A collaborative approach to improve management of childhood

TB – PATH’s fieldexperiences

Fozo Alombah (MD)Global HIV/TB Program

PATH

We can find the missing cases

A Collaborative approach to diagnosing TB in children……..

National Average

Tanzania – Implementation Phase

Onset of interventions

National guidelines and training materials developed

Providers trained to recognize TB in children

Providers receive ongoing mentorship and consultation on challenges

More children accurately diagnosed with TB

More children treated for TB and living healthier lives

How did we do it?

Assessment

Steps

• Guidelines training materials & Job Aids developed

• Training: 49 TOT and 812 HCWs

• Active TB screening introduced

among children in 258 health facilities

• Increased supervision and on-the-job training

• Screening tool (score chart) introduced with simple algorithm

Tools

• A ten-module, five-day training curriculum.• A manual for in-country master trainers.• Easy-to-read posters and job aids that guide health

care providers through the steps of diagnosing TB in children.

• A screening tool, score chart, and algorithms.• Registers known as “counter books” in which

providers track screenings and results.

Truly collaborative endeavor

• NTLP in collaboration with PATH & ICAP

• A multidisciplinary technical expert group (central level) – pediatricians, PH

physicians, clinicians, nurses,

– monitoring and evaluation officers

– experts from Dartmouth's Geisel School of Medicine.

• A cadre of 49 master trainers trained 812 providers from– pediatric wards – reproductive and child

health departments– care and treatment clinics,

and – TB clinics at the district and

regional hospitals.

• Community health workers

Helen, a clinician from the Kitunda Health Center dispensary started using the score chart for diagnosis of pulmonary TB after training.

“I might have missed many children because of lack of awareness on pediatric TB. If I had known this scoring chart before, I would have saved many lives.”

Any impact?

• 8-year-old Aisha Aisha living with HIV

• 3 months history lethargy and swelling node

• Helen used score chart to diagnosed TB lymphadenitis

• started her on anti-TB drugs the same day

• 3 weeks after put on ARV• Completed TB treatment• returned to school and lives a

happy life after

Community Health Management Team member,

“Having received this sensitization, we do follow-up of all cases reported as pneumonia

or bronchitis to know exactly whether they are diagnosed

correctly and [clinicians] don’t miss TB. We do this during our routine supportive supervisions

• A five year Pediatric TB project is planned by NTP in DRC (SP)• An assessment of 73 facilities was conducted in 2012 to inform the pilot.

Key findings:Burden

Children comprised 14.17%

of total TB cases Lack of implication of childcare

providers

Screening: N=73 Screening TB (all): 3% Screening TB (cough): 62% HIV Screening TB: 48%

Training 65 (4.2%) of 1554 doctors

trained 43 (1%) of 4165 nurses trained

Management: N=73 Co-management TB/HIV : 53% Cotrimoxazole: 67% ARV: 26% IPT: 0%

Democratic Republic of Congo – Pilot Phase

Democratic Republic of CongoInterventions:

• Collaborative framework

• National guidelines and algorithm

• Training curriculum Developed

• One year pilot launched on 7 sites in December 2013

• Focus on PMTCT, IMCI, HIV care & support

Lessons learned• A good situational analysis is important to adequately identify the issues

to be addressed

• Lifting childhood TB out of the shadows requires strong national commitment (central & peripheral)

• A partnership between TB community and research institutions increases buy-in

• A truly collaborative approach between the health system, key stakeholders and community creates ownership

• Long-term investment by governments and the entire child health community is necessary for sustainability

Challenges• Lack of tools in the field to adequately disaggregate and

track child TB cases

• Lack of adequate incentives to retain trained local expertise

• Organizing systematic contact tracing (cost, geography)

• Lack of appropriate diagnostics and drug formulations

• Emergent drug resistant TB among children

Thank You

Acknowledgements

Funding for this work came from United States Agency for International Development (USAID) under USAID’s TB IQC Task Order 01

Special thanks to:• NTP - Tanzania• PNLT - DRC• Dartmouth College - Children's Hospital• National Pediatrics Society - DRC