Sierra Leone: New approach radically improves diagnosis and treatment of children with TB

“I left my village and brought my son here because he was not getting better,” says Aruna, father of three-year-old Augustine. “He was losing weight and coughing a lot. He sweats throughout the night – I have to get up and wipe his sweat away. He is my youngest child; I am scared to see him like this.” 

Augustine was diagnosed with tuberculosis (TB) at Makeni regional hospital in Sierra Leone’s Bombali district, which is supported by Médecins Sans Frontières/Doctors Without Borders (MSF). Alongside TB treatment, he is being fed specially formulated therapeutic milk to treat severe malnutrition. “Since he was admitted the nurses have only been feeding him milk,” says Aruna.  

When children are under-nourished, their immune systems are compromised, putting them at heightened risk of developing TB. Malnutrition is a problem countrywide, making it even more important to be alert to the signs of TB in children. 

However, diagnosing TB in young children is particularly challenging, since it can be very difficult for them to produce sputum (mucus expelled from the respiratory tract) – the traditional way of diagnosing TB in the lungs, known as pulmonary TB. In addition, TB in children, more often than in adults, can be located outside the lungs – a condition known as extrapulmonary TB. Getting samples and accurate diagnostic results for extrapulmonary TB is even more challenging.    

 MSF has been working with Sierra Leone’s Ministry of Health through the National Leprosy and Tuberculosis Control Programme (NLTCP) since 2020, where one of its main focuses is to improve the diagnosis and treatment of TB in children. Its teams work in Makeni hospital and 12 Directly Observed Therapy (DOT) sites located in clinics across Bombali district.  

In 2022, MSF started implementing the use of new tools to help diagnose TB, in line with the newly released guidelines from the World Health Organization. These guidelines include ‘treatment decision algorithms’ using stool samples for molecular testing, or urine samples for children living with HIV. The team have also set up an efficient sample transportation system from the 12 DOT sites to the laboratory at Makeni hospital, where the samples undergo molecular testing.  

“We treated a three-year-old patient for TB but, after completing her treatment, her mother brought her back because she had TB symptoms again," says MSF nurse Umu Amara, who works at Makeni hospital. "We did a stool test for the child and the results were still negative for TB. Because she showed all the signs of TB and she was living with HIV, we did the urine test, and the results showed she had TB." 

  As with Augustine, an alarming number of children under five being treated for TB are found to be severely malnourished. MSF’s team in Bombali district also provides malnutrition treatment as part of its paediatric TB programme. 

When patients come for a consultation at one of the DOT sites across the Bombali district, the progress of their treatment is checked and their TB medicine prescriptions are refilled. Malnourished children also receive supplies of ready-to-use therapeutic food – sachets of peanut paste enriched with vitamins and minerals used to prevent and treat malnutrition – which they can eat at home. This reduces the number of consultations patients must attend, which is crucial in places where the closest heath facility is a two-hour journey away. 

“By using the new tools available, by bringing treatment closer to patients, and also by providing nutritional support in the DOT sites to children who are undernourished, we have been able to enrol and successfully treat significantly more patients,” says MSF medical team leader Jobin Joseph.  

“I really miss my school and my friends,” says 14-year-old Fatmata, who is being treated for TB. “As soon as I get well, I will go back to school.” Fatmata was brought to Makeni hospital by her grandmother after she developed symptoms and was quickly diagnosed with TB. Due to the long course of treatment, which takes around six months, children like Fatmata often face prolonged periods away from school. Many also find themselves isolated from their communities due to continuing stigma around the disease.   

In 2023, a total of 2,148 people with drug-sensitive TB (which can be treated with first-line anti-TB drugs) were enrolled in the TB programme in Bombali district. After implementing the new diagnosis tools, the number of children under the age of 15 in the drug-sensitive TB programme increased substantially, from 31 in 2020 to 405 patients in 2023. 

“With the high number of TB cases in children that we see in Sierra Leone, it is clear that the NLTCP needs more support from the government and donors to scale up and replicate this successful TB diagnostic and treatment model throughout the country,” says MSF medical coordinator Dr Kennedy Uadiale. “Therapeutic feeding programmes should also be made available systematically at the DOT sites to promote better treatment outcomes.”