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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:

As of March 2017, the study team has completed more than 1.5 years of participant enrollment in San Juan and Los Baños. Active case findings among household contacts as well as passive case finding continue to be conducted. Weekly monitoring is conducted at both sites. The enrollment status for children aged 0 to 14 years for both sites is as follows: Control: Enrolled, 363; TB disease, 158; Latent TB infection, 4; TB exposure, 51; Intervention: Enrolled, 488; TB disease, 154; Latent TB infection, 10; TB exposure, 101. The team has also enrolled 401 and 454 adults in the control and intervention groups, respectively. Only adults who have been diagnosed with TB are enrolled in the study and this ensures that active case finding in children is conducted. The team has tested 285 nasopharyngeal specimens from the intervention group for both Xpert and culture; 43 sputum specimens for direct smear microscopy from the control and intervention groups; and Xpert and culture from the intervention group; and 148 urine specimens for Xpert. As of February 2017, the team adapted a new technique in performing Xpert on urine specimens, using centrifugation of specimens prior to Xpert testing. Health messages on TB are now being sent to the health worker treatment partners of the TB patients as well as patients whose cellphones have been registered in the study. Ample supplies of anti-TB medications for children are available on both study sites. The team has encountered some challenges during project implementation. There were temporary technical problems encountered with the SMS messaging including wrongly-sent SMS follow-up reminders, the SMS recipients’ mobile phones have weak or no signals; and the recipients changed mobile phone numbers without informing the staff.

PEER Health Cycle 2 Recipients