Background: Somalia has been at civil war for the last two decades and the public health system has virtually collapsed. The majority of the community seeks care from the private health sector. Objectives: To assess the knowledge and practice of private medical practitioners concerning Paediatric Tuberculosis (TB) diagnosis and treatment in Mogadishu and their level of adherence to the National or International guidelines using a cross-sectional study design. Methods: A cascade approach was used to identify private medical practitioners who had experience with treating paediatric TB. A standard tool was used to collect information on their knowledge of diagnosis and treatment among those who consented to participate in the study. In addition, prescriptions were retrieved from pharmacies in Mogadishu to enable independent verification of prescription practice and adherence to National or International guidelines. Results: There were 39 study participants, 31 medical doctors and 8 clinical officers. The most common symptoms used by clinicians to diagnose TB among children were fever for more than 2 weeks (87.19%), cough for more than 2 weeks (89.74%) and loss of weight (92.31%). A few, 5 (12.82%), identified history of TB contact as a suspicion of paediatric TB. More than half of the practitioners, 21 (53.85%), relied on chest x-ray and erythrocyte sedimentation rate for the diagnosis of TB in children. The majority (74%) of the clinicians knew the correct treatment for pulmonary TB in children. Further to this 60% and 79.5% respectively of the clinicians did not know the appropriate treatment regimens extra-pulmonary TB and TB/HIV co-infection. The lack of knowledge was confirmed by review of the prescriptions. Of the 48 prescriptions collected, only one prescription was correctly prescribed according to the weight of the child and even more worrying only 18 (39%) of the anti-TB drugs prescribed were Fixed Dose Combinations (FDC) approved by the WHO. Conclusion: Private medical practitioners in Mogadishu have significant gaps in their knowledge and practice with regard to the management of paediatric TB.
TB remains one of the major health problems and the second leading infectious cause of mortality around the world [
In Somalia, TB is one of the major public health crises. Multi-drug resistant TB was detected in 5.2% of persons with newly diagnosed TB and 40.8% were re-treated patients. These levels appear to be the highest in the south-central region [
It is estimated that only 20% of the Somali population accesses modern health services, 70% of them seeking care from the private health sector [
A cross sectional survey was carried out in Mogadishu, the capital and the largest city in Somalia. The eligible population included all the private medical practitioners in Mogadishu. All medical practitioners working in public health system and those not managing paediatric populations were excluded from the study. The total number of clinicians surveyed was 39. The authorvisited the clinicians in their clinics and requested their participation in the study. On signing the consent form, they were given a standardized self-administered tool to evaluate their knowledge and practice. The tool collected data on the clinician’s qualifications (medical doctor or clinical officer), years of practice and whether they had managed a child with TB in the 2 years preceding study. The study instrument also collected data on clinical symptoms and signs used for diagnosis, the co-morbidities commonly associated with TB in children, investigations and the knowledge regarding the recommended treatment of paediatric TB. The questionnaire also collected data related to whether the clinicians had attended any TB-related training 2 years prior to the study and the availability of National or WHO guidelines. Challenges around service delivery were documented such as the availability of drugs, referral services and follow up of cases. The researcher also collected 48 prescriptions written by different clinicians from different pharmacies in Mogadishu and analyzed them to assess the practice of clinicians in the treatment of paediatric TB and adherence to the national or who guidelines.
The data was analysed using the SPSS version 17. Descriptive statistics including mean, median, standard deviation and frequency distribution were used. Comparison was done between clinicians who had and those who did not have a copy of the Somali national or WHO guideline using the Chi-square test.
Ethical clearance was obtained from the Kenyatta National Hospital/Univer- sity of Nairobi ethical committee and the Ministry of Public Affairs in Somali, Department of Health. A consent form was signed by the private practitioners who met the inclusion criteria and confidentiality was maintained throughout the study.
The data was collected from 13 of the 16 districts in Mogadishu. The researcher identified 51 clinicians who were eligible for this study, but the respondents were 39. The main reasons for non-participation were: being too busy (5), had participated in the pretest (5) and missed appointment (1). Out of the 39 practitioners, there were 31 (79.5%) medical doctors and 8 (20.5%) clinical officers as shown in
A comparison was made between the clinicians who had and those who did not have a copy of the national or WHO guidelines as shown in
The symptoms that most frequently triggered the diagnosis of paediatric TB dis-
Characteristics | Total (%) |
---|---|
Title Medical doctor Clinical officer | 31 (79.5%) 8 (20.5%) |
Years of practice >2 years 2 - 5years 5 - 10 years >10 years | 8 (20.5%) 8 (20.5%) 12 (30.8%) 11 (28.2%) |
Managed child with TB in the last 2 years Yes No | 36 (92.3%) 3 (7.7%) |
Attended any TB training in the last 2 years | 9 (23.1%) |
Has a copy of national or international TB guidelines | 13 (33.3%) |
Characteristics | Total | Copy of national or WHO guideline | P-value | |
---|---|---|---|---|
N = 39 | Yes (N = 13) | No (N = 26) | ||
Attended TB training | 9 | 7 (53.8%) | 2 (7.7%) | 0.001 |
Correct symptoms (National & WHO) TB contact + 3 correct symptoms Only 3 correct symptoms | 5 31 | 1 (7.7%) 12 (92.3) | 4 (15.4%) 19 (73.1%) | 0.1 |
Knows recommended Treatment of pulmonary TB | 29 | 10 (76.9%) | 19 (73.1%) | 0.7 |
Knows recommended Treatment of TB meningitis | 18 | 10 (76.9%) | 8 (30.8%) | 0.6 |
Knows recommended treatment of Miliary TB | 15 | 8 (61.5%) | 7 (26.9%) | 0.03 |
Knows recommended Treatment of TB in the context of HIV | 9 | 5 (38.5%) | 4 (15.4%) | 0.1 |
ease were fever for more than 2 week (87.2%), cough for more than 2 weeks (89.7%), loss of weight (92.3%) and night sweating (64.1%). A small number, 5 (12.8%) of the respondents used history of TB contact to make a diagnosis of paediatric TB. Features not suggestive of paediatric TB like history of trauma were cited by 15% of the practitioners.
The most frequently used investigations in the diagnosis of paediatric TB were a combination of CXR and ESR, or CXR alone by 21 (53.8%) and 16 (41.0%) respectively. None of the clinicians considered Mantoux test as a tool for the investigation of TB in children.
More than two thirds, 29 (74.4%), of the clinicians mentioned the recommended treatment of pulmonary TB but with 11 (28.2%) stating the correct regimen for TB meningitis as shown in
Drug | Dosage calculation as per Somali and WHO guidelines | P-value | |
---|---|---|---|
Appropriate | Inappropriate | ||
Rifampicin | 21 (43.7%) | 27 (56.2%) | 0.4 |
Isoniazid | 2 (4.2%) | 46 (95.8%) | <0.001 |
Pyrazinamide | 3 (6.2%) | 25 (93.7%) | <0.001 |
Ethambutol | 4 (57.1%) | 3 (42.9%) | 0.7 |
HIV infection. About 90% of the practitioners were aware of where TB patients could get free anti-TB drugs but one third (33.33%) referred their TB patients to those centers opting to treat the remaining two thirds in their facilities.
On individual dosage calculation, isoniazid was incorrectly prescribed in 95% of the patients followed by pyrazinamide (86%) and one prescription (2.1%) was correctly written according to the weight of the child of the prescriptions collected from the pharmacies in Mogadishu as shown in
This study revealed that the knowledge and practice of private practitioners regarding the diagnosis and treatment of paediatric TB in Mogadishu was not satisfactory. Although the majority of the clinicians used cough for more than 2 weeks, fever for more than 2 weeks and weight loss for the diagnosis of TB in children, few clinicians 5 (12.8%) stated history of TB contact while about 15% of the clinicians mentioned features not suggestive of paediatric TB like history of trauma. Similar results were found in a study done in Eldoret, Kenya, where few clinicians (12.8%) were aware of the history of TB contact as one of the important clinical features for the diagnosis of TB in children [
More than half of the clinicians used CXR and ESR for the diagnosis of TB in children, while 41.3% relied on CXR alone for the investigation of TB in children. None of the clinicians recommended Tuberculin skin testing (TST) for the diagnosis of TB in children. TST is often not available in low resource setting
Disease | Regimen | Total (%) | Correct response |
---|---|---|---|
Pulmonary TB | Induction phase RHE RHZ RHZE | 1 (2.6%) 29 (74.4%) 8 (20.5%) | RHZ = 29 (74.4%) |
Continuation phase Don’t know RH | 1 (2.6%) 38 (97.4%) | RH = 38 (97.4%) | |
TB Meningitis | Induction phase Don’t know RHE RHS RHS + Steroids RHZ RHZE RHZE + Ceftriaxone RHZE + Steroids RHZES RHZS RHZS + Steroids | 7 (17.9%) 3 (7.7%) 1 (2.6%) 1 (2.6%) 7 (17.9%) 11 (28.2%) 1 (2.6%) 2 (5.13%) 4 (10.6%) 1 (2.6%) 1 (2.6%) | RHZE = 11 (28.2%) |
Continuation phase Don’t know RH | 7 (17.9%) 32 (82.0%) | RH = 32 (82.0%) | |
Miliary TB | Induction phase Don’t know RHE RHS RHZ RHZE RHZE + Steroids RHZS + Steroids | 16 (41.0%) 2 (5.1%) 1 (2.6%) 3 (7.7%) 15 (38.6%) 1 (2.6%) 1 (2.6%) | RHZE = 15 (38.6%) |
Continuation phase Don’t know RH | 16 (41.0%) 23 (59.0%) | RH = 23 (59.0%) | |
TB/HIV co-infection | Induction phase Don’t know RHES RHZE RZ | 28 (71.8%) 1 (2.6%) 9 (23.1%) 1 (2.6%) | RHZE = 9 (23.1%) |
Continuation phase Don’t know RH | 31 (79.5%) 8 (20.5%) | RH = 8 (20.5%) |
R = Rifampicin, H = Isoniazid, Z = Pyrazinamide, E = Ethambutol, S = Streptomycine.
areas and this may be the reason why clinicians did not consider it as a tool for investigation of TB in children [
The researcher found that the clinicians were more familiar with the recommended treatment of pulmonary TB when compared to that for extrapulmonary TB and TB/HIV co-infection. This is may be due to the high burden of pulmonary TB, complexity in the diagnosis of extrapulmonary TB and the low endemicity of HIV in Somalia. The clinicians who had a copy of the national or WHO guidelines were more likely to recommend the appropriate treatment regimen as compared to those who did not have these guidelines. Different studies done in different countries have found that clinicians in the private sector are not familiar with the recommended treatment of TB. A cross-sectional study done in North-Western Somalia by Suleiman et al., revealed that only 4 (7.5%) of the 53 clinicians recruited into the study recommended the correct regimen according to the National TB guideline [
The majority of the private practitioners (89.74%) were aware of where TB patients could get free anti-TB drugs, but few of them (33.33%) referred to the health center and consequently patients treated in private sector are more likely to be not notified to the NTP. A study done in North-west Somalia found that out of 32 (64%) doctors who had treated TB patients, only 1 had reported to the authorities [
The survey found that the majority of the patients were prescribed for inappropriate dosages of anti-TB drugs according to the prescriptions collected from the pharmacies. A similar finding was made by a research done in Nairobi, Kenya by Musila where of the 97 patients recruited in the study, only 19 (19.6%) of the patients had the correct dosage [
The main limitation of the study was that there was limited data related to private medical practitioners registered by the department of health in Somalia. The researcher was forced to collect the data from different districts of Mogadishu, asking assistance from medical practitioners, pharmacists and other health workers to find out private medical practitioners that were running private hospitals or clinics in their district. This could affect the generalizability of the study to the clinicians in Mogadishu. In summary, the poor level of knowledge and practice of the practitioners in Mogadishu regarding diagnosis and treatment of paediatric TB, reflecting the clearly need for urgent TB-related training to the private sector.
There was incomplete knowledge regarding the diagnosis and treatment of paediatric TB. The majority of the patients were prescribed for anti-TB drugs with inappropriate dosages. This is related to the limited access of the TB-re- lated training and national or international TB guidelines.
Mohamoud, A., Murila, F. and Nduati, R. (2017) Knowledge and Practice of Private Medical Practitioners regarding Diagnosis and Treatment of Paediatric Tuberculosis in Mogadishu. Open Journal of Pediatrics, 7, 77-85. https://doi.org/10.4236/ojped.2017.72011