Tibetan Refugee Children Suffer High Rates of Tuberculosis

Although tuberculosis is preventable and curable, it remains one of the top 10 causes of death worldwide. Furthermore, despite widespread eradication and treatment efforts, incidence of the disease has only fallen about 2% per year, which is well below the necessary reduction to meet the 2020 World Health Organization milestone. In 2017, 1.6 million people died from tuberculosis, including 230,000 children. Now, investigators on a new study have found that in Tibet, 1 in 5 children has the disease.

The investigators, from Johns Hopkins Medicine and the University of Wisconsin, found these troubling results among Tibetan refugee schoolchildren during their screening and treatment initiatives in northern India. The initiative, Zero TB Kids, found a dangerous high prevalence of tuberculosis, both active and latent, in children in Himachal Pradesh, India.

From April 2017 to March 2018, investigators screened 5391 schoolchildren and 786 staff across 11 Tibetan schools (7 boarding and 4 day schools). The screening algorithm for tuberculosis included symptoms, chest radiography, molecular diagnosis, and tuberculin skin tests. Patients found to have active tuberculosis and those with the bacteria but without disease were treated with isoniazid-rifampicin for 3 months.

The majority of cases among the schoolchildren (66%) were subclinical; one of which was multidrug-resistant. A total of 46 cases were of active tuberculosis, while 930 were tuberculosis infection without disease (18%). A total of 334 of the 634 staff members (53%) were found to have tuberculosis without active disease, and 1 staff member had extensively drug-resistant tuberculosis.

Investigators provided those with active tuberculosis a 6-month course of antibiotics. A total of 799 of the 930 schoolchildren and 101 of 334 staff with tuberculosis infection were provided the 3-month course previously mentioned. Most of the schoolchildren (95%) were adherent to treatment and finished their regimen.

All medication was paid for by the Zero TB program with support from the Johns Hopkins Center for Tuberculosis Research. This is especially impressive considering the average cost to treat a patient is $1224 for drug-susceptible tuberculosis and $7141 for drug-resistant tuberculosis. These costs increase when treating patients in the United States, where treatment for tuberculosis is $19,000 and $164,000 for multidrug-resistant tuberculosis.

Follow-up examinations are underway for the schoolchildren and staff every 6 months and the program has been expanded to Tibetan refugees living in monasteries and nunneries in the area.

The findings are particularly worrisome as they reveal a high prevalence of tuberculosis among displaced Tibetans. Many Tibetans fled Tibet after the Chinese invasion in the 1950s, moving to India where previous tuberculosis immunity is unknown. The effects of displacement, a new environment, communal living in refugee areas, and a cold winter only furthered the spread of the disease.

Understanding these risks for disease transmission is critical for global health security efforts, especially as there over 68 million individuals displaced worldwide. Public health and strong community surveillance and treatment efforts are critical to combat these infectious disease threats and provide refugees with adequate health care resources.