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ARTICLE: Little victims, big battle
Friday, 22 February 2013 07:06

Little victims, big battle

The Revised National Tuberculosis Control Programme is not age appropriate even though children are included in it. The programme does not provide medicines in syrup form or permit breaking of tablets, making the administration of accurate paediatric doses impossible

Tuberculosis has re-emerged as a major public health challenge in the world. India accounts for nearly one-third of the global TB burden. According to the review of global tuberculosis situation by the World Health Organisation, India comes under a group of high prevalence countries with the Annual Risk of Tuberculosis Infection (ARTI) ranging between 0.6 and 2.0 per cent annually. Although childhood TB has received attention from global health experts, it still remains a major cause for illness and death of children.

Burgeoning burden

India has the highest number of tuberculosis (TB) cases in the world. Each year in India, more than 2 million new cases of TB are diagnosed. Approximately 500,000 persons die of the disease. During the last decade, multidrug-resistant TB has burgeoned in India, resulting in an extremely large number of multidrug-resistant TB cases, second only to the number of cases noted in Latvia. Since 1993, in response to this epidemic, the government of India has implemented the Revised National Tuberculosis Control Programme based on directly observed treatment (DOT).

Akash and Parveen (names changed) are siblings from a small village in North India. Their parents, Meenu and Gyanchand, own a vegetable store. One day, they noticed that their children had a cough that would not go away. The local doctor was not able to find out what was wrong. They took their kids from one health clinic to another till a Delhi hospital diagnosed that both kids were suffering from extensively drug-resistant (XDR) TB. The parents did not know what to do, where to go and how to spend on the children's illness.

Most health facilities in the private and the public sector do not have the tools or the infrastructure needed to diagnose XDR-TB. Though the National TB Programme in India provides most medicines for free, medicines for XDR-TB are not always covered. Global Health Advocates India, an ACTION partner, took up the matter with the government to provide access to free medicines through the government. The cost of medicine was covered and these two children were on the road to recovery.

Social stigma

But the problem did not end there. Meenu and Gyanchand were forced to mortgage their home to fund their children's hospital stay so much was the financial burden. There was also the social stigma attached to TB in India in any form. The children were expelled from the school which deprived them of the right to equality in education. The parents are worried about the future of the children. They feel that the stigma of TB would cloud their opportunities of a better life in the future.

Difficult to diagnose

Sometimes, Indian children, suspected of having contacted TB, find it difficult to respond to early diagnostic tests. They find it hard to cough up the necessary sputum sample from deep inside their chests needed to attempt a diagnosis through microscopy. A solution is sometimes provided by taking an induced sputum test that calls for breathing a saltwater mist through a mask that induces the child to cough deeply from the lungs and helps it produce an adequate sample for analysis.

Another problem that Indian children who are suspected of having contracted TB, face is that many of them are from the lower income groups or from a poor strata and live quite a distance from local hospitals where treatment can be easily accessed. Distance is a big hurdle for poor children whose parents go to work and find it time-consuming and money-consuming to take the child to the local hospital that might be far away.

A study in 2007 by Dr Vishwanath K G, Dr Siddaraju M and Jagannatha P covered 112 children of ages ranging from six months to 14 years attending the TB clinic of the paediatric department of Vanavilas Hospital, Bangalore. They were observed for one year. This study was undertaken to evaluate the clinical spectrum of TB among BCG vaccinated and non-vaccinated children. Among the study group 73.2 per cent children were malnourished. Among malnourished children 76.8 per cent of the children were BCG vaccinated. At least 73.2 per cent of children had intra-familial contact and among these 80.5 per cent children were BCG vaccinated.

The BCG vaccine was discovered in 1924 and has been in use for nearly 90 years. It has not made the impact it was expected to make. Several epidemiological studies have shown wide variations in protection offered by the BCG vaccine. Why do children develop tuberculosis despite being vaccinated? What is the alternative? There is no ready response to these questions.

The 15-year follow up of the Indian Council of Medical Research (ICMR) BCG trial in Chingleput district, concluded that "BCG offers no protection against adult-type bacillary tuberculosis. Consequently, BCG cannot be expected to reduce the transmission of tuberculosis."

Another study by Sunil Karande and Sandeep B. Bavdekar points out that TB is developing in more children in Mumbai today than a decade earlier. Moreover, close proximity to adult patients with multi-drug-resistant TB makes children prone to developing primary multidrug-resistant TB. Similarly, disseminated TB is occurring in large numbers in children living in overcrowded slums in Mumbai with a consequent high death rate.

The AIDS epidemic in adults in Mumbai has also adversely affected the epidemic within the population of children with TB.

Lack of proper facilities

Though children are included in the national control programme, they do not receive the benefit of DOT strategy. The Revised National Tuberculosis Control Programme does not provide drugs in syrup form or permit breaking of tablets, making the administration of accurate paediatric doses impossible. Most children with TB are also sputum-smear negative for acid-fast bacilli.

Doctors must rely on clinical acumen when deciding whether or not to start TB treatment. This lack of a method for definitive diagnosis of TB in children makes treatment centres reluctant to enlist paediatric cases; as a result, these children attend general paediatric outpatient clinics every 28 days to obtain their TB medication.

DOT strategy is not followed in the general outpatient clinics. Compliance with treatment depends on the motivation and perseverance of the parents. Often, one or more of the drugs is out of stock. In such cases parents are forced to dig into their own small resources to purchase the necessary medication. To avoid a long wait in the crowded general paediatric outpatient clinics, some parents intermittently purchase anti-TB drugs from local chemists, who supply the drugs without a current prescription. This practice leads to frequent defaulting and inadequate treatment.

A 12-year-old boy in Mumbai with secondary multidrug-resistant TB had received multiple courses of inadequate treatment with various anti-TB treatment regimens for nine years. The TB gradually progressed in severity and was disseminated with the bacterial load increasing sufficiently for multidrug-resistant TB to develop. This case is not unusual and many children in Mumbai are dying of multidrug-resistant TB because DOT strategy regimens are unavailable.

Improved patient care, better BCG immunisation coverage and multi-drug anti tuberculosis regimen have not created a dent in the mortality due to tuberculosis in children. However, certain remedial measures can be taken to prevent the tuberculosis in children.

So, it must be stressed that the most powerful weapons for controlling tuberculosis and altering the epidemiological situation in a community are case finding and case holding. A sincere effort at all levels of health care delivery system is the need of the day.


In India, nearly 3-4 million children have tuberculosis and another 94 million are at risk for this disease.

Impact of BCG vaccination has demonstrated that classical or generalised tuberculosis meningitis, disseminated TB, disseminated tuberculosis and other serious complications of primary infections continue occurring in malnourished BCG-vaccinated children.

The annual infection rate is about 3 per cent. These figures are not complete as these have not included children under the age of 5 years. The usual sources of infection are adults. An infected individual can transmit the infection to as many as 20 contacts.

Attention to child TB activities are rarely included in the strategic plans and budgets of ministries of health.

Need for better diagnostics that can detect TB in children.

There is lack of appropriate child-friendly, fixed-dose combination drugs for treatment.

Systematic screening of TB is not undertaken among children living in households affected by TB.

Health workers lack sufficient knowledge about child TB diagnosis and management.

Current TB vaccine protects young children against the most severe forms of TB such as meningitis and disseminated TB disease but it does not prevent transmission from an infectious contact.

Recommendations for provision of isoniazid preventive therapy (IPT) for children under 5 years is rarely implemented.