A Cross sectional study of IPT Adherence among childhoodcontacts of smear-positive Pulmonary TB

Introduction

Tuberculosis is one of the leading causes of morbidity and mortality globally and children are estimated to represent between 13% and 15% of cases in high TB burden countries Young children have a high risk of TB infection and disease progression because of their intimate contact with adults with pulmonary TB (PTB) and immature immune system. Isoniazid (INH) Preventive Therapy (IPT) has been shown to prevent new infections and inhibit progression from infection to TB disease. TB control programmes however rarely have the resources and manpower for implementation and several studies have reported that adherence to IPT is generally poor. There is no information on patterns of adherence to IPT and the incidence of TB among children in contact with adults with PTB in India. This study therefore aimed to determine the level of IPT adherence of children in contact with adults with smear-positive PTB and the incidence of TB among children receiving and not receiving IPT.INH preventive therapy is one of the key intervention recommended by WHO to reduce the burden of TB in people living with HIV. Child contact screening and management has great impact on reduction of tuberculosis morbidity and mortality among children by reducing progression of infection to disease state. Though the transmission of tuberculosis from children to others is less, they may form the pool of infection for future.^1-4

There are very few studies on this topic in India and hence the current study was taken up with the objective to determine the level of IPT adherence of children in contact with adults with smear-positive PTB

Materials and Methods

After obtaining permission from State & District TB Cell, the three districtswere randomly selected namely Bangalore urban, Ramanagara and Chitradurga districts. TB officers of three districts were requested to assist in the study. All the TB units were listed in each district and one TB Unit was selected randomly.Three tuberculosis units selected were Jagajeevan Rao Nagara TB unit form Bangalore, Kanakapura Tuberculosis unit from Ramanagar and Holalkere tuberculosis unit from Chitradurga district. Medical officer’s in-charge of TB units and staff working in these TB units were approached and briefed regarding the project objectives, methodology, and there cooperation in conducting the project work was done. All the three TB units in different districts were visited by the project investigator and sensitization of the staff was carried out.

All household contacts of sputum smear positive Pulmonary Tuberculosis patients who were aged <6years, registered under RNTCP in these three different Tuberculosis units in the last quarter of 2014 (Oct-Dec) and first quarter of 2015 (Jan-Feb) were considered for the study. All diagnosed TB patients initiated on treatment were registered in a TB register at Tuberculosis Units, which were maintained by a paramedical supervisory staff (also called as Senior Treatment Supervisor). Using these treatment registers and patient treatment cards, the cases were identified. Households of all these cases were traced using the address details given in the card. An interview of the Patient or head of the householdwasconducted in the local language (Kannada) by trained field investigators using a semi-structured interview schedule, after taking informed consent. Information was collected on the number of household contacts aged <6 years, whether they were screened for TB disease, the number diagnosed with TB disease and in its absence initiation on Isoniazid preventive therapy(IPT), its compliance and reasons for it if compliance is found to be poor. All the households willing to take part in the study were included and those who are not willing, not available even after three visits and those who are transferred out were excluded from the study. Approximately 20% of the cases were cross verified by the principal investigator and Co-Investigator to assess the validity and reliability of the information collected by the trained field investigators. Data was entered into a structured format created in Microsoft Excel, cross verified and compared for consistency and analyzed.

Case definitions

A sputum smear positive Pulmonary TB patient is defined as “A patient with at least 1initial sputum smear examinations (direct smear microscopy) positive for acid-fast bacilli (AFB) in a wellfunctioning External Quality Assessment (EQA) system.

Household members of a sputum positive TB patient were defined as all persons who have food from the same kitchen as that of the sputum positive TB patient. A household contact for this study was defined as “a child aged less than 6 years of age who lives or has lived (irrespective of the duration) within the household of the smear positive PTB patient during the course of his/her disease (after the onset of symptoms) and till the end of treatment”.

Head of the family or households is the person who takes decisions in the family with respect to health seeking, health expenditure, marriages, preparation of food items etc. He/she need not be the person who is the oldest (by age) or higher earning capacity or even the gender.

Results

Out of the 651 patients registered, 621 (95.39%) patients were visited, 30 couldnot be visited as they hadmigrated out of area and some houses were locked onrepeated visits. Number of new cases registered were 485(74.56%), 146(22.37%) were retreatment cases and 20(3.06%) were multi drug resistant cases. 110 contacts less than 6 years were identified by household visits. 41(37.27%) of the contacts were between the age group of 2-4 years. 59(53.63%) of the child contacts were males. And 48(43.63%) had their parents as index case (Table No.1). Out of 110 childhood contacts, 15 (13.63%) contacts were not screened for TB by the health care workers. Of those screened, 2(1.18%) were diagnosed to be having TB and were on antituberculosis treatment (ATT), 22(23.2%) of the contacts didnot start IPT (Table 2). Reasons for not complying with IPT treatment is discussed in Table 3.

Discussion

Out of 110 eligible contacts only 95(86.36%) were screened for the disease remaining 15(13.64%) were not screened. This reflects lack of motivation and poor training of the field staff in this regard. Similar findings were reported by a study in Tamil Nadu⁵ . Among the screened contacts, 22 (23.2%) did not start IPT aselders in the houses felt it was not needed and preferred to send their children to relatives houses rather than putting them on IPT. This explains the lack of awareness and poor knowledge regarding the disease transmission and its severity in the community.

Among the 71(74.74%) who were initiated with IPT, 53(74.64%) of the contacts had incomplete therapy as they felt their children were healthy and did not feel the need for therapy anymore. This high rate of incomplete therapy also indicates that the present six months duration of IPT is longer and difficult to maintain the compliance in supposedly healthy children, hence if some shorter and userfriendly regimens are formulated the compliance rate could be better. This was also recommended by a mixed method study in Bhopal⁷ . Poor documentation of the IPT status was observed in majority of the cases. Very few patient cards had details about the status updates after initiation of IPT. Hence if separate cards are made for childhood contacts it becomes customary to update the status after starting the therapy. It was also opined by Rekha et al in a similar study⁸ .

Finally only 18 (25.35%) of the Contacts completed the IPT therapy. Similar poor performances were reported by various studies2,5,9. This poor performance reflects the gaps in the implementation of the programme. Hence, this neglected aspect priority to decrease the prevalence of child TB and future pool of infections.

Recommendations

The study results show that there is suboptimal implementation of IPT component of the RNTCP and it needs to be strengthened. All the field staff must be sensitized and trained periodically regarding the importance and process of screening In turn they should create awareness inthe communities regarding the need for screening Majority of patient treatment cards were not having details regarding childhood contacts and their IPT status. Some cards mentioned only the number of children, some mentioned date of initiation of IPT but none mentioned about completion status, hence maintaining separate registers and introducing IPT cards may improve follow up and over all performance. Also, improved mechanisms for monitoring and evaluation will go a long way for control of Tuberculosis.

Conclusion

The study illustrates the gaps in childhood contact screening and compliance to IPT in young children. Majority of eligible children were not screened and among them who were started with IPT, majority had incomplete therapy. The lack of compliance was associated with parents' perception of the importance of chemoprophylaxis. The reluctance of parents to resume IPT after counselling indicated that this might be an important barrier for its wider implementation and further studies are needed to develop effective communication strategies to convey these messages.

Source of Support: The study was financially supported by the Rajiv Gandhi University of Health Sciences, Bangalore. Karnataka.