1. Using implementation science to improve child household contact screening for tuberculosis in Eldoret, Kenya: Overview and lessons learned Daria Szkwarko, DO, Brown University Family Medicine Resident, PGY-3 and E. Jane Carter, MD, Brown University Department of Medicine

2. Our Partners The initial child contact register work was supported by the National Institutes of Health Fogarty International Center through the International Clinical Research Scholars and Fellows Program at Vanderbilt University (R24 TW007988) and the American Relief and Recovery Act The ‘child contact screening package’ work was supported by the Stop TB Partnership TB Reach grant

3. Objectives Describe implementation science and its importance in program design Discuss child household contact tuberculosis (TB) screening recommendations and understand the common challenges that local TB programs face implementing these recommendations Review cost-effective tools to quantify exposed child contacts and implement strategies aimed at improving health care access and screening for ALL children exposed to TB

4. Implementation Science As defined by the National Institute of Health conference on implementation and dissemination, implementation science is: ‘The use of strategies to integrate evidence-based health interventions and change practice patterns within specific settings’ Address major bottlenecks (social, behavioral, systematic) that impede effective implementation, test new programmatic approaches, and assess an intervention’s impact

5. Eldoret, Kenya Kenya Population ≈ 43 million HIV/AIDs adult prevalence rate = 6 % in 2013 Life expectancy = 55 years Eldoret 5 th largest city in Kenya. Population ≈ 200,000 people. Academic Model Providing Access to Healthcare (AMPATH): Largest HIV care program in East Africa providing care to > 80,000 HIV infected individuals Moi Teaching and Referral Hospital (MTRH): Second largest referral hospital serving the western half of the country

6. Tuberculosis TB is second only to HIV as the greatest killer worldwide due to a single infection. In 2012, 8.6 million new cases of TB were diagnosed. 1.3 million people died of TB.

7. 80 % of these cases can be found in 22 high burden countries – most of which are in sub Saharan Africa and southeast Asia. Kenya is ranked 10 th. Tuberculosis

8. TB in Children It is estimated that approximately 74,000 children die from TB each year and account for about half a million new cases annually Only 6% of new TB cases in Kenya in 2013 were in children which is likely an underestimate as TB in kids is under diagnosed or unreported.

9. TB Screening in Children World Health Organization recommends that all child contacts be tracked and screened by National TB Programs Isoniazid preventive therapy should be initiated whenever appropriate and possible as it significantly decreases the risk of developing active TB infection

10. Child Contact Tracing in Eldoret, Kenya 2010 The situation: Child contacts were not being tracked in the TB clinic. No child contacts were identified/screened and no children were on isoniazid preventive therapy (IPT) The intervention: Create an easy to use child contact register to track the number of children exposed to tuberculosis. Encourage smear positive source cases to bring children in for screening

11. The Child Contact Register (CCR)

12. CCR Results - 2011 Ratio of children aged < 5 years to index cases queried was 0.41 89 (15%) children were identified as potential IPT candidates (exposed to smear-positive TB, aged < 5 years, asymptomatic OR exposed to smear positive TB, HIV-infected and asymptomatic) 6 (1%) children were brought in for screening and evaluation

13. Child Contact Tracing in Eldoret, Kenya 2012 The situation: CCR in operation but very few children brought in for screening. – Major barrier = COST. Cost includes transportation fees (varies), chest x-ray ($5), and clinic visit ($2) for each child contact Intervention: Using the CCR data, a grant through TB Reach was obtained. One aim of this grant provided a ‘child contact screening package’ – free transportation, chest x-ray, and screening for 500 child contacts < 5 exposed to smear positive pulmonary TB

14. From April 2012 to June 2013, 169 exposed child contacts under five were identified by the CCR 146 (86.4%) were brought in for screening through the ‘child contact screening package’ 43 (29.5%) were diagnosed with active TB disease TB Reach Aim 4 Results

15. The situation: Eliminating cost significantly improved child contact screening, however, children were still being left behind. Intervention: Using the TB Reach data, investigate other variables that may significantly influence children being brought in for screening Child Contact Tracing in Eldoret, Kenya 2013

16. TB Reach Aim 4 Results

17. Child Contact Tracing in Eldoret, Kenya Next Steps… Survey the male index cases and find potential reasons that males are less likely to bring children in for screening (disclosure issues, not the primary care giver) Implement a system to reach out more to the asymptomatic child contacts (additional phone call, additional education from staff) CCR has rolled out to 10 other TB clinic sites and TB Reach expanded to cover 2000 children. National TB program is looking to adopt the CCR and make contact screening less expensive for index cases.

18. Summary Implementation science allows us to study evidence based interventions in real world clinical settings and effectively change practice patterns Household child contact tracing for TB remains a challenge globally. However, simple and cost- effective strategies can move us forward All children exposed to TB deserve to be screened and treated!

19. Thank you! Contact: Szkwarkd@gmail.comSzkwarkd@gmail.com

20. References HIV and AIDs Estimates. UN Joint Programme on HIV/AIDs (UNAIDs). 2013 http://www.unaids.org/en/regionscountries/countries/kenya/. Accessed September 8, 2014. http://www.unaids.org/en/regionscountries/countries/kenya/ Implementation Science Information and Resources. Fogarty International Center. http://www.fic.nih.gov/ResearchTopics/Pages/ImplementationScience.aspx. Accessed September 5, 2014. http://www.fic.nih.gov/ResearchTopics/Pages/ImplementationScience.aspx Kenya Tuberculosis Country Profile. World Health Organization. 2013. http://www.who.int/tb/country/data/profiles/en/. Accessed September 8, 2014. http://www.who.int/tb/country/data/profiles/en/ Roadmap for Childhood Tuberculosis: Towards Zero Deaths. World Health Organization. 2013. Szkwarko D, Ogaro F, Owiti P, Carter EJ. Implementing a tuberculosis child contact register to quantify children at risk for tuberculosis and HIV in Eldoret, Kenya. Public Health Action. 2013; 3(3): 209-213. Tuberculosis World Health Organization Fact Sheet N 104. World Health Organization. March 2014. http://www.who.int/mediacentre/factsheets/fs104/en/. Accessed September 8, 2014. http://www.who.int/mediacentre/factsheets/fs104/en/ World Health Organization. Guidance for national tuberculosis programmes on the management of tuberculosis in children. WHO/HTM/TB/2006.371. Geneva, Switzerland: WHO, 2006.