Every parent knows about the battle to get toddlers to take their medication when they're ill. Imagine the same battle, each day for six months or more, except your child has tuberculosis (TB) and could die if they don't take their medication.
The medicine you're trying to give them isn't a teaspoon of strawberry-flavoured syrup, but a handful of chopped up bitter-tasting pills, made for adults. Paediatric formulations for tuberculosis drugs, are hard to come by.
The World Health Organisation (WHO) estimates that 140 000 children died of tuberculosis (TB) in 2014 – more than 380 a day.
Children respond well to treatment if the disease is diagnosed early. A paper published in the journal Clinical Infectious Diseases in 2010, found that at least 90% of children with ordinary (drug-susceptible) TB are cured. But it isn't always easy to get them to take their medicine.
"Some of the tablets taste very bad, and need to be crushed and broken. [If they have drug-resistant TB] there are also injections, which are painful. It's really not patient friendly," says Anneke Hesseling, the director of Stellenbosch University's Desmond Tutu TB Centre.
"The challenge is to make the treatment of children who have TB more family friendly. This would mean developing medicines that are easier to swallow, and making the treatment regimen shorter."
Paediatric formulations neglectedChildren with ordinary TB need to take medication for six months, but those with those with drug-resistant tuberculosis, for which the usual treatment often doesn't work, require 12 to 18 months of treatment, including six months of injections. These children also need to be admitted to hospital.
The development of paediatric formulations of TB drugs have been neglected, although new formulations are now starting to come on to the market.
The tuberculosis advocacy organisation TB Alliance is among those who have supported the development of paediatric formulations and are trying to make it more widely available. You can watch a video explaining the problem with paediatric dosing here:
"The medicines themselves are not new," says Hesseling, "but the individual medicines – rifampicin, isoniazid and pyrazinamide – are combined in one tablet, in a fixed-dose combination. The tablet is small, can be easily halved and dissolves in water, which is important for small babies."
The formulation is made by the Indian drug company, McCleods Pharmaceuticals, and Hesseling says it's hoped the tablet will soon be available for routine use in South Africa.
Trial for shorter treatmentA new trial, known as the "shorter treatment for minimal TB in children" (Shine), will look at whether doctors can shorten the treatment of drug-susceptible lung TB in children from the standard six-month regimen to four months, using a child-friendly combined tablet. The trial will be conducted in South Africa, Zambia, Uganda and India and will involve about 1 200 children.
But Hesseling says: "The most effective way to treat TB in children is to prevent it in the first place."
Children often get tuberculosis from family members, and, although there is evidence that you can prevent children from developing the illness by treating them with isoniazid for six months, the implementation of this therapy is still very poor, Hesseling says.
Taking TB treatment to the community
The avoidable scourge that is TB
TB diagnosis should start at home
The loss of their penises has ruined the lives of victims of traditional initiation schools in rural South Africa.
Former detainees tell of being denied chronic medication and contracting diseases like TB while incarcerated in the overcrowded Cape Town facility.
Rape and physical abuse rates more than double those reported in national studies have been recorded in Diepsloot in northern Johannesburg
Bhekisisa means "to scrutinise" in Zulu
In South Africa, Zulu patients who would like to be thoroughly assessed by a doctor, would ask the physician to "bhekisisa" them.