Thursday (24 March) is World Tuberculosis (TB) Day. In an opinion piece for Health24, Drs Karen du Preez and Marieke van der Zalm (Desmond Tutu TB Centre / Department of Paediatrics and Child Health) write that we urgently need to outline priorities and get all stakeholders to work together to close the remaining policy-practice gaps for child and adolescent TB in South Africa.
- Read the article below or click here for the piece as published.
Karen du Preez* and Marieke van der Zalm**
On the 24th of March we celebrate the annual World Tuberculosis (TB) Day – an ideal opportunity to reflect on the progress we have made in terms of TB control and to identify remaining priorities to reduce the burden and overall impact of the disease. Despite multiple advances to improve TB care to children during the past decade, more than a million children still develop TB each year. In 2020, less than half of the estimated children with TB were reported as being diagnosed and treated, resulting in nearly 700,000 children missing from TB care globally. The disruption of routine health services due to COVID-19 had a further devastating impact on TB care globally and is expected to continue increasing gaps in TB diagnosis and treatment.
Tuberculosis can be prevented and effectively treated; yet more than 600 children die from it every day. It is also the leading cause of death from infectious diseases for children of all ages. For the first time in more than a decade, TB deaths increased in 2020 due to the negative impact of Covid-19 on routine health services. In the light of the theme of this year's World TB Day “Invest to END TB. Save Lives", more funding and commitment is needed to save the lives of children and adolescents with TB.
South Africa has a very high burden of TB with an estimated 328,000 people who developed TB in 2020. Of these, 30,000 were children younger than 15 years of age, but only 16,500 children were diagnosed and reported as starting treatment. Nearly one out of every two children with TB in South Africa is therefore either not diagnosed, not treated, or not reported.
The South African National TB programme has made substantial investments to develop policies and guidelines, build capacity and integrate health services, but inconsistent uptake and implementation still results in many missed opportunities for prevention, diagnosis and treatment. At the United Nations General Assembly high-level meeting on TB in September 2018, heads of states committed to specific country targets for us to reach the End TB strategy goals. In 2020, South Africa reached only 66% of the child TB case finding target and 35% of the target to start TB preventive therapy (TPT) in young children exposed to TB. We urgently need to outline priorities and get all stakeholders to work together to close the remaining policy-practice gaps for child and adolescent TB in South Africa.
So how can we close these remaining gaps?
As a first step, we need to strengthen routine TB surveillance data for children and adolescents, as accurate and complete data is a critical building block for monitoring and evaluation of any health programme. Data should be collected and reported along the cascade of care and in smaller age bands for children and adolescents. As children are often diagnosed in-hospital, linkage to care after hospital discharge plays an important role in the continuation of care.
Every opportunity to prevent TB should be a priority. Bacille Calmette-Guérin (BCG) vaccination protects young children from severe forms of TB such as TB meningitis and is part of the routine immunisation schedule in South Africa. All infants should receive BCG vaccination at birth, but following global shortages, challenges with uptake and coverage remain an issue. Also, TPT is safe and effective to prevent TB and has been routinely available as six months treatment, however, many challenges remain with implementation and more effort is required to identify and screen child contacts and increase TPT uptake. Access to shorter and child-friendly TPT options would strengthen TPT uptake.
Currently, available TB diagnostic tools perform sub-optimally in children. These challenges are not specific to South Africa, but we could improve diagnostic capacity through regular training of healthcare workers to improve the use of the existing tools. TB meningitis (TBM), a severe and debilitating form of TB, affects a small number of children, but many of those who survive, suffer permanent neurological disability. Early diagnosis and treatment for children with TBM is essential to reduce death and long-term disability.
Once diagnosed, the vast majority of children and adolescents with TB are treated successfully. A newly recommended shorter treatment regimen for non-severe, drug-susceptible TB in children is a great step forward to make TB treatment easier for children and caregivers as well as reduce costs to families and health services. More research is needed to reduce treatment in all children with TB including treatment for drug-resistant TB. The availability of child-friendly treatment options for drug-resistant TB remains a global challenge.
Where do we go from here?
We are in the fortunate position in South Africa to have strong support from the National Department of Health to strengthen child and adolescent TB services. In addition, the World Health Organisation has recently released updated guidelines on the Management of tuberculosis in children and adolescents, with an accompanying operational handbook to support countries with practical implementation.
As a first step, we need to revise the 2013 South African Childhood TB guidelines to include the latest recommendations and work together with different stakeholders to implement these changes. Civil society organisations and TB activists can also help to create a louder voice for children and adolescents. It is possible to reach the ambitious End TB targets, but we need strong commitment and collaboration to close policy-practice gaps and mitigate the negative impact of COVID-19 on TB care for South African children and adolescents.
*Dr Karen du Preez is a senior researcher and Dr Marieke van der Zalm an associate professor at the Desmond Tutu TB Centre, Department of Paediatrics and Child Health at Stellenbosch University.
