Epidemiology of Tuberculosis and Epidemiology

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 3: The Intervention

Prevention programs will need conceptual frameworks in order to develop interventions and select the most efficient policy. In South Africa, there is a policy that all children should receive a BCG vaccination. Although this policy has been in place since 1960, it is quite common knowledge that only a few people have had the vaccination, although the vaccination may be valuable. In addition, South Africa has other TB control strategies such as the treatment of active disease, case finding, and treatment of latent TB infection (Wood et al., 2011). Despite this, rate of TB infection in South Africa has gone high over the past two decades, the country now has the highest TB burdens in the entire world. The rates of TB infection among children and adolescents are expected to be so high especially in areas that have prevalence rates of HIV and TB in adults (Wood et al., 2011). This is an indication that these strategies to control TB have become unsuccessful, implying a need to improve these strategies and reinforce the existing ones, where possible.

First, there is a need to target reducing the high force of TB infection, particularly in high-density townships. It is paramount to understand that the benefits of enhanced case finding will depend on the existing epidemiology of TB transmission (Zhang, Jiang, and Wang, 2009). Detecting a case of TB, especially in a locale with a 10 will, in addition averts up to 10, secondary cases. The advantages of earlier and increased case finding on the spread of TB should be amplified in significantly high-transmission areas. Lessening the TB infection rates is elementary in attaining the long-term goal of TB control of a stable regression of the disease in succeeding generations (Cobelens et al., 2012). An improved and intensified case-finding programs, as part of the use of community-based interventions in historical TB control measures should be re-explored, in the view of the supplementary advantages increment for reducing transmission.

There is a need to decrease the time of diagnosis by use of advanced technologies such as molecular diagnostic technologies (World Health Organization, 2006; Shimao, 2005). This is because lessening of the infectiousness period has an impact on the prevalence of the infectious TB. This time of infectiousness is a result of delays, which include diagnostic delays, health-seeking behavior and health systems delays in starting effectual chemotherapy. There is a need for an intensified case finding to increase awareness of the usual symptoms of the TB infection. There is also a need for enhanced health systems effectiveness that can further lessen the time to begin effective TB treatment.

Investing in intensive campaigns to lobby for the public's participation in BCG vaccination will be a step forward in encouraging the community members to take their children for vaccination. This will work to reduce the number of TB infections among adolescents and children. There is also a necessity to implement age-specific interventions to interrupt the transmission of TB to infants, young children, school going children and adolescents, and adults. A decrease in TB infection rates among children, and a stable decrease in the number of the children who are latently infected would indicate a decrease in the number of TB transmissions to children (Statement, 2006). A decrease in the rates of recent infections, a reduction in the lifetime risk of TB infection, and a reduction in the effective contact number would reflect the control of TB among the adults.

The primary target for the long-term TB control should be to reduce the high force of TB infection, particularly in densely populated sub-urban areas. This is because the effectual contact numbers and the population prevalence of the infectious TB cases are the drivers of the high force of infection for the TB epidemic. Using of antiretroviral therapy (ART) as prevention has a strategy of controlling the HIV epidemic will have a supplementary effect in the control of the TB that is HIV-associated. A full implementation of the available ART guidelines, among the HIV- infected patients, will decrease the pre-ART TB infection burden. There is a need to target high-risk communities, and accompanying a shift in priority concentration from case management to the reduction in TB transmission with the incorporation of new result measures, which reflect continuing TB transmission at the sentinel and national sites.

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: