STANDARD 6.

The diagnosis of intrathoracic (i.e., pulmonary, pleural, and mediastinal or hilar
lymph node) tuberculosis in symptomatic children with negative sputum
smears should be based on the fi nding of chest radiographic abnormalities
consistent with tuberculosis and either a history of exposure to an infectious
case or evidence of tuberculosis infection (positive tuberculin skin
test or interferon gamma release assay). For such patients, if facilities
for culture are available, sputum specimens should be
obtained (by expectoration, gastric washings, or induced sputum)
for culture.

Rationale and Evidence Summary

Children with tuberculosis commonly have paucibacillary disease
without evident lung cavitation but with involvement of intrathoracic
lymph nodes. Consequently, compared with adults, sputum smears
from children are more likely to be negative. Therefore, cultures of
sputum or other specimens, radiographic examination of the chest,
and tests to detect tuberculous infection (generally, a tuberculin skin
test) are of relatively greater importance. Because many children less
than 5 years of age do not cough and produce sputum effectively,
culture of gastric washings obtained by naso-gastric tube lavage or induced
sputum has a higher yield than spontaneous sputum.64

Several recent reviews have examined the effectiveness of various diagnostic tools, scoring
systems and algorithms to diagnose tuberculosis in children.64–67 Many of these approaches
lack standardization and validation and, thus, are of limited applicability. Table
1 presents the approach recommended by the Integrated Management of Childhood
Illness (IMCI) program of WHO that is widely used in fi rst-level facilities in low- and middleincome
countries.68

TABLE 1: An approach to the diagnosis of tuberculosis in children68

The risk of tuberculosis is increased when there is an active case (infectious, smear-positive tuberculosis) in
the same house or when the child is malnourished, is HIV infected, or has had measles in the past few months.
Consider tuberculosis in any child with:

Standards for Treatment

Treatment for tuberculosis is not only
a matter of individual health; it is
also a matter of public health. All
providers, public and private,
who undertake to treat a patient
with tuberculosis, must have
the knowledge to prescribe a
standard treatment regimen
and the means to assess
adherence to the regimen and
to address poor adherence in
order to ensure that treatment
is completed.

STANDARD 7.

Any practitioner treating a patient for tuberculosis is assuming an important
public health responsibility. To fulfi ll this responsibility, the practitioner must not
only prescribe an appropriate regimen but, also, be capable of assessing the
adherence of the patient to the regimen and addressing poor adherence when it
occurs. By so doing, the provider will be able to ensure adherence to the regimen
until treatment is completed.

Rationale and Evidence Summary

As described in the Introduction, the main interventions to prevent the spread of tuberculosis
in the community are the detection of patients with infectious tuberculosis and
providing them with effective treatment to ensure a rapid and lasting cure. Consequently,
treatment for tuberculosis is not only a matter of individual health (as is the case with, for
example, treatment of hypertension or diabetes mellitus); it is also a matter of public health.
Thus, all providers, public and private, who undertake to treat a patient with tuberculosis,
must have the knowledge to prescribe a standard treatment regimen and the means to
assess adherence to the regimen and address poor adherence to ensure that treatment
is completed.69 National tuberculosis programs commonly possess approaches and tools
to ensure adherence with treatment and, when properly organized, can offer these to
non-program providers. Failure of a provider to ensure adherence could be equated with,
for example, failure to ensure that a child receives the full set of immunizations. Communities
and patients deserve to be assured that providers treating tuberculosis are doing so
in accordance with this principle and are thereby meeting this standard.