How innovations in TB detection are transforming pediatric care in Bangladesh

The IMCI health worker believed Rukaya could be at risk for tuberculosis, a disease that killed an estimated 139,000 children under five worldwide in 2022. The results from a Tuberculin skin test, or TST, indicated that indeed she was a presumptive tuberculosis patient.

“I didn’t think it could have been tuberculosis. I’ve never had experience with it,” said Farida Parvin, Rukaya’s mother, before whisking Rukaya off to receive a chest X-ray. “But I feel relieved to be here and have the tests done. If it’s tuberculosis, we’ll follow the procedure.” 

What appeared to be a routine intervention that caught a potentially deadly disease may not have taken place just a few years ago, when IMCI staff weren’t trained to see Rukaya’s history and symptoms as indicative of a possible tuberculosis diagnosis.

But in recent years, there’s been a major push to train IMCI staff members in identifying potential TB cases, led by national health authorities alongside local and international organizations including the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), the Stop TB Partnership, and The Global Fund to Fight AIDS, Tuberculosis and Malaria. 

This, coupled with the deployment of a plethora of innovative diagnostic and treatment tools such as mobile X-ray units installed with artificial intelligence software, has resulted in significant gains in the fight to stop TB in high-burden countries such as Bangladesh.

Tuberculosis continues to be one of the leading causes of death by infectious diseases worldwide, killing 1.3 million people in 2022, according to the World Health Organization — more than HIV/AIDS and malaria combined.

Almost 10% of TB mortalities were in children, but there are significant challenges in diagnosing and treating the youngest patients: They carry lower viral loads, can’t produce sputum, which is vital for high-quality diagnostics, and their symptoms aren’t as obvious as those of adults. That’s why of the some 130,000 people whose TB infection was missed in Bangladesh in 2020, 15% were children.

Despite these challenges, there is a belief among public officials and TB experts that the country has all the right tools to make significant progress in the fight against the disease. 

“Bangladesh has an appetite [for innovation] in the public and private sector,” said Dr. Lucica Ditiu, executive director of the Stop TB Partnership. Organizations such as BRAC and icddr,b “are really frontrunners globally in embracing innovation,”  she added.

One of the biggest obstacles to stopping TB in low-income countries such as Bangladesh is the lack of high-quality diagnostics in underserved areas. Mobile X-ray units that can be transported in a backpack and set up with minimal staff are part of a new breed of innovation that could help overcome that access barrier. 

Abdul Aziz, a rickshaw puller from Korial Basti, Dhaka’s largest slum, has had a cough for three months and a fever for the last five nights. The illness is affecting his ability to work, so when he heard from a community health worker that there would be a mobile X-ray unit at the local primary school, he made sure to come by. 

While AI-assisted X-ray technology has only been approved by the World Health Organization for use in adults, many believe that the next logical innovation is trialing its use with children. Bangladesh has already been at the forefront of another diagnostic innovation that has significantly improved the detection of TB in children under five years old — the use of stool samples instead of sputum in molecular diagnostic tests like Xpert technology. 

Before 2020, when WHO started recommending the use of stool for diagnosing TB in children, medical professionals had to rely on invasive methods such as nasogastric aspiration and sputum induction, which cause significant discomfort for children and require expertise that is lacking in many primary health care facilities. 

Bangladesh helped pioneer research into TB diagnosis with stool samples and local stakeholders are now looking to further innovation in this arena. 

Currently, WHO only recommends using stool samples in Xpert technology. The problem is that GeneXpert, a gold standard in TB diagnostics, requires a sophisticated, energy-intensive laboratory setting, limiting its use beyond hospitals, where the majority of missing cases need to be diagnosed. That’s where new innovations in molecular diagnostics like Truenat, a portable, real-time PCR testing technology for TB, come in. 

Truenat resolves many of the issues around resource and cost intensity that come with Xpert technology, since it’s operated handheld and with batteries. The result is a highly accurate diagnostics test that can be used in patients’ homes. Bangladesh has been ramping up Truenat use through the Stop TB Partnership and the United States Agency for International Development’s introducing New Tools Project, or iNTP, which piloted a 2022 project with 38 Truenat Duo systems. The iNTP also plans to acquire another 112 through the Global Fund in the coming years. 

But many feel that Truenat, like AI-assisted X-ray, isn’t currently being used to its full potential. As of now, insufficient research has been conducted utilizing stool samples with Truenat, which would open doors to diagnosing children under five who can’t access a hospital setting, said Ditiu.

As attractive, and useful, as advancements in diagnostic technology can be, often the most effective interventions can be simple changes in medical procedures. Under current national tuberculosis guidelines, a child would need to show symptoms such as more than two weeks of cough or two weeks of fever to be tested for TB. But children under five often present with nonspecific signs and symptoms, which is the main reason why almost 70% of tuberculosis cases among children under five are missed, according to WHO. 

As part of a series of interventions called TB Reach Wave 10, Stop TB in partnership with icddr,b is piloting a change in pediatric care provided through IMCI corners that would significantly expand the symptoms or signs considered indicative of tuberculosis in children. 

Instead of just a few weeks of cough and fever or weight loss, symptoms that qualify children like Rukaya to be tested for TB include any swollen lymph nodes, contact with a family member with TB, and diarrhea for more than two weeks, among others.

In addition to capacity building for IMCI providers, the project also includes developing an app-based tool for taking patient data and history and introduces robust contact investigation, which is crucial given that children under five almost always get TB from a family member. 

“The diagnosis of TB is not very difficult,” said Dr. Tahmeed Ahmed, executive director of icddr,b. “The challenge is that not many health practitioners are aware of [diagnostic practices].” 

The initial results of the program are promising. The Narsingdi Sadar Hospital, where Rukaya was received, saw the number of children diagnosed with TB double in the period January to March, 2024 compared to the same period the prior year, before the project was implemented, according to data compiled by the hospital. 

Hospital staff are noticing the change in workload. “I’m getting way more X-ray patients — five to seven per day, up from just a few,” said Rashida Parvin, an X-ray technologist at the hospital. “It’s more work but I’m happy because the children are getting evaluated.”

Incorporating TB screening into the IMCI corners has lifted a huge burden on pediatricians, who can see up to 150 children per day in local health centers in Narsingdi District, says Dr. Farhana Ahmed, civil surgeon of Narsingdi District. “This project gives us skilled manpower,”  she said.

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