Decentralised screening strategies such as DETECT Child TB hold promise. But eliminating child TB will require an integrated model combining innovative public health interventions with new technology, research and development for improved, child-friendly diagnostic techniques and treatments and, above all, sustained effort from high-burden and donor countries alike. Achieving these goals, in turn, calls for political leadership and support at the highest levels. Key objectives for controlling child TB must include strengthening:
- The United Nations is preparing to issue its first ever high-level political declaration on TB on 26 September 2018. Past high-level political statements have been instrumental in spurring action on health threats including HIV, non-communicable diseases and antimicrobial resistance. The forthcoming declaration should adopt the recommendations of the Stop TB Partnership, calling for member states to establish inter-ministerial task forces to combat child TB by 2019; setting a goal of 90 percent of at-risk children receiving preventive therapy and 90 percent of children with active TB or MDR-TB receiving diagnosis and treatment by 2022; and calling for new commitments from member states to research child-friendly diagnostics, treatments and an improved vaccine.94
TB Screening and Diagnosis
- Universally implement TB contact screening in order to identify all children who have been in close contact with people with TB. Contact screening is a simple, common sense strategy for discovering child TB cases that otherwise go undiagnosed. Whenever an adult is diagnosed with TB, healthcare workers should immediately find out if there are any children in the household and arrange for additional screening.95
- Use clinical diagnosis i.e. diagnosis made on the systematic evaluation of symptoms of TB in children. Highly effective, low-cost tools are already available for screening and diagnosis of child TB, with trained volunteers identifying child TB cases based on symptoms such as cough, fever and weight loss. This simple technique is easily taught, empowering community-level workers to provide active screening of at-risk children in resource-challenged areas.
- Combine clinical diagnosis with wider use of diagnosis with rapid molecular techniques in cases where children have pulmonary TB and can produce sputum. New technology such as the Xpert Ultra MTB/RIF can provide faster, more accurate diagnosis of TB, often catching cases missed by the common smear technique or microscopy; results are typically available within two hours.96 A battery-powered version of Xpert is in development.
TB Prevention and Treatment
- Treat a cumulative 3.5 million children with TB by 2022, using child-friendly drug regimens. Cost-effective child-friendly treatment became available in 2015 and approximately 80 countries have since ordered these improved medicines. However, access has been delayed in some priority countries, in part due to bureaucratic and procedural hurdles at the national level – for example, unrealistic local procurement quotas or redundant in-country safety studies. Streamlining and simplifying national regulations should lead to wider adoption.97
- Ensure access to preventive treatment. Healthcare providers have long recognised preventive treatment with medications as the most cost-effective means of reducing TB prevalence. However, existing preventive therapies remains underutilised in the developing world, due, in part, to failure to implement rigorous TB screening systems and the lack of knowledge of preventive treatments among health workers, as well as concerns about shortages.98,99,100 Better screening, educating health workers and ensuring adequate supplies should help bring about wider adoption of TB prevention.
- Pursue prevention with short-course therapy. Based on the results of recent research that demonstrated a one-month course of rifapentine and isoniazid was at least as effective and safe as the standard nine-month course of isoniazid for preventing TB in adults and adolescents living with HIV, the use of the shorter regimen should be tested in children. A shorter TB prevention regimen holds huge potential promise for preventing TB in children with far less burden on children, families and health systems.
- Build capacity. Combating TB and other infectious diseases requires strengthening healthcare provision nationally and locally, including training of staff at every level of the healthcare network and decentralising services, as far as possible, to the community. In the model employed by The Union in Uganda, village-level volunteers provide active contact screening of children in households of adults with active TB, using simple clinical criteria. It also calls for the establishment of clinical supervision, monitoring and evaluation to establish baselines and track progress against targets (it is worth noting that TB in children represents recent transmission, so accurate monitoring of the incidence of TB and MDR-TB in children can also be a valuable tool to measure progress towards ending TB overall).
Research: from inclusion in treatment trials to new tools
- Develop a new TB vaccine. For decades the developing world has relied on the BCG vaccine, first introduced in 1921, to provide preventive coverage for children. But the vaccine is flawed, with effectiveness of 60-80 percent against severe forms of TB, and limited ability to protect adults against pulmonary TB.101 BCG interferes with tuberculin skin tests, making this common screening measure less effective, and is not considered safe for use in children with HIV. By one estimate, a new infant vaccine with a 10-year duration could save US$185 million a year in future treatment costs.102,103
- Procure child-friendly MDR-TB treatment. There is still no widely used child-friendly formulation for MDR-TB, threatening to fuel this new, dangerous phase of the global epidemic for generations to come. Countries should make full use of the available child-friendly MDR-TB regimens they can procure from the Global Drug Facility. At the same time, research and development for short, safe child-friendly MDR-TB treatment is urgently needed to prevent millions of new infections and deaths.104,105
- Develop shorter treatments. One of the main obstacles to patient adherence has been the length of TB treatment, so shorter regimens for both active and preventive treatment are needed. New research has shown that a three-month regimen, using the paediatric formulations combining rifampicin and isoniazid, is as effective as six months of isoniazid and is currently recommended by WHO. The Union is studying a three-month regimen using new rifampicin and isoniazid formulations for children.
- Include children in clinical trials. One of the main obstacles to development of more child-friendly diagnostic tools and treatments has been the absence of children from clinical trials, leaving health professionals with no guidance in areas such as dosing, effectiveness, safety, and drug interactions. In future, children should be included in clinical trials from the beginning, rather than waiting to establish efficacy in adults first.106 Children must be included as early as possible in research for new diagnostics, new drugs, short regimens for treatment, and prevention – including for MDR TB – with greater attention to addressing the particular diagnostic challenges for children.
Systems of Justice
- Appeal to the legal system. Children have a human right to TB prevention, treatment and care, guaranteed by a host of conventions, treaties and laws. While using legal measures should usually be a last recourse for forcing government action, precedent shows courts have upheld individuals’ rights to life-saving medical treatment for HIV, TB and other health conditions.
- Place the global TB response on a human-rights foundation. The political declaration to be approved at the UN High Level Meeting on TB must declare human rights as the foundation of the global TB response. The Convention on the Rights of the Child must become the guiding framework for the global response to child TB.