Vikela Ekhaya: A Novel, Community-based, Tuberculosis Contact Management Program in a High Burden Setting

Abstract

BACKGROUND The prevention of tuberculosis (TB) in child contacts of TB cases and people living with HIV is a public health priority, but global access to TB preventive therapy (TPT) remains low. In 2019, we implemented Vikela Ekhaya, a novel community-based TB contact management program in Eswatini designed to reduce barriers to accessing TPT. METHODS Vikela Ekhaya offered differentiated TB and HIV testing for household contacts of TB cases, by utilizing mobile contact management teams to screen contacts, assess their TPT eligibility, and initiate and monitor TPT adherence in participants’ homes. RESULTS In total, 945 contacts from 244 households were screened for TB symptoms; 72 (8%) contacts reported TB symptoms, and five contacts (0.5%) were diagnosed with prevalent TB. 322 of 330 (98%) eligible asymptomatic household contacts initiated TPT. Of 322 contacts initiating TPT, 248 children initiated 3 months of isoniazid and rifampicin and 74 children and adults living with HIV initiated 6 months of isoniazid; 298 (93%) completed TPT. In clustered logistic regression analyses, unknown HIV status (aOR 5.7, p = 0.023), positive HIV status (aOR 21.1, p = 0.001), urban setting (aOR 5.6, p = 0.006), and low income (aOR 5.9, p =0.001) predicted loss from the cascade of care among TPT eligible contacts. CONCLUSION Vikela Ekhaya demonstrated that community-based TB household contact management is a feasible, acceptable and successful strategy for TB screening and TPT delivery. The results of this study support the development of novel, differentiated, community-based interventions for TB prevention and control.

The Impact of the COVID-19 Pandemic on Tuberculosis Case Notification and Treatment Outcomes in Eswatini

“…Eswatini have a high annual TB incidence at 309/100,000 and the highest HIV prevalence in the world at 27% among 15–49 years old [ 4 – 6 ]. Active case finders (ACFs) were introduced in 2016 and their main role was to find and diagnose TB cases in the community through visiting contacts of those already diagnosed, an exercise that helped increase the proportion of TB cases diagnosed [ 7 ]. The TB treatment success rate in Eswatini was reported to be at 86% in the year 2019, 4% less than the global target of 90% which the country is working towards achieving [ 8 ].…”

Treatment decision algorithms for childhood tuberculosis

“…National programme guidelines on data protection, confidentiality, privacy and informed consent should be adhered to. Contact screening is generally experienced in a positive light if the community appreciates this is done to keep vulnerable people and the whole community safe (21). -When the index patient is reluctant to give information regarding household and social contacts, counselling efforts should continue over time to gain the patient's trust.…”

“…Bedaquiline adult tablets (100 mg) crushed and suspended in water have been shown to be bioequivalent to tablets swallowed whole and can be used to treat MDR/RR-TB in children if the dispersible tablet formulation of bedaquiline is unavailable or to facilitate administration in children who cannot swallow whole tablets (123). It is also possible to prepare sugar-containing and sugar-free extemporaneous liquid formulations of bedaquiline using the adult 100 mg formulation (Benefit Kids project, unpublished data) 21 .…”

“…20 A delamanid 25 mg dispersible tablet was not available at the time of the guideline development group meeting in May-June 2021, but it has since become available and is now listed in the GDF medicines catalogue (http://stoptb.org/assets/documents/gdf/drugsupply/ GDFMedicinesCatalog.pdf ). 21 Taneja R, Nahata MC, Scarim J, et al Stable sugar and sugar-free bedaquiline suspensions: practical implementation of pediatric dosing in the field. BENEFIT Kids Project, unpublished data.…”

Child Contact Case Management—A Major Policy-Practice Gap in High-Burden Countries

“…With regard to the eligible children, 72% completed 6 months of TPT and 61% completed the TPT with good adherence [57]. Vikela Ekhaya, a community-based TB household contact management program in Eswatini demonstrated high rates of TPT acceptance (98%) and completion (93%) among eligible children [58]. In the CRESPIT randomized controlled trial, conditional cash transfers, community meetings, and household visits increased the likelihood of completing TPT by 60% in Peru [59].…”