Global Overview of Childhood TB: Plan to scale up training and implement framework

17th Annual Conference The Union – North American Region Vancouver, Canada, 28 February 2013

Malgosia Grzemska WHO Stop TB Department, Geneva, Switzerland

Overview of this presentation

• Global burden of childhood TB and challenges with

establishing estimates

• WHO and Partners' response

• Advocacy efforts and Childhood TB Roadmap

• Updated WHO guidance on childhood TB

• Training in childhood TB

Estimated number

of cases

Estimated number

of deaths

1.4 million (range: 1.3–1.6 million)

8.7 million (range: 8.3–9.0 million)

440,000 (range: 390,000–510,000)

All forms of TB

Multidrug-resistant

TB (MDR-TB)

HIV-associated TB 1.1 million (13%) (range: 1.0–1.2 million)

430,000* (range: 400,000–460,000)

The Global Burden of TB (2012)

about 150,000

Estimated TB incidence rates, by country, 2010

TB cases

per 100 000

0–24

25–49

50–99

100–299

>=300

No estimate

Childhood TB 490,000 (range: 470,000–510,000)

64,000 (58,000 – 71,000)

Incidence: data source

Additional information

• Recent evidence from TB endemic countries (0-14 years)

– Rural Bangladesh: prevalence of 50/100,000

– Urban Pakistan:

> 50% under-reporting in Karachi

• WHO and Union survey – data from 34 countries – Detjen A et al: Adoption of revised dosage

recommendations for childhood tuberculosis in countries

with different childhood tuberculosis burdens. Public

Health Action, Vol.2, No. 4, 21 December 2012 , pp. 126-

132(7)

Why children with TB are not reported?

• Difficulty in confirming a case of childhood TB - lack of accurate, reliable diagnostic tools;

• Focus on smear-positive cases;

• Misperception of childhood TB as a low public health priority;

• Misperception that childhood TB would disappear simply by containing TB in adults;

• Lack of research and investment;

• Lack of advocacy on behalf of children with TB;

• Lack of recognition of childhood TB importance within existing child health programs;

Only 1.6% of 4,821 cases in children

were registered with NTP

Burden of child TB in Java 2005

TB cases Inpatient Outpatient Overall

Total TB cases 5,877 15,694 21,571

Child TB cases N=648 N=4173 N=4821

% of total burden 11% 27% 22%

< 5 years 56% 53% 53%

Smear positive disease 16% 8% 9%

EPTB 15% 6% 8%

Non-teaching hospital 73% 76% 75%

Private health facility 8% 7% 7%

Lestari T, et al. BMC Pub Health 2011

Increasing International Leadership and Guidance

• 2003 – creation of Childhood TB subgroup of

the DEWG (Stop TB Partnership)

– 125 active members in 2013;

• 2006 – 2011 – several policy guidelines: – WHO Guidance for national TB programmes on the

management of TB in children

– WHO recommendation on recording and reporting in two age

groups for children (0-4 years and 5-14 years)

– WHO Rapid Advice on treatment of tuberculosis in children

– WHO/IUATLD Guidance for national TB and HIV programmes

on the management of TB in HIV-infected children

– IUATLD Desk guide for diagnosis and management of TB in

children

Provision of TB drugs childhood

formulations – through GDF

Global Drug Facility (GDF) provided drugs to 60

countries, in Africa, Central, South and

South-East Asia and in the Middle-East and

the Caucasus,

Quality-assured fixed-dose paediatric

formulations for treatment of active disease

and preventive chemotherapy for almost

400,000 children.

Country level activities

• Technical assistance provided to countries on national guidelines: – Bangladesh, Botswana, Cambodia, DPRK, Djibouti, Ethiopia, Indonesia, Iraq, Kenya,

Mexico, Mozambique, Nepal, Pakistan, Philippines, PNG, Rwanda, Sudan (N), Tanzania, Uganda, Vietnam, and Zimbabwe.

• Participation of Childhood TB experts in National TB Programme Reviews – Philippines (2008), Ukraine (2010), Myanmar (2011), Azerbaijan (2012), Cambodia

(2012), India (2009 and 2012), Indonesia (2011 and 2013), Kazakhstan (2012), Lao PDR (2013),

– Ghana (March 2013), Nigeria (April 2013), Philippines (Sep 2013) Thailand (Aug 2013)

• Recent activities of WHO Regional and Country offices: – EURO established an European Task Force on Childhood TB;

– EMRO interested to hold a regional training in Egypt and a national training in Iraq;

– AFRO is developing a framework for pediatric TB working closely with partners to encourage national scale up of childhood TB activities;

– WPRO invited a pediatrician to their regional TAG and planning a regional training workshop

Growing Advocacy

• March 2011 - international childhood TB meeting in Stockholm - by Childhood TB subgroup and the European Centre for Disease Prevention and Control (ECDC):

– Call to Action for Childhood TB, signed by over 1,000 individuals and organizations

• October 2011 - WHO Stop TB Symposium, opening the 42nd Union World Conference on Lung Health in Lille

• November 2012 – plenary session at 43th Union World Conference in Kuala Lumpur

• Kochon Prize - recognized the contribution of the Desmond Tutu TB Centre in Cape Town.

Global momentum

• World TB Day 2012

• Childhood TB Roadmap

– Integration of childhood TB activities in other child health sectors

• Revision of the programmatic management of childhood TB guidelines

• Closing the gap between policy and practice

"Childhood TB Roadmap"

• WHO, Childhood TB subgroup, UNICEF, CDC (US),

The Union, Treatment Action Group

• specifics on childhood TB

• reasons for neglect and barriers to

implementation

• achievements; growing advocacy, integration

with HIV/AIDS, MCH and IMCI and role for all

stakeholders

• funding needs and gaps.

"Childhood TB Roadmap"

• Engage relevant health care programs !!!

– Maternal and Child Health Services

– HIV Services

– Private health care sector

– CBOs/ NGOs

• Develop "integrated" family and community centred strategies: – Integrated Management of Pregnancy and Child Health (IMPAC);

– Integrated Management of Childhood Illnesses (IMCI);

– Integrated Community Case Management (iCCM);

– Child HIV management programs;

– Prevention of Mother-To-Child HIV Transmission (PMTCT);

– Child nutritional programs;

– Family planning and fertility services

Childhood TB worldwide, 2011-2015 (total cost)

US$ millions 2011 2012 2013 2014 2015 2011-2015

Prevention (EPI): BCG 36 37 39 43 48 202

New Vaccines 12 13 13 14 16 69

New drugs 23 24 25 27 31 129

New diagnostics 0.3 0.3 0.3 0.3 0.4 1

Global costs (total) 71 73 77 85 95 401

0

Implementation (NTP) 81 82 85 91 98 437

WG operations 0.6 0.6 0.7 0.7 0.8 3

Implementation costs (total) 82 82 86 92 99 441

Total 153 155 164 177 194 842

ART/CPT 36 40 42 46 51 216

Total with ART 189 196 206 222 245 1058

Revision of Childhood TB Guidance

(2012-2013)

• First Guidance published in 2006

• New developments (policy documents and

guidelines) on: diagnostics, treatment, contact

investigation, TB/HIV, BCG, etc.

• Draft document developed by Union and

WHO (Steve Graham lead)

– Review of new evidence; expert panel (July);

peer-review (Aug-Sept)

– Awaiting editing and GRC clearance

What's new in the Childhood TB Guidance (2012-2013)

• Use of new, rapid, molecular diagnostic tools –

when and where available;

– Roll-out of Xpert MTB/RIF (73 countries as of Sept. 2012)

What's new in the Childhood TB Guidance (2012-2013)

• Treatment with new dosing of H, R, Z, E – Isoniazid (H) 10mg/kg (range 7-15 mg/kg);

– Rifampicin (R) 15mg/kg (range 10-20 mg/kg);

– Pyrazinamide (Z) (35mg/kg (range 30-40 mg/kg)

– Ethambutol (E) 20mg/kg (range 15-25 mg/kg)

• New, "ideal" FDC proposed: RHZ 75/50/150 – Included in invitation to manufacturers for prequalification

Contact screening and management

• Priority should be given to contacts who are:

– children with symptoms suggestive of TB,

– children < 5 years of age,

– children with known or suspected

immunocompromising conditions

(especially people living with HIV (PLHIV)),

and

– child contacts of index cases with MDR-TB

or XDR TB (proven or suspected).

• Children < 5 years of age who are household

or close contacts of people with TB and who,

after an appropriate clinical evaluation, are

found not to have active TB should be given

six months of IPT (10 mg/kg/day, range 7–

15 mg/kg, maximum dose 300 mg/day).

Update on Childhood TB FDCs

• December 2012 - Global Alliance for TB Drug Development Receives 3-year Grant (up to US $16.7M) from UNITAID to Develop Pediatric TB Drugs (appropriate child-friendly formulations)

• TB Alliance, working with WHO and other partners: – To provide manufacturers and other stakeholders with assistance

to address a range of scientific, regulatory, access, and market challenges;

– To lower the barriers for manufacturers, which can produce these medicines on a sustainable basis through; • Better defining the market size for pediatric TB,

• Clarifying the pathway to regulatory approval of child-specific product formulations in regions around the world,

• Incentivizing manufacturers to participate in the production of child-appropriate formulations of existing TB drugs.

• It is expected that new FDC should be available towards 2015

Training material

• Generic training material available

– Modular format with the trainers manual

– Set of ppt slides

– Published literature

• First regional training workshop held in

Cape Town on 1-4 May 2012

– Participants from 12 countries (including 8

TBCARE countries)

• Needs for scale-up in countries

Need to scale up training

• Scale up of training in countries to:

– Increase case-finding of child TB cases in the

community

– Improve the management of children with TB

– Increase implementation of child contact

screening and preventive therapy

– Provide accurate data of child TB for NTPs for

purposes of monitoring and evaluation

Need to scale up training (2)

• The main focus of the training is for three

likely common scenarios:

– The child with suspected TB disease

– The child treated for TB in the community

– The child who is a close contact of a TB case

Need to scale up training (3)

• The main target audiences for training are:

– NTP and the health workers that manage sick

children and/or TB cases of any age in the

community or at primary health care facilities

and district hospitals;

– medical officers, nurses, and healthcare

workers from other community clinics in order

to raise awareness and prompt the proper

referrals.

Need to scale up training (4)

• Training should be consistent with national

guidelines;

• Review and update of national guidelines

for TB, HIV, child health and maternal

health prior to training;

• Attention to monitoring and evaluation of

child TB activities should be an integral part

of training

Acknowledgements

• Steve Graham and the core team of the

Childhood TB subgroup

• Babis Sismanidis and Annemieke Brands,

Stop TB Department/WHO HQ

Thank you for your attention!