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Dr. Ian Kitai, MB, BCh, FRCP is a tuberculosis specialist and Staff Physician in Infectious Diseases at SickKids and Associate Professor in the Department of Paediatrics at the University of Toronto.
March 24th is World TB Day. This commemorates the announcement in 1882 by Dr. Robert Koch of the discovery of the bacillus that causes tuberculosis (TB) disease. If Mycobacterium tuberculosis had a consciousness and could talk, it might say it’s doing fine despite some scientific advances. In 2016, TB surpassed HIV as the leading cause of infectious disease-related deaths globally.
It’s been estimated that in 2016, 10.4 million people fell ill with TB, and there were 1.36 million TB-related deaths in the world.1 There were at least 490,000 new cases of multi-drug resistant TB, a form that is difficult and expensive to treat, and where treatment sometimes fails.1
In 2016, Canada had approximately 4.8 cases of TB per 100,000 people (a slight increase from 2015) and compares with the global incidence rate of about 137 per 100,000. 2 While it may appear that TB is rare in Canada, in fact, the incidence is high in some indigenous communities, as well as in areas where there are large populations of new Canadians. Rates in Nunavut in 2016 were 149 per 100,000, and Toronto and Peel regions have rates above nine cases per 100,000. 2,3
TB disease in children is different from that in adults. In adults, the diagnosis of TB is usually made by examining and culturing their sputum, but children don’t often cough up sputum. Pediatric TB disease less often involves lung tissue than in adults, but involves other parts of the chest and body. So, diagnosis of TB in children is more difficult and the disease may be much more damaging. We don’t really know how much childhood TB there is in the world, but we know it is really under recognised in high TB-burden countries and is a major concealed cause of childhood deaths. In 2012, the World Health Organisation estimated that 500,000 (5.6%) of the 9 million new TB cases were children; for 2016, the estimate is 11% of the 10.4 million cases – that is 1.14 million children. 1
It’s difficult to grasp what these numbers mean, especially when most health-care professionals in Toronto don’t often see TB. Most children and adults diagnosed here are treated and fully cured; in other parts of the world many people die for want of access to diagnosis and inexpensive drugs. But, TB is often not that easy: TB meningitis, the most devastating form, is much more common in young children, begins with vague and nonspecific symptoms, and is often diagnosed late. Even with early diagnosis and treatment, most children do not survive TB meningitis undamaged. In Africa, but also occasionally here in Canada, I have seen too many children who went from normal development to now being unable to walk, see or hear well; who suffered a devastating stroke a few days into treatment; or who died. TB elimination by 2015, a post-millennial goal4, is a very important aim toward which we should continue to work.
William Osler taught that “TB is a social disease with a medical aspect.”5 It can cause disease in anyone, but the poor and marginalised – not only in high-burden countries, but also here in Canada – are most often affected. It is unacceptable that TB so disproportionately affects indigenous Canadians; its elimination from these communities will require markedly improved housing and living conditions, as well as strengthened health systems in remote areas, and must be our first priority. It’s unacceptable that this disease disproportionately affects the foreign born; its elimination will require improved targeted and compassionate screening, better diagnostic tests, better treatment for infection, and most importantly, marked reduction in the very unevenly distributed global burden of TB.
In addition to indigenous Canadians, new Canadians have made this country what it is. We must understand that participating in the global struggle to end TB is not only right – it is in our own immediate and long-term interests.
About the SickKids TB program
For the past 14 years, SickKids staff have led the development of national guidelines for the diagnosis and management of pediatric TB in Canada. SickKids has a multidisciplinary TB clinic that includes physicians, a nurse practitioner and nurses with support from social work and interpreter services. The clinic is closely integrated with public health units and always includes staff from Toronto Public Health. The clinic is one of the only paediatric TB clinics in the world to have high air flow and negative pressure rooms for patient and staff safety. The clinic has more than 1,100 patient visits per year and is the main referral centre for paediatric TB in the Greater Toronto Area. Patients may be referred to the SickKids TB clinic by family physicians, specialist physicians, public health nurses, frontline health care workers or health agency personnel. We also assist with clinical queries related to paediatric TB from other jurisdictions.
SAVE THE DATE: NOVEMBER 19 – 21, 2018