The hidden harm of home-based care: Pulmonary tuberculosis symptoms among children providing home medical care to HIV/AIDS-affected adults in South Africa

Abstract

Millions of children in sub-Saharan Africa undertake personal and medical care for family members who are unwell with AIDS. To date, no research has investigated whether such care provision places children at heightened risk for pulmonary tuberculosis. This study aimed to address this gap by identifying risk factors for paediatric pulmonary tuberculosis symptomatology. In 2009–2011, 6002 children aged 10–17 years were surveyed using door-to-door household sampling of census enumeration areas. These were randomly sampled from six urban and rural sites with over 30% HIV prevalence, within South Africa's three highest tuberculosis-burden provinces. Validated scales and clinical tuberculosis symptom checklists were modelled in multivariate logistic regressions, controlling for socio-demographic co-factors. Findings showed that, among children, severe pulmonary tuberculosis symptomatology was predicted by primary caregiver HIV/AIDS-illness [odds ratio (OR): 1.63, confidence interval (CI): 1.23–2.15, p<0.001], and AIDS-orphanhood (OR: 1.44, CI: 1.04–2.00, p<0.029). Three-fold increases in severe tuberculosis symptoms were predicted by the child's exposure to body fluids through providing personal or medical care to an ill adult (OR: 3.12, CI: 1.96–4.95, p<0.001). Symptoms were also predicted by socio-economic factors of food insecurity (OR: 1.52, CI: 1.15–2.02, p<0.003) and household overcrowding (OR: 1.35, CI: 1.06–1.72, p<0.017). Percentage probability of severe tuberculosis symptoms rose from 1.4% amongst least-exposed children, to 18.1% amongst those exposed to all above-stated risk factors, independent of biological relationship of primary caregiver-child and other socio-demographics. Amongst symptomatic children, 75% had never been tested for tuberculosis. These findings identify the risk of tuberculosis among children providing home medical care to their unwell caregivers, and suggest that there are gaps in the health system to screen and detect these cases of paediatric tuberculosis. There is a need for effective interventions to reduce childhood risk, as well as further support for community-based contact-tracing, tuberculosis screening and anti-tuberculosis treatment for children caring for ill adults in contexts with a high burden of HIV and tuberculosis.

Keywords:

• pulmonary tuberculosis
• HIV
• acquired human immunodeficiency syndrome
• child
• South Africa

Acknowledgements

This study was funded by the Economic and Social Research Council (UK), the National Research Foundation (SA), HEARD at University of KwaZulu-Natal, the National Department of Social Development (South Africa), the Claude Leon Foundation and the John Fell Fund. The authors would like to thank the fieldwork teams, Dr. Nic Cheeseman, and the children and their families who welcomed us into their homes. LC conceptualised the study, and contributed to data collection, analysis and writing. MO contributed to data analysis and writing. MM designed tuberculosis symptom screening and contributed to writing. CK contributed to study design, data collection and writing. All authors have read and approved this text.

Notes

1. This was part of a wider study on health and educational outcomes for children in HIV/AIDS-affected families, and was planned in collaboration with the South African government departments of Social Development, Health and Education, and with NGOs including UNICEF and Save the Children.