TUBERCULOSIS IN INFANCY AND

CHILDHOOD
Chapter 15: Prevention and Control
OVERVIEW

• Control of TB is based on the principles of surveillance

and containment.
• Surveillance is mainly concerned with case finding of TB
and monitoring of cases
• Containment involves treatment and prevention.
Strategies

• 1. Case finding with appropriate therapy

• 2. Contact tracing of exposed individuals for presence of
infection or disease
• 3. Testing of groups with high risk for TB infection to
identify those requiring treatment for latent infection.
SURVEILLANCE

• CASE FINDING OF TB DISEASE

• Identification and diagnosis of TB cases among
individuals with presumptive signs and symptoms for
tuberculosis.
Three types
• Passive case finding
• Involves screening of symptomatic patients for TB disease upon
consultation at the health facility.
• Active case finding
• Involves the lead effort of a health worker to find TB cases in the
community or among those who do not consult with personnel in a DOTS
facility
• Intensified case finding
• Involves active case finding among individuals belonging to special or
defined populations (e.g., high-risk groups including those who consult or find
themselves at the facility for other purposes).
Direct sputum smear microscopy (DSSM)

• DSSM is the easiest, least expensive, readily accessible

and the most rapid procedure to diagnose infectious TB
cases
Direct sputum smear microscopy (DSSM)

• a)monitor progress of patients with TB while they are on

anti-TB treatment
• b)confirm cure at the end of treatment.
TB bacilli isolation in young children

• difficult to obtain due to their inability to expectorate

sputum effectively.

• Young children are considered less infectious than adults

due to:
• 1) the inability of most young children to expectorate
sputum efficiently
• 2) the few numbers of TB bacilli in their sputum i.e
paucibacillary TB
Diagnosis of childhood TB:

• A symptom based screening approach

• History of contact to an infectious TB source
• With tuberculin skin testing (TST)
• Chest radiographs as diagnostic aids.
other tests

• TB culture and drug susceptibility test

• tuberculin skin test
• rapid diagnostic tests (e.g., Xpert MTB/RIF) ( among
presumptive drug resistant TB people living with HiV
(PLHIV) with signs and symptoms of TB smear-negative
adults with chest Xray findings suggestive of TB, smear-
negative children and extra-pulmonary TB.)
CONTACT INVESTIGATION

• Intended to identify persons with previously undiagnosed

or undetected cases of TB among the contacts of an
index case and persons who are candidates for treatment
of latent tuberculosis infection.
• The determination of priorities for contact investigation is
based on the likelihood that a contact:
• 1) has undiagnosed tuberculosis
• 2) at high risk of developing tuberculosis if infected;
• 3) is at risk of having severe tuberculosis if the disease
develops; and
• 4) is at high risk of having been infected by the index
case.
Index case

• The initially-identified TB case of any age in a specific

household or other comparable setting in which others
may have been exposed.
• The Index case may or may not be the source case may
not be the source case.
• A child with TB reflects ongoing transmission of TB cases
and warrants prompt and systematic contact investigation
for an undiagnosed adult/adolescent source case.
• The purpose of the investigation is to find the following:
• (1)contacts (and treat those) who have TB disease in
order to break the cycle of transmission;
• (2)those with latent TB Infection (LTBI); and
• (3)those at high risk of developing TB disease, who
requires treatment until LTBI can be excluded.
• Priority should be given to contacts who are:

• -persons with symptoms suggestive of tuberculosis;

• -children aged <5 years;
• -contacts with known or suspected immunocompromised
states, particularly HIV infection; and
• -contacts of patients with MDR/XDR tuberculosis.
TARGETED TUBERCULIN SKIN TESTING (TST)
FOR LTBI
• Routine TST for TB screening is not recommended.
• Targeted tuberculin skin testing for LTBI identifies
persons who are at high risk for developing TB disease
and who would benefit from treatment of LTBI when
detected.
TARGETED TUBERCULIN SKIN TESTING (TST)
FOR LTBI

• The preferred method of screening for TB infection is

the Mantoux TST.
• Tuberculin skin-testing programs should be conducted
only among populations with high-risk for progression of
infection to disease and discouraged among persons with
low risk.
• Interferon-gamma release assays (IGRAs) should not
replace the tuberculin skin test (TST) in Iow and middle-
income countries for the diagnosis of latent TB infection in
children or for the diagnostic work-up of children
(irrespective of HIV status) suspected of TB disease in
these settings.
WORLD HEALTH ORGANIZATION (WHO)
RECOMMENDATIONS FOR TST SCREENING
• All asymptomatic household contacts less than 5 years old of a
bacteriologically confirmed index case shall undergo TST.
• If TST is negative, these contacts should be given isoniazid
preventive therapy (IPT).
• If positive, rule out TB disease with CXR before starting IPT.
• However, if TST and CXR are not available, the child contact of
a bacteriologically confirmed index case can be given IPT based
on the physician‘s clinical assessment.
WORLD HEALTH ORGANIZATION (WHO)
RECOMMENDATIONS FOR TST SCREENING
• All asymptomatic household contacts less than 5 years-old of a
clinically-diagnosed Index case shall undergo TST.
• If TST is positive, give IPT.
• If TST is negative, do not give IPT and advise to seek consult
immediately if signs and symptoms of TB develop. (in contrast,
CDC recommends that “children less than 5 years of age who are
close contacts to an adult with infectious TB should receive
treatment for LTBI even if the TST result is negative,” as part of
“window prophylaxis”)
WORLD HEALTH ORGANIZATION (WHO)
RECOMMENDATIONS FOR TST SCREENING

• All asymptomatic household contacts 5 years-old and

above (with normal CXR findings if done) are advised to
consult immediately if signs and symptoms of TB develop
CONTAINMENT

• Containment of TB concerns the stopping of spread of

the infection and disease through chemotherapy of
patients with TB disease and treatment of LTBI.
• Preventive therapy refers to the use of a simple regimen
such as isoniazid to prevent the development of active TB
disease in persons known to have or likely to be infected
with M. tuberculosis. However, it is not expected to result
in true prevention (i.e., prevention of infection in persons
exposed to persons with infectious TB)
DIRECTLY OBSERVED THERAPY SHORT-
COURSE (DOTS)
• The five key elements of the DOTS Strategy are:
• (1)sustained political commitment;
• (2)access to quality-assured TB sputum microscopy;
• (3)standardized short-course chemotherapy with direct
observation of drug intake;
• (4)a regular, uninterrupted supply of all essential antiTB
drugs;
• (5)a standardized recording and reporting system.
Bacillus Calmette-Guerin (BCG)

• acille Calmette Guerin (BCG) is a vaccine derived from

a live attenuated strain of Mycobacterium bovis.
• It is the only known vaccine in use against TB.
ISONIAZID PREVENTIVE THERAPY (IPT)

• The progress to active TB usually occurs within 12

months of primary infection.
• 6 months (10 mg/kg/day, range 7-15 mg/kg/day,
maximum dose: 300 mg/day) in children <5 years of age,
who are household or close contacts of people with TB
and who, after an appropriate clinical evaluation, are
found not to have active TB
ISONIAZID PREVENTIVE THERAPY (IPT)

• IPT for 6 months is recommended for children living with

HIV who are >12 Months of age and who are unlikely to
have TB disease on symptom-based screening and have
no contact with a TB case.
The outcomes of IPT:

• (1) completed;
• (2) lost to follow-up (a child who interrupted IPT for two
months or more);
• (3) died (a child who dies for any reason during the
course of IPT);
• (4) failed (a child who develops TB disease during the
IPT), and
• (5 ) not evaluated ( a child who has been transferred to
another health facility with referral for continuation of IPT
and whose treatment outcome is not known).
Structures FOR TB CONTROL

• WORLD HEALTH ORGANIZATION (WHO) GLOBAL

TUBERCULOSIS PROGRAMME

• WHO‘s new End TB Strategy has three pillars namely:

• Pillar 1-Integrated patient, centered TB care and
prevention;
• Pillar 2-Bold policies and supportive systems
• Pillar 3-Intensified research and innovation.
NATIONAL TUBERCULOSIS CONTROL PROGRAM

• The NTP has eight key initiatives namely:

• a. Public-private mix DOTS(PPMD), where the private
sector was engaged to adopt and practice NTP policies
and guidelines and PPMD staff were trained on TB
DOTS;
• b. enhanced hospital TB DOTS, where internal and
external referral systems were strengthened and hospitals
acted either as referring or DOTS-providing hospitals;
• C. Programmatic Management of Drug Resistant TB;
• D. TB HIV collaborative studies, through close
coordination between NTP and National AlDS/ STI
Prevention and Control Program (NASPCP);
• E. TB in jails and prisons;
• F. TB DOTS certification and accreditation, where DOTS
facilities are certified by DOH through the Regional
Offices based on ten DOTS standards, accredited by
Philhealth;
• G. Expansion of TB laboratory services, where there are
108 public and private centers giving free Gene Xpert;
and

• H. Community TB care, where community participation as

well as patient support groups are encouraged to Improve
TB diagnosis and management.
• The goals of effective TB infection control programs are
to:
• -Detect TB disease accurately, early and promptly isolate
those who have or are suspected of having TB disease
(airborne precautions)
• -Treat people who have or who are suspected of having
TB disease
• -The TB infection control (TBlC) measures include three
levels of hierarchy administrative controls, engineering
controls and wearing of respiratory protective equipment
when necessary.
Administrative CONTROLS

• Administrative controls are the first line of defense;

• Involves measures that will reduce risk of TB
transmission by preventing the generation droplet nuclei
or reducing exposure to droplet nuclei
ENVIRONMENTAL CONTROLS

• Involves technologies that will significantly prevent the

spread by reducing the concentration or inactivation of
infectious droplet nuclei in ambient air.
• It is considered as the second line of defense for
preventing the spread of TB
RESPIRATORY PROTECTIVE EQUIPMENT

• When donning masks, make sure the mask would fit

snuggly to the face and below the chin
• Particulate respirators are designed to protect health care
workers and other individuals from inhaling droplet nuclei
and should not be worn by patients.
• Surgical masks should not be worn by the health-care
workers, since these are designed to reduce the number
of droplets being exhaled into the air by persons with
infectious TB disease When they talk, breath, cough or
sneeze.
GENERAL INFECTION CONTROL EFFORTS:
COUGH ETIQUETTE AND HAND HYGIENE
• Hand hygiene is an essential element of good infection
control practices.
• Although hand hygiene does not directly decrease TB
transmission (since the TB bacilli are transmitted only
through the airborne route and not by surface or direct
contact), the implementation of TB control measures
should be observed as part of general infection control
intervention.
• Handwashing with soap and water or disinfecting hands
with at least 70% strength alcohol-based hand sanitizer
gels or wipes is recommended.
• use of physical barriers when coughing or sneezing can
include a piece of cloth, a tissue or a surgical mask; and
such items should be properly disposed of as part of
Respiratory hygiene practice.hUsing bare hands as
physical barrier when coughing or sneezing is not
recommended since it increases transmission of
pathogens through surface contact and direct contact with
other individuals.