Opportunities to improve undernutrition and tuberculosis management in paediatric care

What we know: Tuberculosis (TB) and undernutrition are strongly linked. Undernutrition increases the risk of developing TB and poor outcomes from TB, while TB can both cause and worsen undernutrition. Diagnosis, treatment, and prevention of TB among children can be challenging, particularly in humanitarian and resource-limited contexts. 

What this adds: Recently updated World Health Organization (WHO) recommendations offer opportunities to positively impact the management of TB among undernourished children. One of the main additions is the use of a decision tree to be able to diagnose children with TB in humanitarian and resource-limited contexts, even in the absence of conventional diagnostic tools. Improvements in preventative TB treatment for children and food assistance for household contacts of TB patients are other promising developments. 

TB is the biggest infectious disease killer globally, causing over 1 million deaths annually. TB is caused by bacteria spread through the air when an infected person coughs or sneezes. It most often affects the lungs (pulmonary TB) but can affect any part of the body (extrapulmonary TB). In 2023, 10.8 million people fell ill with TB worldwide. Of the estimated 1.3 million affected children aged under 15 years old, 45% are never diagnosed. Around 96% of the estimated TB-related deaths are among these children, who have never accessed TB treatment. Most people infected by TB bacteria never develop the disease, but those with a compromised immune system have increased risk. Thus, since adequate nutrition is needed for a strong immune system, poor nutritional status is one of the major TB determinants, with over 1 million cases of TB each year attributed to undernutrition (WHO, 2024a; Dodd et al, 2017). 

Undernutrition is not only a factor leading to the development of TB disease after infection but is also a significant consequence of TB. Young children are inherently more vulnerable as their immune systems are still developing, are at more risk of undernutrition, and can become ill more easily. When they fall ill they also become more severely unwell and more frequently die from illness. 

Despite the large global burden of TB, there has been chronic under-investment in research and development for tools dedicated specifically to children and humanitarian and resource-limited settings. In particular, lack of prioritisation has resulted in inadequate tools for early detection, timely treatment, and effective prevention of TB in this vulnerable population. 

Recent and upcoming recommendations from the WHO present an opportunity to address some of the challenges and improve upon the status quo. These are discussed further below. New recommendations for nutrition and TB are expected to be released in 2025. In addition, the 2023 WHO guideline on the prevention and management of wasting and nutritional oedema includes recommendations for children with co-morbidities such as TB (WHO, 2023).

As a medical humanitarian organisation, MSF, also known as Doctors without Borders, frequently encounters children with TB and undernutrition, and the associated challenges. This inspired MSF to develop the TACTiC (Test Avoid Cure TB in Children) project, a multi-country project to improve the management of TB in MSF projects and beyond. The project has three pillars: 1) implementation of the various WHO recommendations; 2) operational research on the effectiveness, feasibility, and acceptability of the recommendations; and 3) advocacy for the implementation of currently available tools, as well as for more research and development into better adapted tools for the management of TB in children.

Drawing on our experience within the TACTiC project, in this article we describe challenges in the management of TB in children with undernutrition and steps toward improvement. 

Informed by new evidence, in 2022 WHO issued new recommendations that offer an opportunity to make a real positive impact on TB management amongst children suffering from undernutrition (WHO, 2022a). Several recommendations stand out in their potential to revolutionise the approach to care for this vulnerable demographic.

Use of treatment decision algorithms

Firstly, WHO recommends the use of treatment decision algorithms (Figure 1) to facilitate clinical decision making and rapid initiation of TB treatment for children aged under 10 years with pulmonary TB. There are two algorithms, one for use where chest X-ray is available and one where it is not (Figure 1). A key feature of the algorithms is the fast-tracking of treatment initiation for children with highest risk of mortality, including those presenting with severe wasting as well as children aged under two years and those living with HIV. The algorithms include a scoring system that uses clinical signs and symptoms, and X-ray findings if available, to decide on treatment initiation. Although laboratory testing for TB is encouraged, even if testing is unavailable or a negative result is obtained this does not hinder starting treatment based on clinical symptoms alone. The algorithms are also designed to encourage repeated assessment when indicated. WHO made an interim recommendation on the use of these algorithms (WHO, 2022b). MSF is among the organisations answering the WHO call for operational research documenting their use in real-life settings.

Figure 1. WHO’s algorithm B* (page 74, WHO 2022b) for children <10 years of age for settings without X-ray.

*Algorithm A (not depicted) is for settings with chest X-ray. ‘mWRD’ and ‘LF-LAM’ are different laboratory tests. 

Data from MSF projects implementing the WHO-recommended treatment decision algorithms in therapeutic feeding programmes have shown a 1.5- to five-fold increase in the number of children with severe wasting diagnosed with TB. Preliminary results from an ongoing MSF study on implementation of the algorithms in five African countries show that up to 80% of children diagnosed with TB are diagnosed via the algorithm’s clinical score rather than laboratory test results. This applies whether using the algorithm with or without chest X-ray. 

These results emphasise the importance of clinical decision making when deciding whether to treat children for TB. They also illustrate how the algorithms facilitate the decision to treat TB in undernourished children, even without access to X-ray or laboratory testing, or in the case of negative results (which can be expected in children with wasting).

Reducing the duration of TB preventive treatment 

WHO recommends a short three-month treatment to prevent the development of TB disease among children who are likely to have been infected by TB by living in the same household as a person affected by TB disease. This preventive treatment can reduce the number of children developing TB disease. The short duration and the availability of new child-appropriate drug formulations for all ages should have an important impact on their scale-up (WHO, 2024b).

Food assistance for household contacts of TB

In 2024, WHO convened a Guideline Development Group to review available data on TB and undernutrition. The updated version of WHO’s 2013 recommendations on TB and nutrition (WHO, 2013) is expected in early 2025. Data from the RATIONS trial in India found that food assistance to all household contacts of a TB case reduced the number of people in the household who developed TB disease (Bhargava et al, 2023).

Integrated protocols, guidance, and decision making

To effectively manage paediatric TB and undernutrition, collaboration between nutrition and TB services is essential. This can be facilitated by the harmonisation of guidance documents, in particular the inclusion of TB treatment decision algorithms in national guidelines for the management of wasting. Clear guidelines that dictate the appropriate contexts and circumstances for utilising treatment decision algorithms will ensure a streamlined diagnostic process rather than additional workload. This includes creating pre-screening questionnaires and decision trees tailored for busy healthcare environments, enabling healthcare workers to more efficiently identify at-risk children and refer or initiate TB treatment when indicated.

In the long term, integration of TB and nutrition services into national health programmes will ensure that management of both TB and undernutrition in children is aligned with broader health goals. Advocacy aimed at making TB a priority within national health agendas is critical for mobilising the resources and attention necessary for comprehensive care.

Improving capacity of healthcare workers

Increasing the clinical capacity of healthcare workers in general paediatric care as well as the clinical overlap between TB and undernutrition is crucial for improving diagnostic accuracy. Capacity-building initiatives can empower frontline health workers to navigate the various illnesses that affect vulnerable young children and to acquire the competencies to recognise the often-subtle signs of TB in malnourished children. 

Community engagement and awareness

Community engagement plays a vital role in reshaping perceptions around TB and undernutrition, and enhancing TB awareness within communities can reduce stigma and promote early healthcare-seeking behaviour among families. Hearing from communities on how to best tailor TB services to their needs can also contribute to improved treatment experiences and results. 

Utilising peer support groups and community health workers can facilitate education and support for families grappling with the compounded challenges of TB and undernutrition. Empowering families with knowledge about the risks and symptoms of TB can lead to timely interventions and increased adherence to treatment, including preventive treatment.

Improved monitoring and evaluation

Implementing effective strategies requires ongoing monitoring and evaluation to assess the impact of integrated care interventions on health and nutrition outcomes for children with TB and undernutrition. Continuous feedback loops integrating children and their families, healthcare workers, and policymakers will enable all stakeholders to refine their approaches based on real-time data, enhancing both programme efficacy and responsive resource allocation.
Data collection on paediatric TB cases in undernourished populations should be prioritised, allowing for a better understanding of the epidemiological trends and disease burden. By leveraging technology such as digital health tools, stakeholders can streamline reporting processes and enhance data accessibility, promoting a culture of transparency and accountability.