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Case Study

Improving the care of under six-years-old contacts of index tuberculosis cases in Kano State

A man with a laptop speaks to three people.
CQI Officer Prosper Onyekachukwu works with a state and facility CQI team in Kano State.

In September 2019, six selected facilities offering tuberculosis (TB) services were underperforming in the provision of TB services. Nigeria CQI staff found that index contact tracking and screening for infected TB patients was only sporadically done. Furthermore, they found a significant number of contacts of index TB cases under six-years-old were not screened, optimally tracked, identified, or placed on INH, an antibiotic used for the treatment of TB.

After conducting a root cause analysis, they identified three main reasons:

  1. Poor reporting and documentation of the index patient and contacts
  2. Treatment refusal by the parents of children under-six
  3. TB directly observed therapy (DOT) officers lacked understanding of the TB algorithm

The Ministry of Health TB teams, alongside the Ciheb team and facility leadership, agreed to implement a four-month CQI intervention to improve the quality of services rendered. The six facilities included two federal teaching and specialist hospitals, known as tertiary institutions, and four general and state hospitals, known as secondary institutions.

Following the root cause analysis, CQI staff created a prioritization matrix to address the gaps in treatment. This led to three interventions:

  1. Staff held an advocacy meeting with facility management to emphasize the need for optimal services to contacts under six-years old of TB clients.
  2. They hired community health workers who were tasked with contact tracing and actively following up with index contacts for screening and placing them on INH.
  3. DOT officers provided monthly supportive supervisory visits, ensured proper documentation, and held regular review meetings to monitor the progress of each facility.

From these interventions, families of infected patients accessing TB care and treatment at the facilities were followed up with for index client tracing. All children under six years old were promptly identified, and parents/guardians were counseled on the need to ensure that children or wards were promptly tested for TB and started on INH treatment.

Within three months of the start of the CQI intervention, records showed improved documentation, counseling, and turnout of contacts under six years old of TB clients accessing treatment at the facilities. Starting at a baseline of 31%, the hospitals recorded over 30% improvement in the documentation of eligible children under six years old who were tracked, screened, and started on INH treatment.