Children and Adolescents

Despite its safety, BCG is an attenuated live vaccine (M. bovis BCG). Contraindications include:

• pregnancy;
• people living with HIV but not on ART, or on ART but not immunologically stable;
• people with other forms of immunosuppression (e.g. candidates for organ transplants, people on immunosuppressive therapy).

Training of health care providers to administer BCG vaccination is important to ensure the correct technique is used. The standard dose of BCG vaccine is an intradermal injection of 0.05 mL of the reconstituted vaccine for infants aged under 1 year, and 0.1 mL for infants aged over 1 year. BCG vaccine can safely be given together with other routine childhood vaccines, including the hepatitis B birth dose. Although efforts should be made to use all doses in BCG multidose vials, children should be vaccinated even if this means part of the vial is wasted.

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.

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.