Generally, our study established that Childhood tuberculosis represented 352 (47%), 222 (63%) childhood cases completed TB treatment, 64 (18%) were lost to follow up, 52 (15%) transferred out and 14 (4%) died. Majority of the cases, 262 (74%) were clinically diagnosed with pulmonary TB. Only one case was HIV positive and all the cases were under the Directly Observed Treatment Short Course (DOTS). In our rapid survey, several risk practices against BTB such as; sharing water sources with animals 12 (48%), drinking raw milk 21 (84%) and eating raw meat/blood 14 (56%). Most of the respondents had good knowledge on some of the causes 86 (85%), transmission 43 (84%) and prevention 132 (88%) of BTB. The commonest signs of BTB in cattle identified were cough 20 (80%) and difficulty in breathing 13 (26%).
Childhood tuberculosis represented 352 (47%) of all registered cases in Moroto district. Similar high case numbers were reported by (5, 20) in Mbarara and Mbale districts respectively, however (6) reported a lower TB frequency of 7.5% in Kampala. Other developing countries such as Pakistan reported high case numbers at 42.4% while Kenya reported low frequency at 9% (21). The regional differences could be attributed to gaps in diagnosis and treatment approaches which implies the need for localized interventions in control programs (22). Childhood TB is difficult to diagnose which contributes to underestimation (22, 23). Indeed, the National Tuberculosis and Leprosy Program (NTLP) does not publish childhood TB statistics in its weekly epidemiology bulletin. Our study findings are in agreement with other studies conducted in the same region in 2015–2018 that reported high TB burden (Simbwa et al., 2021). This calls for increased advocacy yet childhood TB is a sign of on ongoing transmission in the community and a sentinel indicator of the effectiveness of control programs (24). There is need for data aggregation by age in reporting of TB cases but particular attention to childhood TB in Uganda.
The anti-TB drug completion rate was 222 (63%). This could explain why Karamoja region is still grappling with a burden of TB in the country. This could be attributed to the fact that this a nomadic area and chances of people missing or relocating is very common. This could explain why the completion rates are below 100%. Previous studies in Uganda by (20, 25) reported lower completion rates in rural areas at 29% for Butaleja and 48% for Mbale respectively. This increase in completion rate should be attributed to current efforts by Ministry of Health of Uganda and her partners that has put deliberate efforts in improving the coverage treatment coverage in Teso and Karamoja region (Nidoi et al., 2021). Meanwhile, rural areas of Ethiopia reported similar TB completion rate at 63.5% (9).
The main cause of low anti-TB completion rate was loss to follow up (LSF) at 18% which was higher than 13% reported in rural areas of Ethiopia (9). All the TB cases were under the World Health Organization recommended community/hospital based Directly Observed Treatment Short-course (CB/H-DOTS) program but the drug completion rate was still low. Studies by (26, 27) attributed non-drug compliance to anti-TB drug shortages, child unfriendly drugs, stigmatization, long distance to treatment centers and limited funding for control programs. Underfunding control programs means community tracking of cases lost to follow and contact tracing becomes impossible. The National tuberculosis and Leprosy Program needs to focus on addressing gaps in implementation of the CB-DOTS program, design key messages on the importance treatment completion and provide financial support to village health teams that support child caretakers. The control program needs to increase the roll out of TB preventative therapy for children which reduce the need for long time anti-TB treatment.
Children in the 0 to 2 age categories showed the highest burden of TB at 163 (46%) while the 6 to 14 group had the least TB burden at 96 (27%). This was in contrast to studies by (9, 24) in Nigeria and Ethiopia respectively that reported more TB cases in the 5 to 14 age category compared the 0–4 age group. The reason for this variance is not clear but it could be due to differences in diagnostic capabilities especially since TB in the 0 to 4 age group is harder to diagnose or it could be because of under reporting. Age aggregation of TB cases is especially important in Uganda since more TB cases occur in the vulnerable 0 to 2 age category which has been reported to have low treatment success rate and increased risk of mortality (10, 24). The 0–2 age group is more susceptible to TB infection due to immature immune system (5). There is need for more funding by Ministry of Health to the NTLP so that community outreaches and preventative therapy can be prioritized for this age group in high TB burden districts. In this study, only one case was HIV positive so the low anti-TB drug completion rate and high loss to follow up cannot be correlated to HIV status as was reported by (24, 28).
Most respondents, 24 (96%) had knowledge about human tuberculosis, zoonotic diseases including bovine tuberculosis. (19) Reported 97% of cattle owners were aware of human TB however, only 24% were aware of BTB in Ethiopia. Only a few studies in Africa (29, 30) have reported such high knowledge levels for BTB at 46%, 88% in Ethiopia and Ghana respectively. High knowledge levels were also reported in Western Uganda at 37.5% (25). This shows the remarkable health education efforts and community interventions implemented by various stakeholders in Uganda in combating human TB and BTB. Cough 24 (38%) was the main human TB symptoms identified while fever, weakness, headache, night sweat was not identified by most respondents. That was contradictory since most respondents, 17 (68%) previously had a TB case in the family. Cough 20 (40%) and difficulty in breathing, 13 (26%) were the most identified BTB symptoms while other symptoms such as lethargy, lymph node enlargement and emaciation were largely unknown to most participants This is similar to a study by (31, 32) in Bangladesh and Pakistan were only 2.7% and 4.7% of the respondents respectively could identify at least two BTB symptoms. This shows a huge knowledge gap in identification of TB and BTB cases. Delayed diagnosis promotes TB/BTB community transmission. There is need for creation of more health education programs to train childcare takers, pastoralists, Village Health Teams, veterinary extension workers and other stakeholders on identification of TB and BTB cases.
Most respondents, 23 (92%) were aware that BTB was preventable in cattle and TB was curable in humans with freely available modern medicine at health centers. This was in line with (19, 31) who reported that 92% and 84% of the respondents were aware of modern medicine treatment for TB in Ethiopia and Bangladesh respectively. This shows that awareness and prevention approaches have had a positive impact on TB control.
Although the respondents had good knowledge of BTB, majority 5 (20%) were unaware that germs/bacteria were the causative agent which could explain why some of them, 12 (48%) still engaged in risk practices. Misconception of BTB causative agent was reported in previous study by (31). Increase in education level has been linked to achieving higher knowledge levels on BTB by (31). However, majority of the respondents 16 (64%) had no education at all yet most of them 24 (96%) had some knowledge on BTB. The knowledge on BTB among the respondents in this study could however be linked to age since many, 11 (44%) were above 40 years. (19) Reported adequate level of knowledge on BTB was higher among older cattle owners (40–59) at 51% with more experience than younger ones (20–29) at 37%.
Most of the respondents 15(62%) maintained a small cattle herd size of less than 20. Previous study by (33) showed that small cattle herd size of 1–10 had lower odds for BTB at 22.8 compared to larger herd sizes of at least 20 cattle which had 45.6 times more odds for BTB. Hence, herd size is likely not a BTB risk factor in this region due the small herd sizes maintained in this region. However, mixed livestock farming, mixing of animals during grazing 21 (84%) and at water sources 20 (80%) are likely more important BTB risk factors at farm level as reported by (34–36). A study done in the Mediterranean countries (37), reported water sites as the greatest risk points with a score of 86.3% compared to feeding sites that had 7.9%. Ministry of agriculture, Animal Industry and Fisheries (MAAIF) needs to work with various local and non-governmental stake holders to establish more water stations at strategic points along nomadic routes to reduce overcrowding and to create awareness on safe water management practices at these stations.
More than half of the respondents consumed raw milk 21 (84%) and raw meat/blood 14 (56%), higher percentages were reported in Ethiopia at 86% and 83% respectively (38). Bovine tuberculosis was reported in raw milk in Pakistan (37) and cattle in Ethiopia (35, 38). Consumption of raw cattle products is an important risk factor for BTB in humans as reported by Brazil (39) and Ethiopia (19). Majority of the respondents 20 (40%) were aware of BTB transmission through consumption of infect raw cattle products. Similarly, (40) also reported high awareness to BTB transmission from this practice at 77% in Oromia, Ethiopia. Indeed, majority of the respondents 22 (88%) knew that boiling milk and meat killed germs but they still preferred raw products unlike the many respondents 58% and 42% from a study by (19) who boiled milk because of fear of milk borne disease and for cultural practices respectively.
This implies that the Ministry of Science, Technology and Innovation with its partners needs to develop safe culturally acceptable protocols for milk and beef preservation and preparation in this district coupled with continued public health education from Ministry of Health, Agriculture and Social development to foster awareness and behavioral change.
Most respondents, 17 (68%) reported that children are directly involved in cattle management. Children are a vulnerable risk group for tuberculosis and easily develop active TB because of their weak immune systems. Moroto district has high frequency of childhood TB cases and involvement of children in cattle rearing exposes them to BTB. There is a need to train childcare takers on TB and BTB symptom identification to reduce exposure.
Our study has several strengths. This is one of the few studies on childhood tuberculosis in pastoral communities and that also investigated potential risk factors likely associated with exposure to bovine tuberculosis in this area and therefore it brings insights for further interrogation by more strong robust studies. Our study brings attention to the high frequency of childhood TB cases and the need for immediate intervention especially for the 0–4 age group which showed a high burden of TB in Moroto district, something that has always been missed during reporting since the reporting tools do not aggregate age to details. This therefore raises a red flag on the childhood TB management and reporting in Uganda and the region. The study also highlights a variety of risk practices for bovine tuberculosis in this community that could be targeted for future interventions could also protect against other zoonotic diseases.
However, they are a number of limitations arising from the fact this was a cross sectional rapid survey by a graduate student as part of her two months-field mentorship under Abel Wilson Walekhwa but also limited resources for this project. First, we relied on already existing data to understand the burden of childhood TB and we anticipate there could data inaccuracies and inconsistencies. Second, we could not deduce the frequency of childhood TB using healthcare data instead we could have done real-time sampling and testing of people at community level. Third, we only considered high volume TB reporting centres and it’s likely we missed many from other health centres.
We also did a rapid survey of only 25 participants due to resource constraints and we could not ably run multivariate logistic regressions to assess the level of association of different risk factors and therefore our study suffers internal and external validity. Furthermore, we did not use a standard tool for measuring knowledge of the participants and therefore our results may not be generalizable. In addition, we only accessed Christians during our rapid survey and we are likely to have missed insights from other religious affiliations. Lastly, we only conducted a quantitative study yet some of these questions could have been answered through the qualitative approach. We recommend further studies on (1) real-time assessment of TB Frequency in this region using gold standard laboratory procedures, (2) a better designed robust probability-based study with adequate sample size to assess the association of these risk factors we are pointing out.