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WORLD HEALTH O RG AN IZATION
ORGANISATION MONDIAL E DE LA SANTE
DOTS Expansion Working Group
Annual meeting of the Childhood TB Subgroup
La Maison des Polytechniciens
Paris, France, 14 October 2008
Meeting Report
Background
Despite recent developments in childhood TB and issuing the international policy guidelines
on the management of tuberculosis in children (2006 publication "Guidance for national
tuberculosis programmes on the management of tuberculosis in children"
http://whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.371_eng.pdf ), many National
Tuberculosis Programmes (NTPs) do not systematically include the management of children
with TB as part of their routine operations. For the last two years, the childhood TB subgroup
has been promoting the implementation of the guidelines in high TB burden countries through
technical assistance to NTPs and working in close collaboration with other relevant groups of
the Stop TB Partnership, including the DOTS Expansion Working Group, the MDR-TB
Working Group and the TB/HIV Working Group.
This fifth annual meeting of the childhood TB subgroup was held on 14 October 2008 in Paris,
France. The meeting was divided into two parts. The morning session discussed country-level
experience in policy implementation. The afternoon session focused on new developments in
the field of childhood TB.
The meeting was widely attended by the members of the subgroup, NTP managers and other
representatives from 22 high TB burden countries, technical partners and WHO staff.
This report outlines the main issues discussed during the meeting. The agenda appears in
Annex 1 and the list of participants in Annex 2. All the presentation from the meeting are
available and will be circulated to the meeting participants on a CD.
1. Progress report by Robert Gie, chairperson of the childhood TB subgroup.
In the past year the childhood TB subgroup was involved in several initiatives:

Consultation meeting of the group of paediatric experts, organized by WHO in July 2008,
during which the literature review of the pharmacokinetics of isoniazid, rifampicin and
pyrazinamide was discussed. As a result of this consultation, the group recommended



changes to the current drug doses of the above first line drugs and identified future research
areas. A soon as the new dosing is included in the WHO's Essential Drug List, the
"Guidance for national tuberculosis programmes on the management of tuberculosis in
children" will need to be revised.
A workshop coordinated by Penny Enarson and chaired by Robert Gie was convened at the
International Union Against Tuberculosis and Lung Disease (The Union) office in Paris to
discuss and review a draft document on the prevention, diagnosis and treatment of
tuberculosis in HIV-infected children.
Several TB programme reviews included childhood TB issues and technical assistance was
provided to Myanmar, Indonesia, Philippines and Cambodia in developing national
guidelines for management of TB in children.
Participation in the revision of the International Standards for TB Care (ISTC), workshop
organized by the Retooling Task Force and revision of the BCG vaccination guidelines.
Dr Gie also listed main challenges in the field of childhood TB and needs for training in high
burden countries.
2. Three country reports on childhood TB activities
Philippines - presented their experience in developing national guidelines on management of
TB in children - collaborative work between the national TB programme (NTP), Philippine
Paediatric Society and the multiple partners working in TB control.
Integrating childhood TB with HIV - the Malawi experience. The presentation emphasized the
importance of prompt initiation of TB treatment in HIV-infected children with confirmed or
presumptive TB disease and the challenges in initiating the ART after starting TB treatment.
The following issues need to be taken into account: child’s age, pill burden, potential drug
interactions, overlapping toxicities and possible IRIS.
Challenges of managing a child with MDR-TB - presented by Romania listed the difficulties
with the diagnosis (TB in children is rarely culture positive), treatment with 2nd line drugs
(drug formulations are inadequate for paediatric dosing), psychological and educational
problems of children undergoing a very long therapy, sometimes in in-patient conditions.
3. BCG: new considerations for an old vaccine in HIV-endemic settings
Anneke Hesseling presented the new considerations that need to be taken into account before a
BCG vaccine is administered to neonates in high HIV prevalence setting. In view of the recent
findings, mostly from research in South Africa, WHO has revised the BCG vaccination
guidelines for infants at risk for HIV infection.
The revised guidelines can be uploaded from the WHO website.
http://www.who.int/wer/2007/wer8221.pdf
Update from the "Expert group meeting on the dosing of childhood TB medicines" and
proposed next steps on practical implementation of new recommendations
Peter Donald presented the results of the literature review looking at evidence from studies on
pharmacokinetics of three anti-TB drugs (isoniazid, rifampicin and pyrazinamide) in adults and
children. The findings of the review suggest that there is a need for higher dosages in children
to achieve serum concentrations comparable to those in adults.
These findings were presented and discussed at the paediatric expert group meeting organized
by WHO in July 2008. The group recommended an increase of dosing as follows:
 The dose of Pyrazinamide in children above 3 months of age should be 35 mg/kg
(range 30-40) per day. The maximum daily dose should not exceed the recommended
adult daily dose.
 The dose of Isoniazid in children above 3 months of age for treatment or prophylaxis
(treatment of latent TB infection) should be 10 mg/kg (range 10-15) per day. The
maximum daily dose should not exceed the recommended adult daily dose.
 The dose of Rifampicin in children above 3 months of age should be 15 mg/kg (range
10-20) per day. Dosages at higher ranges may be preferable for children under 10 kg
and children with HIV infection or malnutrition. The maximum daily dose should not
exceed the recommended adult daily dose.
The recommendations from this technical meeting were presented to the STB department at
WHO which decided that there is a need to update of the treatment guidelines for children
(2006 document "Guidance for national tuberculosis programmes on the management of
tuberculosis in children"). Another consequence is the need to develop new formulations of the
fixed-dose combinations (FDC) that would be appropriate for the treatment of children.
A full report from that meeting is available at WHO website.
http://www.who.int/selection_medicines/committees/subcommittee/2/TB.pdf
Update on the activities of the Retooling Task Force was presented by Davide Manissero.
The Retooling Task Force was established by the Stop TB Partnership's Coordinating Board in
2006 to plan for adoption and introduction of new tools (vaccine, diagnostics and drugs) in
high TB burden countries. The presenter summarized the activities and plans of the task force.
More information is available at the Stop TB website http://www.stoptb.org/retooling/
Update on the revision of ISTC - reported by Davide Manissero
The International Standards for TB care (ISTC) are undergoing revision to harmonize the
document with WHO guidelines and include all new developments in diagnosis and treatment.
In order to promote Childhood TB within the ISTC, it was decided that Standard 6 becomes the
‘single’ childhood diagnostic standard, incorporating references to pediatric diagnosis found in
other standards. With regard to treatment, new drug dosing will be addressed. The discussion
on treatment of LTBI will be broadened to include HIV - infected patients and other immunecompromising conditions.
Update from the childhood TB - TB/HIV meeting - by Penny Enarson and Lulu Muhe
A 3-day workshop was organized where different stakeholders discussed the draft guideline on
the diagnosis and treatment of HIV+ children suspected of having TB. Participants represented
leading agencies and included HIV experts, childhood TB experts, expert pediatricians, clinical
researchers, appropriate staff from NTPs and NAPs in high HIV prevalent settings. After the
workshop a writing team was established to re-draft the guidelines after which they will be
disseminated for review, including to all members of the Stop TB Partnership's childhood TB
subgroup. The draft will also be reviewed against existing WHO guidelines and any new
recommendation will require grade profiling to take into account the quality of evidence, trade
off between benefits and harms, costs, values and preferences and feasibility of implementation.
The final guideline will become available in the 2nd quarter of 2009.
Proposal to establish a Core-team, participation in other constituencies and next year
planning
The Secretariat and the Chair are receiving an increasing number of requests for technical
assistance from high burden countries as well as a growing number of requests for plans,
reports, slides, etc. from the DEWG and the Stop TB Partnership. In addition, the sub-group
needs to be represented at different constituencies (other working groups and task-forces)
At the same time the size of the sub-group has increased to incorporate more members from
the national TB programmes. All of the above have mad the work of the Chair and the
Secretariat difficult and time consuming.
The Chair and the Secretariat proposed that a core-tem be established with the below suggested
terms of reference:
 Assist with the preparatory work for the annual meeting of the Childhood TB sub-group.
 Assist with the preparatory work for the bi-annual plan of activities and reports to the
DEWG and the Stop TB Partnership.
 Hold regular conferences, usually by telephone, to assist faster decision making related to
the sub-group activities.
 Assist in preparing joint missions in support of countries in need of technical assistance on
behalf of the sub-group.
 Ensure a clear approach to country assistance whereby a technical agency is identified to
coordinate external assistance.
 Identify gaps in country technical assistance and develop plans to fill the gaps.
The proposed composition of the core-team was presented and discussed. It was agreed that the
core-team will consist of:
 Eight members, of which two are permanent
o Chair of the sub-group
o Secretary of the sub-group
 Other non-permanent core-team members will be serving for 2 years (with a possible
renewal for 2 more terms of 2 years) or alternatively 3 years (with a possible renewal for 1
more term of 3 years) and they will represent:
o Technical agency - 2 members
o Donor agency - 1 member
o Country representatives - 2 members
o Civil society representative - 1 member
If and when necessary, ad-hoc members will be invited to join to work on specific topics as
identified by the core-team.
In order to start all necessary arrangements, it was proposed that an interim core-team be
shortly established (with a timeline of 6 months) in order to oversee a formal process of
selecting the permanent core-team. CDC volunteered to be part of that interim core team.
The Secretariat will circulate an email to all sub-group members on the above process.
The representation of the sub-group in other constituencies was discussed.
Anneke Hesseling will attend the meeting of FIND to better understand the requirements for
childhood TB subgroup.
Tony Harries will be representing the sub-group in the TB/HIV working group (as he already is
a member of the TB/HIV core team).
Davide Manissero will continue representing the sub-group in the Retooling Task Force and
the ISTC revision committee.
Ana Bierrenbach and Ikushi Onozaki will represent the sub-group in the Impact Measurement
Task Force.
The sub-group also started planning for next year's annual meeting.
Two options were considered:
 Cancun , Mexico, December 2009 (before the Union's Annual Conference) or
 Prior to DEWG meeting (September- October 2009). This second option would facilitate
the attendance of NTP managers from 22 high burden countries)
The secretariat will circulate an email to the subgroup later in the year when the dates and
venue for the DEWG meeting will be available.
Finally, the bi-annual planning should start early 2009 and will be pursued by the interim coreteam.
Annex 1: Agenda
8:30 - 9:00
Registration
All
Childhood TB sub-group members and NTP managers from 22 HBC
9:00 - 9:15
Opening, welcoming words to the subgroup
members and NTP managers
Chair, Robert Gie
9:15 - 9:30
Report from Chair on sub-group activities since the
last meeting
Robert Gie
9:30 - 10:45
Country reports on childhood TB activities

Development of childhood TB guidelines
Cleotilde Hidalgo How,
Philippines

Integrating childhood TB with HIV
Charles Mwansambo,
Malawi

Challenges of managing a child with MDR-TB
Adriana Sorete-Arbore,
Romania
10:45 - 11:00
Coffee break
11:00 - 11:30
Discussion
11:30 - 12:00
BCG: new considerations for an old vaccine in
HIV-endemic settings
12:00 - 12:15
Discussion
12:15 - 12:30
Next steps on childhood TB activities at country
level
12:30 - 14:00
Lunch break
Anneke Hesseling,
South Africa
Chair and All
Childhood TB subgroup members
14: 00 - 14:30
Update from the "Expert group meeting on the
dosing of childhood TB medicines" and proposed
next steps on practical implementation of new
recommendations
Peter Donald
14:30 - 14:45
Questions and discussion
14:45 - 15:00
Update on the activities of the Retooling Task
Force
Davide Manissero
15:00 - 15:30
Update on the revision of ISTC
Davide Manissero
15:30 - 15:45
Discussion
15:45 - 16:00
Coffee break
16:00 - 16:30
Update from the childhood TB - TB/HIV meeting
Penny Enarson
Lulu Muhe
16:30 - 16:45
Discussion
16:45 - 17:00
Proposal to establish a Core-team
Malgosia Grzemska/
Robert Gie
17:00 - 17:30
Summary, plans for next meeting, etc
Chair, Robert Gie
Annex 2: List of participants
Childhood TB subgroup members
1.
Professor Robert GIE - Chair of the Subgroup
Department Head
Department of Paediatrics & Child Health
University of Stellenbosch, Faculty of Medicine
P.O. Box 19063, 7505 Tygerberg, South Africa
Tel: +27 21 938 9444; Fax: +27 21 938 9138
Email: [email protected]
2.
Professor Valentina AKSENOVA
Head, Laboratory on Prevention
Diagnosis and Treatment of Tuberculosis in Children and Adolescents
Research Institute of Phthisiopulmonology I.M. Sechenov Moscow Medical Academy
4 Dostoievsky Str., 101478 Moscow, Russian Federation
Tel: +7 495 681 8422 (institute) and +7 495 681 9236 (pediatric department )
+7 495 631.1112
Email: [email protected] and [email protected]
3.
Dr Lucia ALVAREZ HERNANDEZ
Paediatric Infectious Diseases
Coordinator Standards for Tuberculosis Care Union and
Centro Nacional de Vigilancia Epidemiologica y control de enfermedades (CENAVECE)
Calle Chihuahua No 228 Colonia Roma Codigo, Postal 06700, Delegación Cuauhtémoc
Mexico Distrito Federal, Mexico
Tel: 52 64 0026 or 25 14 64 36 or 56 52 6262 or 6263
Mobile: +44 55 29 55 34 95
Email: [email protected]
4.
Professor Peter DONALD
University of Stellenbosch
Western Cape
Tygerberg 7505, South Africa
Email: [email protected]
5.
Ms Penny ENARSON
Head, Child Lung Health Division
International Union Against Tuberculosis & Lung Disease (The Union)
68 Blvd St Michel, 75006 Paris, France
Tel: +33 1 56 80 28 25; Fax: +33 1 44 29 90 87
Email: [email protected]
6.
Ms Deliana GARCIA
Migrant Clinicians Network
P.O. Box 164285, Austin, Texas, 78716-4285, USA
Email: [email protected]
7.
Dr Steven GRAHAM
Centre for International Child Health
University of Melbourne Department of Paediatrics
Royal Children's Hospital Melbourne
Flemington Rd, Parkville, VIC 3052, Australia
Tel: +61 3 9345 4788 and +61 3 9345 5522 (Switchboard)
Fax: +61 3 9345 6667
Email: [email protected]
8.
Dr Anthony D. HARRIES
Senior Advisor
International Union Against
Tuberculosis & Lung Disease (The Union)
68 Blvd St Michel
75006 Paris, France
Email: [email protected]
9.
Dr Anneke C. HESSELING
Senior Researcher
Desmond Tutu TB Centre
Department of Paediatrics and Child Health, Faculty of Health Sciences
Stellenbosch University, Room 0084 Clinical Building
PO Box 19063, Francie van Zijl Drive, Tygerberg, 7505, South Africa
Tel: +27 21 9389173; Fax: +27 21 9389179
Email: [email protected]
Address for correspondence
Old Inn Cottage,
Vears Lane,
Colden Common,
Winchester SO21 1TQ, UK
Phone: + 44 1962 714 297
10. Professor Cleotilde HIDALGO HOW
Professor, Department of Pharmacology & Toxicology
University of the Philippines (UP) College of Medicine
547 Pedro Gil Street, Ermita 1000
Manila, Philippines
Tel: +63 2 526 4248; Fax: +63 2 521 8251
Email: [email protected]
11. Dr Mamodikoe MAKHENE
Medical Officer
TB Section
Division of Microbiology and Infectious Diseases
National Institute of Allergy and Infectious Diseases, National Institutes of Health
6610 Rockledge Dr Room 5043, MSC 6604
Bethesda, MD 20892, USA
Tel: +301-496-5305
Fax: +301-496-8030
Email: [email protected]
12. Dr Davide MANISSERO
Unit of Scientific Advice
European Centre for Disease Prevention and Control
Tomtebodavagen 11A
S-171 83 Stockholm, Sweden
Tel +46 8-58-60-1218; Mobile: +46 761251637
Fax +46 8-58-60-1001
Email: [email protected]
13. Dr Heather MENZIES
Centers for Disease Control and Prevention
International Research and Programs Branch
Division of Tuberculosis Elimination
National Center for HIV, STD, and TB Prevention
1600 Clifton Rd, MS E-10
Atlanta, GA 30333
Tel: 404-639-8488
Fax: 404-639-1566
Email: [email protected] and [email protected]
14. Dr Charles MWANSAMBO
Head, Department of Paediatrics
Lilongwe Central Hospital
P.O. Box 149, Lilongwe, Malawi
Tel: +265 (0) 1 753 555; Fax: +265 (0) 1 756 380
Email: [email protected]
15. Dr Clydette POWELL
Medical Officer
Bureau for Global Health
Office of Health, Infectious Disease, and Nutrition
Division of Infectious Disease
US Agency for International Development (USAID)
RRB - GH/HIDN/ID 3.7.82
1300 Pennsylvania Ave, NW
Washington, D.C. 20523-3700, USA
Tel: +1 202 712 0027; Fax: +1 202 216 3702
Email: [email protected]
16. Dr Mary REICHLER
Division of Tuberculosis Elimination
Centers for Disease Control and Prevention (CDC)
Tel: 001 404 639-5350
Fax: 001 404 639-8961
Email: [email protected] and [email protected]
17. Dr Adriana SORETE ARBORE
County Manager
Clinic of Pulmonary Diseases
30-nth, Dr. I. Cihac Street
Iasi, 700115, Romania
Tel direct : +40 0744 647980 and Tel.hospital: +40 0232 239408
Fax hospital : +40 0232 270918
Email: [email protected]
18. Dr Fraser Douglas WARES
Medical Officer WHO India
New Delhi, India
Tel cell: +919810146323, other tel numbers +91 11 23061922, 23061923, 23061926,
Email: [email protected]
19. Dr Carol J. WORRELL
Medical Officer
Pediatric, Adolescent, and Maternal AIDS Branch
Center for Research for Mothers and Children
National Institute of Child Health and Human Development
National Institutes of Health
6100 Executive Boulevard, Room 4B11F
Bethesda, MD 20892-7510, USA
Tel: +301-435-6842; Fax. +301-496-8678
Email: [email protected]
WHO Secretariat
20. Dr Malgosia GRZEMSKA - Secretary to the subgroup
Medical Officer, Stop TB Department
World Health Organization, 1211 Geneva 27, Switzerland
Tel: +41 22 7913989; Fax: +41 22 7914706
Email: [email protected]
21. Dr Ana BIERRENBACH
Epidemiologist, Stop TB Department
World Health Organization, 1211 Geneva 27, Switzerland
Tel: +41 22 791 1248
Email: [email protected]
22. Dr Léopold BLANC
Coordinator, TBS/Stop TB Department
World Health Organization, 1211 Geneva 27, Switzerland
Tel: +41 22 791 4266
[email protected]
23. Dr Christian GUNNEBERG
Medical Officer, Stop TB Department
World Health Organization, 1211 Geneva 27, Switzerland
Tel: +41 22 791 2732;
Email: [email protected]
24. Dr Lulu Mussa MUHE
Medical Officer, Child and Adolescent Health and Development (CAH)
World Health Organization, 1211 Geneva 27, Switzerland
Tel: 41 22 791 3988
Email: [email protected]
25. Dr Ikushi ONOZAKI
Medical Officer, Stop TB Department
World Health Organization, 1211 Geneva 27, Switzerland
Tel: +41 22 791 2583
Email: [email protected]
26. Dr Salah OTTMANI
Medical Officer, Stop TB Department
World Health Organization, 1211 Geneva 27, Switzerland
Tel: +41 22 791 3923
Email: [email protected]
NTP Managers and country representatives who attended the meeting
27. Bangladesh
Dr Abdul Awal MIAH
[email protected]
28. Bangladesh
Professor Pravat Chandra BARUA
Line Director, NTP
[email protected]
29. Brazil
Dr Draurio BARREIRA
[email protected]
30. Cambodia
Dr MAO TANG EANG
[email protected]
31. China
Dr WANG Lixia
[email protected]
32. Democratic Republic of the Congo
Dr André Okumu NDONGOSIEME
[email protected]
33. Ethiopia
Mr Bekele CHAKA
[email protected]
34. Mozambique
Dr Paula SAMO GUDO
[email protected] and [email protected]
35. Mozambique
Dr Z. Cuna
MOH Mozambique
[email protected]
36. Mozambique
Dr Matilde Basiliog
Association national for Nurses Mozambique
[email protected]
37. Mozambique
Prof Dr Elizabete Nunes
Association Medical de Mozambique
[email protected]
38. Myanmar
Dr WIN MAUNG
[email protected]
39. Nigeria
Dr Betrand ODUME
[email protected]
40. Philippines
Dr Rosalind VIANZON
[email protected]
41. Russian Federation
Dr Elena SKACHKOVA
[email protected]
42. Russian Federation
Professor Yulia MIKHAILOVA
[email protected]
43. United Republic of Tanzania
Dr Saidi EGWAGA
NTLP Manager
[email protected]
44. United Republic of Tanzania
Dr Fred Lwilla
NTLP
[email protected]
45. Thailand
Dr Sriprapa NATENIYOM
[email protected] and [email protected]
46. Viet Nam
Dr DINH NGOC SY
[email protected] and [email protected] and [email protected]
47. Zimbabwe
Dr Charles SANDY
[email protected]
Other attendants:
Technical Partners
48. Dr René L'Herminez
Consultant, KNCV Tuberculosis Foundation
P.O. Box 146, 2501 CC The Hague, The Netherlands
Tel. +31 70 416.7250
[email protected]
49. Dr Bonita Mangura
Professor of Medicine
New Jersey Medical School, Global Tuberculosis Institute
225 Warren Street, 2nd Floor, East Wing
P.O. Box 1709, Newark, NJ 07101-1709, USA
Phone: 973-972-3270 Fax: 973-972-3268
[email protected]
50. Dr David McNeele
Tibotec, USA
Phone: +1 609 730.7556
Email: [email protected]
51. Dr Nauman Safdar
Association for Social Development
Pakistan
[email protected]
WHO regional and country staff
AFR
52. Dr Bah Keita
Regional Adviser TB
World Health Organization
Regional Office for Africa
Congo - Brazzaville
Cell: +242 765.4550
Email: [email protected]
53. Dr Wilfred Nkhoma
WHO regional Office for Africa
Harare, Zimbabwe
[email protected]
54. Dr Abebe Eshetu
NPO/TB WHO Ethiopia
Cell: +251 912 014931
[email protected]
55. Dr Daniel Argaw
WHO Ethiopia
PO BOX 3069
Addis Abeba, Ethiopia
[email protected]
56. Dr Diriba Agegnehu
TB/HIV NPO, WHO Ethiopia
PO BOX 3069
Addis Abeba, Ethiopia
[email protected]
57. Dr Ayodele Awe
NPO/TB WHO Nigeria
World Health Organisation, Nigeria Country Office,
FCT, Abuja, Nigeria
Mobile: +234-8023144120, +234-8035250215
e mail: [email protected] , [email protected]
58. Dr Amos Omoniyi
WHO NPO TB/HIV, Nigeria Country Office, FCT, Abuja
[email protected]
59. Dr Mwendaweli Maboshe
NPO TB Zambia
Cell: +260 97872868
[email protected]
AMR
60. Dr Mirtha Del Granado
Regional Adviser TB
Pan American Health Organization/World Health Organization
525, 23rd Street, NW. Washington, DC 20037
[email protected]
61. Dr Rafael Lopez-Olarte
Medical Officer
Pan American Health Organization/World Health Organization
525, 23rd Street, NW. Washington, DC 20037
[email protected]
62. Dr Yamil Silva
Pan American Health Organization/World Health Organization
525, 23rd Street, NW. Washington, DC 20037
[email protected]
EUR
63. Dr Richard Zaleskis
Regional Adviser TB
World Health Organization
Regional Office for Europe
Scherfigsvej 8
DK-2100 Copenhagen Ø
Denmark
Tel: +45 39 171335
[email protected]
SEAR
64. Dr Firdosi Mehta
Medical Officer
WHO Indonesia
[email protected]
WPR
65. Dr Pieter van Maaren
Regional Adviser TB
World Health Organization
Regional Office for Western Pacific
Manila, Philippines
[email protected]
66. Mr Bernard Tomas
Technical Officer TB
World Health Organization
Regional Office for Western Pacific
Manila, Philippines
[email protected]
67. Dr Giampaolo Mezzabotta
Medical Officer
WHO Viet Nam
[email protected]
68. Dr Michael Voniatis
Medical Officer
WHO Philippines
[email protected]