Daily Times

As we approach Valentine’s Day let us resolve to be compassionate and kind, spread solidarity and love in our work, ensure that nobody is stigmatized regardless of any consideration and not ostracize patients if they suffer from a communicable diseases like Tuberculosis. Above all let us resolve to speak up, stand up and step up our efforts for a brighter future for our children in a world free of Tuberculosis. And while gearing up efforts in that direction we must not forget the high proportion of our children suffering from Tuberculosis. To identify and cure those children represents the best manifestation of our love for them.

According to World Health Organization (WHO) estimates, an estimated 1 million children became ill with TB globally, while 233 000 of them die of TB every year. In all probability TB directly or indirectly leads to around 10 000 TB deaths among children under 15 years annually in Pakistan. These figures may, however, be underestimations given the complexities in diagnosing childhood TB and the lack of child-friendly diagnostic tools. WHO has called for sustained advocacy, greater commitment, mobilization of increased resources and a joint effort by all stakeholders involved in childcare and TB control.

Childhood Tuberculosis is a major public health problem in Pakistan with roughly 20% of the tuberculosis patients detected every year being under the age of 15 years. Initially policymakers may have neglected the issue on the premise that children do not transmit the disease to others, however, since more than a decade close attention is being paid to the issue globally and nationally.

The National TB Control Program (NTP) Pakistan with support from the WHO has been accordingly arranging capacity building courses since 2013 for pediatricians, chest physicians and medical officers with a view to increase case detection of TB in children within communities, improve the diagnosis and management of children with all forms of TB, increase implementation of child contact screening and preventive therapy, improve quality of child TB data and enhance child TB case reporting from the private sector.

The fact that girls are more susceptible for Tuberculosis, highlights the crucial role of mothers in reporting any disease symptoms, particularly in their female children to outreach health workers

While it is important to be familiar with the child TB epidemiology, latest diagnostic and management techniques for children with TB (including drug resistant TB) and the diagnostic algorithms, it is equally critical to realize the barriers in the process and common problems encountered in the case detection and notification process, particularly at the district and tehsil levels such as lack of coordination between pediatricians and chest physicians causing most of the diagnosed children to go unnotified in the national/provincial database or lost to follow-up for any reason.

As we approach the target date for ending TB by 2030 in Pakistan, a better understanding on important childhood TB issues is necessary both among parents and healthcare providers. This can be achieved by removing any inconsistencies in the standardized NTP guidelines through coordination with professional bodies such as the Pakistan Pediatrics Association. The need to integrate child TB training into regular NTP TB capacity building activities and medical school curricula constitutes the way forward.

Essentially the principles of TB treatment in children are same as for adults, the duration of treatment is also the same (mostly 6 months except for those with drug resistance) and children usually respond well with symptomatic improvement during treatment with good outcomes. There is also evidence to believe that verbal screening with clinical evaluation and provision of free diagnostics can identify children with TB who may otherwise be missed, particularly in rural health settings. The national guidelines have recommended use of fixed dose combinations of first line pediatric drugs already made available in Pakistan with fruit flavors to be more palatable and avoid complications in dosage encountered while crushing drugs meant for adults. It is also imperative to pay particular attention to children at risk of treatment failure by proper monitoring.

A TB diagnosis in children is usually made consistent with a comprehensive scoring system devised by the Pakistan Pediatric Association and adopted by NTP Pakistan in presumptive cases by giving weightage or scores to factors such as age, closeness of contact with TB patients, evidence of malnutrition, previous history of measles or whooping cough, HIV, immunosuppression for any reason, clinical manifestations, radio diagnostic imaging, tuberculin skin testing and Xpert testing or presence of granuloma.

While discussing these technical details, one is immediately struck between the awareness gaps within communities warranting methods for rectifying the position on the ground with speed and alacrity. Firstly, children with TB infection today represent the reservoir of TB disease tomorrow and if left alone children are more likely to develop more serious forms of TB such as miliary TB and TB meningitis resulting in high morbidity and mortality. It is also important to integrate TB care for children with the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) initiative in Pakistan, while impressing upon parents that the BCG vaccine has limited efficacy against the most common forms of childhood TB.

To address the current situation, the Stop TB Partnership (STP) has advised national TB programs to prioritize childhood TB in their plans while highlighting the need for health care providers to integrate this into their services. It has also encouraged donors and development partners to encourage collaboration with researchers, local communities, TB and HIV control programmes and other stakeholders to address the growing problem of childhood TB concentrating on innovative research to develop child-friendly TB diagnostics, drugs, biomarkers and vaccines and create a demand with the civil society for equitable prevention, diagnostics, treatment and care services for children with TB and to monitor the scale- up of these services.

Dr Lucica Ditiu, the dynamic and passionate Executive Director of the Stop TB Partnership has pointed out that: “The missed or late diagnosis of TB can have catastrophic health impacts for the child and increases their chances of mortality. Suboptimal diagnostic methods, poor screening compliance, and unrealistic treatment guidelines mean that children face even greater barriers to accessing care than adults, making this population even harder to reach. Children often exist as a vulnerable population within already vulnerable populations.

Therefore, it is imperative that TB finally be addressed head-on by policy makers, civil society and health professionals. Not only do children provide the reservoir from which future cases will develop, but continued inaction is costing lives!” Quite recently Dr Ditiu interacted with the well-known and decorated puppeteer Farooq Qaiser (Uncle Sargam) online and urged him to play a meaningful role in educating children and their parents to follow-up on his initiative to create TB advocacy since March 2020. Mr. Farooq Qaiser is known for highlighting important national issues closely wrapped up in his inimitable sense of humor and satire. Dr Lucica Ditiu also engaged with a female TB survivor from Pakistan who is now playing her role in the community for spreading the message that TB is curable if diagnosed at an early stage. Recently Hello Kitty has joined hands with the Stop TB Partnership in creating awareness about TB particularly in children and their parents.

The fact that girls are more susceptible for Tuberculosis, highlights the crucial role of mothers in reporting any disease symptoms, particularly in their female children to outreach health workers. On its part, NTP Pakistan can expand and roll out services for children across all districts after ensuring that the operational guidelines are available for all the public and private sector stakeholders. The childhood TB desk guide developed more than decade ago needs to be updated and distributed to all the prescribing doctors in every district.

Special attention also needs to be paid to children with any co-morbidities to ensure that they are not lost to follow-up and are adhering to their treatment course throughout its duration. Engagement of public sector tertiary care hospitals and private general practitioners is crucial to ensure that all the diagnosed cases are properly notified to the NTP database. Ethical issues often crop up while handling not just the diagnosis and treatment but also the provision of psycho-social support. Although children may not be transmitting the disease to others, it is yet warranted that they should be provided the best possible diagnostic and treatment care, accompanied by counselling and nutritional support, wherever necessary, on ethical grounds.

If Pakistan seriously intends to achieve the Sustainable Development Goal # 3 elating to universal health coverage, it will need to drastically reduce its TB incidence across the country without forgetting its children to a point where it ceases to be a public health problem. That is the best Valentine’s Day gift that parents can provide to their children so that when they grow up, they can breathe air free of Tuberculosis. And yet as the theme of the World TB Day 2021 warns us: The Clock is Ticking!

The author is a senior public health specialist of Pakistan and can be reached at gnkaziumkc @gmail.com