PAKISTAN

Child TB Inventory Study Pakistan

Dr Razia FatimaChief Research-CMU ( TB,HIV/AIDS,Malaria)

PhD Norway, Msc Epi LSHTM UK, MPH Pak, FRSPH UK ,MBBS NTP Pakistan

Ministry of National Health Services, Regulations & Coordination

Pakistan (Country Profile)

Population(M) 193 M

Avg Density population /Km2 245.1sqKm

Rural: Urban Population 68:32

Number of districts 145

DISEASE BURDEN

Incidence Rate

Estimated Incident TB cases

(268 per 100,000)( 174-383)

518,000 (335,000–741,000)

Estimated incident RR/MDR cases

% of TB cases with MDR/RR-TB

15000(12000–18000)

New cases: 4.2%Previously treated: 16%

Ref : http://data.worldbank.org/country/pakistanWHO Global TB Report 2017

Background

• Adult Inventory study provided evidence for huge under-reporting (27%) .

• unregulated Private sector big pool of missing cases ranks 6th

in ten countries in order of the size of gap between notified cases and the best estimate of TB incidence(WHO Global TB report 2017.

• The notified proportion for child TB among all notifications is 12.6%.

• Child TB is relatively neglected because of difficult and atypical presentation it is expected the under-reporting to be high

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Objectives

Primary:

• To quantify the level of under-reporting to the national surveillance system, among diagnosed childhood TB cases.

Secondary:

– To understand relative contribution of types of health facilities to diagnosis and underreporting of CHTB.

– To assess the differences in under-reporting in children < 15 yrs. by age, sex, type of TB, geographical area and type of health providers.

– To facilitate establishment of linkages between different types of health facilities and NTP.

– To describe case management practices for childhood TB of public and private providers

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Methods

Study area

• The nationally-representative study carried out in all health facilities that manage childhood TB in 12 randomly selected districts from around the country.

• District Attock, Chiniot, Hafizabad, Vehari, Buner, Peshawar, Pallundry, Jhal Magsi, Ghizer, Hyderabad, Karachi (1. South, 2.East (jamshaid town, gulshan town, central, west areas), Shikarpur

• Mapping of health facilities from Jan – March 2016

• Data collection from April – June 2016

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Inventory Study Districts Location on Map

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GIS Mapping /Inclusion & Exclusion

Mapping of health facilities

• Exhaustive mapping of all health care providers who manage childhood TB was done in sampled districts, followed by data collection through mobile based GPS system.

Inclusion criteria

• All health care providers who are currently providing health services to childhood TB cases in sampled districts were included in the study.

Exclusion Criteria

• Health facilities and providers not providing services to childhood TB cases

• Presumptive TB cases age > 15 years

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Eligibility Criteria

• All facilities who were treating at least one childhood TB case during the last 03 months were considered as Eligible

• Voluntary consent was taken from each health facility, ensuring recording and reporting practices are not affected by the study

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Case-definitionsAll new or relapsed childhood TB cases aged less than 15 years, with either pulmonary or extra - pulmonary TB disease.

Bacteriologically-confirmed

• A bacteriologically confirmed TB case is one from whom a biological specimen is positive by smear microscopy, culture or WHO-approved rapid diagnostics (such as Xpert MTB/RIF).

Clinically-diagnosed

• A clinically diagnosed TB case is one who does not fulfil the criteria for bacteriological confirmation but who has been diagnosed with active TB by a clinician or other medical practitioner. This definition includes cases diagnosed on the basis of the national scoring system (PPA) or with X-ray abnormalities or suggestive histology and extra pulmonary cases with laboratory confirmation.

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GIS Based application

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Registers for validation

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GIS –Mapping

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Table 1: Enumerated health facilities by sector and type among sampled districts of the

study, Jan – Mar 2016

Type of health facility n %

Public facilities already linked

with the NTP

Tertiary Care Hospital 31 0.3

Secondary Health Care Facility 95 1.0

Primary Health Care Facility 543 5.6

Ministry of Defense 18 0.2

Parastatal 20 0.2

TOTAL 707 7.3

Private facilities not linked

with the NTP

Private Hospital 597 6.1

Private GPs 5,630 57.5

NGO Clinic / Hospital 149 1.5

Private Laboratory 398 4.1

Informal provider* 2,305 23.5

TOTAL 9,079 92.7

02-May-18 14* Reported at least one child during the previous quarter (Q4, 2015)

Table 2. Number of health facilities enumerated, eligible and consented among sampled

districts of the study, Jan – Mar 2016

Province District Enumerated Eligible * Consented %

Public Private Public Private Public Private

Punjab

Attock 105 611 103 406 81 85

Chiniot 65 923 65 893 85 76

Hafizabad 67 808 66 697 81 86

Vehari 86 1,685 84 1,350 90 75

Sindh Shikarpur 65 286 59 244 80 76

Hyderabad 59 1,015 54 781 89 64

Karachi 60 2,135 60 2,068 64 34

KPK Buner 36 522 36 516 98 90

Peshawar 90 800 81 600 99 80

AJK Pallundary 22 155 22 67 100 100

Baloschistan Jhal Magsi 13 25 12 25 100 100

GB Ghizer 39 114 39 91 90 79

TOTAL 707 9,079 681 7,738 88 79

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Table 3: Enumerated children during study data collection (Apr – Jun

2016) by presumptive TB status of child and data source

Status of child Data Source TOTAL

Health facility Laboratory

Presumptive TB 6,519 606 7,125

Not presumptive TB 931 0 931

TOTAL 7,450 606 8,056

Table 4: Type and site of TB case by data source among study population of

presumptive child TB cases, Apr – Jun 2016

Data source TOTAL

Health facility Laboratory

Type of TB case

• Bacteriologically confirmed 558 65 623

• Clinically Diagnosed 4,626 0 4,626

PPA Score interpretationCondition Scores

0 1 2 3 4 5

Age > 2 yrs < 2 yrs

Close contact in last 2 years None TB patient

S –ve

TB patient

S +ve

BCG scar Present Absent

Low immune status No Yes

PCM grade-3 No Yes Not

improved

Physical examination

findings

Normal Suggestive

of TB

Strongly

suggestiv

e of TB

Chest X-ray Normal Non-

specific

Suggestive

of TB

Tuberculin skin test No

reaction

5 – 10 mm > 10 mm

Granuloma Non-

specific

TB

History of measles &

whooping cough in the last:

3 – 6

months

< 3

months

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PPA Interpretation contd

Score Interpretatio

n

Suggested Actions

0 – 2 Unlikely TB Investigate other reasons of illness

3 – 4 Possible TB -Do not treat for TB

-Manage the presenting symptom(s)

-Monitor monthly the condition(s) for 3 months,

using scoring chart

5 – 6 Possible TB -Investigate and exclude other causes of illness

-Investigation may justify therapy

7 or

more

Probable TB - confirm (if possible)

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Table 5: comparison of diagnosis from health providers against PPA score from data

collected during the study

Diagnosis from

health facility

PPA score from study data collected

Unlikely TB

(0-1)

Possible TB

(2-4)

Highly

possible TB

(5-6)

Probable

TB

(6+)

TOTAL

Bacteriologically-

confirmed

61 55 202 305 623

Clinically-diagnosed 891 1,733 984 1,018 4,626

Not available

(referred for

diagnosis + missing)

643 263 87 26 1,019

Not a TB case 359 253 163 11 786

Missing 55 5 9 2 71

TOTAL 2,009 2,309 1,445 1,362 7,125

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Fig 1: Venn diagram showing study participants by source of identification. NTP =

National Tuberculosis Control Programme.

NTP

n=1,267

Non-NTP private health facilities

n=5070

n=188

Level of under-reporting: 78%

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Table 6: Numbers of child TB cases reported and not reported to NTP, as

well as crude percentage of under-reporting by district.

Province District Non - NTP NTP Under-

reporting (%)

Punjab

Attock 409 34 83

Chiniot 334 4 90

Hafizabad 543 12 97

Vehari 326 7 79

Sindh Shikarpur 392 2 88

Hyderabad 808 35 89

Karachi 956 12 62

KPK Buner 105 43 58

Peshawar 994 37 73

AJK Pallundary 112 2 91

Baloschistan Jhal Magsi 27 0 100

GB Ghizer 64 0 85

TOTAL 5,070 188 78

• Data collection Tool was very lengthy according to GPs found it difficult to fill

• Very busy GPs didn’t fill these field officers had to do extra work.

• Remote districts such as Ghizer , Jhal Magsi and pullandary no Xpert facility or culture facility was available mostly referred cases were seen

• The histopathology, Tuberculin test, culture and Gene Xpertwere available in large districts.

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Field Challenges

Recommendations for Pediatric TB PPM Scaleup

• There is huge potential to enhance child TB Notifications from Private providers , following challenges were addressed in NFM..

➢ High Burden Private providers must be focused (correct mapping)

➢ Investigation practices challenge must be overcome (standardized training on guidelines and scoring criteria PPA etc)

➢ Diagnostic challenges ( Gastric lavage not available in clinic settings sputum induction may be encouraged sputum transportation system for xpert/smear).

➢ Reporting challenges ( Robust electronic surveillance system to capture all child TB Cases reported).02-May-18 22

Recommendations cont: • Strengthen child TB surveillance system using (DHIS2) by the

District and provinces and critical analysis.

• Strengthen linkages with private providers and laboratories to increase notification (PPM scale up)

• Diagnostic practices using WHO recommended rapid diagnostic to increase proportion of bacteriological confirmed child TB cases

• Established technical working group for paediatric TB which is done based on sharing the preliminary analysis of child TB Inventory study in “National Consultation On childhood TB care in Pakistan-Road Map to End TB”, 6-7 September, 2016

• Revised PPA score which is also done in light of our study findings in above meeting

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Children aged 0-14 among new and relapse cases (%) Country profile

Acknowledgement

• The WHO HQ Global TB Program (Babissismandis & team)

• MoNHSRC Pakistan

• The WHO Pakistan

• The National TB control program

• The provincial TB Control Program

• Stop TB Partnership

• Pakistan Pediatric Association

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Thanks for your attention