Closing the loop in child TB contact management: completion of TB preventive therapy outcomes in western Kenya

SETTING: Children especially those \u3c 5 years of age exposed to pulmonary tuberculosis (TB) are at a high risk of severe TB disease and death. Isoniazid preventive therapy (IPT) has been shown to decrease disease progression by up to 90%. Kenya, a high TB burden country experiences numerous operational challenges that limit implementation of TB preventive services. IPT completion in child contacts is not routinely reported in Kenya. OBJECTIVE: This study aims to review the child contact management (CCM) cascade and present IPT outcomes across 10 clinics in western Kenya. DESIGN: A retrospective chart review of programmatic data of a TB Reach-funded active, clinic-based CCM strategy. RESULTS: Of 553 child contacts screened, 231 (42%) were reported symptomatic. 74 (13%) of the child contacts were diagnosed with active TB disease. Of those eligible for IPT, 427 (90%) initiated IPT according to TB REACH project data while 249 (58%) were recorded in the IPT register with 49 (11%) recorded as a transfer to other facilities. Of the 249 recorded in the IPT register, 205 (82%) were documented to complete therapy (48% of project initiation children). CONCLUSION: Our evaluation shows gaps in the routine CCM care cascade related to completeness of documentation that require further programmatic monitoring and evaluation to improve CCM outcomes

Evaluation of treatment outcomes and associated factors among patients managed for tuberculosis in Vihiga County, 2012‐ 2015

Background: Tuberculosis (TB) treatment outcomes are used to evaluate program and patient success. Despite this, factors driving and sustaining high rates of poor TB treatment outcomes in Vihiga County are not well understood.Objective: To evaluate treatment outcomes and associated factors among patients managed for TB in Vihiga County between 2012 and 2015.Design: Descriptive cohort study.Setting: Vihiga County.Subjects: Notified TB patients >15years who were on drug susceptible TB treatment.Results: Of the 3288 eligible patients more than half were male 1961 (60%), 85% were from the public sector while 23% were over 45years. Among the TB patients, 2865 (87%) were successfully treated, 299 (9%) died and 124 (4%) had other poor treatment outcomes. On multivariate analysis, advancing age (Adjusted Odds Ratio (AOR) 3.3, 95% CI2.03‐5.38, P<0.001), HIV positive (AOR1.78, 95% CI1.27‐2.49, P0.001), previously treated (AOR1.78, 95% CI1.2‐2.49, P<0.001) and unknown HIV status (AOR 2.11, 95% CI 1.21‐3.68, P 0.008) increased the risk of death. TB patients with positive sputum results during initiation of treatment (AOR=0.68, CI=0.50‐0.94, P‐value 0.018) and those with normal body mass index (BMI) (AOR 0.37, 95% CI 0.24‐0.58, P<0.001), were less likely to die.Conclusion: While higher BMI and bacteriological confirmation reduced the risk of death, advancing age, unknown HIV status, HIV positive, being a previously treated TB case increased the risk of death. We recommend early and accurate diagnosis of TB cases, TB/HIV integration and active involvement of community health volunteers in TB management

Treatment outcomes for drug resistant tuberculosis among children below 15 years in Kenya, 2010‐2016

Background: Tuberculosis is a common cause of morbidity and mortality in children. Children are less likely to acquire resistance during the treatment of tuberculosis (TB). Most of the drug resistant TB infection in children is transmitted from adults.Objective: To determine the characteristics and treatment outcomes among children below 15 years managed for drug resistant TB in Kenya, 2010 – 2016.Design: Retrospective descriptive study.Setting: All health facilities managing drug resistant TB in KenyaSubjects: Children below 15 years treated for drug resistant TB between 2010 and 2016.Results: Sixty three children were notified with DR TB between 2010 and 2016. The median (IQR) age was11 (10‐13) years with a female to male ratio of 1:1. With 32 (52%) and 31 (51%) with smear and culture positive laboratory results respectively. Primary drug resistance was present in 25 (40%) of the children All the sputum and culture converted negative at month three of treatment. HIV testing uptake was 100% with a positivity rate of 26 (41%) and 100% anti‐retroviral therapy uptake. The treatment success rate for the cases was 31(91%) with a mortality rate of 2(5%) and lost‐to‐follow up 1 (3%).Conclusion: Drug‐resistant tuberculosis can be successfully treated and therapy well tolerated among children. There  is need for contact tracing and screening for all at risk including paediatric population

Diagnostic methods and treatment outcomes for TB in children under 15 years in Kisii County, 2012-2016

Background: Diagnosis of TB in children poses a challenge due to the paucibacillairy nature of TB and difficulties in making a bacteriological confirmation. Globally, the TB burden in children is unknown with WHO estimating that they account for 10‐15% of all cases. In Kenya, children contributed to 8.5% of all notified TB cases in 2016.Objective: To describe the diagnostic methods and treatment outcomes among children aged<15 years in Kisii County, 2012‐2016.Design: A descriptive analysis of children aged <15 years in Kisii County diagnosed and notified of TB to the National TB program.Results: We abstracted 825 records of children:217 in 2012,156 in 2013,164 in 2014,136 in 2015 and 152 in 2016.The median age was 8(IQR 2‐13) years with a male: female of ratio 1:1. The 10‐15 years age‐group accounted for 43% (351) while those aged<1year accounted for 10% (81). HIV testing was done among 806 (98%) with a TB/HIV co‐infection of 31% and 96% ART initiation rate. Bacteriological and clinical diagnosis was done for 129/825 (16%) and 696/825(84 %). Gene Xpert was done for 28/825 (3%) in 2016 and 1/825 in 2012. Overall, for the period 2012‐2015, the treatment success rate (TSR) was 96%Conclusion: There has been a decline in notification rates over time, however, it was not clear whether this was due to absence of disease or improved use of diagnostics which requires further research. Older children accounted for majority of the cases diagnosed for TB. Most of the children in the younger age groups <5 years were initiated on treatment based on clinical diagnosis or a chest X‐ray and hence a need to support health workers and health system in general on acquisition of sputum specimen in this younger age group

Gender difference in mortality among pulmonary tuberculosis HIV co-infected adults aged 15-49 years in Kenya

Setting: Kenya, 2012–2015 Objective: To explore whether there is a gender difference in all-cause mortality among smear positive pulmonary tuberculosis (PTB)/ HIV co-infected patients treated for tuberculosis (TB) between 2012 and 2015 in Kenya. Design: Retrospective cohort of 9,026 smear-positive patients aged 15–49 years. All-cause mortality during TB treatment was the outcome of interest. Time to start of antiretroviral therapy (ART) initiation was considered as a proxy for CD4 cell count. Those who took long to start of ART were assumed to have high CD4 cell count. Results: Of the 9,026 observations analysed, 4,567(51%) and 4,459(49%) were women and men, respectively. Overall, out of the 9,026 patients, 8,154 (90%) had their treatment outcome as cured, the mean age in years (SD) was 33.3(7.5) and the mean body mass index (SD) was 18.2(3.4). Men were older (30% men’ vs 17% women in those ≥40 years, p = \u3c0.001) and had a lower BMI \u3c18.5 (55.3% men vs 50.6% women, p = \u3c0.001). Men tested later for HIV: 29% (1,317/4,567) of women HIV tested more than 3 months prior to TB treatment, as compared to 20% (912/4,459) men (p\u3c0.001). Mortality was higher in men 11% (471/4,459) compared to women 9% (401/4,567, p = 0.004). There was a 17% reduction in the risk of death among women (adjusted HR 0.83; 95% CI 0.72–0.96; p = 0.013). Survival varied by age-groups, with women having significantly better survival than men, in the age-groups 40 years and over (log-rank p = 0.006). Conclusion: Women with sputum positive PTB/HIV co-infection have a significantly lower risk of all-cause mortality during TB treatment compared to men. Men were older, had lower BMI and tested later for HIV than women

Drug resistant tuberculosis in Kenya: trends, characteristics and treatment outcomes, 2008 – 2016

Background: Drug resistant (DR) tuberculosis (TB) remains a major public health concern. Failure to treat patients with TB adequately increases the risk of transmission of infection to the general population. Treatment of DR TB is characterized by lengthy treatment duration, use of toxic and less effective drugs and high likelihood of adverse treatment outcomes that include adverse drug reactions, high mortality and loss to follow up.Objective: To determine the trends, characteristics and treatment outcomes of patients >15 years notified with DR‐TB in Kenya from 2008 to 2016Design: Retrospective descriptive cross‐sectional studySetting: Tuberculosis treatment centers in KenyaSubjects: Persons above 15 years notified with DR TBResults: We reviewed records of 1903 DR‐TB patients who were notified between 2008 and 2016. The public sector made the highest contribution of the notified cases (80%). Most of the cases were male (62.3%). The HIV testing rate was 99.5%, with the TB/HIV co‐infection being 36%. Initiation of antiretroviral therapy among those who tested positive for HIV was 94.6%. Co‐trimoxazole preventive therapy uptake was 99.3%. Most patients had secondary DRTB (77.3%). Multi‐drug resistant TB accounted for 78.4% of the DR TB cases while mono drug resistance was observed in 26% of the cases. Treatment success was achieved in 79% of the cases. Mortality and treatment failure during the study period was 11% and 0.2% respectively.Conclusion: An upward trend in notified DR‐TB cases was observed during the period under review. The public sector gave the most contribution. Active surveillance on patients lost to follow up while on treatment and poor drug adherence will be of importance to reduce the potential of development of drug resistance

Outcomes of Kenyan children under five years of age, initiated on isoniazid preventive therapy following exposure to bacteriologically confirmed pulmonary tuberculosis, 2013-2016

Background: Isoniazid preventive therapy (IPT) is one of the key interventions in achieving the End TB Strategy of 90% reduction in Tuberculosis (TB) incidence by 2030 compared with 2015. One of the key pillars in achieving this is preventive treatment of persons at high risk of contracting TB. This group includes children less than five years exposed to bacteriologically confirmed TB. Despite Kenya national IPT roll out in 2015, there still exists limited information on its programmatic coverage, outcomes and missed opportunities for initiation of IPT.Objective: To determine the coverage, outcomes and missed opportunities for initiation of IPT among children under-five years in contact with bacteriologically confirmed pulmonary tuberculosis (PTB) in Kenya.Design: Cross sectional descriptive study.Setting: All the 47 counties in Kenya.Subjects: Children under-five years exposed to bacteriologically confirmed PTB initiated on IPT and notified between 2013 and 2016.Results: During the study period (2013-2016), a total of 6,507 children aged less than five years who were exposed to bacteriologically confirmed PTB were initiated on IPT. The number of children initiated on IPT increased from 721 in 2013 to 3306 in 2016.The number of counties notifying cases increased from 26 in 2013 to 47 in 2016. Treatment completion was 78%, 87% and 82% for 2013, 2014 and 2015 respectively. Of the 1390 children who had completed the 6 month-course of IPT during the study period, 9%had no TB, 7% were not accessed while84% had no documentation of outcomes by the end of the follow up period of 24 months. Missed opportunities for initiation of IPT reduced from 90% (7109) in 2013 to 60% (4872) in 2016.Conclusion: IPT coverage and completion rates have improved from 721 in 2013 to 3306 in 2016 and 78% in 2013 to 82% in 2015 respectively. Despite this, Kenya is yet to meet the targets set by the World Health Organization (WHO). Sustainable measures need to be put in place to achieve the WHO targets

Comparison of demographic and clinical characteristics between pulmonary and extra-pulmonary tuberculosis patients in Kiambu County, 2012-2015

Background: Tuberculosis (TB) continues to be a public health challenge globally. The most common organ to be involved is the lung although it can affect any organ in the body. The diagnosis of extra-pulmonary TB (EPTB) has faced many challenges mainly due to inadequate expertise to diagnose or lack of equipment for diagnosis.Objective: To compare the demographic and clinical characteristics between pulmonary and extrapulmonary tuberculosis in Kiambu CountyDesign: Retrospective cross-sectional studySetting: Kiambu County, KenyaSubjects: Tuberculosis patients notified in TIBU surveillance systemResults: Of the 15, 833 patients analyzed, 2,704 (17%) had extra-pulmonary tuberculosis. Male to female ratio was 1:1.7 in PTB and 1:1.3 in EPTB patients. There was declining trend of TB cases notified over the years for both PTB and EPTB. Pleural TB accounted for 38% with TB lymphadenitis accounting for 14% of the EPTB subtypes. TB-HIV co-infection was higher among EPTB (36%) compared to PTB (30%). The treatment success rate was 85% and 86% among PTB and EPTB cases respectively. The mortality was 10% among EPTB and 5% in PTB cases. The 5-14 age category were more likely to developing EPTB compared to PTB (AOR 4.67 95% CI (1.5-13.99). Kabete zone was most affected with EPTB (AOR 2.11(1.19-2.74) while a protective factor was observed among the HIV positive clients (AOR 0.58 (0.43 - 0.78)Conclusion: There was a general decline in cases for both EPTB and PTB. However, the age category most affected was 5-14 years. The co-infectivity rate was higher among the EPTB patients compared to the PTB patients. High index of suspicion and appropriate diagnostic tools are needed in evaluation particularly in EPTB which will assist in early management of the patients. ART uptake could play a big role in protecting HIV positive clients from getting EPTB

Spatial and temporal distribution of notified tuberculosis cases in Nairobi County, Kenya, between 2012 and 2016

Background: Tuberculosis (TB) is an infectious disease of major public health concern globally. The disease has showed space‐time variations across settings. Spatial temporal assessment can be used to understand the distribution and variations of TB disease.Objective: To determine the spatial and temporal distribution of notified TB cases in Nairobi County, Kenya, between 2012 and 2016Design: A cross sectional studySetting: Nairobi County, KenyaSubjects: Tuberculosis cases notified in Tuberculosis Information for Basic Units from 2012 to 2016Results: A total of 70,505 cases of TB were notified in Nairobi County between 2012 and 2016, with male to female ratio of 3:2 and HIV coinfection rate of 38%.The temporal analysis showed a declining trend of the notified cases. The spatial clusters showed stability in most areas while others varied annually during the study period. The space‐time analysis also detected the four most likely clusters or hotspots. Cluster 1 which covered the informal settlements of Kibera, Kawangware and Kangemi with 4,011observed cases against 2,977expected notified TB cases(relative risk (RR) 1.37, p<0.001). Further, Cluster 2 covered Starehe and parts of Kamukunji, Mathare, Makadara, Kibra and Dagoretti North Constituencies (RR 1.93, p<0.001; observed and expected cases were 4,206 and 2,242, respectively.Conclusion: This study identified high TB case notifications, declining temporal trends and clustering of TB cases in Nairobi. Evidence of clustering of TB cases indicates the need for focused interventions in the hotspot areas. Strategies should be devised for continuous TB surveillance and evidence based decision making

Accuracy of computer-aided chest X-ray in community-based tuberculosis screening: Lessons from the 2016 Kenya National Tuberculosis Prevalence Survey

Community-based screening for tuberculosis (TB) could improve detection but is resource intensive. We set out to evaluate the accuracy of computer-aided TB screening using digital chest X-ray (CXR) to determine if this approach met target product profiles (TPP) for community-based screening. CXR images from participants in the 2016 Kenya National TB Prevalence Survey were evaluated using CAD4TBv6 (Delft Imaging), giving a probabilistic score for pulmonary TB ranging from 0 (low probability) to 99 (high probability). We constructed a Bayesian latent class model to estimate the accuracy of CAD4TBv6 screening compared to bacteriologically-confirmed TB across CAD4TBv6 threshold cut-offs, incorporating data on Clinical Officer CXR interpretation, participant demographics (age, sex, TB symptoms, previous TB history), and sputum results. We compared model-estimated sensitivity and specificity of CAD4TBv6 to optimum and minimum TPPs. Of 63,050 prevalence survey participants, 61,848 (98%) had analysable CXR images, and 8,966 (14.5%) underwent sputum bacteriological testing; 298 had bacteriologically-confirmed pulmonary TB. Median CAD4TBv6 scores for participants with bacteriologically-confirmed TB were significantly higher (72, IQR: 58–82.75) compared to participants with bacteriologically-negative sputum results (49, IQR: 44–57, p<0.0001). CAD4TBv6 met the optimum TPP; with the threshold set to achieve a mean sensitivity of 95% (optimum TPP), specificity was 83.3%, (95% credible interval [CrI]: 83.0%—83.7%, CAD4TBv6 threshold: 55). There was considerable variation in accuracy by participant characteristics, with older individuals and those with previous TB having lowest specificity. CAD4TBv6 met the optimal TPP for TB community screening. To optimise screening accuracy and efficiency of confirmatory sputum testing, we recommend that an adaptive approach to threshold setting is adopted based on participant characteristics