Improving service-provider capacity: Childhood TB

The actual disease burden of childhood TB in Bangladesh is unknown and experts estimate that only a small percentage of TB cases in children is diagnosed. Screening, diagnosis and management of TB in children is difficult and was not a focus of earlier efforts in Bangladesh. According to National Tuberculosis Control Program (NTP) data, childhood TB cases constituted less than 3% of the total case detection reported in 2010. The lack of skilled providers across the health care system is one factor contributing to low detection of tuberculosis in children.

TB CARE II Bangladesh undertook a number of initiatives to address this gap. Working with the NTP, Ministry of Health, and national and upazila (sub-district) hospital professionals, the project facilitated the development of national guidelines for the management of tuberculosis in children in 2012.  Intended for use by NTP managers and health care providers, as well as professionals at central- and peripheral-level facilities, the guidelines provide standardized recommendations and best practices appropriate for management of child TB in Bangladesh country contexts. 

The project also developed a plan to support improvement of service-provider capacity in the screening, diagnosis and management of childhood TB. The resulting partnership with the Bangladesh Pediatric Association (BPA) created training sessions for pediatricians, doctors, general physicians and health care workers from the district and upazila levels to develop their clinical and programmatic management skills in the screening, diagnosis and management of childhood TB cases. 

Health care workers sitting around a conference table working.Through this partnership, the project initiated a “training of trainers” program and prepared 38 medical professionals to lead the childhood TB training sessions. This effort contributed to training of 1,168 doctors, including medical officers (Disease Control), pediatricians, and general physicians from the upazila and district levels. Doctors from upazila health complexes (UHC) were also trained to provide orientation for relevant field staff on screening and referral procedures for childhood TB. BPA also facilitated these doctors to orient a total of 8,345 health workers from their respective upazilas on contact tracing, screening and referral of presumptive child TB cases.   

Doctors who participated in the child TB training were also required to develop local-level plans, which states current levels of detection for childhood TB in the upazila and identifies possible activities to increase its detection and management. The last day of training was dedicated to developing these plans through group exercises. 

Next, the project conducted a rapid assessment to determine the outcome of the training. The assessment was designed to measure improvement and retention of knowledge and standard childhood-TB-management practices, as linked to the training’s learning objectives. The assessment also examined the training’s short-term impact on childhood TB detection. A protocol and questionnaire was developed for the assessment and data was collected from 22 randomly selected UHCs that participated in the training. Two doctors from the training were selected for interviews.

The assessment findings show that a significant number of respondents (67%) could correctly recall proper diagnostic procedures as taught in the training. A majority of physicians (97%) practiced proper physical and clinical examination and sputum microscopy for the diagnosis of TB in children. In addition to physical examination, 95% practitioners also take a history in order to properly diagnose cases of childhood TB. The use of GeneXpert, which is recommended for detection of child TB, is low; only 34% of respondents refer symptomatic child cases for GeneXpert testing. A majority of the respondents (74%) said that they now prescribe isoniazid preventive therapy for children under the age of five, as per guidelines; however, 65% of the facilities do not maintain adequate records to confirm this. 

Data collected demonstrates the change in case detection in the period after training (January–June, 2014), as compared to the corresponding period in 2013. Overall, detection of childhood TB for 0-14 age group has case detection has increased by 29% compared to the baseline period. Case detection has increased by 56% for the 0–4 age group and by 25% for the 5–14 age group.   

Because training is a single component of the overall system of care, it is difficult to attribute changes in case detection exclusively to the training of service providers. While training of service providers is an important input, this must be complemented with systematic contact tracing and referral of symptomatic cases by NGOs, strong monitoring and supervision, and an effective referral network with GeneXpert and other diagnostic facilities.

Through this partnership, the project initiated a “training of trainers” program and prepared 38 medical professionals to lead the childhood TB training sessions. This effort contributed to training of 1,168 doctors, including medical officers (Disease Control), pediatricians, and general physicians from the upazila and district levels. Doctors from upazila health complexes (UHC) were also trained to provide orientation for relevant field staff on screening and referral procedures for childhood TB. BPA also facilitated these doctors to orient a total of 8,345 health workers from their respective upazilas on contact tracing, screening and referral of presumptive child TB cases.   

Doctors who participated in the child TB training were also required to develop local-level plans, which states current levels of detection for childhood TB in the upazila and identifies possible activities to increase its detection and management. The last day of training was dedicated to developing these plans through group exercises. 

Next, the project conducted a rapid assessment to determine the outcome of the training. The assessment was designed to measure improvement and retention of knowledge and standard childhood-TB-management practices, as linked to the training’s learning objectives. The assessment also examined the training’s short-term impact on childhood TB detection. A protocol and questionnaire was developed for the assessment and data was collected from 22 randomly selected UHCs that participated in the training. Two doctors from the training were selected for interviews.

The assessment findings show that a significant number of respondents (67%) could correctly recall proper diagnostic procedures as taught in the training. A majority of physicians (97%) practiced proper physical and clinical examination and sputum microscopy for the diagnosis of TB in children. In addition to physical examination, 95% practitioners also take a history in order to properly diagnose cases of childhood TB. The use of GeneXpert, which is recommended for detection of child TB, is low; only 34% of respondents refer symptomatic child cases for GeneXpert testing. A majority of the respondents (74%) said that they now prescribe isoniazid preventive therapy for children under the age of five, as per guidelines; however, 65% of the facilities do not maintain adequate records to confirm this. 

Through this partnership, the project initiated a “training of trainers” program and prepared 38 medical professionals to lead the childhood TB training sessions. This effort contributed to training of 1,168 doctors, including medical officers (Disease Control), pediatricians, and general physicians from the upazila and district levels. Doctors from upazila health complexes (UHC) were also trained to provide orientation for relevant field staff on screening and referral procedures for childhood TB. BPA also facilitated these doctors to orient a total of 8,345 health workers from their respective upazilas on contact tracing, screening and referral of presumptive child TB cases.   

Doctors who participated in the child TB training were also required to develop local-level plans, which states current levels of detection for childhood TB in the upazila and identifies possible activities to increase its detection and management. The last day of training was dedicated to developing these plans through group exercises. 

Next, the project conducted a rapid assessment to determine the outcome of the training. The assessment was designed to measure improvement and retention of knowledge and standard childhood-TB-management practices, as linked to the training’s learning objectives. The assessment also examined the training’s short-term impact on childhood TB detection. A protocol and questionnaire was developed for the assessment and data was collected from 22 randomly selected UHCs that participated in the training. Two doctors from the training were selected for interviews.

The assessment findings show that a significant number of respondents (67%) could correctly recall proper diagnostic procedures as taught in the training. A majority of physicians (97%) practiced proper physical and clinical examination and sputum microscopy for the diagnosis of TB in children. In addition to physical examination, 95% practitioners also take a history in order to properly diagnose cases of childhood TB. The use of GeneXpert, which is recommended for detection of child TB, is low; only 34% of respondents refer symptomatic child cases for GeneXpert testing. A majority of the respondents (74%) said that they now prescribe isoniazid preventive therapy for children under the age of five, as per guidelines; however, 65% of the facilities do not maintain adequate records to confirm this. 

Health care workers sitting around a conference table while the trainer shows them a flip chart
Health care workers receive orientation on contact tracing, screening and referral of presumptive child TB cases during TB CARE II Bangladesh training
Date 
May 13, 2015
Authors 
Krishnapada Chakraborty, Dr. Paul Daru, TB CARE II Bangladesh
Regions/ Countries