SOUTH AFRICA: Children with TB below the health radar

Photo: Lee Middleton/IRIN
Treating a child with TB is difficult
YSTERPLAAT, 23 March 2012 (PlusNews) - To a casual observer the two dozen children running round in the grassy schoolyard look like ordinary kids playing, but the surrounding buildings are the wards of the Brooklyn Chest Hospital (BCH), which specializes in treating severe cases of tuberculosis (TB), a disease rarely associated with children.

TB affects nearly a million children globally every year, and up to 70,000 die from this preventable and curable disease per annum. Problems in detection, difficulties in diagnosing, and the fact that children rarely spread the disease have kept paediatric TB off the public health radar, but this is changing.

"Before I came here I was feeling so tired - I had pains in my chest, I [couldn't] walk, and I was sleeping all the time," said Yonele Ndamane, 13, who came to BCH in November 2011 to be treated for multidrug-resistant (MDR) TB. He says he got the disease from his 24-year-old brother, with whom he shared a room, and who has also been diagnosed with MDR TB.

"If you see an adult with TB there's going to be a child who's exposed and at high risk," said Anneke Hesseling, Director of the Paediatric TB Research Programme at the Desmond Tutu TB Centre at Stellenbosch University in Western Cape Province.

According to the 2012-2016 National Strategic Plan for HIV, STIs (sexually transmitted infections) and TB, South Africa has the third highest level of TB in the world. New infections have increased by 400 percent over the last 15 years, approximately 1 percent of over 50 million people per year develops active TB, and more than 70 percent of TB patients are co-infected with HIV.

In this context, the number of children thought to be infected with TB is huge. Hesseling estimates that in TB-endemic areas the disease will be active in 15-20 percent of children, but reliable figures are hard to come by.

"Up to the early 2000s there was little money for research into childhood TB. If we wanted to do research… we had to attach it to an adult study," noted Simon Schaaf, who has been conducting research into paediatric TB with Hesseling and others at the Desmond Tutu TB Centre.

Paediatric TB differs from adult TB in several ways. First, the available diagnostic tools make it very difficult to confirm TB in a child. The most common mode of testing - coughing up a sample of sputum to be checked under the microscope for the bacteria - often does not work because young children are usually unable to produce a sample.

Even when a child can provide a sample, it will often come back negative because children are usually infected with far fewer organisms. And as yet there is little evidence that new molecular tests like GeneXpert will assist in paediatric diagnosis.

Better treatment needed

The response to TB treatment is another inadequately understood issue. "For many years children were given the same milligram-per-kilogram dosage [as adults]. But the problem is that if you give 5mg/kg of Isoniazid (a standard first-line TB drug) to an adult, and 5mg/kg of Isoniazid to a child, the levels that are reached in the blood are not the same,” Schaaf told PlusNews.

Yonele Ndamane, "My TB is going to be right" 
“I've been [at Brooklyn Chest Hospital] since November [2011]. I'm going home 24th May [2012]. I have MDR TB. Before I came here I was feeling so tired, had pains in my chest and I [couldn't] walk because I was so tired. I was sleeping all the time. And then my mother said, 'I'm going to take you to the hospital.' And at the hospital they [took] my x-rays, and [the] doctor said to my mother I have TB.

“I was treated there for six months and my TB was... better. Then doctor said, ‘Another two months,’ and during the other two months it was [getting] better. But then doctor said, ‘Another two months.’ After one month... doctor said, 'This TB is not normal.'

They told me, 'We're going to take you to Prof [Dr Simon Schaaf] in Tygerberg [Hospital]’ and Prof took my x-rays there. And then they called us in Khayelitsha [township on the outskirts of Cape Town] and said, ‘You must go to Brooklyn [Chest Hospital].’

“My mother said, ‘You must eat, and run and play.’ Now I'm right. I can do everything, no pain. Doctor said I can go for weekends to my parents and so I am feeling happy. It's nice here because I'm getting healthy food and I'm eating a lot of times and my weight is up. I'm big now! My favourite food? Pudding, and rice and chicken. At home I eat pudding only in December. But healthy food I'm eating here every day.

“I take 15 pills every day. I'm taking white ones, yellow ones, and then a grey one. It's difficult - some of them are not right-smelling. And I get an injection every day - it's okay.

“I'm not missing home all the time because I know my mother will come and visit if I want. I come to school and play on computers and write my subjects, and then Frau, my teacher, she's making us happy, making jokes. It's right here.

“I got TB from my brother, but now he's in Eastern Cape [Province]. Me and my brother were sleeping in one room. He's 23.

“If I can't leave on 24 May? Whoa! I'm going to be very sad. I think [everyone] here knows when they are [being] discharged. The small ones? I don't know, but my friends - they all know [their discharge date].

“My TB is going to be right. And I talk to my friends... They know mostly that my TB is not too spitting [infectious], so we can play soccer together again. It's coming right now.”
“We did several studies and found that we need slightly higher doses for children… Children are not small adults. The liver size is different compared to the rest of the body - a child's liver functions better because of less other toxicity or disease or damage. It could be that kidney function is better - adults have 60 percent body water, children have 80 percent. All of these factors can play a role," said Schaaf.

As result of this research, the World Health Organization (WHO) changed its guidelines on first-line drug dosages for children. Hesseling and Schaaf recently began a similar five-year study funded by the US National Institutes of Health (NIH) to examine the second-line drugs used to treat MDR and extensively drug-resistant TB (XDR TB) in children.

"We actually don't know what dosages children should really have," Schaaf noted. "We were using the doses that we use for adults [to treat MDR] in children, but because we saw that it's not sufficient in first-line drugs, we need now to look at the second-line drugs."

HIV co-infection looms large among the other issues complicating paediatric TB. HIV-positive children and infants are especially vulnerable to the most severe and deadly forms of TB, like TB-meningitis. Known and unknown interactions between drugs also complicate the management of TB in HIV co-infected patients. "With HIV-TB co-infection... you're giving that many more drugs,” Schaaf pointed out. The NIH study will also look at how TB and HIV drugs affect one another.

The results could yield critical information. "I take 15 pills every day,” said Yonele. “I'm taking white ones, yellow ones, and then a grey one. It's difficult - some of them are not right-smelling - and I get an injection every day, but it's okay," he said with impressive equanimity.

Perhaps the biggest problem is that medicines are rarely available in doses suitable for children. "You have to break up tablets and crush them, and it's difficult to get the right dose for a child," Schaaf said.

At the end of the day, if the research into better and more child-friendly methods of diagnosis and child-specific dosages is to be effective, greatly increased awareness of TB as a serious and, in some areas, all too common childhood disease is desperately needed.

"TB can go anywhere, anyhow. It is a disease of poverty and it is a disease associated with HIV, but anyone can get TB, at any age… it's important [to know] that very young babies can get TB," Schaaf commented.

Evelyn Dodgen, the head teacher at the Brooklyn Chest Hospital School, agreed that many parents are unaware of the dangers of TB. She worries that children are living in households with adults who are sick with TB but ignorant of the risks to children, or that when children fall sick it is often unacknowledged for far too long.

"Parents must listen to the children when the children tell them they're sick - there are so many signs to look for: headaches, coughing, vomiting, not eating, and especially when they complain that they are so tired that they just want to sleep... If your child stays absent from school for three weeks, there is something wrong," she said.

Paying attention to the signs can mean more effective treatment. "The other message is that by far the majority of childhood TB is curable, even MDR TB and XDR TB,” said Schaaf. “As long as you identify it early enough and treat it with the correct drugs."


Theme (s): Children, Health & Nutrition,

[This report does not necessarily reflect the views of the United Nations]

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