Identification of Barriers to Diagnosis and Treatment among Households Surrounding Childhood Tuberculosis in Northern Philippines

Northern Philippines is not exempt from the disease burden, particularly among children, due to its geographical locations of mountainous and urbanizing valleys in the Ilocos, Cagayan Valley, and Cordillera regions, encompassing 10 provinces. Childhood tuberculosis (TB) is a significant public health concern in Northern Philippines, with an estimated 1 million cases in 2014 and approximately 136,000 deaths. However, these estimates are vastly different from the total cases disclosed to national TB programs, reflecting under-recognition and under-reporting. In 2014, only 36% of estimated pediatric TB cases were reported to national TB programs. The country achieved an 84% case detection rate for 2012, but thousands of cases go undetected, representing missed opportunities for effective TB control. TB in children has been a neglected field due to challenges in case detection and lack of perceived public health importance. The cure rate is high with the DOTS strategy, but there is a need to increase the detection rate to prevent worsening and spread of TB within the family and community. The spectrum of TB differs in adults and children. Following exposure to M. tuberculosis, an unknown percentage of people will clear infection entirely, while the vast majority develop latency. Populations with occasional replication can be held under immunologic control, but as mycobacterial burden increases, so does the risk of progression to active disease. The rate of progression between exposure and progressive TB is accelerated in children compared to adults. Effective TB control not only detects those with symptomatic disease but also identifies those with subclinical or "latent" infection who are at high risk of developing active disease. Without active screening, this would be impossible. A greater commitment to active screening of at-risk children is imperative to prevent and detect childhood TB cases earlier. The "Roadmap for Childhood Tuberculosis" advocates for intensified case finding and integrating TB care into existing maternal/child health services. Moving toward the "End TB Strategy," which aims to end the TB epidemic by 2030, there is an urgent need for action across all health sectors. Decentralization of TB services from national TB programs into the general health system has been advocated as an effective means of achieving targets to end TB. A cross-sectional survey was conducted among 547 household-indexed cases from 788 enrolled and traced covering all selected sites in the provinces of Isabela, Kalinga, and Pangasinan. The survey aimed to identify barriers affecting diagnosis and treatment of childhood TB that would inform methods to improve successful implementation of national childhood TB guidelines in the Philippines. The study found that the mean age of the respondents was 51 years old, indicating that most of those who got sick with TB were of productive age and elderly. The annual household income of the respondents was PhP46,359.00, which is already far below the poverty threshold. The top three barriers to diagnosis and treatment of childhood tuberculosis identified by the TB-indexed cases were fear of stigma (53%), lack of knowledge about TB (47%), and shame in asking for help (36%). Only one percent of the children referred visited the health facilities for diagnosis and treatment. The study highlights the need to intensify information campaigns on childhood tuberculosis in the concerned provinces and to implement active contact tracing by local governments to reach the goal of ending TB by 2030 in these provinces and country.