NEWS UPDATE

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 percent of the affected population.

Policies to Fight TB Overlook Children

International and national policies to fight TB have set as their main goal limiting further transmission of the disease. Therefore, efforts 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.

"Unfortunately, children do not produce sputum, or only in very limited amounts, and can therefore not be tested," explains Dr. Marie-Eve Raguenaud, a TB specialist with Doctors Without Borders/Médecins Sans Frontières (MSF). "They are thus literally excluded from international efforts to fight TB, which mainly focus on adults. In fact, it is the patients who develop non-contagious forms of the disease that are taken into account. But children 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. Dr. Raguenaud explains that, "According to estimates, children represent more than 20 percent of all TB cases, especially in high prevalence zones. This is not surprising given that between 40 and 50 percent 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 Organization (WHO) policy orientations regarding TB still do not seem to be willing to put in place the necessary measures to fight pediatric TB.

TB is Difficult to Diagnose in Children

The microscope examination of sputum is useless with children who do not produce expectorations. Dr. Raguenaud explains, "In the absence of a rapid and simple test, MSF doctors have to cross check different analyses — like X-rays, complete anamnesis or intradermo-reaction — 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 these types of analysis is often not available, and the presence of a doctor in health centers 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," explains Dr. Raguenaud. "Diagnosing children at the health center level, and not only by a doctor at the hospital, would allow the detection of more cases."

TB is Particularly Deadly For Young Children

"The forms of TB that affect children can cause very high mortality rates," highlights Dr. 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 enroll more children in its TB programs. Today, in Angola, 25 percent of our TB patients are children, in Ambo, Indonesia, they represent 24 percent of our patients, in Mozambique 18 percent, in Somalia 17 percent. Since December 2005, in Monrovia, Liberia, MSF has been providing TB treatment to more than one hundred children in Island Hospital.

Pediatric Formulations and Anti-TB Drugs are not Available

"Pediatric formulations of TB drugs do exist," notes Dr. 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 programs, MSF provides fixed-dose combination pediatric formulations. Nevertheless, in most of those countries, national programs to fight against TB only buy drugs for adults. As a result pediatric formulations are not available.

"Again, priority is given to adults, " says Dr. Raguenaud. "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. Precise dosage is, therefore, 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 programs require that patients come everyday to the health center 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 Dr. Raguenaud. "Indeed, mothers have to travel long distances, which can be expensive, with their child to reach the nearest health center. They often have to take their other children with them if they can't find anyone to take care of them."

Confronted with this problem, in most of its programs MSF has developed 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 counseling sessions. There, the teams explain in detail the importance of adhering to treatment until its full completion.

The child and the "assistant" regularly come back to the health structure to pick up their medicines and receive 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.

© 2006 Doctors Without Borders/Médecins Sans Frontières (MSF)