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Tuberculosis and integrated child health — Rediscovering the principles of Alma Ata

2019; Elsevier BV; Volume: 80; Linguagem: Inglês

10.1016/j.ijid.2019.02.042

1878-3511

Anne Detjen, Shaffiq Essajee, Malgorzata Grzemska, Ben J. Marais,

Chronic Disease Management Strategies

•The renewed commitment to Primary Health Care (PHC) presents an opportunity to reconsider latent synergies and novel partnerships for child health and development.•TB and HIV partners need to align better and jointly formulate strategies to scale up pediatric TB and HIV in an integrated MNCH and PHC context.•Integrated, family-centered approaches, implemented at the community and primary care facility level are key for bridging the pediatric TB and HIV gaps. Tuberculosis (TB) is the number-1 infectious disease killer on the planet, but few people appreciate that TB is also among the top-10 causes of under-5 mortality in TB endemic areas (WHO, 2018World Health Organization Global tuberculosis report.2018Google Scholar; Dodd et al., 2017Dodd P.J. Yuen C.M. Sismanidis C. Seddon J.A. Jenkins H.E. The global burden of tuberculosis mortality in children: a mathematical modelling study.Lancet Glob Health. 2017; 5: e898-e906Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar). Ongoing TB transmission (including of drug-resistant TB) within households and communities, poses a serious threat to young children who are at high risk of disease and death following Mycobacterium tuberculosis infection (WHO, 2018World Health Organization Global tuberculosis report.2018Google Scholar; Dodd et al., 2017Dodd P.J. Yuen C.M. Sismanidis C. Seddon J.A. Jenkins H.E. The global burden of tuberculosis mortality in children: a mathematical modelling study.Lancet Glob Health. 2017; 5: e898-e906Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar, Detjen et al., 2018Detjen A.K. McKenna L. Graham S.M. Marais B.J. Amanullah F. WHO/STOP TB Partnership Child and Adolescent TB Working Group The upcoming UN general assembly resolution on tuberculosis must also benefit children.Lancet Glob Health. 2018; 6: e485-e486Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, Perez-Velez and Marais, 2012Perez-Velez C.M. Marais B.J. Tuberculosis in children.N Engl J Med. 2012; 367: 348-361Crossref PubMed Scopus (377) Google Scholar). These young children are lagging furthest behind in the TB response. In 2017, of the estimated 525,000 children under 5 who acquired TB, fewer than one third were reported to National TB Programmes (NTPs) (WHO, 2018World Health Organization Global tuberculosis report.2018Google Scholar). Furthermore, only 23% of children under 5 with known household TB exposure accessed preventive therapy (WHO, 2018World Health Organization Global tuberculosis report.2018Google Scholar). Children living in TB endemic areas often face multiple health challenges, including malnutrition, diarrhea, pneumonia, malaria and human-immunodeficiency virus (HIV) infection, as well as challenges around access to quality care. Signs and symptoms of TB in young children are non-specific and may be mistaken for common childhood illnesses, especially within primary care facilities and in community settings where frontline health workers may be overburdened and ill-equipped to recognise TB. Disease-specific vertical approaches have successfully mobilized huge investments and deserve credit for major global health achievements, such as the near eradication of polio, greatly reduced malaria prevalence and high levels of access to antiretroviral treatment (ART) in even the most remote locations. However, this has also resulted in a concurrent under-investment in, and reduced emphasis on health systems strengthening for maternal, newborn and child health (MNCH) which has had detrimental effects – especially when it comes to TB diagnosis prevention and treatment in women, children and adolescents. The renewed commitment to Primary Health Care (PHC) as envisaged in the landmark Alma Ata Declaration from 1978 (Alma-Ata Declaration, 1978Alma-Ata Declaration 1978. https://www.who.int/publications/almaata_declaration_en.pdf?ua=1. [Accessed 17 December 2018].Google Scholar) and re-affirmed in the 2018 Astana Declaration (Astana Declaration, 2018Astana Declaration 2018. https://www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdf. [Accessed 17 December 2018].Google Scholar) presents an opportunity to reconsider latent synergies and novel partnerships for child health and development. Many of the health challenges faced by developing nations today require an integrated approach that is deeply rooted in community connectedness and concern for the child's well-being. Such an approach should consider all relevant threats to maternal and child health, irrespective of any specific disease entity. In this advocacy brief, we consider opportunities for childhood TB to be better aligned with HIV care, MNCH and nutrition priorities. We also review the principles of the Astana declaration and the integrated community-focused PHC approach that it espouses, to understand its relevance in addressing the vexing health challenges posed by the 21st century. The TB and HIV epidemics are closely interlinked and children are left behind in both the TB and HIV response. Similar to the large case finding, prevention and treatment gaps in TB, in 2017 only 43% of HIV-exposed infants received a HIV diagnostic test in the first 2 months of life, and less than 50% of children living with HIV were receiving ART (UNAIDS, 2018aUNAIDS Data 2018. http://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf. [Accessed 17 December 2018].Google Scholar, UNAIDS, 2018bhttps://free.unaids.org/. [Accessed 17 December 2018].Google Scholar). There is a need and opportunity to synergize and align advocacy, bring partners together and jointly formulate strategies to scale up pediatric TB and HIV implementation in an integrated MNCH and PHC context. This is especially true for countries in sub-Saharan Africa with large TB and HIV burdens, and where HIV predominantly affects women of reproductive age and thereby their children. Of the 23 focus countries for the Start Free, Stay Free, AIDS Free framework, 21 are on the list of highest TB and TB/HIV burden countries (WHO, 2018World Health Organization Global tuberculosis report.2018Google Scholar, UNAIDS, 2018aUNAIDS Data 2018. http://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf. [Accessed 17 December 2018].Google Scholar, UNAIDS, 2018bhttps://free.unaids.org/. [Accessed 17 December 2018].Google Scholar). The majority of the missing children with TB and HIV will only be found through decentralized, integrated and family-centered service delivery at the PHC level. The most important and effective (yet often neglected) intervention to ensure access to care for children affected by HIV and/or TB focuses on affected adult family members and their households (Dodd et al., 2018Dodd P.J. Yuen C.M. Becerra M.C. Revill P. Jenkins H.E. Seddon J.A. Potential effect of household contact management on childhood tuberculosis: a mathematical modelling study.Lancet Glob Health. 2018; 6 (Epub 2018 Sep 25): e1329-e1338Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar). Using the adult "index case" as the entry point to offer education and services to the whole household ensures that those at highest risk are identified and prioritized. The delivery system required to provide this service, be it for TB- or HIV-affected households, relies on functional community-orientated PHC, with enabled frontline health workers linked to effective communication and referral systems, use of data and availability of quality medicines. TB/HIV co-infection has important implications for the care, treatment selection and additional support of patients and their family. TB screening, prevention and treatment is recommended as part of comprehensive HIV care and needs to be systematically implemented for children, the same way as every child with TB needs to be systematically tested for HIV. Exposure history and careful clinical examination at every visit are crucial, but opportunities to improve TB diagnostic testing also exist through the ongoing expansion of point of care testing for pediatric HIV using Xpert platforms (Ndlovu et al., 2018Ndlovu Z. Fajardo E. Mbofana E. Maparo T. Garone D. Metcalf C. et al.Multidisease testing for HIV and TB using the GeneXpert platform: a feasibility study in rural Zimbabwe.PLoS One. 2018; 13: e0193577Google Scholar). The focus on children through this initiative provides an entry point to sensitize care providers to pediatric TB and encourage specimen collection and use of the Xpert platform for TB testing. Importantly, sick children with undiagnosed TB or HIV do not present to TB or HIV clinics. They can be found among children with acute malnutrition or pneumonia not responding to antibiotic treatment that present to community and primary health care facilities (Oliwa et al., 2015Oliwa J.N. Karumbi J.M. Marais B.J. Madhi S.A. Graham S.M. Tuberculosis as a cause or comorbidity of childhood pneumonia in tuberculosis-endemic areas: a systematic review.Lancet Respir Med. 2015; 3 (Epub 2015 Jan 29): 235-243https://doi.org/10.1016/S2213-2600(15)00028-4Abstract Full Text Full Text PDF Scopus (90) Google Scholar, Chisti et al., 2014Chisti M.J. Graham S.M. Duke T. Ahmed T. Ashraf H. Faruque A.S. et al.A prospective study of the prevalence of tuberculosis and bacteraemia in Bangladeshi children with severe malnutrition and pneumonia including an evaluation of Xpert MTB/RIF assay.PLoS One. 2014; 9: e93776Google Scholar). If they remain undiagnosed they may die or present to hospitals with severe illness — and impact child survival (Graham et al., 2014Graham S.M. Sismanidis C. Menzies H. Marais B. Detjen A.K. Black R.E. Importance of tuberculosis control to address child survival.Lancet. 2014; 383: 1605-1607Scopus (85) Google Scholar). Hence TB and HIV awareness and screening need to be an integral part of child health and nutrition programing in high burden settings, with shared mandates and accountabilities across health programs. Table 1 summarizes proposed areas of fruitful TB and HIV integration.Table 1Proposed areas for to enhance integrated programming for TB and HIV in high TB and HIV burden settings.AreasProposed integrationPolicy• Multi-sectoral engagement and shared accountability to achieve disease specific as well as overall child health targets• Pediatric TB and HIV part of child health and survival and nutrition strategies• Pediatric TB and HIV embedded within PHC including community health strategiesPrevention• Universal BCG vaccination• Family- and community centered approaches to reach TB and or HIV affected households• Universal screening of pregnant women for HIV infection and TB• Prevention of vertical transmission of HIV through highly effective PMTCT programmes• Screening for TB exposure at every ART clinic visit• Providing TB preventive therapy as indicated in global and national guidelinesEarly diagnosis• Testing of all HIV exposed infants• Routine TB symptom-based screening at every ART clinic visit• Routine HIV testing of everyone started on TB treatment• Family centred screening approaches targeting households affected by TB or HIV• Mainstreaming of key interventions for TB and HIV into MNCH and nutrition programs at PHC level including exposure and symptom screen• Systematic TB and HIV screening of hospitalized children, especially those with pneumonia, malnutrition, meningitis• Access to relevant HIV and TB diagnostics• Functional referral system and decentralized diagnostic capacityTreatment• Universal early ART initiation• Access to child-friendly formulations for TB prevention and treatment• Use of compatible treatment regimens• Ensure continuity of care over time and across levels with treatment support and follow up ideally at community levelCommunity engagement• Stigma reduction• Increased education and awareness on the risks of TB and HIV to children in communities as well as among frontline health workersTraining• Inclusion of childhood TB in medical and nursing training curricula, including MCH and nutrition pre- and in-service trainingAdvocacy• Persistent high level advocacy, amplified at the national and local levels• Recognition of pediatric TB and HIV contributing to child health and survival• Ensure that all new TB and HIV drugs have a paediatric development planTB — tuberculosis; MNCH — maternal, newborn and child health. Open table in a new tab TB — tuberculosis; MNCH — maternal, newborn and child health. The integrated management of childhood illness (IMCI) and its community-level equivalent integrated community case management (iCCM) are good examples of integrated PHC service delivery systems in children under 5. These frameworks were developed to provide a standardized, algorithmic approach to the diagnosis and treatment of key childhood illnesses and to prevent morbidity and mortality in children with "danger signs" that require referral. TB has traditionally not been included in IMCI. Generic IMCI charts indicate referral of children with cough lasting for more than two weeks, hence indirectly address TB, but do not include TB contact history or other features of TB. However, over the past years several countries have adapted their IMCI charts to improve TB case finding, including Ethiopia, Rwanda, and Uganda. Similarly, WHO and UNICEF have adapted iCCM tools to include TB and HIV risk assessment (TB/HIV iCCM) (WHO and UNICEF, 2014WHO UNICEF Caring for the sick child in the community. Adaptation for high HIV and TB settings.2014Google Scholar). Early implementation of TB/HIV iCCM in Uganda, Malawi and Nigeria highlighted the limited knowledge of frontline health workers of TB risk factors in children, the negative impact of stigma on caregiver and provider behavior around TB disclosure, as well as the fact that lower level health facilities rarely have the capacity and tools to screen for or manage pediatric TB or HIV. These findings highlight the importance of three key components of the IMCI approach: improving case management skills of health providers, improving overall health systems, and improving family and community health practices. A recent strategic review of IMCI showed that implementation of all components of IMCI greatly enhanced countries' reaching the Millenium Development Goals for child survival (Boschi-Pinto et al., 2018Boschi-Pinto Labadie G. Dilip T.R. Oliphant N. Dalglish S. Aboubaker S. et al.Global implementation survey of Integrated Management of Childhood Illness (IMCI): 20 years on.BMJ Open. 2018; 8: e019079Google Scholar). Largely neglected by child health programs are service delivery approaches that reach children above the age of five. While increased attention, especially by the HIV community, is paid to adolescents (10-19 years), the 5–9 year age group deserves special attention. These needs are currently addressed as part of the so-called child health re-design, co-led by WHO and UNICEF, presenting an opportunity for better alignment and integration across health programs. The focus on vertical disease programming often 'diluted' child-centered programming approaches and this 'fracturing' of holistic community-centred care requires critical reflection. From a systems perspective, integration requires that all critical health system challenges should be addressed at all levels down to the frontline, including limited human resources, inadequate training and supervision, unreliable supply chains, poor data management and dysfunctional referral mechanisms. Integration emphasizes health promotion and disease prevention in addition to curative care to ensure comprehensive approaches that optimize return on investment. Even the donors supporting disease specific control efforts (such as the Global Fund), have recognized its value and invest in strengthening integrated frontline services. Integrated case management of multiple diseases by appropriately trained community health workers has been demonstrated to be feasible, promote care seeking, improve rational antibiotic use and reduce all-cause mortality among children under five (Miller et al., 2014Miller N.P. Amouzou A. Tafesse M. Hazel E. Legesse H. Degefie T. et al.Integrated community case management of childhood illness in ethiopia: implementation strength and quality of care.Am J Trop Med Hyg. 2014; 91: 424-434Crossref PubMed Scopus (113) Google Scholar, Colvin et al., 2013Colvin C.J. Smith H.J. Swartz A. Ahs J.W. de Heer J. Opiyo N. et al.Understanding careseeking for child illness in sub-Saharan Africa: A systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria.Soc Sci Med. 2013; 86: 66-78https://doi.org/10.1016/j.socscimed.2013.02.031Crossref Scopus (106) Google Scholar, Mukanga et al., 2012Mukanga D. Tiono A.B. Anyorigiya T. Källander K. Konaté A.T. Oduro A.R. et al.Integrated community case management of fever in children under five using rapid diagnostic tests and respiratory rate counting: a multi-country cluster randomized trial.Am J Trop Med Hyg. 2012; 87: 21-29https://doi.org/10.4269/ajtmh.2012.11-0816Crossref Scopus (63) Google Scholar, Christopher et al., 2011Christopher J.B. Le May A. Lewin S. Ross D.A. Thirty years after Alma-Ata: a systematic review of the impact of community health workers delivering curative interventions against malaria, pneumonia and diarrhoea on child mortality and morbidity in sub-Saharan Africa.Hum Resour Health. 2011; 9: 27http://www.human-resources-health.com/content/9/1/27Crossref PubMed Scopus (151) Google Scholar). Integrated programming should support, not undermine, the importance of essential functions led by National Disease Control Programs, such as policy settings, drug supply and disease surveillance (Marais et al., 2013Marais B. Lönnroth K. Lawn S. Migliori G.B. Mwaba P. Glaziou P. et al.Tuberculosis co-morbidity with communicable and non-communicable diseases: integrating health services and control efforts.Lancet Infect Dis. 2013; 13: 436-448Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar). The true strength of PHC as envisaged at Alma-Ata, and its impact on and opportunities for ending preventable deaths among children, is the central role of individuals and communities in achieving health for all. In the Astana declaration, leaders from all WHO member states reaffirmed their commitments to the values and principles of Alma Ata (Table 2), envisaging (a) strong health systems, (b) health services that are high quality, safe, comprehensive, integrated, accessible, available and affordable for everyone and everywhere, and (c) individuals and communities engaged and empowered in enhancing their health and well-being (Astana Declaration, 2018Astana Declaration 2018. https://www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdf. [Accessed 17 December 2018].Google Scholar). TB affects children's health and development in multiple ways, directly through disease and its sequellae and indirectly through the health and survival of their primary care givers. Responses to reduce TB-related disease and death in children therefore needs to be family-centered and multi-sectoral, addressing TB within the context of the broader determinants of health. PHC as envisaged by the Alma Ata and Astana declarations calls for health services to be improved through the lens of equity and community vulnerability.Table 2Core principles articulated by the Alma-Ata declaration and the movement for family/community centred integrated primary care.PrinciplesImportance/implementationGovernment responsibility for health• Articulates a responsibility for 'health', in a holistic sense• Focus on inter-governmental and inter-agency partnership (not competition)Community participation and agency• Community input required to identify key health priorities• Communities must be involved in the identification of solutions that are locally feasible and acceptable• Community ownership of the identified solutions are keyServing the best interest of the child (the community)• Health care workers derive pride and job satisfaction from serving the best interests of their community• They are "health champions" and not merely employed by a project, or focussing on a single disease-specific problemFocus on health promotion and prevention• Essential components of comprehensive primary care• Often undervalued in disease focussed programs• Greatest impact/value for money• Includes sectors beyond health eg. water and sanitationCapacity building• Investments in the PHC workforce• Basic skills — train, empower, entrustDecentralization• Provide primary/core service where the need is• Equity focus — reaching the most vulnerableLinkage to appropriate level of care• Sustained, integrated and mutually supportive referral systems• PHC more than a gatekeeper function, more of a pro-active health agent• Avoid health system fragmentation• Ensure continuum of care across levels and over time Open table in a new tab It has been shown that implementing integrated packages of interventions specifically at the community and primary health facility level will avert 77% of preventable maternal, newborn and child deaths (Black et al., 2016Black R.E. Levin C. Walker N. Chou D. Liu L. Temmerman M. et al.Reproductive, maternal, newborn, and child health: key messages from Disease Control Priorities 3rd Edition.Lancet. 2016; 388 (Epub 2016 Apr 9): 2811-2824https://doi.org/10.1016/S0140-6736(16)00738-8Abstract Full Text Full Text PDF Scopus (131) Google Scholar). Renewed focus on holistic PHC will enhance countries' efforts to reach the maternal, newborn and child health targets. The time is right as the global TB and HIV community acknowledge the need for integration to achieve progress and leaders in global child health are revisiting child health programming in the Sustainable Development Goal (SDG) era (Simon et al., 2018Simon J.L. Daelmans B. Boschi-Pinto C. Aboubaker S. Were W. Child health guidelines in the era of sustainable development goals.BMJ. 2018; 362 (bmj.k3151)https://doi.org/10.1136/bmj.k3151Crossref Scopus (16) Google Scholar) with renewed commitment to PHC as a cornerstone for universal health coverage and all health-related SDGs.