New model offers hope for pediatric TB care
Preventative therapy may be the answer
In resource-poor countries, pediatric TB has long been a neglected stepchild. For one thing, children can’t readily produce sputum, so diagnosis through sputum-smear microscopy is nearly impossible; and backup diagnostic tools available in first-world nations (namely, tuberculin skin testing and chest X-rays) are not readily available. Contact investigation? Too expensive, the argument goes.
The tragic result is that an untold number of pediatric TB cases throughout the developing world go undiagnosed and treated, and vast numbers of children, latently infected by adult-source cases in their household, are doomed to suffer active TB later in life.
All that may be about to change, thanks to two U.S. pediatricians. "The bad news is that pediatric TB has been horribly neglected," says Jeff Starke, MD, head of pediatrics at Ben Taub Hospital in Houston, and a leading expert in the country on the subject of TB in children. "The good news is that with the advent of DOTS [the TB control strategy approved by the World Health Organization], we can finally do something about it."
The remedy pushed by Starke and Jane Schaller, MD, the president of the Paris-based International Pediatric Association (IPA), is simple but effective: In households where a DOTS worker is already coming to dispense medication to an adult, all children should be placed on isoniazid for preventive therapy.
"That, in fact, has been the policy in a WHO manual for the past 20 years," says Starke. "It’s simply never been operationalized." That goes, he adds, "regardless of whether or not the child has symptoms, and even if you have no other resources — no skin testing, no chest X-rays. This is a service that should be provided."
A sense of fatalism
The reason for not having done so sooner is mostly the sense of fatalism with which the international community has treated pediatric TB, he says. "I’m really tired of hearing people in the international community discount American methods of TB control, such as contact investigation, and argue that they don’t apply to resource-poor settings," says Starke. "The truth is we’ve done a lot of good things, especially for pediatric TB — and with a fairly minimal use of resources."
A recent modeling study from Harvard University turned the adage — that the best way to control TB in kids is to control it in adults — on its head, he adds. "It may sound like stating the obvious, but that model found that detecting and treating pediatric TB is a far more effective way to control pediatric TB than detecting and treating TB in adults."
What Starke and his colleague Schaller are aiming for is a paradigm shift of sorts — something akin to the way the Cambridge, MA-based nonprofit Partners in Health flipped on its head the old wisdom about not treating multidrug-resistant TB. That means it’s critical to get all the big players on board.
Schaller may have jump-started the process a few years ago when she was cruising the web trying to find topics for IPA discussion groups, she says. Stumbling upon STOP-TB, she was intrigued, and not a little dismayed, to find not a word about pediatric tuberculosis. She promptly wrangled an invitation to the WHO’s upcoming Ministerial Conference in Amsterdam. After some initial resistance, STOP-TB came around, she reports — so much so that "Mario Raviglione," the head of STOP-TB, "is one of my heroes," she now says.
CDC, NIH have pledged campaign support
The Centers for Disease Control and Prevention and the National Institutes of Health (NIH) also have pledged support to the Starke and Schaller’s campaign. The NIH’s involvement probably dates back to the day Anthony Fauci, MD, director of the NIH’s National Institute of Allergy and Infectious Diseases, addressing a congressional hearing on the subject of global TB. He put in a hasty call to Starke asking for data on global pediatric TB. "Actually," Starke replied to the astonished Fauci, "there aren’t any data."
When Starke gives talks on the subject of pediatric TB, he routinely shows a slide he introduces as "our current data on the prevalence and incidence of pediatric TB." That slide is totally blank — a testimony to the Catch-22-style dilemma imposed by the fact that WHO defines a reportable TB case as one that is a sputum culture-positive. But with no sputum to culture, kids, by that definition, cannot by WHO’s definition be said to have TB.
The next step, say Schaller and Starke, is to convene a series of meetings in high-burden TB countries between pediatricians and TB controllers. "In every one of these countries, there’s a pediatrician who knows more about childhood TB than any of the public health programs, " Schaller says. One frequent complaint heard by the widely traveled Schaller is that pediatricians often can’t get isoniazid from the national TB-control program. The reason, again, often turns on case definitions. For their part, the pediatricians need to better understand how the national TB program works.
That kind of coming together can help sort out a wide array of sticking points as well as raise awareness and get health care professionals of every stripe to "think TB" in an arena where, she and Starke concede, diagnosis is tricky, and symptoms — fever, weight loss, cough — are so widespread in third-world settings that they are all too often overlooked. "For so long, we’ve had these two standards when it comes to pediatric TB — one for rich countries, and the other for poor ones," she adds. "It’s time for that to come to an end."
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