title: Intensified tuberculosis case finding among malnourished children in nutritional rehabilitation centres of Karnataka, India: missed opportunities.
abstract: BACKGROUND
  Severe acute malnutrition (SAM) is the most serious form of malnutrition affecting children under-five and is associated with many infectious diseases including Tuberculosis (TB). In India, nutritional rehabilitation centres (NRCs) have been recently established for the management of SAM including TB. The National TB Programme (NTP) in India has introduced a revised algorithm for diagnosing paediatric TB. We aimed to examine whether NRCs adhered to these guidelines in diagnosing TB among SAM children.
  
  
  METHODS
  A cross-sectional study involving review of records of all SAM children identified by health workers during 2012 in six tehsils (sub-districts) with NRCs (population: 1.8 million) of Karnataka, India.
  
  
  RESULTS
  Of 1927 identified SAM children, 1632 (85%) reached NRCs. Of them, 1173 (72%) were evaluated for TB and 19(2%) were diagnosed as TB. Of 1173, diagnostic algorithm was followed in 460 (37%). Among remaining 763 not evaluated as per algorithm, tuberculin skin test alone was conducted in 307 (41%), chest radiography alone in 99 (13%) and no investigations in 337 (45%). The yield of TB was higher among children evaluated as per algorithm (4%) as compared to those who were not (0.3%) (OR: 15.3 [95%CI: 3.5-66.3]). Several operational challenges including non-availability of a full-time paediatrician, non-functioning X-ray machine due to frequent power cuts, use of tuberculin with suboptimal strength and difficulties in adhering to a complex diagnostic algorithm were observed.
  
  
  CONCLUSIONS
  This study showed that TB screening in NRCs was sub-optimal in Karnataka. Some children did not reach the NRC, while many of those who did were either not or sub-optimally evaluated for TB. This study pointed to a number of operational issues that need to be addressed if this collaborative strategy is to identify more TB cases amongst malnourished children in India.
authors.affiliation: Tuberculosis Control Unit, World Health Organisation, Country Office for India, New Delhi, India.
authors.forename: Prashant G
authors.initials: PG
authors.lastname: Bhat
authors.affiliation: Operational Research Unit, International Union Against Tuberculosis and Lung Diseases, South-East Asia Regional Office, New Delhi, India.
authors.forename: Ajay M V
authors.initials: AM
authors.lastname: Kumar
authors.affiliation: Tuberculosis Control Unit, World Health Organisation, Country Office for India, New Delhi, India.
authors.forename: Balaji
authors.initials: B
authors.lastname: Naik
authors.affiliation: Operational Research Unit, International Union Against Tuberculosis and Lung Diseases, South-East Asia Regional Office, New Delhi, India.
authors.forename: Srinath
authors.initials: S
authors.lastname: Satyanarayana
authors.affiliation: Tuberculosis Control Unit, World Health Organisation, Country Office for India, New Delhi, India.
authors.forename: Deepak
authors.initials: D
authors.lastname: Kg
authors.affiliation: Tuberculosis Control Unit, World Health Organisation, Country Office for India, New Delhi, India.
authors.forename: Sreenivas A
authors.initials: SA
authors.lastname: Nair
authors.affiliation: Tuberculosis Control Unit, State Tuberculosis Office, Bangalore, Karnataka, India.
authors.forename: Suryakanth
authors.initials: S
authors.lastname: Md
authors.affiliation: Operational Research Unit, International Union Against Tuberculosis and Lung Diseases, Paris, France.
authors.forename: Einar
authors.initials: E
authors.lastname: Heldal
authors.affiliation: Operational Research Unit, International Union Against Tuberculosis and Lung Diseases, Paris, France.
authors.forename: Donald A
authors.initials: DA
authors.lastname: Enarson
authors.affiliation: Operational Research Unit (LUXOR), Medecins sans Frontieres, Brussels-Luxembourg.
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Reid
mesh_terms: D000465:Algorithms; D015362:Child Nutrition Disorders / Q000150:complications* / Q000453:epidemiology*; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007194:India / Q000453:epidemiology; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008403:Mass Screening; D011159:Population Surveillance; D012189:Retrospective Studies; D014376:Tuberculosis / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology*