Table 2.

Challenges identified and lessons learnt from the DETECT Child TB Project.

Key Challenges and Responses

Feasibility for expansion: The human resources and investment required to establish and scale-up effective decentralisation of services to additional districts or to national coverage may be challenging in a resource-limited setting. A formal evaluation of the cost-effectiveness of the completed pilot project is underway. Sustainability: The time and effort required to provide training of trainers and then training for healthcare workers at primary care and community, followed-up by continuous quality improvement efforts through regular meetings and support may be difficult to sustain. The DETECT Child TB Project model is being applied in other districts in Uganda and has informed operational research and programmatic activities in other countries in the region. Diagnostic support: Although appropriate sampling techniques and laboratory services for bacteriological confirmation remain important, the main emphasis for improving diagnosis of child TB should focus on improving healthcare worker skills to make a clinical diagnosis of TB and increasing availability to diagnostic to aid clinical diagnosis, e.g., chest X-ray. Treatment: TB treatment and TPT dosage guidelines by weight bands must be available as well as appropriate preparations for young children, such as child-friendly fixed-dose combinations for treatment and single-drug formulations for TPT. The fixed-dose combinations for young children are now widely available, and the preparation that is used for continuation phase treatment (4RH) is also suitable, effective and safe as TPT (3RH) for young child contacts without active TB or HIV. Documentation of household contact tracing activities was manually done, which posed challenges in tracking child TB contacts referred from the households to the health system. However, this improved with continued mentoring and supervision of community healthcare workers. Challenges for household contact screening and management included the following: ○ Low case detection especially as symptomatic child contacts referred from households did not always present for further evaluation. ○ HIV testing of well contacts without symptoms was not performed, and so there were missed opportunities for people living with HIV to receive IPT. ○ Refusal by parents to give IPT, usually because they were not convinced that their well child should receive medicine daily for months.

Lessons learnt

Sustainability and scalability: District health teams and political leadership stated that the input and resources provided by implementation partners were pivotal to the success of the DETECT Child TB intervention and, thus a requirement for it to be sustained in the two pilot districts or to be successfully implemented in other districts. Health system strengthening: Training in a workshop setting followed by mentoring and supervision were crucial to effect lasting improvement in healthcare worker confidence and competence for child TB care. Wider capacity strengthening: An integrated approach can provide important benefits for all aspects of TB detection and care beyond the primary focus of the intervention, which in this project was the detection, treatment and prevention of TB in children. Training tools: The Union’s resources and online course on child TB were highly valued for initial group training and continuous in-service updates for healthcare workers. Decentralised detection of child TB: The diagnosis of TB in children, including clinical diagnosis in young children, can be achieved at the primary and secondary health facility level where most sick children with TB initially present. Decentralised treatment of child TB: TB in children can be successfully treated with a first-line treatment regimen at the primary and secondary health facility level. Community-based contact screening and management: Community healthcare workers can be successfully engaged to provide integrated care for household contacts of TB cases, including the detection and referral of symptomatic child contacts. Preventive treatment: Linkage of household contacts with primary care facilities through community healthcare workers can achieve high rates of uptake and completion of TPT. Coordination, communication and management through the consortium of partners was vital for the success of the project.