Provision of Decentralized TB Care Services: A Detect–Treat–Prevent Strategy for Children and Adolescents Affected by TB

Abstract

In this review, we discuss considerations and successful models for providing decentralized diagnosis, treatment, and prevention services for children and adolescents. Key approaches to building decentralized capacity for childhood TB diagnosis in primary care facilities include provider training and increased access to child-focused diagnostic tools and techniques. Treatment of TB disease should be managed close to where patients live; pediatric formulations of both first- and second-line drugs should be widely available; and any hospitalization should be for as brief a period as medically indicated. TB preventive treatment for child and adolescent contacts must be greatly expanded, which will require home visits to identify contacts, building capacity to rule out TB, and adoption of shorter preventive regimens. Decentralization of TB services should involve the private sector, with collaborations outside the TB program in order to reach children and adolescents where they first enter the health care system. The impact of decentralization will be maximized if programs are family-centered and designed around responding to the needs of children and adolescents affected by TB, as well as their families.

A systematic review of clinical, epidemiological and demographic predictors of tuberculosis in children with pneumonia

“…The WHO has updated and consolidated guidelines on the management of TB in children and adolescents, which include new recommendations relevant to child pneumonia and are accompanied by an operational handbook [ 35 ]. Decentralisation of diagnosis and care is supported by practical diagnostic and treatment decision approaches as most children with TB present initially to primary- or secondary-level health facilities [ 36 ]. Xpert ® MTB/RIF or Ultra (Cepheid, Sunnyvale, CA, USA) is the preferred laboratory diagnostic, and stool or nasopharyngeal aspirate samples are recommended when less invasive alternatives to induced sputum or gastric aspirate are preferred, such as in children with respiratory distress.…”

Development and validation of treatment-decision algorithms for children evaluated for pulmonary tuberculosis: an individual participant data meta-analysis

“…These are important given that many children with tuberculosis first present to primary healthcare centres. 28 We believe that the risk-stratification and delayed entry of lower risk children with presumptive tuberculosis (who should tolerate the delay) is a practical attempt to safely raise the pre-test probability when implementing the algorithm in primary health centres. Prospective external validation of the entire algorithms will be critical to determining their accuracy, acceptability and feasibility of use at different levels of the healthcare system.…”

Priority Activities in Child and Adolescent Tuberculosis to Close the Policy-Practice Gap in Low- and Middle-Income Countries

“…Identified underlying drivers contributing to under-detection were the shortage of trained staff, lack of access to diagnostic tools, reluctance to diagnose TB without bacteriological confirmation, and limited access to expertise at central hospitals. Child TB services and expertise tend to be strongly centralized, but most children and adolescents requiring TB treatment or TPT do not present, at least initially, to the specialized services, nor would most require referral if services were more decentralized [99]. All child TB working groups now recognize that strengthening diagnosis (clinical and bacteriological) is critical and needs to happen at all facility levels.…”