Tuberculosis infection prevalence among children in high-burden South African communities
Although TB is one of the major causes of morbidity and mortality in the world, there has been less attention to the children and adolescents who come from communities that have high prevalence rates. There is a need to carry out studies in order to create the association between the HIV prevalence among adults and the rates of transmission to children and adolescents. The study will enable organizations and countries to develop intervention strategies that will help to curb the problem.
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Epidemiology of Tuberculosis
Tuberculosis and Epidemiology
The epidemiology of TB in a highly populated community in a suburban area in South Africa
Tuberculosis (TB) remains a chief cause of mortality and morbidity across the world (World Health Organization, 2009). In order to establish effectual intervention policies for the control of TB, it is essential to comprehend TB transmission in settings of high burden. In South Africa, the HIV and TB prevalence rates are relatively high with the prevalence rate being above 500 people per 100, 000 population (World Health Organization, 2011). Although there have been topical studies to assess TB infection among young children (Shanaube et al. 2009), there are hardly any data evaluating TB infection in adolescents and older children in communities that have high TB and human immunodeficiency virus problems (Wood et al. 2010). There have been routine uses of tuberculin skin test surveys to test for TB illness in communities, although there are only a few data from surveys using the tuberculin skin test from nations in which both (HIV) infection and TB are prevalent. The research shall be on school-going children aged 5 -- 17 years in a neighborhood that is experiencing an increase in the prevalence of HIV and TB. The school is a government school located within the community where there is a high prevalence of HIV. The hypothesis of this study is that there are high rates of TB infections among adolescents and children in a neighborhood with a high prevalence of HIV among adults.
The research questions for this research shall be:
1. What is the HIV and TB infection prevalence in the community?
2. What is the rate of TB infection among children in the community?
3. What is the relationship between HIV infection prevalence among adults and the rate of infection of TB among children and adults?
Section 2: Research Methods
The researcher will perform Tuberculin skin test survey on a population sample of children who attend school in the community under study, which is comprised of predominantly Xhosa-speaking people who live in a high-density and very poor residential area. The research will involve a cross-sectional survey in 2 stages among the school children who are enrolled and attending the local public primary school. Children will be eligible if they are a resident of the community and are enrolled at the local school. Children in the grades 5-7 will be enrolled in June 2013 and those in grades 2 -- 4 will be enrolled in December 2007. The researchers will seek parental consent and assent for participants who are ?6 years of age will be obtained before enrollment. The researcher will carry out the survey on the school grounds and will collect basic demographic information for each participant. However, the researcher will carry out a TST for all participants regardless of their BCG scar status. A trained nurse will administer polysorbate 80, with the standard of 2 TU of purified protein derivative RT23 that the World Health Organization recommends, intradermally on the left forearm's volar surface. Three days after the inoculation, a trained reader will measure the size of the upshot to the tuberculin. The researcher will note the absence or presence of a reaction, and, where present; the research will involve the measurement of the size of the induration along the perpendicular axis by means of standard calipers.
All the children who have a TST reaction induration of ?10 mm will be recalled for examination for active TB, and those children who have symptoms or signs of active TB will be referred to the neighboring clinic for further management. The researcher will analyze data using STATA, version 9.0. The researcher will calculate the results that the researcher will receive as the mean of the TST reaction induration's 2 diameters: a positive reaction will be defined at the cutoff points of 10-mm and 17.4-mm in discrete analyses. The 10-mm cutoff will be on the basis of the guiding principles for infection in clinical settings, and the 17.4-mm cutoff was determined as the mean induration size but after excluding all individuals who are nonreactive (South African Department of Health, 2004). The Annual Risk of Tuberculosis Infection (ARTI) will be as follows:
1-(1-prevalence) 1/mean age+0.5
The research will include the use of age, in full years, of the patient at their closest birthday thereby a need to add 0.5 to the mean age in calculating the ARTI (South African Department of Health, 2004). The researcher will divide the cohort into clusters of participants in ages of 5 -- 9 years, 10 -- 13 years and 13 -- 17 years, and will calculate ARTI and prevalence overall and for every age group. The researcher will also use Wilcoxon rank-sum tests for comparing of TST results between the various age groups. The use of a x2 test for trend will be for examining for a trend between ARTI and age, as well as for shifts in TB notification rates in a period over the 5-year period. All statistical tests will be 2-sided, with ?=0.05
The researcher will obtain the number of notified TB cases in adolescents and children from the TB register at the community's TB clinic. The TB prevalence rates will be calculated employing the Southern African National Census of 1996 and the house-to-house census that the Desmond Tutu HIV Centre conducted in 2003, 2004, and 2006. In calculating the ratios of prevalence of TB and occurrence of new infections from TB, the researcher will use the ARTI and the TB incidence and prevalence data that are already published with regard to this community (Lawn et al., 2006).
Section 4: The Impact
There are a number of benefits that the high-density township areas, particularly in South Africa, will receive in case they implement the above intervention strategies. The major impact of the intervention is a decrease in the number of TB cases among children and adolescents in this community. In addition, a reduction of the number of TB admissions at the hospital, and the decrease of TB transmission within and without the community will be a result that will arise from the implementation of the intervention plan. Other health outcomes to expect from the implementation of this program include an acceptance of TB treatment and prevention, patients receiving appropriate treatment for the TB, patients adhering to treatment and completing treatment in time, an increase in patients' knowledge about the disease, and an enhancement in the overall health of the population. On the other hand, the social outcomes of the program include building trust within the community, a reduction of stigma about TB, an overall improvement of the community's quality of life and patients being able to identify all of their close associates.
Section 5: Evaluation
Below is the evaluation plan that the researcher shall use to assess the effectiveness of the intervention suggestions above in achieving the expected outcomes of the program:
Introduction
The major goals of this evaluation shall be:
To establish the efficacy of the program
To appraise the success and advancement toward the realization of program objectives
To examine segments of the program that are functioning optimally so as to replicate them
To help in the equitable redistribution of resources
The aim of this assessment plan is to offer the researcher, and other stakeholders in the implementation of the intervention strategies, with the necessary information that will be helpful in assessing the effectiveness and progress of the program.
Evaluation Team
The evaluation team shall comprise 10 members and a team leader. The roles of the team leader shall be:
Supervision of all evaluation activities
Coordinator of all meetings of the evaluation team
Chief analyst of the evaluation data
Principal author of the evaluation plan and reports
Top person in the distribution of evaluation materials and reports
The rest of the members of the team shall carry out the following roles:
Data collection
Data analysis
Dissemination of findings
Use of the findings
Members of the evaluation planning committee
These people will include the program manager, epidemiologists, nurses, epidemiologists, and representatives from partner agencies.
Stakeholder Assessment
The table below gives the list of stakeholders who will be included in the program, their perspective, or interest in the program, the function they will have in the evaluation, and how and when they will participate in the evaluation:
Stakeholders
Perspective on or Interest in the TB program and the evaluation function in the evaluation
How and when will they be occupied in the evaluation
Program Managers
Interest in self-improvements and the perfection of the program
Define program processes
Formal Interview
Program staff
See program evaluation as a personal judgment
Define the problem in the program from a staff perspective
Formal Interview
Outreach workers evidence of effects for funding and program development purposes broadcast results to agency leaders and financial support agencies
External reviewer
Nurses
They fear an increase in workload
Collect data
Formal interview
Clinicians
Fear program alteration & job loss
Identify data sources
Formal interview
Program administrators
Interest in self-improvements and the improvements of the program
Providing administrative and funding context
External reviewer
Health department administrators
Concerns about the HIV status of the community
Define health problem
Data collector
Patients
Need for services
Define the problem in program from a client perspective
Participant
Adolescents and children
Fear or reject health system
Participate in providing their view of the program
Participant
Community members
Community image
Identify data sources
Meeting
Community-based organizations
Partnership capacity
Disseminate findings to community audiences
Community planning board
Community health among underserved population
Identify stakeholders
Meeting
Business community
Partnership capacity
Provide funding
Informal interview
Policy makers
Defensive of current system
Provide operational context
Focus group
Health care providers
Proof of effects for funding and program expansion purposes
Define health problem
Formal interview
Schools
They fear an increase in workload
Collect data
Data collector
The roles of the stakeholders will keep changing during evaluation, and this is not the final role appraisal for the stakeholders.
Background and Description of the TB Program
Need
The need for this program is to address the TB problem among adolescents and children living in areas where there is a high prevalence of HIV among adults. In addition, children in this area have not been vaccinated against TB through the BCG vaccine. This problem could be arising because there are only a few health care centers to serve the densely populated community thereby making the vaccines inaccessible. The consequences of this problem include ill health among children and adolescents, high morbidity rates, rise in the treatment costs and backlash against the community's population. This poses potential for a bigger problem, but acting may lessen the problem. In this area, there are a number of trends that are occurring, which have worsened the situation including an increase in the TB incidence and change in the demographic patterns.
Context
The factors that affect this program include:
This TB program will cooperate and coordinate with other social and health services in the community including HIV service programs, housing and food support programs, schools and hospitals among others.
The program is competing for resources with other health programs within the community.
Organization's structural factors
The program will be operating within the context of policy and political environment who may influence the effectiveness of the program
The community does not consider TB as a serious health problem
Target Population
This TB program targets the following groups of people in addressing the TB concerns:
Children and adolescents
People who are infected with HIV
People living in congregate settings
Stage of Program Development
In evaluating the program, one will consider the stages of the following activities:
Needs assessment
Design and planning
Implementation
Well-established implementation
This will be useful in deciding on outcome evaluation, process evaluation, or both.
Resources/Inputs
The resources for implementing the program are:
The TB program staff
Continuing education and Training staff
Financial support
Structural components
Infrastructure resources that are part of the health department
Partner organizations
Outputs
The following are the outputs that the evaluation shall take into account:
A strategic plan for the program
Conducting of TB Tests
Educating of providers about TB
Presenting of education sessions to community groups
Outcomes
The following are the probable expectations of the program, which evaluation will consider:
An increase in patient's knowledge
Acceptance by patients for TB treatment
More children receive BCG vaccine
Patients receive appropriate treatment
Patients stick to the TB treatment
A reduction in hospital admissions for TB
A reduction in the transmission of TB
Trust developed within the community
Patients name all of their close associates
Reduction of stigma about TB
Improved quality of patient's life
Patients are in good health overall
Evaluation Questions, indicators, benchmarks
Process questions:
1. Are there adequate resources to perform the activities of this program?
Indicators:
Availability of funding
Availability of personnel
Availability of physical space
Benchmarks:
Availability of enough funding for all activities
100% availability of personnel to execute the program's activities
100% availability of space for running the affairs of the program
2. Are associates named in the timeframe set by the procedures?
Indicator:
Patients naming of close contact between January and April 2014
Benchmark:
An increase in the number of patients identifying their close associates
3. Have community associates been taken on to work in partnership with us to thwart TB in the high-risk populace?
Indicator:
Associates are already working with the implementation team
Benchmarks:
An increase in the number of associates working with the implementation team
Outcome questions:
1. How did the plan play a part in the decline of TB transmission rate among children and adolescents?
Indicator:
The number of children and adolescents tested with TB between Jan and December 2014
Benchmark:
Reduction in the number of children and adolescents with TB
2. To what extent was the plan able to lessen the incidence of TB among adults?
Indicator:
The number of adults suffering from TB
Benchmark:
A reduction in the number of adults suffering from TB
Evaluation Design
Use of a control group
Measurements will be before and after
Data collection will be retrospective
Qualitative information
Data Collection
The sources
The data sources for evaluation include:
TB Records or charts
TB registry and databases
Interviews and focus groups
Participant observations
Other relevant documents
The tools
The tools for collecting the evaluation data will be:
1. Focus groups
2. Interviews
3. Personal interviews, both formal and informal
4. Self-administered surveys
There will be pilot testing of the tool before using them in the collection of evaluation data to ensure that users can effectively use them to achieve the intended purpose. Based on the pilot test, there shall be appropriate changes in the tools.
Analysis and Interpretation
Below is the plan for analyzing and interpreting the evaluation data:
Analysis
The evaluation team will use STATA data analysis software to analyze the evaluation results. The findings shall be presented in tables and charts.
Interpretation
The evaluation team will develop a draft report and share it with stakeholders as a way of engaging stakeholders in the interpretation of results. There shall be a representative from each of the stakeholders to be among the interpretation team.
Reporting and Dissemination
Reporting and dissemination of evaluation findings to the stakeholders shall be through the following means:
Report
Mailing
Website
Television
Radio
Newspaper
Newsletter
Briefing
Brochure
Meeting
Create your account
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