Advances in pediatric TB care are promising, the result of decades of advocacy, operational and clinical trials research, and political will by national and local TB programs in high-burden countries. However, implementation challenges remain in linking policy to practice and scaling up innovations for prevention, diagnosis, and treatment of TB in children, especially in resource-limited settings. There is both need and opportunity to strengthen clinician confidence in making a TB diagnosis and managing the various manifestations of TB in children, which can facilitate the translation of evidence to action and expand access to new tools and strategies to address TB in this population. This review aims to summarize existing guidance and best practices for clinicians and health care providers in low-resource, TB-endemic settings and identify resources with more detailed and actionable information for decision-making along the clinical cascade to prevent, find, and cure TB in children.

OBJECTIVE: To describe the demographic and clinical characteristics of children and adolescents diagnosed with resistance to any anti-tuberculosis drug (drug-resistant tuberculosis; DR-TB) in South Africa. DESIGN: We retrospectively reviewed medical records of all children (<13 years) and adolescents (13 to <18 years) with DR-TB at specialty hospitals in four South African provinces from 2005 to 2010. RESULTS: During the review period, 774 children and adolescents (median age 11.3 years) were diagnosed with DR-TB at selected facilities. A high proportion of patients had a history of previous TB treatment (285/631; 45.2%), human immunodeficiency virus (HIV) infection (375/685; 54.7%), contact with a TB case (347/454; 76.4%), and smear-positive (443/729; 60.8%), cavitary (253/680, 38.7%) disease. Eighty-two per cent of patients with HIV infection received antiretroviral therapy. Of 626 patients diagnosed with multidrug-resistant TB (MDR-TB), 561 (89.6%) received a regimen consistent with national guidelines; the median length of treatment was 22 months (IQR 16–25). Among 400 patients with any DR-TB and a known outcome, 20.3% died during treatment. CONCLUSION: Pediatric DR-TB in these provinces is characterized by complex clinical features at diagnosis, with one in five children dying during treatment. History of previous treatment and contact with a TB patient indicate opportunities for earlier diagnosis and treatment to improve outcomes.

Multidrug-resistant (MDR) TB is more difficult to diagnose and treat compared with drug-susceptible TB. Young children are at greater risk of severe TB disease and death when treatment is delayed compared to adults. We sought to describe characteristics of children (<13 years) diagnosed with MDR TB between 2008–2010 in three South African provinces and assess factors associated with pre-treatment loss to follow-up. We matched laboratory and medical records at treatment facilities to identify pre-treatment loss and examined demographic and clinical characteristics for association with loss. Categorical variables were examined for association using Pearson’s x² or Fisher’s exact test, employing Bonferroni correction for multiple pairwise comparisons. Between 2008–2010, 156 children were diagnosed with laboratory-confirmed MDR TB. Only 44% (n = 69) were documented as having received treatment. Young children (<2 years) (47/59, 80%), children with extrapulmonary (EP) TB (27/34, 79%), and children diagnosed at general hospitals (60/97, 62%) were most likely to be lost before treatment. Children most vulnerable to death from TB are most likely to be lost before treatment, possibly leading to underestimates of disease burden, case notifications, and poor outcomes among this population. Point-of-care diagnosis and robust follow-up may reduce pre-treatment loss in this population.

Child and adolescent tuberculosis (TB) has been long neglected by TB programs but there have been substantive strides in prioritizing TB among these populations in the past two decades. Yet, gaps remain in translating evidence and policy to action at the primary care level, ensuring access to novel tools and approaches to diagnosis, treatment, and prevention for children and adolescents at risk of TB disease. This article describes the progress that has been made and the gaps that remain in addressing TB among children and adolescents while also highlighting pragmatic approaches and the role of multisectoral partnerships in facilitating integration of innovations into routine program practice.

Introduction: We assessed implementation of tuberculosis (TB) services among children living with HIV (CLHIV) (<15 years) in 16 African countries supported by US President's Emergency Plan for AIDS Relief (PEPFAR) between October 2018 and September 2022 [fiscal year (FY) 2019–FY2022). Methods: We reviewed PEPFAR TB indicators describing symptom screening, treatment initiation, and TB preventive treatment (TPT) initiation and completion among CLHIV. We describe performance of these measures at semi-annual time points from FY2019 to FY2022 with stratification by age, sex, geographic region, and antiretroviral therapy (ART) status for FY2022. Results: During FY2019–FY2022, the proportion of CLHIV with a positive TB symptom screen was low, ranging from 2.5 to 4.1%, while TB treatment initiation among those who screened positive fluctuated from 19 to 43%. Similarly, TPT initiation among CLHIV newly initiating ART fluctuated during this time, ranging from 13 to 37%, while TPT completion rose from 55 to 85%. In 2022, 80% of CLHIV were screened for TB and 3.6% had a positive symptom screen. Among those, 15% of CLHIV already on ART and 40% of CLHIV newly initiating ART were started on TB treatment. In 2022, among CLHIV newly initiating ART, 37% started TPT within 6 months, and 84% completed the full course of TPT. Conclusion: TB screening and screening positivity were suboptimal. CLHIV starting TB treatment following positive symptom screen was higher than expected, especially among those newly initiating ART. Most CLHIV did not start TPT within 6 months of ART initiation. These findings suggest that programs are missing opportunities to diagnose and prevent TB in CLHIV.