DOTS IT, KIDS
Children and the problem of tuberculosis
By JIN PAUL DE GUZMAN
Associate Editor
SINCE TUBERCULOSIS CAN BE EASILY TRANSMITTED AMONG ADULTS, IT WILL BE DIFFICULT TO IMAGINE THAT CHILDREN WOULD HAVE IT BETTER.
IN FACT, THE CHANCES THAT CHILDREN HAVE OF SUCCUMBING TO TB INFECTION AND DISEASE GROW HIGHER THE YOUNGER THEY ARE. JUST CONSIDER SOME RECENT ESTIMATES-FOR ADOLESCENTS 15 AND ABOVE, THEY HAVE A 15-PERCENT CHANCE OF INFECTION AFTER EXPOSURE; FOR KIDS BETWEEN FIVE AND 14, A 25-PERCENT CHANCE; AND WORST OF ALL, CHILDREN UNDER FIVE, WHOSE RISK FOR TB INFECTION CAN GO AS HIGH AS 50 PERCENT.
Infection can be so easy that being in contact with an infected adult-most likely a parent or a relative, or a teacher-should be a cause for alarm.
Sadly, TB in children is often overlooked in favor of other health problems. While routine BCG vaccination is a mainstay of the Department of Health Expanded Program for Immunization, its protective properties are limited. In addition, the national tuberculosis control program has given priority to the management of adult cases. And while there are established protocols concerning the implementation of the directly observed therapy (DOTS) for adults, its pediatric version is not very well known.
KID ALERT
Considering these, it is highly likely that the number of kids suffering from TB in the country may actually be high. Dr. Lourdes Lagayan Mata, officer in charge at the Center for Tuberculosis in Children-Philippines (CTCP), says that of the 4,000 elementary-school students they screened for TB at the Balara Elementary School in Quezon City, close to 400 were found positive for the disease. Many of these children were already exhibiting symptoms, "but parents thought it was just normal"-few of them realized the seriousness of the problem.
If this were to be applied to the rest of the country-by 2005, the under-15 population is projected at 33.8 percent of the national population-there could be close to three million Filipino kids with TB. And this does not even include those between ages 15 and 19.
But at present, says Lagayan, things are starting to look up. She explains that a number of organizations, whether they be professional, government, or nongovernment, are finally seeing the importance of protecting kids from this deadly disease. She says that under current Health secretary Manuel Dayrit-who is himself a TB advocate-the government is starting to "acknowledge that we also have to see TB in children."
After all, what better way to protect the population from the disease than by starting with kids?
NOT SMALL ADULTS
Diagnosing TB in kids is a little more complex than in adults. For instance, sputum-smear microscopy, which is considered the gold standard of detection in adults, is rarely used in kids. She says that getting kids to expel sputum correctly is difficult. So instead, they look for any three of the following criteria-a positive PPD (purified protein derivative or Mantoux tuberculin test), the presence of clinical signs and symptoms, a history of direct exposure to an infected adult, a chest X-ray that indicates the presence of Ghon's complex, and supportive evidence from other laboratory exams.
As for clinical symptoms, one major difference between pediatric and adult TB is the presence of blood in the sputum. Doctors should take note of at least two of the following instead: cough, with or without wheezing, for more than two weeks, even with the administration of antibiotics; weight loss and unexplained poor appetite; unexplained fever lasting over two weeks. The presence of cervical lymphadenopathy, meanwhile, may also be a clue for TB, but Lagayan says it is no longer considered a very good predictor, since many other conditions can be associated with adenopathies.
If a child turns out to be PPD-positive, then this might indicate the presence of infection in other members of the family. Lagayan stresses: "Hanapin nila kaagad kung sino iyon, para doon pa lang, mahinto na."
It follows, of course, that if diagnostic procedures and clinical signs and symptoms of TB in kids are not the same as in adults, then the management, particularly in the area of drug administration, will also be significantly different.
Adults are usually given fixed doses of a three-or-four-drug combo-rifampicin, isoniazid, pyrazinamide, and ethambutol. With kids, meanwhile, three drugs are used (rifampicin, isoniazid, and pyrazinamide), but if they turn out to be positive for extrapulmonary TB (for example Pott's disease or TB mengitis), another drug is added to the regimen. More important, the amount of drugs being administered varies with their body weight and nutritional status. Both kids and adults, however, must follow the entire length of treatment, which lasts at least six months.
STRESSING DOTS
DOTS, which has been declared by the World Bank as "one of the most effective health interventions," is starting to make headway in finally curbing the adult TB problem in the country. The program, which involves the proper diagnosis, medication, monitoring, and documentation of TB cases, is now being actively promoted in the country-in the Global Tuberculosis Control: Surveillance, Planning, Financing Report issued by the World Health Organization last year, the Philippines posted a 57-percent DOTS detection rate and an 88-percent cure rate.
The Philippine Coalition against Tuberculosis (PHILCAT), which is made up of 57 member-groups coming from government, professional, nongovernment, corporate, and international organizations, is at the front line of the fight against TB in the country. In the last few years it has been able to synchronize the TB efforts of different advocates toward a common goal, which is the prevention, control, and eventual elimination of TB in the country. At present, it is actively involved in strengthening the use of DOTS in the private sector, since many private practitioners don't follow DOTS.
Lagayan says that the problem of private practitioners not following the recommended DOTS strategy is also a reality in pediatric TB. She says: "Matagal nang ipino-promote
ang DOTS, matagal na ring sinasabi na the medications are not vitamins,
pero nakakatanggap pa rin ako ng [comments na] these are vitamins
sa baga, [reports where] single-drug or double-drug lang ang ibinibigay, so
nakakalungkot. Mayroon naman tayong mga organizations that cater to continuing education for private practitioners. I don't know
kung ayaw lang talaga nilang i-avail, o ayaw lang talagang sundin, or what."
She adds: "If everybody would agree that DOTS is effective, I think the Philippines would be a better place-TB-free."
INDEFATIGABLE
The CTCP, founded in 1998 by the Magsaysay-award-winning Dr. Fe del Mundo, is the country's leading institution in the promotion and implementation of DOTS in children. Aside from providing services-diagnosis, follow-up, monitoring, and medication-to pediatric TB patients in Old Balara, Quezon City and nearby communities, the CTCP also organizes lay forums that aim to shatter myths surrounding TB in children as well as raise the awareness of parents, teachers, and other adults in the community on the importance of TB control. Already forums have been held in all four districts of Quezon City as well as in Laguna. In the works is the holding of forums in Bulacan, Manila, and Marikina.
These forums have helped improve the knowledge, attitudes, and practices of people concerning TB. Parents began getting their kids-and even themselves-tested for TB, and when the presence of the disease was confirmed, they knew that sticking to the recommended management strategy would ensure cure.
Also, a number of partnerships have emerged after these forums. At present they have ongoing community projects with different organizations such as the Quezon City Ladies' Association, the Rotary Club, and even international organizations, which have been instrumental in providing much needed medications. At present, the Center has a project called "Sponsor a Child," where they are encouraging groups and organizations to provide the entire course of medication of one or more patients.
Also ongoing is the crucial pilot-testing of the guidelines on the detection and management of TB in children. In cooperation with the DOH Task Force on TB in Children and PHILCAT, the CTCP is testing the effectiveness of DOTS for kids in barangay Commonwealth, Quezon City. If it proves effective, this will then be incorporated into the national TB control program.
Finally, Lagayan says: "If we start with children, we are preventing future transmission."
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