Contact Tracing of Children Living With Sputum Positive Adult Cases of Pulmonary Tuberculosis, In Urban Ghaziabad: A Hospital Based Cross Sectional Study

INTRODUCTION

Investigations to find out active TB in the household contacts of an adult TB patients has been internationally accepted as a reliable method for recognizing the children at high risk of developing tuberculosis.[1] The other benefits of this approach are, it being cost effective and convenient opportunity for early TB case detection long before clinical feature become severe enough to be noticed and patient being brought to the medical facility. Unimmunized, undernourished children (the household contacts) are at high risk of contracting TB than the member of general population.[2] We all know that it is not easy to prove that this particular child who is having low grade fever for some days with mild cough and poor appetite and thin built is actually suffering from TB. Reasons range from paucibacillary TB in children leading to poor yield of AFB demonstration in sputum, lymph nodes FNAC and gastric aspirate or non-specific radiological finding in chest X-rays. In low resource developing countries where the burden of TB is high, unfortunately screening of contacts of open adult cases is still highly inadequate and incomplete despite National policy and the Revised National Tuberculosis Control Programme of India (RNTCP). The clear recommendations states that on contact screening, if the child is found to be harboring TB is started on anti-tuberculosis therapy (ATT) while those found Various studies from India have shown that active contact screening detects as many as 2.3% positive pediatric cases of pulmonary tuberculosis among closed contact in low economic and middle economic countries.[1] In China with similar high burden in India, the yield of subjects diagnosed with tuberculosis after thorough contact tracing ranged from 0 to 6.9% in household contact.[3] Diligent screening ensures • early detection of disease • prompt initiation of treatment thus reduce disease burden • decreased risk of disease transmission and poor treatment outcomes. The present study will be beneficial to the society and will help in achieving national goal of TB free India. Analysis of published data from South India revealed that there is unsatisfactory execution of screening and isoniazid prophylaxis application under routine program condition.[4,5] Thus the present study was planned to study the status of contact screening in the locality being catered by us.

• infectiousness of the index patient (open with high bacterial load) • duration of exposure (higher the risk, longer is the exposure) • proximity (higher the risk if index cases is household) [6,7] • susceptibility of the contact (unimmunized undernourished are more susceptible)[6,7]

The various modalities used for contact screening include symptom screening, chest radiography, sputum smear and culture examination, Rapid molecular diagnostic test – GeneXpert, tuberculin skin test and Interferon Y release assay.[2] The pooled sensitivity of chest x-ray reading (98%) was higher compared to screening of symptoms (87%). A sequential screening algorithm with chest x-ray as a second screen for TB symptomatic show a sensitivity and specificity of 90% and 56%.5 Contact investigation also provides the window to preclude the advancement to active disease among person with dormant TB infection.[7]

1) To investigate all child contacts of newly diagnosed adults TB patients 2) To analyze if the child is having active TB disease (will be started on ATT) 3) To analyze if child is although exposed but not having TB (will be started on INH prophylaxis. 4) To determine the proportion of household contacts (aged <6yrs) who will be initiated on Isoniazid preventive treatment. 5) To determine the proportion of household contacts having active disease will be started on ATT. 6) To compare the local data with the state and national data.

The present study was approved by Institutional ethical committee and review board. • STUDY DESIGN-cross sectional study

The cases were enrolled in the proposed study from both General Paediatric OPD as well as DOTS Unit, a part of RNTCP DMC (designated microscopic centre) situated at Santosh Medical College and Hospital, Ghaziabad, UP. SAMPLING-All consecutive eligible tuberculosis subjects with willingness to participate were enrolled after written informed consent.

Where n is the sample size, Z is the statistic corresponding to level of confidence, P is expected prevalence and d is precision (corresponding to effect size).

Medical College and Hospital, Ghaziabad, UP. India Tb Report 2019 (released in Feb 2019) states the prevalence of TB in UP to be approximately 20%. Using the above formula, at 95% confidence interval (CI), with prevalence (P) of 20% and precision (d) of 4% was taken. Sample Size = 0.95×0.95×0.2×0.8/0.0016

=90.25 =90

However, we were able to study a sample of 160.

All children up to age of 18 years with contact of sputum smear –positive TB cases diagnosed in Santosh Hospital as well as DOTS Unit.

• Doubtful cases due to incomplete workup. • All extra-pulmonary tuberculosis index cases.

Details of open sputum, AFB positive adult cases were taken from hospital‘s DOTS centre. A total of 163 such cases identified. The eligible contacts (1-18 years age group) from these index cases were identified. All eligible children aged 1-18 years having a history of contact with sputum smear positive TB cases and all diagnosed adult TB cases attending general pediatric OPD/DOTS centres of Santosh Hospital were enrolled. Enrolled individuals were subjected to the following. 1. A detailed history was taken. 2. All adult cases enrolled in the DOTS center were contacted to extract data about their children details. 3. Index cases were advised to bring all children to the hospital and if not then counseling with instruction and telephonic reminder. The firstly identified sputum smear positive cases in a domiciliary were identified as Index cases. While all of the members sharing the common kitchen with index cases were stated to be as Household contact Following investigations were done to confirm the Positive cases were treated as per RNTCP and for negative cases with only abnormal chest x-ray. course of antibiotics was started and repeat chest x-ray was advised after 15 days with regular follow up. All asymptomatic contacts aged less than 6yrs which were found negative on screening of age were started with isoniazid chemoprophylaxis with 5mg/kg/day for 6 months.

Statistical analysis was done by STATA/SE 9.1. Association of x-ray chest abnormality, socio economic status & tuberculosis among contact was analyzed by Chi- square test. Variable were selected on basis of significance on univariate analysis. The level of significance was 5%, confidence interval was 95% used to interpret statistical significance.

Of 163 eligible index cases, 3 cases did not report for follow up and hence were excluded from the study. A total 778 household cases were identified. Complete evaluation was not done for 33(4.2%) cases as they were lost to follow-up despite telephonic reminders. Median age of index cases (73.6%) symptomatic contacts underwent sputum examination and 16 (29.1%) had positive sputum result. A total of 27/160 (8.7%) had at least one household contact, among 160 index cases. Among 133 household contact between 0-6 years, evaluation of TB successfully done for 76 (65.2%).

A standard modus operandi and methodical execution was done on household contact investigation showed effective and precise monitoring of contact cases. A total of 74 cases went for sputum examination, this reveals tough challenges of implementing field investigation. Some portion of contacts (26.4%) did not report to DOTS center for investigations. so this people might have reported to private hospitals or lab for evaluation of TB. TB progression is variable and we were not able to screen latent tuberculosis. The yield of active tuberculosis cases is 0 -6.9% in high burden countries. Sputum screening and chest x-rays show high sensitivity for presumptive diagnosis of TB. Risk of infection depends on duration of exposure, contact during exposure and environmental factors. First degree relatives, family history of TB, HLA association has strong connection with presumptive TB (11).

1) The laboratory facilities for investigations and chest x-ray were available in hospital for all the household contacts. 2) The methodology for systemic data collection was robust due to DOTS center facility in hospital.

1) The present study was done in clinical setting in hospital, hence might not be a representative sample of population. Thus, the present study has questionable external validity. 2) Only active pulmonary TB index cases included, so latent and extra pulmonary cases were missed, probably missing the accurate burden of TB in community.

CONCLUSION

A standard protocol and systematic implementation done on household contact investigation showed effective and precise monitoring of contact case. Deshpande M, Satyanarayana S. (2015). Evaluation of TB cases finding through systemic contact investigation, Chhattisgarh, india. tuberculosis research and treatment; pp. 1-5. 2. Nair D, Rajshekhar N, Klinton JS, Watson B, Velayutham B, Tripathy JP (2016). Household contact screening and yield of tuberculosis cases.PLoS ONE; 11(9); pp. e0162090. 3. Jia Z, Cheng S, Ma Y. et. al. (2014). ―Tuberculosis burden in china: a high prevelance of pulmonary TB in household contacts with and without symptoms ―. BMC infectious diseases; pp. 14. 4. Shivramakrishna HR, Frederick A, Shazia A. et. al. (2014). ―Isoniazid preventive treatment in children in two district of south India: does practice follow policy‖. International journal of tuberculosis and lung disease; pp. 919-924 5. Shukla, B. and Shukla, D. (2011). ―Study to Assess Physical Health Status of Children at Selected Orphanage in Salem, Chennai ―India‖, IARS‘ International Research Journal. Vic. Australia, 1(2). DOI: 10.51611/iars.irj.v1i2.2011.10. 6. Potghukuchi M, Nagaraja SB, Kelamane S. et. al. (2011). ―Tuberculosis contact screening and isoniazid ptreventive therapy in a south indian district : operational issue for programmatic consideration‖. PLoS ONE. 7. Fork A, Numata Y, Schulzer M, Fitzgerald MJ (2008). ―Risk factor for clustering Tuberculosis cases: A systemic review of population based molecular epidemiological studies ―.Int. J. Tuberc Lung Dis.; 12(5): pp. 480-492 8. Kenyon TA, Valway SE, Ihle WW, Onorato IM, Castro KG (1996). ―Transmission of multidrug resistant mycobacterium tuberculosis during a long airplane flight ―N. Engl. J. Med.; 334(15): pp. 933-938 10. Vant Hogg AH, Laserson KF, Agaya JA, Muchiri BG, Githui WA, et. al. (2012). ―Screening Foot tuberculosis prevelance survey ―the value of chest radiography and survey; 7(7): pp. e38691

12. Jyoti Batra, V.K. Arora (2014): Editorial on Oxidative Stress and Tuberculosis; Indian J Tuberc.; 61, pp. 183-185

Department of Pediatrics, Santosh Medical College, Santosh Deemed to be University, Ghaziabad (UP)