Childhood tuberculosis in Pakistan. The role of the private sector in TB-control

Abstract

Globalt dør omkring 650 barn (0-14 år) daglig på grunn av tuberkulose (TB), som kan både forebygges og behandles. TB hos barn blir ofte oversett siden de mangler typiske symptomer, og diagnostikk er vanskelig. Dermed er det også vanskelig å beregne den faktiske sykdomsbyrden. Helsetjenester fra privat sektor i Pakistan dekker 75% av behovet, men bare 5% av privat sektor samarbeider med det nasjonale TB programmet NTP, og man ville anta at mange barn diagnostisert med TB av privat sektor blir aldri rapportert til NTP, selv om det er meldeplikt.

I Paper-I undersøkte vi rapportering av barnetuberkulose i 12 distrikter i Pakistan. I studieområdet ble et overvåkingssystem etablert ved helsetjenester utenfor selve NTP. Kartlegging ble gjort av de helseinstitusjonene som diagnostiserte og behandlet barnetuberkulose. Alle tilfeller av barnetuberkulose som ble listet i studieperioden ble sammenholdt med listen av barna som var rapportert å ha TB i samme perioden. Av alle barna med TB var 11% diagnostisert bakteriologisk og 89% klinisk, og bare 4% var meldt til den nasjonale TB programmet. Det var betydelig underrapportering på 78% av alle antatte tilfeller. Studien bekrefter at underrapportering av barnetuberkulose er et stort problem i Pakistan. Man bør rette oppmerksomhet både på barneleger og privatpraktiserende allmennleger for å bedre rapporteringen av barnetuberkulose til det nasjonale overvåkingssystemet.

I Paper-II studerte vi hvordan undersøkelser og behandling ble utført hos private helsetjenester for barn som hadde mistenkt tuberkulose. Privat sektor brukte røntgen i 46.1% av tilfellene, mens Mantoux tuberculin test or GeneXpert MTB/RIF ble brukt til et begrenset antall. Det var 7.6% som hadde bakteriologisk bekreftet TB, og 39.3% var diagnostisert bare klinisk. Blant barn med mistenkt TB ble 955(4.6%) diagnostisert og behandlet i privat sektor. Av de barna med mistenkt TB som ble henvist videre kom 3812(68.5%) til NTP for undersøkelser. Studien viste at mange private leger henviser barn til undersøkelser ved laboratorier, men selv om de blir diagnostisert blir de ofte ikke meldt til NTP. Dette kunne bedres ved å styrke kontakten mellom privat sektor, NTP laboratorier og behandlingssentre.

I Paper-III ble prosjektdata brukt til å se hvordan nasjonale retningslinjer for barnetuberkulose blir fulgt av privat sektor. Det var 5195 barn som ble diagnostisert med TB av privat sektor; bare 47.8% fulgte retningslinjene. Barn under 5 år hadde større sjanse for å bli diagnostisert i følge retningslinjene. Det er behov for å bedre kjennskap til NTP retningslinjene for diagnose og behandling kanskje via PPP, initiativet for samarbeid mellom privat og offentlige helsetjenester.

Paper IV studerte tilgjengeligheten av helsetjenester for barnetuberkulose i Pakistan. Geografiske analyser ble gjort med frie programvarer for å måle distanse fra et offentlig helsetilbud til nedslagsfeltet for folk som bodde innenfor 5km radius. Omtrent 74% hadde tilgang innen 5 km fra primærhelse tjeneste, mens 34% hadde tilgang nærmere enn 5km på sekundær og tertiær helsetjenester. I gjennomsnitt var distansen fra et tettsted til et sted som kunne stille diagnostisere barnetuberkulose 26km. Vi fant at tilgang på diagnostiske muligheter for barnetuberkulose er begrenset. Tilgang kan forbedres ved å involvere ‘lady-health-workers’ for å styrke henvisnings systemet særlig i fjerne distrikter.

Worldwide, it is estimated that about 650 children (age 0-14 years) die on daily basis due to TB which is a preventable and treatable. TB among children is commonly not correctly identified due to absence of specific symptoms and difficulties in diagnosis. This has made it challenging to measure the actual magnitude of the disease burden. The private health sector in Pakistan caters for the health care needs of 75% of the general population, but only <5% of them are engaged with National TB Control Program (NTP). Therefore, it is anticipated that many child TB cases were not reported in the national TB surveillance system from the private health sector in spite of notification being mandatory.

In paper I, to estimate the extent of underreporting of child TB cases, a child TB inventory study was conducted in 12 randomly selected districts across Pakistan. A surveillance system was established among all eligible non-NTP providers in the study districts. The mapping was carried out of those health facilities engaged in diagnosis and treatment of childhood TB cases. All child TB cases from all facilities were listed for the study period (April-June 2016) and matched with the list of those child TB cases notified to the national TB surveillance system from the same districts during the same time duration. Amongst the children with TB 11% were bacteriologically confirmed and 89% clinically diagnosed. Only 4% cases among them were reported to the National TB Control Program. The underreporting was estimated about 78% of total child TB cases. The study confirmed that underreporting of child TB is very high in Pakistan. A particular attention needs to be paid in engaging and guiding the general practitioners as well as paediatricians to report their child TB patients to national TB surveillance system.

In paper II, we assessed the investigation and management practices of the private health care providers for managing presumptive TB patients by using child TB inventory study database. Private health care providers relied on chest X-ray in 46.1% patients, while tuberculin skin test and Gene-Xpert MTB/RIF testing was utilized to a limited number of patients. Bacteriological confirmation was present in 7.6%, and clinical evaluation was the only basis for diagnosis among 39.3% of cases. Among the children diagnosed with presumptive TB, private providers diagnosed and treated only 955 (14.6%) children. Among all those referred, 3,812 (68.5%) were sent for investigations to District TB Centre (NTP). This study showed that many private providers use to refer children suspected having TB to the laboratories for further diagnosis, but the TB cases identified by these private health providers were often not notified to the NTP. This problem could be resolved by strengthening the referral linkages between private health providers, NTP laboratories and treatment centres.

In paper III, the child inventory study database was used to evaluate the adherence to the national guidelines by private health providers for the diagnosis of childhood TB. A total of 5,193 children were diagnosed with TB by Non-NTP private health providers. Only 47.8% of cases were diagnosed in line with the NTP guidelines. However, children age <5 years with a history of TB contact had a higher chance of being diagnosed according to the NTP guidelines. There is an urgent need to focus on awareness about the NTP guidelines may be through public-private partnership to address specific gaps in diagnosis, and treatment.

In paper IV, the study determined the health care services access to child TB services in Pakistan. The geospatial analysis was conducted using open-source database to calculate the distance from the nearest public health facility to the catchment population. The population living within the World Health Organization’s recommended 5 km distance, was estimated. About, 74% of the population had geographical access to the general primary health care facilities within 5km radius, compare to 33.5% had geographical access to secondary and tertiary level health facilities within 5km radius. The average distance from a settlement to a facility for diagnosis of childhood TB was estimated at 26 km. This study indicated that access of catchment population to the specialized child TB facilities is limited. Geographical accessibility can be improved by involving lady health workers to create a closer link to higher level facilities through referral system particularly for distant communities.