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INTERVENTIONS TO IMPROVE ADHERENCE TO TREATMENT FOR PAEDIATRIC TUBERCULOSIS IN LOW- AND MIDDLE-INCOME COUNTRIES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Saturday, 4th of July 2015

INTERVENTIONS TO IMPROVE ADHERENCE TO TREATMENT FOR PAEDIATRIC TUBERCULOSIS IN LOW- AND MIDDLE-INCOME COUNTRIES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Excerpts below; full text is at http://www.who.int/bulletin/online_first/BLT.14.147231.pdf?ua=1

Publication: Bulletin of the World Health Organization;

Type: Systematic reviews Article ID: BLT.14.147231

Meaghann S Weaver Improving treatment adherence in paediatric tuberculosis

This online first version has been peer-reviewed, accepted and edited, but not formatted and finalized with corrections from authors and proofreaders.

Interventions to improve adherence to treatment for paediatric tuberculosis in low- and middle-income countries: a systematic review and meta-analysis

Meaghann S Weaver,a Knut Lönnroth,b Scott C Howard,c Debra L Roterd & Catherine G Lama a St Jude Childrens Research Hospital, 262 Danny Thomas Place, MS 721, Memphis, TN 38105, United States of America (USA). b Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland. c World Child Cancer USA, Denver, USA. d Johns Hopkins Bloomberg School of Public Health, Baltimore, USA. Correspondence to Catherine G Lam (email: catherine.lam@stjude.org). (Submitted: 11 September 2014 – Revised version received: 1 May 2015 – Accepted: 7 May 2015 – Published online: 23 June 2015)

Abstract

 Objective To assess the design, delivery and outcomes of interventions to improve adherence to treatment for paediatric tuberculosis in low- and middleincome countries and develop a contextual framework for such interventions.

 Methods We searched PubMed and Cochrane databases for reports published between 1 January 2003 and 1 December 2013 on interventions to improve adherence to treatment for tuberculosis that included patients younger than 20 years who lived in a low- or middle-income country. For potentially relevant articles that lacked paediatric outcomes, we contacted the authors of the studies. We assessed heterogeneity and risk of bias. To evaluate treatment success – i.e. the combination of treatment completion and cure – we performed random-effects meta-analysis. We identified areas of need for improved intervention practices.

Findings We included 15 studies in 11 countries for the qualitative analysis and of these studies, 11 qualified for the meta-analysis – representing 1279 children. Of the interventions described in the 15 studies, two focused on education, one on psychosocial support, seven on care delivery, four on health systems and one on financial provisions. The children in intervention arms had higher rates of treatment success, compared with those in control groups (odds ratio: 3.02; 95% confidence interval: 2.19–4.15). Using the results of our analyses, we developed a framework around factors that promoted or threatened treatment completion.

Conclusion Various interventions to improve adherence to treatment for paediatric tuberculosis appear both feasible and effective in low- and middle income countries. Introduction Paediatric tuberculosis can be controlled or cured if timely and appropriate treatment is completed.1,2 More than 75% of these patients live in low- and middle-income countries in Asia and Africa and have substantial tuberculosis –related morbidity and mortality.2 Up to 20% of children with tuberculosis in low- and middle-income countries fail to complete treatment.3 Interrupted tuberculosis treatment poses a public health challenge because it permits the development of drug-resistant disease and allows patients to remain infectious for a relatively long time. Poor adherence results in disease progression, morbidity and death. The most extreme form of incomplete treatment is known as treatment abandonment or treatment default. For tuberculosis, such abandonment is generally represented by a break in treatment of at least two consecutive months.1 The barriers to treatment completion in low- and middle-income countries include medical expenses, the indirect costs of transportation and time away from work, the stigmas associated with the illness and/or the treatment, communication breakdowns between providers and patients, limited health literacy, the presence of too few health workers and problems in drug procurement.2

We conducted a systematic review and meta-analysis of interventions designed to reduce such barriers to treatment completion among children with tuberculosis in low- and middle-income countries. Our main aim was to appraise the design, delivery and impact of such interventions in such a vulnerable population.