Baloyi Dzunisani Patience, Myburgh Hanlie, Bester Danite, Anthony Michaile Gizelle, Switala Juli, Schaaf H Simon, Naidoo Lenny, Solomons Regan, Nuttall James, Murray Jaco, Rohlwink Ursula, Figaji Anthony, Hoddinott Graeme, Du Preez Karen
Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam, Amsterdam, Netherlands.
PLOS Glob Public Health. 2024 Aug 20;4(8):e0003518. doi: 10.1371/journal.pgph.0003518. eCollection 2024.
Tuberculous meningitis (TBM) occurs when tuberculosis (TB) bacilli disseminate and seed into the meninges, triggering a severe inflammatory response that often leads to brain infarction. It is the most severe and debilitating form of childhood TB with high mortality, and children who survive TBM often suffer lifelong physical and neuro-disability resulting in emotional, social, and economic burdens for families. In the early stages the symptoms may be non-specific and so the diagnosis is often made late when the patient already has significant brain injury. To facilitate earlier diagnosis, it is important to understand how patients are evaluated. This study aimed to chart health systems for paediatric TBM care at both primary healthcare (PHC) and hospital level in Cape Town, South Africa. We conducted fourteen in-depth interviews and eight days of semi-structured observations of patient flow across eight healthcare facilities. We found that children with TBM navigate multiple levels of care categorised into pre-admission and primary care, hospital admission and inpatient care, and post-discharge follow-up care. Healthcare workers identified the following health system barriers along the TBM care pathway for children: limited post-training and mentorship opportunities to manage TBM, overburdened facilities, time constraints, lack of recognition of TBM symptoms, delays in referral between PHC and hospital, lack of standardized diagnostic algorithms, limited diagnostic tests and a lack of child-friendly, easy-to-administer treatment. Regular and compulsory training on TB and TBM in children, including continuous mentoring and support to healthcare workers working in child health and TB services in high TB-burden settings, can facilitate early recognition of symptoms and rapid referral for diagnosis. Algorithms outlining referral criteria for patients with possible TBM at both PHC facilities and district level hospitals can guide healthcare providers and facilitate timely referral between different levels of healthcare services. An integrated data system and alert functions could flag multiple healthcare visits and improve communication between different healthcare facilities during diagnosis and treatment. Children and families affected by TBM are an especially vulnerable sub-population requiring high priority attention and support.
结核性脑膜炎（TBM）是在结核杆菌播散并侵入脑膜时发生的，会引发严重的炎症反应，常导致脑梗死。它是儿童结核病最严重、最使人衰弱的形式，死亡率很高，存活下来的儿童往往会终身身体和神经残疾，给家庭带来情感、社会和经济负担。在早期阶段，症状可能不具特异性，因此诊断往往在患者已经出现严重脑损伤时才做出。为便于早期诊断，了解患者的评估方式很重要。本研究旨在绘制南非开普敦初级医疗保健（PHC）和医院层面儿科TBM护理的卫生系统情况。我们进行了14次深入访谈，并对8个医疗机构的患者流程进行了8天的半结构化观察。我们发现，患有TBM的儿童要经历多个护理层面，分为入院前和初级护理、住院和住院护理以及出院后随访护理。医护人员确定了儿童TBM护理路径上存在的以下卫生系统障碍：管理TBM的培训后指导机会有限、设施负担过重、时间限制、对TBM症状缺乏认识、PHC与医院之间转诊延迟、缺乏标准化诊断算法、诊断测试有限以及缺乏适合儿童且易于给药的治疗方法。对儿童结核病和TBM进行定期和强制性培训，包括对高结核病负担地区从事儿童健康和结核病服务的医护人员持续进行指导和支持，可以促进症状的早期识别和快速转诊诊断。概述PHC设施和区级医院可能患有TBM患者转诊标准的算法可以指导医护人员，并促进不同医疗服务层面之间的及时转诊。一个综合数据系统和警报功能可以标记多次医疗就诊情况，并改善诊断和治疗期间不同医疗机构之间的沟通。受TBM影响的儿童和家庭是一个特别脆弱的亚群体，需要高度优先关注和支持。
