Patients, lawyers, and public health activists have laid the groundwork for a robust defence of children’s human rights in the area of healthcare, but swift voluntary action is clearly preferable to drawn-out legal proceedings.84,85 Fortunately, a number of technical advances in the last few years hold out the promise of greatly reduced child TB mortality, by making it easier and less costly to screen, diagnose and treat children with TB.
Household contact screening, typically performed by frontline health workers, has been shown to increase the number of TB diagnoses by nearly two-thirds in developing countries.86 In household contact screening, health workers determine if there are children who have been exposed to TB, then assess those children for TB signs and symptoms. Household contact screening of children has yielded increases up to tenfold in the number of eligible children who receive preventive treatment with the drug isoniazid.87,88
This model uses online training and a mobile smartphone app to educate and empower frontline health workers.
Recent research advances also point to a breakthrough in TB prevention. In March 2018, researchers with the AIDS Clinical Trials Group, funded by the United States National Institutes of Allergy and Infectious Diseases, demonstrated in a large, international Phase 3 clinical trial that a one-month long regimen of daily doses of the drugs rifapentine and isoniazid was at least as safe and effective at preventing TB in people living with HIV as the standard nine-month regimen using isoniazid. Patients in the trial, which included adults and adolescents, were also more likely to adhere to the full course of treatment than patients taking the standard nine-month regimen. If used widely and shown to be similarly effective in children, the regimen has the potential to transform global TB prevention efforts.
In the meantime, even in resource-limited settings, medical professionals can make better use of diagnosing children with TB based on their pattern of symptoms—known as a clinical approach to diagnosis.
Flavoured child-friendly treatments, dispersible in liquid and in WHO-approved doses, were developed and made widely available by TB Alliance and Unitaid in 2015.89,90 In the area of diagnosis, the Xpert MTB-RIF assay test, endorsed by WHO in 2010, uses nucleic acid amplification in a small machine and detects TB, as well as resistance to rifampicin—one of the most commonly used TB drug—in less than two hours. Cepheid, its manufacturer, is expected to introduce a battery-powered version of GeneXpert, called Omni, enabling wider testing in areas without reliable sources of electricity.91 This is a welcome step forward in moving TB diagnosis to the place at which patients receive care, but since the technology tests samples of sputum, it remains inadequate for diagnosing TB in children.92 The “holy grail” of TB diagnosis in children remains a non-sputum-based biomarker test, such as a blood- or urine-based test, that is delivered at the point of care.
One effective public health approach, implemented in Uganda by The Union, identifies children who have been exposed to someone with TB—typically an adult—who has sought care at the local health center. These children are typically living in households where an adult has been diagnosed with TB, and are diagnosed by health professionals using a clinical approach. Working with partners, including Uganda’s Ministry of Health and local government officials, the Decentralise Tuberculosis services and Engage Communities to Transform lives of Children with Tuberculosis (DETECT Child TB) project created a decentralised model for diagnosing and treating children with TB. This model uses online training and a mobile smartphone app to educate and empower frontline health workers to provide TB screening at the community level, with volunteers identifying likely TB cases based on symptoms.
Children made up nine percent of all TB notifications in Uganda before DETECT Child TB, they represented 16 percent of total cases diagnosed during the initiative.
Strengthening diagnosis of child TB at primary and secondary care levels with simple symptom-based screening for child TB household contacts, yielded a major increase in detection and treatment of child TB. Where children made up nine percent of all TB notifications in Uganda before DETECT Child TB, they represented 16 percent of total cases diagnosed during the initiative, with both test districts more than doubling their total number of child TB diagnoses over this period. The initiative achieved 95 percent success in treating children diagnosed with TB, up from 65 percent, and on larger numbers, while 72 percent of at-risk children received preventive treatment with isoniazid, up from less than five percent previously. Following implementation, case detection was successfully decentralised with the majority of children with TB diagnosed in secondary and primary levels of care.
As a result of the initiative, the majority of children diagnosed with TB in these districts are now diagnosed at village health centres and other peripheral health facilities, rather than in large hospitals, catching the disease earlier and lessening the burden on large, and often more physically distant, health facilities. The initiative also resulted in lower rates of people ‘lost to follow up’, helping to ensure that patients completed their treatment regimens, and decreasing mortality as well as the risk of new drug resistance. Additionally, a spillover effect saw more adults with TB identified based on symptoms, reflecting the increased knowledge and confidence of healthcare workers.
The initiative’s success prompted Uganda’s Ministry of Health to incorporate the DETECT guidelines into the country’s national TB action plan and the ministry is currently scaling up the programme to include eight more districts.93 Looking beyond Uganda, this, or similar community-based approaches, could benefit other high-burden countries facing similar challenges including large underserved populations, rapid unplanned urbanisation and adverse social trends.