Difficult to conduct contact tracing in a rural setting, TB culture services precarious
The World Health Organization (WHO) and most national tuberculosis programs (NTPs) recommend contact tracing, including the children in the household, and call for provision of isoniazid preventive therapy (IPT) for asymptomatic children less than five years old for at least six months. Nevertheless there is a major gap between policy and practice and most NTPs do not implement this policy. When they do conduct contact tracing, they frequently take a passive approach and encourage the newly diagnosed person with TB to bring their close contacts to the health care facility for screening. Mostly they don’t and this can be a huge hardship, especially in rural settings.
Based on his experience in Ethiopia, Mohammed Yassin spoke about the operational challenges implementing IPT in children during the International Union against Tuberculosis and Lung Disease in Lille, France this week.
The bottom line is that very few kids initiate IPT. When therapy is implemented, compliance is poor and poorly documented. There are also frequent drug shortages because IPT is not considered part of the overall TB control plan.
Yassin highlighted a cohort study conducted over a three year period from 2007-10 in Hawassa, Ethiopia. Patients newly diagnosed with smear-positive TB in three heath facilities were linked with health care workers who visited their homes. IPT was started for all asymptomatic children less than five years old – 184 children were connected with 84 active TB patients, and were followed for 24 months. Forty-six percent of the children less than five years old and 67 percent of the children more than five years old had a positive TB skin test (TST). Twelve percent of the children less than five and nine percent of the children more than five years old were HIV-infected.
Twenty-seven children finished at least four months of IPT but only 12 percent completed the full six months of recommended treatment. The main reason for treatment disruption was the opposition of parents about administering drugs to their healthy children for a long period of time. None of the children who initiated IPT developed TB during the study period. Eleven percent of the children more than five years old developed TB disease during the study period. Interestingly, none of the children who developed TB were HIV infected, underscoring the vulnerability of children to developing active TB disease after exposure to TB, even in the absence of HIV infection.