Operational Handbooks

Palliative care is the prevention and relief of the physical, psychological, social and spiritual suffering of adults and children with serious illnesses and psychosocial support for their families (94, 95). The prevalence, types and severity of suffering of people with TB vary by geopolitical situation, socioeconomic conditions, culture, accessibility of primary and specialized health care, and the susceptibility of their TB to anti-TB medicines.

All children and adolescents initiated on TB treatment should undergo a monitoring assessment at the following intervals as a minimum:

5.4.1 Subgroups in which the regimen is recommended

Children with peripheral lymph node TB

Assessing severity of disease

The regimen evaluated by the SHINE trial comprised 2 months of daily isoniazid, rifampicin and pyrazinamide, with or without ethambutol (2HRZ(E)), followed by daily isoniazid and rifampicin (2HR).

The eligibility criteria in children and adolescents are summarized in Box 5.1 (30).

As in adults, TB treatment in children and adolescents includes an intensive phase of 2 months followed by a continuation phase of 2–4 months. In the intensive phase, tubercle bacilli are rapidly killed to prevent disease progression and transmission, and the development of drug-resistance. In the continuation phase, dormant bacilli are eliminated to effect cure and prevent relapse. The choice of TB treatment regimen depends on the severity of disease and age.

The current guidance on monitoring the response to treatment of DS-TB is unchanged. WHO does not recommend baseline electrocardiogram (ECG) monitoring for those receiving the shorter regimen (unless clinically indicated), and laboratory monitoring such as liver function tests (LFT) is the same for both regimens (1). Some countries may have different requirements for LFT and ECG monitoring because of the “black box” warnings for moxifloxacin (related to QTc prolongation).

Data from Study 31 allowed subgroup analyses for four patient groups: People with HIV, people with diabetes, people with a low body weight (i.e. a body mass index [BMI] <17.9 kg/m² ) and patients with extensive pulmonary TB disease (using a cut-off of > 50% lung parenchyma affected) on CXR. Although no statistically significant differences appeared when comparing the 4-month regimen to the current standard 2HRZE/4HR regimen, the number of patients in some of these subgroups was small (1).

Several factors need to be considered when deciding on the implementation of this regimen: DST, treatment support, pill burden, cost of medicines, administration of the shorter regimen with food, training of health care workers and criteria guiding the choice of regimen. These factors are discussed below.

DST