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TB in Children – Getting, diagnosing & preventing TB

TB in children needs to be lifted out of the shadows

  • TB in children is often missed or overlooked due to non-specific symptoms and difficulties in diagnosis. This has made it difficult to assess the actual magnitude of the childhood TB epidemic, which my be higher than currently estimated.
  • Every day, up to 500 children die from TB – a preventable and curable disease.
  • Over three quarters of a million children fall ill with TB each year and struggle with treatment.
  • There is an urgent need for public attention, prioritisation, commitment and funding for this disease that today should never take the life of a child.1“Roadmap for Childhood Tuberculosis”, 2013 www.who.int/tb/publications/tb-childhoodroadmap/en/

How many children get TB?

The World Health Organisation (WHO) estimates for 2016  are that 1 million children (<15 years) currently suffer from TB worldwide, and that more than 210,000 die each year. 2“Global Tuberculosis Report”, WHO, Geneva, 2016  www.who.int/tb/publications/global_report/en/ Others put the number of deaths in children even higher at 239,000 a year. 3Dodd, PJ, Yuen, CM et al. “The global burden of tuberculosis mortality in children: a mathematical modelling study”, Lancet Glob Health 2017;5:e8898-e906  www.thelancet.com/journals/langlo/ This is the estimate for HIV negative children, as children who have TB and who are also HIV positive when they die (i.e. they have TB/HIV co-infection), are internationally classified as having died from HIV.  A 2016 study estimated that 67 million children have latent TB, with about 850,000 developing active TB each year.4“2 million children infected by drug resistant TB”,  Hindustan Times, 2016 www.hindustantimes.com/india-news/2-million-children-infected-by-drug-resistant-tb-study/story-010sNNxcdVMWYGgu2NNHKO.html

Children with TB in South Africa ©WHO/TBP/Gary Hampton

Children with TB in South Africa ©WHO/TBP/Gary Hampton

Many people believe that these numbers underestimate the true extent of the problem.5“Out of the shadows: shining a light on children with tuberculosis”, www.tballiance.org/news/tb-alliance-announces-worlds-first-appropriate-child-friendly-tb-medicines 70-80% of children with TB have the disease in their lungs (pulmonary TB). The rest are affected by TB disease in other parts of their body (extra pulmonary TB).6“Childhood TB: Training Toolkit”, WHO, Geneva, 2014 www.who.int/tb/challenges/childtbtraining_manual/en/

In high burden TB settings it has been noted that 15-20% of all TB cases are among children, whereas in low burden TB settings it is estimated that 2-7% of all TB cases are among children.7“Childhood Tuberculosis Roadmap”, 11th November 2012 www.stoptb.org

Drug resistant TB is also an issue in children. It is estimated that more than 30,000 children become sick every year with strains of multdrug-resistant (MDR-TB)8MDR-TB in children : A Q & A with PIH’s Dr Mercedes Becerra www.pih.org/ Also, an RNTCP survey in India, found that 9% of children with TB were already resistant to rifampicin, before they started treatment. This means that they had become infected with drug resistant TB.9“9% children suffering from TB resistant to key drug: Study shows”, Ekatha A, Times of India, 17th Nov 2015, http://timesofindia.indiatimes.com/india/ Another study estimated that 2 million children were infected with drug resistant TB, requiring the treatment every year of up to 25,000 cases of MDR TB in children.10“2 million children infected by drug resistant TB”,  Hindustan Times, 2016 www.hindustantimes.com/india-news/2-million-children-infected-by-drug-resistant-tb-study/story-010sNNxcdVMWYGgu2NNHKO.html

Why aren’t there better estimates of how many children get TB?

There are various reasons why the number of children that get TB may be underestimated including:11“Childhood Tuberculosis Roadmap”, 11th November 2012 www.stoptb.org

  • Difficulties with access to TB diagnosis and care
  • Clinical similarities with other common childhood diseases
  • Children treated for TB outside of national TB programs (NTPs)
  • A lack of routine recording and reporting of childhood TB cases by age and outcome by some NTPs.

Equally as diagnostic uncertainty is very common in children treated for TB, this can result in over diagnosis particularly for pulmonary TB.

Many National Tuberculosis Programs (NTPs) concentrate on reporting the number of adults who have been identified and treated who have smear positive TB, and who are considered most responsible for the ongoing transmission of infection. With children, even if they have been diagnosed, they will often be smear negative, and will not be included in reports.

In 2006 NTPs were asked by WHO to record and report TB in children, dividing them into two age groups (0 – 4) years and (5 – 14) years.

How does a child get TB?

A child gets TB in basically the same way as an adult, which is by inhaling TB bacteria which are in the air as a result of being released into the air by someone with active TB. The source of infection for children is usually an adult in their household who has active TB, is coughing and is infectious, although there have also been instances of children being infected in a communal setting such as a school.

Once the TB bacteria have been inhaled they may reach the lungs, where they can multiply and then spread through the lymph vessels to nearby lymph nodes. The child’s immune response then develops a few weeks after this primary infection. In most children their immune response stops the TB bacteria from multiplying further although there may continue to be a few dormant bacteria.12“Guidance for national tuberculosis programmes on the management of tuberculosis in children” WHO 2006www.who.int/maternal_child_adolescent/

However in some cases the child’s immune response is not strong enough to stop the multiplication of the bacteria, and TB  disease then develops. The risk of progression to TB disease is greatest when the child is less than four years old, and to a lesser extent when they are less than ten years old. There is also a greater risk of progression in children who have a compromised immune system, for example because they are HIV positive.

Children who develop TB disease usually do so within two years of first being infected. A small number of older children develop TB later, either due to reactivation following a period when the TB bacteria have been dormant, or as a result of reinfection.

Some children are at greater risk of getting TB than others and these include:

  • A child that lives in the same household as a person who has been recently diagnosed with smear positive TB
  • A child less than 5 years old
  • A child with HIV infection
  • A child with severe malnutrition.

How do you diagnose TB in children?

Diagnosing TB in children is difficult as children are less likely to have obvious symptoms of TB, and samples such as sputum are more difficult to collect from young children. Even when sputum can be collected, it may have very few TB bacteria in it (paucibacillary smear-negative disease).

It is recommended that evidence in the following categories is collected and carefully considered before a diagnostic decision is made.13“Out of the Dark: Meeting the Needs of Children with Tuberculosis”, MSF Access to Essential Medicines October 2011 www.msfaccess.org/

Collecting diagnostic evidence of TB in children
Type of evidence Evidence to be collected
Clinical Careful history (including TB contacts; symptoms consistent with TB), Physical examination (including growth assessment), HIV testing (in high HIV prevalence areas)
Non-microbiological Tuberculin skin testing (TST), Other investigations relevant for pulmonary or extra pulmonary TB (e.g. X-rays)
Microbiological Bacteriological confirmation whenever possible

What are the symptoms of TB in children?

Diagnosing TB in children can be difficult

Diagnosing TB in children can be difficult

As with adults the symptoms of TB depend on the type of TB that the child has as well as their age.14“Roadmap for Childhood Tuberculosis”, 2013 www.who.int/tb/publications/tb-childhoodroadmap/en/ The most common type of TB disease in children is pulmonary TB but extra pulmonary TB occurs in approximately 20-30% of all cases in children. Disseminated TB such as TB meningitis particularly occurs in young children less than 3 years old. Miliary TB is another name for disseminated TB.

Infants and young children are at particular risk of developing severe, disseminated and often lethal disease, which may present as TB meningitis or miliary TB. Adolescents are at particular risk of developing adult type disease (i.e. they are often sputum smear positive and highly infectious.15“Out of the Dark: Meeting the Needs of Children with Tuberculosis”, MSF Access to Essential Medicines October 2011 www.msfaccess.org/

In children with pulmonary TB the commonest chronic symptoms are a chronic cough that has been present for more than 21 days, a fever, and weight loss or failure to thrive.

TB diagnosis in practice

It can often be helpful to consult with a colleague when making a diagnosis.16“Guidance for national tuberculosis programmes on the management of tuberculosis in children” WHO 2006 www.who.int/maternal_child_adolescent/ For example:

“It is really difficult for one person to make a diagnosis where the case is not straightforward. So you always consult each other. You can go to the next room, present the case, show the person the x-ray. Then you can have a small discussion in relation to the x-ray and the previous history. Then you can take a collective decision.”

Hussain Kerrow, MSF Clinical Officer, Kenya

Although on some occasions there are no facilitates such as x-ray, and nobody else to consult.

“So most of the time you make a decision based on your clinical observation. Should I or should I not treat this child for TB. And making that decision you’re talking about the life of a child, so it is not something to to be taken lightly.”

Dr Bern-Thomas Nyang’wa, MSF TB Implementer

Sometimes it is necessarily to use the test results from the adult who is believed to have passed TB on to the child, to ensure that the child is properly diagnosed and treated.

How do you treat TB in children?

In the same way as TB treatment is provided for adults, TB treatment for children involves a child taking a number of different drugs at the same time for several months. TBFacts.org has more about TB treatment for children.

How do you prevent TB in children?

The main way that TB is prevented in children is by the use of the BCG vaccine.

TB can also be prevented in children by diagnosing and treating cases of active TB amongst adults, as it is usually adults, particularly adults in the same household, who pass TB on to children. Children with TB are usually not infectious, and so will usually not pass on TB to either other children or adults.17“Childhood TB: Training Toolkit”, WHO, Geneva, 2014 www.who.int/tb/challenges/childtbtraining_manual/en/

Challenges for National Tuberculosis Programs (NTPs)

In relation to childhood TB NTPs face a number of ongoing challenges which include:

  • Insufficient training on diagnosis and treatment of childhood TB
  • Decentralizing and making available new diagnostic technologies
  • Engagement of the private sector in childhood TB diagnosis and reporting
  • Availability of TB drugs in compliance with updated WHO guidance (and inclusion in NTP guidelines)
  • Adequate TB dosing among children due to weight gain

You can read more about:

TB statistics

TB treatment for children

References

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1. “Roadmap for Childhood Tuberculosis”, 2013 www.who.int/tb/publications/tb-childhoodroadmap/en/
2. “Global Tuberculosis Report”, WHO, Geneva, 2016  www.who.int/tb/publications/global_report/en/
3. Dodd, PJ, Yuen, CM et al. “The global burden of tuberculosis mortality in children: a mathematical modelling study”, Lancet Glob Health 2017;5:e8898-e906  www.thelancet.com/journals/langlo/
4. “2 million children infected by drug resistant TB”,  Hindustan Times, 2016 www.hindustantimes.com/india-news/2-million-children-infected-by-drug-resistant-tb-study/story-010sNNxcdVMWYGgu2NNHKO.html
5. “Out of the shadows: shining a light on children with tuberculosis”, www.tballiance.org/news/tb-alliance-announces-worlds-first-appropriate-child-friendly-tb-medicines
6. “Childhood TB: Training Toolkit”, WHO, Geneva, 2014 www.who.int/tb/challenges/childtbtraining_manual/en/
7. “Childhood Tuberculosis Roadmap”, 11th November 2012 www.stoptb.org
8. MDR-TB in children : A Q & A with PIH’s Dr Mercedes Becerra www.pih.org/
9. “9% children suffering from TB resistant to key drug: Study shows”, Ekatha A, Times of India, 17th Nov 2015, http://timesofindia.indiatimes.com/india/
10. “2 million children infected by drug resistant TB”,  Hindustan Times, 2016 www.hindustantimes.com/india-news/2-million-children-infected-by-drug-resistant-tb-study/story-010sNNxcdVMWYGgu2NNHKO.html
11. “Childhood Tuberculosis Roadmap”, 11th November 2012 www.stoptb.org
12. “Guidance for national tuberculosis programmes on the management of tuberculosis in children” WHO 2006www.who.int/maternal_child_adolescent/
13. “Out of the Dark: Meeting the Needs of Children with Tuberculosis”, MSF Access to Essential Medicines October 2011 www.msfaccess.org/
14. “Roadmap for Childhood Tuberculosis”, 2013 www.who.int/tb/publications/tb-childhoodroadmap/en/
15. “Out of the Dark: Meeting the Needs of Children with Tuberculosis”, MSF Access to Essential Medicines October 2011 www.msfaccess.org/
16. “Guidance for national tuberculosis programmes on the management of tuberculosis in children” WHO 2006 www.who.int/maternal_child_adolescent/
17. “Childhood TB: Training Toolkit”, WHO, Geneva, 2014 www.who.int/tb/challenges/childtbtraining_manual/en/