Intensified Tuberculosis Case Finding among Malnourished Children in Nutritional Rehabilitation Centres of Karnataka, India: Missed Opportunities

Abstract

BackgroundSevere acute malnutrition (SAM) is the most serious form of malnutrition affecting children under-five and is associated with many infectious diseases including Tuberculosis (TB). In India, nutritional rehabilitation centres (NRCs) have been recently established for the management of SAM including TB. The National TB Programme (NTP) in India has introduced a revised algorithm for diagnosing paediatric TB. We aimed to examine whether NRCs adhered to these guidelines in diagnosing TB among SAM children.MethodsA cross-sectional study involving review of records of all SAM children identified by health workers during 2012 in six tehsils (sub-districts) with NRCs (population: 1.8 million) of Karnataka, India.ResultsOf 1927 identified SAM children, 1632 (85%) reached NRCs. Of them, 1173 (72%) were evaluated for TB and 19(2%) were diagnosed as TB. Of 1173, diagnostic algorithm was followed in 460 (37%). Among remaining 763 not evaluated as per algorithm, tuberculin skin test alone was conducted in 307 (41%), chest radiography alone in 99 (13%) and no investigations in 337 (45%). The yield of TB was higher among children evaluated as per algorithm (4%) as compared to those who were not (0.3%) (OR: 15.3 [95%CI: 3.5-66.3]). Several operational challenges including non-availability of a full-time paediatrician, non-functioning X-ray machine due to frequent power cuts, use of tuberculin with suboptimal strength and difficulties in adhering to a complex diagnostic algorithm were observed. ConclusionThis study showed that TB screening in NRCs was sub-optimal in Karnataka. Some children did not reach the NRC, while many of those who did were either not or sub-optimally evaluated for TB. This study pointed to a number of operational issues that need to be addressed if this collaborative strategy is to identify more TB cases amongst malnourished children in India.

Integration of childhood TB into guidelines for the management of acute malnutrition in high burden countries

“…8 Data on TB prevalence among acutely malnourished children vary widely: 2-24% of acutely malnourished children in high TB burden settings have been diagnosed with TB. [9][10][11][12][13] The wide range observed between studies can be partly attributed to the use of varying screening strategies and access to TB diagnostics, as well as varying clinical capacity for childhood TB diagnosis and treatment among hospitalized children. Even at referral hospitals, access to diagnostic tests may be limited, 14 highlighting the need for improved access to services across all levels of the health care system, including appropriate referral pathways.…”

“…This can be challenging, particularly in resource-limited settings. 12,13 In India, evaluating for TB among children treated for SAM at nutrition rehabilitation centers resulted in a TB diagnosis for 2-9% of children, and highlighted several challenges, such as lack of qualified health care providers, limited availability of CXR and TST, and difficulties with sputum collection. 12,13 These hurdles could be overcome by increasing the capacity of health care workers to diagnose TB clinically in the absence of diagnostic tests and/or the improvement of referral systems.…”

“…12,13 In India, evaluating for TB among children treated for SAM at nutrition rehabilitation centers resulted in a TB diagnosis for 2-9% of children, and highlighted several challenges, such as lack of qualified health care providers, limited availability of CXR and TST, and difficulties with sputum collection. 12,13 These hurdles could be overcome by increasing the capacity of health care workers to diagnose TB clinically in the absence of diagnostic tests and/or the improvement of referral systems. In Malawi, among 300 children hospitalized for SAM and thoroughly investigated for TB using standard research case definitions, 27 over 25% had signs of TB exposure, <1% were microbiologically confirmed, and 7% had a probable and 66% a possible diagnosis of TB.…”

Advances in Drug Discovery and Development for Pediatric Tuberculosis

“…), virulence of the infecting organism and the immunology of the child [1, 7–9]. Cases of immunosuppression greatly increase this risk, such as age [1, 10–12], malnutrition [13, 14], diabetes, tobacco and alcohol use, or human immunodeficiency virus (HIV)[15]. As stated before, TB remains a very real threat primarily in third-world countries and is in part due to these risk enhancers.…”

Improving Tuberculosis Care for Children in High-Burden Settings

“…Chisti et al 9 prospectively investigated causes of pneumonia in severely malnourished children aged ,5 years in a hospital in Bangladesh. Of 1482 children with severe malnutrition, 405 had respiratory symptoms and an abnormal chest radiograph; TB was confirmed microbiologically in 10 reviewed TB screening at nutritional rehabilitation centers in Karnataka, India, and found that a standardized TB diagnostic algorithm was followed for only 37% of the children. They also found operational challenges at the centers, including nonavailability of a pediatrician, nonfunctioning radiograph equipment, use of an inferior tuberculin solution, and poor training of the staff.…”