Diagnosis, treatment and management of pediatric tuberculosis in health emergencies and disasters PI: Salvacion Gatchalian, University of Philippines, College of Medicine, Philippine General Hospital NIH Partner: Kristy Murray, Baylor College of Medicine Project Dates: February 2015 - April 2019 Project Overview: Background: The province of Bohol was recently struck by earthquake and swept by Typhoon Haiyan, creating destruction and interruption of health services. Included in the disruption were TB screening, prevention and DOTS programs. In addition to concerns over the disruption of services, extensive crowding in emergency shelters and camps potentially put children at higher risk for exposure to TB. Study Rationale: Although there is very limited evidence to guide TB control strategies during displacement following natural disasters, interagency guidelines have been developed to address TB treatment in the acute and recovery periods following a complex emergency. The importance of reconstructing TB services during the post-conflict phase is well recognized and requires coordination and collaboration among key stakeholders. Experience has demonstrated that major impediments to successful reconstruction of TB services include mobile populations, destroyed infrastructure, and lack of coordination and/or interest in TB treatment, leading to poor case detection and sub-optimal TB control. However, all of these challenges are also opportunities to introduce interventions to improve TB control. Proposed Design: (1) Cross-sectional cluster survey using rapid assessment methods to determine the prevalence of TB infection and disease in children under age 15, and (2) a descriptive study using social science mixed methods to assess barriers to pediatric TB control, prevention, and treatment post-disaster. Anticipated Outcome: Assessment of prevalence and risk of TB infection and disease among children displaced by health emergencies and disasters. An understanding of how the disasters impacted TB treatment, prevention, and control. Objectives: To assess prevalence of TB infection and disease in children under age 15 in Bohol and determine if risk for TB disease increased due to displacement associated with densely populated transitional housing, or increase in household members resulting from natural disasters affecting the island in 2013. Aim 1: Estimate prevalence of TB disease in children in the community and those currently residing or having a history of residing in disaster camps/shelters in Bohol using rapid assessment cross-sectional cluster survey methods. Aim 2: Assess correlation between validated risk factor assessment score and positive TB cases and compare actual prevalence of TB to baseline as well as differences in prevalence in displaced versus non-displaced children. Aim 3: Examine sensitivity and specificity of GeneXpert in sputum and stool as compared to direct smear. Aim 4: Document barriers to implementation of IPT and document additional barriers/disruption of services that occurred post-disaster. Final Summary of Project Activities: After receiving approval from the ethics review committee of the University of the Philippines in November 2015, Dr. Gatchalian and her team carried out their study from 2016 through 2018 in the province of Bohol, Philippines, which experienced a strong earthquake in October 2013 and was hit by the extremely severe Typhoon Haiyan in November 2013. The study participants included children ages 0-14 who lived in 184 barangays (villages) located in 14 municipalities (towns), comparing areas heavily affected and less affected by the natural disasters. The original target sample size was 4,200 children, but the team ultimately enrolled 5,475. The researchers found that the prevalence of TB in children was affected by living in a temporary shelter (evacuation center) with more than 25 persons; older age of children; history of prior treatment for TB; known contact with a person with TB; living on a geographically isolated island; and greater distance from healthcare resources. Based on their findings, the team designed three risk assessment tools to help identify children at risk of TB infection. They conducted a stakeholders meeting on August 13, 2018, to share their results and tools with the province’s governor and representatives from all 14 municipalities involved in the study, including mayors, municipal health officers, National Tuberculosis Program coordinators, and community health workers. U.S. partner Dr. Kristy Murray and her student Lauren Leining, who assisted with spatial analysis on the study, also took part. The PEER team also had a separate meeting later with the province’s health officer, who expressed concern over the findings and shared his interests in looking at the prevalence of TB among schoolchildren. Also in August 2018, Dr. Gatchalian and her colleagues presented their work at the annual convention of the Philippine Coalition Against Tuberculosis (PhilCat), which attracted some 1,500 delegates from governmental and non-governmental institutions working on TB, as well as relevant professional societies. Sadly, PI Dr. Sally Gatchalian passed away due to COVID on March 26, 2020. Her legacy will live on in the memories of her patients, students, fellow researchers, and friends, and her research continues to move forward thanks to the efforts of her colleagues. As of the date of the final report submitted by her institution in early 2021, the team had published three papers and had one more in preparation. Publications: Murray, Kristy O.; Castillo-Carandang, Nina T.; Mandalakas, Anna M.; Cruz, Andrea T.; Leining, Lauren M.; and Gatchalian, Salvacion R. on behalf of the PEER Health Bohol Pediatric Study Team. Prevalence of Tuberculosis in Children After Natural Disasters, Bohol, Philippines. Emerging Infectious Diseases 2019; 25(10):1884-1892. https://dx.doi.org/10.3201/eid2510.190619 Leining, Lauren M.; Gatchalian, Salvacion R.; Gunter, Sarah M.; Castillo- Carandang, Nina T.; Mandalakas, Anna Maria; Cruz, Andrea T.; McCormick, Joseph B.; and Murray, Kristy O. Geospatial and hot spot analysis of paediatric latent tuberculosis infection in Bohol, Philippines. Epidemiology and Infection 2020;148:e89. https://doi.org/10.1017/S0950268820000795 Gatchalian, Salvacion R.; Agathis, Nickolas T.; Castillo-Carandang, Nina T.; Gunter, Sarah M.; Murray, Kristy O.; and Mandalakas, Anna M. Design and evaluation of risk assessment tools to identify pediatric tuberculosis infection in Bohol, Philippines, a low HIV-high TB burden setting. The American Journal of Tropical Medicine and Hygiene 2020. https://doi.org/10.4269/ajtmh.20-0244 PEER Health Cycle 2 Recipients