International Journal of Infectious Diseases 32 (2015) 166–169

Contents lists available at ScienceDirect

International Journal of Infectious Diseases

journal homepage: www.elsevier.com/locate/ijid

Regional initiatives to address the challenges of tuberculosis in

children: perspectives from the Asia-Pacific region
Stephen M. Graham a,b,c,*, Malgorzata Grzemska d, Annemieke Brands d, Huong Nguyen e,
James Amini f, Rina Triasih g, Khurshid Talukder h, Shakil Ahmed i, Farhana Amanullah j,
Blessina Kumar k, Pervaiz Tufail l, Anne Detjen a, Ben Marais m, Cornelia Hennig n,
Tauhid Islam n
a
International Union Against Tuberculosis and Lung Disease, Paris, France
b
Centre for International Child Health, University of Melbourne Department of Paediatrics and Murdoch Childrens Research Institute, Royal Children’s
Hospital, Melbourne, Australia
c
Centre for International Health, Burnet Institute, Melbourne, Australia
d
Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
e
KNCV Tuberculosis Foundation Country Office, Ha Noi, Viet Nam
f
National Department for Health, Port Moresby, Papua New Guinea
g
Department of Pediatrics, Dr. Sardjito Hospital/Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
h
Centre for Woman and Child Health, Dhaka, Bangladesh
i
Bangladesh Paediatric Association TB CARE II Porject, Dhaka, Bangladesh
j
The Indus Hospital, Karachi, Pakistan
k
Global Coalition of TB Activists, Delhi, India
l
Organization for Tuberculosis People, Pakistan
m
Marie Bashir Institute for Infectious Diseases and Biosecurity and the Children’s Hospital at Westmead, University of Sydney, Sydney, Australia
n
Stop TB and Leprosy Unit, Division of communicable Diseases, World Health Organization Regional Office for the Western Pacific, Manila, The Philippines

A R T I C L E I N F O A B S T R A C T

Article history: Increasing attention is being given to the challenges of management and prevention of tuberculosis in
Received 21 November 2014 children and adolescents. There have been a number of recent important milestones achieved at the
Accepted 6 December 2014 global level to address this previously neglected disease. There is now a need to increase activities and
Corresponding Editor: Eskild Petersen, build partnerships at the regional and national levels in order to address the wide policy-practice gaps
Aarhus, Denmark for implementation, and to take the key steps outlined in the Roadmap for Child Tuberculosis published
in 2013. In this article, we provide the rationale and suggest strategies illustrated with examples to
Keywords: improve diagnosis, management, outcomes and prevention for children with tuberculosis in the Asia-
tuberculosis Pacific region, with an emphasis on the need for greatly improved recording and reporting. Effective
child collaboration with community engagement between the child health sector, the National Tuberculosis
national tuberculosis programmes control Programmes, community-based services and the communities themselves are essential.
contact screening
ß 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/3.0/).

1. Background decades of neglect where children were generally outside the

boundaries of National Tuberculosis control Programme (NTP)
In recent years, the attention being given to the challenges of activities as these focused primarily on interrupting transmission
tuberculosis in children has been increasing within the global by case-detection and effective treatment of people in the
public health and tuberculosis control agenda. This has followed community with sputum smear-positive tuberculosis.1
The recent change of focus is welcome and a critical opportunity
for a number of reasons:

* Corresponding author. Centre for International Child Health, Department of

1. Tuberculosis is an important treatable and preventable cause
Paediatrics, Royal Children’s Hospital, 50 Flemington Road, Parkville, Victoria
3052 Australia. Tel.: +(+61) 3 9345 4788; fax: +(+61) 3 9345 6667. of morbidity and mortality in infants and young children
E-mail address: steve.graham@rch.org.au (S.M. Graham). (0-4 years) in tuberculosis endemic settings.2,3 Therefore, while

http://dx.doi.org/10.1016/j.ijid.2014.12.013
1201-9712/ß 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
 S.M. Graham et al. / International Journal of Infectious Diseases 32 (2015) 166–169 167

young children with tuberculosis are not a group responsible for

Box 1. The Childhood TB Roadmap - ten key actions to be
most of the ongoing transmission in the community, they are
taken at the global and national levels
important in the context of child survival, and most tuberculosis
endemic countries in the world include reductions in under-5
mortality and improved child health as a major national priority. 1. Include the needs of children and adolescents in research,
2. Older children and adolescents (10-19 years) with tuberculosis policy development and clinical practice.
do transmit tuberculosis and have unique diagnostic and 2. Collect and report better data, including on preventive
treatment challenges3,4, but we have scant knowledge of the measures.
burden and outcomes of tuberculosis in these age groups. 3. Develop training and reference materials on childhood
3. Tuberculosis in children is an important sentinel event that tuberculosis for health care workers.
4. Foster local expertise and leadership among child health
reflects recent transmission.1,3 Therefore, accurate data of the
workers at all levels of the health care system.
burden of tuberculosis in children could potentially provide an
5. Do not miss critical opportunities for intervention (e.g. use
important baseline for monitoring and evaluation of the wider strategies such as intensified case-finding, contact tracing
epidemic or recent outbreaks, including of multidrug resistant and preventive therapy); implement policies for early diag-
tuberculosis. nosis; and ensure there is an uninterrupted supply of high-
4. Young children with tuberculosis have unique treatment needs, quality anti-tuberculous medicines for children.
such as dosages and preparations.5 Therefore, more accurate 6. Engage key stakeholders, and establish effective communi-
data on the potential market of drugs for children are required to cation and collaboration among the health care sector and
inform drug procurement and ensure uninterrupted treatment, other sectors that address the social determinants of health
and also to support efforts in drug development. and access to care.
7. Develop integrated family- and community-centred strate-
gies to provide comprehensive and effective services at the
community level.
2. Increasing attention to tuberculosis in children – recent 8. Address research gaps in the following areas: epidemiolo-
global steps gy, fundamental research, the development of new tools
(such as diagnostics, medicines and vaccines); and address
In March 2011, the first international meeting on child gaps in operational research, and research looking at health
tuberculosis was held in Stockholm as a joint initiative supported systems and services.
by the European Centre for Disease Control and the Stop TB 9. Closing all funding gaps for childhood tuberculosis at the
Partnership. The meeting included a wide range of stakeholders national and global levels.
10. Form coalitions and partnerships to study and evaluate the
representing the child healthcare sector, tuberculosis control
best strategies for preventing and managing childhood tu-
programmes, researchers, non-governmental organizations, fund-
berculosis, and for improving tools used for diagnosis and
ing organizations, advocates, civil society organizations, and treatment.
children and families affected by tuberculosis. The meeting
initiated and endorsed a ‘‘Call to Action’’ with over 1,000
signatories posted on the Stop TB Partnership’s website.6 In
2012, children were the focus of attention on World TB Day for the The World Health Organization (WHO) and The Union also
first time. Sensing the need to provide future direction in addition developed ten training modules to complement the recent
to the guidance of the more technical policy documents, a guidelines that are freely available on the WHO website.9 The
Roadmap for Childhood Tuberculosis was developed by multiple training is particularly focused on the health workers in the
collaborative partners, and this was launched in Washington DC on primary and secondary levels of care where the majority of
October 1st, 2013.7 children with suspected tuberculosis or that are close contacts of
The Roadmap for Childhood Tuberculosis represents a global tuberculosis cases will present and be managed. The separation
‘‘action plan’’ including comprehensive and practical action points into modules with overlap between modules is deliberate so that
aiming to engage a range of stakeholders in a common goal over training on childhood tuberculosis can readily be integrated into
the next decade. A major first step in order to implement key other ongoing activities such as HIV care, maternal and child
actions is to engage the relevant stakeholders and bring together health, integrated community case-management or annual
those representing and working in the maternal and child health reviews of NTPs, rather than encouraging the development of
sector with those representing and working in NTPs. This has been stand-alone childhood tuberculosis training workshops. The
achieved at the global level with the formation and strengthening training material will be further complemented by a self-taught
of the child TB subgroup of the Stop TB Partnership, supported by e-learning course that has been developed by The Union, the WHO
the secretariat from the Global TB Programme. The Box lists ten key and members of the Stop TB Partnership’s Child Tuberculosis
actions that also need to be taken at regional and national levels.7 Subgroup, to be launched in 2015.
Clear policy guidelines based as far as is possible on the current
evidence base are required to provide guidance to NTPs, especially
given the lack of confidence that NTPs and clinicians often have in 3. The development of regional and national initiatives for
engaging in child tuberculosis-related activities. In 2014, the WHO implementation
published the second edition of the ‘‘Guidance for national
tuberculosis programmes on the management of tuberculosis in While members of the global Child Tuberculosis Subgroup have
children’’.8 The second edition includes 28 recommendations and an important role regarding development of guidelines and
expands on the first edition of 2006 by including specific chapters training tools, technical assistance, advocacy and global represen-
on the management of tuberculosis in HIV-infected children, tation; actual implementation to address the huge policy-practice
children with multidrug resistant (MDR) tuberculosis, and gap in childhood tuberculosis requires a decentralized strategy
implementation of integrated care. There are novel recommenda- with strong child TB champions in each country. We have therefore
tions relating to the use of Xpert MTB/RIF in children and for recently engaged and begun to implement such a strategy at the
revised dosages of first-line anti-TB drugs in children less than regional and national levels by supporting the development or
25 kgs. strengthening of ‘‘child tuberculosis working groups’’ linking the
168 S.M. Graham et al. / International Journal of Infectious Diseases 32 (2015) 166–169

child health sector with NTPs. In March 2014, the WHO Western appropriate management for children that are recent, close
Pacific Regional Taskforce on Child Tuberculosis was formed contacts of a case of infectious tuberculosis unless informed by
following a meeting in Viet Nam of national representatives from the district TB unit or community health workers that have
nine countries. Country representatives provided current situa- registered and provide treatment for that TB case. It soon becomes
tional updates, identified priorities for implementation and have clear that there needs to be a mechanism in place that brings
since developed national action plans. In September 2014, a Global together the child health sector that cares for child tuberculosis
Consultation held in Indonesia and facilitated by the WHO brought cases and contacts with the NTP along with advocates and
together representatives from countries in the South-East Asian members representing the broader community.
and Eastern Mediterranean Regions to share experiences and learn An example from Bangladesh of such broad community
further from Western Pacific Regional Taskforce representatives. representation in TB service provision was the training up of
These important workshops have included almost all of the high medicine shop owners to provide DOTS services successfully.20
burden tuberculosis countries in the Asia-Pacific region. The Figure illustrates a possible framework that highlights the
potential roles of the child tuberculosis working group. The need
4. Examples of recent national initiatives for implementation for innovative approaches to integration and engagement of NTPs
with the wider health sector are explicit priorities in WHO post-
It is difficult to know the true burden of tuberculosis in the Asia- 2015 global TB strategy.21 Bangladesh provides an example of an
Pacific region. Until recently, many NTPs reported that childhood active child tuberculosis working group that includes 21 members
tuberculosis accounted for less than 2% of the total burden. This is representing NTP, paediatricians, national paediatric association,
below the estimated global average of 6% by the WHO10, and well researchers, academics, non-governmental organisations engaged
below that which would be expected from high incidence in tuberculosis care and the WHO, with plans to invite a patient
tuberculosis countries with large populations of children.1 One representative.
reason may be poor case-detection in children due to diagnostic In almost all settings, the implementation of child tuberculosis
challenges, and the potential to increase case detection has been activities that ultimately will improve case-detection, manage-
illustrated in a recent study from Bangladesh.11 However, there is ment and prevention of tuberculosis in children will require
also likely to be considerable under-reporting. A recent study from training, especially of those health workers that do not have a high
Indonesia reported that less than 2% of children diagnosed and level of expertise or clinical experience of childhood tuberculosis.
treated for tuberculosis in Java were reported to the NTP.12 For Tools need to be developed or adapted so that training is integrated
countries in the region where children with suspected tuberculosis into other relevant training for the child health sector or NTP. A
access the same public health system and if diagnosed with recent example from Bangladesh developed training manuals and
tuberculosis are routinely reported, the proportion of the total learning tools and has trained 39 doctors as facilitators, 17 district
tuberculosis caseload that is children ranges from 10% to 30%.13–15 health managers, 786 doctors on a 4-day module and 8,964 health
A particularly stark example that illustrates the wide policy- workers including 619 doctors on a 1-day module (Shakil Ahmed,
practice gap relates to the management of children who are close personal communication). While improving diagnosis through
contacts of infectious tuberculosis cases.16 We have known for training is a major need, the importance of routine reporting and
decades that infants and young children are particularly suscepti- recording should also be emphasized at every opportunity.
ble to developing tuberculosis following exposure and infection, Improved data will provide the basis for identifying and addressing
and that preventive therapy can substantially reduce this risk. This the gaps as well as for monitoring and evaluation of progress.
evidence-base provides the rationale for the policy and guidelines
to screen and manage children that are household contacts of 5. The need for community engagement
tuberculosis cases, especially prioritizing those with sputum
smear-positive tuberculosis.8 The guidelines have been in place Efforts to address the wide policy-practice gap in order to reach
for decades, are almost universally accepted and yet rarely the Roadmap’s ultimate goal of achieving zero deaths from
implemented, except in low tuberculosis endemic settings.17 tuberculosis in children requires sustained advocacy, greater
A recent prospective cohort study in Indonesia reported the commitment, mobilization of adequate resources, and joint efforts
effectiveness and safety of implementing the symptom-based by all stakeholders (Table). There are many misconceptions in the
screening approach recommended by the WHO.18 Of children that community and in health workers at primary care settings around
were close household contacts of cases with tuberculosis, 8% had the management and prevention of tuberculosis in children. There
tuberculosis that had not yet been detected, including one child
with tuberculous meningitis, and were successfully treated. Of the
asymptomatic contacts of less than 5 years that received
preventive therapy according to national guidelines, none had
developed tuberculosis after 1 year of active follow-up. Another
recent study from Indonesia quantified the large existing gaps at
each stage of the evaluation and management process.19 Since
2011, the NTP of Viet Nam with the technical support of KNCV has
implemented community-based contact screening and manage-
ment in four provinces in Viet Nam, with the ultimate aim of step-
wise implementation to all provinces by 2020.
There are other practical, structural issues that highlight the
need for the development of communication and collaboration
between the child health and tuberculosis control sectors. Children
with tuberculosis do not present for diagnosis and management to
the district TB unit of the NTP but rather to the general child health
services, and the NTP will usually only become aware of the child
should the child health workers register the case with the NTP. On Figure 1. Interventions that target stages of the continuum in children from
the other hand, the child health services will not be able to provide susceptibility to disease and outcome.
 S.M. Graham et al. / International Journal of Infectious Diseases 32 (2015) 166–169 169

Table 1 6. Summary
Engaging key stakeholders in the community to address child tuberculosis

Stakeholders Main roles We highlight recent regional and national initiatives that aim to
Community-based organizations Support local programmes according to improve diagnosis, management, outcomes and prevention for
and nongovernmental capacity. This may include supporting children with tuberculosis in the Asia-Pacific region. Strong
organizations initiatives aimed at increasing collaborative efforts between the child health sector, the
community education and awareness community and the NTP, and led by local child TB champions,
or providing contact tracing, preventive
are essential to improve the care of children and address persistent
therapy, diagnosis, treatment support
or referral. policy-practice gaps.
Provide technical assistance and Conflict of Interest/Funding: None
training if appropriate (counselling and
treatment literacy)
Community leaders (teachers, Promote tuberculosis education and
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