Tuberculosis (TB) is a preventable and curable disease, but it continues to impact the lives and development of millions of children and adolescents. Children and young adolescents aged under 15 years represent about 11% of all TB cases globally. This means 1.1 million children and young adolescents aged under 15 years fall ill with TB every year.
National tuberculosis programs (NTPs) notify less than half of these children, and there is a large case detection gap of children who are not diagnosed and/or not reported. The gap is largest in children aged under 5 years. Reasons for this gap include challenges with specimen collection and bacteriological confirmation of TB in young children due to the paucibacillary nature of TB in this age group and the lack of highly sensitive point-of-care diagnostic tests. Children and adolescents usually access primary health care (PHC) or child health services, where capacity to recognize presumptive TB and access to diagnostic services are limited. In addition to the case detection gap, only a third of child contacts aged under 5 years eligible for tuberculosis preventive treatment (TPT) actually received it in 2020.
TB is also common in adolescents, especially older adolescents aged 15–19 years, with an estimated half a million cases globally each year. TB has a major impact on the health and well-being of adolescents. Unlike young children, adolescents are an important risk group for transmission due to infectiousness of disease and high social mobility.
This operational handbook is published alongside the WHO consolidated guidelines on tuberculosis. Module 5: management of tuberculosis in children and adolescents, which include the latest evidence-based recommendations related to the prevention and management of TB in children and adolescents.
Surveillance data traditionally refer to children as people aged under 15 years, but the populations of interest in the consolidated guidelines and operational handbook are defined as follows:
- A child is a person aged under 10 years.
- An adolescent is a person aged 10–19 years (inclusive).
1.2. Children and adolescents as a key vulnerable population
Children can present with TB disease at any age, but most commonly between the ages of 1 and 4 years in high TB burden settings. Children who develop TB disease usually do so within a year of TB infection. The presentation of TB in children is an indicator of recent and ongoing transmission of Mycobacterium tuberculosis in the community.
Infants and young children, especially those aged under 2 years, are at higher risk of developing disseminated disease and tuberculosis meningitis (TBM), which are associated with high morbidity and mortality. Adolescents with TB usually present with infectious TB disease, as typically seen in adults (eg with cavities on chest X-ray (CXR) and bacteriologically confirmed disease). Adolescents also form a particularly vulnerable group who face important psychosocial challenges, requiring careful consideration of their growing autonomy, specific adherence support, and assistance with transitioning from paediatric to adult health service provision.
1.3. Rationale and objectives of this operational handbook
The aim of this operational handbook is to provide practical guidance on the implementation of the World Health Organization (WHO) policy recommendations on the prevention and management of TB in children and adolescents under programmatic circumstances and at different levels of the health system.
The practical guidance aims to inform the development or revision of national policies and related implementation guidance (eg handbooks, standard operating procedures) on the management of TB in children and adolescents. This handbook can also help countries adequately plan for the uptake of interventions to better address the specific needs of children and adolescents with or at risk of TB. It can contribute to national efforts to build capacity among national and subnational program managers and among health workers at all levels of the health care system.
The desired overall impact of WHO normative guidance on the management of TB in children and adolescents is a reduction in the burden of TB morbidity and mortality in children and adolescents, in line with the targets included in the WHO End TB Strategy, goal 3 of the United Nations Sustainable Development Goals (SDGs) and the Political Declaration of the United Nations General Assembly High-level Meeting on the Fight against Tuberculosis. At the High-level Meeting, heads of states committed for the period 2018–2022 to successfully treat 3.5 million children and young adolescents aged under 15 years with TB and 115,000 children and young adolescents with drug-resistant TB; and to provide TPT to at least 30 million people, including 4 million children aged under 5 years, 20 million other household contacts, and 6 million people (including children and adolescents) living with HIV. To reach these targets, multisectoral engagement, actions and accountability are needed.
1.4. Preferences of end-users regarding content and structure of this operational handbook
In preparation for the development of the WHO consolidated guidelines and operational handbook on the management of TB in children and adolescents, a survey was conducted among end-users to:
- collect perspectives on the barriers and facilitators for the implementation of WHO recommendations on the management of TB in children and adolescents;
- understand respondents’ preferences regarding the content and structure of the operational handbook;
- inform dissemination approaches.
Respondents (N=182) were from NTPs, United Nations organizations and technical organizations, with a limited number from national human immunodeficiency virus (HIV), nutrition, maternal, child and adolescent health, and PHC programmes. The majority of respondents worked in high TB burden, TB/HIV coinfection or multidrug-resistant tuberculosis (MDR-TB) countries.
Respondents indicated it would be useful for the operational handbook to include dosing and practical implementation guidance (eg standard operating procedures for tuberculin skin tests (TST) and specimen collection methods). Consolidation of all recommendations related to the prevention and management of TB in children and adolescents in one document was considered important. The following were indicated as priorities:
- specific guidance on management of vulnerable children, including children with comorbidities and malnutrition, with case studies and best practices;
- details on the differences in managing children and adults with or at risk of TB;
- practical advice on when and how to initiate TB treatment;
- guidance on managing comorbidities and side-effects of medicines;
- guidance on nutrition for children and adolescents with TB;
- alignment and harmonization with policy recommendations from guidelines in other programs (eg HIV, maternal, newborn, child and adolescent health, nutrition);
- guidance on community involvement;
- optimal engagement of patients, parents and caregivers, and social support for families affected by TB.
Respondents requested translation of the guidelines and operational handbook into multiple languages and indicated that electronic versions of the consolidated guidelines and related operational handbook would be useful. They highlighted the importance of dissemination during webinars (eg on World TB Day), regional consultations involving national programs and national paediatric associations, and international symposia and conferences. Development of user-friendly online training materials was considered useful to increase access.
1.5. Structure of the operational handbook
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).
The pathway involves multiple steps, from exposure to a person with an infectious form of TB, leading to subsequent TB infection and, for some people, progression to TB disease. Each of the steps requires evidence-based interventions to reduce TB transmission, prevent TB disease, enable early and accurate diagnosis of TB disease, and optimize treatment outcomes for children and adolescents with drug-susceptible TB or drug-resistant tuberculosis (DR-TB) . The steps should take place in the context of child-, adolescent- and family-friendly health care services.
Chapter 2 covers TB screening and contact investigation as the first step in the cascade of care. Chapter 3 on TB prevention in children and adolescents covers bacille Calmette-Guérin (BCG) vaccination, TPT and TB infection prevention and control. Chapter 4 covers the diagnosis of pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB) (both drug-susceptible and drug-resistant forms), including the use of diagnostic tests and how to make a decision to start TB treatment based on integrated treatment decision algorithms for use in different settings. The chapters on the cascade of care conclude with Chapter 5 on the treatment of drug-susceptible and drug-resistant PTB and EPTB, with a section on post-TB health. Figure 1.1 is presented at the beginning of each chapter, highlighting the part of the pathway being addressed by the chapter. Chapter 6 covers models of care to improve TB service delivery in line with the special needs of children, adolescents and families. Chapter 7 is on special situations and provides practical guidance on the management of TB in children and adolescents living with HIV; TB in pregnancy and management of babies born to women with TB disease; palliative care for children and adolescents with TB; care for adolescents with or at risk of TB; TB in children with pneumonia; and TB in children with malnutrition.
The annexes include resources, practical tools and standard operating procedures.
Recommendations for which this operational handbook provides operational guidance use the strength (and quality of evidence) as indicated in the consolidated guidelines on the management of TB in children and adolescents (and relevant source guidelines).
A strong recommendation is one for which there is confidence that the desirable effects clearly outweigh the undesirable effects. In this case, the recommendation is formulated using the word “should”.
A conditional recommendation is one for which the guideline development group concluded that the desirable effects probably outweigh the undesirable effects or are closely balanced, but the group was not confident about these trade-offs in all situations. Conditional recommendations are formulated using the word “may” (see web annex 1 of the consolidated guidelines on the management of TB in children and adolescents).
Although the aim is for harmonization of age definitions for children and adolescents, the age cutoffs for recommendations in this handbook were informed by the evidence available at the time it was reviewed and were based on the source guidelines. Throughout the operational handbook, boxes with recommendations are indicated with a green colour, key points are in light blue and examples, case studies and useful resources in light orange.
1.6. Target audience
The target audience for this handbook includes NTPs and other child health programs that provide care for children with or at risk of TB, including maternal, newborn, child and adolescent health programmes, HIV services, and PHC programmes. The handbook also targets paediatricians and other health care workers (HCWs) in the public and private sectors, school health services, civil society and community-based organizations, and health care educators.