NATIONAL GUIDELINES ON MANAGEMENT OF TUBERCULOSIS … · iv Acknowledg ement The Division of...
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NATIONAL GUIDELINES ON MANAGEMENT OF TUBERCULOSIS IN CHILDREN Ministry of Health DIVISION OF LEPROSY, TUBERCULOSIS AND LUNG DISEASE SECOND EDITION AUGUST, 2013 © 2013 Division of Leprosy, Tuberculosis and Lung Disease
Transcript of NATIONAL GUIDELINES ON MANAGEMENT OF TUBERCULOSIS … · iv Acknowledg ement The Division of...
NATIONAL GUIDELINES ON MANAGEMENT OF
TUBERCULOSIS IN CHILDREN
Ministry of Health
DIVISION OF LEPROSY, TUBERCULOSIS AND LUNG DISEASE
SECOND EDITION AUGUST, 2013
© 2013 Division of Leprosy, Tuberculosis and Lung Disease
i
Contents
Foreword ....................................................................................................................................................... iii
Acknowledgement ........................................................................................................................................ iv
List of Abbreviations ..................................................................................................................................... v
Chapter 1: Introduction and Definitions ......................................................................................................... 1
1.1 Introduction ......................................................................................................................................... 1
1.2 Definitions ........................................................................................................................................... 2
1.3 Rationale for Pediatric TB guideline ................................................................................................... 3
Chapter 2: Diagnosis of Tuberculosis in Children......................................................................................... 4
2.1 History ................................................................................................................................................. 4
2.2 P h ys i c a l examination ....................................................................................................................... 5
2.3 Investigations ....................................................................................................................................... 6
Chapter 3: Treatment of Tuberculosis .......................................................................................................... 16
4.1 Classification of TB in Children ........................................................................................................ 16
4.2 Recommended Treatment Regimens ................................................................................................. 17
4.3 Additional Management Decisions .................................................................................................... 19
4.4 Follow-up of a Child on anti-TB Therapy ......................................................................................... 20
4.5 Poor Response to Treatment .............................................................................................................. 21
4.6 Treatment Interruptions ..................................................................................................................... 22
4.7 Side effects of anti TB drugs in children .......................................................................................... 22
Chapter 4: TB and HIV Co-infection ........................................................................................................... 23
4.1 Diagnosis ........................................................................................................................................... 23
4.2 Treatment ........................................................................................................................................... 24
4.3 Prevention .......................................................................................................................................... 24
4.4 Differential Diagnosis in HIV infected Child with Chronic Respiratory Symptoms ......................... 24
4.5 Antiretroviral Therapy in HIV Infected Children with Tuberculosis ................................................. 25
4.5 Cotrimoxazole Preventive Therapy (CPT) ........................................................................................ 30
4.6 IPT in Children .................................................................................................................................. 31
Chapter 5: TB in special circumstances ..................................................................................................... 32
5.1 TB Meningitis (TBM) ....................................................................................................................... 32
5.2 Management of a Newborn born to a Mother with PTB ................................................................... 32
5.3 Drug Resistant TB ............................................................................................................................. 33
Chapter 6: TB Prevention ............................................................................................................................. 35
6.1 Screening for Child Contacts of Known TB Cases ........................................................................... 35
6.2 Management of child exposed to PTB ............................................................................................... 37
6.3 Tracing of TB Source ........................................................................................................................ 38
6.4 BCG Vaccination in Children............................................................................................................ 38
6.5 TB Infection Control.......................................................................................................................... 39
Chapter 7: Roles and Responsibility ............................................................................................................ 41
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7.1 Level 1: (family, patient, CHW, CHEW, community) ...................................................................... 41
7.2 Level 2 and 3: Dispensary and Health Centre .................................................................................. 41
7.3 Level 4, 5 and 6: District, Provincial and Referral Hospitals ............................................................ 41
7.4 Follow-up .......................................................................................................................................... 42
7.5 Health education ................................................................................................................................ 42
7.6 Case recording and reporting for childhood TB ................................................................................ 43
Chapter 8: Child nutrition and TB ............................................................................................................... 44
Annex 1: Tuberculin Skin Test (Mantoux test) ............................................................................................ 47
Administration ......................................................................................................................................... 47
Reading ................................................................................................................................................... 48
Interpretation ........................................................................................................................................... 49
Annex 2: Sputum Collection ........................................................................................................................ 50
Procedures for obtaining clinical samples for smear microscopy ............................................................ 50
Expectoration ...................................................................................................................................... 50
Gastric aspiration ................................................................................................................................ 51
Sputum Induction ................................................................................................................................ 53
Annex 3: Seven Steps for Patient Management to prevent transmission of TB in Community and health
care settings .................................................................................................................................................. 55
Annex 4: Dosages for Paediatric TB treatment using dispersible FDC tablets of RHZ, RH and single
Ethambutol tablets for NEW CASES........................................................................................................... 56
Table A1: Child between 5 and 22 kg ..................................................................................................... 56
Table A2: Child between 23 and 30 kg ................................................................................................... 56
Annex 5: Dosages for Paediatric TB treatment using dispersible FDC tablets of RHZ, RH and single
Ethambutol tablets for RETREATMENT CASES ....................................................................................... 57
Table B1: Child between 5 and 22 kg ..................................................................................................... 57
Table B2: Child between 23 and 30 kg ................................................................................................... 57
Annex 6: Child Tuberculosis Monitoring Card ............................................................................................. 58
Annex 7: Second-line anti-TB drugs for treatment of MDR*-TB in children .............................................. 61
Table C: Second-line anti-TB drugs for treatment of MDR-TB in children ............................................ 61
Annex 8: Taking Anthropometric Measurements ........................................................................................ 62
Annex 9: Growth monitoring charts ............................................................................................................. 65
iii
Foreword
Treatment of tuberculosis has over the years focused more on adults leaving children
unattended appropriately as medical practitioners considered children of little epidemiologic
significance. Available data indicate that more than 11% of TB cases notified in Kenya are
children below 15 years. This is thought to be an under estimate considering the challenges faced
in diagnosing TB in children.
With the emergence of Drug resistant TB, children are victims of contacts and poor case
control of adult TB cases. This pool of cases will defeat the ultimate aim of eliminating TB.
Kenya has pioneered interest in TB control amongst children by defining the epidemiologic
parameters for children in age groups 0–4, 5–9 and 10 – 14 years.
Since children are born without TB and they are an important segment of the society for they
signify the future, these guidelines seek to provide guidance to the management of TB in
children. It seeks to demystify TB diagnosis in children especially with the coming of new
diagnostic methods expected to revolutionalize TB diagnosis and management.
The guideline is specifically designed for general health care workers’ readership and is therefore
expected to stimulate interest in pediatric TB treatment and how to protect the children from
getting infected. This guideline will also act as a reference material for medical students,
researchers and the community.
Dr. S. K. Sharif, MBS, MBChB, M. Med. DLSHTM, MSc.
Director of Public Health
Ministry of Health
iv
Acknowledgement
The Division of Leprosy, Tuberculosis and Lung Disease is indebted to support received from
the Ministry of Health l e a d e r s h i p a n d health care workers in the implementation of TB
control activities in the country.
The Division specifically, acknowledges the support received from the following officers who
worked tirelessly and sometimes worked late into the night in the revision of the first edition
of this guideline.
Dr. Joel Kangangi WHO
Dr. Agnes Langat CDC
Dr. Maurice Maina USAID-Kenya
Dr. Herman Weyenga DLTLD
Dr. Bernard Langat DLTLD
Dr. Kamene Kimenye DLTLD
Dr. Richard Muthoka DLTLD
Dr. Hajara El Busaidy RTLC Coast
Dr. Immaculate Kathure RTLC Nairobi
Dr. Shobha Vakil NASCOP
Prof. Elizabeth Obimbo UON
Dr. Diana Marandu UON
Dr. Evans Amukoye KEMRI
Dr. Francis Ogaro MTRH
Dr. Lorraine Mugambi CHS
Dr. Maureen Syowai ICAP
Dr. Teresa Alwar ICAP
Dr. Kihara Ruth CHS
Ms. Christine Awuor NASCOP
The division extends its appreciation to CDC fo r providing the funds for pr int ing o f this
guideline.
Dr. Joseph Sitienei, OGW, MPH, MBA, MBChB, Dip
Head, DLTLD
Ministry of Health
v
List of Abbreviations
AFB Acid Fast Bacilli
ART Antiretroviral therapy
BCG Bacille Calmette Guerin
CXR Chest X-ray
DLTLD Division of Leprosy Tuberculosis and Lung Disease
DOT Directly observed therapy
DST Drug Susceptibility Testing
HIV Human Immunodeficiency Virus
IPT Isoniazid Preventive Therapy
MDR –TB Multi-drug resistant
NNRTI NonNucleoside Reverse Transcriptase Inhibitor
NRTI Nucleoside Reverse Transcriptase Inhibitor
PPD Purified protein derivative
PTB Pulmonary Tuberculosis
RTLC Regional Tuberculosis and Leprosy Coordinator
TB Tuberculosis
TST Tuberculin Skin Test
WHO World Health Organization
XDR-TB Extensively Resistant Tuberculosis
1
Chapter 1: Introduction and Definitions
1.1 Introduction
It is estimated that one third of the world’s population is infected with Mycobacterium
tuberculosis (the bacterium that causes tuberculosis (TB). Each year, about 9 million people
develop TB, of whom about 2 million die. Of the 9 million annual TB cases, about 15% occur in
children (under 15 years of age). Kenya is among the 22 TB high TB burden countries in the
world and is among the top 5 from sub Saharan Africa. 75% of these childhood cases occur
annually in these 22 high-burden countries that together account for 80% of the world’s
estimated incident cases.
In 2012 Kenya reported a total of 99,159 cases of all forms of TB (case notification rate
of 241/100,000). Paediatric age group of less than 15 years constituted 9.3% of all cases
notified which is a significant proportion requiring special attention. In the last 5 years, Kenya has
reported annual decline in the number of reported TB cases at a rate of 1% possibly due to
effective control interventions coupled with the declining HIV prevalence in the population.
Infection with M. tuberculosis usually results from inhalation of infected droplets produced by a
patient who has pulmonary TB. The source of infection for most children is an infectious adult
in their close environment (usually the household). This exposure leads to the development of a
primary parenchymal lesion (Ghon focus) in the lung with spread to the regional lymph nodes.
The immune response (delayed hypersensitivity and cellular immunity) develops about 4–6
weeks after t h e p r i ma r y infection. In most cases , t h e immune response s t o p s t h e
multiplication o f M . Tuberculosis b a c i l l i at t h i s s t a g e . However, a few dormant bacilli
may persist. A positive tuberculin skin test (TST) where available would be the only evidence of
infection.
In some cases, the immune response is not strong enough to contain the infection and
disease occurs within a few months. Risk of progression to disease and development of
disseminated TB is increased in the very young (0-4 years), immunocompromised and
malnourished children. In the vast majority o f ch i ld ren who develop disease, they usually do
so within 2 years following exposure and infection. Children can present with TB at any age, but
the most common age is between 1 and 4 years. HIV infected children have a lifelong risk of
developing TB.
TB in young children and in the HIV infected is often disseminated and
rapidly progressive
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1.2 Definitions
Infection with Mycobacterium tuberculosis usually results from inhalation of infected
droplets produced by someone who has PTB and who is coughing. The most infectious index
cases are those with sputum smear-positive disease. The closer the contact is to the source case,
the greater the exposure and the greater the risk of getting infected with tuberculosis.
TB infection is when a person carries the Mycobacterium tuberculosis bacteria inside the body.
Many people have TB infection and are well. A positive TST indicates infection - but a
negative TST does not exclude the possibility of infection.
TB disease occurs in someone with TB infection when the bacteria inside the body start to
multiply and become numerous enough to damage one or more organs of the body. This damage
causes clinical symptoms and signs and is referred to as “tuberculosis” or active disease.
Index Case: Usually an adult with smear positive pulmonary TB.
Close contact is defined as living in the same household as, or in frequent contact with
(e.g. child minder, school staff), an index case with PTB.
Children refers to the 0 to 14 year age group
Infant is a child of less than 1 year of age (0-12 month age group)
Pulmonary TB sputum positive
A child is defined as smear positive if any of the following is true:
1. AFB are detected via microscopy on either a sputum or gastric lavage sample.
2. MTB is isolated by culture on either a sputum or gastric lavage sample.
3. MTB is detected by MTB/RIF Gene Xpert on either a sputum or gastric lavage sample.
Pulmonary TB sputum negative.
A child that has the signs and symptoms for pulmonary TB, but does not meet the above criteria for
pulmonary TB sputum positive is classified as smear negative TB. This also includes children in
whom sputum smear not done or not available.
Extra pulmonary TB
Any TB occurring outside the lungs is classified as EPTB.
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Drug Resistant TB
This is a laboratory diagnosis. Drug resistant TB should be suspected if:
1. Child has contact with a known case of DRTB
2. Child has contact with an adult who has suspected DRTB as follows:
The adult remains sputum smear positive after 2 months of treatment,
An adult who has a history of previously treated TB,
An adult with a history of treatment interruption.
3. Child is not responding to the anti- TB treatment regimen
4. Child has a recurrence of TB after successful TB treatment
1.3 Rationale for Pediatric TB guideline
The TB control program has in the past paid less attention on pediatric TB mainly due to the fact
that children with TB rarely transmit the infection. However children contribute a significant
proportion of the disease burden and suffer severe tuberculosis related morbidity and mortality,
particularly in the endemic areas. The diagnosis of TB in children is particularly difficulty, more
so in resource constrained settings like in Kenya with poor laboratory and X-ray services and high
TB/HIV co infection rates. Hence there is need for pediatric TB management guidelines that will
enhance early and accurate case identification and treatment as well as contact screening and
management.
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Chapter 2: Diagnosis of Tuberculosis in Children
The diagnosis of TB in children relies on history physical examination as well as any relevant
investigations e.g. TST, CXR and sputum smear microscopy. Even though microbiological
diagnosis is not always feasible, all efforts should be made to do sputum microscopy where
possible in children with suspected pulmonary tuberculosis. A trial treatment with anti- TB
drugs is not recommended as a method of diagnosing TB in children.
2.1 History
The key elements of History are:
a) H i s t o r y o f contact with an adolescent or adult with proven or suspected TB.
Close contact is defined as living in the same household as or in frequent contact with smear
positive PTB ind ex case.
If no index case is identified, always ask about anyone in the household / dormitory / classroom
/ school transport with chronic cough- if present request assessment of that person for possible TB.
Most children will develop TB within one year of exposure
b) Symptoms suggestive of TB
The commonest symptoms associated with TB include the following:
Progressive and non-remitting cough for more than 2 weeks
Fever for more than 2 weeks
Lethargy / reduced playfulness / less active for more than 2 weeks
Weight loss, no weight gain or poor weight gain (failure to thrive)
The diagnosis of TB in children relies on a careful history and thorough
physical examination
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2.2 Physical examination
Respiratory system
During the physical examination, the following features may be found in the respiratory system:
Child may have increased respiratory rate
Child may have signs of respiratory distress
Percussion may be normal. In pleural effusion have a stony dull percussion note
Auscultation is frequently normal. May have abnormal sounds (e.g. wheezing, crackles,
bronchial breathing)
In some cases, there may be atypical clinical presentations of PTB. In this case the child will
present with features of:
Acute severe pneumonia
Presents with fast breathing and chest in-drawing
Occurs especially in infants and HIV-infected children
Suspect PTB if response to antibiotic therapy is poor. If HIV infected also suspect other HIV-
related lung disease e.g. PCP.
Wheeze
Asymmetrical and persistent wheeze can be caused by airway compression due to enlarged
tuberculous hilar lymph nodes.
Suspect PTB when wheeze is asymmetrical, persistent and non responsive to bronchodilator
therapy.
PTB can also present acutely as bronchopneumonia in children with
tachypnoea, respiratory distress and crackles.
A normal respiratory clinical finding does not rule out PTB.
6
Other systems
TB can affect any part of the body apart from the hair, nails and teeth. Apart from the general
physical features suggestive of TB, a child may also present with features that are specific to the
affected system e.g. in TB meningitis a child may have features of raised intracranial pressure or
neurological deficit.
This further increases the need to have a thorough physical examination.
2.3 Investigations
After history and physical examination, if investigations are available in the facility or
nearby, attempt should be made to investigate every child suspected to have TB as follows:
a) Tuberculin Skin Test (Mantoux test)
A positive Mantoux test is evidence that one is infected with M. Tuberculosis, but doesn’t
necessarily indicate disease. Correct technique o f administering, reading and in terpre ta t io n
o f Mantoux text is very important. (See Annex 1)
Mantoux is positive if induration is:
≥10mm in a well nourished, HIV negative child
≥5mm in a malnourished, or HIV infected child
A negative Mantoux does not rule out TB (especially in the HIV positive or malnourished child)
b) Chest X-Ray
Radiological features suggestive of PTB will include:
Persistent lung opacification especially if focal
Enlarged hilar or subcarinal lymph nodes
Diffuse micronodular infiltrates (miliary pattern)
Pleural effusions
Upper lobe opacification wi t h o r wi t h o ut cavities especially in adolescents.
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Pictures suggestive of Pulmonary TB
Right perihilar lymph node
enlargement with opacity in the right
mid-zzone
Left upper lobe opacification with narrowing
and shift of left main bronchus
Miliary TB - Typical bilateral diffuse
micronodular pattern.
Note differences to LIP X-ray above
Lateral CXR showing enlarged hilar
lymph nodes (“doughnut sign”)
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Bronchiectasis: focal opacification in
right lower zone with thickening of
bronchial walls and honeycomb
appearance
Lymphoid interstitial pneumonitis:
typical features are bilateral, diffuse
reticulonodular infiltration with
bilateral perihilar lymph node
enlargement
TB pleural effusion: large right-
sided effusion. Pleural tap to
differentiate from emphysema
Spinal TB: collapse of thoracic
vertebra causing angulation
Gibbus
Pericardial TB: enlarged cardiac
shadow. Echocardiogram to
differentiate from other causes of
cardiac failure
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Summary: Simplified Clinical TB Diagnosis
Having taken history, done physical examination, Mantoux and chest x ray where available, the health worker may at
this point make a clinical diagnosis of PTB in the child as summarized below and make decisions on treatment.
Presence of 2 or more of the following symptoms
Cough > 2weeks
Weight loss or poor weight gain
Persistent fever and/or night sweats > 2 weeks
Fatigue, reduced playfulness, less active
PLUS
Presence of 2 or more of the following:
Positive contact history
Respiratory signs
CXR suggestive of PTB (where available)
Positive Mantoux test (where available)
Then PTB is likely, and treatment is justified
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ALGORITHM FOR TB DIAGNOSIS IN CHILDREN
Notes:
1. All children with TB should be tested for HIV
2. Mantoux test should be regarded as positive if:
>5mm diameter of induration in high risk children (includes HIV-infected, immune-suppressed and severely
malnourished children)
>10 mm diameter of induration in other children ( whether they have received vaccination or not)
3. Please note that a mantoux may be negative despite the child having TB especially in severe disseminated TB,
malnutrition and HIV disease.
4. Smear Positive result can be obtained from microscopy for ZN, TB culture, GeneXpert
5. A child in close contact with smear positive household member should be considered TB infected and TST may not be
necessary.
No sputum
Positive contact History
Respiratory signs
CXR suggestive of PTB (where available)
Positive Mantoux test (where available)
Treat for TB
If only one or none of the features
are present
If child is very sick, admit to
hospital for further
management
If child is not very sick, give 7 days
antibiotics then review after 1-2 weeks
If child improves, complete the treatment and
discharge home to continue with routine follow
up
If no improvement, re-evaluate for TB (May need CXR, Mantoux test etc) If TB
suspected, start TB treatment, continue regular follow up and complete the treatment
Make a diagnosis of TB if two or more of
these features are present
Sputum for bacteriology*
TB suspected based on two or more typical symptoms (Cough, fever, poor weight gain,
lethargy) for more than 2 weeks
Smear positive Smear negative
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c) Laboratory diagnosis
This can be AFB microscopy and/or Gene Xpert and/or TB culture.
As much as possible collect the appropriate specimen for diagnosis:
Suspected PTB: Sputum or gastric aspirate
Suspected EPTB: Specimen from specific site - CSF, Fine needle aspirate of lymph node, pleural
aspirate, etc (refer to table 2)
These specimens should be subjected to the appropriate test as below:
Microscopy for AFB (all specimens)
Xpert MTB/RIF (currently used only with sputum )
TB culture (all specimens from children under 5 years)
Histopathology (FNAs/biopsies)
Whenever possible, it is particularly important to make a bacteriologic diagnosis in the following situations:
Suspected drug resistant TB
Severe and complicated disease
HIV infected
Diagnostic uncertainties
When sputum should be collected for XPERT MTB/RIF/, Culture & DST
a) Contacts
Immediately a history of contact with a DRTB patient is elicited
One found to have TB symptoms during contact tracing of a DR TB patient
Before initiation of CAT 1 treatment
b) New Smear positive
Before initiation of CAT 1 treatment if:
A contact of DRTB
A Refugee
Patient on IPT who develops TB
At month 3, 4, 5 of treatment if still smear positive
c) New Smear Negative
A contact of DRTB
HIV positive
Relapse
Prior to initiation of retreatment regimen
12
d) Retreatment case
Prior to initiation of retreatment regimen
At month 3 of treatment or after if the sputum prior to treatment was not taken
Return after default should have their samples collected prior to initiation of CAT 11
d) Other Tests for TB diagnosis
Radiologic tests include:
CT scan- In complicated intracranial TB (Tuberculoma)
Ultrasound – useful for abdominal TB
Laboratory tests
Nucleic acid amplification tests
Gamma interferon assays
These are mainly used in research settings.
Non specific tests like ESR and C- reactive protein tests suggest presence of inflammation if increased.
Biochemical tests – Elevated protein and low glucose levels in aspirates or in CSF suggest an exudate
e) HIV test
Making a diagnosis of HIV infection has obvious implications for the management of TB and HIV. All children with
suspected TB should be tested for HIV. (Refer to chapter 4)
Differential Diagnosis for child with Chronic Cough /Respiratory Symptoms
Other conditions to consider in a child with chronic cough /chronic respiratory symptoms who does not fulfill
the classical clinical picture of PTB include:
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Table 1: Common causes of chronic cough/ respiratory symptoms in children
Possible diagnosis Clinical Presentation
Asthma Recurrent wheeze/cough – responds to bronchodilators. Usually
associated with other allergies such as eczema, rhinitis
Upper airway conditions
Allergic rhinitis
Adenoid hypertrophy
Recurrent / persistent runny nose and /or nasal blockage and snoring
Seasonal pattern Triggers
Foreign Body Inhalation Usually sudden onset in previously well child
May have history of choking
Persistent cough
One sided respiratory signs – inspiratory stridor, wheeze
Gastro-esophageal reflux disease Recurrent cough/wheeze
Onset in early infancy
+/- hoarse voice
Bronchiectasis Severe persistent c o u g h , much sputum ( often infected green or yellow
in colour).
Finger clubbing
CXR shows reticular or honey-comb pattern
Congenital Heart Disease Easily fatigueability, breathlessness,
Onset early infancy
Acquired heart disease Older children, palpitations, easy fatiguability, dyspnoea on exertion.
+/- oedema
Congenital respiratory
disorders
Onset early infancy
Commonly premature baby
Noisy breathing during inspiration not responding to bronchodilators
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Extra Pulmonary Tuberculosis (EPTB)
Extra pulmonary TB is common in children and presentation varies with age.
In addition to fever, weight loss, lethargy lasting more than 2 weeks and history of contact, suspect extra-pulmonary
TB if the child also has clinical features suggested in the table.
Table lists typical clinical features for various forms of EPTB and suggested investigations for each category.
Symptoms are usually persistent and progressive. The most common form of EPTB is TB lymphadenitis
Table 2: Diagnosis of Extra Pulmonary Tuberculosis in Children
Site of EPTB Typical clinical presentation Investigation Comment
TB
lymphadenitis
- Asymmetrical, painless,
non-tender lymph node enlargement
for more than one month +/-
discharging sinus
-Most commonly in neck area
Fine needle
aspiration when
possible
Mantoux
Treat.
Pleural TB
Dullness on percussion
And reduced breath sounds
+/-chest pain
CXR
Pleural tap1
-If pleural fluid is straw
colored, treat for TB.
-If pleural tap reveals pus
consider Empyema and refer
TB meningitis
Headache, irritability / abnormal
behaviour, lethargic / reduced level of
consciousness, convulsions, neck
stiffness, bulging fontanel, cranial
nerve palsies
-Lumbar puncture
to obtain CSF2
-Infants-cranial
ultrasound
-Older child do CT
scan brain
- Mantoux test
Hospitalise for TB
treatment
Miliary TB Non-specific, lethargic, fever, wasted -CXR
- Mantoux test
Treat and refer3
where appropriate
Abdominal TB
Painless abdominal
swelling with ascites
-Ascitic tap1
-Abdominal ultra-
sound4
-Mantoux test
Refer3 where
appropriate
Spinal TB
-Painless deformity of spine
-May have lower limb
weakness/paralysis
-Lateral X-ray
spine
- Mantoux test
Refer where appropriate
3
Pericardial TB
-Cardiac failure
-Distant heart sounds
-Apex beat difficult to palpate
-CXR
-Echocardiogram
- Mantoux test
Refer3 where
appropriate
TB bone and joint
( excluding spine)
-Painless, non-tender swelling end of
long bones with limitation of movement
-Painless, non-tender unilateral effusion
of usually knee or hip
-X-ray of
affected bone
and/or joint
-Joint tap
- Mantoux test
Refer3 where
appropriate
1Typical findings: straw coloured fluid, exudates with high protein, white blood cells especially
lymphocytes
2Require 2 - 5ml of CSF.
3Referral may be necessary for investigation procedure and laboratory support as well as clinical care. If
referral is difficult or not readily available, start anti-TB treatment.The above table highlights the more
common forms of EPTB; however TB may infect other organs.
4Abdominal ultra-sound illustrates abdominal lymphadenopathy and shows complex ascites +/- septation
All specimens (FNA, CSF, aspirates etc) should be sent for AFB microscopy and TB
culture
15
Clinical assessment in all cases of EPTB should consider:
Time lapse from exposure to disease presentation can be quite variable – shorter for
young children with disseminated disease, longer for other forms that present in school-
aged children
Common symptoms present in most cases of EPTB include fever, weight loss/poor
weight gain, and lethargy/reduced play lasting > 2weeks. Symptoms and signs
specific to the site of EPTB as shown in the table below
Investigations for TB as appropriate according to site of infection (see table 2)
16
Chapter 3: Treatment of Tuberculosis
The main objectives of anti- TB treatment in children are to:
Cure the child of TB
Prevent death from TB
Prevent the complications arising from TB disease
Prevent TB relapse by eliminating the dormant bacilli
Prevent the development of drug resistance by using a combination of drugs
Decrease TB transmission to others
Some of the important points to note about TB treatment in children are:
Children usually have paucibacillary disease, as cavitating disease is relatively rare (about
6% or less) in children under 13 years of age and the majority of the organisms in adult-
type disease are found in cavities.
Children develop extra-pulmonary TB (EPTB) more often than do adults.
Severe and disseminated TB (e.g., TB meningitis and miliary TB) occur especially in
young children (less than 3 years old).
Treatment outcomes in children are generally good even in the HIV infected provided
treatment is started promptly.
Children generally tolerate the anti- TB drugs better than adults.
3.1 Classification of TB in Children
TB is generally classified as either pulmonary tuberculosis (PTB) or extra- pulmonary tuberculosis
(EPTB). For each case, the patient is either a new TB case (one who has never previously received
TB treatment for a month or longer) or a retreatment case (one who has previously been treated for
TB for one month or longer in the past).
It can also be classified according to severity as in table 3 below.
17
Table 3: TB Classification in children
1. Non Severe TB
Pulmonary TB without extensive parenchymal lung disease
TB lymphadenitis
TB pleural effusion
2. Severe TB
PTB with extensive parenchymal lung disease
Miliary TB
TB bone or joint TB meningitis Pericardial TB Abdominal TB
All other forms of extra-pulmonary TB
3. Retreatment
4. Multi-drug resistant TB
Standard Operating Procedures for Treatment
Classify the case of child TB before starting treatment into pulmonary or extra-pulmonary,
new or retreatment. For extra-pulmonary forms, specify the site.
Record the TB diagnostic category, treatment regimen and date anti-TB treatment
was started on road-to-health book as well as on TB treatment card and facility TB register
A caregiver should be identified as the DOT supporter for all ages including older
children. Educate the DOT supporter on anti-TB regimen and adherence
Take the child’s weight at each visit and record
Calculate drug dosages at every visit according to the child’s current weight (note that
children gain weight while receiving anti-TB treatment)
Once treatment is started it must be completed; “trial of TB treatment” should never be
used as a diagnostic tool
Treatment regimens by disease category are listed in table 4 below.
3.2 Recommended Treatment Regimens
Table below shows the currently recommended TB treatment regimen in children
18
Table 4: WHO Recommended Treatment Regimen
TB disease category Recommended regimen
Intensive phase Continuation phase
All forms of TB except TB
meningitis, bone and joint TB
(osteoarticular TB)
2* RHZE 4 RH
TB meningitis
Bone and joint TB
2 RHZE 10 RH
**Retreatment 3 RHZE 5 RHE
Drug resistant TB Refer to a DRTB specialist
*Numeral refers to number of months of the regimen e.g. 2 HRZE refers to two months of Isoniazid,
Rifampicin, Pyrazinamide and Ethambutol
H= Isoniazid
R= Rifampicin
Z= Pyrazinamide
E= Ethambutol
Table 5: Dosage of Individual anti-TB drugs according to body weight
Drug Recommendations
Average dose in mg/kg
Range in
mg/kg
Maximum Dose
Isoniazid 10 10 – 15 300 mg
Rifampicin 15 10 – 20 600 mg
Pyrazinamide 35 30 – 40 1.5 g
Ethambutol 20 15 – 25 1.6 g
Other important observations to note include:
Treatment regimens are the same for HIV-infected and HIV-uninfected children
Response to treatment in HIV infected may be slower.
Report all children receiving anti-TB treatment to the National TB Program
TB drugs are very well tolerated in children
Side-effects may occur but are not common. The most important is hepatotoxicity
19
Ethambutol can be safely used in all children of all ages at recommended dosages of 20
mg/kg.
3.3 Additional Management Decisions
a) Hospitalization:
The following categories of children with TB should be treated as in- patients
Severe forms of PTB and EPTB (e.g. Spinal TB) for further investigation and initial
management.
TB meningitis
Severe malnutrition for nutritional rehabilitation
Signs of severe pneumonia (i.e. chest in-drawing)
Other co-morbidities e.g. severe anaemia
Social or logistic reasons to ensure adherence
Severe adverse reactions such as hepatotoxicity
b) Steroid therapy:
This should be given in the following situations:
TB meningitis
PTB with respiratory distress
PTB with airway obstruction by hilar lymph nodes
Severe Miliary TB
pericardial effusion
Give prednisone at 2mg/kg once daily for 4 weeks, and then taper down over 2 weeks (1mg/kg for
7 days, then 0.5mg/kg for 7 days)
c) For all HIV-infected children
20
Commence Cotrimoxazole prophylaxis (25 – 30mg/kg once daily, or see table 7 for dose in
weight bands)
Commence antiretroviral therapy within 2 – 8 weeks of starting anti-TB therapy
Conduct family-based care/screening for HIV
d) Immune re-constitution inflammatory syndrome (IRIS)
This is a paradoxical deterioration after initial improvement following treatment initiation.
Seen during the initial weeks of TB treatment with initial worsening of symptoms due to
immune re-constitution. IRIS is commonly seen in the severely immuno-compromised TB/HIV
co- infected child after initiating ARV treatment.
Management: Continue anti-TB therapy; give non steroidal anti- inflammatory drugs or/and
prednisone until severe symptoms subside.
e) Referral of children with TB should be considered if
Child has severe disease
Diagnosis is uncertain
Necessity for HIV-related care e.g. to commence ART
Failure to respond to treatment despite good adherence
f) Pyridoxine
Give pyridoxine 5 – 10 mg once daily to:
All malnourished children throughout the anti-TB therapy.
HIV infected children
Breast feeding infants.
Pregnant Adolescents
3.4 Follow-up of a Child on anti-TB Therapy
This is a critical part of effective TB treatment.
21
Patients visit the health facility weekly during intensive phase and every two weeks during
continuation phase. During the visit, the child should be assessed for:
Adherence
Drug toxicity
Weight gain
Symptom assessment
Sputum should be taken for AFBs at months 2 , 4 and 6 for those who were smear positive
at the beginning of treatment.
The following should be done at each visit:
Weigh the child at each visit. Document the weight and adjust dosage if necessary
Address Adherence issues
Explain and emphasize to care-giver and child why they must take the full course of
treatment even if they are feeling better
Note risk factors for poor adherence such as long distance to health facility, lack
of/transport costs, orphan ( especially if mother has died) or primary care-giver unwell and
adolescents
Education and adherence support especially TB/HIV. Explain that anti-TB drugs in children
are well tolerated and safe.
CXR is not required in follow-up if the child is responding well to anti-TB treatment
3.5 Poor Response to Treatment
Most children with TB will start to show signs of improvement within 4 – 8 weeks of anti-
TB treatment. Weight gain is a sensitive indicator of good response to treatment.
Potential causes of poor response to treatment include:
Poor adherence; this should be evaluated and problems addressed. HIV infection
Wrong diagnosis
22
Other concurrent chronic lung diseases
Under dosage of drugs Resistant form of TB Complications e.g. neurological
complications
Consider treatment failure if child is receiving anti-TB treatment and:
There is no symptom resolution or symptoms are getting worse. In this case, always confirm
adherence is good. If uncertain, a child can have health care worker DOT at the health
facility
There is continued weight loss
If smear positive at baseline and remains smear positive up to 5 months
Refer children with suspected treatment failure for further assessment
3.6 Treatment Interruptions
If a child interrupts anti-TB treatment for a period less than 1 month, continue with
their TB treatment when they resume.
If the child interrupts anti-TB therapy for a period longer than 1 month, put them on a re-
treatment regimen when they resume (Table 5).
3.7 Side effects of anti TB drugs in children
The most important side-effect is hepatitis which may present with nausea and vomiting. Presence of
abdominal pain, jaundice and tender enlarged liver suggest severe hepatotoxicity. Stop the anti-TB
drugs immediately and refer to hospital.
INH may cause symptomatic pyridoxine deficiency, particularly in severely malnourished children
and HIV infected children on highly active antiretroviral therapy (HAART). Supplemental pyridoxine
is recommended.
23
Chapter 4: TB and HIV Co-infection
HIV infection is one of the risk factors associated with development of Tuberculosis in children.
HIV influences TB in several ways:
Reactivation of Latent TB infection
Rapid progression of new TB infection to TB disease. Recurrence of TB after successful
treatment. Increased risk of adverse reactions to anti-TB drugs Increased risk of death
Increased risk of other infectious diseases including invasive pneumococcal disease
HIV infected children may have multiple and concurrent opportunistic lung infections that
clinically present like TB, thus making the diagnosis of TB in a HIV infected child more difficult.
The ARVs and anti -TB drugs have potentially significant drug-drug interactions as well as
overlapping toxicities that pose additional challenges.
Therefore comprehensive approach to management of both TB and HIV is critical.
4.1 Diagnosis
Approach to diagnosis of TB in HIV infected children is similar as for HIV uninfected
children. History of contact with TB is extremely important in pointing to possibility of TB disease
in the HIV infected child.
The clinical presentation of TB is similar between those in early stages of HIV disease and those
without HIV. However, those with advanced HIV disease may not have the typical TB clinical
features, and chronic respiratory symptoms may be due to other causes (see table 6).
HIV test is indicated in all children with suspected TB.
TST (Mantoux test) may be negative.
CXR may be difficult to interpret.
24
4.2 Treatment
TB in HIV infected children should be treated with a 6 month regimen as in HIV- uninfected
children.
Response to TB treatment may be slow
All children with TB/HIV should receive co-trimoxazole prophylaxis. All children with TB/HIV
should receive antiretroviral therapy. Nutritional support is often needed for children with TB/HIV.
The management of children with TB/HIV should be integrated so that all family members are
counseled and tested for HIV and screened for TB. ARVs should be initiated within 2-8 weeks of
starting anti-TB therapy
4.3 Prevention
All HIV-infected children need to be screened for TB. All HIV infected children exposed to sputum
smear positive TB case should be evaluated for TB disease and treated or o ffered Isoniazid
preventive therapy at 10mg/kg/day for 6 months.
All TB infected children should be offered counseling and testing for HIV infection Known
HIV infected children should minimize their exposure to other patients with chronic cough (e.g.
separate waiting area, or fast track their consultation from the waiting area.).
The specific needs of each family should be determined and a plan of action developed to ensure
that the family receives comprehensive care using all available services.
Deliberate efforts be made to expand the prevention of mother to child transmission.
BCG vaccine to be given to all new born babies except those with symptoms of HIV infection or
those on IPT.
Always examine the placenta for tubercles as their presence may implicate vertical TB transmission.
4.4 Differential Diagnosis in HIV infected Child with Chronic
Respiratory Symptoms
The diagnosis of PTB can be particularly challenging in HIV-infected child because of clinical and
radiological overlap with other HIV-related lung disease.
25
The respiratory system is a common site for many opportunistic infections in HIV infected children.
Often there is co-infection as well, which further complicates the diagnosis, other possible causes of
chronic lung disease in HIV infected children are shown in table 6.
Table 6: Causes of chronic respiratory symptoms in HIV infected children
Differential Diagnosis Clinical features
Recurrent pneumonia Recurrent episodes of cough, fever and fast breathing that
usually respond to antibiotics
LIP
Slow onset cough associated with generalized symmetrical
lymphadenopathy, finger clubbing, parotid enlargement.
Nutritional status variable, mild hypoxia CXR: diffuse
reticulonodular pattern and bilateral perihilar adenopathy
Tuberculosis
Persistent respiratory symptoms not responding to
antibiotics. Often poor nutritional status; positive TB contact
especially in younger children
CXR: focal abnormalities and perihilar adenopathy
Bronchiectasis
Cough, productive of purulent sputum, halitosis, finger clubbing,
seen in older children.
CXR: honeycombing usually of lower lobes
Complicates recurrent bacterial pneumonia, LIP or TB
PCP
Common cause of acute severe pneumonia, severe hypoxia
especially in infants. Unusual after 1 year.
CXR: diffuse interstitial infiltration, hyperinflation
Mixed infection
Common problem: LIP, bacterial pneumonia, TBConsider when
poor response to first-line empiric management
Kaposi sarcoma
Uncommon
Characteristic lesions on skin or palate
4.5 Antiretroviral Therapy in HIV Infected Children with
Tuberculosis
Tuberculosis is an increasingly common opportunistic infection in HIV-infected children. HIV
infection increases a child’s risk of progressive primary tuberculosis and reactivation of latent TB in
the older child.
26
The pill burden in TB/HIV co-infection is large. Intensive adherence support and monitoring should
be offered. The risk of adverse drug reactions is increased during concomitant therapy. Perform a full
clinical evaluation at every clinic visit and if there are symptoms suggestive of adverse drug reactions,
particularly liver toxicity, refer the child.
If significant problems are experienced such as severe drug intolerance or erratic adherence, continue
the anti-TB, but consider interrupting ART. Resume after the problem has been adequately addressed
(may occasionally have to wait until completion of anti-TB therapy).
The principles of treatment of tuberculosis in HIV-infected children are similar to those in HIV-
negative children, and the same regimens should be used as those used in HIV negative children.
Recent data suggest that early initiation of HAART early in TB treatment reduces TB morbidity and
mortality, without excess adverse events.
Any child with active tuberculosis should begin TB treatment immediately; and begin ART as soon as
the TB treatment is tolerated; i.e. no nausea or vomiting and no on-going or evolving adverse drug
events, usually 2 to 8 weeks into TB therapy.
The TB/HIV co-infected child has not only diagnostic but also drug management challenges. There
are significant drug-drug interactions between the ARVs and anti-TB medications, overlapping
toxicities between these two classes of medications and a high pill burden.
Rifampicin interacts with both PIs and NNRTIs, reducing their blood levels and hence their
effectiveness. Therefore, when treating TB and giving concurrent ART, the ART regimen may
require adjustment.
ART options with Rifampicin are limited and are based on the various scenarios as indicated.
EFV based ART
Super boosted LPV with ritonavir during TB treatment and revert to the normal LPV/r
dosing after completion of TB treatment.
Triple nucleosides- Triple nucleoside ART is a weak ART combination.
Use of AZT+ABC+3TC may lead to accumulation of mutations including M184V and thymidine
analogue mutations among others. It should be used only when other options are not indicated or
available or when preferred option is not tolerated.
After completion of TB treatment with triple nucleoside ART, never restart NNRTI based ART
regimen. Instead the child should be changed to LPV/r based ART.
Scenario A: Child develops TB before Initiating ART
27
Start anti-TB treatment immediately and ART within 2 – 8 weeks of starting anti- TB therapy.
A child who is severely ill needs to be started on ART sooner (within 2 weeks). A child who is less
severely ill may be started on ART within 2 - 8 weeks.
The ART options are as shown below:
NVP exposed NVP non- exposed
Irrespective of age and
weight
< 3years and <10kg > 3 years and >10 kg
Preferred option:
ABC/AZT + 3TC +
LPV/r + RTV (add extra
dose of RTV to make
the LPV/RTV ratio 1:1-
super boosted LPV)
Preferred option:
ABC/AZT + 3TC + LPV/r + RTV
(add extra dose of RTV to make
the LPV/RTV ratio 1:1- super
boosted LPV)
After completion of the TB
treatment, child can be started on
ABC/AZT+3TC+NVP
ABC/AZT+3TC+EFV
Alternative Option:
ABC+3TC+AZT
Change ART to
AZT+3TC+ LPV/ r
after completion of TB
treatment
Alternative Option:
ABC+3TC+AZT
Change ART to AZT +3TC+
LPV/ after completion of TB
treatment
Continue ART
28
Scenario B: Child develops TB during the first 6 months of first-line ART
Start TB treatment immediately and also change ART regimen as indicated below.
NVP exposed NVP non- exposed
Irrespective of age and
weight
< 3years and <10kg > 3 years and >10 kg
Preferred option:
ABC/AZT + 3TC +
LPV/r + RTV (add extra
dose of RTV to make the
LPV/RTV ratio 1:1-super
boosted LPV)
Preferred option:
ABC/AZT + 3TC + LPV/r + RTV
(add extra dose of RTV to make
the LPV/RTV ratio 1:1- super
boosted LPV)
After completion of the TB
treatment, child can be restarted on
original 1st
line i.e.
ABC/AZT+3TC+NVP
ABC/AZT+3TC+EFV
Alternative Option:
ABC+3TC+AZT
Change ART to AZT
+3TC+ LPV/r after
completion of TB
treatment
Alternative Option:
ABC+3TC+AZT
Change ART to AZT +3TC+
LPV/r after completion of TB
treatment
Continue ART
Scenario C: Child develops TB while on 1st line ART for more than 6 months
There is the possibility that this new episode of TB is an indication of poor response to ART due to
non-adherence or of ARV treatment failure or both. Manage as follows:
Initiate anti-TB treatment immediately.
Evaluate adherence to ART and ensure that any problems in adherence have been addressed
before embarking on a second-line regimen ART.
Evaluate for treatment failure for all.
29
The ART options are as shown below:
NVP exposed* NVP non- exposed
Irrespective of age and
weight
< 3years and <10kg > 3 years and >10 kg
Preferred option:
ABC/AZT + 3TC + LPV/r
+ RTV(add extra dose of
RTV to make the
LPV/RTV ratio 1:1- super
boosted LPV)
Preferred option:
ABC/AZT + 3TC +LPV/r + RTV (add extra
dose of RTV to make the LPV/RTV ratio
1:1-super boosted LPV).
If there is no ART failure, after completion
of the TB treatment, child can be restarted on
original 1st
line i.e. ABC/AZT+3TC+NVP
ABC/AZT+3TC+EFV
Alternative Option:
ABC+3TC+AZT
Change ART to
AZT+3TC+ LPV/r after
completion of TB
treatment
Alternative Option:
ABC+3TC+AZT
Change ART to AZT +3TC+ LPV/r after
completion of TB treatment
Continue ART
If child is confirmed to have failed first line LPV/r based ART, continue failing regimen and consult
therapeutic committee for future ART options
Scenario D. Child develops TB while on 2nd
line ART regimen
Anti-TB therapy should be started immediately.
There is the possibility that this new episode of TB is an indication of poor response to ART due to
non-adherence, or of ARV treatment failure, or both. If treatment failure is confirmed, do not
discontinue ART. In addition their future management of ART should be discussed with a senior
consultant with expertise in the management of HIV infection and the National HIV Therapeutics
Committee.
30
The ART option is as shown below:
Scenario ART options
Child on second line LPV/r
based ART
Preferred option:
ABC/AZT + 3TC + LPV/r + RTV (add extra dose of RTV to make
the LPV/RTV ratio 1:1-super boosted LPV.
Change to normal LPV/r dose after completion of TB treatment
Alternative option:
3TC monotherapy.
Restart original ART after completing TB treatment.
4.5 Cotrimoxazole Preventive Therapy (CPT)
Cotrimoxazole has been shown to reduce mortality among children infected with HIV. All TB/HIV
co-infected children should be offered CPT and it should be started as soon as possible. The duration
of treatment is usually indefinite with a once daily dosing.
The children should be monitored for side effects which include skin rashes and gastrointestinal
disturbances. Severe adverse reactions are uncommon and usually include extensive exfoliative rash,
Steven Johnson syndrome or severe anemia / pancytopenia. CPT should be discontinued if a child
develops severe adverse reactions.
Table 7: Recommended doses for cotrimoxazole.
Weight
in Kg
Child
Suspension
(200mg/40m g
per 5ml)
Child Tablet
(100mg/20mg)
Single strength
adult tablet
(400mg/80mg)
Double strength
adult tablet
(800mg/160mg)
<5 2.5 ml One Tablet ¼ tablet -
5-15 5 ml Two tablets ½ tablet -
15-30 10ml Four tablets One tablet ½ tablet
>30 - - Two tablets One tablet
Triple nucleoside ART should NOT be used in TB/HIV co-infected patients who have
previously failed ART
31
4.6 IPT in Children
Children living with HIV who are more than 12 months of age, who are unlikely to have active TB
on symptom-based screening and have no contact with a TB case should receive six months of
IPT (10 mg/kg/ day) as part of a comprehensive package of HIV prevention and care services.
In children living with HIV who are less than 12 months of age, only those who have contact with a
TB case, and who are evaluated for TB (using investigations) should receive six months of IPT if the
evaluation shows no TB disease.
Table 8: Dose and duration of Isoniazid (INH) for Isoniazid preventive Therapy (IPT) in
children
INH 10 mg/kg/day for 6 months (maximum 300 mg/day).
Weight (kg) Daily Dose in mg Number of 100 mg tablets
<5 50 ½
5.1 – 9.9 100 1
10-13.9 150 1½
14-19.9 200 2
20-24.9 250 2½
>25 300 3*
For children more than 25 kg, one can use 1 adult tablet of 300mg INH once daily.
Table 9: Give IPT with Pyridoxine at the following doses:
Weight (kg) Number of tablets of pyridoxine (50mg)
5-7 Quarter tablet daily
8-14 Half tablet daily
15 and above One full tablet daily
32
Chapter 5: TB in special circumstances
5.1 TB Meningitis (TBM)
TB meningitis is common in young children and is associated with high morbidity and mortality
particularly if the diagnosis is delayed. It is therefore important to consider a diagnosis of TBM in
young children as early as possible, especially in children who have a history of contact with an
adult with infectious TB.
Miliary or haematogenously disseminated TB has a high risk (60–70%) of meningeal
involvement. For this reason, all children with Miliary TB (or suspected of having Miliary TB)
should undergo a lumbar puncture to exclude TB meningitis.
Clinical presentation of TBM is usually insidious and one must have a high index of suspicion all
the time.
Treatment
Children with TB meningitis or Miliary TB should be hospitalized, preferably for at least the first 2
months or until they have clinically stabilized. TB Meningitis is one of the severe forms of
TB and therefore four anti-TB drugs (RHZE) are recommended for the intensive phase.
Isoniazid and Rifampicin are used for the continuation phase. The continuation phase is longer i.e.
given for 10 months instead of 4 months.
Corticosteroids (usually prednisone) are recommended for all children with TB meningitis at a
dose of 2 mg/kg daily for 4 weeks. The dose should then be gradually reduced (tapered) over 1–
2 weeks before stopping.
5.2 Management of a Newborn born to a Mother with PTB
Once a pregnant woman has been on anti- TB treatment for at least 4 weeks before
delivery she is generally no longer infectious and is therefore unlikely that her baby will become
infected. A newborn infant has a high risk of infection/ disease from a mother with smear-
positive pulmonary TB if the mother is diagnosed at delivery or soon thereafter.
If the mother is diagnosed with TB shortly before delivery, then the baby and possibly the
placenta should be investigated for evidence of congenital TB infection. The neonate
should be screened for TB. Signs and symptoms of Neonatal TB disease are usually non
specific and may include, fever, feed intolerance, poor weight gain, hepato-splenomegally and
irritability (symptoms of neonatal sepsis).
33
Those that are symptomatic should be treated for TB.
Those without active TB disease should be on IPT for 6 months.
If child had not received BCG by the time of instituting IPT, BCG should be withheld until 2
weeks after completion of IPT. Breast feeding can be safely continued during this period. Mother
is then educated on Infection Prevention measures she can institute to prevent TB transmission at
home.
If mother has MDR-TB, then IPT is not useful due to resistant bacilli, and in this scenario, BCG
should be given at birth, and neonate is handled as an MDR contact.
5.3 Drug Resistant TB
Resistance to Rifampicin and/or Isoniazid is the most important, as these two
drugs form the backbone of the current TB chemotherapy.
Mono- and poly-resistance
One can develop resistance to one or more anti-TB drug at a time. The treatment varies with the
resistance pattern. The table below outlines the treatment options for children with various TB drug
resistance patterns.
Table 10: Patterns of drug resistance and recommended treatment
Pattern of drug resistance Regimen Duration of treatment
H (±S) R/Z/E/LFX 9 Months
H, E, Z (±S) 3Cm-Lfx-R-Z / 15 Lfx-R-Z** 18 Months
H and Z 3Cm-Lfx-R-Z / 15 Lfx-R-Z** 18 Months
H and E 3Cm-Lfx-R-Z/ 15 -Lfx-R--Z** 18 months
R 8Cm-Pto-Lfx-Cs-Z / 12 Pto-Lfx-Cs-Z* 20 months
R and E (± S) 8Cm-Pto-Lfx-Cs-Z/ 12 Pto-Lfx-Cs-Z* 20months
R and Z (± S) 8Cm-Pto-Lfx-Cs-Z/ 12 Pto-Lfx-Cs-Z* 20 months
* The patient should be started on MDR regimen and another sample collected for DST
**Consider a patient’s previous drug history between the time of sample collection and results being
received before starting the patient on the recommended regimen.
34
Multidrug-resistant TB
MDR-TB is resistance to both Isoniazid and Rifampicin, with or without resistance to other anti-TB
drugs. MDR-TB in children is mainly the result of transmission of a strain of M. tuberculosis that is
MDR from an adult source case, and therefore often not suspected unless a history of contact with
an adult pulmonary MDR-TB case is known. The diagnosis of MDR needs DST and its treatment
is difficult. Referral to a specialist is always advised.
Some basic principles of treatment of MDR are as follows:
Do not add a drug to a failing regimen.
Treat the child according to the drug susceptibility pattern and use the treatment history
of the source case’s M. tuberculosis strain if an isolate from the child is not available.
Use at least four drugs certain to be effective.
Use daily treatment only; directly observed therapy is essential.
Counsel the child’s caregiver at every visit, to provide support, advice about adverse
events and the importance of compliance and completion of treatment.
Follow-up is essential: clinical, radiological and bacteriological (mycobacterial culture
for any child who had bacteriologically confirmed disease at diagnosis).
Treatment duration depends on the extent of the disease, but in most cases will be 20
months or more (or at least 12 months after the last positive culture).
With correct dosing, few long-term adverse events are seen even with the more toxic
second line drugs in children, including Ethionamide and the Fluoroquinolone.
Children with MDR-TB should be treated with the first-line drugs to which their M. tuberculosis
strain (or that of their source case) is susceptible to, including streptomycin, Ethambutol and
Pyrazinamide. Ethambutol is bactericidal at higher doses, so daily doses up to 25 mg/kg should be
used in children being treated for MDR-TB.
Extreme Drug resistant TB (XDR)
By definition XDR is MDR TB that is also resistant to a second line injectable anti- TB drugs and
any Fluoroquinolone. Compared to MDR it is even more difficult to treat and mortality is very high.
35
Chapter 6: TB Prevention
6.1 Screening for Child Contacts of Known TB Cases
Young children living in close contact with an index case of smear positive pulmonary TB
are at a high risk of TB infection and disease. The risk of infection is greatest if the contact is
close and prolonged. The risk of developing disease after infection is much greater for
malnourished children, children under 5 years and HIV infected children than it is for HIV un-
infected children and those over 5 years. If the disease develops it usually does so within 2 years of
infection, but in infants the time lag can be as short as a few weeks.
Isoniazid preventive therapy (IPT) for young children with infection who have not yet developed
disease will greatly reduce the likelihood of developing TB during childhood.
The main purpose of child contact screening is to:
1. Identify symptomatic children (i.e. children of any age with undiagnosed TB disease) and treat
them for TB.
2. Provide Isoniazid preventive therapy (IPT) for the high risk children who have no signs or
symptoms of TB disease i.e
All children aged under 5 years
All HIV infected children
The best way to detect TB infection is the TST, and CXR is the best method to screen for TB
disease in symptomatic children contacts who are not able to produce sputum for AFB microscopy.
Where these two tests are unavailable contact screening and management can be conducted on
the basis of a simple clinical assessment.
Generally clinical assessment is sufficient to decide whether the contact is well or symptomatic.
Contact screening refers to the screening or evaluation for TB infection or
disease of all close contacts of smear positive PTB index case
36
Symptoms for Child Contact Screening
1. Non remitting cough for more than 2 weeks
2. Persistent fever for more than 2 weeks
3. Loss of weight/poor weight gain
4. Lethargy/malaise/reduced play
5. Enlarged cervical LN
IPT should be given at a dose of 10mg/kg for duration of 6 months.
Children on IPT should receive monthly follow up. During the follow up visit:
Continuously reinforce message of adherence
Screen for TB disease i.e. persistent cough, fever, lethargy, poor weight gain
Monitor INH adverse effects.
Maintain a contact register
37
6.2 Management of child exposed to PTB
The algorithm below outlines the management of a Child who has been exposed to an
adolescent or adult with Pulmonary TB
Any child who is symptomatic should be evaluated for TB disease and treated
*Asymptomatic HIV negative child not on IPT should be followed up every 3 months for at least 1
year
Parent should be advised to bring the child to the hospital any time the child develops symptoms
Child exposed to an adolescent or adult with
Pulmonary TB
Under 5 years of age Aged 5 years and above
Symptomatic e.g. cough,
poor weight gain, fever,
lethargy Asymptomatic
Asymptomatic
Evaluate for TB
and treat
accordingly
No IPT
IPT (6 months INH)
If becomes symptomatic
while on IPT
If becomes symptomatic
HIV
negative*
HIV
Positive
IPT (6
months INH)
38
Child contact known to be HIV-infected
If the child contact is HIV-infected and asymptomatic, then IPT should be considered for all
ages, including those 5 years and older. As with other contacts, active disease should be ruled out
before providing HIV-infected children with IPT. HIV infected children who have symptoms
should be carefully evaluated for TB, and if found to have TB should be started on TB treatment.
Suspected HIV infection of contact
If the index case is a parent and is HIV infected, their children may be at risk of both TB and HIV
infection. It is important to counsel and test for HIV as we screen for T B in fec t io n i n a l l
t h e c o n t a c t s . (Consider joint T B /HIV co ntac t investigations)
Child contacts of infectious MDR-TB cases
By definition MDR-TB is resistance to both Isoniazid and Rifampicin. Therefore, it is unlikely
that use of these drugs to treat latent infection caused by a resistant M. Tuberculosis strain
will prevent the development of active TB disease. Close contacts of MDR-TB patients should
receive careful clinical follow-up for a period of at least 2 years. If active disease develops, prompt
initiation of treatment of the child with a regimen designed to treat MDR-TB is recommended.
The regimen is usually based on the resistance pattern of the MDR TB index case.
The use of second-line drugs for chemoprophylaxis in MDR-TB contacts is currently not
recommended.
6.3 Tracing of TB Source
Where the child is the first person in the household diagnosed to have TB, the household members
and other close contacts of the child should be evaluated in order to identify the index case of TB.
Evaluation should include screening for classic TB symptoms: cough, fever, weight loss and lethargy.
Note: The index case may have transmitted TB to the child several months earlier, and may not
currently be living in the household.
6.4 BCG Vaccination in Children
BCG is a live attenuated vaccine derived from M. bovis. It offers protection against the more
severe types of TB such as Miliary TB and TB meningitis, which are common in young
children.
39
All children should be given the BCG vaccine as soon as possible after birth EXCEPT those with
suspected TB infection at birth. The BCG vaccination should then be deferred till 2 weeks after
IPT/ TB treatment.
A child who has not had routine neonatal BCG immunization and has symptoms of HIV disease/
congenital immunodeficiency syndrome should also not be given BCG because of the risk of
disseminated BCG disease.
A small number of children (1–2%) may develop complications following BCG
vaccination. These commonly include:
Local abscesses at the injection site
Secondary bacterial infections
Suppurative adenitis in the regional axillary lymph node
Local keloid formation.
Disseminated BCG disease. If axillary node enlargement is on the same s i d e a s BCG in a
HIV- positive infant, consider BCG disease and refer.
Most reactions will resolve spontaneously over a few months and do not require specific treatment.
Children who develop disseminated BCG disease should be investigated for immunodeficiencies
and treated for TB using a 4-drug first-line regimen: 2RHZE t h e n 4 R H (The BCG b a c i l l u s
h a s p o o r s u s c e p t i b i l i t y t o Pyrazinamide).
6.5 TB Infection Control
Prevention of TB transmission and infection in the household and health facilities are important
components of control and management of TB in children.
The following simple procedures are effective in TB infection control at home and clinics:
Early diagnosis and management of adult TB cases in the household
At the clinic promptly identify potential and known infectious cases of TB; separate and
treat them with minimal delay by conducting triage and screening
Provide health education about TB transmission without stigmatizing TB
patients
40
Encourage proper cough hygiene both at home and at health facilities
Natural ventilation and sunlight:
Keep doors and windows open on opposite sides of the TB clinic and other clinics where
children and adults stay together open to bring in air from the outside.
Advise TB patients to do the same at home
Advise patients and household members to allow sunlight into their ho use (rooms) by
o peni ng the doors and windows
Apply the same in the clinics
41
Chapter 7: Roles and Responsibility
7.1 Level 1: (family, patient, CHW, CHEW, community)
Tuberculosis is an infectious disease, which is transmitted from one person to another through
coughing, sneezing etc. A patient may infect other people who may also develop tuberculosis.
The patient should, therefore, encourage other people with whom he or she has been is in close
contact with to undergo screening for TB.
The TB patient should be encouraged to spend more time in open space so as to reduce indoor
transmission
Children, parents, and other family members should be educated about TB and the importance of
completing treatment. Where possible, someone other than the child’s parent or immediate family
member should observe or administer treatment.
The communities should ensure:
Children get all the primary vaccines.
The chronic coughers to be screened for TB. Those on treatment adhere to treatment.
TB patients who develop complications to be referred to higher level for
evaluation and treatment
7.2 Level 2 and 3: Dispensary and Health Centre
Diagnose children with TB based on signs and symptoms, tuberculin skin test to be done if
possib le . In these leve ls , i t may be poss ib le to conduct smear microscopy and initiate TB
treatment based on the results.
7.3 Level 4, 5 and 6: District, County and Referral Hospitals
These levels provide referral services for lower levels where diagnosis is not possible or for
further management due to complications that may develop in a child started on treatment at
lower levels. At these levels, correct diagnosis through microscopy or bacteriology is done.
Initiation of treatment for all forms of TB is usually started at these levels before referral to lower
42
levels. Generally, these levels diagnose children based on signs and symptoms, tuberculin skin test,
microscopy, chest x-ray and culture and eventually initiate treatment.
7.4 Follow-up
Each child should be clinically assessed a very 2 weeks during the intensive phase, and
every month during the continuation phase until treatment completion. The assessment
should include, at a minimum:
Symptom assessment
Assessment of adherence by reviewing the treatment card
Inquiry about any adverse events
Weight measurement
Drug dosage adjustment to account for any weight gain
A follow-up sputum smear for microscopy at 2 months should be obtained for any child who was
smear-positive at diagnosis. Follow-up chest radiographs are not routinely required in children,
who are improving on treatment as radiological changes usually lag behind clinical response
A child who is not responding to TB treatment should be referred for further assessment and
management (Level 4, 5 and 6).
7.5 Health education
It is the responsibility of health staff to educate tuberculosis patients and their relatives about
their disease. It is essential to obtain the patient's co-operation over the required treatment. An
understanding, sympathetic and concerned attitude on the part of the health staff is essential for
getting the message across.
Health education is a prerequisite for high cure rates and default prevention. It should be provided
every time the patient receives care from the health care provider and should focus on improving
adherence and detecting any untoward events that may compromise the health of the child.
Always remember that medication dosages should be adjusted to account
for any weight gain
43
In addition, health education should be able to detect any index case that may be in the family.
7.6 Case recording and reporting for childhood TB
All children diagnosed and treated for TB should be recorded in the TB facility register and
standard treatment outcomes reported.
44
Chapter 8: Child nutrition and TB
Malnutrition is an important public health issue particularly for children under five years
old who have a significantly higher risk of mortality and morbidity than well nourished children. In
Kenya, the infant and the under-five mortality rates are 77 and 115 per 1000 live births respectively.
The national figure for acute malnutrition of children under five years old is estimated at 6%1.
Malnutrition is defined as “a state when the body does not have enough of the required
nutrients (under-nutrition) or has excess of the required nutrients (over-nutrition). There are two
categories of malnutrition: Acute Malnutrition and Chronic Malnutrition.
Children can have a combination of both acute and chronic. Acute malnutrition is categorized into
Moderate Acute Malnutrition (MAM) and Severe Acute Malnutrition (SAM), determined by the
patient’s degree of wasting. All cases of bi-lateral oedema are categorized as SAM.
Chronic malnutrition is determined by a patient’s degree of stunting, i.e. when a child has not reached
his or her expected height for a given age. To treat a patient with chronic malnutrition requires a long-
term focus that considers household food insecurity in the long run; home care practices (feeding and
hygiene practices); and issues related to public health.
SAM is further classified into two categories: Marasmus and Kwashiorkor. Patients may
present with a combination, known as Marasmic Kwashiorkor. Patients diagnosed with
Kwashiorkor are extremely malnourished and at great risk of death.
Admission criteria for acute malnutrition are determined by a child’s weight and height, by
calculating weight-for-height as “z-score” (using WHO Child Growth Standard, 2006)2, and
presence of oedema. All patients with bi-lateral oedema are considered to have severe acute
malnutrition. See Table 11for anthropometric criteria.
45
Table 11: Anthropometric criteria to identify severe, moderate and at risk categories of acute
malnutrition for Children and Adolescents*
Indicator Severe Acute
Malnutrition
(SAM)
Moderate Acute
Malnutrition (MAM)
At Risk of Acute
Malnutrition
Infants less than 6 months
W/L
W/L < - 3 Z-Score Static weight or losing
weight at home Static weight or
losing
weight at home
Z-Score Oedema Oedema Present Oedema Absent Oedema Absent
Other signs
Too weak to suckle or
feed Poor feeding Poor feeding
Children 6 months to 10 years
W/H Z-
Scores
< -3 Z-Score Between -3 to < -2
ZScore Between -2 to <-1
Z-Score MUAC (6 - 59
months only) <11.5cm 11.5 to 12.4cm 12.5-13.4cm
Oedema Oedema Present Oedema Absent Oedema Absent
Adolescent (10 years to 18 years)
MUAC < 16cm N/A N/A
Oedema Oedema Present Oedema Absent Oedema Absent
*Anthropometric criteria based on WHO Child Growth Standards (2006)
Mid-Upper Arm Circumference (MUAC) is often the screening tool used to determine malnutrition
for children in the community under five years old. A very low MUAC (<11.5cm for children under
five years) is considered a high mortality risk and is a criteria for admission with severe acute
malnutrition. See Table 12 below for MUAC criteria for children under-five years.
Table 12: MUAC criteria to identify malnutrition of children under five years in the community
Severely Malnourished Moderately
Malnourished
At Risk of malnutrition
less than 11.5cm 11.5cm to 12.4cm 12.5cm to 13.4cm
46
Table 13: Triage to determine treatment of either severe or moderate malnutrition
ASK:
1. Has there been any weight loss in previous month?
2. Does the patient have an appetite.
3. Does the patient have any medical condition that will
impair
nutritional status?
4. Is the breast-feeding child suckling well?
LOOK AND FEEL FOR: Visible signs of wasting
CHECK:
MUAC
Weight
Height/length
Bilateral-oedema
DETERMINE: Level of malnutrition using W/H reference charts
LOOK AT SHAPE OF GROWTH
CURVE:
1. Has the child lost weight?
2. Is the growth curve flattening?
47
Annex 1: Tuberculin Skin Test (Mantoux test)
Administering, reading and interpreting a tuberculin skin test
A TST is the intradermal injection of a combination of mycobacterial antigens which elicit an
immune response (delayed-type hypersensitivity), represented by in duration, which can be measured
in millimeters. The TST using the Mantoux method is the standard method of identifying people
infected with M. tuberculosis. Multiple puncture tests should not be used to determine whether a
person is infected, as these tests are unreliable (because the amount of tuberculin injected
intradermally cannot be precisely controlled).
Details of how to administer, read and interpret a TST are given below, using 5 tuberculin units (TU)
of tuberculin PPD-S. An alternative to 5 TU of tuberculin PPD-S is 2 TU of tuberculin PPD RT23.
Administration
1. Locate and clean injection site 5–10 cm (2–4 inches) below elbow joint
Place forearm palm-side up on a firm, well-lit surface.
Select an area free of barriers (e.g. scars, sores) to placing and reading. Clean the area with an alcohol
swab.
2. Prepare syringe
Check expiration date on vial and ensure vial contains tuberculin PPD-S (5
TU per 0.1 ml).
Use a single-dose tuberculin syringe with a short (¼- to ½-inch) 27-gauge needle with a short bevel.
Fill the syringe with 0.1 ml tuberculin.
3. Inject tuberculin (see Figure A1.1)
Insert the needle slowly, bevel up, at an angle of 5–15 °. Needle bevel should be visible just below
skin surface.
4. Check injection site
After injection, a flat intradermal wheal of 8–10 mm diameter should appear. If not, repeat the
injection at a site at least 5 cm (2 inches) away from the original site.
5. Record information
48
Record all the information required by your institution for documentation (e.g. date and time of test
administration, injection site location, lot number of tuberculin).
Figure A1.1 Administration of the tuberculin skin test
Reading
The results should be read between 48 and 72 hours after administration.
A patient who does not return within 72 hours will probably need to be rescheduled for another TST.
1. Inspect site
Visually inspect injection site under good light, and measure induration (thickening of the
skin), not erythema (reddening of the skin).
2. Palpate induration
Use fingertips to find margins of induration.
3. Mark induration
Use fingertips as a guide for marking widest edges of induration across the forearm.
4. Measure diameter of induration using a clear flexible ruler
Place “0” of ruler line on the inside-left edge of the induration.
49
Read ruler line on the inside-right edge of the induration (use lower measurement if between two
gradations on mm scale).
5. Record diameter of induration
Do not record as “positive” or “negative”. Only record measurement in millimeters. If no induration,
record as 0 mm.
Figure A1.2 Reading of the tuberculin skin test
Interpretation
TST interpretation depends on two factors:
Diameter of the induration.
Person’s risk of being infected with TB and risk of progression to disease if infected.
Mantoux is positive if induration is:
10mm in a well nourished, HIV negative child
5mm in a malnourished, or HIV infected child
A negative mantoux does not rule out TB (especially in the HIV positive or malnourished child)
50
Annex 2: Sputum Collection
Procedures for obtaining clinical samples for smear
microscopy
This annex reviews the basic procedures for the more common methods of obtaining clinical
samples from children for smear microscopy: expectoration, gastric aspiration and sputum
induction.
Expectoration
Background
All sputum specimens produced by children should be sent for smear microscopy and, where
available, mycobacterial culture. Children who can produce a sputum specimen may be infectious,
so, as with adults, they should be asked to do this outside and not in enclosed spaces (such as
toilets) unless there is a room especially equipped for this purpose. Three sputum
specimens should be obtained: an on-the-spot specimen (at first evaluation), an early
morning specimen and a second on the- spot specimen (at follow-up visit).
Procedure [adapted from Laboratory services in tuberculosis control. Part II. Microscopy (1)]
1. Give the child confidence by explaining to him or her (and any family members) the
reason for sputum collection.
2. Instruct the child to rinse his or her mouth with water before producing the specimen. This will
help to remove food and any contaminating bacteria in the mouth.
3. Instruct the child to take two deep breaths, holding the breath for a few seconds after each
inhalation and then exhaling slowly. Ask him or her to breathe in a third time and then forcefully
blow the air out. Ask him or her to breathe in again and then cough. This should produce sputum
from deep in the lungs. Ask the child to hold the sputum container close to the lips and to spit into
it gently after a productive cough.
4. If the amount of sputum is insufficient, encourage the patient to cough again until a satisfactory
specimen is obtained. Remember that many patients cannot produce sputum from deep in the
respiratory track in only a few minutes. Give the child sufficient time to produce an expectoration
which he or she feels is produced by a deep cough. If there is no expectoration, consider the
container used and dispose of it in the appropriate manner.
51
Gastric aspiration
Background
Children with TB may swallow mucus which contains M. tuberculosis. Gastric aspiration is a
technique used to collect gastric contents to try to confirm the diagnosis of TB by microscopy and
mycobacterial culture. Because of the distress caused to the child, and the generally low yield
of smear-positivity on microscopy, this procedure should only be used where culture is available as
well as microscopy. Microscopy can sometimes give false-positive results (especially in HIV-infected
children who are at risk of having non-tuberculous mycobacterium). Culture enables the
determination of the susceptibility of the organism to anti-TB drugs.
Gastric aspirates are used for collection of samples for microscopy and mycobacterial cultures in
young children when sputa cannot be spontaneously expectorated nor induced using hypertonic
saline. It is most useful for young hospitalized children. However, the diagnostic yield (positive
culture) of a set of three gastric aspirates is only about 25–50% of children with active TB, so a
negative smear or culture never excludes TB in a child. Gastric aspirates are collected from
young children suspected of having pulmonary TB. During sleep, the lung’s mucociliary system
beats mucus up into the throat. The mucus is swallowed and remains in the stomach until the
stomach empties. Therefore, the highest-yield specimens are obtained first thing in the morning.
Gastric aspiration on each of three consecutive mornings should be performed for each patient.
This is the number that seems to maximize yield of smear- positivity. Of note, the first gastric
aspirate has the highest yield.
Performing the test properly usually requires two people (one doing the test and an assistant).
Children not fasting for at least 4 hours (3 hours for infants) prior to the procedure and
children with a low platelet count or bleeding tendency should not undergo the procedure.
The following equipment is needed:
• Gloves
• Nasogastric tube (usually 10 French or larger)
• 5, 10, 20 or 30 cm3 syringe, with appropriate connector for the nasogastric tube
• litmus paper specimen container
• Pen (to label specimens)
• Laboratory requisition forms
• Sterile water or normal saline (0.9% NaCl) Sodium bicarbonate solution
52
• (8%) Alcohol/chlorhexidine.
Procedure
The procedure can be carried out as an inpatient first thing in the morning when the child wakes up,
at the child’s bedside or in a procedure room on the ward (if one is available), or as an
outpatient (provided that the facility is properly equipped). The child should have fasted for at
least 4 hours (infants for 3 hours) before the procedure.
1. Find an assistant to help.
2. Prepare all equipment before starting the procedure.
3. Position the child on his or her back or side. The assistant should help to hold the child.
4. Measure the distance between the nose and stomach, to estimate distance that will be required to
insert the tube into the stomach.
5. Attach a syringe to the nasogastric tube.
6. Gently insert the nasogastric tube through the nose and advance it into the stomach.
7. Withdraw (aspirate) gastric contents (2–5 ml) using the syringe attached to the nasogastric tube.
8. To check that the position of the tube is correct, test the gastric contents with litmus paper:
blue litmus turns red (in response to the acidic stomach contents). (This can also be checked by
pushing some air (e.g. 3–5 ml) from the syringe into the stomach and listening with a
stethoscope over the stomach.)
9. If no fluid is aspirated, insert 5–10 ml sterile water or normal saline and attempt to aspirate
again.
• If still unsuccessful, attempt this again (even if the nasogastric tube is in an incorrect
position and water or normal saline is inserted into the airways, the risk of adverse
events is still very small).
• Do not repeat more than three times.
10. Withdraw the gastric contents (ideally at least 5–10 ml).
11. Transfer gastric fluid from the syringe into a sterile container (sputum collection cup).
12. Add an equal volume of sodium bicarbonate solution to the specimen (in order to neutralize
the acidic gastric contents and so prevent destruction of tubercle bacilli).
53
After the procedure
1. Wipe the specimen container with alcohol/chlorhexidine to prevent cross- infection and label
the container.
2. Fill out the laboratory requisition forms.
3. Transport the specimen (in a cool box) to the laboratory for processing as soon as possible
(within 4 hours).
4. If it is likely to take more than 4 hours for the specimens to be transported,
place them in the refrigerator (4–8 °C) and store until transported.
5. Give the child his or her usual food.
Safety
Gastric aspiration is generally not an aerosol-generating procedure. As young children are also at
low risk of transmitting infection, gastric aspiration can be considered a low risk procedure for TB
transmission and can safely be performed at the child’s bedside or in a routine procedure room.
Sputum Induction
Note that, unlike gastric aspiration, sputum induction is an aerosol-generating procedure. Where
possible, therefore, this procedure should be performed in an isolation room that has adequate
infection control precautions (negative pressure, ultraviolet light (turned on when room is not in
use) and extractor fan).
Sputum induction is regarded as a low-risk procedure. Very few adverse events have been
reported, and they include coughing spells, mild wheezing and nosebleeds. Recent studies
have shown that this procedure can safely be performed even in young infants (2), though
staff will need to have specialized training and equipment to perform this procedure in such patients.
General approach
Examine children before the procedure to ensure they are well enough to undergo the
procedure.
Children with the following characteristics should not undergo sputum induction.
Inadequate fasting: if a child has not been fasting for at least 3 hours, postpone the
procedure until the appropriate time.
54
Severe respiratory distress (including rapid breathing, wheezing, hypoxia).
Children who are intubated.
Bleeding: low platelet count, bleeding tendency, severe nosebleeds
(symptomatic or platelet count <50/ml blood).
Reduced level of consciousness.
History of significant asthma (diagnosed and treated by a clinician).
Procedure
1. Administer a bronchodilator (e.g. salbutamol) to reduce the risk of wheezing.
2. Administer nebulized hypertonic saline (3% NaCl) for 15 minutes or until 5 cm3 of
solution have been fully administered.\
3. Give chest physiotherapy is necessary; this is useful to mobilize secretions.
4. For older children now able to expectorate, follow procedures as described in section A
above to collect expectorated sputum.
5. For children unable to expectorate (e.g. young children), carry out either: (i) suction of
the nasal passages to remove nasal secretions; or (ii) nasopharyngeal aspiration
to collect a suitable specimen.
Any equipment that will be reused will need to be disinfected and sterilized before use for a
subsequent patient.
55
Annex 3: Seven Steps for Patient Management to
prevent transmission of TB in Community and health
care settings
Step Action Description
1. Screen -Early identification and detection of patients with suspected or confirmed TB disease is the first
step in the protocol. It can be achieved by assigning a staff member in a health facility and
trained community health workers to screen patients for prolonged duration of cough and take
immediate action. -Patients with cough of more than two weeks duration, or who report being
under investigation or treatment for TB*, should not be allowed to wait in the line with other
patients to enter, register, or get a card.
-The patients under investigation and on treatment should be weighed in the treatment room and
not referred to the MCH/FP (well baby clinic) where mothers and infant are waiting Instead;
they should be managed as outlined below.
-Likewise patients with similar prolonged cough should be immediately being referred to a health
facility. Carry out contact tracing of sputum positive PTB including MDR and XDR TB. Actively track
the defaulters and bring them back to treatment. 2. Educate Educating the above-mentioned persons identified through screening, on cough etiquette and
respiratory hygiene. This includes instructing them to cover their noses and mouths when coughing
or sneezing, and when possible providing facemasks, handkerchiefs or tissues to assist them in covering
their mouths.
3. Special
waiting areas
Patients who are identified as TB suspects or cases by the screening questions should be directed
to another separate waiting room away from other patients and requested to wait in a separate well-
ventilated waiting area, and provided with a surgical mask or tissues to cover their mouths and noses
while waiting.
4. Triage Patients in special groups (known HIV positive, the very young and old) should be given
preference in care. Triaging symptomatic patients to the front of the line for the services should
be done. In an integrated service delivery setting known HIV patients should be separated from
smear positive TB patients. Known HIV positive clients in the community should be frequently be
monitored for TB and referred promptly.
5. Investigate
for TB or
Refer
TB diagnostic tests should be done onsite or, if not available onsite, the facility should have an
established link with a TB diagnostic and treatment site to which symptomatic patients can be
referred.
6. Treatment Appropriate TB treatment should be initiated in accordance with National TB guidelines at
the earliest time possible. Directly obse rved t h e r a p y ( DOT) to ensure adherence to treatment.
Follow-up and monitor patients in accordance with National TB guidelines.
Conduct additional diagnostic procedures to ensure the appropriate treatment is given (both for TB
t r e a t m e n t a s we l l as p o t e n t i a l i n t e r a c t i on s wi t h other medications such as ARVs).
Document completion of treatment program.
7. Discharge
Plan
For i n p a t i e n t a n d o u t p a t i e n t s e t t i n g s , c o o r d i n a t e a discharge plan with the patient
(including a patient who is a HCW with TB disease) and the TB-control program of the local,
district or provincial health facilities. If applicable, co-management o f p a t i e n t s w i th H I V or
other diseases should be coordinated with the applicable local, district or provincial
health facilities. For MDR-TB, identify trained HW in referral sites who will be able to manage the
patient according to the national multi-drug-resistant TB guidelines.
56
Annex 4: Dosages for Paediatric TB treatment using dispersible FDC tablets of RHZ,
RH and single Ethambutol tablets for NEW CASES
Table A1: Child between 5 and 22 kg
Intensive phase (2 months RHZE) Continuation phase (4 months RH)
Weight band
(kg)
No. of tablets of RHZ
(60/30/150mg)
No. of tablets of RH
(60/60mg)
Ethambutol
(100mg)
No. of tablets of
RH (60/30mg)
No. of tablets of
RH (60/60mg)
5 - 7 1 1 1 2 0
8- 14 2 1 2 2 1
15 -22 3 2 3 3 2
Table A2: Child between 23 and 30 kg
NOTE: For children above 30kg, do not give RH 60/60 but treat as adults
All children must be on pyridoxine 1-2mg/kg/day
Intensive phase (2 months RHZE) Continuation phase (4 months RH)
Weight band
(kg)
No. of tablets of RHZE
(150/75/400/275mg)
No. of tablets of RH
(60/60mg)
No. of tablets of RH
(150/75mg)
No. of tablets of RH (60/60mg)
23-30 2 2 2 2
57
Annex 5: Dosages for Paediatric TB treatment using dispersible FDC tablets of RHZ, RH
and single Ethambutol tablets for RETREATMENT CASES
Table B1: Child between 5 and 22 kg
Intensive phase (3 months RHZE) Continuation phase (5 months RHE)
Weight
band (kg)
No. of tablets of RHZ
(60/30/150mg)
No. of tablets of
RH (60/60mg)
Ethambutol
(100mg)
No. of tablets of
RH (60/30mg)
No. of tablets of
RH (60/60mg)
No. of tablets of
Ethambutol (100mg)
5 - 7 1 1 1 2 0 1
8- 14 2 1 2 2 1 2
15 -20 3 2 3 3 2 3
Table B2: Child between 23 and 30 kg
For children above 30kg, do not give RH 60/60 but treat as adults
All children must be on pyridoxine 1-2mg/kg/day throughout the course of anti-TB treatment
Do not use Streptomycin for TB retreatment in children. If a child on retreatment is not improving at one month of treatment assess for adherence and
rule out drug resistant TB
NOTE: Use of streptomycin on retreatment cases among the children is discouraged
Intensive phase (3 months RHZE) Continuation phase ( 5 months RHE)
Weight band
(kg)
No. of tablets of RHZE
(150/75/400/275mg)
No. of tablets of
RH (60/60mg)
No. of tablets of
RH (150/75mg)
No. of tablets of
RH (60/60mg)
No. of tablets of
Ethambutol (400mg)
23-30 2 2 2 2 1
58
Annex 6: Child Tuberculosis Monitoring Card E
NR
OL
ME
NT
NAME:
Gender: Male / Female
AGE: years months
DOB:_ _ / _ _ /
TB Registration No: Other factors:
Malnutrition: Y / N
Nutritional
supplement:
Food/Micronutrients
HIV test:
Positive/Negative/Not
done
Date:
CPT: Y/N
Date:
ART Y/N
Date:
Primary Caregiver Name:
Relationship to child:
TEL. NO.
Physical Address:
MUAC:
Weight in kg:
Height or Length of child in cm:
< 5yr: weight for age: Normal /
Low
>5yr: BMI for age: Normal / Low
SITE OF TB (Tick what applies)
PTB EPTB
TYPE OF TB (Tick what applies)
New Retreatment
smear positive
Retreatment
smear negative
Return after
Default Smear
positive
Return after
default smear
negative
Transfer in
Regimen (Circle)
2RHZE 4RH
3RHZE 5RHE
2RHZE 10RH
59
Drug collection schedule
Intensive phase Date started: Continuation phase Date started:
Date drugs were
collected
Date drugs were
collected
Date drugs were
collected
Date drugs were
collected
Week 1 Week 7 Week 1& 2 Week 13 & 14
Week 2 Week 8 Week 3 & 4 Week 15 & 16
Week 3 Week 9 Week 5 & 6 Week 17 & 18
Week 4 Week 10 Week 7 & 8 Week 19 & 20
Week 5 Week 11 Week 9 & 10
Week 6 Week 12 Week 11 & 12
Date treatment was completed:
60
FO
LL
OW
-UP
Phase in Treatment Start of
Treatmen
t
Month
1
Month
2
Month
3
Month
4
Month
5
Month
6
Month
7
Month
8
Month 9 Month 10 Final
Review
Outcome
VISIT DATE (DD/MM/YY)
Weight (kg)
TB DRUGS: INDICATE THE NUMBER OF TABLETS AT EVERY VISIT
Paed RHZ (60/30/150mg)
Paed RH (60/ 60mg)
Paed RH (60/ 30mg)
Ethambutol (100mg)
Ethambutol (400mg)
RHZE
(150/75/400/275mg)
RH (150/75mg)
Vitamin B6 (50mg)
Any Adverse Effect (specify)
Any TB doses missed in past month
(Y/N)
61
Annex 7: Second-line anti-TB drugs for treatment of
MDR*-TB in children
Table C: Second-line anti-TB drugs for treatment of MDR-TB in
children
Drug Mode of action Common side effects Recommended daily
dose (mg/Kg body
weight)
Maximum
daily dose
(mg)
Ethionamide or
Prothionamide
Bactericidal Vomiting,
gastrointestinal upset
15–20 1000
Fluoroquinolone***
Ofloxacin Levofloxacin
Moxifloxacin Gatifloxacin
Ciprofloxacin
Bactericidal
Bactericidal
Bactericidal
Bactericidal
Bactericidal
Arthropathy,
arthritis
15–20
7.5–10
7.5–10
7.5–10
20–30
800
–
–
–
1500
Aminoglycosides
Kanamycin Amikacin
Capreomycin
Bactericidal
Bactericidal
Bactericidal
Ototoxicity,
hepatotoxicity
15–30
15–22.5
15–30
1000
1000
1000
Cycloserine or Terizidone Bacteriostatic Psychiatric, neurological 10–20 1000
Para-Aminosalicylic
acid
Bacteriostatic Vomiting,
Gastrointestinal upset
150 12 000
* MDR- multi drug resistant
*** Although Fluoroquinolone are not approved for use in children in most countries, the benefit of
treating children with MDR-TB with a Fluoroquinolone may outweigh the risk in many instances.
62
Annex 8: Taking Anthropometric Measurements
63
64
65
Annex 9: Growth monitoring charts
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
