title: Assessing the quality of tuberculosis evaluation for children with prolonged cough presenting to routine community health care settings in rural Uganda.
abstract: BACKGROUND
  Improving childhood tuberculosis (TB) evaluation and care is a global priority, but data on performance at community health centers in TB endemic regions are sparse.
  
  
  OBJECTIVE
  To describe the current practices and quality of TB evaluation for children with cough ≥2 weeks' duration presenting to community health centers in Uganda.
  
  
  METHODS
  Cross-sectional analysis of children (<15 years) receiving care at five Level IV community health centers in rural Uganda for any reason between 2009-2012. Quality of TB care was assessed using indicators derived from the International Standards of Tuberculosis Care (ISTC).
  
  
  RESULTS
  From 2009-2012, 1713 of 187,601 (0.9%, 95% CI: 0.4-1.4%) children presenting to community health centers had cough ≥ 2 weeks' duration. Of those children, only 299 (17.5%, 95% CI: 15.7-19.3%) were referred for sputum microscopy, but 251 (84%, 95% CI: 79.8-88.1%) completed sputum examination if referred. The yield of sputum microscopy was only 3.6% (95% CI: 1.3-5.9%), and only 55.6% (95% CI: 21.2-86.3%) of children with acid-fast bacilli positive sputum were started on treatment. Children under age 5 were less likely to be referred for sputum examination and to receive care in accordance with ISTC. The proportion of children evaluated in accordance with ISTC increased over time (4.6% in 2009 to 27.9% in 2012, p = 0.03), though this did not result in increased case-detection.
  
  
  CONCLUSIONS
  The quality of TB evaluation was poor for children with cough ≥2 weeks' duration presenting for health care. Referrals for sputum smear microscopy and linkage to TB treatment were key gaps in the TB evaluation process, especially for children under the age of five.
authors.affiliation: Division of HIV/AIDS, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Carina
authors.initials: C
authors.lastname: Marquez
authors.affiliation: Division of Pulmonary and Critical Care Medicine and Curry International Tuberculosis Center, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: J Lucian
authors.initials: JL
authors.lastname: Davis
authors.affiliation: School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
authors.forename: Achilles
authors.initials: A
authors.lastname: Katamba
authors.affiliation: MU-UCSF Research Collaboration, Kampala, Uganda.
authors.forename: Priscilla
authors.initials: P
authors.lastname: Haguma
authors.affiliation: MU-UCSF Research Collaboration, Kampala, Uganda.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Ochom
authors.affiliation: MU-UCSF Research Collaboration, Kampala, Uganda.
authors.forename: Irene
authors.initials: I
authors.lastname: Ayakaka
authors.affiliation: Division of HIV/AIDS, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Gabriel
authors.initials: G
authors.lastname: Chamie
authors.affiliation: Division of Infectious Diseases, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Grant
authors.initials: G
authors.lastname: Dorsey
authors.affiliation: School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
authors.forename: Moses R
authors.initials: MR
authors.lastname: Kamya
authors.affiliation: Division of HIV/AIDS, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America; Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Edwin
authors.initials: E
authors.lastname: Charlebois
authors.affiliation: Division of HIV/AIDS, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Diane V
authors.initials: DV
authors.lastname: Havlir
authors.affiliation: Division of Pulmonary and Critical Care Medicine and Curry International Tuberculosis Center, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Adithya
authors.initials: A
authors.lastname: Cattamanchi
mesh_terms: D000293:Adolescent; D002648:Child; D002662:Child Health Services / Q000379:methods / Q000592:standards; D002675:Child, Preschool; D003153:Community Health Services / Q000379:methods* / Q000592:standards; D003371:Cough / Q000175:diagnosis* / Q000209:etiology; D003430:Cross-Sectional Studies; D006801:Humans; D009169:Mycobacterium tuberculosis / Q000187:drug effects; D011786:Quality Control; D012423:Rural Health / Q000706:statistics & numerical data*; D013183:Sputum / Q000187:drug effects / Q000382:microbiology; D016896:Treatment Outcome; D014376:Tuberculosis / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D014454:Uganda