1. Child TB: global and regional update Ninth TAG meeting and NTP Managers Meeting 9-12th December 2014 Manila
Steve Graham
Centre for International Child Health, University of Melbourne
International Union Against Tuberculosis and Lung Disease
(The Union)
Child TB sub-group, Stop TB Partnership

3. The objectives of the meeting were:
The Meeting on the Development of Child Tuberculosis Action Plans in the Western Pacific Region: HCMC, Viet Nam, March 2014
The objectives of the meeting were:
To share country experiences, lessons learnt and best practices;
To establish priorities and design activities for strengthening childhood TB initiatives in the Western Pacific Region; and
To form a task force to oversee the activities and progress.
The meeting was attended by 21 country participants from 8 countries (Cambodia, China, Fiji, Lao PDR, Mongolia, PNG, Philippines and Viet Nam). Each country team was composed of focal point from NTP, maternal and child health programme and paediatric association.
Also 17 observers participated the meeting from different technical agencies.

4. Priorities for strengthening childhood TB activities in the WPR
1. Improved political commitment and collaboration with different stakeholders (e.g. MCH, EPI; partners like UNICEF, World Vision; paediatric associations, private providers)
2. Improved case detection
3. Improved case management and logistical management
4. Improved prevention (BCG, IPT, infection control)
5. Improved recording, reporting and data analysis (including private sector)
6. Improved awareness of community and capacity building of health care worker
7. Operational research

5. Formation of a Regional Child TB Task Force
Participants of the Meeting formed an informal taskforce called 'The Regional Childhood TB Taskforce' on the Development of Child TB Action Plans in the Western Pacific Region
The Regional Childhood TB Taskforce will support members to finalise national action plans and convene a regional workshop (with partners). 
Chair: Steve Graham
Co-Chair: Dr James Amini (PNG); Dr Nguyen Thein Huong (Viet Nam)
Vice Chair: Dr Celine Garfin (Philippines); Dr Lin Zhou (China)
Members: All participants of the meeting
Secretariat: WPRO,WHO
Next meeting: Union APR conference, Sydney, August 2015

6. Objectives and activities of the taskforce
Increase awareness of the child TB disease burden in the Asia-Pacific region
Assist the development of pragmatic, contextualized national child TB action plans
Monitor & support implementation of these plans
Provide an education resource (training)
Facilitate collaboration/integration between programs for TB and maternal and child health

7. Child TB at the new millenium
Childhood tuberculosis: out of control?
Donald PR. Curr Opin Pulm Med 2002
JR Starke

8. Putting child TB on the global public health agenda
Child TB subgroup of Stop TB Partnership formed 2003
Children recognised as a vulnerable group in need of increased case-finding: 2009
International Child TB Meeting, Stockholm, 2011

9. TB in the context of maternal and child health
Increasing recognition that TB is an increasingly important cause of morbidity and mortality in infants and young children globally
Pregnancy-related TB – maternal and infant outcomes
Orphans due to TB – estimated to be around 9 million globally
Catastrophic economic costs of TB – families living with TB
TB in adolescents – uncertain burden and specific management issues

10. Millennium Development Goals

11. Innovative approaches
Community-based
Wider health sector
Preventive therapy
Operational research

13. Roadmap for Childhood Tuberculosis
Launched Washington DC, October 1st 2013

14. Situational analysis a critical first step

15. “Know your epidemic” TB in women – best estimate 3,300,000 cases
Deaths:
330,000 HIV negative
180,000 HIV positive
TB in children (0-14 yrs)
actual reported 275,000
15% smear-positive
54% smear-negative
31% EPTB
Best estimates:
550,000 cases and 80,000 deaths

16. Child TB working group and NTP

17. Hiatt T & Nishikori N. WPSAR 2014
Age and sex-specific notification rates of new smear-positive TB cases for the Western Pacific Region, 2012
Hiatt T & Nishikori N. WPSAR 2014

18. Hiatt T & Nishikori N. WPSAR 2014
Age and sex-specific notification rates of new smear-positive TB cases for the Western Pacific Region, 2012
Hiatt T & Nishikori N. WPSAR 2014

19. Risk of TB disease following infection by age
These data explain the rationale for using preventive therapy in infants and young children that have been infected with TB but do not yet have disease.
The risk of developing disease following infection is age-related and is particularly high in children of less than 2 years. The observational studies also found that most children develop disease within one year following infection.
The data are also from before BCG was used. As already noted, the major impact of BCG has been to reduce the size of the red bar.
Adapted from Marais B, et al. Int J Tuberc Lung Dis 2004

20. Incident (new) TB cases
Gap in surveillance
Incident (new) TB cases
Under-diagnosed
Gap
Under-reported
TB case notifications
known to the NTP

21. Poor recording and reporting
Incident (new) TB cases
Under-diagnosed
Gap
Under-reported
TB case notifications
known to the NTP

22. Incident (new) TB cases
From under-diagnosis
Incident (new) TB cases
Under-diagnosed
Gap
Under-reported
TB case notifications
known to the NTP

23. Incident (new) TB cases
to over-diagnosis
Not TB cases
TB case notifications
known to the NTP
Incident (new) TB cases
Under-diagnosed
Under-reported

24. Only 1.6% of 4,821 cases in children were registered with NTP

25. Diagnosis of child TB in Java and level of care
TB cases
Inpatient
Outpatient
Overall
Total TB cases
5,877
15,694
21,571
Child TB cases
N=648
N=4173
N=4821
% of total burden
11%
27%
22%
< 5 years
56%
53%
Smear positive disease
16% 8% 9%
EPTB
15% 6%
Non-teaching hospital
73%
76%
75%
Private health facility 7%
Lestari T, et al. BMC Pub Health 2011

26. Burden of child TB in four provinces of PNG: 2005-6 Law I, et al
Burden of child TB in four provinces of PNG: Law I, et al. Poster – The Union Global Lung Health Conference 2008
Pulmonary TB
Smear positive
Smear negative
Smear not done
1208 (61%)
18 (1%)
138 (7%)
1052 (53%)
EPTB
769 (39%)
Total
1977
Child TB accounts for 30% of total TB burden

27. Pattern of EPTB disease in children in four provinces of PNG: 2005-6
EPTB cases
N=1097
Lymphadenitis
Meningitis
Abdominal
Pleural effusion
Miliary
Spinal
Pericarditis
Bone disease
Not indicated/others
342 (31%)
257 (23%)
173 (16%)
94 (9%)
64 (6%)
41 (4%)
12 (1%)
15 (1%)
99 (9%)
EPTB represented 39% of childhood TB cases

28. NATIONAL TB PROGRAM PAPUA NEW GUINEA
MANUAL ON MANAGEMENT OF CHILDHOOD TUBERCULOSIS

30. Child TB working group and NTP

31. Rapid development of diagnostics
History
Tuberculin
Skin Test
1890
Chest X-ray
1896
Bacteriology
1882

32. Diagnostic yield for pulmonary TB comparing children to adults
Xpert cannot be used to rule out TB
Xpert needs research on implementation to inform optimal usage in children

33. Union – MSF Operational Research Courses
TOTAL: 212 participants
Europe
Moldova
Georgia
Armenia
Ukraine
Azerbaijan
Estonia
Denmark
Latvia
Italy
Belorussia
Asia
India
Singapore
Bangladesh
China
Pakistan
Mongolia
Afghanistan
Uzbekistan
Nepal
Vietnam
Bhutan
Myanmar
Sri Lanka
Indonesia
Timor Leste
Cambodia
South Pacific
New Caledonia
Cook Islands
Tonga
Marshall Islands
Federated States of Micronesia
Solomon Islands
Vanuata
Fiji
South America
Brazil
Peru
Africa
Kenya
Burundi
South Africa
Madagascar
Ethiopia
Lesotho
Malawi
Swaziland
Zimbabwe
Democratic Republic of the Congo
Benin
Sudan
Somaliland
Mozambique
Rwanda
Nigeria
Uganda
Somalia
Ghana
Sierra Leone
Tanzania
Liberia

34. MANAGEMENT OF TB IN CHILDREN IN VIETNAM

35. Activities
Establish childhood TB working group in NTP
Political will and policy
Develop the national guidelines on management of TB in children including child contact screening and diagnostic algorithms, treatment, forms and registers, M&E forms, monitoring checklist, etc…
Develop and distribute IEC materials Q
Training – provide child TB training for NTP staff at provincial, district and community level, and for pediatricians in 4 piloted provinces
Provide Isoniazid, forms and registers with pilot implementation in 4 provinces
Incorporate child TB into annual plans and 5-year strategic plan
Include child TB data in routine reporting and reviews
GFATM funding for rolling out to additional provinces in 2015

36. Community awareness – and support health worker!
12,750 posters
554,400 leaflets

37. Community contact screening in Viet Nam Oct 2012-Dec 2013
Child contacts screened
4109
Eligible for IPT
1577
Numbers received IPT
979 (62%)
% completed to date
88% (n=153)
Children diagnosed with TB
345
Sputum smear positive
37 (11%)
Sputum smear negative PTB
157 (46%)
EPTB
151 (43%)

38. NATIONAL PLAN FOR THE MANAGEMENT OF TB IN CHILDREN: 2015-2020
Goal: To strengthen detection, treatment and preventive therapy for Vietnamese children towards decreasing childhood TB morbidity and mortality in Vietnam.

39. Regional activities in 2014
WHO WPRO, Regional taskforce, Viet Nam, March
China National Child TB, Beijing, August
Global consultation on child TB for high burden countries in EMRO, SEARO and WPRO, Indonesia, September

40. “ There are many contributions which the pediatrician can make to a TB control program.
First the negativism about tuberculosis so prevalent in pediatrics must be overcome…”
Edith Lincoln, 1961
Donald PR. Edith Lincoln, an American Pioneer of Childhood Tuberculosis. Pediatr Infect Dis J 2013