Contact investigation in children living with patients treated for DR-TB
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1 Contact investigation in children living with patients treated for DR-TB Farhana Amanullah, FAAP The Indus Hospital TB Program, Karachi, Pakistan 31 st October 2013, Paris, France.
2 Outline Introduction Contact evaluation protocol Findings Challenges Strategies to overcome challenges Recommendations
3 The Indus Hospital Pediatric TB program Started in 2008 Separate airborne infection control TB facility Daily pediatric TB clinics IPT program- 2012
4 Contact evaluation protocol Index DR-TB patient registered Health worker visits household- identifies HH contacts, demographics etc. advises to bring all children in the HH for a baseline assessment. Inquires about TB symptoms monthly
5 Contact evaluation protocol All <5 year olds: 1. H and P 2. Height weight 3. TST 4. CXR 5. CBC/ESR/CRP 6. If clinically indicated then a) gastric aspirate (smear, xpert, culture) other imaging All 5-14 year olds 1. H and P 2. Height weight 3. TST 5-14 year olds with symptoms a) CXR/ other imaging b) sputum/gastric aspirate-smear/xpert and culture c) CBC/ ESR
6 Findings (1) n=192 59% male 55% child of index patient 42% underweight (<-2 SD) 50% BCG scar
7 Findings (2) 33% PPD>=10mm (n=130) 26.6% sx (any of: cough, fever, night sweats, weight loss, adenopathy) 55% ESR elevated (n=131) 9% TB disease (15/166) 40% culture confirmed DR-TB (6/15)
8 TB disease and LTBI in child contacts Age groups TB disease n (%) LTBI n (%) No disease n (%) Total 0-4 years 4 (8.5) 3 (6.4) 40 (85) years 11 (9.2) 29 (24) 79 (66) 119 Total 15 (9) 32 (19.2) 119 (72) years 5-14 years TB disease LTBI No disease
9 Flow chart showing numbers evaluated at each step of the protocol Households with DR TB patients =220 HH evaluated= 84 Number of children evaluated=192 Child received TST No=62 Yes=130 CXR normal=30 CXR abnormal= 8 CXR normal=44 TST neg=87 CXR abnormal= 15 CXR normal=25 TST pos=43 CXR abnormal= 9 TB disease=3 TB disease=1 TB disease=2 TB disease=9 Confirmed DR=1 Confirmed DR=0 LTBI=32 Confirmed DR=5
10 Challenges in implementation contacts evaluated complete evaluations
11 Challenges in implementation Erratic contact evaluation efforts inconsistent human resources, funding constraints Poor turnout for child contact evaluation Bringing well children to the hospital twice- expensive No follow-up after initial evaluation Incomplete evaluation- no TST reads No provision of preventive therapy, for <5 year old contacts or LTBI No funds for preventive regimens
12 Strategies to overcome some challenges TST placement and reading done daily at the TB clinic All testing and CXR done in the TB clinic Daily pediatric TB clinic as of mid 2011
13 Strategies to be implemented Travel reimbursement for contact evaluation visit SMS reminders for contact evaluation and follow-up Health worker capacity building in reading TSTs Incentives such as: Contacts get a complete pediatric checkup and immunization as part of evaluation package MVI, iron supplements, de-worming, nutrition evaluation and supplements Helpline number for reporting a symptomatic child and a fast track for free workup and treatment of illnesses
14 Recommendations Strategies for replication in other settings Situation in high burden settings 1. Routine systematic contact management not done apart from few time limited GF projects 2. PMDT implemented - DR-TB in children? Child contact management programs? 3. Children not included in national strategic plansas funding needs not known.
15 Recommendations Mandatory notification of all TB including child contact management Child TB and child contact management in the context of family centered care to be included in National strategic plans for TB control Funding and human resource for contact management and drugs for treatment of diagnosed cases Integration of symptom screens in ANC, MNCH, EPI centers with clear referral systems for further evaluation Community programs and NGO strengthening Research studies eg. TB CHAMP- outcomes will inform concrete preventive therapy guidance for DR-TB child contacts.
16 Thank you
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