TB and TB-HIV care for adolescents and young adults.

SETTING: Nine high-burden public tuberculosis (TB) clinics in Gaborone, Botswana.OBJECTIVE: To evaluate the challenges encountered, healthcare worker (HCW) approaches, and supported interventions in TB and TB-HIV (human immunodeficiency virus) care for adolescents and young adults (AYA, aged 10-24 years).DESIGN: Semi-structured interviews with HCW in TB clinics, analyzed using thematic analysis.RESULTS: Sixteen HCWs were interviewed. AYA developmental needs included reliance on family support for care, increasing autonomy, attending school or work, building trust in HCWs, and intensive TB education and adherence support. Stigma strongly influenced care engagement, including clinic attendance and HIV testing. Health system barriers to optimal AYA TB care included limited staffing and resources to follow-up or support. HCWs utilized intensive education and counseling, and transitioned AYA to community-based directly observed therapy whenever feasible. HCWs supported implementation of youth-friendly services, such as AYA-friendly spaces or clinic days, training in AYA care, use of mobile applications, and peer support interventions, in addition to health system strengthening.CONCLUSION: HCWs utilize dedicated approaches for AYA with TB, but have limited time and resources for optimal care. They identified several strategies likely to improve care and better retain AYAs in TB treatment. Further work is needed to study interventions to improve AYA TB care and outcomes.

Initiation of anti-tuberculosis treatment in children following gastric aspirate testing, Botswana, 2008-2012.

SETTING: Diagnosing pediatric tuberculosis (TB) is difficult; to improve diagnosis, gastric aspiration (GA) was performed in 121 Botswana health facilities. OBJECTIVE: To describe treatment initiation and outcomes in children with a positive GA result and those treated empirically. METHODS: Children with smear or culture-positive GA or those clinically diagnosed were referred for anti-tuberculosis treatment. Treatment initiation and outcomes were assessed from February 2008 to December 2012 using name-based matching algorithms of the GA database; treatment initiation was captured in the electronic TB registry. Analyses included descriptive statistics and regression models. RESULTS: GA was conducted in 1268 children. Among these, 121 (9.5%) were GA-positive; and treatment was initiated in 90 (74.3%). An additional 137 (11.9%) were treated empirically. More than a third (36.4%) had known human immunodeficiency virus status (positive or negative); this was significantly associated with TB treatment initiation (adjusted odds ratio [aOR] 1.8, 95%CI 1.3-2.5); P < 0.05). Among the 90 children with a positive GA result, nearly all either completed treatment (78.9%) or were on treatment (20.0%) at the time of data collection. CONCLUSION: We could not find documentation of treatment for more than a quarter of the children with laboratory-confirmed TB, an important gap that calls for further examination. The failure to initiate prompt treatment requires investigation and urgent action.

Risk factors for gastric aspirate culture contamination in children evaluated for tuberculosis in Botswana.

SETTING: Gastric aspirate (GA) sample culture is commonly performed in children evaluated for tuberculosis (TB) who cannot expectorate sputum. Contamination limits culture yield and negatively impacts care. OBJECTIVE: To evaluate the proportion of and factors associated with GA contamination at a central TB reference laboratory in Botswana. DESIGN: This was a 5-year cross-sectional study of untreated children aged 12 years evaluated for TB with the first GA sample registered at the National Tuberculosis Reference Laboratory. We performed descriptive statistics to assess the risk of contamination with patient age, sex, transport time and distance, culture medium, and facility type. We generated multivariable logistic regression models using generalized estimating equation extension. RESULTS: We analyzed 3642 samples. The median age was 2 years (interquartile range [IQR] 1-4), median transport time was 4 days (IQR 2-7), and 64.1% of samples were from clinics or health posts. TB culture positivity was 1.6% (60/3642), and contamination was observed in 35.6% (1298/3642). Hospital collection was associated with lower contamination risk (adjusted OR [aOR] 0.53, 95%CI 0.40-0.69) and Mycobacteria Growth Indicator Tube vs. Löwenstein-Jensen medium with higher risk (aOR 1.88, 95%CI 1.51-2.34). CONCLUSION: In routine care settings, high sample contamination and low TB culture yield were observed. This raises questions about the collection technique and storage in lower-level facilities and affirms higher risk with a liquid culture medium.

Survey of health care worker knowledge about childhood tuberculosis in high-burden centers in Botswana.

BACKGROUND: Quantifying health care workers' (HCWs') knowledge about tuberculosis (TB) informs educational interventions. We assessed HCWs' knowledge about childhood TB in Botswana. METHODS: Semi-structured interviews were conducted with HCWs at 46 sites around Botswana using a piloted instrument. Transcripts were double-coded using a coding schema. Discrepancies were resolved by consensus and a systematic thematic analysis was performed. RESULTS: The sites (42 clinics and 4 hospitals) were urban (n = 9, 20%), semi-urban (n = 10, 22%) and rural (n = 27, 58%). HCWs included nurses (n = 42, 89%) and nurse assistants (n = 4, 11%). Sixteen (56%) HCWs were the TB focal persons for their site. Themes did not vary by type of site, HCW or TB focal person. Although the level of knowledge about secondary prevention using isoniazid prophylaxis therapy was fair, implementation was poor and contact tracing was not being performed. Barriers to TB diagnosis included poor knowledge about TB in the community, minimal diagnostics at site of care and not receiving test results. However, most HCWs reported that treatment initiation and the calculation of appropriate dosages were easy once the diagnosis had been made. CONCLUSIONS: In Botswana, HCWs' levels of knowledge about childhood TB varied greatly. The areas of TB diagnosis, screening and prophylaxis in children need additional attention in TB training courses; however, increased knowledge alone would not overcome all the barriers identified by the HCWs.

'That's when I struggle' Exploring challenges faced by care givers of children with tuberculosis in Botswana.

SETTING: Government-funded public health clinics in and around Gaborone, Botswana. OBJECTIVE: To explore the challenges faced by care givers of children on treatment for tuberculosis (TB) to inform a more child-friendly approach to Botswana's National TB Programme (NTP) strategy. DESIGN: Qualitative study using 28 in-depth interviews with care givers of children receiving anti-tuberculosis treatment. RESULTS: Care givers identified five main challenges: long delays in their child's diagnosis, difficulty attending clinic for daily treatment, difficulty administering TB medications, stock-outs of TB medications leading to treatment interruptions, and inadequate TB education. Care givers prioritized these same five areas to improve the overall management of their child's TB. CONCLUSION: Our findings suggest that despite accessing care through an NTP that adheres to World Health Organization guidelines, care givers for children on treatment in Botswana continue to encounter significant challenges. While each of these represents a potential threat to successful treatment, they can be addressed with relatively small systematic and programmatic adjustments. These results will inform the next version of the Botswana NTP guidelines towards a more child- and care giver-centered approach.

Loss to follow-up among adolescents with tuberculosis in Gaborone, Botswana.

SETTING: Nine high-burden public tuberculosis (TB) clinics in Gaborone, Botswana. OBJECTIVE: To describe clinical characteristics and outcomes among adolescents with TB and compare loss to follow-up (LTFU) rates with that among youth and adult cases. DESIGN: Retrospective cohort study of TB cases registered from 2012 to 2014. Clinical characteristics and treatment outcomes were compared among adolescents (age 10-19 years), youth (20-24 years) and a systematic sample of adults (⩾25 years). RESULTS: We analyzed 120 adolescent, 210 youth, and 548 adult cases. Adolescents had twice the risk of LTFU over adults (RR 2.0, 95%CI 1.1-3.7, P = 0.03), and higher LTFU than youth; this was not significant (RR 1.4, 95%CI 0.7-2.9, P = 0.32). Of those with human immunodeficiency virus (HIV) infection, 8/35 (22.9%) adolescents were LTFU, compared with 3/51 (5.9%) youth, and 25/407 (6.1%) adults (P = 0.001). In a multivariable model, adolescence (OR 3.0, 95%CI 1.3-6.5, P < 0.01), HIV positivity (OR 2.2, 95%CI 1.1-4.5, P = 0.02), and extra-pulmonary TB (OR 2.2, 95%CI 1.2-4.0, P = 0.01) were each associated with LTFU. CONCLUSION: Adolescents treated for TB had greater LTFU than youth and adults, particularly in the setting of TB-HIV coinfection. Further work should clarify the generalizability of these findings and investigate poor outcomes among adolescents with TB.

The effect of exposure to wood smoke on outcomes of childhood pneumonia in Botswana.

SETTING: Tertiary hospital in Gaborone, Botswana. OBJECTIVE: To examine whether exposure to wood smoke worsens outcomes of childhood pneumonia. DESIGN: Prospective cohort study of children aged 1-23 months meeting clinical criteria for pneumonia. Household use of wood as a cooking fuel was assessed during a face-to-face questionnaire with care givers. We estimated crude and adjusted risk ratios (RRs) and 95% confidence intervals (CIs) for treatment failure at 48 h by household use of wood as a cooking fuel. We assessed for effect modification by age (1-5 vs. 6-23 months) and malnutrition (none vs. moderate vs. severe). RESULTS: The median age of the 284 enrolled children was 5.9 months; 17% had moderate or severe malnutrition. Ninety-nine (35%) children failed treatment at 48 h and 17 (6%) died. In multivariable analyses, household use of wood as a cooking fuel increased the risk of treatment failure at 48 h (RR 1.44, 95%CI 1.09-1.92, P = 0.01). This association differed by child nutritional status (P = 0.02), with a detrimental effect observed only among children with no or moderate malnutrition. CONCLUSIONS: Exposure to wood smoke worsens outcomes for childhood pneumonia. Efforts to prevent exposure to smoke from unprocessed fuels may improve pneumonia outcomes among children.

Yield of contact tracing from pediatric tuberculosis index cases in Gaborone, Botswana.

SETTING: Contact tracing using pediatric index cases has not been adequately investigated in high tuberculosis (TB) and human immunodeficiency virus (HIV) prevalence settings. OBJECTIVE: To determine the yield of contact tracing in household contacts of pediatric TB index cases in Botswana. DESIGN: Index cases included all pediatric (age ≤ 13 years) TB admissions from January 2009 to December 2011 to Botswana's largest referral hospital. A contact tracing team identified cases, conducted home visits, symptom-screened contacts and referred those with ≥ 1 TB symptoms. The primary outcome was newly diagnosed TB in a contact. RESULTS: From 163 pediatric index cases, 548 contacts were screened (median 3 contacts/case, interquartile range [IQR] 2-4). Of these, 49 (9%) were referred for positive symptoms on screening and 27/49 (55%) were evaluated for active TB. Twelve new TB cases were diagnosed (12/548, 2.2%); the median age was 31 years (IQR 23-38); 11 (92%) were smear-positive. Ten (83%) had known HIV status: 7 (70%) were HIV-positive. To find one new TB case, the number needed to contact trace (index cases/new cases) was 13.6, and the number needed to screen (contacts/new cases) was 46. CONCLUSION: This yield of contact tracing using pediatric index cases is similar to the traditional adult index case approach. Improving the proportion of symptomatic contacts evaluated may increase yield.