Adherence to Antituberculosis Drugs in Children and Adolescents in A Low-Endemic Setting: A Retrospective Series

Identifying adolescents at risk for suboptimal adherence to tuberculosis treatment: A prospective cohort study

Adolescents account for an estimated 800,000 incident tuberculosis (TB) cases annually and are at risk for suboptimal adherence to TB treatment. Most studies of adolescent TB treatment adherence have used surveillance data with limited psychosocial information. This prospective cohort study aimed to identify risk factors for suboptimal adherence to rifampicin-susceptible TB treatment among adolescents (10-19 years old) in Lima, Peru. We collected psychosocial data using self-administered surveys and clinical data via medical record abstraction. Applying k-means cluster analysis, we grouped participants by psychosocial characteristics hypothesized to impact adherence. Then, we conducted mixed effects regression to compare suboptimal adherence-defined as <90% (missing >10% of doses)-between clusters. Treatment setting (facility vs. home) and drug formulation (single drug vs. fixed dose combination) were interaction terms. Of 249 participants, 90 (36.1%) were female. Median age was 17 (IQR: 15, 16.6) years. We identified three clusters-A, B, and C-of participants based on psychosocial characteristics. Cluster C had the lowest support from caregivers, other family members, and friends; had the weakest motivation to complete TB treatment; were least likely to live with their mothers; and had experienced the most childhood adversity. Among the 118 (47.4%) participants who received facility-based treatment with single drug formulations, adherence did not differ between Clusters A and B, but Cluster C had six-fold odds of suboptimal adherence compared to Cluster A. In Clusters B and C, adherence worsened over time, but only in Cluster C did mean adherence fall below 90% within six months. Our findings have implications for the care of adolescents with TB. When caring for adolescents with low social support and other risk factors, clinicians should take extra measures to reinforce adherence, such as identifying a community health worker or peer to provide treatment support. Implementing newly recommended shorter regimens also may facilitate adherence.

Adolescent, caregiver and provider perspectives on tuberculosis treatment adherence: a qualitative study from Lima, Peru

OBJECTIVES

To understand the perspectives of adolescents (10-19 years old), their caregivers and healthcare providers regarding factors that impact adherence to tuberculosis (TB) treatment among adolescents.

DESIGN

We conducted in-depth interviews using semistructured interview guides based on the World Health Organization (WHO)'s Five Dimensions of Adherence framework, which conceptualises adherence as being related to the health system, socioeconomic factors, patient, treatment and condition. We applied framework thematic analysis.

SETTING

Between August 2018 and May 2019, at 32 public health centres operated by the Ministry of Health in Lima, Peru.

PARTICIPANTS

We interviewed 34 adolescents who completed or were lost to follow-up from treatment for drug-susceptible pulmonary TB disease in the preceding 12 months; their primary caregiver during treatment; and 15 nurses or nurse technicians who had ≥6 months' experience supervising TB treatment.

RESULTS

Participants reported numerous treatment barriers, the most common of which were the inconvenience of health facility-based directly observed therapy (DOT), long treatment duration, adverse treatment events and symptom resolution. The support of adult caregivers was critical for helping adolescents overcome these barriers and carry out the behavioural skills (eg, coping with the large pill burden, managing adverse treatment events and incorporating treatment into daily routines) needed to adhere to treatment.

CONCLUSION

Our findings support a three-pronged approach to improve TB treatment adherence among adolescents: (1) reduce barriers to adherence (eg, home-based or community-based DOT in lieu of facility-based DOT, reducing pill burden and treatment duration when appropriate), (2) teach adolescents the behavioural skills required for treatment adherence and (3) strengthen caregivers' ability to support adolescents.

The Impact of Tuberculosis on the Well-Being of Adolescents and Young Adults

The health needs of adolescents and young adults (AYAs) have been neglected in tuberculosis (TB) care, control, and research. AYAs, who are distinct from younger children and older adults, undergo dynamic physical, psychological, emotional, cognitive, and social development. Five domains of adolescent well-being are crucial to a successful transition between childhood and adulthood: (1) Good health; (2) connectedness and contribution to society; (3) safety and a supportive environment; (4) learning, competence, education, skills, and employability; and (5) agency and resilience. This review summarizes the evidence of the impact of TB disease and treatment on these five domains of AYA well-being.

Perceptions of Adolescents and Health Workers Towards Adolescents' TB Diagnosis in Central Uganda: A Cross-Sectional Qualitative Study

PURPOSE

Prompt diagnosis of TB among adolescents may reduce transmission and improve individual outcomes. However, TB diagnosis in adolescents is challenging. This study sought to understand challenges to adolescent TB diagnosis.

METHODS

We conducted qualitative focus group discussions (FGDs) to explore adolescents' and health workers' perspectives on challenges to TB diagnosis among adolescents seeking care at four secondary health care facilities in Uganda. Eight FGDs were conducted: four with 32 adolescents consulting for medical care and four with 34 health workers involved in TB care.

RESULTS

Adolescents were aware of TB and associated risk factors and believed behaviours like smoking and alcohol use are risk factors for TB. They reported school schedules limit them from seeking TB care and have to miss school or wait for holidays to seek TB diagnosis. They noted school nurses do not take much interest in diagnosing TB and do not refer them to hospitals for further evaluation when they present with TB symptoms. Furthermore, adolescents reported cross-cutting issues like loss of trust in public health systems, encountering unfriendly, judgmental and uncooperative health workers. Health workers mentioned the school environment exposes adolescents to TB as the dormitories they sleep in are overcrowded. They indicated that it was difficult to make a diagnosis of TB in adolescents as the adolescents do not disclose health information. They reported fellow health workers perceive adolescents as being at low risk of TB as they believe most often adolescents are HIV negative and thus have reduced risk of TB.

CONCLUSION

Adolescents present unique challenges that need to be addressed if TB diagnosis is to improve. These challenges could be handled by interventions that lead to minimal disruptions on school schedules, provision of adolescent-friendly services and intervention to build capacity of health care workers in the provision of adolescent-friendly services.

A scoping review of paediatric latent tuberculosis infection care cascades: initial steps are lacking

BACKGROUND AND OBJECTIVES

Identifying and treating children with latent tuberculosis infection (TB infection) is critical to prevent progression to TB disease and to eliminate TB globally. Diagnosis and treatment of TB infection requires completion of a sequence of steps, collectively termed the TB infection care cascade. There has been no systematic attempt to comprehensively summarise literature on the paediatric TB infection care cascade.

METHODS

We performed a scoping review of the paediatric TB infection care cascade. We systematically searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Cochrane and Embase databases. We reviewed articles and meeting abstracts that included children and adolescents ≤21 years old who were screened for or diagnosed with TB infection, and which described completion of at least one step of the cascade. We synthesised studies to identify facilitators and barriers to retention, interventions to mitigate attrition and knowledge gaps.

RESULTS

We identified 146 studies examining steps in the paediatric TB infection care cascade; 31 included children living in low-income and middle-income countries. Most literature described the final cascade step (treatment initiation to completion). Studies identified an array of patient and caregiver-related factors associated with completion of cascade steps. Few health systems factors were evaluated as potential predictors of completion, and few interventions to improve retention were specifically tested.

CONCLUSIONS

We identified strengths and gaps in the literature describing the paediatric TB infection care cascade. Future research should examine cascade steps upstream of treatment initiation and focus on identification and testing of at-risk paediatric patients. Additionally, future studies should focus on modifiable health systems factors associated with attrition and may benefit from use of behavioural theory and implementation science methods to improve retention.

Preventive therapy compliance in pediatric tuberculosis - A single center experience

INTRODUCTION

Despite its importance, there are some barriers to patient compliance in preventive therapy (PT) of tuberculosis (TB). The purpose of this study was to evaluate the compliance to appointments, PT and follow-up in a pediatric population after TB exposure, followed in a single TB outpatient center, and the subsequent identification of compliance determinants.

METHODS

Retrospective analysis of all pediatric patients who underwent PT in Gaia TB outpatient center from January 2015 to June 2016. Patients were divided into two groups: compliant and non-compliant, according to adherence to screening, visits and medication. The data collection was based on review of medical records.

RESULTS

A total of 72 patients were enrolled, 33 (45.8%) on chemoprophylaxis and 39 (54.2%) on latent tuberculosis infection (LTBI) treatment. The majority of patients were compliant (63.9%, n=46). Non-compliance was found in 36.1% (n=26): in 12 patients to contact screening, in 11 patients to PT and 22 patients did not attend medical appointments in the first place. In 10 patients, non-compliance was related to social problems/family dysfunction (low socioeconomic status and parent's unemployment). After putting in place several strategies, such as telephone contact, activating social services and direct observation of therapy, a compliance of 98.6% was achieved. Isoniazid was the main drug used (91.7%), during 9 months for LBTI.

CONCLUSION

PT compliance in TB can be challenging, probably related to the lack of risk perception and caregiver's reluctance to undergo a prolonged treatment to an asymptomatic condition. We conclude that implementing interventions can considerably improve treatment compliance and reduce the risk of future tuberculosis development. We emphasize the success in compliance to a 9 month regimen of isoniazid in the vast majority of patients with LTBI.

Impact of nursing interventions on adherence to treatment with antituberculosis drugs in children and young people: A nonrandomized controlled trial

AIM

To evaluate the association of a new nursing intervention on the adherence to antituberculosis treatment in a paediatric cohort (<18 years).

BACKGROUND

Tuberculosis remains a public health problem worldwide. The risk of developing tuberculosis after primary infection and its severity are higher in children. Proper adherence to antituberculosis treatment is critical for disease control.

DESIGN

Nonrandomized controlled trial; Phase 1, retrospective (2011-2013), compared with Phase 2, prospective with intervention (2015-2016), in a referral centre for paediatric tuberculosis in Spain (NCT03230409).

METHODS

A total of 359 patients who received antituberculosis drugs after close contact with a smear-positive patient (primary chemoprophylaxis) or were treated for latent tuberculosis infection or tuberculosis disease were included, 261 in Phase 1 and 98 in Phase 2. In Phase 2, a new nurse-led intervention was implemented in all patients and included two educational steps (written information in the child's native language and follow-up telephone calls) and two monitoring steps (Eidus-Hamilton test and follow-up questionnaire) that were exclusively carried out by nurses.

RESULTS

Adherence to antituberculosis treatment increased from 74.7% in Phase 1% to 87.8% in Phase 2 (p = 0.014; Chi-square test), after the implementation of the nurse-led intervention. In Phase 2, nonadherence was only associated with being born abroad (28.6% vs. 7.8%; p = 0.019; Chi-square test) and with foreign origin families (27.3% vs. 0%; p < 0.0001; Chi-square test).

CONCLUSION

The nurse-led intervention was associated to an increase in adherence to antituberculosis treatment. Immigrant-related variables remained major risk factors for sub-optimal adherence in a low-endemic setting.