Childhood Tuberculosis: Current
Scenario in India
Gedam DS1,
Patel U22
1Dr D Sharad Gedam, Professor of Pediatrics, 2Dr
Umesh Patel, Associate
Professor of Pediaatrics. Both are affiliated with L N Medical College,
Bhopal, India & member of Editorial board.
Address for
correspondence: Dr Umesh Patel, Email:
drumeshpatel@gmail.com
Abstract
Almost one third of Indian population is having tubercular infection.
Children always get infection from open cases of Tuberculosis.
Associated malnutrition further increases intensity of tuberculosis. In
this editorial we have discussed about current scenario of tuberculosis
in India with special emphasis on children.
Key words:
Tuberculosis in children, prevalence, Tuberculosis.
Introduction
“Measurement is the first step that leads to control and
eventually to improvement. If you can’t measure something,
you can’t understand it. If you can’t understand
it, you can’t control it. If you can’t control it,
you can’t improve it.” — H. James
Harrington. What James Harrington said is very relevant to
childhood TB and in particular, to those children under five years who
are in close contact with an adult who has been recently diagnosed with
active pulmonary TB. Tuberculosis (TB) is one of the most
ancient diseases of mankind. It is considered greatest killer of
mankind [1]. TB is now among the 10 major causes of mortality in
children [2, 3]. Children with TB infection today represent the
reservoir of TB disease tomorrow. Childhood TB has historically been
neglected by the global TB community and the health community and never
consider major public health problem. As children with TB are usually
less infectious than adults, they have received little attention from
national TB control programmes. Even when children are diagnosed with
TB and treated for it, many are not registered with or reported to/by
national TB programme.
The actual burden of pediatric TB is not known but has been assumed
that 10% of total TB load is found in children. Globally, about 1
million cases of pediatric TB are estimated to occur every year
accounting for 10-15% of all TB; with more than 100,000 estimated
deaths every year [3,4]. A September 2010 paper in the
Infectious Disease Clinics of North America journal states why
childhood TB should be taken seriously [5]. “Pediatric TB can
be regarded as an emerging epidemic in areas where the adult epidemic
remains out of control and Mycobacterium tuberculosis transmission is
ongoing. A 2009 study published in the International Journal of
Tuberculosis and Lung Diseases by V.V. Banu Rekha et al. from the
Chennai-based National Institute for Research in Tuberculosis (formerly
TRC) found that only 14 per cent of child contacts were screened and
only 19 per cent were initiated on isoniazid preventive therapy![6].
According to World Health Organization (WHO), TB is a worldwide
pandemic. It is a leading cause of death among HIV-infected people. In
2011, the first year when WHO included the estimates of pediatric TB in
its annual report, the incidence among children was about
half-a-million and the number of children killed was 64,000. WHO
estimates that the annual global burden of TB in children, in 2012 was
approximately 530,000 cases (or 6% of global TB burden), and that up to
74000 children died from TB that year [7]. It is important to note that
TB-related deaths in children infected with HIV are not included in
these estimates because they are classified as deaths caused by HIV
(i.e. not TB) [7]. These estimates have further limitations, and the
burden of TB in children is likely to be higher. There is no data on
the burden of multidrug-resistant (MDR-TB) in children. The prevention,
diagnosis and management of MDR-TB in children provide special
challenges for TB programme and is often only accessible at referral
levels of care. So actual burden of TB in children is very likely to be
much higher, given the fact that diagnosing childhood TB is a big
challenge. Of all the countries that report their TB statistics to WHO,
there are 22 countries that are referred to as the TB "high burden"
countries (India is one of them) and they have been prioritized at a
global level since 2000. These countries accounted for 82% of all
estimated cases of TB worldwide in 2011. Even today in India, two
deaths occurs every three minutes from tuberculosis [9]. HIV
not only makes diagnosis of TB more difficult in children, but
increases the risk of contracting TB disease 20-40 times
[10].
Children differ from adults TB as children much more likely to develop
extra-pulmonary TB, as many as 25% of childhood TB cases are
extra-pulmonary cases, compared with 16% in adults. Children are also
more likely to develop other severe forms of TB including disseminated
TB and TB meningitis. But the lack of an accurate “gold
standard” diagnostic test for TB in young children is major
challenge, and adds to the potential for both an under-diagnosis and an
over-diagnosis of cases. A misplaced faith in the protective efficacy
of the bacille Calmette–Guérin (BCG) vaccine
(although the BCG vaccine has been shown to prevent about 60% to 90% of
cases of meningeal TB and disseminated TB in young children) and lack
of research and investment again make difficult to tackle childhood
tuberculosis properly.
Major challenges to control TB in India include poor primary
health-care infrastructure in rural areas of many states; unregulated
private health care leading to widespread irrational use of first-line
and second-line anti-TB drugs; spreading HIV infection; lack of
political will; and, above all, corrupt administration [9]. Recently
scenario is gradually start changing. Contrary to traditional national
TB programmes, pediatric tuberculosis has always been accorded high
priority by RNTCP since the inception of the programme. In order to
simplify the management of pediatric TB, RNTCP in association with
Indian Academy of Paediatrics (IAP) has described criteria for
suspecting TB among children, has separate algorithms for diagnosing
pulmonary TB and peripheral TB lymphadenitis and a strategy for
treatment and monitoring patients who are on treatment [11,12].Today
India’s DOTS program is the fastest expanding and the largest
programme in the world in the term of patients initiated on treatment
and second largest, in terms of population coverage [13].
If the global goal of eliminating TB, initiated by WHO with its
“STOP TB” strategy, by 2050 is to be met, treatment
and prevention of TB in children needs as much attention as in adults.
Unfortunately, BCG, has limited efficacy against the most common forms
of childhood TB and its effect is of limited duration. However,
screening of household contacts of adult TB patients and provision of
preventive drugs to young children must receive higher priority. The
time has come to shift our focus from patient-centric care to
family-centric care. As India moves towards universal access to
prevention, diagnosis and treatment of TB, the little ones amongst us
must not be forgotten.
Funding:
Nil, Conflict of
interest:
Nil
Permission
from IRB:
Yes
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How to cite this article?
Gedam DS, Patel U, Childhood Tuberculosis: Current Scenario in India.
Pediatr Rev: Int J Pediatr Res
2014;1(1):1-2.doi:10.17511/ijpr.2014.01.01.