Operational Handbooks

About a quarter of the world’s population has been infected with Mycobacterium tuberculosis. The vast majority of these people do not have TB disease (10). It is estimated that 7.5 million children and young adolescents aged under 15 years are newly infected with M. tuberculosis each year (11). Cumulatively, about 67 million children and young adolescents aged under 15 years are infected with M.

The chapters in the handbook are structured around the pathway of TB infection and disease in an individual child or adolescent and the interface with and retention across sequential stages of care (cascade of care), as shown in Figure 1.1 (5).

Figure 1.1. Pathway through TB exposure, infection and disease

WHO provides guidance on the principles²⁹ and recommendations for nutritional care and support of people with TB as part of their regular TB care.

Five guiding principles are key for providing nutritional care and support as an integral part of TB care and prevention (105):

In people with TB/HIV coinfection, the dose of DTG needs to be doubled by giving it twice instead of once a day because of drug–drug interactions with rifampicin. This extra dose of DTG is well tolerated, with equivalent efficacy in viral suppression and recovery of CD4 cell count compared with EFV (182, 183).

Table 7.2 summarizes changes needed to ART regimens for neonates, children and adolescents who are on ART when TB treatment is started, or who start ART while on TB treatment.

A key challenge with rifamycin-based TPT regimens in people living with HIV is drug–drug interactions. Rifampicin and rifapentine can be co-administered with EFV or DTG without dose adjustment. In people on RAL and rifamycins, however, a higher dosage of RAL (800 mg twice a day instead of 400 mg twice a day) should be used.

TB is a common cause or comorbidity in children with clinically diagnosed pneumonia. A systematic review on TB in acute respiratory infection found that M. tuberculosis was identified in around 5–10% of children with pneumonia aged under 5 years in TB endemic countries (223). Limited data from clinical and autopsy studies suggest that TB was also associated with mortality in these children. Prevalence studies, including the multisite PERCH study (224), confirm these findings.

This annex provides examples of standard operating procedures for the most common methods of obtaining clinical samples from children for rapid molecular testing: expectoration, gastric aspiration, nasopharyngeal aspiration (NPA) and sputum induction. 

As part of the review for the background question on adolescents, a group of experts was convened to propose actions for optimizing adolescent engagement in TB care. The proposed actions focused on two areas: reforming current practices that are harmful to adolescents with TB; and developing an adolescent-specific plan within each NTP to provide high-quality adolescent-centred TB services.
Box 7.6 summarizes the proposed interventions.