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© REBECCA SULLIVAN

ACTION
f
ADVOCACY TO CONTROL TB INTERNATIONALLY
CHILDREN AND
TUBERCULOSIS
Exposing a Hidden Epidemic
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ACTIONf ADVOCACY TO CONTROL TB INTERNATIONALLY ACTIONf ADVOCACY TO CONTROL TB INTERNATIONALLY
Tuberculosis (TB) remains among the top ten killers of children
worldwide
1
, yet virtually no public or political attention is paid to TB
as a children’s health issue. Children have weak immune systems,
making them prime targets for TB. Data show that in 2009, at
least 1 million children became sick with TB. The World Health
Organization (WHO) estimates that approximately 176,000 children
died
2
, but the consensus among researchers says that actual
figures are higher. TB preys on the most vulnerable children — the
orphaned, the malnourished, those living with HIV — and it causes
an almost unimaginable burden to children and their families. We must
stop neglecting TB as a children’s health issue and take immediate
steps to stop TB from needlessly infecting and killing children.
TB is an infectious disease caused by bacteria that often
attack the lungs. It is spread through the air when an
infected person coughs, sneezes, laughs, or even sings.
When exposed to TB, most healthy people are able to
fight the bacteria by sealing it off within a part of the
body, usually the lungs. These people have a latent TB
infection. They do not feel sick and they cannot spread
the infection to others. Latent TB infection can be
treated using only one drug, isoniazid, over the course
of six to nine months.
In some cases, people are unable to fight the bacteria,
and they become sick with active TB disease. If not
treated properly, active TB is often fatal. Active TB is
treated using numerous drugs taken over a six-to-12-month period. It is crucial that patients take
medication exactly as prescribed and complete the full course of treatment. If the medication is
taken incorrectly or stopped prematurely, TB disease can easily reemerge and become resistant to
medication. Drug-resistant strains of TB are much harder to cure and extremely expensive to treat.
What is TB, and How is it Treated?
© GARY HAMPTON
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CHILDREN AND TUBERCULOSIS: EXPOSING A HIDDEN EPIDEMIC
1
WHAT IS THE NATURE AND MAGNITUDE OF TB AMONG CHILDREN?
According to Dr. Jeffrey Starke, a leading TB specialist at Texas Children’s
Hospital, childhood TB “is a fundamentally different disease from adult
tuberculosis. Its proper diagnosis, treatment, and prevention require spe-
cific planning and resources. We must consider the unique nature of child-
hood TB if we’re to successfully eliminate TB anywhere in the world.”
According to WHO, approximately 9 million people
become sick with TB each year.
2
At least 10-15 percent
of these cases are in children under 15 — but the per-
centage is probably much higher, because childhood
TB is under-reported.
1
Most children have a type of TB
classified as sputum smear-negative TB (see box on
pg. 2: Types of TB), which makes them less likely to
spread the disease to others — but it’s still deadly if left
untreated. Because on average children are less conta-
gious than adults, they’ve been overlooked by national
TB programs.

CHILDREN ARE PRONE TO SEVERE TYPES OF TB
f
While adults most often get TB in their lungs, in chil-
dren the disease often spreads to other parts of the
body. Children are therefore more likely than adults to
develop severe forms of TB, including TB meningitis.
1

TB meningitis occurs when the bacteria spread to the
central nervous system, including the brain. The bac-
teria inflame the tissue that protects the brain, causing
it to swell. TB meningitis is most common in children
under two years old, and the disease is almost always
fatal without treatment. TB can attack virtually any part
of a child’s body in similar fashion.
RATES OF TB IN CHILDREN ARE
GROSSLY UNDER-REPORTED
f
Most countries only report childhood TB cases that are
considered “sputum smear-positive” (see box on pg. 2:
Types of TB).
2
Because only 10-15 percent of children
have this kind of TB, the vast majority of childhood TB
cases go unreported — making it very difficult to deter-
mine the true burden of childhood TB that exists in the
world. WHO estimates that 1 million children become
sick with TB each year, but the real numbers are likely
much higher. However, the true burden is unknown
because nobody is collecting and merging enough
data. According to Dr. Anneke Hesseling, a childhood
TB expert at the Desmond Tutu TB Center at Stellen-
bosch University in South Africa, training health work-
ers to diagnose TB in children leads to a significant
jump in the proportion of cases detected — even using
the inadequate tools currently available.
3
MULTIDRUG-RESISTANT TB IN CHILDREN
f
Multidrug-resistant TB (MDR-TB) — defined as TB that
is resistant to at least the two most powerful anti-TB
drugs, isoniazid and rifampicin — afflicts approximately
440,000 people each year.
4
Despite studies that show
children get MDR-TB, only adults are included in global
MDR-TB surveys — meaning no one knows for sure
how many children suffer from MDR-TB.
1
However, a
few localized studies exist showing the burden is sub-
stantial. Studies in South Africa indicate nearly nine
percent of childhood TB cases are drug resistant — a
rate similar to adults.
5,6
Further research is needed to
determine the true burden of childhood MDR-TB. While
MDR-TB is curable in children, it takes expert medi-
cal care and extremely expensive treatment. It is far
cheaper to prevent the development of MDR-TB in the
2
ACTIONf ADVOCACY TO CONTROL TB INTERNATIONALLY
WHAT FACTORS PLACE CHILDREN AT RISK FOR TB?
POVERTY
f
Poverty is a major risk factor for TB. Poor
children often lack access to care and live in over-
crowded conditions that make them vulnerable to TB.
YOUNG AGE
f
Infants and very young children have
weak immune systems, which place them at higher
risk of developing active TB. While the average adult
with latent TB infection has a 5-10 percent lifetime risk
of developing active disease, infants with a latent TB
infection have a 40 percent chance of developing active
TB during their first year of life.
7
MALNUTRITION
f
Malnourished children have weaker
immune systems that make them more susceptible to
developing active TB.
8
ORPHANS AND VULNERABLE CHILDREN
f
Orphans and
vulnerable children are more likely to be malnourished,
live in poverty, and lack access to medical care, which
places them at higher risk of developing active TB.
9 ,10,11
HIV
f
HIV weakens the immune system, making a
person vulnerable to TB. Children with HIV are up to
20 times more likely to develop TB than children with
healthy immune systems.
12
TB remains the third leading
killer of children with AIDS and nearly half of new child-
hood TB cases occur in children with HIV.
13
MATERNAL TB
f
Children whose mothers have TB are
likely to both contract the disease and be born at a low
birth weight. A child born to a mother with TB has an
overall higher risk of death.
14
TB bacteria typically infect the lungs (called pulmonary TB) but may spread to virtually
any other organ outside the lungs (called extrapulmonary TB), often the lymph nodes,
brain, spine, or genital tract. Patients suspected to have pulmonary TB are asked to
cough up phlegm — or sputum — which a laboratory technician then examines under
a microscope. If a technician can see TB bacteria under the microscope, the patient
is considered to have smear-positive TB, which is highly infectious. Many patients,
especially children and people living with HIV/AIDS, have smear-negative TB — a form
of the disease where the patient is sick but a technician does not detect TB bacteria
under the microscope.
In December 2010, the World Health Organization endorsed a new tool to diagnose
TB, Xpert MTB/RIF. Instead of using a microscope, this revolutionary tool uses DNA
technology to rapidly identify TB bacteria in sputum samples in less than two hours.
Types of TB
CHILDREN AND TUBERCULOSIS: EXPOSING A HIDDEN EPIDEMIC
Gisele is the mother of twin boys, Anthony and Jordan. Both boys are very lively, so when
Anthony stopped actively playing with Jordan, Gisele knew something was wrong. Anthony
began to cry often and always appeared tired, so Gisele brought him to see the doctor. At first,
the doctor thought Anthony had the flu and prescribed him flu medicine. Anthony didn’t get
better, so they returned to the doctor. Again, Gisele was told that Anthony had the flu. A few
days later, Anthony’s eyes started to glaze over and Gisele brought him to the emergency room.
Anthony was then transferred to Texas Children’s Hospital in Houston, TX, where doctors diag-
nosed Anthony with TB meningitis.
“It was terrifying to hear that he could die,” says Gisele. Doctors traced Anthony’s infection to a
family friend who had been ill and provided Anthony life-saving surgery and medication for TB.
Within weeks, he started to run around again with Jordan. Gisele is still troubled that it took
so long to diagnose Anthony with TB. If detected earlier, chances are Anthony would not have
needed surgery. “I was so angry. I did what I was supposed to do. I had been to the doctor so
many times,” exclaims Gisele. “It was heartbreaking to know how sick he was and how much
pain he was in.”
Abhijat and Abhishakt are playful twin boys, always giggling and running around. Their par-
ents, Mamta and Jacob, are well educated and work as health advocates in India. One day
Mamta and Jacob noticed their boys began coughing and wheezing, so they went to a private
health facility. Since Jacob has a history of asthma, the doctor assumed asthma was causing
Abhijat and Abhishakt to cough. He prescribed steroids and an antibiotic. Worried the humid
weather was contributing to their coughing, Mamta and Jacob moved their family to a drier city
in India.
Over the next six months, Mamta and Jacob brought their boys to see four different doctors
at private health clinics, but their boys remained very ill. A friend suggested they see a public
sector doctor, who was quickly able to diagnose Abhijat and Abhishakt with pulmonary TB. The
boys were provided treatment and are happy and healthy today. For the first time in their life,
Mamta and Jacob realized that TB is not “the other man’s disease.” It can happen to anyone.
If the private medical doctors realized TB was not a disease that only affects the poor and
given attention to their symptoms, Abhijat and Abhishakt would have been cured much earlier.
In many countries such as India, TB control efforts are focused around public health facilities.
However, most people receive health care from private clinics. After their experience Mamta
and Jacob believe the private health sector needs to be better integrated with national TB con-
trol efforts.
ANTHONY'S STORY
ABHIJAT AND ABHISHAKT'S STORY
4
ACTIONf ADVOCACY TO CONTROL TB INTERNATIONALLY
HOW CAN TB IN CHILDREN BE PREVENTED?
It is more cost effective to prevent disease than it is to
treat it. The most effective way to prevent childhood
TB is to stop the disease from spreading in the wider
community. According to Dr. Starke, “Even with the
limited tools currently available, better organization of
services and aggressively identifying recently exposed
and infected children would prevent tens of thousands
of tuberculosis cases in children every year.” This is
achieved by what is commonly referred to as the four I’s
15

— intensified case finding, isoniazid preventive therapy,
infection control, and integration.
THE FOUR I’S
f
· Intensiñed Case Finding — When an adult is diag-
nosed with TB, all close contacts and family mem-
bers — including children — should be identified and
screened for TB, a method called intensified case
finding. People with latent TB infection or active TB
disease are then provided appropriate treatment,
stopping the spread of the disease. Children who are
considered high risk — especially those with HIV —
should also be routinely screened for TB.
16,17
· Isoniazid Preventive Therapy (IPT) — People with
latent TB infection should be provided IPT, which pre-
vents infection from developing into active disease.
· Infection ControI — Homes, schools, health facilities,
and other community settings need to be made safe
from TB. Simple measures such as opening windows
and doors in health facilities can establish natural
ventilation and prevent the spread of disease.
18
· Integration — TB services need to be integrated with
primary health care, maternal and child health, and
HIV services so that they’re widely available. Early
initiation of antiretroviral therapy (ART) helps reduce
the likelihood a child will become sick with TB.
19
Chil-
dren with HIV should be placed on antiretroviral ther-
apy (ART) immediately upon HIV diagnosis to reduce
TB risk and death.
These methods are very effective at reducing childhood
TB and are endorsed by WHO.
20
A program in Bangla-
desh is implementing active case finding by training
community health workers to go door-to-door and
screen children for symptoms of TB.
21
Unfortunately,
many countries with constrained resources don’t fol-
low the Four I’s. More supplies, training, and health care
workers are needed to make TB prevention a reality.
Tuberculosis is a disease of families. When one family member gets TB, the
disease can pass through the rest of the family. It happens easily, because TB
germs spread from person to person through the air. Children typically get TB from
parents or extended family, and oftentimes multiple family members are sick at
the same time.
3
Even when parents aren’t sick, they take time off of work to care
for their ill children, resulting in a loss of family income. The high cost of health
care forces families to sell their belongings to pay for TB treatment, leading them
into poverty. When parents are too sick to work, their children leave school to
earn money for the family. Children with TB fall behind in their education and are
heavily stigmatized, harming their ability to earn good wages in the future. In many
countries, women with TB are abandoned by their families, who fear becoming
infected themselves.
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CHILDREN AND TUBERCULOSIS: EXPOSING A HIDDEN EPIDEMIC
5
It started when Kofi’s mother couldn’t stop
coughing, even after several weeks of tak-
ing medicines her husband had purchased
from their local market in Kangemi, Kenya.
Kofi, only four months old, was also sick
and getting worse despite the treatment.
After becoming too sick to work and care
for her children, Kofi’s mother found a ride
to the clinic where she was diagnosed with
pulmonary tuberculosis. Because Kofi was
so young and had received the BCG vaccine
which protects children against some forms
of TB (see page 7 to learn more about BCG
vaccine), Kofi’s mother never imagined his sickness might also be pulmonary TB, she never
imagined his sickness might also be TB.
Kofi’s health continued to deteriorate. He became listless, had difficulty breathing, and lost a
lot of weight. His mother took him to the hospital, where he was diagnosed with pneumonia and
admitted. After two weeks in the hospital, further tests were run and Kofi’s mother was inter-
viewed. She described her own illness, and only then was Kofi diagnosed with TB.
At first, Kofi’s father did not understand what it meant for Kofi to have TB. He blamed Kofi’s
mother, believing TB to be a hereditary illness passed from mother to son. After all, his wife’s
father and sister died of TB three years earlier. To Kofi’s father, his son had been given ugonjwa
ya familia ya bibi — a disease from the wife’s side of the family.
A community health worker educated both Kofi’s mother and father about TB — how it spreads,
how to look for signs and symptoms, and how it was important to take an entire course of
treatment to cure the disease. They were assured about the importance of seeking proper
health services, rather than self-medicating, when their children became very sick. After nine
months of receiving treatment and care, Kofi and his mother were both cured and returned to
normal health.
KOFI'S STORY
At first, Kofi’s father did not understand what it meant for
Kofi to have TB. He blamed Kofi’s mother, believing TB to
be a hereditary illness passed from mother to son.
© GARY HAMPTON
ACTIONf ADVOCACY TO CONTROL TB INTERNATIONALLY
HOW ARE CHILDREN WITH TB DIAGNOSED AND TREATED?
6
There’s no gold standard for diagnosing TB in children.
Children have difficulty coughing up sputum to test for
TB. Health workers therefore have to rely on other tests,
including screening children for the symptoms of TB,
seeing if the child has been in contact with an infected
adult, and giving a tuberculin skin test (TST).
22
A TST
— where a needle is placed under the skin, a solution
is injected, and the injection site swells if the body is
infected with TB — can merely tell if a child has been
infected, not if he or she has active disease. Chest
x-rays and other scans are helpful to diagnose active
TB, but they’re rarely accessible in developing countries
where they’re needed. Oftentimes, children suspected
to have TB are treated with a broad spectrum of antibi-
otics. Those who fail to respond to treatment are given
a speculative TB diagnosis.
1
DIAGNOSING AND TREATING CHILDREN WITH MDR-TB
f

If diagnosed early and given proper treatment, children
with MDR-TB can often be cured. However, there are
many challenges to diagnosing and treating children with
drug-resistant TB. Diagnosis is often done by trial and
error. Children are diagnosed with MDR-TB when they do
not respond to regular treatment, get recurring TB, or live
in close contact with someone confirmed to have MDR-
TB.
23
MDR-TB is particularly dangerous to children with
HIV, who are at greater risk of severe illness and death.
Early diagnosis and treatment, combined with the use of
ART, greatly improves outcomes. It is critical that these
children are diagnosed early and receive proper treat-
ment for both MDR-TB and HIV.
24

© GARY HAMPTON
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CHILDREN AND TUBERCULOSIS: EXPOSING A HIDDEN EPIDEMIC
7
WHAT ARE THE CHALLENGES SURROUNDING CHILDREN AND TB?
THERE’S A VACCINE TO PREVENT TB —
BUT IT’S OLD AND DOESN’T WORK WELL
f
The only TB vaccine that exists, called the Bacille
Calmette-Guérin (or BCG) vaccine, was invented
before World War II. In most developing countries,
BCG vaccine is given at birth to help protect young
children against the most severe forms of TB, includ-
ing TB meningitis. However, it fails to protect children
and adults against most other forms of TB. WHO rec-
ommends that all children who live in countries with
high TB rates receive the immunization, saving even
a small percentage of children is a big success. Unfor-
tunately, as children grow older the effect of the vac-
cine wears off. Furthermore, children with HIV are
unable to receive BCG vaccine because it can make
them sick.
25
Scientists are working on developing a new
vaccine that addresses these shortcomings, but further
funding is needed to develop and deliver it worldwide.
WE NEED NEW TB DIAGNOSTICS
THAT WORK FOR CHILDREN
f
Further resources are needed to certify a rapid, point-
of-care test that accurately diagnoses TB in children.
The most widely used diagnostic dates to the turn of
the 20th century — predating the automobile. Although
WHO has yet to approve Xpert MTB/RIF for use in chil-
dren, preliminary studies indicate the new DNA-based,
rapid diagnositc test is effective in children under 15.
26

Studies are now being conducted to see if Xpert can be
used to diagnose TB in children.
Xpert represents the very latest in TB diagnostics, but
it relies on the patient’s ability to cough up sputum —
something many children, particularly young children,
have difficulty doing. While Xpert is a vital tool, pedia-
tricians believe new tests should also be designed for
children that use easy-to-get samples like urine or feces.
A few innovative approaches are showing promise. In
Peru, physicians are using the ‘string test’ to diagnose
TB in children as young as four.
27
Children swallow a gel
capsule with a nylon string that unravels once inside.
When the string is retrieved four hours later, it is tested
for TB bacteria. Recent studies of the string test show
promise, however further research is needed to deter-
mine its effectiveness.
THERE ARE NO TB TREATMENT
OPTIONS SPECIFICALLY FOR CHILDREN
f
No child-specific TB drugs exist, and children are rou-
tinely excluded from drug treatment clinical trials.
Currently, children with TB are treated using many
different medicines, up to 15 tablets a day, over six
to nine months. Although some companies started
manufacturing smaller, crushable tablets that are
easier for children to take, these are not widely avail-
able. Often, doctors crush adult tablets and estimate
appropriate doses, which runs the risk of over- or
under-dosing a child.
28

WHO has proposed a better way to treat children with
TB using one tablet containing all medicines — a Fixed
Dose Combination (FDC).
29
An FDC would make TB
treatment easier, more effective, and ensure more chil-
dren are cured of TB. Currently there is no FDC to treat
TB in children. Development of a WHO-approved FDC is
a top research priority requiring urgent funding.
CHILDREN ARE EXCLUDED FROM
TB DRUG CLINICAL RESEARCH TRIALS
f
The exclusion of children from clinical trials is the main
reason no child-friendly TB treatment options exist.
Children are left out of clinical trials for a number of rea-
sons, including the difficulty of confirming diagnosis,
concerns about pediatric-specific adverse effects, and
complex regulatory requirements.
30
Nearly forty years
after modern anti-TB drugs were developed, questions
still exist regarding the appropriate dosages to give
children. Barriers from including children in clinical tri-
als ostensibly exist to protect children from the poten-
tial harm of participating in scientific studies. However,
many pediatricians are worried that this attempt to pro-
tect children has done the opposite — instead denying
children new lifesaving treatment.
8
ACTIONf ADVOCACY TO CONTROL TB INTERNATIONALLY
8 WWW.ACTION.ORG
CHILDREN AND TB: A CALL TO ACTION
A lack of political will, inadequate funding, and children’s exclusion from
research remain barriers to eliminating childhood TB. To date, little has
been done to prioritize childhood TB in national health programs and to
eliminate the disease as a major killer of children. “For too long, childhood
tuberculosis has been neglected throughout the world,” says Dr. Starke.
“Pro-actively finding and treating children with TB will not only improve
child health, it will prevent millions of new infections in people of all ages.”
s Fighting childhood TB must become a global health
priority among both donors and national TB pro-
grams. New resources are needed to eliminate TB as
a killer of children.
s Children need universal access to the current tools
available to diagnose and treat TB. National TB pro-
grams must implement the Four I’s and ensure that
all children who are in contact with an adult who has
TB are actively traced, treated, and given isoniazid
preventive therapy.
s TB diagnostics, treatment, and care services should
be integrated with child health primary care, mater-
nal and child health programs, and HIV services.
s The scientific community needs to include children
of all ages in clinical trials. Children have the same
right as adults to receive treatment and benefit from
research.
s Innovative research is needed to develop child-
friendly TB diagnostics, drugs, and vaccines.
s Through advocacy, civil society must demand equi-
table prevention, diagnostics, treatment, and care
services for childhood TB and monitor the scale-up
of these services worldwide.
s Children with HIV should be placed on ART imme-
diately upon diagnosis to reduce risk of TB disease
and death.
© REBECCA SULLIVAN
WWW.ACTION.ORG
CHILDREN AND TUBERCULOSIS: EXPOSING A HIDDEN EPIDEMIC
9
Endnotes
1 Starke, J. (2004). “Tuberculosis in Children: Clinical, Radio-
graphic, and Laboratory Findings.” Seminars in Respiratory
and Critical Care Medicine 25(3).
2 Middelkoop, K. et al. (2009). “Childhood tuberculosis
infection and disease: A spatial and temporal transmission
analysis in a South African township.” South African Medical
Journal 99(10): 783-743.
3 Bryden, D. (2010). “The TB Crisis in Children.” Science
Speaks: HIV & TB News. Accessed 9 May 2011. <http://sci-
encespeaksblog.org/2010/11/17/the-tb-crisis-in-children/>.
4 WHO (2010). Multidrug and extensively drug-resistant
TB (M/XDR-TB): 2010 Global Report on Surveillance and
Response. Geneva, World Health Organization.
5 Fiarlie, L. (2011). “High prevalence of multi-drug resistant
tuberculosis in Johannesburg, South Africa: a cross sec-
tional study.” BMC Infectious Diseases 11(28).
6 Schaaf, H.S. et al. (2009). “Surveillance of antituberculosis
drug resistance among children from the Western Cape
Province of South Africa – an upward trend.” American Jour-
nal of Public Health 99(8): 1486-1490.
7 Donohue, M. (2001). “Child’s Risk Factors Guide Decision
on TB Testing”. Pediatric News. Accessed 9 February 2011.
<http://findarticles.com/p/articles/mi_hb4384/is_10_35/
ai_n28871755/>.
8 Sharan, S. (2005). “Childhood Tuberculosis in Nepal.” Jour-
nal of Young Investigators 12(3): Accessed 10 March 2011.
<http://www.jyi.org/features/ft.php?id=102>.
9 Mandalakas, A.M. et al. (2007). “Predictors of Mycobac-
terium tuberculosis Infection in International Adoptees.”
Pediatrics 120: 610-616.
10 Braitstein, P. et al. (2009). “The clinical burden of tuberculo-
sis among human immunodeficiency virus-infected children
in western Kenya and the impact of combination antiret-
roviral treatment.” Pediatric Infectious Disease Journal
28(7):626-632.
11 Thomas, T.A. et al. (2010). “Extensively drug-resistant
tuberculosis in children with human immunodeficiency virus
in rural South Africa.” International Journal of Tuberculosis
and Lung Disease 14(10): 1244-1251.
12 Hesseling, A.C. et al. (2009). “High incidence of tuberculosis
among HIV-infected infants: evidence from a South African
population-based study highlights the need for improved
tuberculosis control strategies.” Clinical Infectious Disease
48(1): 108-14.
13 UNAIDS (2007). Report on the global AIDS epidemic.
Geneva, Joint United Nations Programme on HIV/AIDS.
14 Lin, H.C. and Chen, S.F. (2010). “Increased Risk of Low
Birthweight and Small for Gestational Age Infants Among
Women with Tuberculosis.” BJOG: An International Journal
of Obstetrics and Gynaecology 117(5): 585.
15 World Health Organization (2008). WHO Three I’s Meeting:
Intensified Case Finding (ICF), Isoniazid Preventing Therapy
(IPT), and TB Infection Control (IC) for people living with HIV.
Geneva, World Health Organization.
16 Corbett, E.L. et al. (2007). “Epidemiology of Tuberculosis in
a High HIV Prevalence Population Provided with Enhanced
Diagnosis of Symptomatic Disease.” PLoS Medicine 4(1): e22.
17 Corbett, E.L. et al. (2009). “Prevalent infectious tuberculosis
in Harare, Zimbabwe: burden, risk factors and implications
for control.” International Journal of Tuberculosis and Lung
Disease 13(10): 1231-7.
18 Marais, B.J., Rabie, H. and Cotton, M.F. (2011). “TB and HIV in
children – advances in prevention and management.” Pediat-
ric Respiratory Reviews 12(1): 39-45.
19 Walters, E. et al. (2008). "Clinical presentation and outcome
of Tuberculosis in Human Immunodeficiency Virus infected
children on anti-retroviral therapy." BMC Pediatrics 8(1): 1-12."
20 World Health Organization (2006). Guidance for national
tuberculosis programmes on the management of tuberculo-
sis in children. Geneva, World Health Organization.
21 ICDDR,B (2008). A simple method of detecting tuberculosis
among children in rural areas. Dhaka, ICDDR,B. Accessed 10
March 2011. <http://www.icddrb.org/publication.cfm?classifi
cationID=46&pubID=10344>.
22 Marais, B. et al. (2006). “Childhood Pulmonary Tuberculosis:
Old Wisdom and New Challenges.” American Journal of
Respiratory and Critical Care Medicine 173: 1078-1090.
23 Moore, D.P. et al. (2009). “Childhood tuberculosis guidelines
of the Southern African Society for Paediatric Infectious Dis-
eases.” South African Journal of Epidemiology and Infection
24(3): 57-68.
24 Schaaf, S. (2009, August 21). “What’s new in drug resistant
tuberculosis in children?” PowerPoint presentation given at
the third congress of the Federation of Infectious Diseases
Society of Southern Africa. Accessed 21 March 2011. <http://
www.critcare.co.za/images/FidssaPres/Eland/14h00%20
S%20Shcaaf%20MDR-TB%20Children_Schaaf_FIDSSA_
Aug_2009.pdf>.
25 WHO (2007). “Global Advisory Committee on Vaccine Safety,
29-30 November 2006.” Weekly Epidemiological Record
82(3): 17-24. Accessed 1 April 2011. <http://www.who.int/
wer/2007/wer8203.pdf>.
26 Nicol, M.P. et al. (2011). "Accuracy of the Xpert MTB/RIF
test for the diagnosis of pulmonary tuberculosis in children
admitted to hospital in Cape Town, South Africa: a descrip-
tive study. "The Lancet Infectious Diseases Accessed online
18 July 2011 <http://www.thelancet.com/journals/laninf/
article/PHS1473-3099(11)701670/fulltext>.
27 Chow, F. et al. (2006). “La cuerda dulce – a tolerability and
acceptability study of a novel approach to specimen collec-
tion for diagnosis of paediatric pulmonary tuberculosis.”
BMC Infectious Diseases 6: 67.
28 Médecins Sans Frontières (2011). DR-TB drugs under the
microscope: The sources and prices of medicines for drug-
resistant tuberculosis. Geneva, Médecins Sans Frontières.
29 WHO (2009). Dosing instructions for the use of currently
available fixed-dose combination TB medicines for children.
Geneva, World Health Organization.
30 Burman, W.J. et al. (2008). “Ensuring the Involvement of
Children in the Evaluation of New Tuberculosis Treatment
Regimens.” PLoS Medicine 5(8): 1168-1172.
c/o RESULTS Educational Fund
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burden countries and donor countries. With effective
policy advocacy and greater political will, rapid progress
can be made against the global TB epidemic.
To learn more about ACTION’s advocacy strategies
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. They do not feel sick and they cannot spread the infection to others. isoniazid. the malnourished. at least 1 million children became sick with TB. What is TB. If the medication is taken incorrectly or stopped prematurely. people are unable to fight the bacteria. active TB is often fatal. Children have weak immune systems. Active TB is treated using numerous drugs taken over a six-to-12-month period. It is crucial that patients take medication exactly as prescribed and complete the full course of treatment. or even sings. The World Health Organization (WHO) estimates that approximately 176. those living with HIV — and it causes an almost unimaginable burden to children and their families. yet virtually no public or political attention is paid to TB as a children’s health issue. It is spread through the air when an infected person coughs. over the course of six to nine months. We must stop neglecting TB as a children’s health issue and take immediate steps to stop TB from needlessly infecting and killing children. In some cases.000 children died2. Latent TB infection can be treated using only one drug. Drug-resistant strains of TB are much harder to cure and extremely expensive to treat. usually the lungs. TB disease can easily reemerge and become resistant to medication. but the consensus among researchers says that actual figures are higher. sneezes. Data show that in 2009. These people have a latent TB infection. and How is it Treated? © GARY HAMPTON TB is an infectious disease caused by bacteria that often attack the lungs.ACTION ADVOCACY TO CONTROL TB INTERNATIONALLY Tuberculosis (TB) remains among the top ten killers of children worldwide1. most healthy people are able to fight the bacteria by sealing it off within a part of the body. When exposed to TB. laughs. and they become sick with active TB disease. making them prime targets for TB. If not treated properly. TB preys on the most vulnerable children — the orphaned.

2 At least 10-15 percent of these cases are in children under 15 — but the percentage is probably much higher. Its proper diagnosis. the vast majority of childhood TB cases go unreported — making it very difficult to deter- WWW. in children the disease often spreads to other parts of the body. the true burden is unknown because nobody is collecting and merging enough data.4 Despite studies that show children get MDR-TB. Because on average children are less contagious than adults. including TB meningitis. However. We must consider the unique nature of childhood TB if we’re to successfully eliminate TB anywhere in the world.ACTION. approximately 9 million people become sick with TB each year. childhood TB “is a fundamentally different disease from adult tuberculosis. training health workers to diagnose TB in children leads to a significant jump in the proportion of cases detected — even using the inadequate tools currently available.1 Most children have a type of TB classified as sputum smear-negative TB (see box on pg. Jeffrey Starke.000 people each year. and prevention require specific planning and resources. 3 CHILDREN ARE PRONE TO SEVERE TYPES OF TB While adults most often get TB in their lungs. a few localized studies exist showing the burden is substantial.5. because childhood TB is under-reported. Children are therefore more likely than adults to develop severe forms of TB. it takes expert medical care and extremely expensive treatment. they’ve been overlooked by national TB programs.” According to WHO.1 TB meningitis occurs when the bacteria spread to the central nervous system. 2 Because only 10-15 percent of children have this kind of TB. 2: Types of TB).6 Further research is needed to determine the true burden of childhood MDR-TB. treatment.ORG 1 . MULTIDRUG-RESISTANT TB IN CHILDREN Multidrug-resistant TB (MDR-TB) — defined as TB that is resistant to at least the two most powerful anti-TB drugs. It is far cheaper to prevent the development of MDR-TB in the RATES OF TB IN CHILDREN ARE GROSSLY UNDER-REPORTED Most countries only report childhood TB cases that are considered “sputum smear-positive” (see box on pg. While MDR-TB is curable in children.CHILDREN AND TUBERCULOSIS: EXPOSING A HIDDEN EPIDEMIC WHAT IS THE NATURE AND MAGNITUDE OF TB AMONG CHILDREN? According to Dr. TB can attack virtually any part of a child’s body in similar fashion. which makes them less likely to spread the disease to others — but it’s still deadly if left untreated. 2: Types of TB). Studies in South Africa indicate nearly nine percent of childhood TB cases are drug resistant — a rate similar to adults. Anneke Hesseling. The bacteria inflame the tissue that protects the brain. including the brain. only adults are included in global MDR-TB surveys — meaning no one knows for sure how many children suffer from MDR-TB. mine the true burden of childhood TB that exists in the world. TB meningitis is most common in children under two years old.1 However. and the disease is almost always fatal without treatment. a leading TB specialist at Texas Children’s Hospital. a childhood TB expert at the Desmond Tutu TB Center at Stellenbosch University in South Africa. According to Dr. WHO estimates that 1 million children become sick with TB each year. but the real numbers are likely much higher. causing it to swell. isoniazid and rifampicin — afflicts approximately 440.

Many patients. which is highly infectious.12 TB remains the third leading killer of children with AIDS and nearly half of new childhood TB cases occur in children with HIV. spine. Infants and very young children have weak immune systems. have smear-negative TB — a form of the disease where the patient is sick but a technician does not detect TB bacteria under the microscope. especially children and people living with HIV/AIDS.10. If a technician can see TB bacteria under the microscope. infants with a latent TB infection have a 40 percent chance of developing active TB during their first year of life.7 YOUNG AGE ORPHANS AND VULNERABLE CHILDREN Orphans and vulnerable children are more likely to be malnourished.13 MATERNAL TB Children whose mothers have TB are likely to both contract the disease and be born at a low birth weight. or genital tract.9 .11 HIV HIV weakens the immune system. brain. this revolutionary tool uses DNA technology to rapidly identify TB bacteria in sputum samples in less than two hours.14 MALNUTRITION Malnourished children have weaker immune systems that make them more susceptible to developing active TB. Poor children often lack access to care and live in overcrowded conditions that make them vulnerable to TB. 2 . Children with HIV are up to 20 times more likely to develop TB than children with healthy immune systems. often the lymph nodes. Instead of using a microscope. A child born to a mother with TB has an overall higher risk of death. live in poverty. the World Health Organization endorsed a new tool to diagnose TB. Patients suspected to have pulmonary TB are asked to cough up phlegm — or sputum — which a laboratory technician then examines under a microscope.ACTION ADVOCACY TO CONTROL TB INTERNATIONALLY WHAT FACTORS PLACE CHILDREN AT RISK FOR TB? POVERTY Poverty is a major risk factor for TB. making a person vulnerable to TB. In December 2010. which place them at higher risk of developing active TB. which places them at higher risk of developing active TB. Xpert MTB/RIF. and lack access to medical care.8 Types of TB TB bacteria typically infect the lungs (called pulmonary TB) but may spread to virtually any other organ outside the lungs (called extrapulmonary TB). While the average adult with latent TB infection has a 5-10 percent lifetime risk of developing active disease. the patient is considered to have smear-positive TB.

If detected earlier. the doctor thought Anthony had the flu and prescribed him flu medicine. Worried the humid weather was contributing to their coughing. always giggling and running around. Mamta and Jacob moved their family to a drier city in India. Both boys are very lively. I had been to the doctor so many times. Again. Gisele knew something was wrong. At first.” exclaims Gisele. One day Mamta and Jacob noticed their boys began coughing and wheezing. who was quickly able to diagnose Abhijat and Abhishakt with pulmonary TB. so they returned to the doctor. Anthony’s eyes started to glaze over and Gisele brought him to the emergency room. TX. However. Mamta and Jacob brought their boys to see four different doctors at private health clinics. If the private medical doctors realized TB was not a disease that only affects the poor and given attention to their symptoms. Anthony was then transferred to Texas Children’s Hospital in Houston. Mamta and Jacob. but their boys remained very ill. . He prescribed steroids and an antibiotic. Mamta and Jacob realized that TB is not “the other man’s disease. so they went to a private health facility. After their experience Mamta and Jacob believe the private health sector needs to be better integrated with national TB control efforts.” says Gisele. A few days later. “I was so angry. Doctors traced Anthony’s infection to a family friend who had been ill and provided Anthony life-saving surgery and medication for TB. Within weeks. so Gisele brought him to see the doctor. In many countries such as India. I did what I was supposed to do. “It was terrifying to hear that he could die.” ABHIJAT AND ABHISHAKT'S STORY Abhijat and Abhishakt are playful twin boys. most people receive health care from private clinics. he started to run around again with Jordan. Gisele was told that Anthony had the flu. chances are Anthony would not have needed surgery. Their parents. where doctors diagnosed Anthony with TB meningitis. For the first time in their life. Anthony and Jordan. Anthony didn’t get better. Over the next six months.” It can happen to anyone. Anthony began to cry often and always appeared tired. Since Jacob has a history of asthma. the doctor assumed asthma was causing Abhijat and Abhishakt to cough. TB control efforts are focused around public health facilities.CHILDREN AND TUBERCULOSIS: EXPOSING A HIDDEN EPIDEMIC ANTHONY'S STORY Gisele is the mother of twin boys. Abhijat and Abhishakt would have been cured much earlier. A friend suggested they see a public sector doctor. Gisele is still troubled that it took so long to diagnose Anthony with TB. The boys were provided treatment and are happy and healthy today. so when Anthony stopped actively playing with Jordan. are well educated and work as health advocates in India. “It was heartbreaking to know how sick he was and how much pain he was in.

Simple measures such as opening windows and doors in health facilities can establish natural ventilation and prevent the spread of disease. harming their ability to earn good wages in the future. many countries with constrained resources don’t follow the Four I’s. the disease can pass through the rest of the family. resulting in a loss of family income. they take time off of work to care for their ill children. leading them into poverty. all close contacts and family members — including children — should be identified and screened for TB. 20 A program in Bangladesh is implementing active case finding by training community health workers to go door-to-door and screen children for symptoms of TB. When parents are too sick to work. and oftentimes multiple family members are sick at the same time. training. — Homes. women with TB are abandoned by their families. These methods are very effective at reducing childhood TB and are endorsed by WHO. People with latent TB infection or active TB disease are then provided appropriate treatment.” This is achieved by what is commonly referred to as the four I’s15 — intensified case finding. a method called intensified case finding.16.3 Even when parents aren’t sick. 21 Unfortunately.17 — People with latent TB infection should be provided IPT.19 Children with HIV should be placed on antiretroviral therapy (ART) immediately upon HIV diagnosis to reduce TB risk and death. infection control. and integration. Children typically get TB from parents or extended family. It happens easily. and HIV services so that they’re widely available. vents infection from developing into active disease. stopping the spread of the disease. maternal and child health. The high cost of health care forces families to sell their belongings to pay for TB treatment. which pre- Tuberculosis is a disease of families. . More supplies. Starke.18 — TB services need to be integrated with primary health care. The most effective way to prevent childhood TB is to stop the disease from spreading in the wider community. When one family member gets TB. Early initiation of antiretroviral therapy (ART) helps reduce the likelihood a child will become sick with TB. Children who are considered high risk — especially those with HIV — should also be routinely screened for TB. In many countries. because TB germs spread from person to person through the air.ACTION ADVOCACY TO CONTROL TB INTERNATIONALLY HOW CAN TB IN CHILDREN BE PREVENTED? It is more cost effective to prevent disease than it is to treat it. According to Dr. Children with TB fall behind in their education and are heavily stigmatized. THE FOUR I’S — When an adult is diagnosed with TB. better organization of services and aggressively identifying recently exposed and infected children would prevent tens of thousands of tuberculosis cases in children every year. health facilities. and other community settings need to be made safe from TB. and health care workers are needed to make TB prevention a reality. who fear becoming 4 infected themselves. schools. isoniazid preventive therapy. “Even with the limited tools currently available. their children leave school to earn money for the family.

After two weeks in the hospital. Kofi. and how it was important to take an entire course of treatment to cure the disease. A community health worker educated both Kofi’s mother and father about TB — how it spreads. Kofi’s father did not understand what it meant for Kofi to have TB. His mother took him to the hospital. rather than self-medicating. his wife’s father and sister died of TB three years earlier. To Kofi’s father. even after several weeks of taking medicines her husband had purchased from their local market in Kangemi. further tests were run and Kofi’s mother was interviewed.CHILDREN AND TUBERCULOSIS: EXPOSING A HIDDEN EPIDEMIC KOFI'S STORY It started when Kofi’s mother couldn’t stop coughing. At first. Because Kofi was so young and had received the BCG vaccine which protects children against some forms © GARY HAMPTON of TB (see page 7 to learn more about BCG vaccine). where he was diagnosed with pneumonia and admitted. Kofi’s mother never imagined his sickness might also be pulmonary TB. She described her own illness. Kofi and his mother were both cured and returned to normal health. when their children became very sick. Kofi’s mother found a ride to the clinic where she was diagnosed with pulmonary tuberculosis. Kenya. WWW. and lost a lot of weight. had difficulty breathing. and only then was Kofi diagnosed with TB. He became listless. At first. only four months old. Kofi’s father did not understand what it meant for Kofi to have TB. After all. was also sick and getting worse despite the treatment. believing TB to be a hereditary illness passed from mother to son. his son had been given ugonjwa ya familia ya bibi — a disease from the wife’s side of the family. how to look for signs and symptoms. After becoming too sick to work and care for her children. After nine months of receiving treatment and care. They were assured about the importance of seeking proper health services. He blamed Kofi’s mother. Kofi’s health continued to deteriorate.ORG 5 . He blamed Kofi’s mother.ACTION. she never imagined his sickness might also be TB. believing TB to be a hereditary illness passed from mother to son.

not if he or she has active disease. It is critical that these children are diagnosed early and receive proper treatment for both MDR-TB and HIV. Health workers therefore have to rely on other tests. 23 MDR-TB is particularly dangerous to children with HIV. there are many challenges to diagnosing and treating children with drug-resistant TB.ACTION ADVOCACY TO CONTROL TB INTERNATIONALLY HOW ARE CHILDREN WITH TB DIAGNOSED AND TREATED? There’s no gold standard for diagnosing TB in children. a solution is injected. Oftentimes. However. Those who fail to respond to treatment are given a speculative TB diagnosis. children with MDR-TB can often be cured. Early diagnosis and treatment. Chest x-rays and other scans are helpful to diagnose active TB. 22 A TST — where a needle is placed under the skin. including screening children for the symptoms of TB. Children have difficulty coughing up sputum to test for TB. who are at greater risk of severe illness and death.1 DIAGNOSING AND TREATING CHILDREN WITH MDR-TB If diagnosed early and given proper treatment. get recurring TB. and giving a tuberculin skin test (TST). greatly improves outcomes. or live in close contact with someone confirmed to have MDRTB. and the injection site swells if the body is infected with TB — can merely tell if a child has been infected. Diagnosis is often done by trial and error. Children are diagnosed with MDR-TB when they do not respond to regular treatment. seeing if the child has been in contact with an infected adult. combined with the use of ART. but they’re rarely accessible in developing countries where they’re needed. 24 6 © GARY HAMPTON . children suspected to have TB are treated with a broad spectrum of antibiotics.

WHO recommends that all children who live in countries with high TB rates receive the immunization. preliminary studies indicate the new DNA-based. While Xpert is a vital tool. When the string is retrieved four hours later. doctors crush adult tablets and estimate appropriate doses. 28 WHO has proposed a better way to treat children with TB using one tablet containing all medicines — a Fixed Dose Combination (FDC). have difficulty doing. Although some companies started manufacturing smaller. However. 26 Studies are now being conducted to see if Xpert can be used to diagnose TB in children. CHILDREN ARE EXCLUDED FROM TB DRUG CLINICAL RESEARCH TRIALS The exclusion of children from clinical trials is the main reason no child-friendly TB treatment options exist. 29 An FDC would make TB treatment easier. rapid diagnositc test is effective in children under 15. however further research is needed to determine its effectiveness. 27 Children swallow a gel capsule with a nylon string that unravels once inside. children with TB are treated using many different medicines.ACTION. it fails to protect children and adults against most other forms of TB. In most developing countries. as children grow older the effect of the vaccine wears off. saving even a small percentage of children is a big success. Furthermore. Development of a WHO-approved FDC is a top research priority requiring urgent funding. Barriers from including children in clinical trials ostensibly exist to protect children from the potential harm of participating in scientific studies. A few innovative approaches are showing promise. In Peru.30 Nearly forty years after modern anti-TB drugs were developed.25 Scientists are working on developing a new vaccine that addresses these shortcomings. crushable tablets that are easier for children to take. Currently. Recent studies of the string test show promise. called the Bacille Calmette-Guérin (or BCG) vaccine. questions still exist regarding the appropriate dosages to give children. it is tested for TB bacteria. was invented before World War II. but further funding is needed to develop and deliver it worldwide. more effective. and children are routinely excluded from drug treatment clinical trials. and ensure more children are cured of TB. particularly young children.or under-dosing a child. Xpert represents the very latest in TB diagnostics. WWW. Currently there is no FDC to treat TB in children. THERE ARE NO TB TREATMENT OPTIONS SPECIFICALLY FOR CHILDREN No child-specific TB drugs exist. but it relies on the patient’s ability to cough up sputum — something many children. BCG vaccine is given at birth to help protect young children against the most severe forms of TB. these are not widely available. including TB meningitis. which runs the risk of over. concerns about pediatric-specific adverse effects. over six to nine months. and complex regulatory requirements. up to 15 tablets a day. The most widely used diagnostic dates to the turn of the 20th century — predating the automobile. Unfortunately. Although WHO has yet to approve Xpert MTB/RIF for use in children. WE NEED NEW TB DIAGNOSTICS THAT WORK FOR CHILDREN Further resources are needed to certify a rapid. Often. including the difficulty of confirming diagnosis. pediatricians believe new tests should also be designed for children that use easy-to-get samples like urine or feces.CHILDREN AND TUBERCULOSIS: EXPOSING A HIDDEN EPIDEMIC WHAT ARE THE CHALLENGES SURROUNDING CHILDREN AND TB? THERE’S A VACCINE TO PREVENT TB — BUT IT’S OLD AND DOESN’T WORK WELL The only TB vaccine that exists. pointof-care test that accurately diagnoses TB in children. Children are left out of clinical trials for a number of reasons. children with HIV are unable to receive BCG vaccine because it can make them sick. many pediatricians are worried that this attempt to protect children has done the opposite — instead denying children new lifesaving treatment. physicians are using the ‘string test’ to diagnose TB in children as young as four.ORG 7 . However.

Children need universal access to the current tools available to diagnose and treat TB. Children have the same right as adults to receive treatment and benefit from research. civil society must demand equitable prevention. WWW. it will prevent millions of new infections in people of all ages. Children with HIV should be placed on ART immediately upon diagnosis to reduce risk of TB disease and death. To date. and care services should be integrated with child health primary care. diagnostics.ORG 8 8 © REBECCA SULLIVAN . inadequate funding. and children’s exclusion from research remain barriers to eliminating childhood TB. “Pro-actively finding and treating children with TB will not only improve child health. “For too long. New resources are needed to eliminate TB as a killer of children. National TB programs must implement the Four I’s and ensure that all children who are in contact with an adult who has TB are actively traced. and given isoniazid preventive therapy. and vaccines. drugs. TB diagnostics.ACTION. and care services for childhood TB and monitor the scale-up of these services worldwide. treatment. Through advocacy. treated.” says Dr. childhood tuberculosis has been neglected throughout the world. Innovative research is needed to develop childfriendly TB diagnostics.ACTION ADVOCACY TO CONTROL TB INTERNATIONALLY CHILDREN AND TB: A CALL TO ACTION A lack of political will.” Fighting childhood TB must become a global health priority among both donors and national TB programs. The scientific community needs to include children of all ages in clinical trials. little has been done to prioritize childhood TB in national health programs and to eliminate the disease as a major killer of children. Starke. and HIV services. maternal and child health programs. treatment.

jyi. (2006).CHILDREN AND TUBERCULOSIS: EXPOSING A HIDDEN EPIDEMIC Endnotes 1 Starke.” International Journal of Tuberculosis and Lung Disease 13(10): 1231-7. Middelkoop. “Childhood tuberculosis guidelines of the Southern African Society for Paediatric Infectious Diseases.critcare. WHO (2007). Report on the global AIDS epidemic. Sharan. (2007). A.php?id=102>.” Clinical Infectious Disease 48(1): 108-14. Corbett. W. “Increased Risk of Low Birthweight and Small for Gestational Age Infants Among Women with Tuberculosis. Walters. Médecins Sans Frontières (2011). “Epidemiology of Tuberculosis in a High HIV Prevalence Population Provided with Enhanced Diagnosis of Symptomatic Disease. risk factors and implications for control. (2009). Geneva. “High incidence of tuberculosis among HIV-infected infants: evidence from a South African population-based study highlights the need for improved tuberculosis control strategies. et al.org/publication. <http://findarticles. et al. “What’s new in drug resistant tuberculosis in children?” PowerPoint presentation given at the third congress of the Federation of Infectious Diseases Society of Southern Africa. <http://sciencespeaksblog. Dosing instructions for the use of currently available fixed-dose combination TB medicines for children. “The clinical burden of tuberculosis among human immunodeficiency virus-infected children in western Kenya and the impact of combination antiretroviral treatment. Geneva.F. et al. Schaaf. et al. “Child’s Risk Factors Guide Decision on TB Testing”. Marais.P.” Seminars in Respiratory and Critical Care Medicine 25(3). "Accuracy of the Xpert MTB/RIF test for the diagnosis of pulmonary tuberculosis in children admitted to hospital in Cape Town. et al. Geneva.com/p/articles/mi_hb4384/is_10_35/ ai_n28871755/>.L. <http:// www. Donohue. WHO (2010). and Laboratory Findings.pdf>.za/images/FidssaPres/Eland/14h00%20 S%20Shcaaf%20MDR-TB%20Children_Schaaf_FIDSSA_ Aug_2009. “Ensuring the Involvement of Children in the Evaluation of New Tuberculosis Treatment Regimens. B. “La cuerda dulce – a tolerability and acceptability study of a novel approach to specimen collection for diagnosis of paediatric pulmonary tuberculosis. Geneva. (2009). (2011). Joint United Nations Programme on HIV/AIDS. Hesseling. World Health Organization. Dhaka. 17 2 18 3 19 4 20 5 21 6 22 7 23 8 24 9 10 25 11 26 12 27 13 14 28 29 15 30 16 WWW. Lin. P. Rabie. D.M.” Journal of Young Investigators 12(3): Accessed 10 March 2011. (2006). DR-TB drugs under the microscope: The sources and prices of medicines for drugresistant tuberculosis. World Health Organization. (2009). (2011).” South African Medical Journal 99(10): 783-743. J. "The Lancet Infectious Diseases Accessed online 18 July 2011 <http://www.org/2010/11/17/the-tb-crisis-in-children/>. H. et al. Geneva. August 21). (2009).ORG 9 . Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 Global Report on Surveillance and Response." BMC Pediatrics 8(1): 1-12. (2005).co. “Childhood Pulmonary Tuberculosis: Old Wisdom and New Challenges. K.” American Journal of Respiratory and Critical Care Medicine 173: 1078-1090. et al. World Health Organization. Radiographic.who.P. Nicol." World Health Organization (2006). WHO (2009). “Prevalent infectious tuberculosis in Harare. ICDDR. E. “Global Advisory Committee on Vaccine Safety. “Surveillance of antituberculosis drug resistance among children from the Western Cape Province of South Africa – an upward trend.” BJOG: An International Journal of Obstetrics and Gynaecology 117(5): 585. World Health Organization (2008).C. Pediatric News. Bryden. D.C.” PLoS Medicine 4(1): e22.J. Geneva. Accessed 9 May 2011. et al. (2004). (2009). “Childhood tuberculosis infection and disease: A spatial and temporal transmission analysis in a South African township. “The TB Crisis in Children. (2008). <http://www. “Childhood Tuberculosis in Nepal. et al.” American Journal of Public Health 99(8): 1486-1490. and TB Infection Control (IC) for people living with HIV. World Health Organization. (2001). M. Schaaf. (2011). “Tuberculosis in Children: Clinical.” Pediatrics 120: 610-616.. Accessed 9 February 2011.L.J. S.S.B (2008). Guidance for national tuberculosis programmes on the management of tuberculosis in children. et al.com/journals/laninf/ article/PHS1473-3099(11)701670/fulltext>. S. Accessed 1 April 2011.thelancet. and Cotton. L. Burman. T.” Pediatric Respiratory Reviews 12(1): 39-45. et al.” Weekly Epidemiological Record 82(3): 17-24.” Pediatric Infectious Disease Journal 28(7):626-632. H. Mandalakas.B. 29-30 November 2006. ICDDR. <http://www. A.” International Journal of Tuberculosis and Lung Disease 14(10): 1244-1251. Moore. “Predictors of Mycobacterium tuberculosis Infection in International Adoptees. "Clinical presentation and outcome of Tuberculosis in Human Immunodeficiency Virus infected children on anti-retroviral therapy. E. S. (2009). B. (2007).int/ wer/2007/wer8203. Médecins Sans Frontières. South Africa: a cross sectional study. A simple method of detecting tuberculosis among children in rural areas. Isoniazid Preventing Therapy (IPT). H.cfm?classifi cationID=46&pubID=10344>.” Science Speaks: HIV & TB News. F. Accessed 10 March 2011. Chow. “High prevalence of multi-drug resistant tuberculosis in Johannesburg. (2010). et al. Thomas. (2010). Zimbabwe: burden.org/features/ft.” BMC Infectious Diseases 11(28). UNAIDS (2007). <http://www. Marais. E.” South African Journal of Epidemiology and Infection 24(3): 57-68. “TB and HIV in children – advances in prevention and management. (2008).F. “Extensively drug-resistant tuberculosis in children with human immunodeficiency virus in rural South Africa. Braitstein.ACTION. and Chen.” PLoS Medicine 5(8): 1168-1172. M. WHO Three I’s Meeting: Intensified Case Finding (ICF). Corbett. (2010).” BMC Infectious Diseases 6: 67. Accessed 21 March 2011. et al.A. M.pdf>. South Africa: a descriptive study. (2009. et al. Fiarlie.icddrb.

With effective policy advocacy and greater political will. ACTION’s mission is to build support for increased resources for effective TB control. especially among key policymakers and other opinion leaders in both high TB burden countries and donor countries. a global disease that kills one person every 20 seconds. rapid progress can be made against the global TB epidemic.THE “WHO” OF ACTION ACTION (Advocacy to Control TB Internationally) is an international partnership of civil society advocates working to mobilize resources to treat and prevent the spread of tuberculosis (TB). DC 20036 Tel: (202) 783-4800 www. To learn more about ACTION’s advocacy strategies and tactics. NW.action. 4th Floor Washington.org . go to: You can also access ACTION’s Best Practices for Advocacy at: ACTION PARTNERS AIDES Global Health Advocates France Global Health Advocates India Kenya AIDS NGOs Consortium (KANCO) RESULTS Australia RESULTS Canada RESULTS Educational Fund (US) RESULTS Japan RESULTS UK © 2011 by Advocacy to Control TB Internationally c/o RESULTS Educational Fund 1730 Rhode Island Ave.