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Effect of a smoking cessation intervention program for families of children diagnosed with TB

PI: Benjamin Sablan, Philippine Ambulatory Pediatric Association
NIH Partner: Jonathon Winickoff, Massachusetts General Hospital and Harvard Medical School
Project Dates: February 2015 - June 2018

Project Overview:

The Philippine Program for Tuberculosis has largely focused on adult TB. Recently childhood TB has been addressed because they have more serious clinical presentations and the patients usually become the reservoir for adult TB cases. However, issues on the implementation of the childhood TB program identified problems with the clinical diagnosis and treatment of children with TB. As a result, the Philippines case detection rate for childhood TB is very low at twelve percent (12%). Children are a particularly vulnerable group with a developing immune system exposed to environmental modulators affecting this system. Substances found in tobacco have been shown to have effects not only in carcinogenesis, but in the susceptibility to diseases such as TB. In the 2011 Global Youth Tobacco Survey, it showed 48% of youth are exposed to smoke inside the homes. The study aims to look into correlation of serum cotinine levels due to tobacco use and exposure to second hand smoke (SHS) in children diagnosed with active and latent TB disease. It also aims to look into effects of a brief advice on smoking cessation and a tobacco control resource center in a community health center on outcomes of treatment of active cases of TB in children. Specifically, the study would like to look into the following: 1. The correlation of the level of urine cotinine, used as a proxy measure of secondhand smoke exposure, with the development of active TB and latent TB in children; 2.To determine the effect of a brief advice on smoking cessation on the number of quit attempts of smoking parents and/or guardians of the child diagnosed with pulmonary TB; and 3. To determine the effect of secondhand smoke exposure of children diagnosed with pulmonary TB on time to resolution of the child’s clinical signs and symptoms related to TB. The research proposed is a case control study on a community in Pampanga with a population of 230,000. Exposure to tobacco use and SHS will be determined with a validated interview tool developed by Richmond Center and the USG-supported partner which will be translated and adapted to the local environment and correlated with levels of urine cotinine. The urinary cotinine levels will be compared among those children without TB disease and with TB disease, both latent and active. A tobacco cessation intervention composed of brief advice by healthcare workers will be conducted on TB patients identified to have been exposed to tobacco or SHS. The effect on treatment of TB in children will be correlated with smoking cessation or decreased exposure to SHS and levels of urinary cotinine. The computed sample size for this study is two hundred fifty (250) children. The primary hypothesis is that tobacco use and SHS exposure predisposes children to TB disease. The second hypothesis is that a brief advice for smoking cessation will increase quit attempts and quit rates of smoking which will result in decreased levels of exposure to SHS.

Summary of Recent Activities:

The study was completed in June 2018. The study took a convenience sampling of all children identified as suspect for TB in Mabalacat and Guagua Pampanga, Philippines which yielded 327 children were enrolled in the study. Using an adapted survey for second hand smoke exposure from the Richmond Center, parents and caregivers were identified as smokers and children’s exposure to SHS was confirmed. All children were screened for TB and samples taken for urine cotinine. Using HPLC Elisa test, urinary cotinine concentration was determined. Findings showed all three groups of children, no TB, TB infection and TB disease to be comparable in age, sex and nutritional status. There was no significant difference in the urinary cotinine levels in the three classes of patients (p=0.7703). However, there was an association found between the disease state and the number of smokers in the household (χ2=14.1768, p=0.028). For the second objective, brief advice was seen to increase quit attempts of adult smokers significantly. Lastly, there was no relationship noted on the effect of SHS to the time to improvement of signs and symptoms associated with TB in children.

This prospective study concluded that the number of smokers in the household was shown to be significantly correlated to the child’s development of TB infection and TB disease. Determining the number of smokers in the household should be an important step to identify children at risk for TB. The researchers were able to validate the measurement of urine cotinine using HPLC Elisa technique which can serve as an alternative to HPLC Mass Spectrometry, especially in resource limited locations in the country. Finally, brief advice to smoking cessation was shown to produce more quit attempts among smoking adults when delivered in the context of a child suspected or diagnosed to have TB.

PEER Health Cycle 2 Recipients