How do private practitioners in Pakistan manage children suspected having tuberculosis? A cross sectional study

Abstract

Background In Pakistan, private providers provide a large portion of health care, including for tuberculosis (TB). All TB patients are supposed to be reported to the National Tuberculosis Program (NTP), which provides drugs free of charge in addition to monitoring, supervision, and support. However, diagnosis of TB in children is difficult. We aimed to assess the private health care providers’ investigation practices and management of childhood TB. Methods We used a cross-sectional study, which was based on a national survey measuring under-reporting of children with TB in 12 selected districts in Pakistan from April–June, 2016. We explored the practices of the private health care providers, including the health care workers i.e. general practitioners, pediatricians, pulmonologists and chest specialists, who were involved in the diagnosis of TB in children under 15 years for investigating and managing children suspected having TB. Results Among 6519 presumptive child TB cases, a total of 5193(79.7%) children under 15 years were diagnosed as TB by private health care providers during second quarter, 2016. Only 187(2.9%) were notified to NTP. The majority of presumptive child TB cases reported cough, fever, and failure to thrive; few had TB contacts with pulmonary TB patients. Failure to thrive, loss of body weight and absence of BCG (Bacillus Calmette–Guérin) scar was more common in female children. Private providers relied on chest X-ray in 46.1%, while tuberculin skin test and Gene-Xpert MTB/RIF testing was little utilized. Bacteriological confirmation was present in 7.6%, and clinical assessment was the only basis for diagnosis in 39.3%. Of children with presumptive TB, only 955(14.6%) children were treated by private provider, while 3121(47.9%) cases were referred for diagnosis and 2443(37.5%) were referred after diagnosis for treatment; among all the referred, 3812(68.5%) were sent for investigations to District TB Centre (NTP). Conclusion This study showed that many private providers referred children suspected having TB to laboratories for further diagnosis, but the cases identified in these investigations were often not notified to the NTP. This problem could be resolved by strengthening the referral linkages between private health providers, NTP laboratories and treatment centres through capacity building and training of their staff.

Under-Reporting of Tuberculosis Disease among Children and Adolescents in Low and Middle-Income Countries: A Systematic Review

“…Patients with disseminated disease, more severe disease, and those under the age of five years were less likely to be reported [ 16 , 17 , 18 , 19 ]. Those diagnosed by and started on medicine by private providers were less likely to be reported to national TB registers [ 15 , 20 ]. Cases were less likely to be reported if death occurred prior to reporting/registration [ 17 ].…”

“…Private health systems also present a unique challenge. There were higher rates of under-reporting from the private sector reported in Kenya, India, and Pakistan [ 15 , 20 , 21 , 23 , 30 ]. Private practitioners often do not have direct links to national TB programs and thus may not provide data to NTPs.…”

“…Private practitioners often do not have direct links to national TB programs and thus may not provide data to NTPs. They frequently need to refer patients to TB clinics, but referral systems are weak [ 20 ]. Incentives, treatment access, and costs were brought up as challenges for private practitioners with fewer cases reported when private practitioners started treatment themselves as compared to referring children to the public system to commence TB treatment [ 20 ].…”

“…Methods of diagnosis can also differ. One article from Pakistan found that private practitioners were more likely to diagnose TB disease based on X-ray and clinical criteria rather than bacteriologically confirmed samples [ 20 ]. Education and standardization may also play a role with one study noting that private practitioners were less likely to utilize national TB guidelines for diagnosis [ 21 ].…”

“…In addition, the adolescent population was not frequently referenced individually in our included studies. One study from Pakistan highlighted that the adolescent population is unique in potential means of spread in schools and in patients’ ability to produce sputum for testing when compared to younger populations [ 20 ]. Further studies focusing specifically on this population may identify additional opportunities for improvement in adolescent TB reporting.…”