Evaluating the integration of tuberculosis screening and contact investigation in tuberculosis clinics in Ethiopia: A mixed method study

Abstract

Background Aligned with global childhood tuberculosis (TB) road map, Ethiopia developed its own in 2015. The key strategies outlined in the Ethiopian roadmap are incorporating TB screening in Integrated Maternal, Neonatal and Child Illnesses (IMNCI) clinic for children under five years (U5) and intensifying contact investigations at TB clinic. However, these strategies have never been evaluated. Objective To evaluate the integration of tuberculosis (TB) screening and contact investigation into Integrated Maternal, Neonatal and Child Illnesses (IMNCI) and TB clinics in Addis Ababa, Ethiopia. Methods The study used mixed methods with stepped-wedge design where 30 randomly selected health care facilities were randomized into three groups of 10 during August 2016-November 2017. The integration of TB screening into IMNCI clinic and contact investigation in TB clinic were introduced by a three-day childhood TB training for health providers. An in-depth interview was used to explore the challenges of the interventions and supplemented data on TB screening and contact investigation. Results Overall, 180896 children attended 30 IMNCI clinics and145444 (80.4%) were screened for TB. A total of 688 (0.4%) children had presumptive TB and 47(0.03%) had TB. During the pre-intervention period, 51873 of the 85278 children (60.8%) were screened for TB as compared to 93570 of the 95618 children (97.9%) in the intervention (p<0.001). This had resulted in 149 (0.30%) and 539 (0.6%) presumptive TB cases in pre-intervention and intervention periods (p<0.001), respectively. Also, nine TB cases (6.0%) in pre-intervention and 38 (7.1%) after intervention were identified (p = 0.72). In TB clinics, 559 under-five (U5) contacts were identified and 419 (80.1%) were screened. In all, 51(9.1%) presumed TB cases and 12 (2.1%) active TB cases were identified from the traced contacts. TB screening was done for 182 of the 275 traced contacts (66.2%) before intervention and for 237 of the 284 of the traced (83.5%) under intervention (p<0.001). Isoniazid prevention therapy (IPT) was initiated for 69 of 163 eligible contacts (42.3%) before intervention and for 159 of 194 eligible children (82.0%) under intervention (p<0.001). Over 95% of health providers indicated that the integration of TB screening into IMNCI and contact investigation in TB clinic is acceptable and practical. Gastric aspiration to collect sputum using nasogastric tube was reported to be difficult. Conclusions Integrating TB screening into IMNCI clinics and intensifying contact investigation in TB clinics is feasible improving TB screening, presumed TB cases, TB cases, contact screening and IPT coverage during the intervention period. Stool specimen could be non-invasive to address the challenge of sputum collection.

Tuberculosis care models for children and adolescents: a scoping review

“…46 Many studies described multifaceted interventions and interventions were heterogeneous ( Table 1 ; available at: https://www.who.int/publications/journals/bulletin/ ). The primary intervention was decentralization for 23 studies, 19 – 39 , 44 , 46 integration for three studies 40 , 41 , 45 and family-centred care for two studies. 42 , 43 Because of the small number of studies of integrated and family-centred care models, we incorporated into the evidence synthesis 19 additional studies without comparative outcomes (six studies reporting on integrated models 47 – 52 and 13 studies reporting family-centred models; 53 – 65 Table 2 ; available at: https://www.who.int/publications/journals/bulletin/ ).…”

“…We identified three comparative studies where integration was the primary intervention ( Table 4 ). 40 , 41 , 45 A stepped-wedge trial in Ethiopia showed that screening in integrated maternal, neonatal and child illnesses clinics increased tuberculosis diagnoses among children (0.5; 95% CI: 0.2–0.7; additional cases per clinic per 4-month period). 41 A pre-post study from Zambia showed that having antiretroviral services and tuberculosis services in the same health facilities led to increased case notifications in the 0–14 year age group (IRR: 2.67; 95% CI: 1.05–6.76).…”

“… 40 , 41 , 45 A stepped-wedge trial in Ethiopia showed that screening in integrated maternal, neonatal and child illnesses clinics increased tuberculosis diagnoses among children (0.5; 95% CI: 0.2–0.7; additional cases per clinic per 4-month period). 41 A pre-post study from Zambia showed that having antiretroviral services and tuberculosis services in the same health facilities led to increased case notifications in the 0–14 year age group (IRR: 2.67; 95% CI: 1.05–6.76). 40 A pre-post study from Kenya showed that screening in the maternal–child health, nutrition and acute care departments of a hospital did not significantly increase tuberculosis treatment registrations in the 0–14 year age group (IRR: 0.88; 95% CI: 0.44–1.77).…”

Treatment decision algorithms for childhood tuberculosis

“…Given the variation in country-specific settings, and the variety of settings within countries, the NTP should consider a flexible approach guided by the existing infrastructure, availability of resources and disease burden -for example, decentralization of a single component of TB services versus a combination of components; phased implementation versus full-scale implementation; or operational research setting versus programmatic implementation. Some studies have shown that interventions delivered at the primary health facility and community levels (combined) have resulted in increased TB case notifications and TPT initiations compared with more centralized approaches (158)(159)(160)(161)165).…”

Provision of Decentralized TB Care Services: A Detect–Treat–Prevent Strategy for Children and Adolescents Affected by TB

“…Efforts in high-burden settings to integrate TB screening into primary care settings such as outpatient clinics and IMNCI clinics have been shown to increase the referral of children at risk of TB, as well TB case detection [12,47]. The ongoing multi-country Catalyzing Pediatric TB Innovations (CaPTB) project has undertaken the systematic integration of TB screening and strengthening of decentralized diagnostic capacity at different service delivery entry points, including outpatient, inpatient, well-child, nutrition, and HIV clinics.…”