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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, David Geffen UCLA School of Medicine
Project dates: February 2015 - June 2019

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:

The project has ended as of June 2019. The team conducted a cluster-randomized study in San Juan, Batangas and Los Baños, Laguna to assess the package of interventions. San Juan has 42 and Los Baños, 19 barangays (communities). Barangays were randomly assigned as control or intervention. BHWs and midwives in the intervention group underwent training as regards the study procedures, including use of the mobile app for notification of positive tests of their patients for faster contact tracing, nasopharyngeal aspiration and referral of children assessed in the Integrated Management of Childhood Illness to the National TB Program (NTP) staff in the clinic. BHWs and midwives in the control group were informed of the study, no additional training was provided. At the time of referral to the NTP, research staff obtained informed consent and assent (as appropriate) for study participation. Those in the intervention group who cannot expectorate underwent nasopharyngeal aspiration for smear, Xpert and culture.

From September 2015 to August 31, 2017, 1,017 children with presumptive TB and 1,075 adults with diagnosed TB were screened. Among the children screened, 586 (57.6%) and 431 (42.4%) were eventually enrolled in the intervention and control groups, respectively, and among adults enrolled 562 (52.2%) and 513 (47.7%) in the intervention and control groups, respectively. Among children, there were more presumptive TB cases in the Intervention group, with more coming from Los Baños compared to San Juan among those who were enrolled. The majority of presumptive TB cases were identified during contact tracing followed by the IMCI program. Similarly, there were more diagnosed TB cases in the intervention group. Among adults, there were 562 and 513 enrolled in the intervention and control groups, respectively.

They found that the package of intervention improved identification of presumptive TB cases, but did not significantly increase detection of TB cases and latent TB infection cases. The majority of the presumptive TB cases were identified through contact tracing and the children were mostly exposed to TB cases in the household. The team's findings support that improving and consistently monitoring contact tracing will improve identification of presumptive TB cases. In addition, identifying cases in the IMCI also contributes to identification of presumptive TB cases. Nasopharyngeal aspiration was also tolerated and found acceptable by parents and children alike.

These are preliminary results from the study. Both San Juan and Los Baños are now implementing screening for TB during IMCI visits, as well as consistently screening and inviting household contacts for TB. It is important to disseminate these results, as they should be helpful in further screening for TB and referring cases for treatment.

PEER Health Cycle 2 Recipients