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Paediatric tuberculosis - new advances to close persistent gaps
Ben J Marais1, Sabine Verkuijl2, Martina Casenghi3
1The Children's Hospital at Westmead and the Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia.
Insights
Young children face high tuberculosis (TB) mortality due to diagnostic challenges. Improving access to TB preventive treatment (TPT) requires better diagnostics and embracing pragmatic approaches, even accepting some over-treatment.
Area of Science:
- Pediatrics
- Infectious Diseases
- Public Health
Background:
- Young children are disproportionately affected by severe tuberculosis (TB) and TB-related deaths.
- Lack of diagnosis and treatment access significantly contributes to pediatric TB mortality.
- Current strategies for TB preventive treatment (TPT) in children face barriers like resource allocation and diagnostic limitations.
Purpose of the Study:
- To address the challenges in diagnosing and treating tuberculosis in young children.
- To explore strategies for improving access to TB preventive treatment (TPT) for vulnerable children.
- To evaluate the potential of new diagnostic tools and pragmatic approaches in pediatric TB care.
Main Methods:
- Reviewing the vulnerability of young children to severe TB and associated mortality.
- Examining barriers to TPT access, including diagnostic needs and decentralized care models.
- Considering the role of Xpert MTB/RIF Ultra® and novel urine assays (Fujifilm SILVAMP TB LAM®) for improved case detection.
- Discussing the implications of limited diagnostic accuracy and the tolerance of TB drugs in children.
Main Results:
- Young children are highly vulnerable to severe TB, with most deaths occurring without diagnosis or treatment.
- Symptom-based screening is less risky for drug resistance generation in children than in adults.
- New diagnostic tools like urine assays show promise but require further validation.
- Limited diagnostic accuracy necessitates considering pragmatic approaches, potentially including some over-treatment, to close the case detection gap.
Conclusions:
- Closing the pediatric TB case detection gap requires innovative approaches beyond traditional methods.
- Decentralized care models and improved diagnostics are crucial for enhancing TPT access in children.
- Accepting a degree of over-treatment may be necessary to effectively manage and reduce childhood TB burden given current diagnostic limitations.
Abstract:
Young children are most vulnerable to develop severe forms of tuberculosis (TB) and are over-represented among TB deaths. Almost all children estimated to have died from TB were never diagnosed or offered TB treatment. Improved access to TB preventive treatment (TPT) requires major upscaling of household contact investigation with allocation of adequate resources. Symptom-based screening is often discouraged in adults for fear of generating drug resistance, if TB cases are missed. However, the situation in vulnerable young children is different, as they present minimal risk of drug resistance generation. Further, the perceived need for additional diagnostic evaluation presents a major barrier to TPT access and underlies general reluctance to consider pragmatic decentralised models of care. Widespread roll-out of Xpert MTB/RIF Ultra® represents an opportunity for improved case detection in young children, but attaining full impact will require the use of non-sputum specimens. The new Fujifilm SILVAMP TB LAM® urine assay demonstrated good diagnostic accuracy in HIV-positive and malnourished children, but further validation is required. Given the limited accuracy of all available tests and the excellent tolerance of TB drugs in children, the global community may have to accept some over-treatment if we want to close the persistent case detection gap in young children.
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