Keeping Kids in

the Picture:
Pediatric TB in
the COPs process
 Pediatric TB: The stats
• At least 1 million children become ill with TB every year (Global TB Report,
2017). Yet only 386,600 pediatric TB cases were notified in 2016

• Children represent about 10-11% of all TB cases (higher % in TB HBCs).

• In 2015, 210,000 children died of TB including 40,000 TB deaths among

children who were HIV positive;

• It is estimated that 67 million children are infected with TB and therefore at

risk of developing disease in the future (Dodd et al, 2016).

• In 2015, globally, only 87,000 children under five (7% of the 1.2 million
children eligible) were known to be provided with preventive therapy.

• Researchers estimate that 25,000 children develop multi-drug resistant TB

every year (Dodd et al, 2016).

• The majority of pediatric TB cases are in sub-Saharan Africa and the Indian
sub-continent
 Pediatric TB: Challenges & Opportunities
• TB infection in children • TB risk
– More likely to progress to active TB – Household contacts – mostly
– Higher case fatality primary caregiver!
– More disseminated and extra-
pulmonary
• TB treatment
–
– Once kids get on treatment they
• TB is difficult to diagnose in kids
do well with high treatment
– Extra-pulmonary
– Don’t produce sputum success rates
– Low bacillary (bacterial) load
– Not great diagnostic options
– Often must rely on clinical diagnosis
and Xray

• Patient presentation
– Can be vague
– May present with fevers, weight loss,
failure to thrive…not very specific!
 Technical step process to switch to ne
Advances in Pediatric TB tuberculosis formulation
paediatric

Dispersible Single Formulations

Isoniazid
Ethambutol
Pyrazinamide
 Advances in LTBI Treatment
Dispersible Single
Formulations
Isoniazid

New Fixed Dose

Combination
Isoniazid-Cotrim
Slide from John Jerub

• 3 RH – 3 months of an INH-rif FDC rather

than 6 months of INH
 Advances in Pediatric TB Care

• Integration of TB screening, diagnosis and

treatment: Finding children where they are
• MNCH and/or under 5 clinics
• HIV
• Malnutrition and pediatric inpatient
• Decentralization: Closer to home
• Index case tracing: Bringing care to the highest risk
 Innovations to Consider

Innovation Description
Models of care
Integration of TB Integration of TB screening, diagnosis, and treatment
care in key entry initiation in MNCH, U5Y, nutrition and pediatric
points and private inpatient entry points. Building integration and private
sector sector capacity (especially in countries with heavy use of
private sector)
Community-based Training of and support for community health workers
household contact to perform: Household contact investigation; TB
tracing, screening, screening of identified pediatric contacts of TB index
and initiation of cases; initiation of preventive therapy (if feasible
preventive therapy depending on country context); monitoring of treatment
adherence
Innovations to Consider: Models of Care

• Site assessments
• Development or strengthening of referral networks
• Site upgrades
• Updating policies, practices, guidance
• Development of training manuals, job aids, SOPs
• Potential development or introduction of new registers
and logbooks
• Sensitization of health districts
• Training of trainers, training at facility level
• Site monitoring and mentorship
• Potential hiring of new staff at facility or referral level
 Innovations to Consider

New diagnostics
Xpert Ultra WHO policy in March 2017. Expected to improve
detection yield in children due to improved sensitivity.
Need support for product switch and roll-out of this new
cartridge, in combination with use of more child-friendly
sample types. Improved access to Xpert for pediatric
populations (still relatively low uptake as compared to
other populations).
Omni Omni is expected to be released in the market in Q1/2
2018. Potential for additional decentralization and
access. There are issues with current deal for Omni –
may need additional advocacy ahead of release.
Digital X-ray Digital X-ray has been shown to have improved accuracy
and may be read by expert readers at referral facilities
(teleradiology).
Innovations to Consider: Diagnostics

• Site assessments
• Development or strengthening of sample transport or
referral networks (including teleradiology)
• Site upgrades
• Quantification, procurement planning
• Ensuring adequate in-country supply-chains
• Development of training manuals, job aids, SOPs
• Training of trainers, training at facility level
• Site monitoring and mentorship
• Potential hiring of new staff at facility or referral level
• Community sensitization
 Innovations to Consider

New drugs and treatment options for childhood TB

INH-Rif-PZA FDC WHO PQ’d and already being ordered in 60 countries
pediatric globally. Need to ensure full and rapid transition occurs.
dispsersible
EMB and INH EMB dispserible has received WHO PQ. If country not
single dispersible transitioning to 3RH for LTBI, may want to invest in
formulations dispsible INH.
3 RH and 3HP In countries that are interested in introducing the 3 RH
regimens regimen for treatment of latent TB, transition to this
regimen (expected to be recommended in WHO LTBI
guidelines). 3HP not yet approved for <2 years of age
and not yet available generically or in a dispersible form.
MDR formulations Several are now pre-qualified.
for children!
Innovations to Consider: Treatment

• Quantification, procurement planning

• Updating guidelines and policies
• Transition planning
• Ensuring adequate in-country supply-chains
• Development of training manuals, job aids, SOPs
• Community sensitization
• Ensuring in-country registration
• Training of trainers, training at facility level on new
formulations (and on improving uptake of LTBI
treatment for children)
• Site monitoring and mentorship
Conclusions

• Pediatric TB is often forgotten

• Important opportunities to improve the care and
outcomes for children with TB infection and disease
• Can’t be just an “add on” – we have to go beyond “and
children” to specify their specific needs and make sure
we are planning programming and funding for these
needs
• The 2018 COPs process is an ideal time to highlight
pediatric TB
Thank you!