1. Keeping Kids in the Picture: Pediatric TB in the COPs process

2. Pediatric TB: The stats
At least 1 million children become ill with TB every year (Global TB Report, 2017). Yet only 386,600 pediatric TB cases were notified in 2016
Children represent about 10-11% of all TB cases (higher % in TB HBCs).
In 2015, 210,000 children died of TB including 40,000 TB deaths among children who were HIV positive;
It is estimated that 67 million children are infected with TB and therefore at risk of developing disease in the future (Dodd et al, 2016).
In 2015, globally, only 87,000 children under five (7% of the 1.2 million children eligible) were known to be provided with preventive therapy.
Researchers estimate that 25,000 children develop multi-drug resistant TB every year (Dodd et al, 2016).
The majority of pediatric TB cases are in sub-Saharan Africa and the Indian sub-continent

3. Pediatric TB: Challenges & Opportunities
TB infection in children
More likely to progress to active TB
Higher case fatality
More disseminated and extra-pulmonary
TB is difficult to diagnose in kids
Extra-pulmonary
Don’t produce sputum
Low bacillary (bacterial) load
Not great diagnostic options
Often must rely on clinical diagnosis and Xray
Patient presentation
Can be vague
May present with fevers, weight loss, failure to thrive…not very specific!
TB risk
Household contacts – mostly primary caregiver!
TB treatment
Once kids get on treatment they do well with high treatment success rates

4. Advances in Pediatric TB
Dispersible Single Formulations
Isoniazid
Ethambutol
Pyrazinamide

5. Advances in LTBI Treatment
Dispersible Single Formulations
Isoniazid
New Fixed Dose Combination
Isoniazid-Cotrim
Slide from John Jerub
3 RH – 3 months of an INH-rif FDC rather than 6 months of INH

6. Advances in Pediatric TB Care
Integration of TB screening, diagnosis and treatment: Finding children where they are
MNCH and/or under 5 clinics
HIV
Malnutrition and pediatric inpatient
Decentralization: Closer to home
Index case tracing: Bringing care to the highest risk

7. Innovations to Consider
Description
Models of care
Integration of TB care in key entry points and private sector
Integration of TB screening, diagnosis, and treatment initiation in MNCH, U5Y, nutrition and pediatric inpatient entry points. Building integration and private sector capacity (especially in countries with heavy use of private sector)
Community-based household contact tracing, screening, and initiation of preventive therapy
Training of and support for community health workers to perform: Household contact investigation; TB screening of identified pediatric contacts of TB index cases; initiation of preventive therapy (if feasible depending on country context); monitoring of treatment adherence
To mention while speaking on this slide:
e-health and m-health technologies to support TB care delivery (solutions will be tailored to country context and rolled-out only upon assessment of feasibility for country absorption and sustainability)
Examples:
-Bi-directional SMS to support Treatment adherence (for DS-TB and LTBI)
-e-health solution for surveillance in EGPAF supported regions : Building on the existing EGPAF platform for real-time visualization of epidemiological data, Cap TB will develop and provide access to visual dashboards reporting pediatric TB epidemiological data from the regions where the project is implemented

8. Innovations to Consider: Models of Care
Site assessments
Development or strengthening of referral networks
Site upgrades
Updating policies, practices, guidance
Development of training manuals, job aids, SOPs
Potential development or introduction of new registers and logbooks
Sensitization of health districts
Training of trainers, training at facility level
Site monitoring and mentorship
Potential hiring of new staff at facility or referral level
To mention while speaking on this slide:
e-health and m-health technologies to support TB care delivery (solutions will be tailored to country context and rolled-out only upon assessment of feasibility for country absorption and sustainability)
Examples:
-Bi-directional SMS to support Treatment adherence (for DS-TB and LTBI)
-e-health solution for surveillance in EGPAF supported regions : Building on the existing EGPAF platform for real-time visualization of epidemiological data, Cap TB will develop and provide access to visual dashboards reporting pediatric TB epidemiological data from the regions where the project is implemented

9. Innovations to Consider
New diagnostics
Xpert Ultra
WHO policy in March Expected to improve detection yield in children due to improved sensitivity. Need support for product switch and roll-out of this new cartridge, in combination with use of more child-friendly sample types. Improved access to Xpert for pediatric populations (still relatively low uptake as compared to other populations).
Omni
Omni is expected to be released in the market in Q1/ Potential for additional decentralization and access. There are issues with current deal for Omni – may need additional advocacy ahead of release.
Digital X-ray
Digital X-ray has been shown to have improved accuracy and may be read by expert readers at referral facilities (teleradiology).
To mention while speaking on this slide:
e-health and m-health technologies to support TB care delivery (solutions will be tailored to country context and rolled-out only upon assessment of feasibility for country absorption and sustainability)
Examples:
-Bi-directional SMS to support Treatment adherence (for DS-TB and LTBI)
-e-health solution for surveillance in EGPAF supported regions : Building on the existing EGPAF platform for real-time visualization of epidemiological data, Cap TB will develop and provide access to visual dashboards reporting pediatric TB epidemiological data from the regions where the project is implemented

10. Innovations to Consider: Diagnostics
Site assessments
Development or strengthening of sample transport or referral networks (including teleradiology)
Site upgrades
Quantification, procurement planning
Ensuring adequate in-country supply-chains
Development of training manuals, job aids, SOPs
Training of trainers, training at facility level
Site monitoring and mentorship
Potential hiring of new staff at facility or referral level
Community sensitization
To mention while speaking on this slide:
e-health and m-health technologies to support TB care delivery (solutions will be tailored to country context and rolled-out only upon assessment of feasibility for country absorption and sustainability)
Examples:
-Bi-directional SMS to support Treatment adherence (for DS-TB and LTBI)
-e-health solution for surveillance in EGPAF supported regions : Building on the existing EGPAF platform for real-time visualization of epidemiological data, Cap TB will develop and provide access to visual dashboards reporting pediatric TB epidemiological data from the regions where the project is implemented

11. Innovations to Consider
New drugs and treatment options for childhood TB
INH-Rif-PZA FDC pediatric dispsersible
WHO PQ’d and already being ordered in 60 countries globally. Need to ensure full and rapid transition occurs.
EMB and INH single dispersible formulations
EMB dispserible has received WHO PQ. If country not transitioning to 3RH for LTBI, may want to invest in dispsible INH.
3 RH and 3HP regimens
In countries that are interested in introducing the 3 RH regimen for treatment of latent TB, transition to this regimen (expected to be recommended in WHO LTBI guidelines). 3HP not yet approved for <2 years of age and not yet available generically or in a dispersible form.
MDR formulations for children!
Several are now pre-qualified.
To mention while speaking on this slide:
e-health and m-health technologies to support TB care delivery (solutions will be tailored to country context and rolled-out only upon assessment of feasibility for country absorption and sustainability)
Examples:
-Bi-directional SMS to support Treatment adherence (for DS-TB and LTBI)
-e-health solution for surveillance in EGPAF supported regions : Building on the existing EGPAF platform for real-time visualization of epidemiological data, Cap TB will develop and provide access to visual dashboards reporting pediatric TB epidemiological data from the regions where the project is implemented

12. Innovations to Consider: Treatment
Quantification, procurement planning
Updating guidelines and policies
Transition planning
Ensuring adequate in-country supply-chains
Development of training manuals, job aids, SOPs
Community sensitization
Ensuring in-country registration
Training of trainers, training at facility level on new formulations (and on improving uptake of LTBI treatment for children)
Site monitoring and mentorship
To mention while speaking on this slide:
e-health and m-health technologies to support TB care delivery (solutions will be tailored to country context and rolled-out only upon assessment of feasibility for country absorption and sustainability)
Examples:
-Bi-directional SMS to support Treatment adherence (for DS-TB and LTBI)
-e-health solution for surveillance in EGPAF supported regions : Building on the existing EGPAF platform for real-time visualization of epidemiological data, Cap TB will develop and provide access to visual dashboards reporting pediatric TB epidemiological data from the regions where the project is implemented

13. Conclusions Pediatric TB is often forgotten
Important opportunities to improve the care and outcomes for children with TB infection and disease
Can’t be just an “add on” – we have to go beyond “and children” to specify their specific needs and make sure we are planning programming and funding for these needs
The 2018 COPs process is an ideal time to highlight pediatric TB
To mention while speaking on this slide:
e-health and m-health technologies to support TB care delivery (solutions will be tailored to country context and rolled-out only upon assessment of feasibility for country absorption and sustainability)
Examples:
-Bi-directional SMS to support Treatment adherence (for DS-TB and LTBI)
-e-health solution for surveillance in EGPAF supported regions : Building on the existing EGPAF platform for real-time visualization of epidemiological data, Cap TB will develop and provide access to visual dashboards reporting pediatric TB epidemiological data from the regions where the project is implemented

14. Thank you!