A prospective evaluation of symptom based screening for child contact screening and management of tuberculosis in Yogyakarta, Indonesia

© 2013 Dr. Rina TriasihChildren who are in close contact with a case of tuberculosis (TB) have a high prevalence of infection with Mycobacterium tuberculosis (M. tuberculosis).Infected children, and in particular young infants, are at high risk of developing severe disseminated TB such as tuberculous meningitis or miliary TB, which is associated with high mortality rates.Screening and management of children who are in close contact with a case of pulmonary TB has the potential to increase TB case finding and prevent disease. This is universally recommended but rarely implemented in TB endemic settings. The WHO recommends a symptom based screening approach that may improve implementation at the primary care level. The main aim of the study was to prospectively evaluate the performance of symptom based screening approach for child contact screening and management. A prospective cohort study of children who were close contacts of a pulmonary TB patient in Yogyakarta, Indonesia, was conducted from August 2010 to December 2012. Clinical assessment, tuberculin skin test and chest X ray (CXR) were performed on all eligible children irrespective of symptoms at baseline. Sputum smear and culture or other appropriate investigations were performed only in children with suspected TB. Following assessment, children were assessed as having TB disease, latent TB infection (LTBI) or TB exposed only. They were treated appropriately as TB disease or with isoniazid preventive therapy (IPT) if they did not have TB and were less than 5 years of age, as per WHO guidelines. All children were followed for 12 months to evaluate response to therapy if diagnosed as TB at baseline evaluation, or to monitor for the development of TB among those without disease at baseline. The effectiveness and cost of the symptom-based screening approach was compared to other possible screening approaches. Data were further analysed to determine factors associated with the risk for infection with M. tuberculosis and with TB disease, to evaluate adherence to IPT, to describe CXR findings and to measure inter-observer agreement in the interpretation of CXR findings in the context of child contact screening and management. At baseline evaluation, of 269 child contacts, 8% had TB disease, 38% had LTBI and 64% were TB exposed only. The results of further evaluations and follow up showed that symptom-based screening provides a simple, effective and low-cost approach to child TB contact management that can be implemented at the primary health care setting. An important strength of this study was that it observed outcomes in the cohort for 1 year with a very low rate of lost to follow up. We identified that children who had close contact with a TB case that was sputum smear-positive case or female were most likely to be infected with M. tuberculosis. We observed that none of 99 children who were provided IPT at baseline developed TB in the first year of observation. Incomplete adherence to IPT was common, and problems related to health care service were identified as possible barriers to adherence. The majority of CXRs of child contacts were normal but there was substantial disagreement between reviewers on the quality and the findings of the CXR. This study provides original data from a prospective and comprehensive evaluation of the symptom-based screening approach. The findings support implementation of contact screening and management at a primary care level, with implications for global efforts to detect and prevent TB in children