Dillon T Wademan and Lario Viljoen
Cape Town - Tuberculosis (TB) is a life-threatening bacterial infection that affects the health and well-being of people across the world.
Due to disruptions in health services during the Covid-19 pandemic, 2021 was the first time TB incidence increased in over a decade. An estimated 10.6 million people became ill with TB worldwide and about 1.6 million people died.
African and South-East Asian regions have the highest incidences of TB globally because of high levels of poverty and poor access to health-care services.
South Africa is among the 30 countries with the highest TB burden with 304 000 people diagnosed with TB in 2021, 30 000 of whom were children under 15 years of age.
Over the past two decades there have been increased efforts to develop medication specifically for the treatment of children with TB, and there have been several breakthroughs.
In 2016, the World Health Organization (WHO) announced the availability of a new fixed-dose combination, child-friendly regimen for children with drug-susceptible TB.
This was a major step in improving the treatment made available to children.
Subsequently, a large treatment shortening trial conducted in South Africa and India found that four months of this regimen is as effective at treating minimal (non-severe) TB as the standard six months of care in children and adolescents.
In addition, as of 2018, South Africa has offered injectable-sparing regimens to children and adolescents with multi-drug resistant TB.
However, many of the medications available for children and adolescents are still difficult to administer, were not developed with children in mind, and are difficult to incorporate into the lives of people in lower socio-economic settings.
The recently observed World TB Day (March 24) was an opportunity for us to reflect on the need for providing life-saving treatment for children that is not only safe and effective, but also appropriate and acceptable.
After diagnosing children with TB, which is itself a complex task, initiating and adhering to treatment for children with TB is notoriously difficult.
Children with drug-susceptible TB have to take, on average, two to six tablets daily for four to six months, while children with drug-resistant TB can take between six and 14 daily tablets for nine to 18 months, depending on their age and weight, the regimen prescribed, available medications, and other health conditions affecting the child.
These medications are rarely child-friendly, are unpalatable, difficult to dose, swallow or dissolve and/or mix with food, and many children experience adverse side-effects.
Treating children with TB also places a major burden on households and caregivers, where resources are limited and the ability to care for these children is compromised by both social and economic challenges.
TB is often transmitted between household members, which means multiple family members might be receiving care and treatment for TB.
Caregivers therefore have to manage the administration of multiple TB treatment regimens.
In South Africa, many people with TB are also affected by other health conditions, and comorbidities like HIV and diabetes are common.
Navigating multiple complex treatment regimens over an extended period while ensuring that patients have access to nutritious food and adequate care can be difficult to balance in households with limited means.
While there have been major steps in developing effective treatment for children and adolescents with TB, there is also a call to ensure that acceptable treatment is developed for this vulnerable group.
Acceptable treatment refers to the ability of the children and caregivers to use the treatment as intended and prescribed.
While palatability, ease of use and adherence are often used as proxy measures of treatment acceptability, other factors including social well-being, economic survival, health services access, prior treatment experiences and stigma, may also influence treatment acceptability.
Overall, acceptable treatment should be treatment that is usable by caregivers and children, treatment that aligns with caregivers’ and children’s health beliefs, and medicine that can be integrated into the context of daily care practice.
This includes medications that are informed by the preferences of children, including taste and texture, and medication that can be practically administered with the least disruption possible to the children and their families.
Having access to acceptable treatment that can be integrated into households is important. Research has shown that it ensures that children are more likely to take all of their treatment as prescribed, ensures that they can be cured, and prevents onward transmission to other vulnerable groups.
To ensure that more acceptable treatment is made available, the WHO has advocated for what has been called a patient-centred care approach.
Patient-centred care involves care that goes beyond a concern with patients’ health outcomes and takes into consideration the social, economic and environmental context in which people live and receive care.
Part of the shift towards person-centred care involves providing treatment that is developed and delivered in a way that is appropriate and acceptable to communities most affected.
It involves patient participation and shared decision-making, particularly when multiple treatment options are available and together plan their treatment journey.
For example, when child-friendly treatment options (syrups or dispersible options) are available, to make sure these are prescribed.
In addition, health workers are advised to co-operate with patients to dispense medication in a way that works for the entire family so that they do not have to undertake repeat visits to clinics to get medication for multiple conditions, or several sick family members, placing an extra burden on the household.
There are multiple clinical trials designed to get the best possible treatment for children diagnosed with TB.
While there is a need to find optimal treatment to cure children, to ensure that they and their families are able to adhere and complete treatment regimens, it is vital that medication is acceptable to children, their families and the communities where care is being offered.
Drs Wademan and Viljoen are affiliated with the Desmond Tutu TB Centre in the Department of Paediatrics and Child Health at Stellenbosch University.
Cape Times