Implementation of digital chest radiography for childhood tuberculosis diagnosis at district hospital level in six high tuberculosis burden and resources limited countries

Abstract

Abstract Objectives Chest X-ray (CXR) plays an important role in childhood tuberculosis (TB) diagnosis but access to quality CXR remains a major challenge in resource-limited settings. Digital CXR (d-CXR) can solve some image quality issues and facilitate their transfer for quality control. We describe the implementation of introducing d-CXR in twelve district hospitals (DH) in 2021-22 across Cambodia, Cameroon, Ivory Coast, Mozambique, Sierra Leone and Uganda as part of the TB-Speed decentralization study on childhood tuberculosis diagnosis. Methods For digitization of CXR Digital Radiography (DR) plates was set-up on existing analogue radiography machines. D-CXR were transferred to an international server at Bordeaux University and downloaded by sites’ clinicians for interpretation. We assessed the pre-intervention (baseline situation and d-CXR set-up) and per-intervention (uptake, challenges and health care workers’ (HCW) perceptions) of d-CXR implementation. We used a convergent mixed method approach utilizing process data, individual interviews with 113 HCWs involved in performing or interpreting d-CXRs and site support supervision reports. Results Of 3104 children with presumptive TB, 1642 (52.9%) had at least one d-CXR including 1505, 136 and 1 children with one, two and three d-CXR respectively, resulting in a total of 1780 d-CXR. Of them, 1773 (99.6%) were of good quality and 1772/1773 (99.9%) were interpreted by sites’ clinicians. 164 children had no d-CXR performed despite attending the radiography department: 126, 37 and 1 with one, two and three attempts, respectively. D-CXRs were not performed in 21.6% (44/203) due to connectivity problem between the DR plate captor and the computer. HCWs reported good perceptions of d-CXR and of the DR plates provided. The main challenge was the upload to and download from the server of d-CXRs, due to limited internet access. Conclusion D-CXR using DR plates was feasible at district hospital level and provided good quality images but required overcoming operational challenges.