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Johns Hopkins-Led Program Significantly Reduces Childhood TB in India

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Johns Hopkins-Led Zero TB in Kids Program Dramatically Reduces TB in Schoolchildren

A prospective analysis of the first eight years of the Johns Hopkins Medicine-led Zero TB in Kids program has shown that significant reductions in tuberculosis (TB) transmission and burden among schoolchildren in high-burden areas can be achieved using existing TB screening, treatment, and follow-up protocols. This groundbreaking study, funded by the federal government's National Institute of Allergy and Infectious Diseases (NIAID), was recently published in The Lancet Regional Health – Southeast Asia.

Program Implementation and Unique Impact

Since 2017, the Zero TB in Kids program, which includes comprehensive TB screening and tuberculosis preventive treatment (TPT), has been implemented in northern India. The program focuses on Tibetan refugee schoolchildren residing in congregate settings such as schools, monasteries, and nunneries.

Kunchok Dorjee, M.D., Ph.D., project director and principal investigator of Zero TB in Kids, noted the program's significance. He highlighted that previous studies demonstrating meaningful population-level TB reduction from large-scale screening and TPT programs were not identified, making these findings particularly impactful.

Striking Reductions Achieved

The program's efforts between 2017 and 2024 yielded remarkable results:

  • An 83% reduction in TB incidence among children.
  • A 32% reduction in the prevalence of latent TB infection among children.
  • After just one round of screening and TPT, the occurrence of new TB infections declined by 59% in the child population.

Significantly, the prevalence of TB disease also declined in participants who did not receive TPT, indicating an overall reduction of TB transmission across the entire population. These achievements stand in stark contrast to the approximate 2% annual reduction in global TB rates.

Understanding Latent TB and Overcoming Challenges

Latent TB infection occurs when an individual acquires the Mycobacterium tuberculosis bacterium but does not exhibit symptoms and can still transmit it.

Despite the program's success, it faced challenges, notably from the COVID-19 pandemic. The pandemic initially caused a resurgence of TB conversions and disease among schoolchildren. However, declines returned once screening and TPT resumed in 2024, demonstrating the program's resilience and effectiveness.

Another observed challenge involved participants with comorbidities. Those with seizures and hepatitis B were less likely to receive TPT during the study period. Researchers believe this was due to physicians' uncertainty or lack of confidence in TPT for these groups, or concerns about potential liver toxicity or drug interactions.

A Blueprint for Global TB Control

Dorjee stated that the success of the Zero TB in Kids program offers a powerful message for global health:

"The success of the Zero TB in Kids program, which emphasizes community-led screening and TPT, demonstrates that rapid and sustained reduction of TB transmission and impact in high TB burden areas is possible with optimized use of existing medications, tools, and protocols for TB control."

Key Recommendations

Based on these compelling findings, the researchers put forth three critical recommendations for advancing global TB control efforts:

  • A shift in global TB control to emphasize surveillance of TB infections and TPT implementation.
  • Mass screenings and TPT should be conducted across schools and other congregate settings in high TB burden areas to accelerate TB elimination in children and adolescents.
  • Guidelines are needed to implement TPT in people with comorbidities, such as hepatitis B and seizures, for improved uptake and acceptance of TPT.