WORLD TB DAY : 24 March 2006

World TB Day 2006 : Children, forgotten victims of a neglected disease

Each year, tuberculosis (TB) silently kills about two million people, almost exclusively in developing countries. Among the anonymous victims of the disease, children are literally excluded from international efforts against TB, even though they represent more than 20% of the affected population. On World TB day 2006, here are five good reasons to focus on children.

» Read the background paper of TB : Tuberculosis patients still waiting for new diagnostic tools and treatment here

» Watch this short video from Kuito, Angola, which focuses on paediatric TB issues:

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Gabriela Adao is a Brazilian nurse who worked with MSF in Island Hospital, Monrovia, Liberia on alternative adherence tools to make sure TB patients take their drugs properly, and ultimately recover. » Listen to the short sound file here to hear Gabriela Adao talking about the constraints to adherence that the programme had to address. » For a more in-depth description on her work on adherence for children infected with TB, you can read the rest of the interview here.

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 not 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 : ‘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’ highlights 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 of 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 if 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.

Tuberculosis patients still waiting for new diagnostic tools and treatment

The number of TB cases is increasing worldwide. This is particularly true in countries with high HIV prevalence. There is still no evolution in terms of development of new diagnostic tools and treatment. The only available ones are archaic and do not allow the efficient detection and treatment of TB in developing countries, where 99% of deaths occur.

Tuberculosis is one the three main killer infectious diseases. Each year, nearly 9 million people develop the disease of which about two million die, mainly in developing countries. The worst situation is found in Africa where most of the patients co-infected with HIV live.

In this context, diagnostic tools and treatments remain limited and archaic. ‘To diagnose the disease, we still rely on the microscope examination of sputum, a method developed more than 120 years ago and that only allows the detection of 45-65% of cases. This rate is even lower for patients infected by both HIV and TB’, explains Marie-Eve Raguenaud, TB expert at Médecins Sans Frontières. Due to the inefficiency of the test, the treatment of half the patients in developing countries is often delayed or not started at all.

Also, treatment is long and complex. First line treatments used today were developed 50 years ago. Patients have to follow a daily treatment for 6 to 8 months which is cumbersome and therefore likely to be interrupted if no support system is in place. At the same time, it is crucial to follow the treatment until its completion to make sure it is efficient and to avoid the development of drugs resistance. This may lead to a new episode of sickness or even to death.

To avoid the interruption of treatment, the strategy recommended by the World Health Organisation (WHO) requires that patients take their drugs under the direct supervision of medical staff or a trained member of the community. This means that, in most cases, patients have to go to a health centre to perform this daily action. This strategy is burdensome for patients and limits access to treatment for TB patients.

Tuberculosis in post-conflicts settings
In some countries characterised by insecurity, absence of road network or simply the collapse of the health system, access to health structure is often very difficult for the population. This is the case in several contexts where MSF fights against TB, mainly in countries with chronic conflict or in post-conflict situation.

Angola is a case in point. 30 years of civil war left the country in limbo when peace finally came about in 2002. In that context, access to health is denied for most people due to the lack of proximity health structure. In 2002, MSF and the directors of Kuito Hospital therefore decided to build an accommodation centre for people coming from remote municipalities to allow them to follow their treatment on the spot to its completion. It is a temporary solution in order to improve access to health care and therefore allow the number of patients treated for TB to increase.

HIV/AIDS Co-infection
Treating people infected both with HIV and TB is also a huge challenge. Today, about 30% of the 40 million people living with HIV or AIDS worldwide are also infected with TB. People with HIV or AIDS are more likely to develop TB since their weaker immune system prevents them to fight efficiently against the disease. TB is the most common opportunistic infection and the main cause of death for people living with HIV. Still, the efficiency of the only existing test for TB is even more limited for HIV positive patients.

Regarding treatment, it is very heavy for TB patients. It gets even worse for patients co-infected with HIV/AIDS. ‘These patients have to take between 13 and 16 pills a day. Also, there are interactions between AIDS and TB treatment which cause side effects like liver problems or allergies’ highlights Dr Van Cutsem who coordinates a specific MSF programme in South Africa. To face the co-infection threat, MSF provides TB treatments in the context of its AIDS programmes in several countries: South Africa, China, Cambodia, Kenya, Malawi and Zambia.

Alternative treatment models developed by MSF
In order to improve treatment adherence in contexts where medical supervision is difficult, MSF has introduced more flexible strategies for patients while keeping high adherence levels. Self-administered treatment models have been launched in Somalia. Paediatric treatments were started in Angola and community and family observation schemes introduced in Cambodia and Mozambique. This allows patients to take their drugs at home and benefit from regular medical follow up.

Other models were also developed by MSF, including some to treat patient who are hard to follow like migrants and nomads. For instance, efforts were made to limit the number of visits patients were requested to pay to the clinic, by introducing home visits in Cambodia or factory visits in Thailand.

Also, in all its programmes, MSF is increasingly using fixed dose combination (FDC) drugs against TB that are easy to use and limit the period of treatment to 6 months (instead of 8). The use of combined drugs also reduces the number of tablets to take everyday, which simplifies the treatment a lot for the patient. MSF also provides paediatric formulation to its projects to improve the way children are treated for TB.

In addition to these recent evolutions and its projects to improve TB treatment, MSF also aims to determine, in collaboration with other experts, how to accelerate the development of diagnostic tests that match the needs of patients and medical staff in developing countries. MSF is committed to supporting the development of new test by evaluating new technologies on its projects on the ground.

What is tuberculosis ?
Tuberculosis is an infectious disease caused by a bacteria, myco-bacterium tuberculosis, that could, according to the World Health Organisation (WHO), infect one third of the world population.

Between 5 and 10% of infected people develop the disease and become contagious at some point in their lives.

Tuberculosis usually develops in the lungs, the main zone of infection. Major symptoms are: prolonged cough, bloody expectorations, chest pain, and alteration of the general health status. Actions like coughing, sneezing, talking and spitting can all spread the bacilli in the air where they can remain for several hours before being inhaled by another person.

People with weak immune system are more exposed to the disease. This is why people living with HIV or AIDS are more likely to develop the disease if infected.

In the last few decades, the number of multi-drug resistant TB cases has been on the increase. Interruption of treatment is usually the cause for the disease becoming resistant to one or more drugs.

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