Systematic review reveals extent of childhood TB epidemic

Tuberculosis has once again become the world’s deadliest infectious disease, surpassing HIV/AIDs in 2015 and killing an estimated 1.8 million people. TB’s impact on children is not well understood, but an expanding body of evidence points to an epidemic unfolding in the shadows.

Last month, the leading medical journal The Lancet published the world’s first systematic review of the risk of death in children suffering from tuberculosis. An international consortium of leading universities reviewed 31 published studies on childhood TB, involving 35 datasets representing more than 82,000 children with tuberculosis.

Here are some of its stark conclusions:

  • One million children fall sick to tuberculosis each year.
  • Only one in three children with TB is diagnosed, much less treated.
  • Nearly half of children under five who get TB die.

This seminal review adds support to a growing consensus that far more children die from tuberculosis than the medical community has previously had reason to believe.

The good news is that 99 percent of children with TB who receive treatment survive. But without treatment, 22 percent of infected children under 15 die — with the death rate climbing to 44 percent for those under five years old.

Considering that we know tuberculosis kills more people than any other infectious disease in the world, how is it that vast numbers of children are left without even a diagnosis? And what can we do about it?

 In 2013, the World Health Organization, CDC, UNICEF, The Union and other global health groups released the Roadmap for Childhood Tuberculosis (PDF 3MB). The Roadmap describes a childhood TB epidemic that spent “decades of being relegated to the shadows,” for several reasons. The standard TB diagnostic tests are not designed for children, leaving many undiagnosed. Making diagnosis even more of a challenge, children often don’t develop the same characteristic TB symptoms that adults do. At the same time, TB is not included within the group of illnesses that public health experts see as crucial to ensuring “child survival,” such as pneumonia, malnutrition and malaria. This means TB has historically been left off of the child survival agenda, which informs what activities health systems prioritize.

The Union has developed a promising approach that is already showing how feasible it is to diagnosis TB in far more children, even in resource-strapped settings.

In 2015, The Union’s national office in Kampala, Uganda began coordinating DETECT Child TB — a project implemented in partnership with the Uganda Ministry of Health, Baylor College of Medicine Children’s Foundation Uganda, and local governments within Uganda’s Kabarole and Wakiso Districts. The project trains existing healthcare workers and local volunteers to diagnose TB, relying most heavily on clinical technique. (A clinical diagnosis is one made based on symptoms rather than, in the case of TB, the confirmed presence of bacteria.)

Already the results are striking. A pending external evaluation has found that this surprisingly simple and low-cost approach has doubled the proportion of child TB cases diagnosed in one of the districts, and increased it by more than five-fold in the other. The project has also successfully implemented TB preventive therapy for the first time in these districts, significantly reduced the need to refer childhood TB cases to higher levels of the health system, and improved treatment adherence rates.

The project provides a model that can be replicated in other settings, even in the absence of new diagnostic tests designed specifically for kids. It offers a direction that we can and should pursue immediately as we work to end TB, including the long-neglected epidemic of TB among children. The Union will soon be sharing findings from the evaluation more widely.

As former UN Secretary General Kofi Annan wrote in the 2000 State of the World’s Children report, “There is no trust more sacred than the one the world holds with children.” We have not kept this trust as we should have when it comes to TB in children. This needs to change.

Last month, the United Nations passed a resolution calling for a high-level meeting on tuberculosis to be convened at the UN General Assembly in 2018 — the first-ever global meeting of heads of state to be focused on tuberculosis. Childhood tuberculosis must be on the agenda, and any outcome document or declaration that the meeting produces should include measurable targets for reducing the large numbers of preventable TB deaths among children.

A version of this article originally appeared on The Union's Medium channel, follow us there to read more like this.

DETECT-TB is supported by the ELMA Foundation and by an anonymous gift.