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Management of Multidrug-Resistant Tuberculosis in Children: A FIELD GUIDE - Sentinal Project

Sentinal Project - Management of Multidrug-Resistant Tuberculosis in Children: A FIELD GUIDE
Publication date: 
Feb 2019

Multidrug-resistant (MDR) tuberculosis (TB) is a growing global health crisis; MDR-TB is defined TB disease caused by strains of Mycobacterium tuberculosis with in vitro resistance to at least isoniazid and rifampicin, and it is estimated there are more than five million people infected and sick with drug-resistant forms of TB in the world today. With the increasing use of the Xpert MTB/RIF® to detect both TB and rifampicin resistance, the term “rifampicin-resistant TB” (RR-TB) is increasingly used as well. In general, RR-TB is treated the same as MDR-TB and thus the term MDR-TB will be used in this field guide to encompass RR-TB as well.

Children represent a significant proportion of persons with TB disease with an estimated 30,000 children becoming sick with MDR-TB each year. Yet they lack the same access to diagnosis and treatment as their adult counterparts. Two meta-analyses of treatment for MDR-TB among children showed that about 80% have positive outcomes when treated for MDR-TB. These reviews also demonstrated that, with the exception of the injectable agents, children tolerated second-line medications well. However, fewer than 5% of children who become sick with MDR-TB are ever started on appropriate treatment for their disease.

Urgent action is needed to address this significant gap in care. Based on experiences with pediatric HIV, equitable access for children with MDR-TB will only occur once systematic approaches to diagnosing and treating children are developed and once access to pediatric formulations of second-line medications is widespread. This field guide is intended to serve as a tool for practitioners working with children at risk of MDR-TB infection and those who are sick with MDR-TB disease. Following the example set by Médecins Sans Frontières (MSF) in their publication “Treating drug-resistant tuberculosis: what does it take,” this guide focuses on issues relevant in clinical and programmatic practice and does not offer extensive background materials on management of MDR-TB, which can be found in multiple other guidelines. This field guide should be considered complementary to existing recommendations.

In general, a guide such as this should be developed using evidence-based research. The World Health Organization (WHO) has established methodologies for the development of their guidelines that follow a systematic evaluation of available evidence. And although there are multiple planned and ongoing clinical trials focused on optimal treatment of MDR-TB infection and disease in children, to date, there are few completed studies to form the basis of pediatric-specific treatment guidelines. While many aspects of the adult recommendations apply to children, there are some unique aspects of pediatric MDR-TB that may require different approaches. While awaiting the results of pediatric clinical trials, however, practitioners in most countries are already seeing children at risk for, or sick with, MDR-TB, who require immediate access to high-quality care. This field guide was developed by a team of experts who jointly have treated thousands of children with MDR-TB over the last two decades in every region of the world. It combines the best available research evidence with clinical experience. We hope it will be used as a tool to rapidly increase the number of children receiving care for MDR-TB. Case examples are included throughout the guide to show how these recommendations can be put into practice. The WHO have been very supportive of the development of this field guide to provide advice that extends beyond their guidelines.

Whenever possible, management of children with MDR-TB should take place within the activities of a National TB Program (NTP). There are multiple advantages to doing this, including a contextual approach, integration with other health initiatives, and health systems strengthening. If activities occur outside of an NTP, all efforts should be made to report standardized outcomes and to collaborate with the NTP whenever possible.

Finally, we recognize that the term “children” encompasses a broad range of individuals and ages with widely different needs. A 2-year-old child requires a different approach to a 12-year-old, and the treatment of children with MDR-TB will never be a “one size fits all” approach. Many experts feel that children older than 10 years of age can be managed as adults using the same diagnostic methods and medications, although the specific emotional needs of adolescents and their caregivers should be considered. We focus mainly on the care of younger children, which is most problematic for most practitioners and hope to offer a compendium of practical experience that can be useful for programs and providers caring for children with MDR-TB. We trust that this initial attempt will be greatly expanded and improved as the world gains and documents more experience with this neglected population in the coming years.