TB Infection Control

Paediatric TB has been over diagnosed and over treated with all kinds of formulations. Trouble has been brewing in the govt and the private sector for a long time even when the DOTS programme had been implemented. A few years back I saw how the paediatric formulations for the first time came out to tackle the childhood TB .But shockingly the weight band formulations were used for adults who had low weight. The children were unable to swallow the several tablets which were not dispersible and were having a wrong taste for them to have . And now I see intravenous drug users and truckers having TB and they have several children and NONE ever have any access to DOT at all . HIV programs need to be integrated immediately along with the maternal and child health care services IF we are to maximise the benefits of the resources that have been pooled already ?

The most important issue is of access. In 2006, the Indian Govt declared 100% DOTS 'coverage'. But 2 million new cases a year in India is proof of community transmission. We have to make DOTS available to patients at their doorsteps, at a time and place convenient to them. Paediatric TB indices reflect rate of transmission in the community, and therefore high numbers of children getting TB is a sure sign of high prevalence. Other challenges are lack of diagnostic tests, lack of fixed formulations, and stigma against school children.

In this scenario, the solution lies in leveraging technology. This, together with community empowerment, is the only way we can achieve the MDGs.

For more info, write to me at

Thank you both for your insightful replies.
Dr Shanta Ghatak, I agree with your assertion that HIV programs need to be integrated. However, our research at MSF very much confirms that Paediatric TB is being under diagnosed as opposed to over diagnosed. Could you elaborate on why you think Paediatric TB is being over diagnosed and over treated?

Shelly that's an interesting point about high numbers of paediatric TB directly reflecting high TB prevalence amongst adults in a community. Can you go into a bit more detail about leveraging technology? Which technology in particular? How do you go about doing this?

MSF have just published a follow up systematic review and meta-analysis on treatment outcomes for children with multidrug-resistant TB. I have attached it to this reply; please do have a look and feel free to comment.

our research at MSF very much confirms that Paediatric TB is being
under diagnosed as opposed to over diagnosed. Could you elaborate on
why you think Paediatric TB is being over diagnosed and over treated?

Dear Rebecca
I am attending a few hospitals with in patient facilities as well as
running OPDs and also the HIV integrated programs in project areas in
5 states of India . I am fortunate that I could get the time to run
the show at times in terms of follow up and case histories as well.
While the treatment cards may be difficult to access as the doctors
are unwilling to give the treament documents for documentation
purposes.
Out of approximate 850 -1000 children in a day at least half of them
are being prescribed Ciprofloxacillins in all the OPDs where children
are attended c/o fever FTT and cough
Not all fever/cough/FTT are TB
But they are getting INH-Rifampicin syrups and Ciprofloxacillin
dispersible tablets as well at least prescribed by 4 medical
specialists out of the 12 available.
It is difficult to assess a situation at random but this is what is
happening and when I interview they have expressed a notional ...

our research at MSF very much confirms that Paediatric TB is being
under diagnosed as opposed to over diagnosed. Could you elaborate on
why you think Paediatric TB is being over diagnosed and over treated?

Dear Rebecca
I am attending a few hospitals with in patient facilities as well as
running OPDs and also the HIV integrated programs in project areas in
5 states of India . I am fortunate that I could get the time to run
the show at times in terms of follow up and case histories as well.
While the treatment cards may be difficult to access as the doctors
are unwilling to give the treament documents for documentation
purposes.
Out of approximate 850 -1000 children in a day at least half of them
are being prescribed Ciprofloxacillins in all the OPDs where children
are attended c/o fever FTT and cough
Not all fever/cough/FTT are TB
But they are getting INH-Rifampicin syrups and Ciprofloxacillin
dispersible tablets as well at least prescribed by 4 medical
specialists out of the 12 available.
It is difficult to assess a situation at random but this is what is
happening and when I interview they have expressed a notional concern
without the updated knowledge about peaditric Tb or TB formulations or
emerging resistance and the young lives who are at their mercy!
This is wierd. Because inspite all slogans and available materials on
TB , trasmission and rationality of treatment protocols have not
worked for so many many years with the medical fratenity?
Accountability data generation and analysis , and catching them early
with emerging drug resistance should be a high priority at all COSTS.
Every institution Every Formulation available and Every child MUST be
documented and notified to well meaning and technically updated
watchdogs . Advocay and correct handholding needs to be implemented
for the mothers as well so that they internalise the goodness of
properly scored medications and proper diagnostic services . Why cant
any of our health systems including the private sector big players be
roped in for ONLY paediatric TB ? Why can't we stand up to the
prescriptions in the govt sectors and other private players be
scrapped if they are prescribing the wrong substandard formulations
for wrong duration of time and they are incorrectly diagnosing the TB
? whenever there is an awareness campaign they are screening more -
the suspicion index becomes higher and the treatment schedule becomes
lengthier? And no one is bothered about the second line and further
available drugs that are to be cascaded as per the patients response.
The knowledge updation is poor quality and awareness among the the
parents and general population is also so less. And the doctors they
are just playing safe GODs...that one of the prescribed formulations
will work .
And much too many kids are on the irrational medications. It is a
practice that has caught on the fancy. It is time we get a bit
judgemental and do soemthing about the number they are prescribing
INH-Ref and Ciprofloxacillin without diagnosing properly and
performing repeated CXRs .
NO ONE keep a tab as these are well know reputed pediatricians ....
Sad scene
And it wont work without high level interventions and supervisory
mechanisms which is really hard to accept .
I hope I was able to clarify?

One thing more - the ususal statistics based on community population
doesnt work as these are Childrens' hospitals and clinics where only
children are seen . But then also a line must be drawn that all these
emaciated cachectic children suffering from PCM or other skin
disorders and amebiasis and fever and lymphadenppathy may not be
suffering from TB . My concern is the treatment schedule the standard
protocols violation.

Here is a relevant blog by Grania Brigden (TB advisor to the MSF Campaign for Access to Essential Medicines) about paediatric TB.
http://blogs.plos.org/speakingofmedicine/2012/03/23/a-spotlight-on-children-w...