Children and Adolescents

Adolescents are at risk of TB infection, progression to TB disease, and loss to follow-up from TB care. Adolescents with MDR-TB or with TB/HIV coinfection are at particular risk of poor treatment outcomes, including death. Adherence, stigma, mental health and quality of life are impacted negatively by adverse effects of TB treatment, especially second-line treatment.

Treatment of congenital TB and neonatal TB is the same. Both should be managed by a clinician experienced in the management of paediatric TB. A complete investigation of mother and neonate should be undertaken. CXR should be done and appropriate specimens collected for Xpert MTB/RIF or Ultra to confirm the diagnosis of TB in the neonate (see Chapter 4). Treatment should be started based on the likelihood of TB, even before bacteriological confirmation is received, as TB can progress rapidly in neonates.

Congenital TB is TB disease acquired in utero through haematogenous spread via the umbilical cord or at the time of delivery through aspiration or ingestion of infected amniotic fluid or cervicovaginal secretions. Congenital TB usually presents in the first 3 weeks of life and has a high mortality rate. Neonatal TB is TB acquired after birth through exposure to a person with infectious TB (usually the mother but sometimes another close contact). It is often difficult to distinguish between congenital and neonatal TB.  Management is the same.

TB contributes to 6–15% of all maternal mortality and leads to adverse pregnancy outcomes (187). A national registry study found incidence rate ratios for TB in pregnant and postpartum women of 1.4 and 1.9, respectively, compared with non-pregnant women (188). TB in pregnancy is associated with adverse maternal outcomes and complications during birth, such as pre-eclampsia, eclampsia, vaginal bleeding, hospitalization and miscarriage.

Also known as a paradoxical reaction, IRIS is a temporary clinical deterioration that may occur within 3 months (most commonly within the first month) of starting ART. As the immune system starts to recover after ART is initiated, the CD4 count increases and the viral load is suppressed. This reconstitution of cell-mediated immunity in response to mycobacterial antigens can trigger an inflammatory reaction to TB antigens at the sites of TB disease. This causes either deterioration of a treated infection or new presentation of a previously subclinical infection (6, 184, 185).

ART in children and adolescents living with HIV aims to improve the length and quality of life, reduce HIV-related morbidity and mortality by reducing the incidence of opportunistic infections (including TB), reduce the viral load, restore and preserve immune function, and restore and preserve normal growth and development. ART improves TB treatment outcomes for children and adolescents living with HIV (6).

Children living in settings where the prevalence of HIV is high or who are living with HIV should be treated for TB with a four-medicine regimen (isoniazid, rifampicin, pyrazinamide and ethambutol) for 2 months followed by a two-medicine regimen (isoniazid and rifampicin) for 4 months or 2 months (for non-severe TB) at standard dosages given daily.

The approach to diagnosing TB in children and adolescents living with HIV is essentially the same as diagnosing TB in HIV-negative children (see Chapter 4). Diagnosis of TB in children and adolescents living with HIV can be more challenging than in HIV-negative children, however (6):

Global efforts to control the co-epidemics of TB and HIV will benefit children and adolescents. They include the expansion of prevention of mother-to-child transmission programmes, which will reduce the number of new HIV infections in young children. In addition, all children living with HIV should be screened for TB, and all children and their families with TB should be offered HIV testing and counselling in settings of high HIV prevalence.

Because of their increased risk for TB, children aged under 10 years living with HIV should be screened for TB at every encounter with a HCW, with the following screen: cough, fever, poor weight gain or close contact with a person with TB (see Chapter 2 on screening). For recommendations on screening tools for adolescents aged 10–19 years living with HIV, see Box 2.7 in Chapter 2 (13).