‘In 2003, RNTCP had eight lines in the guidelines that related to TB in children’

After years of neglect by the WorldPu Health Organisation and almost all the national tuberculosis programmes [NTP] across the world, the global spotlight is now on childhood TB. Prof. Steve Graham from the University of Melbourne and Murdoch Children’s Research Institute, Australia, and also The Union, France has seen the focus of WHO shifting to childhood TB from close quarters. He was the Chair of the Childhood TB subgroup of the Stop TB Partnership that led the Roadmap for Childhood Tuberculosis; the Roadmap was released recently.

In an email to R. Prasad, Prof. Graham detailed the several changes that have happened over the past few years before childhood TB finally got the attention that was long overdue.

After years of neglect, what was the sudden provocation in 2006 for WHO to realise that childhood TB needs special attention?

The momentum was building up for some time, not suddenly — going back to articles published around 2000 the recognition that at that time there were very few national tuberculosis programme (NTP) guidelines that addressed TB in children.

What role did researchers play in turning the spotlight on childhood TB? Did researchers from South Africa, by any chance, play a pivotal role in this?

Prominent researchers from South Africa (especially from Stellenbosch University in Cape Town) were involved including the founding Chair of the child TB subgroup when formed in 2003 (Prof. Robert Gie) as well as folks representing the resource-limited setting (such as myself in Malawi) where we had been doing original operational research and publishing nationwide data.

Till 2006, were there no guidelines provided by the WHO to NTPs on the management of childhood TB?

No — and most NTPs had their own guidelines where there might be at most one page on issues relating to children — including India. In 2003 (when I went there to help RNTCP move forward) comprised eight lines in the guidelines that related to TB in children.

Did countries, especially South Africa, undertake or at least realise a need to conduct contact screening of children aged under five years from households where an adult has been recently diagnosed with sputum smear-positive pulmonary TB?

Household contact screening was about the only thing in most NTP guidelines (not just South Africa). Everyone acknowledged its importance and the policy was almost universally accepted. [Yet] it just did not happen [practised], except in low-burden well-resourced settings like U.K. or the U.S. etc.

Did countries — developed and developing — realise that children younger than five years are vulnerable to getting infected/diseased with TB from a TB diseased adult in the same household before WHO came out with the guidelines in 2006?

The knowledge of children being vulnerable and even the value of IPT [isoniazid preventive therapy] were available since the 1960s.

What were the main contributions of the childhood TB subgroup that was formed in 2003? How many members did it have when it started?

It developed a focus for folks interested in childhood TB in TB endemic countries — and the main first step was development of WHO 2006 childhood TB guidelines, plus representing children in other fora. Initial membership at the 2003 meeting in Paris was about 12. [There are currently 125 active members.]

Ever since 2006, WHO seems to have taken childhood TB quite seriously and has come out with several documents/guidance/desk guide etc. What was the reason for the tide to turn?

[It is a] Recognition of the importance of children as a vulnerable population — as WHO expanded its TB control strategy beyond the limited DOTS approach, which largely did not include children.

What led to childhood TB gaining a lot of traction in the last 2-3 years? Did the arrival of GeneXpert, a rapid molecular diagnostic technology, and its approval by WHO turn out to be the defining moment for turning the attention on childhood TB?

None of those — just the eventual development of momentum that gets to a critical mass that then becomes weighty enough. The first International meeting on Childhood TB was held in Stockholm in 2011 — joint ECDC and WHO Stop TB. At that meeting, I was elected to replace Prof. Robert Gie [of Desmond Tutu TB Centre, Stellenbosch University in Cape Town] as Chair. We took on a number of initiatives at the same time, including putting childhood TB into the World TB Day 2012, revision of guidelines, technical assistance drug issues, development of training materials and desk-guide.

What do you think was the most significant or game-changing moment in addressing childhood TB — the Stockholm childhood TB meeting?

I would say so, and coinciding with childhood TB subgroup meeting.

What was the significance of the Oct 2011 WHO Stop TB symposium at the 42 Union World Conference on Lung Health in Lille, France?

[This was the] First time a symposium [was] dedicated to the needs of mothers and children.

The World TB Day in 2012 had childhood TB as its theme. Quite strange, considering that there was a long neglect of childhood TB. Your comments.

Not strange given that WHO Stop TB was broadening its strategy to the less traditional focus of just smear positive cases all at same time. So, as for a wider group, children always bring wider publicity focus.

Considering that evidence of childhood TB was plentiful in scientific journals, what new evidence came up for the WHO to take childhood TB seriously?

Nothing particularly new except the impact of HIV on TB in children which was devastating — mainly the focus of WHO on children was new.

The resurgence of TB in the U.S. due to the peaking of childhood TB in the 1990s clearly demonstrated the vulnerability of children to TB disease. Why did WHO take no cognisance of this?

This issue is highlighted in retrospect and did not get a lot of attention (at least outside of the U.S.) at the time.

How did the Roadmap for Childhood Tuberculosis materialise? With the complete neglect of childhood TB clearly spelt out in the report, was it an admission of lack of action and a clarion call for action?

Many now recognised the need to move on from neglect and also recognised the need to spell out how to do that etc.

The WHO also revised the programmatic management of childhood TB guidelines. What was the provocation?

WHO revises guidelines every five years or so — trying to keep current — plus there were a few new things that needed consideration such as 2010 Rapid Advice drug dosages and Xpert and the need to have more on MDR-TB.

Coming out with the “No more crying, no more dying” report is telling. What is the background of this?

Not my favourite choice of title! It came out because the Roadmap had started to be developed — but along came World TB Day 2012 and the Roadmap was nowhere near ready to be launched, so we agreed to put together a short highlighting document.

From complete neglect to “zero TB deaths in children” the pendulum has swung to the other end in a matter of a few years. Your comments.

Ambitious goals are what the post-2015 global TB strategy is all about, so we need to fall in line — plus our advocates insisted on need for simple and ambitious goals.

(The Correspondent is a recipient of the 2013 REACH Lilly MDR-TB Partnership National Media Fellowship for Reporting on TB.)

Published in The Hindu on December 14, 2013

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