6.2.5 Considerations for implementation

Contact screening can be difficult. Once the contacts of a TB patient have been identified, they should be screened for TB symptoms and/or undergo CXR, followed by appropriate diagnostic evaluation (4, 5). Tracing of household contacts usually identifies many close contacts who are eligible for screening and TPT; however, it is expensive and time-consuming for health-care workers to identify the contacts of all known TB patients. Additionally, TB is still a highly stigmatized disease in many countries and contexts, and the visit of a health worker to a patient’s home may draw attention to a diagnosis, risking violation of a patient’s right to medical privacy and discrimination against the household. Alternatively, health-care workers can ask patients to bring their contacts, including children, to a health centre for TB screening, although caretakers or parents may not be able to bring children in for evaluation, for a variety of reasons, such as financial or time constraints, lack of appreciation of the importance of screening or distrust of health-care services (42). Health-care providers, health-care managers and health programmes should therefore consider the potential preferences and concerns of parents and caregivers and manage them with sensitivity and tact.

Like contacts of any age, children and adolescents who are exposed to someone with TB and who are found not to have TB disease should be assessed for TPT as per national guidelines (4, 5). Inability to conduct CXR should not prevent a child from receiving TPT. Health managers should plan for the resources and logistics necessary to deliver screening tests according to the chosen algorithm, to register data on contact-tracing, including the results of screening tests (preferably electronically) and to integrate screening and TPT services.

Routine screening of children who access health care is currently not recommended. Children and adolescents < 15 years who access health care represent a much larger population for potential screening than contacts of TB patients, which has important resource implications for scaling up screening, particularly with more expensive screening and diagnostic tools. In addition, the generally low pre-test probability of TB disease in children and the diagnostic pathway that children typically follow when they screen positive, could lead to false-positive diagnoses and inappropriate treatment of large numbers of children.

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