Tuberculosis: MSF responds to updated WHO guidelines for tuberculosis in children

Atul Loke

The deadly tuberculosis diagnostic gap in children remains a major challenge

Geneva – Doctors Without Borders/Médecins Sans Frontières (MSF) welcomes the updated World Health Organization (WHO) guidelines for the management of tuberculosis (TB) in children and adolescents, which provide recommendations to diagnose TB in children, and to rapidly initiate treatment at more decentralised levels of care. With over 60% of children with TB remaining undiagnosed, MSF urges all countries, especially high-TB-burden countries, to adopt these recommendations in order to prevent unnecessary deaths among children.

Testing TB in children is challenging because it’s difficult for children to produce sputum, the standard specimen to test TB, and because of the low levels of bacteria in children’s specimens. WHO now recommends the testing of stool, in addition to other samples, with the GeneXpert Ultra test which is exclusively produced by US corporation Cepheid. However, many countries face challenges in accessing this test as it is too expensive, and the machine needed to run the test is not adapted for use in remote settings where most children with TB live. Cepheid charges US$9.98 per test in low- and middle-income countries, which is more than double the price it costs the company to produce the test, based on MSF’s analysis.

Dr Lazro Fidelle, TB operational Research Manager, MSF, Malakal, South Sudan:

“Amid years of war and a fragile health system, MSF and other health care providers in South Sudan face extreme challenges to diagnose and treat TB in children. We are encouraged by the improved WHO guidelines that could facilitate the timely diagnosis and treatment of TB in children in many resource-limited and conflict-ridden countries, and so could substantially reduce the number of deaths among children due to this deadly but treatable disease.

In our setup, despite an experienced team and access to all available tests, in most cases we are not able to confirm TB diagnosis in children. Therefore, we have to balance the need for timely and life-saving TB treatment with the need to avoid unnecessary TB treatments amongst those who might have other possible diagnoses. When using tests, our biggest challenge lies in sample collection. Generally, sputum samples are of poor quality and alternatives such as gastric lavage are not well accepted. Therefore, we are still in desperate need of a TB test for children that can be used in even the most remote settings and that can test samples that are easy to collect, such as with mouth swabs or finger-prick blood.”

Stijn Deborggraeve, Diagnostics Advisor, MSF Access Campaign:

“TB programmes in many countries struggle to access the WHO-recommended GeneXpert Ultra test from Cepheid because it’s too expensive and requires fragile equipment that is hard to operate in the remote settings where we need to diagnose children. As treatment providers struggling to save the lives of children with TB, we call on Cepheid to urgently reduce the price of the GeneXpert tests and urge other companies to develop tests that are suited for use in remote settings.

It’s painful to see how despite decades-long calls for more efforts to improve tools for TB, children continue to die of the disease without ever being put on treatment due to delayed diagnosis and a lack of access to effective tests.”

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