Where is TB in maternal & child health? September 7-9, 2016

Thursday -September 8: Making TB part of the package

Good morning and welcome to day 2. Yesterday we addressed the overall problem of making childhood TB recognized as a neglected disease in the context of child health and survival. Today we want to start looking into how TB progresses in a child and where the health system and its different stakeholders can intervene effectively and in ways to facilitate access for children and their families.

TB’s pathway through care – missed opportunities

Take a look at the graphic below:
TB graphic

Children, living in communities or households affected by TB progress in stages from being susceptible and unexposed to exposure, resulting in TB infection. Early access to the health system determines whether a child enters the prevention pathway or is likely to progress to disease where, again depending on access to care, effective diagnosis and treatment is likely to lead to cure.

Addressing TB at the primary care level

A lot of the interaction with the health care system does or should take place within the primary care service delivery platform. Given that childhood TB often presents with signs and symptoms of common childhood illness and we don’t and won’t in the near future have point of care diagnostic tools for childhood TB, diagnosis and treatment will most likely require referral and take place at a higher/the secondary level. After this step children will be referred back to the community.

We think that, if HCWs are trained and have the necessary tools and guidance, a majority of childhood TB interventions can take place at the primary care level and in the community.

For example:

Along the prevention pathway:

  • Detection of exposed/infected children
  • Initiation of preventive therapy
  • Follow-up and
  • Disbursement of medicines during the time of preventive treatment.

Along the Disease pathway:

  • Early identification of sick children that are at risk of TB
  • Referral for diagnosis and treatment initiation
  • Follow-up and
  • Disbursement of medicines during the time of TB treatment.

Providing these services close to where children and their families live and as part of existing services at this level will likely improve access and reduce costs for families. It will increase case finding, prevention and, most important, outcomes not only for childhood TB but also for child health.

What we want to discuss today is how we practically address the relationship between TB and MNCH at primary level. By the end of today we would like to have a better understanding of the practical issues around existing MNCH tools and platforms and including TB into these.

Day 2 Discussion Questions

D2Q1: Are current MNCH tools and approaches robust enough to incorporate TB?
For example:

  • Are iCCM and IMCI approaches appropriately structured and deployed to detect children at risk of or with TB?
  • Can our services cope with the demand of identifying children with TB? If not – what can we do about this situation?
  • Do strategic opportunities exist within delivery models to improve the prevention, detection and management of TB?

D2Q2: How can TB programs capitalize on existing community systems?
Much of TB management is dependent on community outreach systems for key elements of TB program delivery such as household contact screening and support for community-based treatment. A lot of effort by the MNCH community is currently going into the strengthening of community systems, so how can TB programs become part of that effort?

D2Q3: Do we have functioning referral systems?
Children identified at the primary community or facility level need to be referred for diagnosis and treatment initiation. Are existing referral systems between primary care and higher levels functioning? Are referral sites ready to manage these children?

Day 2 Resources

  1. African Strategies for Health. THE POLICY AND PRACTICE DIVIDE FOR CHILDHOOD TUBERCULOSIS IN AFRICA: A LANDSCAPE ANALYSIS. March 2016
    African Strategies for Health in 2015 performed a landscape analysis to assess the gap between policies for childhood TB and their implementation in Africa.
  2. A Framework for Integrating Childhood Tuberculosis into Community-based Child Health Care. October 2013. Washington, D.C: CORE Group.
    CORE group and The International Union Against TB and Lung Disease launched a framework on integration of childhood TB into community-based child health, outlining some potential approaches as well as principles.
  3. Flyer: Adapting CHW training packages to integrate actions for HIV and TB. WHO, UNICEF 2014.
    WHO and UNICEF with partners adapted training and management tools for integrated community case management (iCCM) to include risk assessment for TB and HIV. This is one example for how childhood TB can be integrated into an existing child health platform. However, a lot of considerations have to \go into implementation of these materials.
  4. Video: Call to Action: New Childhood TB Medicines Will Help Save Lives. TB Alliance 2015

Day 2 Summary

Thank you everyone for a second day of stimulating discussions and experiences shared from many different settings and backgrounds. Membership to our seminar keeps increasing with almost 140 participants and close to 40 people actively participating in today’s discussions.

Vast experience and stories of success and challenges were shared from countries including Afghanistan, Ethiopia, Brazil, Uganda, Malawi, Bangladesh, South Sudan and others in response to today’s questions:

Question 1: “Are current MNCH tools and approaches robust enough to incorporate TB?”

  • Sabine Verkuijl suggested that current tools may be limited by sensitivity (IMCI does not perform well in detecting children not responding to treatment) or system failures (children detected but referral system does not effectively respond to the needs of the referred child).
  • Several discussants stressed the complexity and challenges faced by CHWs in many settings, the tasks and responsibilities they often have to juggle and the feasibility of adding even more interventions.

There was agreement

  • the need to prioritize interventions: screening of TB contacts, ideally as the household level as a number one priority that will promise high yield, followed by risk assessment of sick children seen by MNCH providers as well as HIV and nutrition services.
  • To make it feasible, interventions such as risk assessments must focus on simple questions that will result in a clear answer, leading to a concrete action
  • Primary care services should not be tasked with diagnosis – if risk assessment and referral are implemented well, diagnosis can take place at a higher level

Question 2: “How can TB programs capitalize on existing community systems?”

  • The established system of MNCH programs with CHWs and volunteers, home visits and outreach activities could decisively increase the coverage and quality of neglected TB interventions
  • Rashidi from Afghanistan highlighted the fact that community systems can deliver services close to the patient’s homes and Muluken Melese of Ethiopia noted that the HEAL TB project has found success in decentralizing treatment in this way.
  • Karen W. suggested to apply tools such as the Community Action Cycle to build local capacity to explore root causes, identify and prioritize local health challenges and work together to plan actions that address childhood TB and drive demand for quality assessment and referral services as close to the community as possible.

Question 3: “Do we have functioning referral systems?”

  • Ehsan from Afghanistan shared a comprehensive approach on how TB capacity is expanded to health facilities in order to provide services as close as possible to patient’s homes and explained how CHWs are engaged to ensure patients access these facilities (including the use of referral forms) as well as to support treatment of TB.
  • Sabine Verkuijl stressed the importance of documentation to ensure and also monitor referrals and back-referrals
  • Sara Holtz posed the question on how much quality and functioning of referral systems vary within a country and might be impacted by support through partners (e.g. NGOs) or other factors
  • The need for capacity building in childhood TB diagnosis and management at referral sites was stressed by Martha from South Sudan.

Today we defined important priorities for interventions and agreed that the existing community and primary care platform is well placed and key for addressing childhood TB. Given the complex environment, tasks and challenges faced by CHWs the priorities must be clear, simple and followed by clear actions with systems set up to ensure proper referral-back referral and management of children at referral sites.

This leads us to the discussion for day 3: The proposed linkage between activities overseen or initiated by the NTP as a disease control program and services provided at the primary care level, managed by MNCH/primary care require effective communication, coordination and collaboration between these actors. Please check out the introduction to day 3 leading to our final question of this seminar.

We look forward to our final day of discussions! Rudi and Anne

P.S. Feel free to invite colleagues to join the seminar for day 3. Please direct them to the seminar homepage to register.