Summary Stop-TB eForum Theme 1

(11-25 February 2012)

Theme 1: Getting to zero new TB infections in children by 2015
- What can be done more (or less of) at the family, community or your country level to prevent new TB infections in children?
114 comments were posted from more than 17 countries including Bangladesh, Canada, India, Indonesia, Kenya, Mexico, Mozambique, Nepal, Nigeria, Pakistan, South Africa, Taiwan, Tanzania, Thailand, Uganda, Ukraine, USA, among others on the new Stop-TB eForum (to join, send an email to:, SEA-AIDS, Facebook CNS Page, Twitter, Blog, and other channels including CNS Key Informant Interviews with healthcare providers and parents/ caretakers of children with TB. All blog comments are online at:

 Rights and responsibilities based framework along with the Patients’ Charter for Tuberculosis Care be truly implemented and children’s rights and social protection be ensured  Increased support for prevention as it is more cost-effective than curative strategies, in terms of financing and human resource  Recognizing Community Competence or expertise in being equal partners in TB care and control is vital  Indoor air pollution can increase the risk of TB such as that from secondhand tobacco smoke, cook stove smoke using bio mass fuels,etc  Over-crowding, lack of hygiene (cough hygiene etc) increases risk of TB  Malnutrition was cited by experts as one of the most common risk factors that escalate risk of getting TB in children  No exclusive breastfeeding also adversely impacts a child’s immunity and ups the TB risk  Children with type 1 diabetes are at higher risk of TB  Children living with HIV also are at higher risk of TB  Infection control in healthcare settings and community/ household settings must be maintained  “Curing adult TB to prevent childhood TB” was echoed by many experts  Isoniazid Preventive Therapy (IPT) for children with latent TB was debated  BCG vaccination and related issues  Broad based health literacy and treatment literacy related to TB  Collaborative programmes beyond TB-HIV like those for TB and diabetes comorbidity, TB and malnutrition, among others  Training, retraining and supervision (support) to all healthcare and community workers  Health systems strengthening (HSS)  Community systems strengthening (CSS)  TB related stigma came up too  Children and women programmes

A participant said: “Get back to basics – as soon as someone is identified with TB, immediately do contact tracing and consider prophylactic treatment in children.”

The TB programme should recognize community competence and expertise of people such as those who have successfully completed TB treatment for instance) and engage them in the programme, as equal partners, with dignity, and at all levels. The human rights based approach to TB care and control was strongly advocated. The children’s rights and social protection also was in spotlight. TB prevention is more cost-effective, a public health imperative, and should get full support alongside treatment, care and support services in terms of financing, human resource, mobilizing political will, among others. Waste management should get support because it prevents infection - injection waste, sputum samples from TB clinics and other such infectious waste need to be disinfected as soon as possible. Infection control in healthcare facilities and in communities must be implemented. A participant said: “The majority of the children get TB disease from a parent or a close relative, someone that the child spends most time with. In the settings I work in children are always being held, carried around and sleep on the same mat with a parent, a grandparent or/and a sibling. The longer is the exposure the higher the risk for infection.” Many participants shared similar experiences. Another participant said: “We have a large number of adult TB infections that can potentially be transmitted to children. First and foremost measure that can control childhood TB is to early diagnose and successfully treat the adult TB. So all adult TB cases must be treated effectively and priority should be given to those whose sputum is positive for AFB. If we can intervene in early diagnosing and successfully treating adult TB then a secondary outcome will be to effectively control childhood TB.” Another participant agreed: “More effectively we cure the adult TB more effectively we will prevent the childhood TB. Studies show that children with TB usually don’t infect the adults rather adults with TB infect children. It is only one way transmission of TB from adults to children.” The most important risk factor for childhood TB in India is malnutrition. A participant said: “According to the data, about 49% of children between 0-5 years of age are malnourished in this country. Malnutrition is single most strong risk factor for childhood TB. If we see the immunopathology of TB, TB disease occurs as a result of interaction between Mycobacterium tuberculosis load and body’s resistance or immunity. Body’s resistance or immunity is directly related to nutrition. That is why malnutrition is a very important risk factor in development of active TB disease in children.” Another participant added: “TB is a poverty disease and half of the children in the developing countries go without meals. They are malnourished, which makes them even more vulnerable to TB. Addressing the nutrition needs is of outmost importance.” Poverty does put people at risk of TB and so poor children are more at risk due to poverty and other risk factors such as malnutrition, over-crowded housing, lack of 2| Theme 1: Getting to zero new TB infections in children

hygiene, exposure to secondhand tobacco smoke or bio mass cook stove smoke, close proximity of people with TB disease, among others. Emphasizing on infection control in hospitals, a participant said: “The usual dictum is that when somebody goes to the hospital, children accompany. This practice should stop. All hospitals should be instructed to convey to their patients that whenever they visit the hospital children shouldn’t accompany unless needed – because hospitals are a very important source of spreading infections.” Speaking about infection control and other measures at the household level, a participant said: “At the household level we can do a lot to reduce risk of TB – stopping passive smoking is one of them. Exposure to biomass or cook-stove smoke is also a risk factor for developing active TB disease. In rural areas many people still use biomass fuel for cooking, and exposure of children to cook-stove smoke can up their TB risk. Practice of using biomass fuel should be replaced by other energy options which are not detrimental for one’s health or that of the society.” This is another area for linkages of TB control programmes with tobacco cessation programmes. Strengthening of the DOTS programme must be a priority. A participant shared that “If we had a quality DOTS program the health staff would have been able to accurately diagnose and successfully treat the mother. They would have being able to prevent TB and the needless suffering in her children.” Programmes reaching out to children and women need more attention. Orphans and other vulnerable children should be provided a safe home (orphanages) if the community they live in is exposing them to risky situations. This will enhance programme outcomes. Supporting and scaling up collaborative activities between different programmes with those on TB was another key suggestion. Diabetes, HIV, and nutrition were some suggested areas where collaborative activities were recommended for enhanced programme outcomes. Training, retraining and supervision (support) to all health workers and community workers and refresher courses need support not only in management of TB within healthcare settings but also in community. TB related stigma should not be ignored. CNS team members when went to interview urban slum residents no one came forward with adulthood or childhood TB. However neighbouring DOTS centre was treating many. Stigma still lurks within our communities and must be addressed so that it doesn’t become a barrier to access existing healthcare services. Investing in Health Systems Strengthening (HSS) will have system-wide effects, not only on HIV/TB but also maternal, newborn and child health (MNCH), immunization, nutrition and many other areas.

3| Theme 1: Getting to zero new TB infections in children

Community Systems Strengthening (CSS) develops and strengthens community-based organizations so that they can achieve improved health service delivery. Many members felt CSS and HSS should both be further promoted A participant said: “I might sound to you pessimistic, I am a little bit because TB is very political and things are moving very slowly; we cannot afford to move slowly anymore, we should not allow it. We need to step up and step up very fast. What we should all see at the end of 2015 is not just the numbers, the statistics showing fewer deaths, we should see children, happy and smiley faces, children free of TB. Where there is a will there is a way and collective voices will find the way.”

This e-consultation on childhood TB is being facilitated by the Citizen News Service (CNS), a partner of the Stop TB Partnership, along with the following organizations and networks that have endorsed this initiative and joined as a partner, thanks: International Union Against Tuberculosis and Lung Disease (The Union), Irish Forum for Global Health (IFGH), McGill TB Research Group, Treatment Action Group, International Council of Women living with HIV (ICW) Zimbabwe, Asian Harm Reduction Network (AHRN), ACTION, TB Alert, International Treatment Preparedness Coalition-India (ITPC-India), Global Health Strategies, PATH, Cambodian Health Committee (CHC), L’Association de Lutte Contre la Pauvreté en abrégé (ALCP), Positive Muslim Group Myanmar, Life Foundation Pakistan, The Good Neighbour Nigeria, University of Nairobi Kenya, Medical Care Development Inputs (MCDI) Kenya, Kenya Consortium to Fight TB, Malaria and AIDS (KECOFATUMA), Partnership for TB Care and Control in India, Karnataka Health Promotion Trust (KHPT), National Coalition of PLHIV in India (NCPI+), PCI India, MAMTA Health Institute for Mother and Child, SNEHA, Institut Pasteur de Madagascar, Institute for Plantation Agricultural And Rural Workers (IPARW), Advocates for Health International, Rural Youth Advocate for Health and Development in Nigeria (RYAN), Citizens for Healthy Lucknow (CHL) initiative, Saaksham Foundation, TEST Foundation, PREPARE Foundation, JBS Foundation, Abhinav Bharat Foundation (ABF), Asha Parivar, Samadhan, National Alliance of People's Movements (NAPM), PRAYAS Health Group, Indian Society Against Smoking (ISAS), Citizen News Service (CNS)

. All blog comments of Theme 1 e-consultation are available online at: For further information, please contact: Bobby Ramakant,

4| Theme 1: Getting to zero new TB infections in children