB pandemic focus on the contagious form of the disease, pulmonary TB which can be detected with the traditional sputum examination with a microscope.
"But children do not produce sputum, or very limited amounts, and can therefore not be tested," explains Marie-Eve Raguenaud, TB expert for MSF. "They are thus literally excluded from international efforts to fight against TB, which mainly focus on adults. In fact, it is all the patients who develop non-contagious forms of the disease that are taken into account. But they are patients like others. As far as MSF is concerned, they deserve an adapted treatment as well."
Statistics tend to show that TB is insignificant for children because national data in many developing countries are incomplete and do not make a distinction between age groups. But it is actually far from being the case. Marie-Eve Raguenaud explains that "according to estimations, children represent more than 20% of all TB cases, especially in high prevalence zones. This is not surprising given that between 40 and 50% of the population in developing countries is aged 15 or under. Many children also live in precarious shelters in the company of many adults, which increases TB transmission."
In spite of these telling numbers, recent World Health Organisation (WHO) policy orientations regarding TB still do not seem to be willing to put in place the necessary measures to fight paediatric TB.
TB is difficult to diagnose in children
The microscope examination of sputum is useless with children who do not produce expectorations. Marie-Eve Raguenaud said, "In the absence of a rapid and simple test, MSF doctors have to cross check different analyses - like X-rays, complete anamnesis or intradermoreaction - to diagnose children. It is an interpretation rather than a confirmation of the disease. It is a clinical judgment expressed by the doctor."
But in developing countries, the equipment to undertake those kinds of analysis is often not available, and the presence of a doctor in health centres is not always guaranteed.
TB is therefore under-diagnosed in children because it can only be detected by a doctor, and quite often only at hospital level.
In a struggle to find a new user-friendly and efficient diagnostic tool, MSF is involved in the development of new tests by evaluating the viability of new technologies on its field operations.
"While waiting for a rapid and efficient diagnostic test, MSF teams also consider new methods to simplify clinical TB diagnostic in children," said Marie-Eve Raguenaud. 'Diagnosing children at the health centre level, and not only by a doctor at the hospital, would allow the detection of more cases."
TB is particularly deadly among young children
"The forms of TB that affect children are the cause of a very high mortality rate', highlights Marie-Eve Raguenaud. "Among children, there are more cases of acute and complex forms of TB like TB-meningitis, military TB, a widely spread and severe form."
MSF has set as a goal to enrol more children in its TB programmes. Today, in Angola, 25% of our TB patients are children, in Ambo (Indonesia) they represent 24% of patients, in Mozambique 18%, in Somalia 17%. Since December 2005, in Monrovia (Liberia), MSF provides TB treatment to more than a hundred children in Island Hospital (see Gabriela Adao Interview).
Paediatric formulations and anti-TB drugs are not available
"Paediatric formulation of TB drugs do exist," notes Marie-Eve Raguenaud. "They are fixed dose combinations, a mix a several molecules in a single table allowing to reduce the number of daily intakes (between two and four pills once a day). Moreover, these drugs are soluble in water which guarantees good dosage."
In countries where our teams undertake TB programmes, MSF delivers fixed dose combination paediatric formulations. Nevertheless, in most of those countries, national programmes to fight against TB only buy drugs destined to adults. As a result paediatric formulations are not available.
"Again, priority is given to adults. In their struggle against the transmission of TB, national and international actors do not show any concern for the delivery of a treatment adapted to children."
The small number of children on treatment receive drugs for adult in proportions related to their weight and height. In that context, precise dosage is difficult.
Treatment for children is burdensome for parents and family
Even is an adapted treatment existed, the currently available treatment is quite long: daily drug intake for about six to eight months. In most sub-Saharan African countries, national TB programmes require that patients come everyday to the health centre for the whole treatment period (six to eight months), to receive their drugs under the supervision of a health professional.
"This approach, based on the daily supervision by health staff (also known as DOTS) is, when it comes to children, burdensome for families," explains Marie-Eve Raguenaud. "Indeed, mothers have to travel long distances, which can be expensive, with their child to reach the nearest health centre. They often have to take their other children with them if they can't find anyone to take care of them."
Confronted to this problem, MSF has developed in most of its programmes innovative methods involving self-administration of treatment. With these methods, the mother of the child or the caregiver becomes the person in charge of treatment and is given the drugs for specific periods. Beforehand, the child and his or her "treatment assistant" are trained for the treatment through counselling sessions. There, the teams explain in details the importance to adhere to treatment until its full completion.
The child and the 'assistant' regularly come back to the health structure to pick up the drugs, treatment follow up and medical check-ups. In Kuito, Angola, children were the first patients to test this new approach to adherence. Early evaluations indicate encouraging results as patients show very good adherence levels.