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Global And Immigrant Health Work

Item Definition

The Global TB program worked under the 2014 expansion of Baylor College of Medicine and Texas Children's Hospital in Papua New Guinea. The Global TB Program collaborated with Dr. Henry Welch and other faculty from the Papua New Guinea School of Medicine to improve care and treatment of families affected by TB.

One of these areas includes the development of postdoctoral projects in TB research. These projects focused on the areas of improving the diagnosis of TB in children, evaluating the utility of GeneXpert on gastric and fine needle aspirate samples in PNG children. Two paediatric trainees have been published, and one of them has presented at the International Union Against TB and Lung Disease

Over the last 4 years, the Global TB program has been working with the PNG Paediatric Society to introduce a new child-friendly TB medication. In December, 2015 a new child-friendly TB medication became available worldwide. In anticipation of this, the Global TB Program helped coordinate with local partners including the World Health Organization (WHO) the first ever national workshop in child TB. The workshop took place Nov. 2016 and served to update/educate issues surrounding pediatric TB and included clinicians from all 22 provinces in the country. Approximately 80 participants were in attendance including stakeholders from the Burnett Institute, World Vision, UNICEF, TB Alliance, MST, and Australian DFAT. In addition to the introduction of the new FDC, Dr. Anna Mandalakas lectured and met with local partners on the cost-effectiveness of isoniazid preventive therapy (IPT).

Working with the PNG Paediatric Society, PNG became the 1st country in the Western-Pacific Region, and the 4th country worldwide to introduce this medication under a locally owned and directed initiative known as the Child TB Project. This project is ongoing and is works toward improving diagnosis, care, treatment, and prevention for families with TB. Since its inception, the project has secured funding into its' 4th year from the Australian DFAT and the Baylor International Pediatric Aids Initiative. A monitoring and evaluation system has been established to report on these outcomes and decrease lost to follow up.

In the area of multi-drug resistant TB (MDR-TB), the Global TB Program has worked with the National Department of Health and local partners to update national guidelines for both drug sensitive and drug resistant TB. Finally, they have implemented these practice guidelines at the largest referral hospital in the country at Port Moresby General Hospital. Since 2014, the Baylor Global TB Program has worked side by side with staff to diagnose and treat 50 children with MDR-TB. Finally, the Global TB Program is working on ways to monitor and prevent children from acquiring MDR-TB.

Where We Work - ESwatini

Content

The fulcrum of the Global TB Program is based in Mbabane, eSwatini. In May 2015, the Program completed construction on a clinical and laboratory facility to serve as a Swazi national referral center for pediatric TB and host a broad range of translational research projects. The facility has been specifically designed to support cutting edge immunologic and microbiome research that will elucidate the pathophysiology of HIV-TB co-infection and inform the development of future preventive and treatment interventions.

The Global TB Program has made a substantial investment in the construction of a clinical, radiologic, and laboratory facility in Mbabane, eSwatini, the country ranking first globally for HIV-TB co-infections rates and rapidly increasing rates of drug-resistant TB. The Ministry of Health dedicated this building as a national reference laboratory for pediatric TB. Construction of a TB pediatric reference center is situated on the grounds of the current Baylor College of Medicine Children's Foundation – eSwatini Center of Excellence (COE). The Prime Minister, the Right Honorable Dr. Barnabas Sibusiso Dlamini, performed the dedication May 8, 2015.

The TB reference center contains a dedicated open air space to support advanced sputum collection methods including gastric and nasopharyngeal aspirates and sputum induction. In addition, there are two multi-functional consultation rooms, a laboratory, and a radiology room with a digital x-ray machine as describe in more details below. This building is a free standing 178 square meters of TB clinical and laboratory facility will be completed adjacent to the existing COE structure with the purpose of strengthening TB clinical and lab facilities within the COE complex which also houses HIV services.

The new facility will include exam and counseling rooms, a dedicated open air space induced sputum procedures, a 38.3 square meter X-ray room to hold a digital X-ray machine, worth $250,000 USD, donated by the eSwatini Ministry of Health through the Global Fund, and a 30.99 square meter laboratory. The new laboratory is equipped for PBMC isolation, Elispot assays, DNA isolation, Microscopy and GeneXpert NAAT technology. The facility has also been expanded to offer child and adult audiology services in order to facilitate the management of multidrug resistant TB patients.

Cyber Attack On National Health Lab Delays Rollout Of New Test For Children With TB

The National Health Laboratory Service's plans to pilot a new way for finding TB in kids have been put on hold after a cyber attack shut down computer systems at the state labs. (Dino Lloyd/Gallo Images)

The National Health Laboratory Service's plans to pilot a new way for finding tuberculosis in kids have been put on hold after a cyber attack shut down computer systems at state labs.

South Africa isn't doing well at finding children with TB, and just 60% of those with the disease are on treatment.

That's because finding TB in young children is tricky in the first place, as they usually have so little of the germs in their lungs that sputum tests often come back negative. 

Plans to kick off a study this month to test a new way for finding tuberculosis (TB) in kids - by looking at their poop - have been put on hold after a cyber attack in late June shut down the National Health Laboratory Service's (NHLS) computer systems, but Farzana Ismail, a clinical microbiologist with the lab network, says it "remains a priority". 

Because of the IT problems at the country's public pathology lab service, test results now have to be processed and reported manually, slowing down feedback to doctors and patients - and upsetting plans like those for the TB testing study.  

The pilot, in which stool samples were to be tested for signs of the TB germ, would have taken place over the next two months at six labs in Gauteng, the Eastern Cape and the Western Cape, she told Bhekisisa at the 8th TB Conference in Durban in early June.

Together with the National TB programme, they are working toward rolling out the method at labs nationwide, said Ismail.  

Finding TB in children is difficult, because young kids (those younger than 5) often have only a small amount of the bacteria in their lungs.

This means the bug might not show up in a sputum sample (a mix of saliva and mucus from the airways), and so the test result could come back negative even though the child is actually sick with TB. 

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Around 27 000 children younger than 15 in South Africa are thought to have TB - almost 10% of the country's total cases - and about 40% of them went untreated in 2022. TB is the third biggest killer in this age group even though it is a preventable and curable disease. 

Roughly six out of every 10 childhood TB cases are among kids under the age of 5, the group in whom it's particularly difficult to pick up the TB bug.   

The difficulty in getting good sputum samples from kids means other, often more uncomfortable, and sometimes painful, ways have to be used to get a specimen that will be good enough to give a reliable result.  

For example, a health worker can take a sample from someone's stomach (because people often swallow phlegm, which can contain TB germs if they're infected).

But for this, a tube has to be fed through the child's nose down into their stomach, and they can't eat for three or more hours before the test.  

South Africa's guidelines on how to test and treat children for TB were last revised in 2013 and, says Norbert Ndjeka, chief director for TB at the national health department, they are "impatiently waiting for the updated paediatric TB guidelines [to be published]" to help them better diagnose children, because "currently we're not doing particularly well in this area".  

Stool is cool  

"To improve specimen collection [in children], we're trying to get to child-friendly methods, like [taking] a [mouth] swab or stool [sample], so that it's not so invasive," says Karen du Preez, a senior clinical researcher at the Desmond Tutu TB Centre.

"The reality is that because kids typically don't have a lot of bugs, the diagnostic accuracy in the current tests is expected to be low."  

Using stool samples to test for TB will be included in the new guidelines, which are being written jointly by the health department and the TB Think Tank, a group of experts who advise the government on policies for curbing TB infections, and follow after the World Health Organisation (WHO) published an update of their standards document in 2022.  

The WHO has recommended testing faeces for TB since 2021 - and in countries like Vietnam, Zambia and Ukraine the method has been widely used.

Moreover, because the same rapid-result equipment can be used as for sputum tests, namely the GeneXpert machine, any lab that's already set up for this will be able to run tests on stool samples too.  

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With a GeneXpert test, a sample (such as sputum or stool) can be analysed for TB within two hours, and in South Africa, most labs where TB gets tested are equipped with such machines. 

Findings from a systematic review of studies in Africa and Asia, where stool samples were used to test for TB, found that the bug was correctly picked up in, on average, about 67% of close to 1 700 cases.

This is in line with the WHO's ideal sensitivity rate of 66% for rapid non-sputum-based TB tests in children. (Africa and Asia make up more than two-thirds of all TB cases globally.)   

Correctly identifying kids who did not have TB was almost perfect when using the stool sample test, the review showed. (The stool test's specificity was 99%, meaning that only one out of every 100 test results was a false positive.)

Having a TB test with a high specificity means that fewer people will incorrectly be put on antibiotic treatment when they don't need it, which can last between six and nine months and so add to the chances of drug-resistant germs developing. 

In the same way, using a TB test that yields accurate results fast and so identifies kids who do have the germ, means that they can get onto treatment early, rather than having to wait for a bacterial culture test to be done, which can take two to six weeks.   

Du Preez said:

The longer we wait [to make a diagnosis], the sicker someone can get.

Getting results from a culture test takes long because a small dish with a gel-like food source in which bacteria can grow has to stand at a suitable temperature for a few weeks to allow enough time for a clump of bacteria to grow.   

Moreover, given that taking only one type of sample from children isn't guaranteed to identify the bug in someone who is indeed sick, the WHO says using stool together with another specimen type may improve the chance of getting an accurate diagnosis. 

What about other options?

Researchers are also looking at adding other ways of sample collection to the TB test choices. For example, taking a swab from someone's mouth and or tongue may be promising.  

*This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter. 

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