Dr Amber Kumar Assistant Professor Department of Pediatrics AIIMS, Bhopal. Amber Kumar, Akashranjan Singh, Bhavna Dhingra Bhan

Transcription

1 Determinants of prevalence, adherence to RNTCP diagnostic guidelines and outcome of Tuberculosis among severe acute malnourish children admitted to nutritional rehabilitation centres of Madhya Pradesh Dr Amber Kumar Assistant Professor Department of Pediatrics AIIMS, Bhopal Amber Kumar, Akashranjan Singh, Bhavna Dhingra Bhan

2 INTRODUCTION In TB-endemic countries, the commonest age of presentation of childhood TB is between 1 and 4 years. Pulmonary TB is the commonest type of TB in children. Extrapulmonary disease is seen in around 30-40% of cases. Children who develop TB disease usually do so within 1 year following infection,[1] which is why the presentation of childhood TB is an indicator of recent and ongoing transmission of Mycobacterium tuberculosis in the community and reverse contact tracing can find out missed cases of tuberculosis. 1. Marais BJ et al. The natural history of childhood intra-thoracic tuberculosis: a critical review of literature from the pre-chemotherapy era. International Journal of Tuberculosis and Lung Disease, 2004, 8:

3 Burden of Malnutrition in MP state The level of stunting in children is above the national average in Madhya Pradesh (50%) whereas prevalence of wasting is highest in Madhya Pradesh (35%)(NFHS-4, ).[2] So, Madhya Pradesh is in the epitome of nutritional crisis with every second child in the State being malnourished. 2. International Institute for Population Sciences. National Family Health Survey - 4 ( ) [Internet]. Mumbai; Available from:

4 Complex interplay of Tuberculosis and Malnutrition The immune response to TB infection is complex, initially involving the uptake of the bacterium into macrophage cells,, and later recruitment of both B- and T-lymphocytes of the cellular immune response. These cells isolate the bacterium as a granuloma, typically in the lung and lymph nodes.[3] Active tuberculosis occurs when the infection is no longer contained by the immune system, and can occur at any time as in malnutrition and other immunodeficiencies. The reverse is also true as the infection may cause undernutrition through increased metabolic demands and decreased intake. Saunders BM, Britton WJ. Life and death in the granuloma: immunopathology of tuberculosis. Immunology and Cell Biology2007;85:

5 Justification for the conduct of this study We propose that the actual burden of childhood TB is likely to be higher than the earlier reported estimates and the low rate is likely due to poor case detection due to nonadherence to diagnostic guidelines of TB screening and simultaneously we wanted to explore the health system challenges for the screening of Tuberculosis.

6 In view of the above, this retrospective study was carried out with the following objectives: Among Severe Acute Malnourished children admitted at Nutritional Rehabilitation Center s of Madhya Pradesh in year To estimate the prevalence of TB, 2. Determine the level of adherence to diagnostic guidelines of TB screening 3. To assess the initiation & completion rate of tuberculosis treatment. 4. To explore the health system challenges for the screening of Tuberculosis

7 Material and Methods Mixed-methods study (Explanatory design) 1. The quantitative data collection (phase I Cross sectional study; Record review) To estimate the prevalence, Determine the level of adherence to diagnostic guidelines of TB screening and To assess the initiation & completion rate of tuberculosis treatment among those who diagnosed as tuberculosis. 2. Qualitative data collection (phase II - focus group discussion and Keyinformant interview) To explore the health system challenges for the screening of Tuberculosis among SAM children admitted at NRC s.

8 Material and Methods. Study period February 2018 to May Study subjects Ethical clearance Children with SAM, who were admitted to the NRC s of district Sagar & Sheopur in the year 2017 IHEC, AIIMS, Bhopal Programmatic approval National Health Mission, MP The selection of district Sagar and Sheopur was purely purposive, based on the consensus among the investigators and other stakeholders (NHM-MP)

9 RESULTS Of the 3,230 children admitted at NRC s, 63% were identified and referred from Anganwadi centers, 11% by community (i.e. doctors, paramedical workers, NGO etc.) and for 26%, the source of referral was not recorded. The Number of children screened for TB (n-2989) as per guidelines were 1.8% (55/2989), however a total of 7% (209/2989) children diagnosed as having TB disease. Of these 209, the microbiologically confirmed (AFB/CBNAAT positive) cases were 23. However, all these 209 diagnosed TB cases were initiated on anti tubercular treatment (ATT)

10 Care pathway of TB diagnosis & management as per guidelines for SAM children admitted to Nutritional Rehabilitation Centers of Sagar & Sheopur district in year 2017

11 Care pathway...

12 Time-gap between NRC admission and DOT initiation among children diagnosed as TB disease at NRC

13 Perceived challenges related to screening of TB among children admitted at NRC by Healthcare workers of NRC & RNTCP, Madhya Pradesh (2017)

14 Discussion This study showed only 7% prevalence of tuberculosis in children with severe acute malnutrition, compared to results of other studies with prevalence of 4-20%. The low incidence is likely due to poor case detection. 1. Children below the age of 7 years cannot produce sputum. 2. Paucibacillary nature of childhood TB 3. Non adherence to diagnostic guidelines The revised Technical and operational guidelines of RNTCP recommend up- front testing of sputum and /or gastric lavage with a molecular TB diagnostic test among presumptive pediatric pulmonary TB (PTB) patients. Sunguya Bruno (2006) Effect of infections on severe malnourished children in KilifiMombasa and Dar Es Salaam: A Comparative Study. DMSJ 2006 Vol. 14 (Suppl.1)

15 Strength of the study Mixed method design. The sampling frame was the calendar year 2017 to minimize seasonal variation. The data of quantitative phase was obtained from the records of both the programmes(i.e. NRC and RNTCP) and been triangulated to make the conclusions. The quantitative and qualitative phases of study were in the compliance to STROBE and COREQ guidelines respectively

16 Limitations It is not appropriate to generalize the findings of quantitative phase of study for the entire state. However, findings from the qualitative phase won t be very different for other districts.

17 Conclusions & Implications of the study The Severe Acute Malnourished (SAM) children admitted at Nutritional Rehabilitation Center s (NRC) provides a window of opportunity for screening and Management of TB at an early stage as well as for reverse contact tracing. The greatest concern is on Nonadherence to diagnostic algorithm as well as overreliance on Mantoux test

18 Recommendations of the study based on the quantitative and qualitative results 1. Reforming and reinforcement of result oriented quality training methods with periodic evaluation Proper training of health workers on gastric aspirate collection, induced sputum collection, TST method, interpretation and significance with more emphasis on history taking to find out constitutional symptoms/ contact tracing/ clinical Examination and definition of true TB contact. Standardized and simplified mechanism of record keeping should be prescribed for health workers. The evaluation of training should be based on Kirkpatrick Model, which is one of the best-known model for analyzing and evaluating the results of training programs.

19 Figure : Training evaluation model for NRC staff based on Kirkpatrik model

20 Recommendations 2. Uniform adoption of RNTCP guidelines at NRC: Active screening of tuberculosis in all children of SAM with molecular diagnostic test 3. Integration of NRC with TB Centre s for TB treatment and follow-up 4.To increase Resources for detection of Extra Pulmonary Tuberculosis

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