US$120 million required to fight TB among children.

By Masimba Biriwasha | Op-Ed | @ChiefKMasimba | January 09, 2014

According to an ambitious plan launched last year by leaders in the TB field, a total of  US$120 million is required to stem the TB among children.

The plan titled, The Roadmap for Childhood TB: Toward Zero Death, outlines three priority areas that require attention in order to turn the tide in the fight again TB including: a sense of urgency beyond the TB community, improvement in research, policy development and clinical practices as well as increased funding. Continue reading

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In TB Fight, Children Must Be a Priority

 

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HARARE, Zimbabwe – TB mostly affects the world’s poorest; among those, the most vulnerable are children. Despite that an estimated 500,000 new annual cases of children with tuberculosis (TB), there are no appropriate medicines for them according to UNITAID and the TB Alliance.

TB, one of the world’s most neglected diseases with almost no new treatments developed in the past 50 years, is one of the top ten causes of childhood death. According to WHO, Tuberculosis (TB) often goes undiagnosed in children from birth to 15 years old because they lack access to health services – or because the health workers who care for them are unprepared to recognize the signs and symptoms of TB in this age group.

With no alternatives available, treatment providers for children are forced to adapt medicines for adults as best they can, such as by cutting pills. This leads to improper treatment, treatment failure, spread of this highly-contagious disease, and conditions ripe for the development of drug-resistant strains of the bacteria.

“Despite the world’s capabilities to address this disease, pediatric tuberculosis has been ignored for far too long, resulting in a complete lack of appropriate medicines,” said Denis Broun, Executive Director of UNITAID.

The extent of the childhood TB pandemic is not fully understood. Most experts believe that TB in children goes largely undiagnosed and that the true scope of the problem is far higher than the estimates today.

Childhood tuberculosis is estimated to constitute about 6% out of all incident cases, with the majority of cases occurring in high TB burden countries. 

“Developing treatments for children with TB is an urgent humanitarian imperative,” said Mel Spigelman, M.D., President and CEO of TB Alliance. “An appropriate formulation for the decades-old drugs is not even available. We need to immediately rectify the situation for the present drugs, and also ensure that the improved treatments in the pipeline will be developed for children soon after they are approved for adults.”

In 2010, the World Health Organization released new guidelines for pediatric drugs. However, to date, no quality-assured products have been produced to these specifications.

World TB Day, March 24, commemorates the day in 1882 that Robert Koch discovered the tubercle bacillus, the bacteria responsible for tuberculosis. Since that discovery, progress against the disease has surged and ebbed. Now with outbreaks of more deadly forms of TB, documented around the world, it’s time to help protect children from this disease.

TB in Children: Why Zimbabwe Must Act Now

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.Image

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.

Why Tuberculosis Matters to Women’s Health

Tuberculosis (TB) has a major impact on women’s sexual reproductive health and that of their children.

For pregnant women living in areas with high TB infection rates, there are increased chances of transmission of TB to a child before, during delivery or after birth.

The disease, especially if associated with HIV, also accounts for a high incidence of maternal and infant mortality.

Unfortunately, there is little to no attention about women’s vulnerability in the current discussion and media blitz of a resurgent TB internationally, and in particular, sub-Saharan Africa.

In sub-Saharan Africa, TB is threatening to unravel public health developments gains around increased HIV awareness yet the solutions are not easy, particularly where they concern the well-being of women.

There is need for huge financial, human, research and technological investments to fight the problem, but such investments will work only if they radically put women’s health needs at the core.

More importantly is the need to align TB services and sexual reproductive health services, so that men and women know about the implications of the disease to their sexual lives and households.

In sub-Saharan Africa, however, there are pervasive systemic factors driving TB and drug resistance which cannot be ignored in the search of an effective solution to the problem.

A myriad of social and economic factors, as well as weaknesses in the health care system, inadequate laboratories combined with high HIV infection rates are fueling the resurgence of the TB in the region. Food insecurity, poor sanitation and overcrowding also contribute to the easy spread of the disease.

According to WHO, although Africa has only 11% of the world’s population, it accounts for more than a quarter of the global TB burden with an estimated 2.4 million TB cases and 540,000 TB deaths annually.

Governments in the region are grappling with inadequate infrastructure and the increasing threat of drug-resistant strains and co-infection with HIV.

HIV infection increases the likelihood of active TB more than 50-fold. An estimated one-third of the 24.5 million people living with HIV (PLHIV) in sub-Saharan Africa also have TB.

For women in the region, the prospect of a growing TB epidemic is harrowing, but discussion about the disease rarely sheds light nor seeks to address women’s specific needs.

Given the high rates of HIV infection among women in the region – the majority of people living with HIV in sub-Saharan Africa (61% or 13,1 million) are women – it is clear that they are the largest group at threat to develop active TB, and more likely drug resistance.

Even with the availability of TB drugs women’s socio-economic status and gender roles including child-bearing and caring puts them at high risk of both HIV and TB infection.

For many women in the region, the costs required to access health care centers for TB treatment are usually out of reach due to poverty and undermined socio-economic positions.

The social stigma associated with a TB diagnosis and its association with HIV forces both men and women to delay going to get tested for the disease. In some cases, when men in marital relationships test positive for TB, they are likely to withhold the information, thereby increasing the likelihood to spread the disease to both their partner and children.

Moreover, women in the region are largely responsible for the upkeep of the family, including looking after children, which may also affect consistent uptake of TB drugs. When a woman is infected with TB, the likelihood of spreading the disease to young children is very high.

An additional concern for women is that the uptake of TB drugs interferes with contraceptive use, pregnancy, and fertility.

According to researchers, Rimfampicin, a key component of TB treatment can reduce the effectiveness of oral contraceptive pills and possibly other hormonal methods, such as implants, injectables and emergency contraception.

TB in pregnant women not only increases the rate of maternal mortality, but is also a major factor contributing to the risk of mother-to-child transmission of the disease.

A study conducted in South Africa revealed mother-to child-transmission of TB in 15% of infants born to a study cohort of pregnant women in which 77% were HIV-infected. Maternal HIV/TB coinfection also increases the risk of mother-to child transmission of HIV.

Screening and treatment for TB in pregnant women at antenatal clinics must therefore be a major public health priority in the region. Information about TB needs to be an integral component of sexual reproductive health services.

To be precise, women infected with TB need to be empowered so that they can take control of their own care and lives.