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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.
Adolescents with TB often present with bacteriologically infectious disease typical in adults (e.g. cavities seen on CXR) and therefore pose a high risk for transmission in households and congregate settings such as schools. Adolescents face unique challenges due to peer pressure and fear of stigma, increasing prevalence of comorbidities such as HIV, and risk behaviours such as use of alcohol, tobacco and other substances. People aged 10–19 years need adolescent-friendly services that include relevant psychosocial support and minimal disruption of education (5).
Palliative care for children with TB is similar to that for adults, but applied to the specific needs of this age group. While the definition and principles of palliative care described above apply to the entire lifespan, paediatric palliative care requires attention to physical, developmental, psychosocial, ethical, spiritual and relational phenomena unique to children and their families and caregivers (203). The following should be considered:
Palliative care for people with TB has not received adequate attention, as the focus has been on access to curative treatment. Palliative care aims to relieve suffering due to disease and illness and should be provided in conjunction with curative treatment. Although TB is curable, MDR/RR-TB (including pre-XDR and XDR-TB) is an increasing problem in many high TB burden and low- and middle-income countries, with poorer treatment outcomes reported for this group.
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.
Pregnant women living with HIV are a key population for screening for TB disease, given the suppressed immune status of the mother and the importance of protecting the health of the fetus. TB screening for this population should be integrated with prevention of vertical transmission and antenatal care. Table 7.4 provides an overview of the diagnostic accuracy of different screening tools (13).
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).
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.