This study complies with the guidelines of the Standards for Reporting Implementation Studies (StaRI) checklist (see Additional file 1) .
Implementation pathway for diagnosis and treatment of childhood tb
Figure 2 shows the pathway of diagnosis and treatment of tb in BRAC operated areas in Bangladesh (insert figure 2 here). A suspected case is identified in the community (by SS) and send for sputum collection. Sputum is collected either at the mobile sputum collection camps or fixed clinics (DOTS centres in Urban areas or Upazilla Health Complex -UHC in rural areas). If the sputum examination is positive for Mycobacterium tuberculosis, treatment is initiated in the DOTS centre, but if negative, the child is referred to a paediatrician. Treatment for such children is initiated upon the recommendation of a paediatrician. The child is registered at the DOTS centre and medication is handed over to SS who lives close to the patient. Every morning, patients must visit the house of SS for medication. If for any reason, a SS is not available to provide medicine, alternate provisions were made to offer treatment under direct observation of a community leader or a family member. Treatment was monitored fortnightly by the field/program organizers and the area managers.
Final sample size collected was 111 (response rate = 95.6%). Table 1 shows the demographic characteristics of the respondents (insert table 1 here). The mean±Standard Deviation (SD) age of the respondents was 40.3 (± 0.9) years and work duration was 9.5 (± 0.3) years. The average number of adult tb patients treated over the last 12 months was 8 (± 0.7). About half (48.7%) of the respondents were from high performing centres. The average duration of treating a child tuberculosis patient was 6 years (± 1.1). The majority (89%) recalled that refresher training addressed over five out of seven components - diagnosis, treatment, disease prevention, isoiniazid prevention therapy (IPT), counselling, stigma, and supply chain.
Knowledge on childhood tb
Most of the participants (94%) knew children can be infected with tb. Less than a third had correct information about the transmission during childbirth (25%) and through breastfeeding (30%). One in four (23%) didn’t know that fever of ≥2 weeks is one of the cardinal symptoms of tuberculosis in children. Only half (51%) identified that BCG vaccination could protect children from tb. About 96% knew tb is curable in children and 90% believed that adult drugs cannot be provided to them. Only one-third of the respondents knew that the duration of treatment of tb in children is the same as in adults.
KAP Score on different domains
The mean (± S.D.) for the total score on knowledge, attitude, and practices were 43.6 (± 0.5), 10.8 (± 0.9) and 13.2 (± 0.2) respectively. Detailed information on the scores (± S.D.), 95% CI on different domains of knowledge, attitude, and practices on childhood tuberculosis is available as a supplementary document along with this manuscript (Additional file 2).
The knowledge on symptoms of childhood tb was significantly associated with the number of adult tb patients treated by SS in the last 12 months (p=0.02) and components of tb care addressed during training (p=0.04). There was no association of KAP scores on respondent characteristics (age, duration of work, duration of treating child patients, number of patients treated). There was no difference in KAP scores among high performing and low performing centres.
Table 2 presents the key facilitators and barriers to implementation of childhood tuberculosis in Bangladesh for each of the three strategic pillars of “the End TB Strategy” (insert table 2 here). Figure 3 shows the factors that facilitated and hindered the diagnosis and treatment of childhood tuberculosis in Bangladesh (insert figure 3 here).
Pillar 1: Integrated patient-centred care
Training and capacity building
It was found that frontline health workers were adequately trained and played a key role in identifying potential cases and ensuring treatment compliance. A program manager at the national tuberculosis centre, which is the governing body for all activities for tuberculosis control in Bangladesh, informed that around 9000 doctors from Dhaka and Sylhet divisions, especially paediatricians were trained in childhood tuberculosis in 2013. Besides, the government of Bangladesh has developed training modules and guidelines individualized for different levels of healthcare professionals so that they can provide an appropriate amount of information required by healthcare workers. For example, periodic refresher training was provided to all SS. Each refresher training used to be a few hours long, mostly during the monthly meetings and addressed seven components (diagnosis, treatment, prevention, IPT, counselling, stigma, and supply chain).
The SS also mentioned that due to periodic refresher training they are confident talking about the preventive strategies, diagnosis criteria, and treatment for childhood tb.
“In the field level, their (community volunteers’) role is to identify the suspects; they need to learn these criteria (for diagnosis)… they need to know how to refer these cases and when diagnosed, how to link these cases to DOTS provider...” (KII 4)
Program/field organizers routinely visited patients at their home, cross-check medicine with SS or DOTS provider to check compliance to treatment. All the family members of a patient under treatment were closely monitored for symptoms of tb. Any presumptive cases sent for investigations were followed up until the results were obtained.
“To ensure they go for diagnosis, I go with them and help them with it, and if I can’t go, I contact them and ask whether they visited the doctor or not.” (IDI 27)
The complexity of diagnosis of childhood tb
It was reported that even doctors do not suspect tb during the initial workup of a sick child. Most of the time, children were diagnosed with tb only after physicians failed to reach other diagnosis.
“… When other diagnosis cannot prove, then the physician will be thinking that it might be a case of tuberculosis”. (KII 1)
The key informants highlighted that investigation like the Mantoux test, biopsy and culture were not available in most of the government health facilities (Upazilla health complex). Field organizers and SS highlighted that due to lack of proper investigations, people had to travel to the district hospital and tertiary care hospitals which resulted in financial constraints for the family.
Guideline for childhood tb
The introduction of guidelines for the management of childhood tb in 2012 was identified as a key turning point in identifying a child with tb. This guideline facilitated symptomatic diagnosis under-5 children eliminating the need for mandatory sputum examination.
Financial assistance for diagnosis
A program officer at the national tuberculosis control program informed that sputum examination and Mantoux tests were provided free of cost from all the health facilities, either public or private. The monitoring and evaluation manager of the BRAC tb program mentioned that the financial support provided by BRAC also contributed to increased case detection. It was revealed that sputum negative patients, referred from BRAC DOTS centre, were eligible to receive financial support (a maximum of 2000 Taka, equivalent to US$ 25 in 2017) as reimbursement of expenses for diagnostic tests related to tb. However, the field staff reported that most of the children were often unable to use this facility as they cannot produce sputum.
Awareness of childhood tb
The interview participants highlighted a lack of availability of information, education, and communication (IEC) materials on childhood tb. A key informant from NTP informed that the government of Bangladesh was working on audio-visual materials for childhood tb to be aired through the national media. It was further revealed that creating community awareness on childhood tuberculosis was the responsibility of implementing partners as they had funds for these activities. In contrast, the key informants from BRAC informed that it was the responsibility of the government to take the initiatives for awareness.
Delay in diagnosis
Figure 4 shows the pathway of diagnosis in four child tb patients who participated in the study (insert figure 4 here). Three out of four cases had months of delay in diagnosis. The parents of these children went back and forth between traditional healers, public, and private health facilities before they eventually visited tertiary care hospitals. Besides, all four mothers reported that despite having a range of investigations - for example, fine needle aspiration cytology (FNAC), GeneXpert, and magnetic resonance imaging (MRI) - tb was suspected when other conditions were ruled out.
Active monitoring of treatment:
The treatment of tb (DOTS) is supervised mostly by the SS. The BRAC program manager revealed strict supervision ensured higher compliance with treatment. In-depth-interview with SS revealed that every day, a patient had to visit their home for medication. If a parent doesn’t come for medicine, they visit the patient’s home to provide medicine and counsel them on the importance of completing the total dose of medicine. The SS considered that to make a child take medication for six months was a herculean task. Besides, if any member of a family is diagnosed with tuberculosis, children in those families are monitored for the symptoms of tuberculosis, and if eligible, provided with isoniazid prevention therapy (IPT) for six months.
“The medicine is for 6 months. After completing the dose for 2 months, the child starts feeling better. That time child does not want to continue medicine. These are the barriers. That is why our duty (supervision) is going on”. (IDI-3)
Children friendly regimen:
The government has introduced child-friendly drugs with fixed drug combinations (FDC) for tb. An orally dispersible tablet was available with 2FDC (Isoniazid, Rifampicin) and 3FDC (Rifampicin, Ethambutol, and Pyrazinamide) combinations. However, there is no child-friendly regimen for the 4FDC combination (Isoniazid, Rifampicin, Ethambutol, Pyrazinamide). Those who need to take 4FDC need to take 3FDC and isoniazid. Taking two tablets instead of one was not easy for children. Besides, children often vomit out medicine. Difficulty in administrating medicine was an important factor that hindered the treatment in children. Mothers of two children, aged thirteen months and six years respectively, expressed it was difficult to give medicine to small children.
Pillar 2: Bold policies and supportive systems:
A key informant from the WHO country office claimed that there was smooth coordination between NTP and partner organisations. Periodic policy review and addressing gaps and challenges through the Joint Monitoring Mission (JMM), conducted every 3 years, was one of the key reasons behind the successful implementation of the tb control program in Bangladesh. For example, the JMM had identified a shortage of trained human resources as a key challenge for childhood tuberculosis and the government responded by intensified training of paediatrician and other health care workers. The government has introduced childhood tb management into the MBBS curriculum following suggestions from JMM. The medical students are oriented on existing protocols with the hope of creating uniformity and reduce the load to train one of the important groups of health professionals.
Pillar 3: Intensified research and innovations:
A key informant from NTP highlighted the need of investigating the effectiveness of the recently developed mobile application for case notification. He further mentioned the need to evaluate the outcomes of introducing childhood tb guidelines in the MBBS (bachelor of medicine and bachelor of surgery) curriculum. However, the key informants had divided voices on who should be engaged in supervising the research activities. Key informants from BRAC and Damien foundation suggested the government should take initiatives. On the other hand, the government authorities pointed out that conducting research was the responsibility of the partner organisations. Both parties agreed on the lack of budget for research activities.