Dr Kalpana Satarkar Gauns
The World Tuberculosis (TB) day is observed on March 24 every year. Tuberculosis has existed since antiquity. Global TB report 2018 reveals that in India, an estimated 2.2lakh children suffer from tuberculosis (TB) each year (22% of global TB burden). Pulmonary (lung) TB is the most common form in children but the extra pulmonary TB forms larger portion of the cases in adults.
Childhood TB is a formidable problem. Just as children are not miniature adults, TB among children is also not a miniature version of the adult form. Children up to 14years constitute about 35% of the population in our country and are expected to contribute about 10% of the case load. Death of a breadwinner adult from family to TB constitutes a major catastrophe to the family including children.
Stigma also harms the livelihoods, and health of individuals and their families who experience TB. Correspondingly TB stigma severely hinders Global and National TB responses to management. It exacerbates the medical and social hardship of TB and acts as a barrier to accessing treatment care and support. When the surrounding environment is discriminatory, it begins to push those with TB to stigmatize themselves. People who fear losing their jobs, their loved ones or being kicked out of school or their homes because of TB are less likely to seek testing and treatment for the disease, making the already challenging response even more difficult. Stigma and discrimination are not only human rights violations; they are a fundamental cause of population health inequalities. To end TB everyone must recognize it as such and work together to eliminate TB stigma.
TB is usually an airborne infection and children can also be infectious especially older children and adolescents. Virulence of bacteria and host immunity would determine the progress of infection/ disease to either only infection, whether it would remain latent or would lead to a primary disease. Persistent latent infection can lead to late reactivation of disease. Rapid progression can occur in presence of severe malnutrition or HIV- TB co- infection.
Children with presumptive TB refers to children with persistent fever and/or cough for more than 2 weeks, loss of weight (loss of >5% body weight) or no weight gain and/or history of contact with infectious TB cases (within last 2 years). Chest radiograph forms mainstay of diagnosis in children.
From late 2018 there was a shift to daily therapy of anti TB medication from that of alternate day dosing under RNTCP updated TB guidelines. Children should be closely monitored for treatment progress and disease response. Children should also be observed for side effects of medications especially liver toxicity. Co- morbid conditions like HIV, severe acute malnutrition, diabetes mellitus should be monitored. We need to revisit adherence to therapy at each visit with Pill count, social support, family based DOTS and treatment supervisors.
Incentives are given to patient via ‘Nikshay Poshan Yojana’ launched on April 2018- DBT transfer of Rs 500 per month for all patients on TB treatment throughout duration of treatment. The patient needs to be registered in the Nikshay Portal. In tribal areas, the amount is Rs 750 per patient. There are incentives to providers too. Private Provider incentives: Rs 500 at notification and 500 INR on reporting treatment outcome are provided to the private providers who 1st notify the case to the programme.
As is true with other stigmatized conditions including HIV and mental illness, the most promising approach to reducing TB stigma may be to empower individuals with TB to resist stigmatizing external judgments, while working to change community norms about the disease. We are committed to eliminate the disease from the world.
(The writer is a senior pediatrician at Hospicio hospital, Margao and also a member of Indian Academy of Pediatrics, Goa branch)
