Child Contact Case Management—A Major Policy-Practice Gap in High-Burden Countries

The 2021 Global Tuberculosis (TB) report shows slow progress towards closing the pediatric TB detection gap and improving the TB preventive treatment (TPT) coverage among child and adolescent contacts. This review presents the current knowledge around contact case management (CCM) in low-resource settings, with a focus on child contacts, which represents a key priority population for CCM and TPT. Compelling evidence demonstrates that CCM interventions are a key gateway for both TB case finding and identification of those in need of TPT, and their yield and effectiveness should provide a strong rationale for prioritization by national TB programs. A growing body of evidence is now showing that innovative models of care focused on community-based and patient-centered approaches to household contact investigation can help narrow down the CCM implementation gaps that we are currently facing. The availability of shorter and child-friendly TPT regimens for child contacts provide an additional important opportunity to improve TPT acceptability and adherence. Prioritization of TB CCM implementation and adequate resource mobilization by ministries of health, donors and implementing agencies is needed to timely close the gap.

Assistance of health cadres to improve the ability of tuberculosis contact investigation

Indonesia menempati urutan kedua dengan jumlah Tuberkulosis (TBC) terbanyak didunia. Investigasi kontak merupakan salah satu strategi eliminasi TBC yang dapat dilakukan oleh kader kesehatan namun kader belum mampu melakukan investigasi kontak TBC di masyarakat. Tujuan kegiatan pengabdian masyarakat ini untuk meningkatkan kemampuan kader dalam melakukan investigasi kontak TBC. Metode pengabdian yaitu kegiatan pendampingan berupa orientasi, simulasi dan praktek. Hasil kegiatan ini dapat meningkatkan pengetahuan dan keterampilan kader kesehatan dalam melakukan investigasi kontak TBC sehingga kader memiliki kemampuan dan dapat berperan aktif dalam melakukan investigasi kontak untuk penemuan terduga TBC secara dini.

Tuberculosis contact investigation following the stone-in-the-pond principle in the Netherlands – Did adjusted guidelines improve efficiency?

Background In low tuberculosis (TB) incidence countries, contact investigation (CI) requires not missing contacts with TB infection or disease without unnecessarily evaluating non-infected contacts. Aim We assessed whether updated guidelines for the stone-in-the-pond principle and their promotion improved CI practices. Methods This retrospective study used surveillance data to compare CI outcomes before (2011–2013) and after (2014–2016) the guideline update and promotion. Using negative binomial regression and logistic regression models, we compared the number of contacts invited for CI per index patient, the number of CI scaled-up according to the stone-in-the-pond principle, the TB and latent TB infection (LTBI) testing coverage, and yield. Results Pre and post update, 1,703 and 1,489 index patients were reported, 27,187 and 21,056 contacts were eligible for CI, 86% and 89% were tested for TB, and 0.70% and 0.73% were identified with active TB, respectively. Post update, the number of casual contacts invited per index patient decreased statistically significantly (RR = 0.88; 95% CI: 0.79–0.98), TB testing coverage increased (OR = 1.4; 95% CI: 1.2–1.7), and TB yield increased (OR = 2.0; 95% CI: 1.0–3.9). The total LTBI yield increased from 8.8% to 9.8%, with statistically significant increases for casual (OR = 1.2; 95% CI: 1.0–1.5) and community contacts (OR = 2.0; 95% CI: 1.6–3.2). The proportion of CIs appropriately scaled-up to community contacts increased statistically significantly (RR = 1.8; 95% CI: 1.3–2.6). Conclusion This study shows that promoting evidence-based CI guidelines strengthen the efficiency of CIs without jeopardising effectiveness. These findings support CI is an effective TB elimination intervention.

Descriptive analysis of a tuberculosis outbreak from a northern Saskatchewan First Nations community—December 2018 to May 2019

Background: The tuberculosis (TB) incidence rate for northern Saskatchewan First Nations on-reserve is 1.5 higher than the national average. In December 2018 a member of one of these communities was diagnosed with 4+ smear-positive TB, spurring an outbreak investigation. Objectives: To describe the public health response to TB outbreak investigation and highlight the risk factors associated with TB transmission in northern Saskatchewan; and to highlight the relevance of social network contact investigation tool in outbreak management. Methods: Descriptive analysis included active TB cases and latent TB infection (LTBI) cases linked by contact investigation to the index case. Data were collected from active TB case files. Statistical analyses were performed and social network analysis conducted using household locations as points of contact between cases. Results: A total of eight active TB cases and 41 LTBI cases were identified as part of the outbreak between December 2018 and May 2019. Half of the cases (4/8) were 25 to 34 years old, and five were smear negative. One-third of the people with LTBI were 15 to 24 years old, and about a half tested positive to the new tuberculin skin test (TST). The commonly reported risk factors for TB and LTBI cases were alcohol use, cigarette use, marijuana use, previous TB infection and homelessness. Social network analysis indicated a relationship between increased node centrality and becoming an active case. Conclusion: Real-time social network contact investigation used in active-case finding was very successful in identifying cases, and enhanced nursing support, mobile clinics and mobile X-ray worked well as a means of confirming cases and offering treatment. TB outbreaks in northern Saskatchewan First Nations on-reserve communities are facilitated by population-specific factors. Efforts to implement context-specific interventions are paramount in managing TB outbreaks and preventing future transmission.

798. Incomplete Contact Investigation and Risk of Developing Tuberculosis Among Healthcare Professionals After Tuberculosis Exposure

Background Tuberculosis (TB) contact investigation is recommended for healthcare professionals (HCPs) after TB exposure. However, association between no participation in or incomplete contact investigation and subsequent TB development has not been well-described. This study aims to determine TB incidences and factors associated with TB development among HCPs requiring contact investigations. Methods We conducted a prospective cohort study among Thai HCPs with TB exposure from January 2013 to December 2017. Contact investigations, including baseline TB and latent tuberculosis infection (LTBI) screening and follow-up at 3 months after TB exposure, were recommended to all HCPs. The two-step tuberculin skin test (TST) was used for LTBI testing. All HCPs were followed for 2 years for TB development. Results Of the 342 HCPs with TB exposure included in the study, 311 (91%) participated in the contact investigations and 252 (74%) completed baseline TB and LTBI screening. Among the 210 HCPs with negative baseline TST, 45 (21%) completed the follow-up tests. The overall incidence of TB was 2.92/100 person-years. HCPs who did not complete follow-up TST had significantly higher TB incidence than those completed baseline and follow-up TST (3.55 vs. 0/100 person-years; P=0.01). No participation in the contact investigation and no chest radiograph performed at baseline were the independent factors associated with TB development among the HCPs [adjusted odds ratio (aOR) 6.69; P< 0.001 and aOR 8.85; P=0.01, respectively]. Contact with an index patient with concomitant TB at extrapulmonary sites (aOR 49.76, 10.03-246.99; P< 0.001) and with negative sputum AFB but positive sputum GeneXpert MTB/RIF (aOR 3.18, 1.35-7.50; P=0.008) were independently associated with no participation in the contact investigation. Conclusion The findings indicate the risk of TB development among the HCPs who did not undergo or complete contact investigations and underscore the need for interventions to improve contact investigation participation and completeness. Disclosures All Authors: No reported disclosures

Leprosy in children in Cuba: Epidemiological and clinical description of 50 cases from 2012–2019

Introduction In 1993, Cuba achieved leprosy elimination according to the World Health Organization’s (WHO) indicator of less than one case per 10,000 population. Despite this achievement, detection of new cases occurs every year among all age groups including children. Detection of new cases in children reveals persistent transmission of the infection. Objective To describe the clinical and epidemiological features of leprosy in individuals younger than 15 years (childhood leprosy) reported to the Cuban National Leprosy Control Program (NLCP) between 2012 and 2019. Methods We conducted a retrospective descriptive study between 2012 and 2019 to assess the clinical and epidemiologic features of individuals under the age of 15 years with a confirmed diagnosis of leprosy reported to the NLCP. We reviewed the NLCP database and collected data to better define the total number of cases of leprosy in adults, children (younger than 15 years). We assessed socio-demographic variables (age, gender, and province of residence) as well as variables of clinical interest including operational classification and staging at diagnosis, bacillary index, grade of disability by WHO staging. Additionally, we evaluated epidemiological variables including passive versus active surveillance of cases, contact investigation focusing specifically in household transmission, and the degree of kinship as well as standing of the child within the focus of transmission when there were additional cases. Results We identified fifty children during the study period corresponding to 3% of the overall cases of leprosy comprising all age groups in Cuba. In the age group younger than 15 years, the majorities of cases was from the Granma province and most were between the ages of 10 and 14 years. Clinically, multibacillary/lepromatous forms were the most common type identified with positive bacillary index. The majority of children diagnosed with leprosy during our study period had a history of a relative with a confirmed diagnosis of leprosy. Conclusions Detection of cases of leprosy in individuals younger than 15 years of age in Cuba demonstrates ongoing transmission of M. leprae in specific geographic hotspots. Its frequency in the early adolescence, the predominant clinical forms, and the mode of detection associated with sources of suspected familiar infection demonstrated that there is a need for further efforts by the NLCP to conduct active surveillance activities among affected communities to identify cases of leprosy earlier with the goal of preventing further household and community transmission.

Cost-effectiveness of household contact investigation for detection of tuberculosis in Pakistan

ObjectivesDespite WHO guidelines recommending household contact investigation, and studies showing the impact of active screening, most tuberculosis (TB) programmes in resource-limited settings only carry out passive contact investigation. The cost of such strategies is often cited as barriers to their implementation. However, little data are available for the additional costs required to implement this strategy. We aimed to estimate the cost and cost-effectiveness of active contact investigation as compared with passive contact investigation in urban Pakistan.MethodsWe estimated the cost-effectiveness of ‘enhanced’ (passive with follow-up) and ‘active’ (household visit) contact investigations compared with standard ‘passive’ contact investigation from providers and the programme’s perspective using a simple decision tree. Costs were collected in Pakistan from a TB clinic performing passive contact investigation and from studies of active contact tracing interventions conducted. The effectiveness was based on the number of patients with TB identified among household contacts screened.ResultsThe addition of enhanced contact investigation to the existing passive mode detected 3.8 times more cases of TB per index patient compared with passive contact investigation alone. The incremental cost was US$30 per index patient, which yielded an incremental cost of US$120 per incremental patient identified with TB. The active contact investigation was 1.5 times more effective than enhanced contact investigation with an incremental cost of US$238 per incremental patient with TB identified.ConclusionOur results show that enhanced and active approaches to contact investigation effectively identify additional patients with TB among household contacts at a relatively modest cost. These strategies can be added to the passive contact investigation in a high burden setting to find the people with TB who are missed and meet the End TB strategy goals.

The yield of tuberculosis contact investigation in low- and middle-income settings: a systematic review and meta-analysis

Background Contact investigation, the systematic evaluation of individuals in close contact with an infectious tuberculosis (TB) patient, is a key active case-finding strategy for global TB control. Better estimates of the yield of contact investigation can guide strategies to reduce the number of underreported and underdiagnosed TB cases, approximately three million cases per year globally. A systematic review (Prospero ID # CRD42019133380) and meta-analysis was conducted to update and enhance the estimates of the yield of TB contact investigation in low- and middle-income countries (LMIC). Pubmed, Web of Science, Embase and the WHO Global Index Medicus were searched for peer-reviewed studies (published between January 2006–April 2019); studies reporting the number of active TB or latent tuberculosis infection (LTBI) found through contact investigation were included. Pooled data were meta-analyzed using a random effects model and risk of bias was assessed. Results Of 1,644 unique citations obtained from database searches, 110 studies met eligibility criteria for descriptive data synthesis and 95 for meta-analysis. The pooled yields of contact investigation activities for different outcomes were: secondary cases of all active TB (defined as those bacteriologically confirmed or clinically diagnosed) 2.87% (2.61–3.14, I2 97.79%), bacteriologically confirmed active TB 2.04% (1.77–2.31, I2 98.06%), and LTBI 43.83% (38.11–49.55, I2 99.36%). Yields are interpreted as the percent of contacts screened who are diagnosed with active TB as a result of TB contact investigation activities. Pooled estimates were substantially heterogenous (I2 ≥ 75%). Conclusions This study provides methodologically rigorous and up-to-date estimates for the yield of TB contact investigation activities in low- and middle-income countries (LMIC). While the data are heterogenous, these findings can inform strategic and programmatic planning for scale up of TB contact investigation activities.

Functional components of a community of practice to improve community health worker performance: A qualitative study

Background: Communities of Practice (CoPs) are a low-cost strategy for health workers to share and create knowledge through social interactions to improve the delivery of high-quality care. However, there remain critical gaps in understanding the behavioral mechanisms through which CoPs can facilitate community health worker's (CHWs) performance. Therefore, we carried out a qualitative study of a CoP to identify the behavior change techniques (BCTs) and intervention functions that improved CHWs' performance. Methods: We organized CHWs from two tuberculosis (TB) clinics in Kampala, Uganda into a CoP from February to August 2018. We conducted interviews with CoP members to understand their perceptions of how the CoP influenced delivery of TB contact investigation. Using an abductive approach, we first applied inductive codes characterizing CHWs' perceptions of how the CoP activities affected their delivery of contact investigation. We then systematically mapped these codes into their functional categories using the BCT Taxonomy and Behavior Change Wheel framework. We triangulated all interview findings with detailed field notes. Results: All eight members of the CoP agreed to participate in the interviews. CHWs identified five CoP activities as improving the quality of their work: (1) individual review of feedback reports, (2) collaborative improvement meetings, (3) real-time communications among members, (4) didactic education sessions, and (5) clinic-wide staff meetings. These activities represented nine different BCTs and five distinct intervention functions. Taken together, CoP meetings enabled members to foster social support, problem solving, and knowledge sharing. The CoP enabled CHWs to identify barriers they face in the field and develop solutions. The CoP was motivating, strengthened their social and professional identities within and outside of the group, and improved their self-efficacy. Conclusions: We identified several behavioral mechanisms through which CoPs may improve CHW performance. Future studies should evaluate the importance of these mechanisms in mediating the effects of CoPs on program effectiveness.

DISCLOSURE OF CORONAVIRUS DISEASE-19 (COVID-19) PATIENT DATA: ETHICAL AND LEGAL PERSPECTIVES IN INDONESIA

The contact tracing policy strategy implemented during the COVID-19 pandemic requires data on COVID-19 patients to be accessible to the public so that people who have been in contact with the positive patient can do self-isolate. However, this is contrary to medical secrets and the confidentiality of COVID-19 patient data as a form of private law. This research is normative research with a statutory approach (statue approach) and conceptual (conceptual approach). Based on ethical and legal aspects, the confidentiality of COVID-19 patient data must be maintained. This data can be disclosed with the patient consent or disclosed to the Health Office to conduct epidemiological investigations. Suppose the contact investigation involves several parties: the neighborhood unit, the village head, Village Community Empowerment Service, police, and other parties. In that case, further regulation is needed to ensure the commitment of these parties in maintaining COVID-19 patient data. Disseminating patient data openly or publicly can make harm to the patient, especially in the not good environment with risk of stigmatization. There is also a need for harmony between existing regulations and the programs or policies implemented by the government.