The challenges fraughting isoniazid prophylaxis as a child tuberculosis prevention strategy in high burden settings in Nairobi, Kenya
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Background: Paediatric Tuberculosis (TB) is rapidly becoming a major public health concern among the urban poor. Though contacts' tracing and Isoniazid Prophylaxis Therapy (lPT) is an effective prevention strategy, its benefits have not been realized in many resource poor settings. Barriers to its uptake have not been fully elucidated. Objectives: To evaluate the challenges that fraught the implementation of' contact tracing and IPT, as a TB prevention strategy in children in household contact with adults with TB from informal settlements in Nairobi, Kenya. Metbodology: A prospective longitudinal multicenter cohort study was done, where 366 recently diagnosed TB smear positive source cases were asked to enroll their child contacts for IPT. Consent was sought. Structured standard questionnaire was used to get information on source case TB treatment, socio-demographics, TB knowledge and perceptions. Baseline screening was done to exclude those with TB and/or other chronic illnesses. Contacts were then put on daily isoniazid for 6 months and followed up monthly for one year for new TB disease. Adherence, safety and challenges were monitored. Focused group discussions and key informant interviews were used to provide secondary data. Results: All the 366 source cases interviewed were on first line anti- TB treatment. IPT acceptability was 87.3%. A total of 428 child contacts were screened, but 14(3.2%) had TB disease hence excluded. Compliance rates were 93% (95% CI 90.1 - 96.2%) and 85% (95% CI 80.2%- 88%) after 1'1and 6th months respectively. Challenges reported included; side effects in 22%, programmatic concerns in 86%, drug related issues in 70.1 %, and various health system challenges. The leading programmatic challenge was too many hospital visits (65.2%) and the drug related challenge was difficulty in administering tablets to children (44.3%). IPT completion rate was 368 out of 414 (88.8%). By endpoint, IPT failure was documented in 6( 1.6%), hence the relative risk of new TB disease in contacts on IPT was 0.49 (95% CI 0.21 -0.86). Conclusion: IPTwas an effective and safe child TB prevention strategy in informal settlements, but it's implementation had been hampered by relatively low acceptability, sub-optimal adherence, programmatic challenges, and high defaulting rates and by limited benefits realized.