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Enhancing childhood tuberculosis identification and treatment in the Philippines

PI: Anna Ma. Lena Lopez, Institute of Child Health and Human Development, University of the Philippines Manila--National Institutes of Health
NIH Partner: Karin Nielsen and David Geffen, UCLA School of Medicine
Project dates: February 2015 - January 2018

PH 2-5 Lopez team photo
Los Banos Health Care Center staff. (photo courtesy of PI Lopez)

PH 2-5 Lopez NPA photo
Training for diagnosis of tuberculosis using a nasopharyngeal aspirate (NPA). (photo courtesy of PI Lopez)

Project Overview:

Childhood tuberculosis (TB) in the Philippines remains under-diagnosed, despite significant gains in the control of adult cases of TB. Learning from our experience in the previous year from a prospective community-based surveillance for TB in San Juan, Batangas, Philippines, we propose various interventions to increase case detection and improve treatment outcomes of TB in the Philippines. We propose to conduct a cluster-randomized field trial to assess the effect of an intervention package on tuberculosis case finding, treatment outcomes, and identification of children for isoniazid preventive therapy. The intervention package will be implemented in randomly chosen barangays of two study sites. Aside from the childhood TB activities included in the National Tuberculosis and Control Programme (NTP) manual, no additional interventions will be offered in the rest of the barangays. This package includes: a) enhanced contact tracing through the use of a mobile phone application (app) that automatically notifies barangay health workers (BHW) of patients enrolled in the NTP; b) reinforce public health programs such as the Integrated Management of Childhood Illnesses (IMCI) and the nutrition program requiring referral of children with prolonged cough or fever, or with acute malnutrition for assessment of TB; c) use of an USAID-funded field guide for health workers on childhood TB; d) use of nasopharyngeal aspirates as a specimen for microbiologic testing among children who cannot expectorate; e) use of a phone app that automatically informs patient’s follow-up date; and f) use of text (or SMS) blasts to provide TB health education to enrolled study subjects. This proposal will utilize existing programs as well as collaborate with a USG-supported partner who will provide support in all aspects of the proposed project, including study design, study implementation, clinical, epidemiologic and laboratory training of study personnel (if necessary), laboratory analysis of specimens, data analysis, manuscript preparation and dissemination of study findings. If proven effective, this package of interventions may be easily adapted into local practice since public health programs are already in place. Automated notifications will increase the efficiency of the NTP through enhanced contact tracing and improved case detection. Findings from this proposal can be readily implemented within the system because it uses the existing framework for health care in the communities. It uses existing technologies that may be harnessed to enhance health care delivery and TB control in the Philippines.

Summary of Recent Activities:

During the reporting period between April and June 2018, the research team focused on analyzing the data gathered from the 1,018 children (aged 0 to 14 years) enrolled in the study. Among the children, 412 were diagnosed with tuberculosis (TB) and 18 with latent tuberculous infection (LTBI). We are currently completing data analysis. More males were enrolled in both intervention and control groups compared to females (54.7% in intervention group, 55.2% in control group). The participant age varied widely. The majority of the participants were seen first at a public health facility (at least 80% for both groups), half of which were referrals from the National Tuberculosis Program (NTP) while approximately 40% were from the Integrated Management of Childhood Illness (IMCI) program. Preliminary results showed a significant difference among the diagnosis of the childhood TB suspects enrolled in the two study groups – more participants were assessed not to have TB in the intervention group (41.7% vs 32.7%), while more are diagnosed with TB in the control group (47.3% vs 35.4%) (p=0.004). This suggests that the intervention package increased the number of children being screened for TB in the intervention group. Overall, there were more presumptive childhood TB cases in the intervention group, but the difference was not statistically significant. Conversely, there appears to be no difference in the enrolled diagnosed TB cases in children. The research team will be running further analyses in the future. In addition, 1,111 adults with diagnosed TB who were part of the National TB Control Program (NTP) were enrolled during the same time period and the team has completed the follow up of the patients enrolled in the study. Several manuscripts are in preparation to be submitted to journals. As a result of the team’s experience with the automated SMS, the local government health unit has adopted a free app-based notification of the community health workers when a patient located in the area they are assigned turns up smear positive. This results in faster notification of the patient and earlier treatment.

PEER Health Cycle 2 Recipients