|BRIEF RESEARCH ARTICLE
|Year : 2013 | Volume
| Issue : 1 | Page : 36-39
Characteristics of childhood tuberculosis patients registered under RNTCP in Varanasi, Uttar Pradesh
Ruchi1, Harshad P Thakur2
1 PG Student, Center for Public Health, School of Health Systems Studies, Tata Institute of Social Sciences (TISS), Mumbai, India
2 Professor, Center for Public Health, School of Health Systems Studies, Tata Institute of Social Sciences (TISS), Mumbai, India
|Date of Web Publication||4-May-2013|
Harshad P Thakur
Professor, Center for Public Health, School of Health Systems Studies, Tata Institute of Social Sciences (TISS), Mumbai - 400 088
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Childhood tuberculosis (TB) reflects on-going transmission. Data on childhood TB from TB registers under Revised National Tuberculosis Control Program of 2008 and 2009 in Varanasi district was analyzed. Proportion of childhood TB was 8.3% of total registered cases 12,242. It was lower than estimated 10-20% in endemic areas. In rural Tuberculosis Units childhood case detection was poor. Case detection in ≤5 years was very less. The childhood cases were detected mainly in adolescent age group. Thus, childhood TB is remaining a under diagnosed/under reported disease in India. It needs attention to increase the detection of childhood TB cases to control TB in general population.
Keywords: Childhood tuberculosis, Revised national tuberculosis control program, DOTS
|How to cite this article:|
Ruchi, Thakur HP. Characteristics of childhood tuberculosis patients registered under RNTCP in Varanasi, Uttar Pradesh. Indian J Public Health 2013;57:36-9
|How to cite this URL:|
Ruchi, Thakur HP. Characteristics of childhood tuberculosis patients registered under RNTCP in Varanasi, Uttar Pradesh. Indian J Public Health [serial online] 2013 [cited 2020 Feb 21];57:36-9. Available from: http://www.ijph.in/text.asp?2013/57/1/36/111367
One-fifth of the global tuberculosis (TB) incident cases occur in India. Each year approximately 2,000,000 people in India develop TB, of which around 87,000 are infectious cases.  An exact number of childhood TB is however not known because of the difficulty in establishing a definitive diagnosis and requirement of specialist consultation to diagnose extra pulmonary cases. Childhood TB is also considered a lesser public health priority because of belief that very few children presents with smear positive TB.  The World Health Organization has estimated approximately 1,000,000 new cases and 400,000 deaths per year in children are due to TB.  The infection acquired during childhood promotes reactivation of adult disease maintaining the chain of transmission. Thus, childhood TB needs equal attention for effective control of TB. 
In India yearly report of Revised National Tuberculosis Control Program (RNTCP) provides information about the percentage of children (0-14 year) among all new TB cases and sex of only sputum positive cases. It does not provide information of childhood TB in different age groups (like 0-4, 5-9 and 10-14 years), sex and type of cases.
Thus a study was conducted during 2010 in Varanasi, Uttar Pradesh to know the situation of childhood TB and to analyze secondary data of childhood TB, registered under RNTCP in Varanasi. Varanasi has highest population density in Uttar Pradesh.
There were seven Tuberculosis Units (TUs) in Varanasi District, each covering around 500,000 population. Two TUs were covering only rural, two covering only urban and three covering both urban and rural population. All the seven TUs were contacted and data was collected from TB registers for year 2008 and 2009. TB register contain information of TB cases registered under a TUs on name, age, sex, address, type of TB, sputum smear results, and treatment starting date and result of treatment. Under RNTCP children are classified as below 15 years of age. Total registered cases were taken as provided in RNTCP yearly report. Data was analyzed using EpiInfo 3.5.1.
[Table 1] gives the distribution of childhood TB cases in TUs. Total 1016 childhood TB cases were registered (i.e., 8.3% out of total registered 12,242 cases) at Varanasi in 2008 and 2009. Though total registered case distribution was almost similar in all TUs, the detection of childhood cases were very less in rural TUs (4.4% compared to urban). There was huge variation in percent of childhood TB cases over total registered cases showing poor childhood TB case detection in rural TU.
[Table 2] presents, distribution of childhood TB patients as per sex, type of TB, and sputum smear status in different age groups. Out of 1016 registered childhood TB cases, majority (62%) were females. More than 70% cases were registered under Category one. Overall pulmonary TB (66%) was more common in childhood TB than Extra Pulmonary TB. Within pulmonary TB cases, less than half, i.e., 47% were sputum positive. Majority of cases (97%) were newly registered cases. Among all childhood registered TB cases, only 9% were in 0-5 years. More than 60% of childhood TB cases were in age group 10-14 years. A treatment result of 907 children was provided as 109 children were on treatment during the time of data collection. Out of these 907 children, 95% were cured or had completed the treatment; only 4% had defaulted; four (0.4%) died and there were 4 (0.4%) of treatment failure.
|Table 2: Distribution of childhood tuberculosis patients as per sex, type of tuberculosis and sputum smear status in different age groups|
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In the 0-4 year age group, more boys (56.2%) were registered than girls but with increasing age more girls were registered - 56.3% in 5-9 year and 67.8% in 10-14 year age groups. More extra pulmonary cases were diagnosed in children below 5 years (56.2%) and more pulmonary cases in age group 5-9 (63.64%) and 10-14 year (70.9%). Sputum negative cases were higher in 0-4 years (87.2%) and 5-9 years (57.8%) while sputum positive cases were slightly higher in 10-14 years (52.7%). The Chi-square test for the trend over the age groups was statistically significant for sex, type of TB, and type of sputum.
In this study 8.3% of total registered TB cases (12,242) were children in Varanasi, similar to Lala Ram Swaroop (LRS) Delhi study where 9.4% of total TB cases were children.  According to RNTCP data of year 2008 and 2009, percentage of childhood TB cases over all new cases was 11% in Varanasi. , Thus it seems there is misreporting of childhood TB for Varanasi in RNTCP data. This needs to be studied further.
It is estimated that with accurate diagnosis and good reporting systems, children <15 years are likely to contribute 10-20% of the disease burden in TB endemic areas.  In a report from a TB endemic area in Cape Town, South Africa, children less than 13 year of age contributed 13.7% of the total disease burden.  Beyers et al.  found that 40% of TB notifications from a high incidence area in South Africa were children. Thus, 7% of childhood TB cases in India is definitely an under estimation which might be because of passive approach of RNTCP.
TB case detection was unevenly distributed in TUs in Varanasi with variation in case detection between urban and rural areas. Possible reason is more cases in urban areas compared to rural. However, this cannot be true considering the occurrence elsewhere in India as reported by RNTCP. Another possibility is difficulty in case detection in rural areas because of poor health facilities, infrastructure, and migration. Again this is not possible as the problem is only for pediatric cases, not for adult TB cases. In rural TUs though the population served by TUs was same, but the area covered is much larger. Furthermore, detection of childhood TB cases is not given that much priority by the local providers. TUs where majority of childhood cases were registered had pockets of areas, where chain of transmission was maintained among low socioeconomic and marginalized families. These areas were located under urban TUs. Alvarez-Hernαndez et al.  found that few areas had high incidence and mortality due to TB in a city in Mexico. Similar findings are seen in few areas of Espirito Santo, Brazil.  Middelkoop et al.  in South Africa found that childhood TB infection should be monitored in high-burden areas because it reflects ongoing transmission.
In our study 62% of all childhood cases were females, a finding which is similar to Satyanarayana et al.  (61%) and LRS study  (63%). In our study, EPTB was seen in 34% compared to 63% reported by Satyanarayana et al.,  47% by LRS study  and 53% by Sivnandan et al.  In our study, 53% were sputum smear negative among pulmonary cases compared to 58% in Satyanarayana et al.  and 47% in LRS study. 
Case detection in ≤5 year was very less. Satyanarayana et al.  had similar finding and found only 11% were <5 years of age. Reason for this might be diagnosis of TB in young children is difficult. In Varanasi more childhood TB case detection in adolescent years might be because of RNTCP focus on detection of sputum positive cases. In adolescents signs and symptoms of TB are similar to adults hence comparatively easy to diagnose. In younger children getting adequate sputum sample is difficult.
There were total 739 childhood cases in category one, out of which 319 (43%) were sputum positive. The rest 420 (67%) were seriously ill sputum negative or seriously ill extra-pulmonary cases, which can be reduced to minimum with early detection of sputum negative and EPTB cases. This shows that these children were getting DOTS treatment in late stage of their disease. There is a possibility of wrong classification as large numbers of seriously ill NSP cases are included here.
As per RNTCP reports, , there was huge variation in percentage of childhood TB cases in different states in India. This variation was not only present in different states but also in different districts of these states. The poor childhood TB case detection in these districts negatively affects the total percentage of India's childhood TB cases. These low detection districts need attention.
Childhood TB cases registered under RNTCP in Varanasi were less than the estimated figure of 10-20% and low case detection in ≤5 years. There is misreporting of childhood TB cases in Varanasi. Childhood TB case detection was poor in rural TUs than urban and urban-rural mixed TUs. Even in many states in India percent of childhood TB cases were less.
To detect more childhood TB cases under rural TUs local village doctors (Qualified and Non-qualified practitioner) of each village should be involved. There is a need to motivate the community people to join as health volunteer and increase parents' awareness about childhood TB especially, among mothers. A policy is required to provide knowledge of few important diseases like TB in schools curriculum. Children are more receptive and can disseminate the information to their families. At present few indictors are measured for childhood TB in RNTCP. More indicators should be used to assess childhood TB situation in India.
| References|| |
|1.||World Health Organisation India, 2011. Available from: http://whoindia.org/en/Section3/Section123.htm. [Accessed on 2011 Jan 9]. |
|2.||World Health Organisation SEARO, 2011 Available from: http://www.searo.who.int/en/Section10/Section2097/Section2106_10681.htm. [Accessed on 2011 Jan 9]. |
|3.||World Health Organisation Global TB report, 2009. Available from: http://www.who.int/tb/publications/global_report/2009/pdf/full_report.pdf. [Accessed on 2011 Jan 9]. |
|4.||Amdekar YK. Tuberculosis - Persistent threat to human health. Indian J Pediatr 2005;72:333-8. |
|5.||Arora VK, Agarwal SP. Pediatric tuberculosis: An Experience from LRS Institute of Tuberculosis and Respiratory Diseases. Tuberculosis Control in India. New Delhi: Ministry of Health and Family Welfare; 2005. p. 115-8. |
|6.||RNTCP Annual Report 2009. TBC India. Available from: http://www.tbcindia.org/pdfs/tb%20india%202009.pdf. [Accessed on 2011 Jan 9]. |
|7.||RNTCP Annual Report 2010. TBC India. Available from: http://www.tbcindia.org/pdfs/TB%20India%202010.pdf. [Accessed on 2011 Jan 9]. |
|8.||Marais BJ, Schaaf HS. Childhood tuberculosis: An emerging and previously neglected problem. Infect Dis Clin North Am 2010;24:727-49. |
|9.||Marais BJ, Gie RP, Schaaf HS, Hesseling AC, Enarson DA, Beyers N. The spectrum of disease in children treated for tuberculosis in a highly endemic area. Int J Tuberc Lung Dis 2006;10:732-8. |
|10.||Beyers N, Gie RP, Zietsman HL, Kunneke M, Hauman J, Tatley M, et al. The use of a geographical information system (GIS) to evaluate the distribution of tuberculosis in a high-incidence community. S Afr Med J 1996;86:40-1, 44. |
|11.||Alvarez-Hernández G, Lara-Valencia F, Reyes-Castro PA, Rascón-Pacheco RA. An analysis of spatial and socio-economic determinants of tuberculosis in Hermosillo, Mexico, 2000-2006. Int J Tuberc Lung Dis 2010;14:708-13. |
|12.||Sales CM, Figueiredo TA, Zandonade E, Maciel EL. Spatial analysis on childhood tuberculosis in the state of Espirito Santo, Brazil, 2000 to 2007. Rev Soc Bras Med Trop 2010;43:435-9. |
|13.||Middelkoop K, Bekker LG, Morrow C, Zwane E, Wood R. Childhood tuberculosis infection and disease: A spatial and temporal transmission analysis in a South African township. S Afr Med J 2009;99:738-43. |
|14.||Satyanarayana S, Shivashankar R, Vashist RP, Chauhan LS, Chadha SS, Dewan PK, et al. Characteristics and programme-defined treatment outcomes among childhood tuberculosis (TB) patients under the national TB programme in Delhi. PLoS One 2010;5:e13338. |
|15.||Sivanandan S, Walia M, Lodha R, Kabra SK. Factors associated with treatment failure in childhood tuberculosis. Indian Pediatr 2008;45:769-71. |
[Table 1], [Table 2]