About one million of the 10.4 million incident Tuberculosis (TB) patients in 2015 were children  . Childhood TB is often neglected due to atypical clinical presentation and inability to expectorate sputum among children, the need for appropriate diagnostic facilities and specialists, focus of national programs on bacteriologically-confirmed TB and poor estimates of disease burden    .
With about 40% of per 187 million people under the age of 15 years and at risk from the disease, the issue of childhood TB is of significance for Pakistan  . Analysis of programme data indicates that secondary and tertiary care hospitals (TCH), while limited in number, contribute to managing about half of childhood TB cases in Pakistan due to large patient volumes, availability of multiple diagnostics and pediatricians  . But, their engagement with National TB Programme (NTP) has been limited due to poor physician response, limited ownership from the hospital administration and general lack of priority and neglect associated with TB-related activities  . To address this, NTP implemented a package of interventions (hereafter referred as Hospital DOTS Linkages, HDL) in 2015: 1) Engagement of hospital administration and specialists to prioritize TB; 2) Training of hospital staff to identify presumptive TB patients; 3) Defining patient-flows and staff roles and responsibilities; 4) Regular facility-based review meetings by NTP staff. We aim to assess the effect of HDL on percent change in childhood TB notifications in 2015 compared to 2014 (pre-intervention).
The study was a retrospective record review of routine TB07 data. This data was sourced from 144 HDL sites from the 4 provinces and Federal capital. These include 43 tertiary care hospitals and 101 District Headquarter Hospitals. 3 regions of GB, FATA and AJK were excluded due to differences in reporting mechanisms and lack of guideline implementation. The outcome of this study was notified childhood TB cases before and after guideline revision, disaggregated by province, type of health facility, age, sex, availability of GeneXpert and screeners. Data was extracted TB07 registers and entered in Epidata v3.1. Descriptive analysis was done in EpiAnalysis V2.2. Permission to use program data was received from NTP, Pakistan. Ethics approval was obtained from The Union Ethics Advisory Group, Paris, France.
The childhood TB notifications increased by 35% at HDL sites compared to a 16% increase in non-HDL sites under study (Table 1). The increase was marginally higher in TCHs (38%) than DHQs (32%). All provinces and regions showed an increase barring TCHs in Khyber Pakhtunkhwa. Table 2 indicates that the increase was marginally higher among males. The increase in notifications did not appear to correlate with age, the availability of Xpert MTB/RIF or “screeners” (trained health care workers deployed to screen the child contacts of adult TB cases visiting the hospital).
Table 1. Childhood TB case notifications from hospital DOTS linkage (HDL) sites in 2014 (before intervention) and 2015 (after intervention), disaggregated by site type, Pakistan.
1Data for Punjab, Sindh, Baluchistan, Khyber Pakhtunhwa & ICT, all public sector management units; 2Islamabad Capital Territory.
Table 2. Change in childhood TB case notifications from hospital DOTS linkage (HDL) sites in 2014 (before intervention) & 2015 (after intervention), disaggregated by sex, age, availability of screeners and Xpert MTB/RIF®, Pakistan.
1Identification and active segregation of coughers in OPD waiting areas/wards, 32 sites had screeners and 112 sites had no screeners in both years.
This study found that HDL was associated with a 35% increase in childhood TB notification, twice higher than non-HDL sites. These findings are important as no other previous study has assessed the performance of the HDL intervention at the national level, particularly for children in our setting. All provinces registered an increase in cases although the extent was variable. This increase was seen in both TCHs and DHQs except in Khyber Pakhtunkhwa where TCH reporting declined probably due to resignation of implementing staff mid-year.
Generally, TCHs are often the best staffed and equipped health facilities, catering to large volumes of patients and thus a priority for national programs  . However, being complex systems, engaging TCHs has remained difficult, with issues in collaboration within the TCH, as well as with health department under whose purview they operate  . The HDL model was designed to involve TCHs and has been implemented successfully in Indonesia as well  . The key factors for successful implementation were defining specific roles and responsibilities within TCH, ensuring all presumptive cases were routed to the facility DOTS centre and engagement of hospital administration to increase their ownership  . The revised guidelines developed by NTP Pakistan sought to systemize these factors, as well as attempt to expand the internal network beyond chest clinics and pulmonology departments to include all specialities.
These findings have implications for passive case finding under HDL as a supplement to Active Case Finding mechanisms due to its cost effectiveness  . We did not find evidence of positive association with Xpert MTB/RIF®, which might have probably increased the number of bacteriologically confirmed TB cases. A disaggregated analysis by type of TB would have been helpful in this regard, but could not be done due to lack of data. The future revisions of TB recording and reporting should address this limitation. Also, we did not find any association with “screeners” who might have contributed to the total number of presumptive TB cases identified and referred. This needs further evaluation.
HDL was associated with an increase in childhood TB case notification in secondary and tertiary care hospitals of Pakistan. We hope this will positively impact Pakistan’s overall efforts towards TB Control by addressing the burden of childhood TB.
This research was conducted through the Structured Operational Research and Training Initiative (SORT IT), a global partnership led by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization (WHO/TDR). The model is based on a course developed jointly by the International Union against Tuberculosis and Lung Disease (The Union) and Medecins Sans Frontières (MSF). The specific SORT IT programme which resulted in this publication was jointly developed and implemented by: National Tuberculosis Program Pakistan, through the support of The Global Fund and WHO-TDR, University of Bergen, The Union, Paris, France, and The Union South-East Asia Office, New Delhi, India.
The program was funded by the World Health Organization and the Global Fund for AIDS, Tuberculosis, and Malaria in Pakistan. The publication fees were covered by the WHO/TDR.
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 Dodd, P.J., Gardiner, E., Coghlan, R. and Seddon, J.A. (2014) Burden of Childhood Tuberculosis in 22 High-Burden Countries: A Mathematical Modelling Study. Lancet Global Health, 2, e453-e459.
 Fatima, R.Q.E., Enarson, D.A. and Bissell, K. (2011) Comprehensiveness of Primary Services in the Care of Infectious Tuberulosis Patients in Rawalpindi, Pakistan. Public Health Action, 1, 1099-1104.
 Probandari, A., Lindholm, L., Stenlund, H., Utarini, A. and Hurtig, A.-K. (2010) Missed Opportunity for Standardized Diagnosis and Treatment among Adult Tuberculosis Patients in Hospitals Involved in Public-Private Mix for Directly Observed Treatment Short-Course strategy in Indonesia: A Cross-Sectional Study. BMC Health Services Research, 10, 113.
 Irawati, S.R., Basri, C., Arias, M.S., Prihatini S., Rintiswati, N., Voskens, J., et al. (2007) Hospital DOTS Linkage in Indonesia: A Model for DOTS Expansion into Government and Private Hospitals. The International Journal of Tuberculosis and Lung Disease, 11, 33-39.
 Rie, V. and Hanrahan, C. (2014) Active Case Finding for Tuberculosis: What Is the Most Informative Measure for Policy Makers? The International Journal of Tuberculosis and Lung Disease, 18, 377-378.