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Addressing Childhood Tuberculosis at Dar es Salaam’s Center of Excellence
Each March, World TB Day raises awareness for the global effort to prevent, find, treat and cure all cases of tuberculosis (TB). This is challenging in the pediatric population because TB in children is particularly difficult to diagnose and manage due to factors such as non-specific symptoms and a lack of appropriate pediatric diagnostic tests. According to World Health Organization (WHO) estimates, children account for nearly 500,000 new TB cases each year.
Tanzania is one of 22 countries that account for 80% of global TB cases. Since 2011, ICAP has worked with Tanzania’s Ministry of Health and Social Welfare (MOHSW) to improve care and treatment for TB/HIV co-infected children. With support from the President’s Plan for Emergency AIDS Relief (PEPFAR), through the Centers for Disease Control and Prevention (CDC), ICAP supported the establishment of a Pediatric TB Center of Excellence at the Mwananyamala Hospital in Dar es Salaam, the region with 22% of the nation’s TB burden.
Since opening its doors, the Center of Excellence has expanded access to TB screening, introduced the gastric aspirate procedure specifically for children to yield a good sample for diagnosis, and begun using Xpert MTB/RIF technology for rapid diagnosis and identification of drug resistant strains. Together, these innovations in pediatric care have dramatically expanded diagnosis of TB in this population.
By the end the project’s second year, 193 new pediatric TB cases were detected, representing 83% of all pediatric cases in the region recorded by the national TB program. Of the positive TB pediatric patients diagnosed at the Center of Excellence, 100% received anti-TB treatment. In addition, expanded TB screening at the Center of Excellence included 1,683 HIV-positive children, and the proportion of TB/HIV co-infected children starting both TB treatment and ART increased from 79% to 100%, by September 2013.
A critical part of this success is the role played by MKUTA, a local NGO staffed by former TB patients who support community TB care at Mwananyamala Hospital and five satellite sites within the municipality. MKUTA provides community-based TB health education and also leads intensive case finding and contact tracing to identify the source of TB infection and help exposed individuals access treatment. Through ICAP training, MKUTA has expanded their scope of work beyond TB care in adults to include children. With the support of the former TB patients from MKUTA, approximately 67% of the all cumulative TB cases were found during community-level activities.
“The program has successfully increased the capacity of health care workers to diagnose childhood TB, even among outpatient and reproductive and child health clinicians,” said Dr. Maliwaza, clinician and District TB and Leprosy Coordinator, who works in the TB program at the Center of Excellence said. “Previously TB cases were often thought to be recurrent pneumonias, but now the diagnosis is clear. Confirmed childhood TB case notification has increased from seven cases per quarter to around 30.”
Building on these achievements, ICAP has scaled-up pediatric TB testing services at five additional public health facilities across Dar es Salaam, training health care workers at these facilities to perform gastric aspirate and sending samples to the Center of Excellence for Xpert MTB/RIF testing.
Fostering local expertise to respond to the demands of pediatric TB is an essential part of achieving the goal of ending TB deaths. At Mwnanayamala Hospital, ICAP and its partners are reaching more children with life-saving treatment sooner. Based on this success, ICAP is readying a second TB Center of Excellence in Tanzania’s Kagera Region, using the same model of innovation, collaboration and mentorship. These investments in institutional capacity enable clinicians and patients to envision the end of this preventable and treatable disease.