Introduction
Childhood tuberculosis (TB) is a major global health problem. There are an estimated 1.1 million children living with TB1 and 250,000 deaths caused by TB annually2. Tuberculosis ranks among the top ten global causes of death for children, including children under five years3. The prevalence of TB is especially high among children and adults from low- and middle-income countries such as South Africa4; 5. South Africa has one of the highest country burdens of TB globally with over 300,000 people falling ill with TB in 2018, of which 9% were children1.
Conceptual hierarchical frameworks are useful to characterize etiology of chronic health conditions such as TB. Previous studies have utilized frameworks that organize determinants of chronic disease into proximal, medial and distal levels of the ecosystem6; 7. Consideration of these ecosystem dimensions of health can guide efforts to reduce disease burden for priority populations in the TB epidemic such as children. Attention towards the ecological aspects of TB health for children is vital for several reasons. Diagnosis and appropriate treatment of TB among children are dependent on having an effective, healthy caregiver. Individuals and families affected by TB are often faced with challenging economic environments. These adverse economic environments can contribute to psychological distress, reduce access to protective resources and increase individual vulnerability to poor TB outcomes8; 9. Such environments can predispose children to malnutrition, which can increase the risk of childhood TB10-12. More directly, caregiver health including psychological distress and substance abuse has been linked to TB non-adherence among adults; these caregiver factors may also affect TB outcomes among children. Therefore, the overarching child ecosystem may affect childhood TB incidence and outcomes.The child ecosystem, including caregiver health and the broader social and economic environment are vital factors to address.
The aim of this study was to investigate factors associated with PTB in children and explore health markers that characterize the ecosystem of childcare to better understand the links between the childhood ecosystem and PTB.