The theme of last year's World Tuberculosis (TB) Day was 'Invest to end TB' - an apt theme acknowledging the critical shortfall in funding for TB if we are to meet the 2035 goal of eliminating TB globally.
South Africa is one of the highest TB-burdened countries and has the additional burden of a high proportion of HIV co-infected TB patients, and a high prevalence of drug-resistant TB.
Children, particularly those younger than five, are the most at risk for contracting TB and are more likely to have poor outcomes if diagnosed late. The World Health Organization (WHO) estimates that South Africa has approximately 27 000 children (under the age of 15) living with TB but, with a detection rate of 65%, approximately one-third of children are being left undiagnosed or unreported. If identified early, children do very well on treatment, including when they have drug-resistant TB.
So why are children not being prioritised?
'a renaissance period for paediatric TB'
Prior to 2012, TB in children was not being documented by conventional surveillance, with the WHO only starting to provide estimates in 2012. Since then, "the decade was to be considered as a renaissance period, with [a] rise in attention, effort, advocacy and investment focused on paediatric TB", reads an article published in Pathogens MDPI. Despite this rise in investment, the $91 million (10% of total annual TB R&D spending) raised globally for TB research in children, still falls far short of the $200 million needed to achieve the global targets for TB elimination, the authors write.
Children, particularly those younger than five, are the most at risk for contracting TB and are more likely to have poor outcomes if diagnosed late.
In South Africa, spending on children likely reflects international trends - this is despite South Africa being a high TB burden country with multiple overlapping epidemics such as drug resistance, HIV, and malnutrition that further strain children's health.
In response to the call by the WHO in 2013 to invest more resources in surveillance and detection in children, South Africa committed at the United Nations High-Level Meeting in 2018 to identify over 95 500 children between 2018 and 2022. By the end of 2021, we had achieved 63% of the target.
Developments and challenges in paediatric TB care
In 2020, the bacillus Calmette-Guerin (BCG) vaccine celebrated its centenary. The inclusion of the vaccine in the national immunisation schedule has played a significant role in preventing severe disease amongst children and its anniversary has focused the spotlight on current developments around TB care in children. There are 14 candidate vaccines undergoing investigations, several diagnostic tools, and shorter prevention and treatment regimens under study.
Despite the advances in shortening treatment duration (South Africa is rolling out a four-month regimen for most kids), the management of paediatric TB is still unacceptably long.
The challenge with diagnosis in children is their complex and often non-specific symptomatology. Diagnostic tests are usually designed for adults and subsequently adapted for children. Children struggle to produce sputum (most diagnostic tests are sputum based), while other investigations are often disappointing in their ability to detect disease, and with reduced investment from National Tuberculosis Programmes in paediatrics, investigations also tend to be limited.
Our experience with designing a paediatric drug-resistant TB management model in the Nelson Mandela Metro - the Qinisela Paediatric TB project - also reflected some of these international and national trends. Resources for contact investigation, clinical evaluation, and referral are frequently inadequate. Tools (including training materials) are designed for adult care and then adapted for children. Referral pathways that children and their caregivers must navigate are often complex and not well understood by primary healthcare staff, let alone caregivers, at tremendous cost to them. Resource materials such as educational pamphlets and TB messaging demonstrate little consideration of how to involve children in their treatment journey.
Despite the advances in shortening treatment duration (South Africa is rolling out a four-month regimen for most kids), the management of paediatric TB is still unacceptably long, necessitating disruptions in schooling and other important social activities. Funding for social support, education, occupational therapists, and other allied health services is a dire need.
Considering these varying needs and consequences of the disease, an integrated response is imperative. Departments of Social Development and Basic Education have a critical role to play in identifying at-risk children and in the management plan. It is unacceptable that a preventable and curable disease remains amongst the leading causes of mortality in children in South Africa. If children are to receive quality healthcare - inter-departmental cooperation should form part of the basic health package.
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To paraphrase Mahatma Gandhi - "The true measure of a society is judged by how it treats its children." So, if we are to heed the call for World TB Day on 24 March 2023, 'Yes! We can end TB', we will need to significantly ramp up dedicated investment for an integrated approach for addressing TB in children. Like the canaries in a coal mine, TB in children points to significant disease prevalence in the community - and a TB prevalence of 27 000 children is extremely worrying. Investment in TB elimination strategies needs to include children. Not only is it an investment in our future health but is also an indicator of the health of our communities. If our children are safe, we can all indeed say Yes! We have ended TB!
*Dr Nyathi is the Director for Health Programs at AQUITY Innovations and is also leading the development of a scalable treatment model for addressing drug-resistant tuberculosis in children in Nelson Mandela Metro - the Qinisela Paediatric TB project. The Qinisela TB project is being implemented in collaboration with the Eastern Cape Department of Health, Jose Pearson Hospital, with funding from Janssen Pharmaceutica.
