Operational Handbooks

As highlighted in Box 2.7, systematic screening for TB disease should be conducted among adolescents living with HIV using the WHO-recommended four-symptom screen (W4SS). Those who report any one of the symptoms of current cough, fever, weight loss or night sweats may have TB and should be evaluated for TB and other diseases. Adolescents living with HIV may also be screened using CRP (using a cut-off of >5 mg/L), CXR or mWRDs.

Children living with HIV should be followed up closely in the health care system. Those living in high TB incidence settings should be screened for TB at every contact with the health care system. 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, nutritional screening and food support programme visits.

There are currently inadequate data to extrapolate use of CXR, point-of-care C-reactive protein (CRP)-based TB screening or mWRDs as screening tests in adults to children aged under 10 years living with HIV. CXR can be used for screening children living with HIV who are close contacts of people with infectious TB (see Section 2.3.1). Tests for TB infection such as IGRA are not useful for TB screening.

Children living with HIV have a high risk of rapid progression to severe disease and death if a diagnosis of TB is missed. A child living with HIV is 3.5 times more likely to progress to TB disease than a child who is HIV-negative (29). The risk, although greatly reduced, remains elevated in children on antiretroviral therapy (ART). An estimated 10% of paediatric deaths from TB are among children living with HIV, with 21 000 deaths annually (1).

Once the contacts of a person with TB have been identified, the contacts should be screened for TB symptoms and/or undergo CXR, followed by appropriate diagnostic evaluation (15, 28). Contact investigation can be expensive and time-consuming for HCWs. Additionally, TB is a highly stigmatized disease in some settings, and the visit of a health worker to a person’s home may risk discrimination against the household.

As in adults, TST and IGRA should not be used to screen for TB disease in children (26, 27), as these tests cannot distinguish TB infection from TB disease and cannot predict who will progress to TB disease. Both tests provide a marker of TB infection but may be influenced by mechanisms unrelated to TB infection and give false-negative or false-positive results. The role of these tests in decisionmaking for TPT and in the diagnostic evaluation of children with presumptive TB is discussed in

mWRDs are not currently recommended for screening for TB disease in children and young adolescents aged under 15 years, but they should be used to diagnose TB in children who screen positive using a symptom screen or CXR (see Chapter 4).

Step 10.1 – Monitor implementation of the diagnostic test

During the initial planning phase, countries should establish a set of key indicators and milestones that can be used to monitor the implementation process. Once the testing services have been launched, use of the services should be tracked.

 Step 9.1 – Develop terms of reference and position descriptions