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Child Malnutrition and TB

An Adult and Child Lung Health scientific section working group

Overall Goal:
To improve child health globally by advocating for - and contributing to - clinical research, implementation science, and providing an evidence base for policy-making that addresses the challenge of co-occurring TB and severe acute malnutrition (SAM) in children.

Group Objectives: 

  1. Improve awareness in the global child health community of the strong association between TB and SAM, and the need for focused intervention and development of models of care for these two conditions.
  2. Promote, and advocate for, research to improve the understanding of key areas for management of TB and SAM: epidemiology; screening, diagnosis, and prevention of each condition in the face of the other; and optimized treatment of TB for children with SAM.
  3. Promote evidence-based policy-making that addresses the burden of co-occurring TB and SAM in children.

Activities

Objective 1: Improve awareness in the global child health community on TB and SAM

  • Year 1
  1. Engage and recruit working group members representing a broad range of countries, sectors, and disciplines.
  2. Establish three group meetings, two virtual and in-person at The Union annual conference. 
  3. Engage WG members to submit TB-SAM related abstracts at Union conferences.
  4. Building upon the success of the symposium presented at The Union 2023, present a symposium at The Union 2024 that further expands awareness of the current state of evidence in the field.
  • Year 2
  1. Continue to engage and recruit working group members.
  2. Maintain regular group meetings three times per year, virtual and in-person at The Union annual conference.  
  3. Engage working group members to submit TB-SAM related abstracts at The Union conferences.
  4. Present a symposium at The Union 2025 that describes recent progress in the field since the group’s formation in 2023.

Objective 2: Promote research to improve the understanding of key areas for management of TB and SAM

  • Year 1
  1. Identify priority areas for research in TB and SAM. 
  2. Start an email listserve to disseminate new research in the field.
  • Year 2
  1. Design and conduct a needs assessment survey and disseminate results describing current research gaps on SAM and TB.
  2. Formulate research questions and develop concepts notes aimed at supporting researchers that can tackle identified areas of research, support them to submit to specific funding calls.
  3. Plan and host a plenary session on TB and SAM at an international conference.

Objective 3: Promote evidence-based policymaking aimed at addressing the burden of TB and SAM

  • Year 1
  1. Advocate for a specific PICO question for a revision of WHO pediatric guidelines on TB screening, diagnosis and management in children with SAM.
  • Year 2
    1. Propose and hold consultative workshop(s) on TB and SAM involving TB and nutrition experts, stakeholders, WHO, UNICEF, etc. to share current state of evidence and propose policy directions for implementations.
    2. Conduct advocacy activities through a webinar on policy direction for screening, treatment and prevention of TB and SAM based on current state of evidence.

Expected outputs: 

  1. Establishment of a sustainable multidisciplinary and geographically diverse working group of experts on TB and SAM.
  2. Annual Union World Conference on Lung Health symposia that promote awareness and action in the field.
  3. Stakeholder engagement on review of global policy on TB/SAM.  

Background:

Especially in resource-limited settings and for children under the age of five years, both tuberculosis (TB) and severe acute malnutrition (SAM) are major causes of mortality. Children under five years are the age group with highest risk to progress from TB infection to disease, to have disseminated forms of TB such as miliary TB and meningitis, and to die from untreated disease.1 According to the WHO, there were an estimated 10 million incident TB cases worldwide in 2019. Children <15 years of age represented 12% of incident cases but 16% of the estimated 1·4 million deaths from TB.2 Global and regional estimates of the burden of SAM are limited by inconsistent definitions and underreporting, with the epidemiology of edematous SAM, or kwashiorkor, particularly poorly defined.4 That said, severe wasting (weight for length/height z-score less than -3) affects an estimated 16·6 million children under the age of five years worldwide.5 Global deaths attributable to severe wasting for children under the age of five in 2011 were estimated at 516,000.7 Understanding the association between childhood TB and SAM, and improved management of co-occurring disease, is important for improving child health globally.

There is growing recognition of malnourished children as a key high-risk group for TB, with recent calls to focus on malnourished children for targeted TB case finding efforts.8 The World Health Organization (WHO) emphasized the association between malnutrition and child TB in its 2018 Roadmap towards ending TB in children and adolescents9 and its 2022 updated operational handbook on management of tuberculosis in children and adolescents.10 With growing attention globally to the childhood TB epidemic after decades of neglect, and with the burden of SAM remaining unacceptably high worldwide, the collision of these two diseases is an important focus for improving child health. Public health officials and clinicians must understand the unique considerations for co-prevalent TB and SAM, and much research is needed in the areas of epidemiology, screening and diagnosis, prevention, and treatment to mitigate the vast suffering of young children from these diseases. Policy-level and implementation research is needed to shift paradigms and optimize integrated models of healthcare that address TB and SAM in children.

References

1.        Basu Roy R, Whittaker E, Seddon JA, Kampmann B. Tuberculosis susceptibility and protection in children. Lancet Infect Dis. 2019;19(3):e96-e108. PMID:30322790

2.        World Health Organization. Global Tuberculosis Report.; 2020. https://apps.who.int/iris/bitstream/handle/10665/336069/9789240013131-eng.pdf?ua=1

3.        Dodd PJ, Yuen CM, Sismanidis C, Seddon JA, Jenkins HE. The global burden of tuberculosis mortality in children: a mathematical modelling study. Lancet Glob Heal. 2017;5(9):e898-e906. PMID:28807188

4.        Frison S, Checchi F, Kerac M. Omitting edema measurement: How much acute malnutrition are we missing? Am J Clin Nutr. 2015;102(5):1176-1181. PMID:26377162

5.        World Bank, United Nations Children’s Fund, World Health Organization. Levels and Trends in Child Malnutrition: Key Findings of the 2019 Edition of the Joint Child Malnutrition Estimates.; 2019. PMID:15003161

6.        Olofin I, McDonald CM, Ezzati M, et al. Associations of Suboptimal Growth with All-Cause and Cause-Specific Mortality in Children under Five Years: A Pooled Analysis of Ten Prospective Studies. PLoS One. 2013;8(5):e64636. PMID:23734210

7.        Black RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427-451. PMID:23746772

8.        Reuter A, Hughes J, Furin J. Challenges and controversies in childhood tuberculosis. Lancet. 2019;394(10202):967-978. PMID:31526740

9.        World Health Organization. Roadmap towards Ending TB in Children and Adolescents. 2nd ed.; 2018. http://www.who.int/tb/publications/2018/tb-childhoodroadmap/en/

10.      World Health Organization. Operational Handbook on Tuberculosis. Module 5: Management of Tuberculosis in Children and Adolescents.; 2022. https://apps.who.int/iris/bitstream/handle/10665/340256/9789240022614-eng.pdf