Overcoming pediatric drug-resistant TB crisis

Special message from Dr Tereza Kasaeva, Director of WHO's Global TB Programme on the occasion of World Children's Day and World Antimicrobial Awareness Week

World Children's Day marks the day, over three decades ago, on which world leaders adopted the historic Convention of the Rights of the Child, promising to every child to promote and protect their rights, including the right to life and the right to health.

Tuberculosis (TB), the world's top infectious killer, continues to violate children's right to a safe and healthy childhood. In 2019, an estimated 1.2 million children under 15 years of age fell with TB and
230 000 children lost their lives to this preventable and curable disease. Of the children who lost their lives to TB, 80% had not even reached their fifth birthday. Any child who dies from TB is one too many!

This week also marks World Antimicrobial Awareness Week. Researchers have estimated that between 25,000 and 32,000 children develop multidrug-resistant TB (MDR-TB) every year. MDR-TB, a form of TB that is resistant to two of the most potent anti-TB drugs (rifampicin and isoniazid), is a major contributor to antimicrobial resistance. Children acquire MDR-TB mainly through transmission from close contact with an infectious adult or adolescent with MDR-TB. The diagnosis of MDR-TB can be challenging, especially in young children, as they cannot easily produce a sputum sample for bacteriological testing, and because tests lack sensitivity to detect the low number of bacilli in samples of children.

WHO now recommends the use of less invasive, non-sputum based, samples to test with rapid molecular diagnostics, to confirm the diagnosis of (rifampicin-resistant) TB, such as stool and naso-pharyngeal aspirates. In children who are highly likely to have MDR-TB (based on typical TB signs or symptoms and being a contact of a patient with confirmed MDR-TB), but who test negative for TB or do not have access to rapid testing, a clinical diagnosis can be made, and second-line treatment started. Treatment for drug resistant TB can be especially difficult for children given the multiple toxic drugs and safety considerations.

The latest WHO guidelines stress that injectables are no longer recommended as they lead to worse outcomes and serious side effects, including hearing loss, which has a profound impact on language acquisition and ability to learn at school. Therefore, all children should receive all oral regimens. Many of the second line medicines now have child friendly formulations, available through the Stop TB Partnership's Global Drug Facility, which should be used rather than crushing adult pills.

In September 2018, at the UN General Assembly high-level meeting on TB, Heads of State, Ministers and other leaders committed to providing care to at least 3.5 million children with TB and 115,000 children with MDR-TB by 2022. The 2020 WHO Global TB Report includes data on MDR-TB in children under 15 years for the first time. These data show that 3,400 and 5,500 children with MDR-TB were started on second-line treatment in 2018 and 2019, respectively, which means that globally we have only reached 8% of the global target of 115,000 in the first two years since the UN High Level meeting on TB. For childhood TB overall, we are at 30% of the five-year target of 3.5 million.

The COVID-19 pandemic further threatens to reverse gains made towards targets and impacts severely on pediatric MDR-TB case detection and care. Lockdowns for instance, lead to delays in TB diagnosis and treatment in all age groups, and increased household exposure and transmission of TB. There is also indirect impact, for example through reduced household income, increased poverty, food insecurity and malnutrition, missed health checks and vaccinations, amongst others.

Faster progress therefore requires ensuring access to essential TB services even in times of crisis and harnessing the power of innovations. This includes a scale-up of case detection efforts through contact investigation to identify children in need of further evaluation or TB preventive treatment, roll-out of rapid molecular tests, implementation of child-friendly specimen collection methods, access to chest radiography, and capacity building of healthcare workers at all levels of the health system, development and uptake of child-friendly formulations as well as use of digital technologies.

We call on all countries, partners and civil society to unite forces and implement the key actions included in the 2018 Roadmap towards ending TB in children and adolescents to improve case finding, prevention and care to reach the UN High Level Meeting targets related to children and ultimately end TB and MDR-TB in children.

Children and adolescents are our future. While we place the spotlight on them for World Children's Day and for World Antimicrobial Awareness Week, this spotlight should continue through the year and years to come – to ensure no child or adolescent loses their life or suffers from TB- a preventable and curable disease. We are accountable to them – as people with power to shape their lives and our collective future. We cannot let them down!

It's time for action! It's time to end TB!

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