Every three minutes, a child dies from tuberculosis (TB) somewhere in the world. And more than half of all children with TB are never diagnosed.
Upon the release of a new set of recommendations from the World Health Organization (WHO), Doctors Without Borders/Médecins Sans Frontières (MSF) has launched a worldwide project aiming to improve diagnosis and treatment of TB among children and prevent new cases. This initiative, called "TACTiC" for “Test, Avoid, Cure Tuberculosis in Children,” will support the implementation of the new WHO recommendations in over a dozen countries in Africa and Asia.
The project also aims to contribute to knowledge-building through several multi-country studies on the validity and feasibility of the WHO recommendations, while advocating for their widespread implementation and the development of better tools to diagnose TB in children.
Why it’s difficult to diagnose children with TB
The TACTiC project is based on grim observations: most children with TB are never diagnosed, and 96 percent of children who die from TB never received appropriate treatment. There are several reasons why TB is underdiagnosed among children, including the reluctance of clinicians and programs to start long-term treatment of children without a test confirming the diagnosis.
Unfortunately, even very small amounts of the bacteria that causes TB can make children sick, which means that the TB diagnostic tests currently available are unable to confirm the presence of the disease-causing germs. In addition, the tests were developed for adults and often rely on specimens such as sputum (phlegm from deep inside the lungs), which is difficult for most children to cough up.
Other barriers include the lack of human resources to screen for and diagnose TB in many primary health care facilities as well as lack of access to diagnostic tools such as X-rays and molecular tests. Delays in the diagnosis of TB in children are common, and because children are most at risk of developing the most serious forms of TB, these delays are often fatal.
Child TB patients from MSF projects around the world.
How TACTiC helps bridge gaps
"Recent WHO recommendations on the diagnosis of TB in children can be a game changer to increase the number of children diagnosed and put on correct treatment,” said Cathy Hewison, head of MSF's tuberculosis working group. “They provide clinicians and TB programs with the confidence to make the decision to treat TB in children using clinical signs and symptoms without having to rely on laboratory test results or X-rays,” which may be unavailable or, in the case of tests, false negatives.
“The implementation of these simple treatment decision-making algorithms can help clinicians and national TB programs diagnose and treat more children,” said Hewison. “Our initial experiences in pilot projects have shown the number of children diagnosed with TB can increase five-fold with the introduction of these new recommendations. However, the new recommendations have not yet been widely put into practice, so there is a lot of work to do.”
The TACTiC project aims to help MSF projects and teams, particularly those not specialized in the management of tuberculosis, to initiate the implementation of the new WHO recommendations.
“Of course, it would be preferable to have a simple, reliable, inexpensive, and easily accessible diagnostic test to detect TB in children,” said Hewison. “However, to date, these do not exist, therefore we are also advocating for a massive increase in resources for research and development of new and adapted tests to diagnose TB in children.”
A patient-centered approach beyond diagnosis
TACTiC aims to improve not only the diagnosis of TB in children, but also TB treatment and prevention for this vulnerable age group.
WHO has recommended a patient-centered approach to TB treatment in children based on a point system based on the assessment of a child's symptoms, which enables early detection and rapid initiation of treatment. If the points surpass a certain threshold, a short four-month course of treatment is recommended, which is effective in milder cases and when using the same child-friendly formulations already widely available. The shorter treatment can be an enormous relief for children and their families, reducing travel costs and follow-up time, and improving the child’s treatment experience.
Children under five who live in close quarters with adults who have TB are at high risk of infection and of developing the active disease. Despite the longstanding global objective to improve access to TB-preventive treatment, only one in two TB contacts under five years old can access it. The WHO has now made it easier to protect children from becoming sick in these circumstances by recommending short three-month preventative treatments. TACTiC also aims to increase knowledge and access to these treatments.
Building knowledge about TB testing and treatment of children
Epicentre, the epidemiology and medical research branch of MSF, will conduct operational research to assess the feasibility, acceptability, and performance of the treatment decision algorithms in the communities where we work. Studies have been enrolling patients in five MSF projects since last fall: in Maiduguri, Nigeria; Madarounfa, Niger; Conakry, Guinea; Malakal, South Sudan; and Mbarara, Uganda. These projects will make it possible to document any difficulties encountered while implementing the program and help propose solutions for when the project is rolled out in other countries.
MSF teams and their Ministry of Health and national TB program partners will be trained on treatment decision algorithms, the interpretation of X-rays, the newly recommended use of stool samples, contact case finding and follow-up, and health promotion. A toolkit of materials adapted to settings where MSF and partners work will be developed. In addition, TACTiC will include advocacy at global, national, and local levels to speed up the implementation of existing recommendations and call for the development of more adapted diagnostic tools.
By sharing findings with the international community fighting TB, TACTiC strives to remove barriers to treatment for children, improve their treatment experience, prevent more cases, and ultimately reduce the number children dying from this disease.
