Children and Adolescents

The following options for TPT are recommended by WHO for use in children and adolescents:

• 6 months or 9 months of isoniazid daily (6H or 9H) (all ages); or
• 3 months of isoniazid plus rifapentine weekly (3HP) (age 2 years and over); or
• 3 months of isoniazid plus rifampicin daily (3HR) (all ages).

1 month of daily isoniazid plus rifapentine (1HP) (aged 13 years and over) or 4 months of daily rifampicin (4R) (all ages) may be offered as alternative regimens.

Children and adolescents living with HIV should be screened for TB disease at every visit to a health facility or interaction with a health worker, using standard screening questions, as part of routine clinical care (see Chapter 2). Those who do not have any of the symptoms in the questionnaire are unlikely to have TB disease and should be offered TPT, regardless of their ART status. CXR may be offered to adolescents living with HIV and on ART; if there are no abnormal radiographic findings, they may be given TPT.

It is important to exclude TB disease before initiating TPT. A clinical algorithm based on screening for symptoms of TB, history of contact with a person with TB, HIV status, age, TB infection test results and abnormal findings on CXR is recommended (15). Figure 3.4 shows an algorithm applicable to children aged under 5 years with and without HIV, and children and adolescents aged 5 years and over.

The WHO consolidated guidelines on tuberculosis (28) and the WHO operational handbook on tuberculosis (15) identify two broad at-risk child and adolescent populations that need systematic assessment for eligibility for TPT:

BCG vaccine is used extensively worldwide, with about 100 million newborns vaccinated each year. Severe adverse events are reported only occasionally. For some adverse events (e.g. disseminated BCG disease), the diagnosis may depend on the culturing of M. bovis BCG to distinguish it from other forms of mycobacterial disease (33). It is important to recognize that M.

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.

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