Detecting TB in Children to Save Lives in Malawi

Mallita Chipungu (age 26), who hails from a village in the southern region of Malawi, was all smiles when she gave birth to twins on August 6, 2019, at Thyolo District Hospital. She already had two children, so with the birth of her twins, Aisha and Idah, she became a mother of four.

Shortly after giving birth, Mallita had a rude awakening when doctors explained her children were underweight (weighing less than two kilograms). Due to their condition, clinicians at the hospital admitted the twins for close monitoring.

Mallita and her twins spent almost a month in the kangaroo ward for special, premature babies, although there was no meaningful improvement to their conditions. Cough monitors—volunteers trained by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to support clinics with the active screening of children for TB under the Catalyzing Pediatric Tuberculosis Innovations (CaP TB) project—recommended that Aisha and Idah be screened for TB.

“Using the Pediatric TB Intensive Case Finding Screening Tool, we noted some symptoms ranging from fever, night sweats, neck swelling and difficulties in breathing,” says Enock Saka, a cough monitor at Thyolo District Hospital.

Using an advanced sample collection procedure known as gastric aspiration, the health care workers removed specimens from the children’s stomachs, which tested positive for TB. The gastric aspiration technique involves the insertion of a tube through the nostrils into a baby’s stomach where the specimen is drawn.

“Immediately (after) my children were diagnosed with TB, they were put on treatment, and by January 4, 2020, I collected the last lot of medication at Mataphwa Health Centre, located within our community. The district hospital has all along been sending the medication to this clinic which was a relief for me as I could not visit the district hospital due to transport challenges,” Mallita said. Now, Mallita’s twins are improving, thanks to the clinical team supported by the CaP TB project.

The district hospital has all along been sending the medication to this clinic which was a relief for me as I could not visit the district hospital due to transport challenges Mallita Chipungu

In another southern region’s district, an 11-year-old girl was referred from Milepa Health Centre to Chiradzulu District Hospital complaining of purulent discharge from her right ear for two weeks. She also experienced a fever, vomiting, neck pains, night sweats, and weight loss among other complications. An initial clinical diagnosis of severe malaria and meningitis was made, and she was put on the relevant treatment.

However, later results from laboratory investigations showed the girl did not have malaria, and her chest x-ray showed no irregularities. She continued having spiking fevers and ear discharge despite being on treatment. A TB otitis media diagnosis was made after the discharge from her ear was collected for microscopy, and she was then was put on an eight-month anti-TB treatment.

Tuberculous otitis media is a chronic infection of the ear. Its diagnosis is often delayed because it can easily be confused with other acute or chronic middle ear conditions.

The twins and the 11-year-old girl are among 321 TB-diagnosed children across CaP TB supported clinics in 2019. CaP TB is a Unitaid-funded project, implemented by EGPAF in nine sub-Saharan African countries including Malawi. The project seeks to end childhood TB illnesses and deaths through increased access to models of care that are innovative for pediatric TB.

EGPAF works in collaboration with the Ministry of Health (MOH) through the National TB program to promote effective and innovative models of care to improve the detection and treatment of pediatric TB in Malawi. The project screened nearly 211,000 children for TB who visited project-supported clinics, doubling the number of children diagnosed with TB in these sites compared to the 2018 baseline.

However, with the introduction of CaP TB, we are able to pay much closer attention to pediatric patients that are suspected to have TB, and [this] has positively helped to effectively care and treat TB patients. Dr. Precious Kadzamira, Senior Medical Officer, Ndirande Health Center

Diagnosing TB in children is particularly challenging; it is often missed due to non-specific symptoms and a lack of sensitive and child-friendly diagnostic tests. Additonally, health care workers often lack not only sufficient knowledge about TB, but also the capacity to screen for TB in children and provide prevention services. As a result, many children with TB pass through the hands of health care workers without ever knowing they have TB.

The CaP TB project, therefore, brought innovations for routine TB screening for children into all service delivery points. This included training of cough monitors and 324 health care workers on pediatric TB management, such as improved clinical diagnosis and chest X-ray interpretations.

“Previously, we used to have challenges in screening children for TB because of high patient volumes that seek the attention of a clinician. However, with the introduction of CaP TB, we are able to pay much closer attention to pediatric patients that are suspected to have TB, and [this] has positively helped to effectively care and treat TB patients,” said Dr. Precious Kadzamira, senior medical officer at Ndirande Health Center.

Commending EGPAF for the impactful partnership with the National TB Program, Dr. Kuzani Mbendera, childhood TB Programme Officer at NTP said the milestones achieved under the CaP TB project are due to the joint technical expertise rendered to the health facilities.

EGPAF has also empowered Paradiso TB Trust, a civil society organization advocating for childhood TB at the national and community levels. Paradiso is critical in ensuring key TB messages are disseminated at the community level; and at the national level, Paradiso is a member of the Global Fund Country Coordinating Committee (CCM) and aims to use this platform to advocate for more resources for childhood TB.
The project also procured equipment for advanced sample collection for children, who were placed in six sites.

“The innovative diagnostic and care approaches have become a game-changer in childhood TB care,” says Yusuf Bhamu, CaP TB project manager in Malawi.

The innovative diagnostic and care approaches have become a game-changer in childhood TB care. Yusuf Bhamu, CaP TB Project Manager

“In collaboration with the National TB program, we want to ensure that the new differentiated model of care for TB in children is defined as Malawi adopts a patient-centered approach so children are provided with optimal TB care,” Bhamu continued.

In line with this year’s World TB Day theme, “It’s Time,” EGPAF, in collaboration with the National TB Program of Malawi, is moving swiftly to embark on a scale-up of the innovative project from 16 to 40 high TB-burden facilities in seven districts.

Childhood TB is contributing to nine percent of all new and relapsed TB cases in Malawi. However, in 2019, the World Health Organization estimated childhood TB contributes to 11 percent of all notified TB cases. Therefore, “it’s time” to increase efforts in TB screening and diagnosis to move from nine percent to 11 percent.

“Our core mission is to support and work hand-in-hand with the Ministry of Health to deliver services to improve the health of children at risk,” says Veena Sampathkumar, EGPAF Country Director in Malawi.

She added, “TB is preventable and treatable. It is imperative that we leverage innovations effectively in our public health programs to stop children from contracting or dying from TB.”