New approach improves diagnosis and treatment of children with TB

Undernourished children are at heightened risk of developing TB, and treatment decision algorithms are helping MSF more accurately diagnose young children in Sierra Leone.

Lab technician reviews test results in Sierra Leone.

Sierra Leone 2023 © Ammar Obeidat/MSF

Doctors Without Borders/Médecins Sans Frontières (MSF) has been working with Sierra Leone’s Ministry of Health through the National Leprosy and Tuberculosis Control Program since 2020, with a focus on improving the diagnosis and treatment of tuberculosis (TB) in children. MSF teams work in Makeni Hospital and in 12 directly observed therapy sites located in clinics across Bombali district.

In 2022, MSF started implementing the use of new tools to help diagnose TB, in line with the newly released guidelines from the World Health Organization. These guidelines include treatment decision algorithms using stool samples for molecular testing, or urine samples for children living with HIV. MSF teams have also set up an efficient sample transportation system from 12 directly observed therapy sites to the laboratory at Makeni Hospital, where the samples undergo molecular testing. 

Lab technician analyzes test samples.
Sputum and stool samples at the MSF-supported TB laboratory at Makeni Regional Hospital, Bombali district, Sierra Leone.
Sierra Leone 2023 © Ammar Obeidat/MSF

Diagnosing TB in young children, however, is particularly challenging, since it can be very difficult for them to produce sputum (mucus expelled from the respiratory tract)— the traditional way of diagnosing TB in the lungs, known as pulmonary TB. In addition, TB in children can be located outside the lungs—a condition known as extrapulmonary TB, which makes getting samples and accurate diagnostic results even more challenging.

Malnutrition increases the risk of TB

When children are undernourished, their immune systems are compromised, putting them at heightened risk of developing TB. Malnutrition is a problem countrywide in Sierra Leone, making it even more important to be alert to the signs of TB in children.

“I left my village and brought my son here because he was not getting better,” said Aruna, father of three-year-old Augustine. “He was losing weight and coughing a lot. He sweats throughout the night—I have to get up and wipe his sweat away. He is my youngest child; I am scared to see him like this.”

Augustine was diagnosed with TB at the Makeni Regional Hospital in Sierra Leone’s Bombali district, which is supported by MSF. Alongside TB treatment, he is being fed specially formulated therapeutic milk to treat severe malnutrition. “Since he was admitted, the nurses have only been feeding him milk,” said Aruna. 

“We treated a three-year-old patient for TB but, after completing her treatment, her mother brought her back because she had TB symptoms again," said  MSF nurse Umu Amara, who works at Makeni Hospital. "We did a stool test for the child and the results were still negative for TB. Because she showed all the signs of TB and she was living with HIV, we did the urine test, and the results showed she had TB."
 
As with Augustine, an alarming number of children under five being treated for TB are found to be severely malnourished. MSF’s team in Bombali district also provides malnutrition treatment as part of its pediatric TB program.

Health session at direct observation therapy site in Bombali, Sierra Leone.
Health promotion session with patients at the MSF-supported Binkolo Direct Observation Therapy Site in Bombali district.
Sierra Leone 2023 © Ammar Obeidat/MSF

Teams are treating significantly more patients

Across Bombali district, when patients come for a consultation, the teams at directly observed therapy sites check the progress of their treatment and refill TB medicine prescriptions. Malnourished children also receive supplies of ready-to-use therapeutic food—like Plumpy’Nut—sachets of peanut paste enriched with vitamins and minerals used to prevent and treat malnutrition—which they can eat at home. This reduces the number of consultations patients must attend, which is crucial in places where the closest health facility is a two-hour journey away. 

“With the high number of TB cases in children in Sierra Leone, it is clear that the National Leprosy and Tuberculosis Control Program needs more support from the government and donors to scale up and replicate this successful TB diagnostic and treatment model throughout the country,” said MSF medical coordinator Dr. Kennedy Uadiale.

“By using the new tools available, bringing treatment closer to patients, and providing nutritional support in the directly observed therapy sites to children who are undernourished, we have been able to enroll and successfully treat significantly more patients,” added MSF medical team leader Jobin Joseph. 

Helping children recover

Fatmata was brought to Makeni Hospital by her grandmother after she developed symptoms and was quickly diagnosed with TB. Due to the long course of treatment, which takes around six months, children like Fatmata often face prolonged absences from school. Many also find themselves isolated from their communities due to continuing stigma around the disease.  

In 2023, a total of 2,148 people with drug-sensitive TB (which can be treated with first-line anti-TB drugs) were enrolled in the TB program in Bombali district. After implementing the new diagnosis tools, the number of children under the age of 15 in the drug-sensitive TB program increased substantially, from 31 in 2020 to 405 patients in 2023.  

Girl wearing a face mask.

Sierra Leone 2023 © Grigor Simonyan/MSF

“I really miss my school and my friends. As soon as I get well, I will go back to school."
Fatama, MSF patient

About our work in Sierra Leone

MSF has been working in Sierra Leone since 1986 and is currently providing medical care in three districts: Bombali, Tonkolili, and Kenema. At Makeni Regional Hospital, Bombali district, MSF teams support the Ministry of Health in providing treatment for patients with drug-resistant tuberculosis, while working to improve the diagnosis and care of adults and children with drug-sensitive tuberculosis in primary health care facilities across the district. In Mile 91 and Magburaka town, Tonkolili district, MSF teams work with the Ministry of Health to provide health care for mothers and children in local health centers and in Magburaka District Hospital. In Kenema district, MSF teams finished the construction of a mother and child hospital in Hangha in 2019, where its teams provide comprehensive emergency obstetric and newborn care. Our teams also provide general health care in a number of Ministry of Health-run local health centers across Kenema district.