Diagnostic practices and estimated burden of tuberculosis among children admitted to 13 government hospitals in Kenya: An analysis of two years’ routine clinical data

Abstract

Background True burden of tuberculosis (TB) in children is unknown. Hospitalised children are low-hanging fruit for TB case detection as they are within the system. We aimed to explore the process of recognition and investigation for childhood TB using a guideline-linked cascade of care. Methods This was an observational study of 42,107 children admitted to 13 county hospitals in Kenya from 01Nov 15-31Oct 16, and 01Nov 17-31Oct 18. We estimated those that met each step of the cascade, those with an apparent (or “Working”) TB diagnosis and modelled associations with TB tests amongst guideline-eligible children. Results 23,741/42,107 (56.4%) met step 1 of the cascade (≥2 signs and symptoms suggestive of TB). Step 2(further screening of history of TB contact/full respiratory exam) was documented in 14,873/23,741 (62.6%) who met Step 1. Step 3(chest x-ray or Mantoux test) was requested in 2,451/14,873 (16.5%) who met Step 2. Step 4(≥1 bacteriological test) was requested in 392/2,451 (15.9%) who met Step 3. Step 5(“Working TB” diagnosis) was documented in 175/392 (44.6%) who met Step 4. Factors associated with request of TB tests in patients who met Step 1 included: i) older children [AOR 1.19(CI 1.09–1.31)]; ii) co-morbidities of HIV, malnutrition or pneumonia [AOR 3.81(CI 3.05–4.75), 2.98(CI 2.69–3.31) and 2.98(CI 2.60–3.40) respectively]; iii) sicker children, readmitted/referred [AOR 1.24(CI 1.08–1.42) and 1.15(CI 1.04–1.28) respectively]. “Working TB” diagnosis was made in 2.9%(1,202/42,107) of all admissions and 0.2%(89/42,107) were bacteriologically-confirmed. Conclusions More than half of all paediatric admissions had symptoms associated with TB and nearly two-thirds had more specific history documented. Only a few amongst them got TB tests requested. TB was diagnosed in 2.9% of all admissions but most were inadequately investigated. Major challenges remain in identifying and investigating TB in children in hospitals with access to Xpert MTB/RIF and a review is needed of existing guidelines.

Perspectives and practices of health workers around diagnosis of paediatric tuberculosis in hospitals in a resource-poor setting – modern diagnostics meet age-old challenges

“…This was an exploratory qualitative study using an embedded case study approach [20], where the broader 'case' of TB policy implementation (investigated at national level), and individual case studies (indepth studies at the hospitals) are embedded within the study. It was designed to provide an understanding of the reasons for the low case detection of TB in children and minimal use of available diagnostic tests including Xpert® in Kenya [4,5].…”

“…Although most Kenyan county hospitals now have the machines, there is a wide policy-practice gap. Many TB patients (especially children) do not seem to bene t-over 80% have a clinical diagnosis alone and only around 1% have documented use of Xpert® [4,5]. Given its potential to improve diagnosis due to same day results, and the effort and resources put into making it available, it is important to try to understand the reasons for underuse of Xpert®, and to identify challenges relevant to the use of it and other newer diagnostics.…”

“…Alongside the underuse of Xpert® for the diagnosis of TB in Kenyan county referral hospitals, studies have found a general problem with the diagnosis of TB among children-very few children with suggestive symptoms get a proper history and examination as per the TB guidelines [5,8]. Documented constraints to diagnosing TB in children include the fact that TB mimics many other childhood illnesses; di culty in obtaining suitable specimens; and low sensitivity of available tests leading to low adoption and poor utilisation [4,5,[9][10][11][12]. A qualitative study from Peru (a high TB burden, low-resource setting) also identi ed constraints to diagnosing TB in children related to ignorance and stigma; limited access to diagnostic tests; inadequately trained health centre staff; and provider shortages [13].…”

“…Understanding these "old systems"-the context into which the new equipment is introduced, is essential to identifying practices and behaviours that are likely to enhance or constrain uptake and use. This study built on quantitative descriptions of TB detection and management in Kenyan public hospitals [4,5] and aimed to understand how context in uences/shapes TB case detection and use of TB diagnostic tests including Xpert® in children within these hospitals. It was undertaken as part of a larger body of work describing the epidemiology, adherence to clinical guidelines and use of diagnostics for childhood TB in Kenya to develop theorydriven contextually-appropriate interventions to address the gaps in detection of TB in children by targeting potentially modi able in uencers (Additional File 1).…”

Perspectives and practices of health workers around diagnosis of paediatric tuberculosis in hospitals in a resource-poor setting – modern diagnostics meet age-old challenges

“…They included paediatricians, medical o cers, nurse managers and public health o cers, selected due to their roles in management to explore perspectives of heads of wards/mid-level managers in the care of children with tuberculosis in Kenyan hospitals. Phase 2: Based on emerging quantitative ndings from the broader TB study [4,5], and to further explore issues identi ed in Phase 1, an in-depth study of health care provider perceptions and practices was undertaken in two purposively selected busy CIN hospitals (paediatric admissions > 1000/year). Both hospitals were in counties with a high burden of TB but one hospital had low numbers while the other had high numbers of TB cases identi ed [7], and were selected to explore common and unique issues in uencing diagnosis of TB in children.…”