Tuberculosis (TB) is one of the leading causes of serious illness and death in young children worldwide. On World Tuberculosis Day, Dr Jacquie Narotso Oliwa details the challenges that still remain before the global eradication of childhood tuberculosis can be achieved. For more information on childhood tuberculosis, please explore Pneumoniaof thematic series edited by Ben Marais.
The clock is ticking towards 2030, the year in which world leaders pledged to end the TB and TB epidemic. However, not much is still known about the burden of childhood TB and how best to treat or diagnose it.
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Tuberculosis (TB) is a primary cause of debilitating diseases and deaths among children around the world. However, it is often described as a hidden epidemic as the true burden of this disease in children remains unknown. This knowledge gap can be attributed to the many challenges that healthcare professionals face in confirming a diagnosis of pediatric TB.
Tuberculosis mimics many other common childhood illnesses, including pneumonia, malnutrition, and HIV, and is therefore severely underdiagnosed and undertreated in children. This is of particular concern in young children, as they carry the highest risk deaths from tuberculosis. Recent studies suggest that up to one in ten children hospitalized in TB-endemic countries with severe pneumonia may also have TB. Overworked clinicians in busy and generally under-resourced facilities can often miss these cases.
Diagnosis is also complicated due to unreliable testing methods. To test for tuberculosis, clinicians test samples of a patient’s phlegm for bacteria in the lungs that cause tuberculosis. However, children tend to swallow their phlegm, making it almost impossible to get the samples needed to confirm a diagnosis. As a result, many children with TB go undiagnosed and untreated and often die from a centuries-old disease that is both curable and preventable.
While identifying all cases of TB in a community poses many challenges, it is particularly unfortunate that children with clear signs and symptoms of TB are not properly assessed for a diagnosis. Although the limited availability and accuracy of diagnostic tests present challenges, this should not be a barrier, as many children with TB can be diagnosed and treated using only clinical assessment.
We recently observed this phenomenon in a to study among Kenyan children hospitalized. Almost 60% of these children presented with signs and symptoms suggestive of tuberculosis. However, although tests are available, many of these children were never properly investigated for tuberculosis, and less than three percent resulted in a diagnosis of tuberculosis. Clinicians do not appear to have a high index of suspicion of tuberculosis in children, which is of concern in high burden countries such as Kenya. The country has seen tremendous efforts from government and other partners to provide evidence-based guidance, training and new technologies to support TB case detection. Nevertheless, significant gaps in policy and practice remain, particularly in pediatric care.
While global efforts to eradicate tuberculosis have saved an estimated 63 million lives since 2000, many high-burden countries are lagging behind, particularly in detecting tuberculosis in young children. Of real concern is that the COVID-19 pandemic is reversing recent gains due to reduced TB case detection and poorer treatment outcomes compared to pre-COVID years. Patients stay away from health facilities, and those on treatment cannot get the support they need to make sure it is completed.
The clock is ticking for 2030, the year in which world leaders committed to end tuberculosis. We all need to pause and reflect on World Tuberculosis Day to see if we will actually achieve the goals of ending tuberculosis. Everyone needs to be part of the solution, from the general public, policy makers, governments, funders, researchers, health workers, civil society and down to the patients themselves. The efforts, investments, political will and rapid achievements that characterized the response to the COVID-19 pandemic have been impressive, especially the rapid development of vaccines. These efforts can similarly be replicated in the face of the pressing need to end the hidden TB epidemic in our lifetime, ensuring that vulnerable populations like children are not missed.