Fighting to close the GAP on global pediatric TB care

Photo credit: Smiley N. Pool

When many people think about tuberculosis (TB), they consider it a long gone, archaic disease. Their minds might conjure up images of a bygone era – of “consumption,” overcrowded sanatoriums, and rows of patients lying outside in bitter cold air in hopes of relief. TB is often no more than a fleeting thought for much of the developed world…for it has been cred and eradicated, right? WRONG!

TB is the leading infectious disease killer in the world. Every year across the world, it causes disease and suffering in 10 million people and claims the lives of 1.5 million. Despite the discovery of effective treatment some 70 years ago, TB remains dangerously prevalent in our world and targets with precision some of the world’s most vulnerable populations – children and youth, people living with HIV, the immunocompromised and/or malnourished, and those living in poverty. Of these, children and youth (both with and without HIV) are disproportionately affected by TB due to inadequate preventive services, poor diagnostic tests, large case detection gaps, limited access to TB care, treatment adherence challenges and the existence of suffocating stigma.

To tackle these challenges, in 2011 Texas Children's Hospital and Baylor College of Medicine recruited Dr. Anna Maria Mandalakas to develop and launch the Global TB Program. The program aims to address gaps associated with pediatric TB care and treatment in the most vulnerable populations throughout the world. The program is an affiliate of Texas Children’s Global Health and works in alignment with the World Health Organization (WHO) Sustainable Development Goals and END TB Strategy. They use the tools of research, education, program implementation and advocacy to prevent, diagnose and treat TB in children.

Since its inception, the long-term goal of the Global TB Program has been to establish a network of Tuberculosis Centers of Excellence built upon Texas Children Hospital’s and Baylor College of Medicine’s existing clinical infrastructure throughout many high TB and high HIV-burden settings. Leveraging partnerships and collaborative efforts between numerous institutions, the Global TB Program has been able to develop effective, sustainable, standardized methods of diagnosing TB in children, identifying biomarkers correlating with progression from TB infection to disease, and standardizing screening processes to better characterize epidemiological risk factors for TB.

Global TB Program Lead Nurse and Research Project Coordinator, Godwin Mtetwa, has been a driving force in proving care and treatment for children and adolescents with TB in Eswatini. Working with the Global TB Program since 2014, Mtetwa has seen the Program evolve into a national leader in pediatric TB care and treatment. Reflecting upon over a decade of experience in TB service delivery, he advocates for all children and adolescents to receive high-quality TB care and treatment. On behalf of children and adolescents, the team is committed to delivering a family-centered care approach and ensuring their safety and protection.

Throughout the COVID-19 pandemic, the number of patients presenting at clinic has declined, as a measure to social distance and reduce the spread of the virus. Mtetwa shared that this ongoing commitment and dedication to caring for pediatric TB patients not only averts deaths, but also mitigates the loss of innocence and positive energy that is associated with children when TB disease flourishes among our global young citizens.

Building upon the energy of Global TB Program staff members and with nearly a decade of robust TB experience and innovation, the Global TB Program was most recently awarded a five-year, $5 million Centers for Disease Control and Prevention (CDC) grant that will operate from September 2020 through September 2025. This five year project, “Closing – TB GAPS – for people living with HIV: TB Guidance for Adaptable Patient-centered Services” (TB GAPS), will focus on finding and preventing TB in children and youth, while simultaneously determining the most cost-effective prevention strategy and promoting best practices to sustain the impact of our work. TB GAPS will work in five high TB, high HIV burden sub-Saharan African (SSA) CDC priorities countries – Eswatini, Lesotho, Malawi, Tanzania and Uganda – and aims to generate evidence to inform interventions targeting weaknesses within the TB and TB/HIV cascades of care.

The specific aims of the project are as follows:

1. Define more accurate TB screening and testing strategy among people living with HIV.
2. Identify the most effective TB preventive therapy (TPT) delivery strategy by leveraging approaches effective at improving HIV treatment adherence.
3. Generate evidence to determine the cost-effectiveness of newer short-course TPT to fill this gap and inform policy.
4. Provide quality mentorship to sustain best practices in accordance with evolving country guidelines and harnessing the proven capacity of our Network of SSA sites.