Pérez-Vélez has been studying TB in the port city of Buenaventura, Colombia, since 2006. According to Pérez-Vélez, drug-susceptible and drug-resistant TB in children is underdiagnosed and underreported, and efforts to combat it are therefore underfunded. TB in children is a “hidden epidemic” and a major neglected child health problem he suggested, especially in communities that are ill equipped to address the problem adequately.
Data typically include only microbiologically confirmed and mainly smear-positive cases, yet children frequently have extrapulmonary TB, which can be difficult to diagnose clinically and confirm bacteriologically and carries its own set of complications. There are two additional reasons why accurate information on the epidemiology of TB in children is limited: (1) the criteria for defining a case of TB in a child vary, and (2) of the four WHO criteria for diagnosing TB in children, two (PPD-tuberculin test and radiography) often are not available in resource-limited settings—those with the highest burden of TB.
Furthermore, until 2007 WHO typically grouped all children in one age category—ages 0–14—rather than analyzing them in more precise subgroups. Even today, WHO reports results only for ages 0–4 and 5−14, even though children aged 5−10 tend to develop TB at much lower rates, thus confounding the latter grouping. In countries with an intermediate burden of TB, including many Latin American nations, many regions have high-burden pockets of TB; when averaged with the TB notifications from low-burden regions, however, the high-burden areas effectively disappear and consequently receive little attention. Native Indians (Amerindians) are an example of a highly vulnerable population, with some reservations having incidence rates as high as 1,000 per 100,000 population and high mortality. Another group underrepresented in surveillance reports consists of peasants, including many children, displaced by civil wars and often living in camps.
Children also have traditionally been excluded from surveillance of TB drug resistance. In the report series Anti-Tuberculosis Drug Resistance in the World (WHO, 2008), children originally were not included, and when they were, age groups between 0 and 14 were combined. In many health policy meetings and clinical training courses, pediatric TB is not even on the agenda.
Pérez-Vélez suggested that children be divided into different age groups and that a strong effort be made to eliminate underreporting. To advocate
1 This section is based on the presentations of Carlos Pérez-Vélez, National Jewish Health and University of Colorado School of Medicine, Denver, Colorado; Dr. Shin; and Gary Reubenson, Rahima Moosa Mother and Child Hospital, South Africa.