Children Can’t Wait For A TB-Free Future In The Era Of COVID-19

While it may surprise some, tuberculosis (TB) was?second?only to COVID-19 as the leading global cause of death from an infectious disease in 2020. TB remains one of the top 10 causes of death in children even though it is preventable, treatable, and curable. Children with TB rarely die when they receive standard treatment for the disease,?but according to UNICEF, 96 percent of children who die from TB worldwide go untreated. Further, people living with HIV are?18 times?more likely to develop active TB than those without HIV, and?21 percent?fewer people received TB care in 2020 than in 2019. COVID-19 has significantly disrupted progress against both pandemics, with HIV testing services dropping significantly and global TB-related deaths rising for the?first time?in a decade. While COVID-19 has galvanized global cooperation to drive decentralized access to diagnostics, rapid testing and vaccine production, efforts to end childhood TB are often overlooked and underfunded.?

To reverse these troubling trends, global health leaders and agencies must prioritize ending childhood TB through increased funding and clear political will. Without both commitments, hundreds of thousands of children will die unnecessarily. The Catalyzing Pediatric Tuberculosis Innovations (CaP TB) project in?10 countries?with a high TB burden was created to improve pediatric case finding through innovative models of care with the support of multi-year catalytic funding from?Unitaid. Through careful technical analysis and strategic programmatic efforts, critical insights have emerged on ways that the global health community can improve measures to end TB in children and meet the ambitious?targets set at the United Nations High-Level Meeting in 2016. These targets include successfully diagnosing and treating TB in 3.5 million children, and preventing TB in four million children under the age of five who are at high risk of getting TB disease.?

Prioritizing Pediatric TB Case Identification

To end childhood TB, the global health community must close the pediatric TB case detection gap. Only by doing so can children with TB receive the critical and timely treatment needed to avoid preventable deaths.?Data from the World Health Organization (WHO) 2021 global TB report?indicates that children younger than 15 accounted for 11 percent of the total burden of TB in 2020—equivalent to 1,090,000 cases. During the same period, 226,000 children died from TB, with data showing that only about 40 percent of the cases of TB in children were actually reported—leaving the majority of children with TB either undiagnosed or unreported. Without closing the pediatric TB detection gap, the global health community ultimately fails at bringing TB services to one of the populations at higher risk and to control the spread of the disease in households and communities. This is simply unacceptable.

Integrating Pediatric TB Care In Child Health Entry Points

Data from the CaP TB project have shown that promoting TB screening in the entry points at health facilities most frequently attended by children and strengthening linkages between those entry points and TB services can improve case finding.?Preliminary evidence?generated so far shows that the number of children needed to be screened to identify one child with TB was lowest in inpatient departments and HIV services, followed by nutrition, outpatient departments, and maternal and child health, respectively (Note 1). Pediatric TB screening and assessment should be offered systematically across all entry points that are attended by children in high TB burden countries. If resources are limited, integration of TB screening should be prioritized in health services designed to treat sick children.

Decentralizing Diagnostic Capacity For Pediatric TB Care

Often, the diagnostic capacity to diagnose children with TB is centralized at the highest levels of health care systems rather than the peripheral ones, which are often the first point of contact with health care for children. Decentralizing pediatric TB services to lower-level facilities can improve accessibility and thereby improve pediatric TB case finding. CaP TB data demonstrate that building capacity to manage pediatric TB at primary health care–level facilities significantly contributes to improved pediatric TB case detection (Note 2). Therefore, efforts to close the pediatric TB detection gap must prioritize decentralized models of care. Continuously monitoring and assessing the impact of decentralization can ensure that the quality of TB services remains high. Programs should routinely use data to improve service delivery where possible. Collecting age-disaggregated data can?promote a deeper understanding of the disparities in TB care access?within child and adolescent age groups.

Implementing Contact Investigation For TB Diagnosis And Prevention

Pediatric contact investigation is a systematic process to identify and screen for TB all children who have been in close contact with a person diagnosed with active TB. The process allows for early and timely diagnosis and treatment of TB in children who either might have contracted the active form of the disease or for whom active TB has been ruled out.?Preliminary data?show that the pediatric TB detection yield is significant for this intervention, with one child detected with TB for every 43 child contacts screened. Moreover, when contact investigation activities were put into practice, the average monthly rate of child contacts younger than the age of five initiated on TB preventive treatment increased by four-fold (Note 3). Contact investigation interventions at the facility and community levels are key to improving childhood TB case finding and prevention; these activities should be prioritized by national TB programs and supported through adequate resources and staffing to ensure impact. By implementing innovative models of care that focus on community-based and patient-centered approaches to household contact investigation, the global community can more effectively narrow case management implementation gaps across countries.

Bolstering Governmental Support For TB Responsiveness

It is critical that national and international government bodies provide the financial investment and political support necessary to end this disease—particularly in countries with a high burden of TB. A recently launched?policy assessment?illustrates that country governments, non-governmental organizations, patient groups, technical agencies, and donors must collaborate to address existing policy gaps in care and meet the global TB targets.

As with all global health interventions, ending TB has been further complicated by the havoc caused by the COVID-19 pandemic. Yet, unlike COVID-19, generating the political will to end TB has long been a struggle. The global community must not back down from the complex challenges posed by TB. With increasing numbers of children dying from TB and limited funding being allocated to recover the hard-won gains against it, global leaders and governments must coordinate their efforts and drive progress by bolstering vital programs such as?PEPFAR,?Unitaid, and the?Global Fund. Meaningful investment and prioritization of childhood TB will save thousands of lives and help meet the?UN targets?that will signal an end to TB once and for all. Failure to take action on childhood TB would be a missed opportunity with consequences for years to come. Children don’t have time to wait.

This article was written by Charles Lyons,?Martina Casenghi, and Aimé Loando Mboyo and was originally published on Health Affairs.

Note 1

Closing the pediatric TB detection gap: Where can we find the missing children? Symposium?SP-22 models of care for children and adolescents affected by TB. 52nd World Conference of the International Union on Tuberculosis and Lung Disease, October 19–22, 2021.

Note 2

Decentralizing pediatric TB detection efforts increases case finding in nine sub-Saharan countries. Lemaire J-F, et al., oral abstract presentation (abstract Ep-34-431). 52nd World Conference of the International Union on Tuberculosis and Lung Disease, October 19–22, 2021. Abstracts book available?here.

Note 3

Implementing TpT for children: experiences from the Cap TB project in nine sub-Saharan African countries. Berset M, Oral presentation, Symposium sp-02 The ‘ABCs’ of scaling up 3Hp in children. 52nd World Conference of the International Union on Tuberculosis and Lung Disease. October 19–22, 2021. Abstracts book available?here.