Operational Handbooks

BCG in children living with HIV

BCG is a live attenuated bacterial vaccine derived from Mycobacterium bovis that was originally isolated in 1902 from a tuberculous cow. BCG has demonstrated significant effectiveness, but protection has not been consistent against all forms of TB in all age groups. BCG has also shown effectiveness in preventing leprosy (caused by Mycobacterium leprae) and Buruli ulcer (caused by Mycobacterium ulcerans) (31).

This chapter describes strategies for the prevention of TB in children and adolescents. It covers BCG vaccination, TPT and TB infection prevention and control. This chapter relates to the section of the pathway highlighted in blue in Figure 3.1.

Figure 3.1. Pathway through exposure, infection and disease covered in Chapter 3

Figure 2.8. Algorithm for TB screening of children living with HIV with symptoms

This annex provides information on administering, reading and interpreting tuberculin skin tests (TSTs).

A TST is the intradermal injection of a combination of mycobacterial antigens that elicit a delayed-type hypersensitivity immune response, represented by induration, which can be measured in millimetres.

TB disease should be excluded in neonates born to women with presumptive or confirmed TB. The level of infectiousness and drug susceptibility in the mother should be determined. It is not necessary to separate the neonate from the mother. Breastfeeding should be continued and the mother advised to wear a surgical mask when close to the baby (191).

Children with TBM should preferably be hospitalized for initiation of treatment and close monitoring. Children aged under 2 years with miliary TB should be evaluated for TBM regardless of the presence of CNS symptoms. If these children are not evaluated for TBM for any reason, extension of treatment to 12 months may be considered.

Any child aged under 10 years who has had close contact with a person with TB disease should be screened for TB with a symptom screen or CXR as part of contact investigation. Symptoms used to screen for TB are cough for more than 2 weeks, fever for more than 2 weeks, and poor weight gain or weight loss in the past 3 months. In young children, reduced playfulness or lethargy should also be included, since prolonged cough may be absent in children with disseminated disease.

Screening serves to identify children and adolescents who may have TB disease (presumptive TB) and who need further evaluation to make or confirm a TB diagnosis (see Chapter 4). It also helps to identify children and adolescents who are eligible for and could benefit from TPT. A screening test is not intended to be a diagnostic tool. People with positive results on a screening test should undergo further diagnostic evaluation.

In addition to planning and budgeting, NTPs should consider the following key implementation steps in contact investigation: