Now that the PMTCT project is running smoothly (and we are actually screening in the right place! fingers crossed...), I have been brainstorming side project ideas, and I think that I found a topic that I am very excited about. Ever since my first two weeks on the wards, it became very apparent that at Moi Teaching and Referral Hospital, adult tuberculosis is far better managed than pediatric tuberculosis. I attribute this to a combination of the following:
1) diagnosis is very difficult in kids and the scoring systems available have yet to be validated in HIV endemic and malnourished populations.
2) children contribute little to transmission so previous research efforts have focused more on adult TB.
3) In high burden TB regions, only 15-20% of TB cases are believed to be pediatric TB cases.
4) Clinicians lack updated knowledge regarding childhood TB diagnosis and treatment.
The last point became painfully obvious last Friday when I heard the following story on the wards:
An 8 month old girl was admitted with a one month history of dry cough, night sweats, and weight loss. She is HIV sero-exposed and has a history of a TB household contact. The Kenyan interns and students consulted two scoring systems and appropriately determined that she should be started on anti-TB meds. The Kenyan consultant came to rounds on Friday, and when he assessed this little girl, he instructed the team to take her off the TB drugs. When a student questioned how he arrived at his clinical decision, he responded "I can see tuberculosis in a child's face. This child does not have tuberculosis."
Even if you are not in the medical field, I think that you can guess that this diagnostic approach is not exactly accurate. This scenario can (and does) occur in any country, and for me, it reiterated the importance of continuing medical education particularly in low-resource settings. I think that it would be useful to create a refresher workshop for medical students and clinicians on pediatric TB diagnosis and management. It's a difficult topic, and I think that this will be a great opportunity to discuss issues that have been encountered on the wards and brainstorm what can be done in the future to do a better job at diagnosing and treating peds TB. I am going to talk to my mentor about it this week and hopefully this is a feasible goal to accomplish this year!
As for my official research project, I think that I am going to focus on household contacts of peds TB cases. It is believed that a significant number of childhood TB cases have an active TB household contact. As far as I can tell, follow up is not done on the active case in the household so I want to look into this a bit more, and hopefully implement screening to get these active cases diagnosed and treated!
I will post more details as the project gets going...
