Operational Handbooks

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.

Health-related quality of life is the perceived quality of a person’s daily life. It is an holistic way to quantify and measure illness-associated morbidity and the impact of health interventions. Examples of generic, non-disease-specific tools that can be used in young children, including those with TB, are EQ-5D-Y and TANDI (153, 154). EQ-5D-Y is a widely used self-report measure for children aged 8 years and over (155).

Although osteoarticular TB is uncommon (approximately 1–2% of all children with TB and 8% of children with EPTB), the potential long-term consequences of the disease, particularly in children, can be major (149).

Data from adults with TB show that a substantial proportion of people report residual symptoms, including cough and dyspnoea, despite microbiological cure at the end of TB treatment. This impacts on their quality of life and increases the risk of premature death (141–143). Previous PTB substantially increases the risk of recurrent TB, which may, at least in part, be due to residual lung damage (144, 145).

TBM is the most debilitating form of TB in children. It has high rates of neurological sequalae despite cure and disproportionately affects children aged under 5 years (4, 134). The pooled risk for neurological sequelae in children with TBM was approximately 50% in a systematic review of treatment outcomes, with more advanced clinical stage of disease at diagnosis (stages 2a/b and 3) associated with worse outcomes at the end of treatment (94).

Awareness of the consequences of TB disease in children and adolescents that go beyond survival and completion of treatment has increased (131, 132). Each child or adolescent on TB treatment should be assigned a mutually exclusive treatment outcome at the end of treatment, but follow-up and care may need to go beyond the conclusion of TB treatment (71).

Routine safety monitoring of treatment should generally follow the recommended approach in adults and should be guided by the known adverse effect profile of the medicines included in the regimen.

Table 5.14 summarizes the most common adverse effects of the medicines used for MDR/RR-TB.

Table 5.14. Adverse effects of medicines used for multidrug-resistant and rifampicinresistant TB by group

Monitoring the response to treatment in children and adolescents includes clinical, radiological and microbiological parameters. In children, microbiological monitoring of the response to treatment may be challenging for the same reasons as it being difficult to obtain a microbiological diagnosis. In children and adolescents with a bacteriologically confirmed diagnosis, however, it is important to monitor smear and culture conversion and confirm cure, as recommended by WHO.

Once on MDR/RR-TB treatment, children and adolescents must be monitored regularly to evaluate their response to treatment; identify treatment failure early; monitor for adverse events; and provide adherence, psychosocial and financial support to children and their caregivers.