Rising TB prevalence among children

Based on an Editorial Piece published in The Hindu on 17 July 2017 - "A looming threat "

The context
  • Recently, a survey was carried out under the Revised National TB Control Programme.
  • Under this, a limited number of children tested for TB.
  • The findings are worrisome.
    • About 5,500 out of about 76,000 children tested in nine Indian cities have been diagnosed with tuberculosis
    • 9% of such children have multi-drug resistant TB (MDR-TB)
    • It shows the silent spread of the disease in India.
    • The actual prevalence of MDR-TB among children in India is not known.
    • According to a 2015 study, of the over 600 children who had tested positive for TB in four cities, about 10% showed resistance to Rifampicin, a first-line drug.
What we can learn from the finding
  • Incidence of TB among children is a reflection of the prevalence of the disease in the community at large.
  • Very often, children who test positive for TB have been in close contact with adults with the disease in the same household.
  • The high prevalence of both drug-sensitive TB and drug-resistant TB in children shows the failure of the health-care system to diagnose the disease early enough in adults and start them on treatment.
  • There is usually a couple of months’ delay in diagnosing the disease. Due to this, there is a continuing threat of TB spreading among household contacts and in the larger community.
  • Children are certainly the most vulnerable in contracting TB.
What needs to be done?
  • The World Health Organisation guidelines and the RNTCP strategy must be followed.
  • It requires all household contacts, particularly children, of a newly diagnosed pulmonary TB patient to be tested and started on treatment if needed.
  • It also says that the children below six years of age in the household of a newly diagnosed patient are required to be given the drug Isoniazid as a prophylactic even when they do not have the disease.
What more can be done?
  • A proactive approach is needed. Timely testing helps in early and correct diagnosis of all contacts and in cutting the transmission chain.
  • Intensify contact screening: The results from this limited study should make the government to take up contact screening more urgently.
  • Leverage FDCs: In 2010, WHO had revised the dosage of certain TB drugs for children. Fixed-dose combination (FDC) drugs that take into account the revised dosages for children were made available in late 2015. The FDCs are meant for treating children with drug-susceptible TB. All Indian States will be covered by the end of this year. Adherence to treatment will improve, and correct dosage for children weighing less than 25 kg will become easier when child-friendly FDCs become available throughout the country.
  • Using the Xpert molecular diagnostic test to screen children with TB is a positive step and should be welcomed, but all the diagnosed children should be guaranteed paediatric FDCs.
Comment

Immediate steps need to be taken, since the spectre of TB now looms large over the children of India. As such, India probably has the highest burden of the disease in the world. If the prevalence of resistant TB increases among children, it will be disastrous.

Related information
  • Xpert molecular diagnostic test: It is a new molecular test for TB which detects the presence of TB bacteria. It also tests for resistance to the drug Rifampicin. The test is a molecular test which detects the DNA in TB bacteria. It uses a sputum sample and can give a result in less than 2 hours. It can also detect the genetic mutations associated with resistance to the drug Rifampicin.
  • Revised National Tuberculosis Control Progreamme (RNTCP) is TB control initiative of the Government of India. India has had an on-going National TB Program, NTP since 1962, which was modified in 1972. Program reviews showed that only 30% of estimated tuberculosis patients were diagnosed and only 30 percent of those were treated successfully. In 1992, the Government of India, together with the World Health Organization (WHO) and Swedish International Development Agency (SIDA), reviewed the national programme and concluded that it suffered from managerial weakness, inadequate funding, over-reliance on x-ray, non-standard treatment regimens, low rates of treatment completion, and lack of systematic information on treatment outcomes. As a result, a Revised National Tuberculosis Control Programme (RNTCP) was designed.  It later adopted the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy, as the most systematic and cost-effective approach to revitalise the TB control programme in India. Large-scale implementation of the RNTCP began in late 1998. As per the National Strategic Plan 2012–17, the program has a vision of achieving a “TB free India”, and aims to achieve Universal Access to TB control services.