TB care is not meeting the needs of adolescents

The review paper Adolescent tuberculosis was published in The Lancet Child & Adolescent Health on 18 November by a global team with affiliations to The Union.  The review summarised current understanding about tuberculosis (TB) in adolescents from a clinical and public health perspective, highlighting scant evidence and gaps in knowledge.

Adolescence is characterised by a substantial increase in the incidence of TB, with an estimated 1.8 million adolescents and young adults (10–24 years) worldwide developing TB each year. This increase is due, in part, to the impact of puberty on immunological changes and a broadening of social contacts. This high incidence is exacerbated by the fact that most of the world’s adolescents live in low-income and middle-income countries where TB remains common and adolescents make up a quarter of the population.

Despite these facts, a historic focus on children and adults in TB control has meant that adolescents have not been addressed as a distinct population, neither in terms of TB policy-making or treatment services. The evidence suggests that current models of care are not meeting the needs of this group. The Lancet review highlights issues that need to be addressed and areas that require further study:

  • TB diagnosis can be complex in adolescents, with younger adolescents often proving difficult to confirm by microbiological testing.
  • Once diagnosed, the accessibility and acceptability of TB services is very important for young people. Staff attitudes should be respectful, appreciating the individual’s desire for autonomy. Models of care should be age-appropriate, recognising adolescent-specific needs related to mental health, substance use, and sexual and reproductive health.
  • Adolescents have higher loss to follow-up than children and adults, and higher partial adherence to treatment. This means adherence support is very important, and should recognise the vulnerability of many adolescents, particularly those with HIV or drug-resistant TB.
  • Educational interventions may be necessary, including efforts to reduce stigma, address social isolation and minimise unnecessary exclusion from school. Peer support groups, which have been shown to help adolescents with HIV to remain engaged with care, may be beneficial, alongside psychosocial support, and the option for confidential consultations.
  • Effective prevention should include novel vaccines, shorter regimens, and improved contact investigation.
  • The long-term consequences of TB on health and wellbeing should be further investigated.

Earlier this year, The Union launched the Child and Adolescent TB Centre of Excellence in Uganda, to promote collaboration and learning across the Africa region to prevent needless child and adolescent TB deaths. The Union had already identified that adolescents with TB are neglected, despite being a high-risk age group for developing TB, and having age-specific challenges to access diagnosis and care. As a response this initiative is creating a virtual network of TB professionals and organisations across Africa, offering technical leadership, capacity building and funding opportunities to improve child and adolescent TB research and practice.

For more than a decade The Union has provided global leadership to address the neglected needs of child and adolescent TB, and has been at the forefront of activities that have greatly increased attention to child TB, such as Silent Epidemic: A Call To Action Against Child Tuberculosis, and The Union-led DETECT Child TB project. Recently at the 50th Union World Conference on Lung Health, new study results across the five highest TB burden countries found that adolescents and young adults are disproportionately driving TB transmission.

Two days ago, on World Children's Day, Dr Tereza Kasaeva, Director of WHO's Global TB Programme, said: “Every child has the right to a safe and healthy childhood. Yet, TB, the world’s top infectious killer, continues to violate this very right.”

The Union's Senior Consultant and co-author of the article, Steve M Graham said: “This article makes a compelling case that adolescents must no longer be neglected in the fight against tuberculosis, including drug-resistant tuberculosis. Tuberculosis is not only an important cause of morbidity and mortality among adolescents and young adults, but effective implementation and greater focus to detect, treat and prevent in this age group will be critical to achieve the necessary reductions in transmission and new infections.”

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