Consolidated Guidelines

5.1.3. Implementation considerations

Assessing severity of disease:The feasibility of assessing the severity of TB disease, particularly in settings without access to CXR or capacity for CXR interpretation and WHO-recommended diagnostic tests was identified as a major implementation consideration. Chest radiography was identified by the GDG as a critical tool to evaluate the severity of intrathoracic disease.

5.1.2. Subgroup considerations

Children with peripheral lymph node TB: Although the number of children with peripheral lymph node TB in the SHINE trial were small (N=19 in the 16-week arm and N=21 in the 24-week arm), there was no difference in the proportion of unfavourable outcomes between the two arms. The SHINE trial also found that 16 weeks of treatment was non-inferior compared to 24 weeks of treatment among children with both peripheral lymph node disease and pulmonar y disease (N=182 in the 16-week arm and N=171 in the 24-week arm).

5.1.1. Justification and evidence

The majority of children with TB have less severe forms of the disease than adults. Treatment regimens that are shorter than those for adults may be effective in treating children with TB, however solid evidence to substantiate this has been lacking to date. Shorter treatment regimens can result in lower costs to families and health services, potentially less toxicity, lower risks of drug-drug interactions in children living with HIV, and fewer problems with adherence.

4.2.4. Monitoring and evaluation

The integrated treatment decision algorithms need to be monitored and evaluated for their impact on case notifications and treatment outcomes.

Clinical monitoring of people with TB started on treatment based on clinical criteria is equally important, such as the need to monitor response to treatment (to identify an alternative diagnosis for children who may be misdiagnosed as having TB), adverse events and deterioration in the clinical condition.

4.2.3. Implementation considerations

Algorithms included in the operational handbook: In the follow-up to the GDG meeting, new integrated treatment decision algorithms for specific populations and settings have been developed and internally validated, using regression modelling with pre-determined cut-off values for sensitivity and specificity against the reference standard (using updated clinical case definitions to define pulmonary TB, outlined in Graham S et al. (31)), based on the individual patient data set used for the evidence review conducted to answer this PICO question.

4.2.2. Subgroup considerations

For HIV-infected children under the age of 10 years, the pooled sensitivity of the algorithms reviewed ranged from 24% (Marais et al. criteria) to 92% (Uganda NTLP algorithm), and the pooled specificity from 15% (Uganda NTLP algorithm) to 87% (Stegen-Toledo score, cut-off 5).

For children with SAM the pooled sensitivity varied between 33% (Marais et al. criteria) and 93% (Uganda NTLP algorithm and Keith Edward score), while the pooled specificity varied between 10% (Keith Edward score) and 88% (Stegen-Toledo score, cut-off 5).

4.2.1. Justification and evidence

TB diagnosis in children relies on a thorough assessment of all evidence derived from a careful history of exposure, clinical examination and relevant investigations. While various algorithms and scoring systems for TB diagnosis in children exist, these have not been systematically evaluated. There is a need for evidence-based, practical treatment decision algorithm(s), ideally for different settings with varying access to diagnostic tests and CXR.