Why is TB Testing So Difficult in Children?

Have you ever had your child tested for tuberculosis (TB)? It's not required in all American school districts, but in our school it's required of all 8th graders before they head off to service projects in the fall. Chances are you might have had this done if you are in a caregiving profession like daycare or occupational therapy. Whenever I hear Americans surprised that tuberculosis still even exists, it's further evidence to me that my global advocacy work on tuberculosis treatment and prevention is still needed. This bacterial infection is still found in EVERY country in the world and it is the leading infectious cause of death worldwide. TB sickens 10.4 million people a year and kills 1.7 million of them. Since 2015, it has been the leading global infectious disease killer, surpassing even HIV/AIDS! Tuberculosis is a global pandemic that kills one person about every 18 seconds, according to TB Alliance. 

Happily, TB is treatable and - in almost all cases - curable. Yet at the RESULTS International Conference for the past two years, I've been hearing about how the main problems with the fight against TB have to do with lack of advances in methods of treatment as well as diagnostics. With a highly infectious airborne disease like TB, diagnosis is of critical importance. If you can't find it, you can't fight it. We're failing to deliver quality treatment to 40% of people in the world who are sick with TB. And who is bearing the biggest burden of this failure? Children. 

Dr. Jeffrey Starke, director of Children's Tuberculosis Clinic at Texas Children's Hospital, told Infectious Diseases in Children, "Children are the most neglected group of individuals regarding controlling TB." Today, 90% of children with TB go untreated. Combine that with the fact that children usually respond very well to TB treatment, even for drug-resistant TB, and that tells me that a lot of kids could be saved if we could better diagnose them. 

My question of the day is: "Why is it so hard to accurately test kids with TB?"

First, let's be clear about two kinds of TB since each requires a different test. There is TB infection, which is when someone has inhaled the bacteria and the body contains the infection in the lungs. At that stage it is serious and requires a course of preventive antibiotics, but it is NOT ACTIVE and it is NOT CONTAGIOUS. Then, there is the active form when the relatively dormant infection becomes TB disease. Active TB, usually found in the lungs, is life-threatening and must be treated with antibiotics. When occurring in the lungs, it can be spread through coughing, though once a patient is on effective treatment they quickly become non-infectious. 

In the US, 9105 people developed the disease in 2017 and another 13 million have the infection according to the CDC. According to an estimate published in the Lancet in 2019, more than 30,000 people in the US have a form of TB infection that is multi-drug resistant. 

Clinical Exams

Let's start with the simple clinical examinations. Most people associate tuberculosis with a persistent cough, but for kids a cough is not a prominent way TB presents. Adults can describe other symptoms like night sweats, and weight loss, but tiny kids might not be as verbal about such things. If an x-ray machine is available, the disease will show up there for adults. But children don't usually get cavities in their lungs that would indicate the presence of TB. That makes it harder, but not impossible, to make an accurate diagnosis.

Good news! No bump.
My daughter doesn't have TB!

PPD Injection Test
Now let's look at the injection test that my child just had. In the U.S., we have a standard purified protein derivative (PPD) test that is given to both kids and adults. A small shot of PPD is administered just under the top layer of skin, which will cause a small bump to form. After 2 days, a medical professional needs to check to see that the bump disappeared to indicate the patient doesn't have TB. There are a few problems with this.

1. The test takes 2 days for a result, so that is obviously inconvenient.
2. Many kids in developing countries get a BCG vaccine, which helps prevent some forms of childhood tuberculosis and would test positive. That would be a false positive, however, since it would not indicate TB infection. 

Hold up right there. A TB vaccine? Why doesn't everyone use that? Because the BCG vaccine isn't a reliable way to prevent kids from being infected with TB or developing TB disease. It does protect younger children against certain complicated and lethal forms of TB, but the efficacy varies and it does not protect against TB disease in the lungs, which is the most common form. So, it's better than nothing in countries with a high TB burden, but it screws up PPD test results.

Ok, so that PPD test doesn't work for a lot of situations. What's next?

IGRA Blood Test
The best alternative to the PPD skin test is a blood test for infection called IGRA. This is a rapid test and will not be affected by BCG, but it is more expensive than PPD and so it is not available everywhere.

Sputum Test

The usual method for diagnosing active TB disease is to test sputum, a mixture of saliva and mucus coughed up from the respiratory tract. One problem with this method is that is that it's hard for little kids to cough up the sputum. But you can get a sample from the stomach because children often swallow the sputum. You can also find TB germs sometimes in spinal fluid or lymph nodes, but those samples aren't super easy to collect. A low-tech way to test the sputum is to look at it under a microscope, but those tricky kids tend to have fewer bacteria and the TB might not be detectable that way. Only 1 in 3 children with TB test actually positive with a sputum test.

GeneXpert

If a community is lucky, they can test using a GeneXpert system that can rapidly detect TB and whether it's a drug-resistant strain in under two hours. Wow! No wonder this was heralded as a breakthrough tool. It's still a relatively new tool as it was launched in 2010. It takes a while for something like GeneXpert to get to underfunded medical facilities in communities of extreme poverty. The commonly used system costs about US$17,000, not to mention a widely varying installation cost of US$2600-7000. So, "wow" indeed. I can see why everyone doesn't have one yet. 

So, now you and I both know a bit more about TB testing. Probably the main reason testing is so difficult for both the infection and the disease is that very little money has been put into the research and development of new tests, particularly ones that are work for kids. TB is vast problem and this is one of the many reasons why we need a spirit of global cooperation among governments to tackle this disease the way we fight HIV/AIDS and polio. The best thing that you and I can do about TB right now is to call our senators right now and ask them:

"Would you support U.S. efforts to control and treat TB and drug-resistant TB? I'd like to senator to sign onto the Stop TB Now Act, which has the number S. 2438.  It updates old and, in some cases, obsolete instructions to USAID about how to end TB. It imposes new requirements, including a full program evaluation and better coordination."

Soap Brings Health and Dignity

As the school year begins, moms are running around trying to make sure that everyone has everything they need to start the school year off right. Teachers need kleenex and Clorox wipes for the classroom, high schoolers need whatever the heck binder types the teacher asked for, the Starbucks donation box needs some more backpacks for kids who don't have one. But another mundane, yet oh-so-necessary item is on my mind: Soap.

Soap is one of those things you don't think about much until you don't have it. Soap protects us all from getting sick and spreading illness to others, so everyone can keep going to school and work. It keeps our skin clear (or clearer anyway). It keeps us from being smelly so other people don't shy away from us because of our body odor. When you add those all up, soap gives us dignity.

Soap is also one of the very necessary items that you cannot buy with food stamps along with toilet paper, laundry detergent, shampoo, deodorant, feminine hygiene products and diapers. If you're having trouble imagining what it feels like to live without those things check out Pamela Covington's book "A Day at the Fare" that I reviewed this summer. 

Everyone needs to be clean and on my mind especially are the kids sitting alone in schools across America with so many problems that a lack of soap might not even make the top five. There are lots of reasons why kids might be ostracized by peers, but one very real and very fixable reason can be body odor. Now, I KNOW I'm not alone in the world of moms in having had to find ways to try to convince adolescent kids that they stink when they don't shower. It's so common among pre-teens to genuinely not know why people don't want to sit near them when they're fouling the air around them. It's painful to consider that a simple lack of soap is adding to the social isolation of kids in poverty. 

Thank goodness that in St Louis, we have Circle of Concern. The text on their website reads: "Feeding families is just the beginning." Their food pantry provides fresh, nutritious food for over 600 families each month that reside in the Parkway, Rockwood and Valley Park school districts of Greater St Louis. Circle of Concern has a limited supply of personal care items and is currently in need of soap.

Wherever you are when you're reading this, please consider making a donation of soap and care products to a facility like Circle of Concern. It's not only a gift of health, but a gift of dignity.

Add Acts to your Thought and Prayers

I used to have a lot of time to think when I had only one baby and no job. I used to pray a lot about the things that really worried or scared me the most. I still pray. I still think. But now I also act.

This morning, I read an op-ed from Dana Milbank of the Washington Post called "Republicans' thoughts and prayers have become cruel joke." He's talking about the roll call of empty tweets from lawmakers professing to care a lot about the victims of gun violence in the midst of their inaction. It's easy for me to also cast an accusing finger at members of Congress for their neglect and inaction. But instead, I'm going to extend an olive branch and say, "Hey...that was once me, too."

Look, I don't talk a lot about my faith on this particular blog. But today, I will. Because I think there are a lot of people - members of Congress and regular constituents alike - who need to hear this about the "Thoughts and Prayers" phrase that gets bandied about so casually. 

I, too, was someone who looked to G-d to solve all kinds of problems that I thought were too big for me to handle. Famine. AIDS. Malaria. My awareness of children suffering in Haiti was keeping me up at night. I read newspapers and magazines about it. I learned and I thought. I prayed with my congregation and on my knees at night. But it took some special activists in my life to introduce me to advocacy and show me that it was G-d acting through humans that was making steady progress in ridding the world of such suffering. And things might go a heck of a lot faster if I would become one of those humans! One Lenten season, I decided that in addition to praying every day about children dying for 40 days, I would also take an action every day. It could be an email, a phone call, or submitting a letter to the editor, but I would speak out in some way every day for forty days. In that discipline, I began to see bits of progress that were so much more impactful than my years of empty prayers without adding the conviction of sacrificing some time, giving some energy, and maybe even risking some public reputation.

I'm no biblical scholar, but as an average, run-of-the-mill Christian, I favor the words of James who declared, "What does it profit, my brethren, if someone ways he has faith, but does not have works? Can faith save him? If a brother or sister is naked and destitute of daily food, and one of you says to them, "Depart in peace, be warmed and filled," but you do not give them the things which are needed for the body, what does it profit? Thus also faith by itself, it it does not have works, is dead." (NIV James 2:14-17) And here, I'll share that my personal understanding of this interprets "faith" to be "sincere thoughts and prayers" and "works" to be "personal acts to bring about change."

He didn't say to stop having faith. He was saying we need to have both. I'm not willing to say prayers are useless. Actions make prayers more full and robust. They bring intention into being. I believe they bring us closer to G-d as we act together in concert to bring about a better world. I think when we pray to do G-d's will and then do something about it, G-d blesses our actions and is the wind in our sails. Thoughts and prayers combined with actions can be immensely powerful. They can bolster our own strength and conviction and help us choose the wise and morally right actions. I mean, we don't want anyone acting without thinking, right? 

So, I'm urging everyone to pair their thoughts and prayers with actions. Act in positive ways that will push back against the indolence that allows not only children to be gunned down in classrooms, but also allows babies to die of malnutrition and AIDS and TB to take parents from their children forever. If a member of Congress reads this...man, do we need you NOW to align your public thoughts and your actions! As I write this, gunsense legislation needs a push to be brought to the Senate AND the White House is looking to work around Congress and cut poverty-focused foreign aid. But even if you are a reader who doesn't hold office, we need you, too. Join a group or call a senate office. Don't just go to worship and then shake your head helplessly. Pray about it and then do something.

Think.
Pray.
Act.