Finding the missing children for TB care and prevention in Kenya

Abstract

SETTING: One hundred high TB burden facilities in nine counties in Kenya.OBJECTIVES: 1) To increase uptake of TB preventive therapy (TPT) among child contacts aged <5 years, and 2) to increase TB diagnosis in children aged <15 years presenting to health facilities for routine care.DESIGN: For objective 1, a clinic-based child contact management strategy incorporating transport/healthcare cost reimbursement, monitoring and evaluation tools, and healthcare worker education was utilized. For objective 2, community health screeners were established in pediatric outpatient departments to perform verbal screening, flagging symptomatic children for further evaluation.RESULTS: Over 15 months, identification of 8,060 individuals diagnosed with bacteriologically confirmed TB led to 2,022 child contacts. Of these, 1,848 (91%) were evaluated; 149 (8%) were diagnosed with TB disease, leaving 1,699 (92%) eligible for TPT; 1,613 (95%) initiated TPT and 1,335 (83%) completed TPT. In outpatient settings, 140,444 children were screened; 54,236 (39%) had at least two TB symptoms; 2,395 (4%) were diagnosed with TB diseaseCONCLUSION: Health system strengthening supporting a clinic-based child contact management program increased the number of children initiating TPT. Systematic screening in outpatient clinics can lead to increased TB case notifications; however, optimal screening tools and clearer diagnostic pathways for the evaluation of these children are needed.

Improving TB detection among children in routine clinical care through intensified case finding in facility-based child health entry points and decentralized management: A before-and-after study in Nine Sub-Saharan African Countries

“…The interventions led to an increase in the number of children diagnosed with TB in eight out of the nine project countries and in four of them the increase observed was statistically significant. This study, which has a large sample size and is based on prospectively collected data, strengthens the evidence previously generated by single-country studies [12][13][14][15] and demonstrates that implementation of multi-pronged interventions to improve paediatric TB case detection is feasible and effective in routine clinical settings across a variety of geographical settings, although effect size may be variable depending on local context.…”

“…This observed gap may be over-estimated because the project data collection system did not record how many children were prescribed a broad-spectrum antibiotic and requested to come back for a follow-up visit, or how many had an alternative diagnosis. However, other studies have documented similar gaps in the paediatric TB case detection cascade, suggesting this may be driven by clinicians’ reluctance to consider TB as part of their differential diagnosis [ 14 , 28 , 33 , 34 ]. Intense training, site monitoring and mentorship, as well as improved access to tools such as molecular testing and radiology, may help increasing adherence to diagnostic algorithms and proportion of children undergoing TB investigations among those identified as presumptive.…”

“…Introducing systematic TB screening across different health facility services and strengthening TB services at the primary healthcare level can improve paediatric TB case finding in resource-limited settings [ 10 , 11 ]. Integration of systematic TB screening in maternal and child health (MCH) services and strengthening of child contact investigation in urban health centres in Ethiopia [ 12 ], integration of TB screening in outpatients clinics, paediatric emergency rooms, and HIV clinics in Nigeria [ 13 ], implementation of community-based household contact investigations (HCI) and intensified paediatric TB case finding in outpatient clinics in Kenya [ 14 ], and decentralisation of child TB services in Uganda [ 15 , 16 ], have been associated with improved paediatric TB case detection.…”