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Scaling up of management of childhood tuberculosis in Bangladesh

Patients sit in the non-paying sick ward at the National Institute of Diseases of Chest and Hospital in Dhaka, Bangladesh. © 2014 Probal Rashid, Courtesy of Photoshare

Research Overview

TRAction is funding a study examining the effectiveness of tuberculosis (TB) interventions and services whose aim is to improve case control of tuberculosis in children in Bangladesh.  This implementation research and delivery science study tailored the intervention based on a comprehensive situational analysis conducted at baseline, acknowledging stakeholder involvement as a key component for successful scaling up. 

Among 22 countries where TB is considered “high burden,” Bangladesh is ranked 6thwith a mortality rate of 45/100,000 and an incidence rate of 225/100,000 annually.  The National Tuberculosis Control Program (NTP) is credited with implementing directly observed therapy short course (DOTS) countrywide as of 2006 with an impressive 92% treatment success rate. Unfortunately, limitations in reporting and data capture create difficulties in understanding the effect of this burden on Bangladesh’s children.  By some estimates, up to 11% of the total burden of disease can be attributed to childhood TB but the country’s capacity to treat TB has largely centered on adults, creating a need for child-specific interventions.  In particular, the Government of Bangladesh is concerned that this information gap could be an element in explaining the high prevalence of under nutrition despite gains in health elsewhere.

Diagnosing TB in children is difficult because of barriers to access but also because of the “non-specific clinical manifestations” that the disease may take, especially in young children. Where adults develop cavitation in their lungs, this symptom does not always present in children making false-negative diagnoses more common than the National Tuberculosis Control Program (NTP) is able to capture.  Other biological facets that make detection difficult in children include lower sputum production and the more complex lab-based processes necessary to bacteriologically verify the presence of TB in children.  When coupled with resource constraints in the health system generally, research into the effects and prevalence of TB in children is necessary to better understand the true burden of childhood TB on population health.

Project Location

Bangladesh: Dhaka

Research Objectives

Primary Objective: to understand whether childhood tuberculosis can be managed at the community-level within the health system by implementing a package of interventions including: involvement of policy makers, capacity development of health professionals and field workers, facilitating logistic support and improving community awareness.

Secondary objectives:

  1. Improve health providers’ capacity for screening, referral, diagnosis and management of childhood TB through tailored training,
  2. Facilitating adequate and timely logistical arrangements,
  3. Increase community awareness of TB in children

Study Approach

Researchers employed a mixed methods, longitudinal approach with a pre and post-evaluation questionnaire.  153,400 children were selected into the study from one of three sub-districts using a convenience sampling approach with geographic locale and existing TB control capacity as the selection criteria. A situational analysis was conducted at baseline to identify appropriate community stakeholders for inclusion in the mobilization component of the study.  A capacity assessment was carried out for existing government-affiliated TB control structures and personnel so that trainings could be tailored appropriately.  To gauge community awareness, the researchers employed a quantitative survey gauging knowledge and attitudes at baseline and endline.

Key Findings

Evaluation of these interventions showed that the proportion of case detection among children increased how much (range) in all sites compared to baseline with relatively higher proportion in urban site. Interestingly, there were more female TB cases than male cases (80 vs 10 in 2014), and majority of the children were affected by extra-pulmonary TB. Awareness regarding child TB symptoms and subsequent management among target populations increased significantly compared to baseline. However, the supply and maintenance of necessary diagnostics remained suboptimal. There was no provision of X-ray machines in urban study clinics, while poor maintenance and lack of skilled radiographers were observed in health complexes in rural sites.

Research into Action 

The study’s results will identify strategies for improving TB control activities to be more responsive in detecting and managing the childhood TB burden in Bangladesh. This study will also provide evidence in the form of feedback to improve the operation of the NTP and toward improving the function of overall TB control activities.

Implemented by

International Centre for Diarrheal Disease Research (icddr,b)

Principle Investigator: Dr. Taheem / Dr. Ziaul Islam

Project Status

 

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