It's hard work, but it's worth it: the task of keeping children adherent to isoniazid preventive therapy

Abstract

HIV-infected children, previously paralysed postexposure IPT programmes have been enhanced through the introduction of IPT registers and the increased availability of single-drug dispersible paediatric isoniazid (INH) formulations.South Africa, an upper middle-income country, has a medium human development index, but it fi gures among the 22 countries with the highest burden of TB disease. 12 Although the South African National TB Programme (SANTP) has been recommending postexposure IPT for many years for child contacts aged <5 years, IPT uptake ranges from <5% 10 to 21% in routine health care settings, 9 to 73% in clinical research settings, 5,13 while adherence is approximately 24%. 5,13 Among South African children hospitalised for TB, opportunities for IPT are missed in up to 70% of young children. 14,15 A growing body of literature shows that obstacles to the effective delivery of postexposure IPT are many and inter-related. 9,10 Many of the major barriers identifi ed in a recent review of problems in IPT implementation have been resolved in South Africa using a standardised screening protocol for children. However, the issues of maintaining adherence to extended prophylactic treatment programmes and the negotiation of care giver acceptability needs further consideration. 16 A recent survey of parents currently administering IPT in Cape Town found very positive responses to IPT once these barriers had been overcome. 17 We completed a qualitative assessment to understand factors infl uencing parents' decisions to allow IPT to be administered to their children and completion of the 6-month course of treatment. RESEARCH SETTINGThe study was set in three impoverished urban communities in Cape Town, Western Cape Province, South Africa. Study Communities 1 and 2 are geographically adjacent and their ethnicity is classifi ed as 'coloured' or 'mixed race'. The third community is of predominantly black ethnicity. In 2011, the overall TB notification rate in the Western Cape Province was 994 per 100 000 population and >1000/100 000 in the communities studied; TB reported in children aged 0-13 years accounted for 17% of the disease and an age-specifi c TB notifi cation rate of 620/100 000 in 2008 (unpublished data, Western Cape Department of Health, 2009). The estimated annual risk of M. tuberculosis infection was 4.1% in the fi rst two communities, where 30% of children aged 6-9 years were tuberculin skin test (TST) positive. 18 In the third community, 26% of In-depth interviews were conducted with two parents of children adherent to IPT and two staff members from three primary health care clinics in high TB prevalence communities. Themes explored were knowledge and attitudes towards IPT, problems in accessing and adhering to treatment, and community responses. Results: Parents administering treatment valued it positively, realised their children's risk of TB, and were positive about the clinic. Nurses acknowledged that resistance to treatment remained, with some parents not wanting to acknowledge risk nor willing to...

An assessment of the isoniazid preventive therapy programme for children in a busy primary healthcare clinic in Nelson Mandela Bay Health District, Eastern Cape Province, South Africa

“…Caregivers' refusal to medicate has been shown to be a significant barrier to providing children with IPT. [20] …”

“…[16] Qualitative studies in Cape Town have shown that barriers to a successful IPT programme included health systems issues, such as staff shortages and patient-and communityrelated factors, including poverty, stigma and parents' resistance to treatment. [20] The successful implementation of child contact screening and management is hampered by a variety of challenges and barriers unique to each setting. [7] Information regarding IPT services in the Eastern Cape and NMBHD is lacking, with no baseline data.…”

“…Additional barriers to initiation of and adherence to IPT include stigma related to TB, community misconceptions around the role of IPT and social problems, such as substance abuse and domestic violence. [20] There were 74 IPT cards for children starting IPT during the study period, which represents 69% of those who started preventive therapy and 40% of the total number who were screened. There were 9 IPT cards for 9 children who started IPT, who were either >5 years of age or who were contacts of non-bacteriologically confirmed pulmonary or extrapulmonary TB index patients.…”

Childhood tuberculosis: no longer an orphan disease? [Editorial]

“…4 What has been lacking, however, is operational research exploring the barriers to TB diagnosis, treatment and prevention among children. It is heartening to see this edition of Public Health Action dedicated to the topic, [5][6][7][8][9] and it is hoped that this will inspire others in this important fi eld of research.There are many areas that need urgent attention. These include the development and implementation of point-of-care diagnostics for children, new childfriendly drugs for children with drug-susceptible and drug-resistant tuberculosis, randomised controlled clinical trials to ensure optimal treatment for complicated cases such as TB meningitis, new short-course interventions to prevent TB and a new, effective vaccine.…”

“…4 What has been lacking, however, is operational research exploring the barriers to TB diagnosis, treatment and prevention among children. It is heartening to see this edition of Public Health Action dedicated to the topic, [5][6][7][8][9] and it is hoped that this will inspire others in this important fi eld of research.…”