Title
TB Control Program Guidelines for Children
Law
Doh Administrative Order No. 2008-0011
Decision Date
May 21, 2008
The Department of Health establishes revised guidelines to enhance tuberculosis control in children aged 0-14, focusing on improved case detection, treatment protocols, and preventive measures in alignment with WHO standards.
tuberculosis
childhood tb
public health

Legal basis and related issuances

  • The national approach aligns with the National Strategic Plan to Stop TB 2006-2010 and the Western Pacific Regional Strategic Plan 2006-2010.
  • The program framework includes adaptation of DOTS to respond to high-risk populations and to ensure equitable access to care.
  • DOH established a Task Force (TF) on Childhood TB through Department Order (DO) 248-H s. 1998, as amended by DO 66-D s. 2001.
  • DOH previously released Administrative Order (AO) 178 s. 2004 to guide TB in children and enable nationwide expansion to 16 cities.
  • 2005 MOP for the National Tuberculosis Control Program (NTP) governs consistency for the operational procedures covered by these guidelines.
  • WHO Guidance for National Tuberculosis Programmes on Management of TB in Children (issued in 2006) is used for alignment of the revised national child TB guidelines.
  • Contact screening and management follow WHO guidance on childhood TB and are incorporated for implementation under the revised guidelines.
  • Caseholding mechanisms follow AO 178 while treatment regimens and drug dosages follow WHO guidance (as referenced in the guidelines).

Policy objectives and intended program outcomes

  • The guidelines establish standard policy for casefinding of TB in children.
  • The guidelines require treatment of children with TB in accordance with WHO-recommended dosages and regimens.
  • The guidelines require contact tracing for children at risk of developing TB for preventive therapy.
  • The guidelines require inclusion of all childhood TB cases in routine NTP recording and reporting using the DOT strategy.

Coverage and operative scope

  • The guidelines apply to all health facilities, agencies, and organizations implementing a Tuberculosis Control Program among children 0–14 years old.
  • Screening applies to all children 0–14 years old who present with signs and symptoms of TB at a health facility.
  • Screening also applies to children 0–14 years old who are in close contact with a known TB case (usually an adult).
  • The definition of screening coverage includes both symptomatic children and close contacts.
  • Reporting uses two age-group categories: 0–4 years old and 5–14 years old.

Key definitions for implementation

  • Close contact means a person who lives in the same household as a source case or is in frequent contact with the source case.
  • Contacts for screening means all children 0–4 years old (whether sick or well) and children 5–14 years old if symptomatic, who are in close contact with a source case.
  • Isoniazid Preventive Therapy (IPT) means taking a course of isoniazid by individuals who have not been infected in order to prevent development of TB disease.
  • Source case means a case of pulmonary TB (usually sputum smear-positive) that results in infection or disease among contacts.
  • TB Diagnostic Committee (TBDC) is a committee established at the province, city or district level to review sputum smear-negatives with chest X-ray findings suggestive of pulmonary TB; it is composed of NTP medical/nurse coordinators, a radiologist, and a clinician (internist or pulmonologist).
  • TB symptomatic status for a child is determined by specific symptom criteria stated under the diagnostic approach for childhood TB.

Universal screening, diagnosis, and treatment rules

  • All children 0–14 years old who come to a health facility with signs and symptoms of TB shall be screened for TB.
  • All children 0–14 years old who are close contacts of a known TB case shall be screened for TB.
  • The diagnosis of TB in children requires careful and thorough history and clinical examination and relevant investigations, including TST, DSSM, and CXR.
  • Anti-TB medicine initiation as a method of diagnosing TB in children is prohibited; a trial of treatment is not used as a diagnostic method.
  • When a child is diagnosed with TB, the guidelines require an effort to detect and cure the source case.
  • TB treatment for children and IPT shall follow WHO 2006 guidelines on recommended dosages and regimen.
  • Directly Observed Treatment (DOT) shall be followed for all children undergoing therapy.
  • Quarterly reports shall be submitted to the Infectious Disease Office through the established channels.
  • BCG vaccination shall be given to all infants to prevent severe TB types in children under EPI policies and procedures; BCG revaccination is not recommended.
  • When DSSM turns positive, treatment shall start immediately and TST shall no longer be performed.

Casefinding mechanics and diagnostic standards

  • TB in children is identified in two instances:
    • the child sought consultation, was screened, and was found to have signs and symptoms of TB; or
    • the child is a close contact of a TB case.
  • The diagnostic approach must include careful history and clinical examination, including growth assessment.
  • A child is TB symptomatic if with any three (3) of the following signs and symptoms:
    • Cough/wheezing of 2 weeks or more
    • Unexplained fever of 2 weeks or more after common causes such as malaria or pneumonia have been excluded
    • Loss of weight/failure to gain weight/weight faltering/loss of appetite
    • Failure to respond to 2 weeks of appropriate antibiotic therapy for lower respiratory tract infection
    • Failure to gain previous state of health 2 weeks after a viral infection or exanthema (e.g., measles)
    • Fatigue/reduced playfulness/lethargy
  • Physical signs highly suggestive of extrapulmonary TB include:
    • gibbus, especially of recent onset
    • non-painful enlarged cervical lymphadenopathy with fistula formation
  • Tuberculin Skin Testing (TST) must use the Mantoux method with:
    • 2 TU of tuberculin PPD-RT 23, or 5 TU of tuberculin PPD-S if the former is not available
  • A positive TST is an area of induration with diameter of 10mm or more read between 48 and 72 hours after injection, whether or not the child received BCG vaccination.
  • Only a trained health worker may perform tuberculin testing and reading.
  • Investigations for suspected pulmonary TB require:
    • Direct Sputum Smear Microscopy (DSSM) and bacteriologic confirmation whenever possible
    • DSSM shall be performed among:
      • younger children (5–9 years old) who can expectorate; and
      • children (10–14) years old who have cough for 2 weeks
    • Bacteriological confirmation (culture) is especially important for children with:
      • suspected drug-resistant TB
      • HIV infection
      • complicated or severe disease
      • an uncertain diagnosis
  • For suspected childhood pulmonary TB, CXR shall not be used alone in diagnosis unless the finding is miliary tuberculosis.
  • For suspected pulmonary TB, persistent CXR changes suggestive of TB may include persistent opacification with enlarged hilar or subcarinal lymph glands.
  • If persistent opacification does not improve after a course of antibiotics, the patient must be investigated for TB.
  • Suspected extrapulmonary TB shall be diagnosed from the clinical picture and confirmed by histology or other special investigations.
  • The guidelines permit use of serological tests, nucleic acid amplification (e.g., polymerase chain reaction), computerized chest tomography, and bronchoscopy, while providing that these are not currently recommended for routine diagnosis in children.
  • Where a functional TBDC exists:
    • CXR of children with results suggestive of TB must be referred for evaluation; and
    • the TBDC evaluation result must be available within 2 weeks to minimize delay in diagnosis and treatment.

Case definitions, classification, and treatment holding

  • Case definitions in childhood TB are determined by:
    • the site of disease,
    • the result of any bacteriological tests,
    • the severity of TB disease, and
    • the history of previous anti-TB treatment.
  • TB in children shall be classified based on:
    • the location of lesions, and
    • the result of DSSM.
  • Types of TB in children are categorized based on the history of anti-TB treatment.
  • Case definitions and classifications/types in childhood TB follow AO 178 and include those from the 2006 WHO guidelines.
  • A caseholding mechanism shall follow AO 178.
  • The TB treatment regimen for TB disease and corresponding drug dosages shall follow the 2006 WHO guidelines.
  • Fixed-dose combinations (FDC) of drugs shall be used whenever possible; single drug formulations may be used.

Hospitalization, adverse reactions, and follow-up monitoring

  • Children with severe forms of TB shall be hospitalized initially for intensive management where possible.
  • Hospitalization is required/indicated for:
    • TB meningitis
    • miliary TB
    • respiratory distress
    • spinal TB
    • severe adverse events, including clinical signs of hepatotoxicity (e.g., jaundice)
  • Management of adverse reactions requires:
    • stopping treatment and immediately referring the patient upon occurrence of liver tenderness, hepatomegaly, or jaundice.
  • Routine monitoring of serum liver enzyme levels is not required.
  • Monitoring response to treatment requires:
    • smear-positive children to have follow-up DSSM similar to adult TB cases under the 2005 MOP
    • for extra-pulmonary and most childhood TB cases, response to be assessed clinically
    • follow-up CXRs not to be routinely required.
  • Treatment outcomes must follow the case outcome definitions in AO 178 and the 2006 WHO guidelines.

Contact investigation, special circumstances, and reporting

  • Contact screening and management shall adopt the approach in the 2006 WHO guidelines.
  • Special circumstances must be managed under the revised guidelines, including:
    • a baby born to a mother with infectious TB
    • contacts of confirmed drug-resistant TB
  • Recording and reporting must use the following age-group categories:
    • 0–4 years old
    • 5–14 years old
  • Program indicators include the following, among others:
    • number of children screened, categorized by age group
    • number treated for TB disease
    • proportion of all childhood TB cases by age group
    • proportions of children with pulmonary TB and extrapulmonary TB
    • proportion of children with miliary TB and TB meningitis
    • proportion of children who are cured (smear-positive)
    • proportion of children who complete treatment (smear-negative pulmonary and extrapulmonary TB)
    • number given IPT and outcome, including treatment completion

Implementing mechanisms, training, and compliance effects

  • Roles and responsibilities of agencies, health workers, and partners implementing the program must conform to the 2005 MOP for the NTP.
  • Training modules must be updated to conform to the revised Administrative Order.
  • Provisions from previous issuances that are inconsistent or contrary to the Order are rescinded and modified accordingly.

Repeal and separability

  • Inconsistent or contrary provisions from previous issuances are rescinded and modified to the extent of inconsistency with the Order.
  • The Order provides for the effect of rescission/modification for conflicting provisions.

Date of adoption and immediate operational timeline

  • The Order is adopted on 21 May 2008.
  • The Order takes effect immediately upon adoption.

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