TB/MNCH Integration: Challenges & Opportunities

From September 7 to 9, I was fortunate to participate as technical discussant, in a LeaderNet online seminar: Where is TB in maternal and child health? The seminar was moderated by Rudi Thetard (MSH) and Anne Detjen (UNICEF), with Karen Waltensperger (Save the Children) and Jon Rohde (MSH) also participating as technical discussants.

We had 151 registered participants who posted 125 messages during the three-day event. Postings were made from around the world, including Brazil, Afghanistan, Nigeria, Uganda, Ethiopia, Rwanda, USA, Belgium, South Sudan, and South Africa.

Currently, childhood TB is gaining significant policy attention at the global and national levels, but widespread alignment of field practices among TB and maternal, newborn and child health (MNCH) providers have yet to occur in many countries.

Why don’t MNCH practitioners think about TB while assessing children?

Participants commented that the major reasons for MNCH practitioners not thinking of TB while assessing a healthy or sick child, both at community and facility levels, can be grouped as:

1. We erroneously believe that TB is a disease of adolescents and adults, i.e. those older than 15 years. However, around 10% of TB cases worldwide occur before 15 years of age, which can increase to 10-20% among populations with high TB prevalence. Seminar participants agreed that an important step in raising local and national commitment towards childhood TB was to quantify the burden of disease share this information with key stakeholders.
2. We don’t think on TB as a cause of disease among small children. Around 20-30% of TB in children doesn’t have a typical pulmonary manifestation; it can affect the lymph nodes, the meninges of the brain, or be disseminated throughout the body. TB can also accompany children with malnutrition, pneumonia, and HIV. We frequently fail to ask for TB household contacts as part of the medical assessment of the sick child.
3. We also erroneously believe that TB can’t be diagnosed in small children. However, a family history of close exposure and the presence of suggestive symptoms (e.g. loss weight, fever, cough) can suggest TB disease to an alert MNCH practitioner. This suspicion could trigger the life-saving patient referral to a designated TB provider who can confirm the diagnosis and provide treatment.
4. We don’t know what to do if we suspect TB in a child (e.g. refer? Treat?). This is a product of the traditional verticality of MNCH and TB programs where MNCH practitioners are seldom trained and encouraged to think on TB as a childhood disease and what to do if we suspect it in a sick child. Moreover, MNCH and TB practitioners usually have none or limited collaboration for patient consultation and referral.

There are some positive examples of synergy between MNCH and TB programs
More optimistically, participants shared positive experiences of synergies achieved by MNCH and TB programs to improve the detection and care of childhood TB in Afghanistan, Ethiopia, Uganda, Rwanda, and Brazil/Parana.

1. During the care of healthy children, e.g. MNCH providers can screen children (with a single question) for the presence of TB patients or chronic coughers as household or close contacts during well-child clinics, immunization campaigns, and growth monitoring sessions. If the contact history is positive, timely and appropriate, referral to a designated TB provider is important.
2. During the care of sick children, e.g. integrated community case management (iCCM), integrated management of childhood illness (IMCI), nutrition rehabilitation programs, outpatient clinics, hospital wards. Here the expected behavior is similar to the first situation, but MNCH providers can also (if resources are available) undertake the diagnosis of the suspected case.
3. Activities of the TB program where the MNCH programs can add significant value to the former’s coverage and quality, e.g. active case finding with the participation of community-based MNCH providers, implementation of community-based peer support groups to adhere TB treatment, administration of DOTS by community-based or facility-based MNCH providers.

I invite you to read the participants’ postings to this LeaderNet online seminar. You might learn a little more on the synergies of TB and MNCH programs, as I did during these three days.