BUTIMBA: Intensifying the Hunt for Child TB in Swaziland through Household Contact Tracing

Abstract

BackgroundLimited data exists to inform contact tracing guidelines in children and HIV-affected populations. We evaluated the yield and additionality of household contact and source case investigations in Swaziland, a TB/HIV high-burden setting, while prioritizing identification of childhood TB.MethodsIn partnership with 7 local TB clinics, we implemented standardized contact tracing of index cases (IC) receiving TB treatment. Prioritizing child contacts and HIV-affected households, screening officers screened contacts for TB symptoms and to identify risk factors associated with TB. We ascertained factors moderating the yield of contact tracing and measured the impact of our program by additional notifications.ResultsFrom March 2013 to November 2015, 3,258 ICs (54% bacteriologically confirmed; 70% HIV-infected; 85% adults) were enrolled leading to evaluation of 12,175 contacts (median age 18 years, IQR 24–42; 45% children; 9% HIV-infected). Among contacts, 196 TB cases (56% bacteriologically confirmed) were diagnosed resulting in a program yield of 1.6% for all forms of TB. The number needed to screen (NNS) to identify a bacteriologically confirmed TB case or all forms TB case traced from a child IC <5 years was respectively 62% and 40% greater than the NNS for tracing from an adult IC. In year one, we demonstrated a 32% increase in detection of bacteriologically confirmed child TB. Contacts were more likely to have TB if <5 years (OR = 2.0), HIV-infected (OR = 4.9), reporting ≥1 TB symptoms (OR = 7.7), and sharing a bed (OR = 1.7) or home (OR = 1.4) with the IC. There was a 1.4 fold increased chance of detecting a TB case in households known to be HIV-affected.ConclusionContact tracing prioritizing children is not only feasible in a TB/HIV high-burden setting but contributes to overall case detection. Our findings support WHO guidelines prioritizing contact tracing among children and HIV-infected populations while highlighting potential to integrate TB and HIV case finding.

"Knock Knock": A qualitative study exploring the experience of household contacts on home visits and their attitude towards people living with TB in South Africa

“…Our study ndings are consistent with other qualitative studies in Africa and South-East Asia, which found that community members supported the concept of HHCT 11,18,22,23 . A common reason for appreciation of TB services at home was it removed barriers of access and cost.…”

“…Community members did not have to travel long distances to access clinic services. Despite the overall positive attitude in these studies 11,18,22,23 , there have been examples in South Africa where HHCs were not comfortable with home visits from research staff, speci cally concerned with associated stigma and the opinions of their community members 22 . In contrast, our study participants did not express this same concern implying that there was no stigma attached to HHCT.…”

“…The additional value of HHCT is the ability to evaluate children for TB or refer them to the health facility for investigation; studies in Africa and Asia have demonstrated success in doing this 11,12,13,14,15,16,17 . Studies in Swaziland and Uganda found that prioritizing children in HHCT is a major contribution to case nding 11,13 . In The Gambia, among 4,000 child contacts (<15 years) screened at home, 1.6% had TB, of which 40% were asymptomatic 14 .…”

Disseminated tuberculosis in a Nigerian child: making a case for active contact tracing

“…11 It is invaluable in the TB program, and has been recommended as a strategy to increase TB case finding for many years. 14,15 Contact tracing follows the identification of a tuberculosis index case, and it is an important strategy for the early identification and treatment of childhood tuberculosis, and for the provision of prophylaxis for cases with a high risk of progression of disease. 16 This prophylaxis involves Isoniazid Preventive Therapy (IPT), and the initial targets are those at most risk of disease progression, such as young children and human immunodeficiency virus (HIV) infected individuals in contact with an infectious adult with TB.…”

Effectiveness of WHO's pragmatic screening algorithm for child contacts of tuberculosis cases in resource-constrained settings: A prospective cohort study in Uganda

“…Household tracing of child contacts has been widely recommended by global health organizations and disease experts for over a decade [10][11][12] because child contacts have a high yield of both Mycobacterium tuberculosis infection and disease. [13][14][15][16] Despite this, contact tracing has been implemented poorly or not at all in high-burden, lowincome settings. 11,17 For example, <20% of contacts of tuberculosis patients diagnosed in Ethiopia were programmatically screened for disease.…”