Why Are Child TB Cases Rising?

Children below the age of 15 years account for about 10 to 12 per cent of India's overall TB burden.

Kindly note the image has been posted only for representational purposes. Photograph: Kind courtesy Edward Jenner/Pexels.com

The number of notified paediatric tuberculosis (TB) cases has increased by 38 per cent in children aged up to 14 years in the last five years, mainly due to malnutrition, COVID-19 effect and rise in drug-resistant TB among other factors.

According to government data, the cases rose from 102,090 in 2020 to 141,182 in 2024.

Paediatric TB refers to the notification of the disease in children aged up to 14 years, according to the World Health Organization.

An analysis of the India TB Report by the ministry of health and family welfare, as well as responses to parliamentary queries, showed that the rise in paediatric TB cases has been sharp.

While notified cases have been rising, concerns have been raised over possible under reporting of overall TB cases.

Dr Kuldeep Kumar Grover, head of Critical Care and Pulmonology at the C K Birla Hospital, Gurugram said that estimates by WHO and India's National TB Elimination Programme (NTEP) indicate that children below the age of 15 years account for about 10 to 12 per cent of India's overall TB burden.

"This number equates to about 300,000 to 350,000 cases per year," he added.

According to the India TB Report 2024, 5 to 7 per cent of all patients notified under NTEP annually are children, compared to the around 12 per cent proportion of incidence of paediatric cases expected.

Dr Kumar said that the difference in numbers can be due to diagnostic difficulties related to sputum sample collection problems and non-specific presentation in children, indicating continued underreporting despite increased surveillance and diagnostics.

"Paediatric TB is frequently extrapulmonary, affecting the lymph nodes and other organs, rather than the lungs, leading to delayed detection due to non-specific symptoms," a public health expert said.

The increased incidence of paediatric tuberculosis could also be due to transmission from adult family members, high rates of malnutrition and other underlying health disorders, such as diabetes, as major reasons.

Doctors indicate that while advances in diagnostic capabilities may be a reason behind increased numbers of paediatric TB, the COVID-19 pandemic could also have indirectly caused the increase.

"Steroid treatment was given to some people during the pandemic, which can weaken the immune system and possibly reactivate latent TB infection, including among children who had been infected previously," Dr Kumar said.

Meanwhile, the Centre is looking to promote early diagnosis of TB patients, prompt treatment with quality assured drugs and treatment regimens under its National Strategic Plan for elimination of TB in India.

Another issue remains the incidence and diagnosis of multidrug resistant TB (MDR-TB) and extremely drug resistant TB (XDR-TB) among children.

"These occur when the tuberculosis bacteria develops resistance to first-line medicines such as Rifampicin and Isoniazid (for MDR-TB), and Fluoroquinolones and at least one injectable second-line medicine (for XDR-TB)," Dr Kumar said.

Diagnosis and treatment of both these versions of TB in children are more complicated as it requires longer treatment periods (ranging between 18 to 24 months or longer) and use of more toxic and costly second-line drugs, he added.

The Centre is aiming to increase TB screening among all age groups to ensure early diagnosis.

This comes even as India has set 2025 as its target year for TB elimination, five years ahead of the Sustainable Development Goals target of 2030.

'To address paediatric TB, the government has expanded BCG vaccination at birth as part of the Universal Immunisation Programme,' Minister of State for Health and Family Welfare Anupriya Patel said in her response to a parliamentary query.

Other steps being taken include providing upfront rapid molecular diagnostics in all cases of presumptive pediatric TB and child-friendly formulations provided for treatment including for drug resistant TB.

While India has separate guidelines for paediatric TB, experts suggest that implementation gaps may persist, highlighting the need to train healthcare professionals working with the disease.

The public health expert quoted above said that many private practitioners suspecting drug resistant TB in children lack access to diagnostic facilities, causing treatment delays.

"As children cannot easily produce sputum, which is essential for TB diagnosis, doctors rely on gastric aspiration, but many healthcare workers are either unaware of this method or hesitant to perform it," he added.

Notified paediatric TB cases in India