By Chief K.Masimba Biriwasha | iZiviso Editor-in-Chief
Harare, Zimbabwe – Tuberculosis (TB) is a major public health problem in Zimbabwe yet very little is known about the impact of the disease on children. Without a functional health-care system and research into pediatric TB, Zimbabwe is likely to continue losing its children to this hidden epidemic.
Among African nations, Zimbabwe is one of those most heavily affected by TB. The 2009 Global Tuberculosis Control Report from the World Health Organisation (WHO) ranks Zimbabwe 17th among 22 countries worldwide with the highest TB burden.
Zimbabwe had an estimated 71 961 new TB cases in 2007, with an estimated incidence rate of 539 cases per 100,000 people. While, Zimbabwe has fought TB fairly successfully since attaining statehood in 1980, in the past few years the disease has re-emerged as a leading killer, especially among people living with HIV, who are often not identified through long-established TB tests. Put simply, the TB control programme has been adversely affected by a lack of adequate financial, human and material resources.
As it is, there’s very little epidemiological data on the extent of TB among children in the country. Experts say that child TB is widely under-reported and can represent as much as 40% of the TB caseload in some TB high burden settings such as Zimbabwe. Children are at high risk of TB, are prone to disseminated disease and the diagnosis of paediatric TB may be difficult, since complaints often are unspecific and contacts may not been known.
To make matters worse, the HIV epidemic has affected TB in children enormously, as it has adults. It has increased the risk that infants and young children will be exposed to TB, since many adults with TB-HIV are young parents.
HIV-infected children have a 20-fold risk of developing TB compared to HIV-uninfected children. It also makes diagnosis and treatment more complicated and increases the risk of TB-related death about 5-fold. The HIV epidemic has also orphaned many children (with or without TB-HIV themselves).
Unfortunately, Zimbabwe’s national tuberculosis programme has historically not given child TB high priority because of diagnostic challenges (e.g., children under 10 have difficulty producing enough sputum for microscopy and the majority are smear-negative); children are not a major source of the spread of the disease; resources are limited; recording and reporting forms did not include boxes for recording ages 0–4 and 5–14 until 2006.
“Our ability to even assess the magnitude of the problem is severely hampered by the lack of diagnostics in children. The problem is that diagnostic tools, both current and in development, do not adequately take into account the special requirements for assessing children,” said Dr Steve Graham, chair of Stop TB’s Child TB Subgroup of the DOTS Expansion Working Group.
Once infected with TB, infants and young children are at greater risk than adults for developing active TB disease, as well as of having the TB disseminate throughout the body, including to the brain, where it causes meningitis. This type of TB is often fatal or leaves the child with major disability.
Many health workers regard the management of a child with suspected TB as ‘difficult cases’, especially with regard to diagnosis. Children are thought of as needing specialised care.
Against this background, TB case-finding efforts should target children under 5 years of age living in a household with a sputum-smear positive adult. If the children are well, they should receive isoniazid preventive treatment (IPT) to help prevent their developing active TB disease. If they are not well, TB treatment should be considered and a clinical examination is recommended.
Suggestions for national tuberculosis programmes include:
- Establish a dedicated child TB working group that includes National Tuberculosis Control Programme (NTP) staff and national child TB experts.
- Use the working group to set practical priorities and goals, develop guidelines, implement activities for child TB, support health workers managing child TB and raise awareness through advocacy and health education.
- Include the needs of child TB in routine NTP activities, such as training, drug procurement, strategic plans and recording and reporting.