A new WHO report calls attention to the high mortality of childhood TB and the low price tag for making progress towards zero deaths.
A new World Health Organisation report calls attention to the high mortality of childhood TB and the relatively low price tag for making significant progress towards zero deaths.
The ‘Roadmap for Childhood Tuberculosis’, published on 1 October by WHO and collaborating agencies, including the Stop TB Partnership and UNICEF, is the first-ever plan to address continuing high numbers of children infected with, and dying from, tuberculosis (TB).
After all the hullabaloo of late around HIV infection in children and young people, this report refocuses on a much more ancient disease. Will the world take notice?
Each year, 74,000 children die from TB. In the light of other causes of childhood mortality such as malnutrition (6.6m annual deaths), malaria (around 500,000) or even measles (158,000), the number dying from TB is relatively low. But, TB is in many ways an unusual disease, which has been infecting humans for at least 70,000 years.
A vaccine and effective treatment has been available for half a century. It is essentially preventable. Yet mortality among children and adults remains high, in total around 1.7m per year, mostly in low or middle-income countries.
There are a number of key challenges to reducing childhood TB mortality that exacerbate the situation. TB in children is difficult to diagnose due to children having lower levels of TB bacteria than adults. There is also, generally, a lack of child-focused national strategies and poor implementation of treatment guidelines. Also, there is often poor coordination between services, and perhaps most significantly a lack of effective community-level advocacy; a factor that has proved so important in the HIV sector for maximizing access to treatment and care.
Joined-up thinking for better services
So, mortality remains high, and this is the driving force behind the Roadmap’s release. Ten actions are recommended in the Roadmap that include gathering better data, providing sustainable capacity building for health care workers, engaging the health sector to ensure better diagnosis and access to treatment, and integrating family and community-led strategies for comprehensive services.
Speaking ahead of the Roadmap’s release, Dr Tom Kenyon, director of the Center for Global Health at the US Centers for Disease Control and Prevention, said: “We must ensure systems are in place to serve children through existing health, community, and child-centred services.”
However this requires much collaboration and while the HIV sector has made great strides towards a more holistic approach to the support of children and young people living with HIV, one of the greatest challenges has been ensuring sufficient access and retention in the health system.
Lack of child-friendly services
In the context of HIV, a recent multi-country study (McNairy et al, 2013) suggests child death rates are still high in spite of treatment availability. Factors include children being lost to follow up, and being diagnosed only in advanced stages of disease. And in resource-starved, very rural areas systems struggle to meet even the most basic health needs of populations, and providing child-friendly services will always remain a challenge – this applies to both TB and HIV, where for the latter lack of appropriately age-related services creates significant difficulties for young people (Hodgson, Ross et al, 2012).
One approach proposed by the Roadmap promises to be the most effective. According to Jose Luis Castro, interim executive director of the International Union against Tuberculosis and Lung Disease: “If we can shift TB diagnosis and treatment out of specialised programmes and into other existing maternal and child health activities, we automatically gain reach and scale.”
Mainstreaming services and developing joined-up interventions are two key lessons to be learnt from the HIV sector, especially the promotion of a family-centred approach. A Joint Learning Initiative on Children and HIV/AIDS (JLICA) report, published in 2009, stated: “By focusing policy and service provision predominantly on the individual child, we miss the opportunity to draw on and strengthen the structure that is most effective in responding to children’s needs: the family.” Maximising family support has been central to the HIV response for years; bringing this approach to the TB response now is a vitally needed initiative.
Show me the money: what, only $120m?
Perhaps most surprising is that the Roadmap’s recommendations are expected to require only $120m extra funding per year; $40m for antiretroviral therapy (in the case of HIV and TB co-infection) and the rest for better diagnostic tools, and integration of TB treatment into mainstream services.
The aim of getting to zero TB deaths is ambitious, but, as we have seen in the adult HIV sector, significant mortality reduction can be achieved through sustained and funded international and national interventions and strategies. The Roadmap suggests that great improvements against childhood TB are possible for a yearly investment of less than the price of footballer Gareth Bale’s September 2013 transfer from Tottenham Hotspur to Real Madrid (which actually cost $135m).
Hodgson, I. Ross, J. et al. (2012). Living as an adolescent with HIV in Zambia: lived experiences, sexual health and reproductive needs. AIDS Care, 24(10), 1204-1210.
McNairy ML et al. (2013). Retention of HIV-infected children on antiretroviral treatment in HIV care and treatment programs in Kenya, Mozambique, Rwanda and Tanzania. J Acquir Immun Defic Syndr, 62(3), e70-81
World Health Organisation (and collaborating agencies) (2013), Roadmap for childhood tuberculosis
JLICA (2009). Home truths: facing the facts on children, AIDS, and poverty. Final report of the Joint Learning Initiative on Children and HIV/AIDS