Barriers to Early Treatment Initiation in Childhood Tuberculosis in High Incidence Setting

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Funded by the Fogarty International Center and led by PI Dr. Chhaya Tukaram Valvi, the aim of this study is to evaluate the time to treatment initiation and barriers to early treatment initiation in childhood tuberculosis.
TB diagnosis in children is challenging, often overlooked or missed, because the symptoms and signs of TB can present the same as pneumonia, malnutrition, meningitis and HIV. In addition, there is a lack of accurate and reliable diagnostic tools for children with TB.
Children are at a higher risk of progression to active TB disease than adults. The risk of developing disease after infection with Mycobacterium tuberculosis has been estimated to be 43% in infants <1 year old, 24% in children 1–5 years old, 15% in adolescents, and 5–10% in adults. Childhood TB has a panoramic dimension from limited pulmonary disease, lymph node involvement, to severe disease as disseminated or adult-type cavitary disease and tuberculous meningitis. Delay in diagnosis and treatment leads to severe sequelae and poor outcomes. Numerous studies reveal tubercular meningitis as the most severe and lethal form of extra pulmonary TB (EPTB), with neurological sequelae in 50-80% of the survivors, despite adequate administration of TB therapy.
Management of TB in high burden settings such as India should focus on reducing the time delay from symptom onset to treatment initiation. Numerous studies of TB in adults explored the delays and barriers in tuberculosis diagnosis and treatment. 
There is only one study by Beyers et al in 1994 that evaluated time to treatment initiation, delays and barriers to childhood TB diagnosis and treatment, which can be adapted as a guide in childhood TB programs. Multiple steps are required from patient’s symptom onset to frequent visits to health care system for diagnosis and treatment initiation. Each of these steps has potential barriers. It is expected patient delay in children will be lesser compared to adults as parents usually seek timely treatment for their children with symptom onset. Significant time can be lost in children after their first contact with health care system due to various diagnostic challenges.
Currently with limited tools available for confirming TB diagnosis, better organization of services by identifying and addressing specific barriers could improve treatment outcomes in India; accounting for 27 % of the global burden of childhood TB.