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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 24-27

Status of contact screening and isoniazid preventive therapy for children under age six in Puducherry district, under the Revised National Tuberculosis Control Programme: An operational research


Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission02-Dec-2019
Date of Decision20-Jan-2020
Date of Acceptance22-Mar-2020
Date of Web Publication20-Jul-2020

Correspondence Address:
Ariarathinam Newtonraj
Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_47_19

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  Abstract 


Introduction: We assessed the contact screening of smear-positive pulmonary tuberculosis (PTB) and the coverage of isoniazid preventive therapy (IPT) in Puducherry district of Puducherry State.
Methods: A retrospective record review of treatment cards, under the Revised National Tuberculosis Control Programme, was conducted between the reference period of October 2018 and December 2018.
Results: A total of 145 index cases were linelisted. Among them, the number of household contacts of >6 years was 399, of which 359 (90%) were screened for PTB and one was diagnosed with PTB and initiated on treatment. Among the 35 children<6 years, 31 (89%) were screened and none was found to be positive for PTB. All patients were put on treatment (89%), of which 25 (71%) completed 6 months of IPT.
Conclusions: Implementation of IPT in Puducherry district was satisfactory, and still, there is a hope to improve further. Nationwide data on contact screening and IPT implementation are required.

Keywords: Isoniazid, isoniazid preventive, isoniazid preventive therapy, Revised National Tuberculosis Control Programme, tuberculosis


How to cite this article:
Newtonraj A, Purty AJ, Manikandan M. Status of contact screening and isoniazid preventive therapy for children under age six in Puducherry district, under the Revised National Tuberculosis Control Programme: An operational research. J Curr Res Sci Med 2020;6:24-7

How to cite this URL:
Newtonraj A, Purty AJ, Manikandan M. Status of contact screening and isoniazid preventive therapy for children under age six in Puducherry district, under the Revised National Tuberculosis Control Programme: An operational research. J Curr Res Sci Med [serial online] 2020 [cited 2020 Oct 31];6:24-7. Available from: https://www.jcrsmed.org/text.asp?2020/6/1/24/290253




  Introduction Top


Each year, the global incidence of tuberculosis (TB) is around 10.4 million, in which India contributes around 2.8 million.[1],[2] Each year, approximately 1 million new cases of TB occur among children aged 15 years worldwide.[3] Young children in close contact with a smear-positive pulmonary TB (PTB) case are at high risk of latent TB infection (LTBI) and development of TB disease.[4] It is estimated that up to 43% of infected children aged 12 months and 24% of those aged 1–5 years develop TB disease.[4] In addition, children aged 5 years are at a higher risk of developing disseminated forms of TB, including miliary TB and TB meningitis, frequently resulting in death.[4],[5] The World Health Organization recommends screening the household contacts of an infectious source case to identify children with TB disease and enable prompt treatment. Screening also provides an opportunity to provide isoniazid preventive treatment (IPT) for household contacts who do not have disease.[6] Daily isoniazid (INH) given as a preventive therapy to young children for at least 6 months has been shown to greatly reduce the likelihood of the progression from LTBI to active TB disease.[7] IPT is safe, as side effects in children are extremely rare, and its efficacy in preventing disease is as high as 90% when taken correctly.[6] India is having the highest TB burden in the world.[2] The Government of India's Revised National TB Control Programme (RNTCP) recommends screening of all household contacts (especially children aged, 6 years) of all smear-positive PTB cases. For adults, if there is an active TB after screening, treatment will be initiated, and for children with no evidence of active TB disease, IPT at 5 mg/kg/day is recommended for 6 months. Despite these recommendations, implementation of contact screening and IPT initiation in children are suboptimal in India.[3],[6],[8],[9] Although this aspect (IPT) was stressed, it was not systematically documented (contact screening and IPT) in patient treatment cards and not reported in the quarterly program reports. Detailed documentation of IPT was introduced in the patient treatment cards of Puducherry district since January 2017. In recent days INH prophylaxis tablets were supplied to the programme office, in a separate boxes in pediatric strength. This will also have an impact on the coverage of prophylaxis. No nationwide data on the contact screening for children aged<6 years in TB are available. Few state-specific studies conducted on this issue had reported varying prevalence. After the introduction of systematic documentation of contact screening and IPT under RNTCP, this provides us a unique opportunity to study the status of the same in programmatic settings in Puducherry. In this research, we aimed to know the contact screening status of households of diagnosed and treatment-initiated PTB and to know the status of IPT initiation and completion among the contacts<6 years in Puducherry district of Puducherry, India.


  Methods Top


Study design

This is a retrospective record review of RNTCP treatment cards of PTB patients, whose treatment was initiated from October 1, 2018, to December 31, 2018.

General setting

The study was conducted in Puducherry district, one of the four districts in the union territory of Puducherry (population ~1.4 million). The RNTCP was implemented in the district during 2002. The district TB center is located at the Government Chest Clinic, Puducherry. It has four subdistrict administrative units (tuberculosis units [TUs]) and 24 designated microscopy centers (DMCs). Among the 24 DMCs, eight are located in medical colleges, one in the district hospital, and 15 in primary health centers.

Implementation of isoniazid prophylaxis

In Puducherry, INH prophylaxis was introduced around 8 years before in RNTCP. Once a patient has been diagnosed as having sputum-positive, a TB health visitor (TBHV) visiting the house will also screen the households for symptoms and will refer the presumptive TB cases among the households to the health center for screening. Once the screening is completed based on the Treatment and Operational Guidelines for Tuberculosis control in India 2016 (TOG guideline), those who are diagnosed as having TB will be treated as per the RNTCP TOG guideline, whereas asymptomatic contacts<6 years will be initiated with INH prophylaxis and will be continued for 6 months.[2] To improve contact screening and to monitor the initiation and completion of IPT among children, since 2017, the Government of India has included the provision for recording information regarding contact screening on new treatment cards. It became mandatory for the staff to complete the information if the index case is sputum positive. Specific informations to be filled in the treatment cards related to contact screening are (1) Number of contacts screened (2) No of children started on IPT (3) No of children completed IPT. In Puducherry, from January 2017, new cards were implemented.

Study population

Household contacts of all sputum-positive TB patients were notified from October 2018 to December 2018.

Operational definition

Index cases were defined as all sputum smear-positive patients with TB registered for treatment. Household members were defined as all persons who shared food from the same kitchen as that of the index case. For this study, childhood household contacts were defined as children aged up to 6 years who lived with an index case during the course of their anti- TB treatment (irrespective of duration). Contact tracing was defined as household contacts of index cases of all the groups indentified by the health-care providers and registered in the RNTCP treatment card. Eligible for IPT referred to children aged<6 years and a household member of index case (sputum smear-positive case), who are not having active TB. Completed IPT children referred to children who have completed 6 months of IPT.[2],[9]

Data management and analysis

Data on outcome of interest were retrieved from a review of record from the patient's treatment card as secondary data collection. Data validation was carried out by contacting a subset of patients over phone. The age of the contacts was adjusted accordingly. Data collected based on the data extraction form were double-entered, validated, and analyzed using EpiData version 3.1 for entry and version 2.2.2.182 for analysis (EpiData Association, Odense, Denmark).[10]

Ethical approval

Ethical issues

Ethical approval was obtained from the Institutional Ethics Committee of the Pondicherry Institute of Medical Sciences, Puducherry, India (RC 17/44) and Ethics Advisory Group of the International Union Against Tuberculosis and Lung Disease, Paris, France (EAG No. 94/17), and an administrative approval was obtained from RNTCP officer of Puducherry (PSHM/RNTCP/Acc/S2/2017-18/239).


  Results Top


In our study, among the 399 household contacts >6 years, 359 (90%) were screened for PTB and one was diagnosed with PTB and initiated on treatment. Among the 35 children<6 years, 31 (89%) were screened, and none was found to be positive for PTB. All the patients were put on treatment (89%), of which 25 (71%) completed 6 months of IPT [Figure 1]. Details about the index case are summarized in [Table 1].
Figure 1: IPT among child contact of smear-positive TB patients in Puducherry district of Puducherry, India, between October 2018 and December 2018. IPT: Isoniazid preventive therapy, TB: Tuberculosis

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Table 1: Sociodemographic and clinical profile of smear-positive tuberculosis patients registered in Puducherry from January 2017 to August 2017

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  Discussion Top


The main finding in our study was that 89% of the children were screened and initiated on IPT and 71% have completed IPT. Banu Rekha et al. found that only 80% of children were screened, of which only 19% of children were initiated on IPT in a rural and urban setting of Tamil Nadu.[8] The study of Pothukuchi et al. in Andhra Pradesh found that 67% of eligible children were screened for TB, of which 56% of the eligible children were started on IPT.[3] Shivaramakrishna et al. (2014) conducted a similar study in two districts of Tamil Nadu, which revealed that 80% of eligible children were screened, of which only 33% received IPT.[6] More recently, Singh et al. conducted a study in Bhopal and found that among eligible children, 37% were screened, of which only 22% received IPT.[9] Even though IPT is an important intervention, there is a wide variation in implementing this initiative throughout the country and in general, implementation was not satisfactory.[3],[6],[8],[9] Our study has proven that the contact screening and IPT initiation was satisfactory, and there is still some hopes to improve. Our study evaluated the existing RNTCP on contact screening and IPT initiation. Ours is the latest study and differs from other studies, where we evaluated the new initiative recording contact screening and IPT prophylaxis details in the treatment card of RNTCP. This was expected to bring an accountability to the TBHVs in contact screening and initiation of IPT.

Limitations

First, we have retrospectively evaluated the data and confirmed the data quality by retrospectively calling the participants. Second was smaller sample size. A bigger sample size could have been provided better estimates. Third, it would be more appropriate and ideal if we could visit the houses of the PTB cases and collected more detailed data. However, from our previous experience, we decided not to reach the home of the participants due to stigma in the community. Usually, most of the TB patients do not like to get their status revealed to others by the frequent health workers visit, and they like to answer our queries over phone. Finally, a mixed–methods approach including qualitative part would be a better design to bring out perceptions.


  Conclusions and Recommendations Top


Our study by evaluating the newer initiative of documenting contact screening and IPT initiation in RNTCP found that both of them are satisfactory in Puducherry district, and still, there is a hope to improve. Our study is simple and feasible (could be easily done at every district-level facilities to evaluate their performance) and is also acceptable to the patients. We recommend to report countrywide details in the future TB India annual reports to improve the system. More studies are required in this area to assess the coverage and effectiveness of IPT from India.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Global Tuberculosis Report 2016. CDC 2016. Geneva, Switzerland: World Health Organization; 2016. Available from: http://scholar.google.com/scholar?hl=en and btnG=Search&q=intitle: No+Title#0%0Ahttp://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle: No+title%230. [Last Accessed on 2018 Aug 22].  Back to cited text no. 1
    
2.
Revised National Tuberculosis Control Programme. Central TB Division. TB India 2017. New Delhi: Ministry of Health and Family Welfare, Government of India; 2017. Available from: http://www.tbcindia.nic.in/WriteReadData/TB India 2017.pdf. [Last accessed on 2019 Jun 14].  Back to cited text no. 2
    
3.
Pothukuchi M, Nagaraja SB, Kelamane S, Satyanarayana S, Shashidhar, Babu S, et al. Tuberculosis contact screening and Isoniazid Preventive Therapy in a South Indian district: Operational issues for programmatic consideration. Marais BJ, editor. PLoS One 2011;6:5-8. Available from: http://dx.plos.org/10.1371/journal.pone. 0022500. [Last accessed on 2017 Sep 24].  Back to cited text no. 3
    
4.
Nelson LJ, Wells CD. Global epidemiology of childhood tuberculosis. Int J Tuberc Lung Dis 2004;8:636-47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15137548. [Last accessed on 2017 Sep 24].  Back to cited text no. 4
    
5.
Marais BJ, Ayles H, Graham SM, Godfrey-Faussett P. Screening and preventive therapy for tuberculosis. Clin Chest Med 2009;30:827-46, x. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0272523109000884. [Last accessed on 2017 Sep 06].  Back to cited text no. 5
    
6.
Shivaramakrishna HR, Frederick A, Shazia A, Murali L, Satyanarayana S, Nair SA, et al. Isoniazid preventive treatment in children in two districts of South India: Does practice follow policy? Int J Tuberc Lung Dis 2014;18:919-24. Available From: http://openurl.ingenta.com/content/xref?genre=article&issn=1027-3719&volume=18&issue=8&spage=919. [Last accessed on 2017 Sep 06].  Back to cited text no. 6
    
7.
Ayieko J, Abuogi L, Simchowitz B, Bukusi EA, Smith AH, Reingold A. Efficacy of isoniazid prophylactic therapy in prevention of tuberculosis in children: A meta–analysis. BMC Infect Dis 2014;14:91. Available from: http://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-14-91. [Last accessed on 2017 Sep 24].  Back to cited text no. 7
    
8.
Banu Rekha VV, Jagarajamma K, Wares F, Chandrasekaran V, Swaminathan S. Contact screening and chemoprophylaxis in India's Revised Tuberculosis Control Programme: A situational analysis. Int J Tuberc Lung Dis 2009;13:1507-12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19919768. [Last accessed on 2017 Sep 24].  Back to cited text no. 8
    
9.
Singh AR, Kharate A, Bhat P, Kokane AM, Bali S, Sahu S, et al. Isoniazid preventive therapy among children living with tuberculosis patients: Is it working? A mixed-method study from Bhopal, India. J Trop Pediatr 2017;63:274-85. Available from: https://academic.oup.com/tropej/article-lookup/doi/10.1093/tropej/fmw086. [Last accessed on 2017 Sep 24].  Back to cited text no. 9
    
10.
Epidata Association. Epidata Software; 2014. Available from: https://www.epidata.dk/about.htm#about. [Last accessed on 2019 Aug 08].  Back to cited text no. 10
    


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