Operational Handbooks

For TB case detection and provision of TPT , the feasibility and effectiveness of decentralization and integration may vary by setting based on, for example, the local burden of TB disease, available resources, existing infrastructure, regulatory framework and structure of the NTP. The NTP should consider starting with an assessment of the feasibility and potential utility of decentralization or integration at different levels of care, or in urban versus rural settings, or in public versus private settings.

Decentralization includes the provision of, access to or capacity for child and adolescent TB services at a lower level of the health system than the lowest level where it is currently routinely provided. In most settings, decentralization applies to the district hospital level (first referral level), PHC level or community level.

After a clinician has decided to start treatment in a child based on bacteriological testing or as a result of a treatment decision algorithm, the child should be registered with the NTP. This applies to all services and programmes where children and adolescents with TB are diagnosed, including public non-NTP services and private-sector facilities and practitioners. Underreporting of children and adolescents diagnosed with TB in these sectors contributes to the high proportion of missing children and adolescents with TB.

Figure 4.4. Algorithm A

Figure 4.5. Algorithm B

Pyridoxine (vitamin B6) supplementation is recommended in children and adolescents living with HIV and in malnourished children and adolescents who are treated for TB, at a dosage of 0.5–1 mg/kg/day. Children weighing up to 25 kg receive half a 25 mg tablet or quarter of a 50 mg tablet (6). Supplementation with pyridoxine aims to prevent symptomatic pyridoxine deficiency, which presents as peripheral neuropathy, especially in children with severe malnutrition and children living with HIV.

In children and adolescents, severity of TB disease ranges from mild to severe. Children with nonsevere, drug-susceptible TB are now eligible to receive a shortened 4-month treatment regimen. For consideration of a 4-month treatment regimen for non-severe, drug-susceptible PTB in children and young adolescents aged 3 months to 16 years, non-severe TB is defined based on the clinical presentation of disease as assessed through physical examination and CXR.

Routine HIV testing should be offered to all children and adolescents completing evaluation for exposure to TB, with presumptive TB or diagnosed with TB. Early and accurate detection of HIV infection is important to support the integrated management of TB/HIV coinfection. All children and adolescents with HIV-associated TB are eligible for ART and co-trimoxazole prophylaxis (6, 78).