Downloaded from http://adc.bmj.com/ on December 7, 2014 - Published by group.bmj.com
ADC Online First, published on December 5, 2014 as 10.1136/archdischild-2013-304816 Global child health
Are TB control programmes in South Asia ignoring children with disease? A situational analysis Sadia Shakoor,1,2 Farah Naz Qamar,2 Fatima Mir,2 Anita Zaidi,2 Rumina Hasan1 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ archdischild-2013-304816). 1
Department of Pathology and Microbiology, Aga Khan University, Karachi, Pakistan 2 Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan Correspondence to Professor Rumina Hasan, Department of Pathology and Microbiology, Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800, Pakistan;
[email protected] Received 30 September 2014 Revised 12 November 2014 Accepted 14 November 2014
To cite: Shakoor S, Qamar FN, Mir F, et al. Arch Dis Child Published Online First: [ please include Day Month Year] doi:10.1136/ archdischild-2013-304816
ABSTRACT Paediatric tuberculosis (TB) has long been an evasive entity for public health practitioners striving to control the disease. Owing to difficulty in diagnosis of paediatric TB, incidence estimates based on current case detection fall short of actual rates. The four highburden countries in South Asia (SA-HBC)—Afghanistan, Pakistan, India and Bangladesh—alone account for >75% of missed TB cases worldwide. It follows that these countries are also responsible for a large although unmeasured proportion of missed paediatric cases. In view of current Millennium Development Goals recommending a scale-up of paediatric TB detection and management globally, there is a dire need to improve paediatric TB programmes in these high-burden countries. Inherent problems with diagnosis of paediatric TB are compounded by programmatic and social barriers in SA-HBC. We have reviewed the current situation of TB control programmes in SA-HBC countries based on published statistics and performed a strengths, weaknesses, opportunities and threats situational analysis with a view towards identifying critical issues operant in the region posing barriers to improving paediatric TB control. Of an estimated nine million new cases of tuberculosis (TB) occurring across the globe each year, children account for nearly half a million (490 000), with two-thirds residing in 22 high-burden countries (HBCs).1 In 2011 alone, 64 000 childhood deaths (among ≤15 years) were attributed to TB.2 Current WHO-recommended case detection methods (sputum smear positivity) identify only an estimated 5% of TB cases among children,3 a demographic with classically sputum smear-negative, and predominantly culture and Xpert negative, disease. It is therefore not surprising that children make up the majority of an estimated three million people with TB who remain undiagnosed and untreated.1 It is imperative that in the move towards zero TB deaths in children, programmes are strengthened and equipped to detect and control the disease in this ‘vulnerable’ subgroup in high-TB burden areas of the world. Here, we review evidence on paediatric TB burden, and capacity of national TB control programmes (NTPs) for paediatric scale-up in four high-burden countries of South Asia (SA-HBC)1: Afghanistan, Pakistan, India and Bangladesh. The purpose of this review is to evaluate the current capacity of TB control programmes in these four countries to diagnose, treat and quantify childhood TB, and propose practical solutions to gaps in achieving integrated paediatric TB management.
TEASING APART THE PROPORTION OF CHILDREN IN THE TB EPIDEMIC IN SA-HBC (AFGHANISTAN, PAKISTAN, INDIA AND BANGLADESH) Paediatric cases (occurring in children aged 0–14 years) are an early indicator of ongoing transmission of TB among adolescents and adults aged 15–34 years, the demographic responsible for highest transmission rates.4 5 Children develop disease earlier and contract the disease through contact with adult cases. South Asia houses half of the world’s high TB-burden countries, two-third of which are also high incidence for multidrug-resistant (MDR)-TB.1 Table 1 presents information available on health and demographic indicators of relevance in Afghanistan, Pakistan, India and Bangladesh.1 6–11 Incidence estimates show that all four countries are high burden for TB (40–499 incident cases per 100 000 population), and sparing Afghanistan, also high burden for MDR-TB cases. Around onequarter of the world’s youth (the greatest proportion among all geopolitical regions) lives in this region.12 This skewed age demographic indicates that the TB epidemic in South Asia represents a large proportion of childhood TB cases in the world. The main programmatic challenge lies in capturing all incident childhood TB cases, despite sputum smear limitations in this age group.13
Case detection rates and missed paediatric TB cases TB case detection rates (CDRs) for all age groups range from 49% to 65% in SA-HBC. These fall short of the 70% CDR global target.14 Pakistan, India and Bangladesh are among 12 countries where 75% of the three million ‘missed’ cases occurred in 2012, with India contributing to as much as 31%, Pakistan 5% and Bangladesh 6% to the total 75% cases.14 Figure 1 shows all reported TB cases in 2011 and 2012, disaggregated by site, and age.1 Although 29–47% of the population in these countries comprises children 0–14 years,7 paediatric cases comprise a very small proportion of total reported cases. A recent estimation of missed paediatric cases, based on a mathematical model built on household exposure to adult cases, reports that India alone accounts for 27% of the missed cases in 22 HBCs.15 Even this staggering proportion may be an underestimate as this model assumes that BCG confers protection against extrapulmonary TB and partial protection against pulmonary TB, a vaccine that we now know does not have protective efficacy more than 0–50%16 17 in high-prevalence populations. To increase CDRs, some HBCs have declared TB to be a notifiable disease; however, compliance
Shakoor S, et al. Arch Dis Child 2014;0:1–8. doi:10.1136/archdischild-2013-304816
1
Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.
Downloaded from http://adc.bmj.com/ on December 7, 2014 - Published by group.bmj.com
Global child health
1.4 2.2 3.5 3.5
ARI, acute respiratory infections; CDR, case detection rates; MDR, multidrug resistant; TB, tuberculosis.
MDR in incident (new) cases %1
Y
49
2012 2012 2012 2007 10 11
Last update of national TB guidelines8 9
Y Y 9 10 11
Paediatric TB guidelines available8
Y
225 176
59 65 52
231 189 TB incidence best estimates 20121
CDR all cases %1
7.0 (2012) Health expenditure as % government expenditure7
TB programme indicators
35.2 (2012)
7.7 (2012) 9.4 (2012)
69 (2006)
Factors contributing to missed paediatric cases
4.7 (2012)
60.5 (2011) Percentage of under five seen by physician for ARI7
69.3 (2007)
31
36.5 (2011) 43.5 (2006) 32.9 (2004) Percentage of under five malnourished (weight for age)7
30.9 (2011)
