Stellenbosch University: DTTC provides leadership in WHO update of TB guidelines for children

When the World Health Organisation (WHO) recently released its new guidelines for the treatment of multi-drug resistant tuberculosis (MDR-TB) in children and adolescents, it was the culmination of an intensive global process in which the Desmond Tutu TB Centre (DTTC) played a major role.

The release of the guidelines, which coincided with World TB Day, also saw the launch of a hands-on operational handbook on the management of TB in children and adolescents.

The guidelines include six new recommendations ranging from the diagnosis to the treatment of TB, which, according to Professor Anneke Hesseling, director of the DTTC, is a “huge accomplishment”.

“The release of the guidelines and the handbook will make it easier in the field to diagnose, treat and prevent TB. It makes the handling of TB more accessible and family friendly,” Hesseling said in an interview. “The handbook serves as an excellent field guide and is extremely useful for people working on the ground in TB.”

Hesseling said the release of the guidelines creates a new sense of awareness of the importance of childhood and adolescent TB. “It is extremely timely to have it released this year and will help us regain the losses suffered because of the negative impact of Covid-19 on the treatment of TB.”

She said the guidelines were compiled following many months of preparation by a range of TB experts across the globe.

“We then held an online guideline meeting which was three weeks long and across multiple time zones. It was the longest guideline meeting ever held. It was an absolute marathon, but the sense of solidarity, cohesion and pride was just wonderful.”

Hesseling said the DTTC contributed data to all six of the new recommendations and led the evidence for several of these aspects.

The recommendations in the guidelines include an expansion to include non-invasive specimens, such as stools, in diagnostic testing with rapid molecular diagnostics being recommended as the initial test for TB diagnosis in children and adolescents.

Another recommendation is that patients who have non-severe forms of drug-susceptible TB can be treated for four months instead of six months. This is also the case for TB meningitis, where six-months treatment is now recommended instead of 12 months.

A further recommendation is that two of the newest TB medicines to treat drug-resistant TB (bedaquiline and delamanid) can be used in children of all ages, making it possible for children with drug-resistant TB to receive all-oral treatment regimens regardless of their age.

Also recommended are new models of decentralized and integrated TB care which will allow more children and adolescents to access TB care or preventive treatment, closer to where they live.

Hesseling said the DTTC has been involved with the WHO for many years in terms of guideline development for TB.

“We work very closely with them and when we plan our research, we let them know we have research in the pipeline which could affect the guidelines, and we get input from them. It is a close relationship which everybody concerned hopes translates into international policy and guidelines and which can be translated on the ground to impact on the lives of children and adolescents affected by TB.”

Hesseling paid tribute to her predecessors at the DTTC, saying it was their contributions that have got the centre to where it is today. “Our centre is about 20 years old. The knowledge we have and the trials we do today all build on the foundations of people who started this work in years gone by. These include wonderful professors like Peter Donald, Robert Gie, Nulda Beyers and Simon Schaaf.

“All the good research questions come from what we see clinically and it is only when you know the local clinical story that you know what is needed. The work we do is built on the shoulders of these giants.

“What is also very important in our work is the fact that we are very closely aligned to the community needs and civil society. We have a very strong community advisory board, that helps with research. Community involvement is very important and so is our partnership with local TB services and TB control groups.

“We partner with them to do our research so as to ensure the findings translate to something meaningful to be applied in routine care.”

Simultaneously to the WHO guidelines being released, the International Union Against TB and Lung Diseases (of which Hesseling is an honorary member, launched a test x-ray diagnostic atlas, a tool geared to enable people to read x-rays in children to make a TB diagnosis and to assess what treatment is needed for the children being tested.

“The first one was developed in 2003 and the DTTC’s Dr Megan Palmer led the updates. It’s a wonderful resource for clinicians in the field to interpret x-rays,” Hesseling said.