Fighting Childhood TB in Kenya
Project Overview and Background
Catalyzing Pediatric TB (CaP TB), is a Unitaid-funded project that ran from 2017 through to 2021. It has been managed and implemented by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) in 10 countries, including Kenya.
In Kenya, TB remains a major public health problem. It’s the leading cause of death among children and adults combined ranking above HIV and AIDS. Childhood TB made up only 9.7% of these patients; this was much lower than the estimated 15% a likely indication of significant number of children being undiagnosed and untreated.
CaP TB sought to address these baseline gaps with informed interventions and to reposition the focus on pediatric TB agenda in Turkana and Homabay countries. Among the challenges it sought to address were limited integration of TB screening into other services leading to missed opportunities for identification, limited capacity for pediatric TB diagnosis services such as use of GeneXpert, and clinical-radiological evaluation, low pediatric TB case finding, few GeneXpert sites with un coordinated sample networking especially for diagnostics, low awareness of TB in the community and delays in TB contact tracing activities and enrolment on TB prevention therapy (TPT) to protect exposed children from contracting active TB.
The project consequently helped to increase TB case detection in children, initiation on TB treatment and preventive TB therapy through integrated and decentralized models of care, introduction of improved diagnostics and treatment for latent and active TB, as well as household contact tracing.
The project also helped to develop innovative models of care and catalyze their wide-scale sustainable uptake to improve case detection and treatment of children with active and latent TB.
From the initial presence in 15 facilities; 3 in Turkana and 12 in Homabay the project scaled up to 34 sites; 10 in Turkana and 24 in Homabay by 2021. Turkana was identified due to high TB burden and Homa Bay county due to high HIV TB coinfection.
Diagnosing TB in Children
The project introduced effective and innovative models of care to improve detection of TB in children. These include advanced sample collection aids for microbiological confirmation of TB in children. Homa Bay County Referral Hospital and Lodwar County Referral Hospital were supported with the purchase of sputum induction and nasopharyngeal aspiration devices and consumables to aid in obtaining quality sputum specimen for microbiological confirmation of TB in children.
The project also trained 311 HCWs on sample collection and 6 healthcare workers on specialized TB diagnosis procedures and provided additional equipment such as Nebulizer machine, suction machine, pulse oximetry, oxygen concentrator and assorted consumables to support the procedure.
Through these interventions, the facility now conducts advanced sample collection among the children unable to expectorate, identify those with TB and put all of them on treatment.
Over the period gastric aspiration has been conducted on 89 children out of which 3 were diagnosed and initiated on treatment for TB.
Using Tele-radiology to Improve Quality Reading of Chest X-rays
CaP TB supports clinical radiological diagnosis of TB to increase identification of TB among children and facilitate online transmission of difficult chest x-rays from the hospital to contracted radiologist firm based in Nairobi for interpretation. The findings and results were transmitted online within two hours for clinical decision making.
Before CaP TB rolled out tele-radiology in September 2019, there were no radiologists in Turkana and Homabay county referral hospitals to interpret difficult chest x-rays. Simple chest x-rays were read by medical officers and clinical officers in the facility. Patients with difficult chest x-rays took longer to diagnose and initiate treatment since various clinicians needed to give their opinions before making a final decision.
To facilitate this, desktop computers, printers, modems, flash discs and monthly data bundles were provided and clinicians and radiographers trained on how to determine difficult chest x-rays for children aged 0-4 years and transmit them to the contracted radiologist.
An X-ray waiver voucher was provided in Homa bay to support those children who could not afford the cost of chest X-rays services for TB diagnosis. Consequently, 103 difficult chest x-rays were interpreted by the contracted radiologist company, out of which 12 patients were confirmed to have TB disease representing 12 percent positivity rate. All confirmed TB cases were linked to TB treatment units for TB initiation.
Donation of GeneXpert Machine in Turkana
Children with TB must be identified quickly and put on treatment before they become extremely ill.
Challenges of diagnosing TB in children are compounded by the fact that very young children often cannot produce sputum for testing and even when a sample is taken for microscopy, the quantity of TB bacteria in samples from children is often lower(paucibacillary) than in adults, making TB more difficult to detect.
A DNA-based molecular near point-of-care diagnostic testing, GeneXpert has improved sensitivity over older and more commonly used diagnostic techniques. The test detects TB infection in patients and also determines if a patient’s TB bacterium is resistant to a common TB drug, rifampicin. Use of GeneXpert is recommended by the World Health Organization (WHO) as the first test for pediatric TB suspects. However, availability and uptake of GeneXpert for pediatric TB testing is still limited in many sub-Saharan African countries.
CaP TB donated a GeneXpert machine which also includes a laptop and a back-up inverter was installed at Lopiding Sub-County Hospital. This helps to generate more accurate diagnosis and results for better patients’ outcome in the region. Lopiding had proved to be a high TB burden facility since the hospital had been diagnosing more than a quarter of all TB cases in Turkana county for the last three years.
Robust Specimen Referral System to Improve Detection of TB Cases in Children
Robust specimen referral systems allow patients to receive care and treatment at one location, while their specimens are transferred to various levels of a tiered laboratory system for testing. Centralized testing requires rapid and safe transport of specimens from health facilities or lower-level laboratories to the higher-level laboratory, as well as expedite reporting of results back to clinicians.
To ensure seamless specimen networking within the county, the project introduced motorbike riders to network TB samples to a GeneXpert Hubs. The project uses the Hub and spoke model to collect and network the specimen and relay back the result for clinical decision making. Facilities were also supported with refrigerators for storage of TB specimens to maintain sample quality and integrity.
As a result, the sample referral system has reduced the turn-around time for processing and receipt of results for TB samples from 10 days to less than 24 hours. This has also increased access to GeneXpert leading to increased bacteriologically confirmed cases as well as timely initiation to treatment for patients diagnosed with TB and increased initiation of TB preventive therapy (TPT) for under 5s as contact tracing activities are initiated early enough. TPT is given to children under five who are household contacts of individuals with active and infectious TB. It is also given to children of up to 14 years of age who are newly diagnosed and living with HIV.
Improving Pediatric TB Treatments
TB contact tracing is a gateway for active case finding and TB treatment Prevention Therapy (TPT) initiation.
To identify children infected with TB, the project employed a facility- and community-based approach. At the facility level, the project engaged 76 cough monitors who were trained on TB screening and then deployed at the targeted entry points of health facilities. TB screening was integrated in to outpatient department (OPD), maternal and neonatal child health (MNCH), nutrition, HIV Clinic, and pediatric in-patient departments (IPD) in all the implementation facilities by use of a developed CaP TB intensified case finding (ICF) and CaP TB optimization forms. Cough monitors carry out active TB screening for children, while clinicians conduct further screening to confirm if the child is a true TB presumptive case.
Community health volunteers identify children exhibiting symptoms of the diseases at the community level and refer them to hospital for testing and treatment. They also monitor progress of TB patients as they take medications, advising patients on recommended nutrition practices and importantly contact tracing.
Because of their contribution to increased TB diagnosis, CaP TB recommends integration of cough monitors in routine TB services to support intensive case finding and linkage of presumptive cases for diagnostics, treatment and TPT.
Line-listing: Improving TB Preventive Therapy Coverage
To increase coverage and uptake of TPT among child contacts under 5 years the project intensified TB contact identification through listing and tracing to improve access and coverage of TPT.
Contact listing is conducted by clinicians at the time of TB treatment initiation in the contact management register and supported by cough monitors who inquire about the patient’s household contacts. The contacts are allocated to CHVs to conduct house hold investigation and refer eligible children for TPT and TB diagnosis to health facility. This strategy has been observed to yield more contacts compared to when it’s done in the course of TB treatment.
More Stories from Homabay County
Unitaid is a global health agency engaged in finding innovative solutions to prevent, diagnose and treat diseases more quickly, cheaply and effectively, in low- and middle-income countries. Our work includes funding initiatives to address major diseases such as HIV/AIDS, malaria and tuberculosis, as well as HIV co-infections and co-morbidities such as cervical cancer and hepatitis C, and cross-cutting areas, such as fever management.
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Team EGPAF
Kenya
Tuberculosis
