Commentary: A targets framework: Dismantling the invisibility trap for children with drug-resistant tuberculosis

Abstract

Tuberculosis (TB) is an airborne infectious disease that is both preventable and curable, yet it kills more than a million people every year. Children are highly vulnerable, but often invisible casualties. Drug-resistant forms of TB are on the rise globally, and children are as vulnerable as adults but less likely to be counted as cases of drug-resistant disease if they become sick. Four factors make children with drug-resistant TB 'invisible': first, the nature of the disease in children; second, deficiencies in existing diagnostic tools; third, overreliance on these tools; and fourth, our collective failure to deploy one effective tool for finding and treating children -contact investigation. We describe a nascent science-advocacy network -the Sentinel Project on Pediatric Drug-Resistant Tuberculosis -whose goal is to end child deaths from this disease. Provisional annual targets, focused on children exposed at home to multidrug-resistant TB, to be updated every year, constitute a framework to focus attention and collective actions at the community, national, and global levels. The targets in two age groups, under 5 and 5-14 years old, tell us the number of: (i) children who require complete evaluation for TB disease and infection; (ii) children who require treatment for TB disease; and (iii) children who would benefit from preventive therapy.

Two methods for setting child-focused tuberculosis care targets

“…The general principle behind these methods is that multiplying the number of infectious adult cases with TB by the number of children likely to be found in each adult patient's household yields the number of children who require evaluation for TB. 8 Multiplying this number by appropriate risk estimates yields the number of children expected to have TB disease and tuberculous infection on contact investigation. All of these estimates are restricted to children in the households of adults who have been diagnosed with TB.…”

Global burden of childhood tuberculosis

“…The reasons behind the need to understand disease burdens are broadly similar across diseases: without robust estimates of the true burden of disease, we cannot identify gaps in identification of cases, estimate the resources required to reduce this burden, begin to plan the types of interventions that might be effective or measure the impact of these interventions. The specific reasons for understanding the burden of childhood TB have been covered previously [9] but include the need to raise advocacy for childhood TB, which has been traditionally much neglected [10]; a need for increased research into improved diagnostics and treatment regimens specifically for children; demonstration of the importance of TB in the context of overall childhood morbidity and mortality; and also because childhood TB is a surveillance indicator for recent transmission within a community [11]. …”

“…Difficulties with obtaining bacteriologically positive sputum from children with TB only serve to amplify these issues [30]. It is believed that the majority of cases of pediatric drug-resistant TB are undiagnosed as such and therefore inappropriately treated [11], if they receive any treatment at all. With so much under-diagnosis of pediatric drug-resistant TB, how do we know how many children globally develop active TB disease annually due to a drug-resistant strain?…”

New and Repurposed Drugs for Pediatric Multidrug-Resistant Tuberculosis. Practice-based Recommendations

“…This differential standard of care is due, in part, to the exclusion of children from most TB clinical trials (10). There is some consensus that adolescents should be included in adult TB efficacy trials, but it may not be necessary to repeat efficacy trials in younger children.…”