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.

In high TB burden countries, the capacity to manage TB in children and adolescents is often centralized at the tertiary or secondary level of health care rather than being decentralized at the PHC level where children and adolescents with TB or TB exposure commonly seek care (5, 157). Care at higher levels in the health system is often managed in a vertical, non-integrated way.

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.

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.

For children and adolescents weighing 25 kg or over, adult guidance and dose recommendations should be followed. These children and adolescents can be treated with adult formulations.

The recommended dosages by weight band for the 6-month intensive regimen (6HRZEto) to treat bacteriologically confirmed or clinically diagnosed TBM (without suspicion or evidence of MDR/RR-TB) in children and adolescents weighing less than 35 kg are shown in Table 5.6. These dosages were developed to limit formulation manipulation (splitting tablets), top-up with standalone medicines, number of weight bands and pill burden.