Strategies to promote uptake of appropriately formulated paediatric

TB drugs

Dr Malgosia GrzemskaGlobal TB Programme

World Health Organization, Geneva, Switzerland

Photo: Riccardo Venturi

WHO and Union survey – data from 9 countries, 2010

Detjen A et al: Adoption of revised dosage recommendations for childhood tuberculosis in countries with different childhood tuberculosis burdens. Public Health Action, Vol.2, No. 4, 21 December 2012 , pp. 126-132(7)

Country TB notification (in 100,000)

New TB cases reported to WHO

New TB cases reported in survey

Child TB of all cases notified

Afghanistan 28,238 642 2,946 10.4% (2.3%)

Bangladesh 158,252 4,235 4,235 2.7% (2.7%)

Ethiopia 156,928 3,190 17,566 11.2% (2%)

India 1 522,147 13,415 85,756 5.6% (0.8%)

Indonesia 302,861 28,312 28,312 9.3% (9.3%)

Myanmar 137,403 302 32,471 26,3% (0.2%)

Pakistan 269,290 24,474 24,474 9.1% (9.1%)

Uganda 45,546 669 662 1.5% (1.5%)

Zimbabwe 47,557 4371 4383 9.2% (9.2%)

Do NTPs "neglect" Childhood TB?

• Focus on smear-positive cases (mostly adults); – Misperception that childhood TB would disappear simply by containing TB in

adults;– Misperception of childhood TB as a low public health priority; – Use of "old" reporting formats (age/sex disaggregation for SS+ only)

• Difficulty in confirming a case of childhood TB - lack of accurate, reliable diagnostic tools;

• Lack of fixed-dose paediatric formulations

• Lack of recognition of childhood TB importance within existing child health programs;

• Hospitals and private providers not linked and not reporting;

Several international guidelines

• WHO Guidance for NTPs – 2006 and Rapid Advice on Treatment in 2010

• WHO TB/HIV guidance on ICF and IPT - 2010

• Union's Guidance on TB/HIV – 2009 and Desk Guide in 2010

• WHO Guidance -2nd edition 2014

Childhood TB Roadmap• Document writing and

coordination led by the Child TB Subgroup of Stop TB Partnership

• Discusses engagement and responsibilities of policy makers, health workers and advocates at all levels

• Emphasizes broad-based approach and engagement of entire maternal and child health community

• Launched on 1 October 2013

WHO Guidance on the management of TB in children - 2nd edition 2014

• Rifampicin 15 (10-20) mg/kg/day

• Isoniazid 10 (7-15) mg/kg/day• Pyrazinamide 35 (30-40) mg/kg/day• Ethambutol 20 (15-25) mg/kg/day

• From 25 kgs, can change to adult dosages and preparations

Regional and country level activities• Participation of Childhood TB experts in National TB Programme Reviews

– Ukraine (2010), Myanmar (2011), Azerbaijan (2012), Cambodia (2012), India (2009 and 2012), Indonesia (2011 and 2013), Kazakhstan (2012), Lao PDR (2013), Ghana (March 2013), Nigeria (April 2013), Philippines (Sep 2013) Thailand (Aug 2013), Ethiopia (2013), Uganda (2013), South Africa (2013), Tanzania (2014), Kenya (2014), Bangladesh (2014), Swaziland (2014)

• Technical assistance provided to countries on national guidelines and training: – Bangladesh, Botswana, Cambodia, DPRK, Djibouti, Ethiopia, Indonesia, Iraq, Kenya, Mexico,

Mozambique, Nepal, Pakistan, Philippines, PNG, Rwanda, Sudan (N), Tanzania, Uganda, Vietnam, and Zimbabwe.

• Activities of WHO Regional and Country offices: – EURO/Copenhagen established an European Task Force on Childhood TB;– EMRO/intercountry training in Pakistan (PAK and AFG); – AFRO/Brazzaville developing a framework for pediatric TB working closely with partners to

encourage national scale up of childhood TB activities;– WPRO/Manila - Regional Action Plan on scaling up childhood TB (7 countries)– AMRO/PAHO/Washington – Regional workshop in Panama (Dec 2013)– SEARO/New Delhi – plans for a Regional Consultation in 2014

Do TB programs "neglect" Childhood TB?

CountryIs there a pediatric guideline or a

chapter in the National TB guidelines?

Do the guidelines follow the WHO 2010 Rapid Advice?

Has implementation of the WHO 2010 Rapid Advice started?

Which formulations are being used?

Has there been any training on pediatric TB recently?

Afghanistan* Yes WHO 2006 No Action No Info Available No Info Available

Bangladesh* Yes WHO 2010 Yes FDC+L and ACB Yes

Brazil Yes WHO 2010 Yes FDC+L Yes

Cambodia* Yes Underway Info Divergent FDC+L Yes

China No Info Available No Info Available No Info Available No Info Available Yes

DR Congo Yes WHO 2010 Info Divergent FDC+L Yes

Ethiopia Yes WHO 2010 Yes FDC+L and ACB Yes

India Yes Thrice-weekly intermittent Info Divergent FDC+L and L Yes

Indonesia Yes WHO 2010 (adapted) Yes FDC+L Yes

Kenya* Yes WHO 2010 Info Divergent FDC+L and ACB Yes

Mozambique Yes Underway Planning FDC+L and ACB and L Yes

Myanmar* Yes WHO 2010 Yes FDC+L and ACB and L Yes

Nigeria* Yes Info Divergent Info Divergent FDC+L and ACB and L Yes

Pakistan* Yes WHO 2010 Yes FDC+L Yes

Philippines Yes WHO 2010 Yes FDC+L and L Yes

Russian Federation Yes No Info Available No Info Available ACB No Info Available

South Africa Yes WHO 2010 Yes FDC+L Yes

Tanzania (UR) Yes WHO 2010 Yes FDC+L Yes

Thailand Yes WHO 2010 Planning FDC+L and ACB and L Yes

Uganda Yes WHO 2010 No Action FDC+L and ACB and L Yes

Viet Nam Yes WHO 2010 No Action FDC+L Yes

Zimbabwe Yes WHO 2010 Yes FDC+L Yes

Regional/country preparation for uptakeWorkshops with multiple stakeholders

– March 2014, Viet Nam – 7 countries of WPR (CHN, PHL, VTN, CAM, PNG, LAO, MON)• framework action plans• Informal task force on Childhood TB

– September 2014, Indonesia – global consultation for EMR, SEAR and WPR• 10 countries attended (AFG, PAK, IND, INO, NEP,

BAN, THA, PNG, CHN, VTN)• Framework action plans• Country level planning

Regional/country preparation for uptake Plans for 2015

• Workshops with multiple stakeholders– AFRO – NTP managers meeting with childhood TB

subgroup – quarter 1, 2015– SEARO – workshop on childhood TB – quarter 1 or 2 of

2015– EURO – workshop for priority countries of EE and CA

Country preparation for uptake TA needs for 2015

• National stakeholders meetings – including NTP, private sector, child health workers, hospital doctors, paediatric associations, NGOs and others

• Assistance in developing country action plans, guidelines and training materials

• Continuous TA on inclusion of childhood TB in NSPs and concept notes to GF

• Assistance in regulatory pathways for registration of the new product

• Help in supply and distribution – reaching the right places at the right time

More information

WHO/Union Childhood TB Training Toolkithttp://www.who.int/tb/challenges/childtbtraining_manual/en/

Guidance for national tuberculosis programmes on the management of tuberculosis in children

– Second Editionhttp://www.who.int/tb/publications/childtb_guidelines/en/

Thank you for your attention to childhood TB!