Strategies to promote uptake of appropriately formulated paediatric TB drugs Dr Malgosia Grzemska Global TB Programme World Health Organization, Geneva, Switzerland Photo: Riccardo Venturi

WHO and Union survey – data from 9 countries, 2010 Detjen A et al: Adoption of revised dosage recommendations for childhood tuberculosis in countries with different childhood tuberculosis burdens. Public Health Action, Vol.2, No. 4, 21 December 2012, pp (7) CountryTB notification (in 100,000) New TB cases reported to WHO New TB cases reported in survey Child TB of all cases notified Afghanistan28, , % (2.3%) Bangladesh158,2524, % (2.7%) Ethiopia156,9283,19017, % (2%) India1 522,14713,41585,7565.6% (0.8%) Indonesia302,86128, % (9.3%) Myanmar137, ,47126,3% (0.2%) Pakistan269,29024, % (9.1%) Uganda45, % (1.5%) Zimbabwe47, % (9.2%)

Do NTPs "neglect" Childhood TB? Focus on smear-positive cases (mostly adults); –Misperception that childhood TB would disappear simply by containing TB in adults; –Misperception of childhood TB as a low public health priority; –Use of "old" reporting formats (age/sex disaggregation for SS+ only) Difficulty in confirming a case of childhood TB - lack of accurate, reliable diagnostic tools; Lack of fixed-dose paediatric formulations Lack of recognition of childhood TB importance within existing child health programs; Hospitals and private providers not linked and not reporting;

Several international guidelines WHO Guidance for NTPs – 2006 and Rapid Advice on Treatment in 2010 WHO TB/HIV guidance on ICF and IPT Union's Guidance on TB/HIV – 2009 and Desk Guide in 2010 WHO Guidance -2 nd edition 2014

Childhood TB Roadmap Document writing and coordination led by the Child TB Subgroup of Stop TB Partnership Discusses engagement and responsibilities of policy makers, health workers and advocates at all levels Emphasizes broad-based approach and engagement of entire maternal and child health community Launched on 1 October 2013

WHO Guidance on the management of TB in children - 2 nd edition 2014 Rifampicin 15 (10-20) mg/kg/day Isoniazid 10 (7-15) mg/kg/day Pyrazinamide 35 (30-40) mg/kg/day Ethambutol 20 (15-25) mg/kg/day From 25 kgs, can change to adult dosages and preparations

Regional and country level activities Participation of Childhood TB experts in National TB Programme Reviews –Ukraine (2010), Myanmar (2011), Azerbaijan (2012), Cambodia (2012), India (2009 and 2012), Indonesia (2011 and 2013), Kazakhstan (2012), Lao PDR (2013), Ghana (March 2013), Nigeria (April 2013), Philippines (Sep 2013) Thailand (Aug 2013), Ethiopia (2013), Uganda (2013), South Africa (2013), Tanzania (2014), Kenya (2014), Bangladesh (2014), Swaziland (2014) Technical assistance provided to countries on national guidelines and training: –Bangladesh, Botswana, Cambodia, DPRK, Djibouti, Ethiopia, Indonesia, Iraq, Kenya, Mexico, Mozambique, Nepal, Pakistan, Philippines, PNG, Rwanda, Sudan (N), Tanzania, Uganda, Vietnam, and Zimbabwe. Activities of WHO Regional and Country offices: –EURO/Copenhagen established an European Task Force on Childhood TB; –EMRO/intercountry training in Pakistan (PAK and AFG); –AFRO/Brazzaville developing a framework for pediatric TB working closely with partners to encourage national scale up of childhood TB activities; –WPRO/Manila - Regional Action Plan on scaling up childhood TB (7 countries) –AMRO/PAHO/Washington – Regional workshop in Panama (Dec 2013) –SEARO/New Delhi – plans for a Regional Consultation in 2014

Do TB programs "neglect" Childhood TB? Country Is there a pediatric guideline or a chapter in the National TB guidelines? Do the guidelines follow the WHO 2010 Rapid Advice? Has implementation of the WHO 2010 Rapid Advice started? Which formulations are being used? Has there been any training on pediatric TB recently? Afghanistan*YesWHO 2006 No Action No Info Available Bangladesh*YesWHO 2010YesFDC+L and ACBYes BrazilYesWHO 2010YesFDC+LYes Cambodia*YesUnderway Info Divergent FDC+LYes ChinaNo Info Available Yes DR CongoYesWHO 2010 Info Divergent FDC+LYes EthiopiaYesWHO 2010YesFDC+L and ACBYes IndiaYes Thrice-weekly intermittent Info Divergent FDC+L and LYes IndonesiaYesWHO 2010 (adapted)YesFDC+LYes Kenya*YesWHO 2010 Info Divergent FDC+L and ACBYes MozambiqueYesUnderwayPlanningFDC+L and ACB and LYes Myanmar*YesWHO 2010YesFDC+L and ACB and LYes Nigeria*Yes Info Divergent FDC+L and ACB and LYes Pakistan*YesWHO 2010YesFDC+LYes PhilippinesYesWHO 2010YesFDC+L and LYes Russian FederationYesNo Info Available ACBNo Info Available South AfricaYesWHO 2010YesFDC+LYes Tanzania (UR)YesWHO 2010YesFDC+LYes ThailandYesWHO 2010PlanningFDC+L and ACB and LYes UgandaYesWHO 2010 No Action FDC+L and ACB and LYes Viet NamYesWHO 2010 No Action FDC+LYes ZimbabweYesWHO 2010YesFDC+LYes

Regional/country preparation for uptake Workshops with multiple stakeholders –March 2014, Viet Nam – 7 countries of WPR (CHN, PHL, VTN, CAM, PNG, LAO, MON) framework action plans Informal task force on Childhood TB –September 2014, Indonesia – global consultation for EMR, SEAR and WPR 10 countries attended (AFG, PAK, IND, INO, NEP, BAN, THA, PNG, CHN, VTN) Framework action plans Country level planning

Regional/country preparation for uptake Plans for 2015 Workshops with multiple stakeholders –AFRO – NTP managers meeting with childhood TB subgroup – quarter 1, 2015 –SEARO – workshop on childhood TB – quarter 1 or 2 of 2015 –EURO – workshop for priority countries of EE and CA

Country preparation for uptake TA needs for 2015 National stakeholders meetings – including NTP, private sector, child health workers, hospital doctors, paediatric associations, NGOs and others Assistance in developing country action plans, guidelines and training materials Continuous TA on inclusion of childhood TB in NSPs and concept notes to GF Assistance in regulatory pathways for registration of the new product Help in supply and distribution – reaching the right places at the right time

More information WHO/Union Childhood TB Training Toolkit Guidance for national tuberculosis programmes on the management of tuberculosis in children –Second Edition

Thank you for your attention to childhood TB!