Child Contact Screening Research Articles

Household costs incurred under community- and facility-based service-delivery models of tuberculosis preventive therapy for children: a survey in Cameroon and Uganda

Background Tuberculosis preventive treatment (TPT) in child household contacts is recommended by World Health Organization (WHO) but limited data has been reported on the costs experienced by households with children receiving TPT. Methods We evaluated the economic impact on households with children receiving TPT within a service-delivery model cluster-randomised controlled trial in Cameroon and Uganda. The intervention included community health worker-led home-based child-contact screening, TPT initiation and monitoring, and referral of children with presumptive tuberculosis or side effects, and was compared with each country’s facility-based standard of care (control). We used a retrospective cross-sectional survey adapted from the WHO Global task force on tuberculosis patient cost surveys. All costs were collected between February 2021 and March 2021 and are presented in 2021 US$. Results The median household costs estimated using the human capital approach were higher in the control arm ($62.96 [interquartile range, IQR; $19.78-239.74] in Cameroon and $35.95 [IQR; $29.03-91.26] in Uganda) compared to the intervention arm ($2.73 [IQR; $2.73-14.18] in Cameroon and $4.55 [IQR; $3.03-6.06] in Uganda). Using a threshold of 20% of annual household income, 15% (95%CI; 5-31%) of households in Cameroon and 14% (95%CI; 4-26%) in Uganda experienced catastrophic costs in the control compared to 3% (95%CI; 1- 8%) in Cameroon and 3% (95%CI; 1-8%) in Uganda in the intervention. Using the output-based approach to estimate income losses increased costs by 14-32% in the control and 13-19% in the intervention across the two countries. The proportion of participants experiencing any dissaving was higher in the control, 53% (95%CI; 36-71%) in Cameroon and 50% (95%CI; 31-69%) in Uganda, compared to 18% (95%CI; 10-29%) in Cameroon and 17% (95%CI; 8-28%) in Uganda in the intervention. Conclusions Households with child contacts initiated on TPT under a facility-based model incur significant costs. Community-based interventions help to reduce these costs but do not eliminate catastrophic expenditures. Registration https://clinicaltrials.gov/ct2/show/NCT03832023.

Community intervention for child tuberculosis active contact investigation and management: study protocol for a parallel cluster randomized controlled trial

BackgroundThere are major gaps in the management of pediatric tuberculosis (TB) contact investigation for rapid identification of active tuberculosis and initiation of preventive therapy. This study aims to evaluate the impact of a community-based intervention as compared to facility-based model for the management of children in contact with bacteriologically confirmed pulmonary TB adults in low-resource high-burden settings.Methods/designThis multicenter parallel open-label cluster randomized controlled trial is composed of three phases: I, baseline phase in which retrospective data are collected, quality of data recording in facility registers is checked, and expected acceptability and feasibility of the intervention is assessed; II, intervention phase with enrolment of index cases and contact cases in either facility- or community-based models; and III, explanatory phase including endpoint data analysis, cost-effectiveness analysis, and post-intervention acceptability assessment by healthcare providers and beneficiaries. The study uses both quantitative and qualitative analysis methods. The community-based intervention includes identification and screening of all household contacts, referral of contacts with TB-suggestive symptoms to the facility for investigation, and household initiation of preventive therapy with follow-up of eligible child contacts by community healthcare workers, i.e., all young (< 5 years) child contacts or older (5–14 years) child contacts living with HIV, and with no evidence of TB disease. Twenty clusters representing TB diagnostic and treatment facilities with their catchment areas are randomized in a 1:1 ratio to either the community-based intervention arm or the facility-based standard of care arm in Cameroon and Uganda. Randomization was stratified by country and constrained on the number of index cases per cluster. The primary endpoint is the proportion of eligible child contacts who initiate and complete the preventive therapy. The sample size is of 1500 child contacts to identify a 10% difference between the arms with the assumption that 60% of children will complete the preventive therapy in the standard of care arm.DiscussionThis study will provide evidence of the impact of a community-based intervention on household child contact screening and management of TB preventive therapy in order to improve care and prevention of childhood TB in low-resource high-burden settings.Trial registrationClinicalTrials.gov NCT03832023. Registered on 6 February 2019

Post-trial perceptions of a symptom-based TB screening intervention in South Africa: implementation insights and future directions for TB preventive healthcare services

BackgroundTuberculosis is a top-10 cause of under-5 mortality, despite policies promoting tuberculosis preventive therapy (TPT). We previously conducted a cluster randomized trial to evaluate the effectiveness of symptom-based versus tuberculin skin-based screening on child TPT uptake. Symptom-based screening did not improve TPT uptake and nearly two-thirds of child contacts were not identified or not linked to care. Here we qualitatively explored healthcare provider perceptions of factors that impacted TPT uptake among child contacts.MethodsSixteen in-depth interviews were conducted with key informants including healthcare providers and administrators who participated in the trial in Matlosana, South Africa. The participants’ experience with symptom-based screening, study implementation strategies, and ongoing challenges with child contact identification and linkage to care were explored. Interviews were systematically coded and thematic content analysis was conducted.ResultsParticipants’ had mixed opinions about symptom-based screening and high acceptability of the study implementation strategies. A key barrier to optimizing child contact screening and evaluation was the supervision and training of community health workers.ConclusionsSymptom screening is a simple and effective strategy to evaluate child contacts, but additional pediatric training is needed to provide comfort with decision making. New clinic-based child contact files were highly valued by providers who continued to use them after trial completion. Future interventions to improve child contact management will need to address how to best utilize community health workers in identifying and linking child contacts to care.Trial registrationThe results presented here were from research related to NCT03074799, retrospectively registered on 9 March 2017.

Provider attitudes about childhood tuberculosis prevention in Lesotho: a qualitative study

BackgroundThe World Health Organization estimated that 1.12 million children developed tuberculosis (TB) in 2018, and at least 200,000 children died from TB. Implementation of effective child contact management is an important strategy to prevent childhood TB but these practices often are not prioritized or implemented, particularly in low- and middle-income countries. This study aimed to explore attitudes of healthcare providers toward TB prevention and perceived facilitators and challenges to child contact management in Lesotho, a high TB burden country. Qualitative data were collected via group and individual in-depth interviews with 12 healthcare providers at five health facilities in one district and analyzed using a thematic framework.ResultsHealthcare providers in our study were interested and committed to improve child TB contact management and identified facilitators and challenges to a successful childhood TB prevention program. Facilitators included: provider understanding of the importance of TB prevention and enhanced provider training on child TB contact management, with a particular focus on ruling out TB in children and addressing side effects. Challenges identified by providers were at multiple levels -- structural, clinic, and individual and included: [1] access to care, [2] supply-chain issues, [3] identification and screening of child contacts, and [4] adherence to isoniazid preventive therapy.ConclusionsGiven the significant burden of TB morbidity and mortality in young children and the recent requirement by the WHO to report IPT initiation in child contacts, prioritization of child TB contact management is imperative and should include enhanced provider training on childhood TB and mentorship as well as strategies to eliminate challenges. Strategies that enable more efficient child TB contact management delivery include creating standardized tools that facilitate the implementation, tracking, and monitoring of child TB contact management coupled with guidance and mentorship from the district health management team. To tackle access to care challenges, we propose delivering intensive community health education, conducting community screening more efficiently using standardized tools, and facilitating access to services in the community.

Barriers to screening and isoniazid preventive therapy for child contacts of tuberculosis patients

India's guidelines recommend tuberculosis (TB) screening of household contacts aged <6 years and isoniazid preventive therapy (IPT) for children without active disease. We evaluated the current status and barriers to screening and IPT provision among the child contacts of TB patients. Questionnaire and health record data were collected from index cases and health care providers (HCPs) at Sassoon General Hospital, Pune, India. Of 80 adult TB cases, 24 (30%) reported that an HCP recommended TB screening of their child contacts; 49/178 (28%) child contacts were screened. Sixteen (33%) children had active TB, and 28 (85%) of those who screened negative were prescribed IPT. Nineteen (76%) HCPs reported recommending child contact screening. Only 8 (32%) reported ever prescribing IPT. Lack of TB screening and IPT provision for child contacts was associated with inadequate HCP counseling (aOR 19.5, P < 0.001), a non-parent index case (aOR 3.72, P = 0.008) and lack of postgraduate HCP qualification (aOR 19.12, P = 0.04). TB screening and IPT provision for child contacts of adults with TB were infrequent. Many screened children had active TB. Universal, timely TB screening and IPT for exposed children are urgently needed to reduce pediatric TB in India.

Child Contact Screening and Chemoprophylaxis against Tuberculosis in South Indian Districts-Situation Analysis

Child Contact Screening and Chemoprophylaxis against Tuberculosis in South Indian Districts-Situation Analysis

A Cross sectional study of IPT Adherence among childhoodcontacts of smear-positive Pulmonary TB

Background Tuberculosis is one of the leading causes of morbidity and mortality in children globally and in Developing countries. They should be promptly screened and treated.Objective to determine the level of IPT adherence of children in contact with adults with smear-positive PTB Methods A cross sectional study was conducted by house to house visits patients or head of the family were interviewed after taking informed consent. Number of children lt6 years in the households the extent of screening and isoniazid preventive therapy and various factors affecting it were studied.Results Totally 110 eligible Contacts of lt6years were identified by household visits 9586.36 of contacts were screened for tuberculosis 7164.54 were initiated with isoniazid preventive therapy in which 5348.18 of the contacts had incomplete therapy and only 1816.36 completed the IPT therapy.Conclusion Implementation of child contact screening is suboptimal. This component needs to be strengthened to prevent the children becoming the future pool of infections and progression of infection to disease state.

Missed opportunities for screening child contacts of smear-positive tuberculosis in Zambia, a high-prevalence setting.

To evaluate whether contact screening recommendations for child household contacts of adult smear-positive tuberculosis (TB) cases were implemented in Lusaka, Zambia. A cross-sectional survey of smear-positive adults receiving anti-tuberculosis treatment was conducted. The main outcomes were proportions of TB patients with under-five children who were aware, informed and/or had a child screened and/or commenced on isoniazid (INH). Of 371 TB patients (median age 33 years, 70% males), 259 (70%) lived with a child aged <15 years, of whom 48% (177) were aged <5 years. Overall, 32% (n = 119) were aware about child contact screening; 49% were informed by community agents vs. 38% by health care providers. Of the 259 TB patients with children, 32% (n = 84) were aware of contact screening, 32% (56/177) of whom had children aged <5 years. Of the 92/259 (36%) who were asked to have their children screened by the health care provider, 19% (49) complied. Of 177 eligible children, 11% (n = 20) were commenced on INH. Patients were more likely to comply when informed by the health care provider vs. the community agent. Screening of child contacts of adult smear-positive TB patients in areas with a large burden of adult disease is not routinely implemented. Interventions are required to ensure compliance with contact screening recommendations.

Cross Sectional Study Evaluating Routine Contact Investigation in Addis Ababa, Ethiopia: A Missed Opportunity to Prevent Tuberculosis in Children.

The 2013 global roadmap for childhood tuberculosis calls for countries to implement contact screening and provide preventive therapy to children younger than 5 years. Therefore, this study designed to evaluate the implementation status of child contact screening and management in the health facilities of Addis Ababa, Ethiopia. Smear positive TB patients living with children attending daily observed treatment at the TB clinic and health care workers providing service were approached to address the study objective. Structured questionnaires were administered to smear positive index cases living with children whether they were requested to bring children age five year and below for TB screening and to health care providers in HIV, TB and child health clinics to assess their knowledge and practice on contact screening and management. Double data entry and analysis was done using EpiData software 3.1. In 27 health centres, 688 smear-positive index tuberculosis patients were approached of whom 203 (29.5%) reported to have children five years and below in their household. A total of 48 (23.6%) index cases had been requested by the health care workers to bring their children for tuberculosis screening and 45 (93.8%) had complied with this request. Of 230 children living with index smear positive tuberculosis patient, 152 (66.1%) were not screened for tuberculosis, 78 (33.9%) children screened, 2 had tuberculosis, 76 screened negative of which 3 (3.8%) received preventive treatment. None of the health care workers indicated to routinely record and report on child contact management. Household child contact screening and preventive intervention was sub-optimal in Addis Ababa. An important opportunity lost to prevent tuberculosis in young children. Training of health care workers, availing simple symptom based screening tool, and proper documentation could improve implementation.

Editorial Commentary: More Evidence to Support Screening of Child Contacts of Tuberculosis Cases: If Not Now, Then When?

Evidence Q2 that informs the rationale for 10 screening of children who are close contacts of a case of tuberculosis and for providing preventive therapy for this high-risk group has been available for >50 years [1, 2]. The policy is almost universally accepted, being 15 included in global and almost all national tuberculosis control program guidelines [3]. However, in practice it is rarely implemented except in low-tuberculosis-burden, resource-rich settings [4]. Contact screening 20 has 2 main roles. One is to identify at-risk contacts such as young or human immunodeficiency virus (HIV)–infected children who require preventive therapy. The other is to identify contacts of any age who have 25 tuberculosis, that is, active, case finding. In this issue of Clinical Infectious Diseases, Jaganath et al [5] provide additional compelling evidence from a well-conducted study of the potential of contact investiga30 tion as a public health intervention in a tuberculosis-endemic and resource-limited setting. Although the findings are largely consistent with previous studies, there are features worth highlighting that make this an important study. It is a large prospective study reporting 761 Ugandan children who were household contacts of an adult with tuberculosis, and half of the contacts were young children (aged <5 years). Case definitions were clearly defined, and contacts were carefully evaluated, including samples for culture taken from those with symptoms or suggestive radiological findings, thereby strengthening diagnostic certainty. Furthermore, the cohort was followed for 2 years, providing important outcome data that are not available from the many previous cross-sectional studies that have reported a high prevalence of infection with Mycobacterium tuberculosis in child contacts [6, 7]. Tuberculosis was diagnosed in 10% of child contacts. This represents a higher prevalence than is usually reported [6, 7] but cannot be dismissed as simply overdiagnosis given that the majority (71%) of cases were culture confirmed. Diagnostic yield from culture was 4-fold higher than from smear and, as expected, tuberculosis was significantly more common in the young children. The prevalence of disease in the young child contacts was extremely high, equivalent to 16 400 per 100 000 young child contacts. Active case finding identified 79 children with tuberculosis who had not been diagnosed previously. These data provide strong support for case finding in this high-risk age group. 35 Moreover, this age group is still poorly represented by recording and reporting practices in many endemic settings. A tuberculin test was positive at baseline in 63% of child contacts without disease, 40 at the upper range of infection prevalence reported previously [6, 7]. Isoniazid preventive therapy (IPT) is very effective in preventing disease in these children [1, 8] but is rarely implemented in tuberculosis45 endemic settings, and, when implemented, uptake and adherence are often poor. In this study, 74% of eligible contacts completed at least 6 months of IPT. Only 2 (<1%) children developed tuberculosis 50 while receiving IPT and 1 after completion. This is a very positive outcome and an important observation strengthened by the 2 years of follow-up. The efficacy of IPT in this population cannot be deter55 mined from this study, but this finding supports the benefit of IPT for child contacts. The main characteristics that were identified for disease were young age, HIV 60 infection, and lack of a BCG scar. The increased risk for HIV-infected children is well established, and IPT is recommended for HIV-infected contacts irrespective of age once disease is excluded [3]. A recent 65 study from Tanzania reported an additional protective effect of antiretroviral therapy Received 22 August 2013; accepted 23 August 2013. Correspondence: Stephen M. Graham, PhD, FRACP, Centre for International Child Health, The University of Melbourne Department of Paediatrics, Royal Children’s Hospital, Flemington Road, Parkville, VIC 3052, Australia (steve.graham@rch. org.au). Clinical Infectious Diseases © The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. permissions@oup.com. DOI: 10.1093/cid/cit647

Implementing a tuberculosis child contact register to quantify children at risk for tuberculosis and HIV in Eldoret, Kenya.

Tuberculosis (TB) clinic in Eldoret, Kenya. To identify TB exposed children through the implementation of a child contact register (CCR). To assess the demographics of children exposed to TB and the potential for initiation of isoniazid preventive therapy (IPT) in this cohort. A CCR was implemented in routine care with health care workers querying index cases regarding child contacts. Data were retrospectively analyzed. In 12 months, the CCR revealed 580 children exposed to TB. Of these, 58% were exposed to smear-positive TB and 30% were aged <5 years. Of those exposed to smear-positive TB, 15% may have qualified for IPT initiation. Only 6 (1%) child contacts were screened for TB disease. More than 50% of the children with human immunodeficiency virus (HIV) positive mothers had not been HIV tested. Implementation of a CCR is a possible first step in child contact identification and management, which requires minimal resources and identifies children at risk for TB and HIV. Child contact screening and IPT initiation remain a challenge, and additional strategies are urgently needed.

Contact investigation of children exposed to tuberculosis in South East Asia: a systematic review.

Background. Screening of children who are household contacts of tuberculosis (TB) cases is universally recommended but rarely implemented in TB endemic setting. This paper aims to summarise published data of the prevalence of TB infection and disease among child contacts in South East Asia. Methods. Search strategies were developed to identify all published studies from South East Asia of household contact investigation that included children (0–15 years). Results. Eleven studies were eligible for review. There was heterogeneity across the studies. TB infection was common among child contacts under 15 years of age (24.4–69.2%) and was higher than the prevalence of TB disease, which varied from 3.3% to 5.5%. Conclusion. TB infection is common among children that are household contacts of TB cases in South East Asia. Novel approaches to child contact screening and management that improve implementation in South East Asia need to be further evaluated.

Childhood tuberculosis in an urban population in South Africa: burden and risk factor.

To study the epidemiology of childhood tuberculosis (TB) in a developing country. Two urban communities of Cape Town, South Africa with a TB case notification rate of 1149/100 000. Retrospective descriptive study using the national population census (1991), 10 year official TB notification records, and a geographical information system. The case notification rate of TB in children 0-5 years old was 3588 cases/100 000 children aged 0-5 years, 3.5 times the case notification rate in adults. Children (0-14 years) accounted for 39% of the total case load. Childhood TB case notification rate correlated with parental education (r = -0.64), annual household income (r = -0.6), and crowding (r = 0.32). Children, especially those living in poor socioeconomic conditions, form an important epidemiological group and account for a notable proportion of the morbidity caused by TB. Efforts to improve TB control must therefore not only target adults (case detection and cure of infectious cases) but also children (screening of child contacts of adult cases) and the socioeconomic living conditions.

Tuberculin tests: Comparison of heaf and imotest

During the course of a study to compare alternative methods of B.C.G. vaccination, it had been found that in one participating school conversion rates at 12 weeks had been very low. One hundred and fifty-nine children at this school who had been given B.C.G. were re-tested giving Imotest on one arm and Heaf test on the other. Using the 2 mm + criterion of positivity, the Imotest proved a more sensitive form oftuberculin test, yielding 86 positives, compared with 15 positives to the Heaf test. Subsequent Heaf tests on eight of the negative reactors who were still at school 12 months after vaccination showed that all had converted. It is suggested that the greater sensitivity and earlier detection of conversion achievedby the Imotest renders this the more suitable test for screening of child contacts of a case of tuberculosis.