Operational Handbooks

Children living with HIV should be followed up closely in the health-care system and should be screened for TB at every routine contact with an HIV care provider, at a health facility or in the community. Given the high risk of progression to TB disease and the high mortality rate, combined symptom screening should also be done at every contact with the health-care system, including events such as vaccination days, maternal health appointments, at nutritional screening and at food support programmes.

There are currently inadequate data to extrapolate use of CXR, CRP or mWRDs as screening tests in adults to children < 10 years living with HIV. Tests for TB infection are not useful for TB screening (see also 6.2.4).

Children with HIV who are < 10 years should be screened for TB at every encounter with a health-care worker, with the following screen: cough, fever, poor weight gain or close contact with someone who has TB.

Children living with HIV have a high risk of rapid progress to severe disease and death if a diagnosis of TB is missed. A child with HIV infection is 3.5 times more likely to progress to TB disease than a child who is HIV-negative (39). An estimated 16% of paediatric deaths from TB are among HIV-positive children, resulting in 36 000 deaths annually (2). It is for this reason that WHO strongly recommends that children with HIV be screened for TB.

Contact screening can be difficult. Once the contacts of a TB patient have been identified, they should be screened for TB symptoms and/or undergo CXR, followed by appropriate diagnostic evaluation (4, 5). Tracing of household contacts usually identifies many close contacts who are eligible for screening and TPT; however, it is expensive and time-consuming for health-care workers to identify the contacts of all known TB patients.

As for adults, tuberculin skin tests and interferon-g release assays should not be used to screen for TB disease in children (12, 34), as these tests cannot distinguish TB infection from TB disease and cannot predict who will progress to TB disease. Both tests may be influenced by mechanisms unrelated to TB infection and give false-negative or false-positive results. The role of these tests in decision-making for TPT is discussed elsewhere (4, 5).

mWRDs are not currently recommended for screening for TB disease in children < 15 years.

The sensitivity for TB of “any abnormality” as reported on CXR in children is 84%, and the specificity is 91%. It is thus more specific than symptom screening alone.

Child contacts are at high risk of TB disease, and the risk varies substantially by age. Newborn infants are at particularly high risk of infection with TB if the mother had untreated TB disease when they were born. Apart from the risk of exposure because of close proximity to adults in a household with TB, children < 5 years who are infected with TB have a 19% chance of progression to TB disease within 2 years (39). Most paediatric mortality occurs in this age group, with 80% of paediatric deaths from TB occurring in children < 5 years (40).