Tuberculosis (TB) is a leading cause of debilitating illness and death in children globally. However, it is often described as a hidden epidemic because the true burden of this disease in children remains unknown. This dearth of knowledge can be attributed to the many challenges faced by healthcare professionals in confirming a diagnosis of paediatric TB.
TB mimics many other common childhood diseases including pneumonia, malnutrition and HIV, and is therefore severely under-diagnosed and under-treated in children. This is of specific concern in young children, because they carry the highest risk of death due to TB. Recent studies suggest that as many as one in ten children hospitalised in TB endemic countries with severe pneumonia may also have TB. Overworked clinicians in busy, usually poorly resourced facilities may often miss these cases.
Diagnosis is also complicated due to unreliable testing methods. To test for TB, clinicians test samples of a patient’s phlegm for the bacteria in the lungs that cause TB. However, children tend to swallow their phlegm, making it nearly impossible to obtain the samples needed to confirm a diagnosis. Therefore, many children sick with TB remain undiagnosed and untreated, and often die from an age-old disease that is both curable and preventable.
While there are many challenges to identifying all TB cases in a community, it is particularly unfortunate when children who present clear signs and symptoms of TB are not appropriately assessed to make a diagnosis. Although limited availability and accuracy of diagnostic tests present challenges, this should not be a barrier, as many children with TB can be diagnosed and treated using clinical assessment alone.
We recently observed this phenomenon in a study among hospitalised Kenyan children. Almost 60% of these children had signs and symptoms suggestive of TB. However, despite testing being available, many of these children were never appropriately investigated for TB, and fewer than three percent ended up with a diagnosis of TB. Clinicians seem to lack a high index of suspicion for TB in children, and this is concerning in high burden countries, like Kenya. The country has seen considerable efforts by the government and other partners to provide evidence-based guidelines, training, and new technologies to support case detection of TB. Nevertheless, major policy-practice gaps remain, especially concerning paediatric care.
While global efforts to eradicate TB have seen an estimated 63 million lives saved since the year 2000, many high burden countries are lagging behind, especially in the detection of TB in young children. A real concern is that the COVID-19 pandemic is reversing recent gains due to reduced case detection of TB and poorer treatment outcomes compared to pre-COVID years. Patients are staying away from health facilities, and those on treatment are unable to get the necessary support to ensure they complete it.
The clock is ticking towards 2030, the year by which global leaders committed to end TB. There is need for all of us to pause and reflect on this World TB Day, on whether we will indeed meet the End TB goals. Everyone needs to be part of the solution, from the general public, policy makers, governments, funders, researchers, health workers, civil society, and down to the patients themselves. The effort, investment, political will, and rapid achievement that have characterised the response to the COVID-19 pandemic have been impressive, especially the rapid development of vaccines. These efforts can be similarly replicated towards the compelling need to end the hidden epidemic of TB in our lifetime, by ensuring vulnerable populations like children are not missed.