Designing a community intervention for tuberculosis household child contact management and assessing the feasibility of its evaluation in Cameroon and Uganda

Résumé

The World Health Organization estimates that 10 million people had tuberculosis (TB) in 2019. Children are estimated to represent 15-20% of TB cases in high-prevalence countries but many go untreated, especially children under 5 years of age, due to difficulties in diagnosing TB in young children and poor implementation of routine TB screening in contact children. When children are exposed to TB in their homes, parents are asked to take them to a health center for TB testing. After ruling out TB, preventive tuberculosis treatment (TPT) is offered for children at high risk of developing severe forms, such as children under 5 or children living with HIV, regardless of their age. Many exposed children go undetected due to barriers such as cost of transport, other competing priorities, especially when children are well, and lack of communication between health workers and TB patients.My PhD thesis focuses on the design of a community-based approach for TB screening and TPT dispensing in contact children and on the conditions for its evaluation in the context of an international comparative study in two countries with a high prevalence of TB. and resource-poor sub-Saharan Africa, Cameroon and Uganda.We first confirmed the possibility of using a simplified symptom screening tool for the exclusion of TB before TPT initiation. I performed a systematic review and meta-analysis comparing symptomatic screening with radiological screening in contact children in resource-limited settings. The combined negative predictive value of the included studies is 98.7% (96.9–99.8) for children under 5 years and 98.1% (93.8–100) for children 5-14 years. These results confirmed our choice of a simple symptomatic screening tool at the community level. We developed the research protocol for a randomized controlled trial in clusters including a total of 20 clusters (health centers or hospitals and their catchment area) distributed between the 2 countries, the main objective of which was to compare the community intervention for TB contact investigation and TPT management with the standard of care. The sample size is 1,500 children eligible for TPT. The project is composed of three phases: initial phase, intervention phase and evaluation phase.During the initial phase of the project, we carried out a feasibility study to assess (1) the recruitment capacity into the study by a retrospective cohort, (2) the acceptability of the community intervention by TB patients, caregivers and community representatives through focus group discussions and in-depth interviews and (3) the adaptation and integration of study tools and procedures into existing TB services through a cross-sectional survey. Our results showed that a community intervention was considered acceptable by TB patients, caregivers and community representatives, made it possible to adjust the intervention to the local context and define the conditions for its implementation. In particular, we identified key elements like the selection and training of community health workers, ways of approaching families and visit preparation. The data from the retrospective cohort and the register checks reassured us about the recruitment capacity and the possibility of using the national registers as source documents for the study. The evaluation of TB services via the cross-sectional survey made it possible to better integrate the tools of the study into the organization of the local health system.This preliminary work enabled the implementation of the trial which began in October 2019.

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