With an estimate of more than half a million cases
and 65,000 deaths in children occurring globally each year, tuberculosis
is still an important cause of morbidity and mortality in children in
many countries [1]. In India, there are around 400 million children who
constitute nearly one-third of the total population [2]. The extent of
childhood tuberculosis in India is estimated to be around 10% of the
total adult incidence [3]. It is alarming to note that drug resistance
rates in children reflect adult rates [1].
Tuberculosis in children reflects ongoing community
transmission. The most critical gap in control of tuberculosis is the
neglect of pediatric disease. There are many challenges in addressing
pediatric tuberculosis, and there exists a wide policy-practice gap.
Even under optimal circumstances, the sensitivity of smear microscopy
for the diagnosis of childhood tuberculosis remains low [4-6].
Cartridge-based Nucleic Acid Amplification Tests are now recommended by
WHO as preferred diagnostic test in smear-negative tuberculosis, and in
children [7-9].
Access to
Xpert MTB/RIF testing to diagnose pediatric cases of tuberculosis has to
be ensured at the earliest. Mantoux test is considered positive if the
induration is 10 mm or more. It is recommended that the 10 mm cut-off
may continue to be used for strengths of Purified Protein Derivative
(PPD) only up to 5 TU; however, 2TU PPD RT23 is considered to be the
most suitable strength. PPD available in the market should be
standardized and the appropriate strength PPD should be made available.
Serological tests for diagnosing tuberculosis (IgM, IgG, IgA antibodies
against Mycobacterium tuberculosis antigens) are banned by the
Government of India, but the ban may only be in paper, and has not come
really into practice. Commercially available Interferon Gamma Release
Assays are expensive tests, and they do not differentiate the tubercular
infection from disease. Exact advantage of these tests in high burden
situation is still not clear.
Children in households with any adult with pulmonary
tuberculosis are at very high risk of infection. Screening of household
members for tubercular disease and latent infection is included in the
RNTCP protocol, but contact screening and Isoniazid Preventive Therapy
implementation under routine programmatic conditions is sub-optimal
[10,11]. Regarding, Directly observed treatment strategy (DOTS), the
number of tablets is too many to consume, and younger patients may have
difficulty in swallowing them. Fixed dose combinations with good
bioavailability should to be made available in the program and outside
the program.
The Joint Monitoring Mission report states that the
National vision of tuberculosis control will be best achieved with the
innovative engagement of Private sector, but the Public sector is still
not oriented enough to energize and own public-private partnerships.
Standards of tuberculosis care in India, emphasising on evidence-based
diagnosis, standard anti-tubercular regimens, ensuring treatment
adherence, prevention of spread, and notification of disese need to be
disseminated. Indian Academy of Pediatrics (IAP) has planned strategies
to train pediatricians on tuberculosis control, and disseminate
standards of tuberculosis care in India. IAP will also facilitate
disease notification, provided the confidentiality of the patients is
ensured. A Pediatric Tuberculosis Control Task Force need to be
formulated at State level and district level.
Let us be part of the global effort to find, treat
and cure the persons affected with tuberculosis, and accelerate progress
towards zero tuberculosis-related deaths, infections, suffering and
stigma. Let every child enjoy the right to breathe air free of
Mycobacterium tuberculosis.
References
1. World Health Organization. Global Tuberculosis
Report. 2012 WHO Geneva WHO/HTM/TB/2012.6
2. Government of India. Census 2011.
3. Nelson LJ, Wells CD. Global epidemiology of
childhood tuberculosis. Int J Tuberc Lung Dis. 2004;8:636-47.
4. López Ávalos GG, Prado Montes de Oca E. Classic
and new diagnostic approaches to childhood tuberculosis. J Trop Med.
2012;2012:818219. doi:10.1155/2012/818219.
5. Swaminathan S, Rekha B. Pediatric tuberculosis:
Global overview and challenges. Clin Infect Dis. 2010;50:184-94.
6. Nicol MP, Zar HJ. New specimens and laboratory
diagnostics for childhood pulmonary TB: Progress and prospects. Paediatr
Respir Rev. 2011;12:16-21.
7. Rachow A, Clowes P, Saathoff E, Mtafya B, Michael
E, Ntinginya EN, et al. Increased and expedited case detection by
xpert MTB/RIF assay in childhood tuberculosis: A prospective cohort
study. Clin Infect Dis. 2012;54:1388-96.
8. Lawn SD, Brooks SV, Kranzer K, Nicol M, Whitelaw
A, Vogt M, et al. Screening for HIV-associated tuberculosis and
rifampicin resistance before antiretroviral therapy using the Xpert
MTB/RIF assay: A prospective study. PLoS Med. 2011;8:e1001067.
9. Scott LE, McCarthy K, Gous N, Nduna M, Van Rie A,
Sanne I, et al. Comparison of Xpert MTB/RIF with other nucleic
acid technologies for diagnosing pulmonary tuberculosis in a high HIV
prevalence setting: A prospective study. PLoS Med. 2011;8:e1001061.
10. Banu Rekha VV, Jagarajamma K, Wares F,
Chandrasekaran V, Swaminathan S. Contact screening and chemoprophylaxis
in India’s Revised Tuberculosis Control Programme: A situational
analysis. Int J Tuberc Lung Dis. 2009;13:1507-12.
11. Pothukuchi M, Nagaraja SB, Kelamane S,
Satyanarayana S, Shashidhar, Babu S, et al. Tuberculosis contact
screening and isoniazid preventive therapy in a South Indian district:
Operational issues for programmatic consideration. PLoS One.
2011;6:e225100.
