India is home to 21% of the world’s tuberculosis cases, with 1.8 million new cases diagnosed each year, yet the case notification for children is less than 2%, according to a presentation given by Dr. Soumya Swaminathan at the 40th Union World Conference on Lung Health in Cancun, Mexico.
“Contact tracing could greatly improve the number of children identified with tuberculosis,” said Dr Swaminathan, who has recently joined the World Health Organization, “and preventive therapy could decrease childhood TB, though both interventions are underutilised.”
Background
The Indian Revised National TB Control Program (RNTCP) recommends household contact tracing of smear-positive pulmonary TB cases to identify adults and children at high risk for TB; it also recommends that six months of isoniazid preventive therapy (IPT) be administered for asymptomatic children under six years of age.
Dr. Swaminathan and her former colleagues at the Tuberculosis Research Centre in Chennai conducted a study in two rural and two urban TB units in the state of Tamil Nadu to assess whether the RNTP’s child contact screening and IPT policy is being implemented.
The study
Using TB treatment registers and patient treatment cards, they identified smear positive TB patients who started treatment between April and June 2008. Among the 253 TB patients identified, there were 607 adult household contacts and 136 children, of whom 84 were less than six years old.
Twenty four percent of patients were informed by health care workers that their close contacts needed screening; 14% of child contacts aged
0-14 were screened for TB. Only 19% of children under six years old were initiated on IPT.
In focus groups with health care workers, differences in knowledge and performance were noted between rural and urban health workers — with rural health care workers being more reluctant to screen for TB and less aware of the concept of initiating IPT for children under six.
An assessment of the procedures for screening and delivering IPT found some critical gaps— for example, there was no mechanism for the periodic follow-up of children on IPT, or for ensuring drug intake.
None of the patient treatment cards documented the details of contact screening, administration of IPT, drug monitoring or follow-up. Completion of IPT often ended after treatment of the index case was completed, whether or not the child had completed the recommended six months of IPT.
Implications
Dr Swaminathan believes that simple lessons can be drawn from the study and lead to practical recommendations that — if implemented — could improve the rate of household contact tracing and implementation of IPT in young children.
For instance, creating a separate treatment card for contacts and children receiving chemoprophylaxis should be developed.
Training on contact tracing and IPT should be given a high priority, particularly in rural districts.
Health workers need to be reassured that every child does not need to be seen by a physician before initiating IPT.
“This information is timely”, Dr Swaminathan concluded, “and can be particularly useful to the World Health Organization as it develops its revised contact tracing guidelines in the coming months.”