Objectives of the Revised Guidelines
- Establish a standard policy for TB case finding and treatment in children.
- Implement contact tracing for children at risk to provide preventive therapy.
- Include childhood TB cases in routine NTP recording and reporting using the DOT strategy.
Scope and Coverage
- Applies to all health facilities, agencies, and organizations implementing TB control programs for children aged 0-14 years.
Key Definitions
- Contacts for Screening: All children aged 0-4 years (regardless of symptoms) and symptomatic children aged 5-14 years in close contact with a source case.
- Close Contact: Individuals living in the same household or frequent contact with a source case.
- Isoniazid Preventive Therapy (IPT): Preventive treatment with isoniazid for non-infected individuals.
- Source Case: Pulmonary TB usually sputum smear-positive patient causing infection among contacts.
- TB Diagnostic Committee (TBDC): Local committee reviewing smear-negative cases with suggestive chest x-rays, composed of NTP coordinators, radiologists, and clinicians.
Screening and Diagnosis Protocols
- All children presenting TB symptoms or identified as close contacts must be screened.
- Diagnosis based on history, clinical exam, Tuberculin Skin Test (TST), sputum smear microscopy, and chest x-ray.
- Trial treatment not permitted as a diagnostic method.
- Efforts must be made to detect and treat the source case upon diagnosis in a child.
- Treatment and IPT to follow 2006 WHO recommended dosages and regimens.
- DOT is mandatory for all treated children.
- Quarterly reporting to Infectious Disease Office is required.
- Universal BCG vaccination at infancy recommended; revaccination not advised.
Detailed Diagnostic Approach
- TB symptomatic criteria: presence of any three specific signs/symptoms related to respiratory issues, fever, weight loss/faltering, failure to respond to antibiotics, post-viral health deterioration, or fatigue.
- Physical signs for extrapulmonary TB include new gibbus and non-painful enlarged cervical lymphadenopathy with fistula.
- TST using Mantoux method with defined tuberculin units; positive if induration ≥10mm, irrespective of BCG status; only trained personnel to perform.
- Diagnostic investigations for pulmonary TB include sputum smear microscopy for children capable of expectorating and chest x-ray; bacteriology confirmation (culture) especially in complicated cases.
- Chest x-rays alone not diagnostic except in miliary TB; persistent opacification after antibiotics should prompt TB investigation.
- Extrapulmonary diagnosis primarily clinical and histological.
- Advanced tests like PCR and CT not routinely recommended.
- TBDC evaluates and expedites smear-negative suspicious cases within 2 weeks.
Case Classification and Definitions
- Classification based on lesion location, bacteriological test results, disease severity, and treatment history.
- Types of TB cases classified following AO 178 and 2006 WHO guidelines.
Treatment and Case Management
- Caseholding follows AO 178; dosing regimens per 2006 WHO guidelines.
- Fixed-dose combination drugs preferred, yet single drug formulations remain permissible.
- Hospitalization advised for severe TB forms (TB meningitis, miliary TB, spinal TB, respiratory distress, severe adverse reactions).
- Adverse drug reaction management requires immediate cessation and referral if hepatotoxicity signs occur; routine liver enzyme monitoring not mandatory.
- Treatment response monitored by sputum smear microscopy for smear-positive cases; clinical evaluation for most extrapulmonary and childhood cases; routine follow-up x-rays not required.
- Treatment outcome definitions comply with AO 178 and WHO standards.
Contact Tracing and Special Circumstances
- Contact screening and management adopt 2006 WHO guidelines.
- Specific management protocols for babies born to infectious mothers and contacts of drug-resistant TB patients.
Recording, Reporting, and Program Indicators
- Reporting age groups divided into 0-4 years and 5-14 years.
- Program indicators include number screened and treated, childhood TB case proportions, pulmonary vs extrapulmonary TB, severe TB forms, cure and treatment completion rates, and IPT outcomes.
Implementation Responsibilities and Training
- All implementing agencies and health workers adhere to roles defined in the 2005 MOP for the NTP.
- Training modules updated to align with revised guidelines.
Repealing Clause and Effectivity
- Previous issuances inconsistent with this Order are rescinded and modified.
- Immediate effectivity upon issue date.