6. Models of TB care for case detection and provision of TPT in children and adolescents

This chapter contains two new recommendations and other valid WHO recommendations that apply to patient support and models of care (section 6.2). The two new recommendations, on the implementation of decentralized models of care and integrated family-centred models of care to improve both case detection and the provision of TPT, are described in full detail as this information is being published for the first time. Other consolidated recommendations in this chapter are related to patient support, health education and counselling, the provision of treatment support or video supported treatment and decentralized models of care for MDR/RR-TB services.

The recommendations in this chapter have been consolidated from current WHO guidelines on TB treatment and the context in which it should be provided, namely the Guidelines for treatment of drug-susceptible tuberculosis and patient care, 2017 update (97) and the WHO consolidated guidelines on tuberculosis. Module 4: treatment - drug-resistant tuberculosis treatment, 2020 update (9). For more information on each recommendation including the remarks, source of evidence, justification, subgroup-, implementation- and monitoring and evaluation considerations, the source guidelines or WHO TB KSP should be consulted.

Capacity for paediatric TB is often highly centralized at secondary/tertiary level, where children may present as seriously ill, after delays in accessing care. At higher levels of care, services are often managed in a vertical, non-integrated way (10, 98). Health care workers at the PHC level may have limited capacity and confidence in managing paediatric TB, although this is where most children with TB or at risk of TB seek care (10). In addition, TB screening is often not systematically part of clinical algorithms for child health, such as integrated management of childhood illness (IMCI) and integrated community case management (iCCM). Private sector providers play an increasing role as first point of care in many countries (99). There are many missed opportunities for contact tracing, as well as TB prevention, detection and care due to weak integration of child and adolescent TB services with other programmes and services.

Decentralization and provision of family-centred, integrated care are highlighted as one of 10 key actions in the 2018 Roadmap (10). The Roadmap highlights that consistently and systematically addressing gaps and bottlenecks along children's and adolescents' pathway through TB exposure, TB infection and TB disease can lead to reduced transmission of TB, expansion of prevention of TB infection and earlier TB diagnosis with better outcomes. Achieving this continuum of care requires collaboration across service areas, practice disciplines and sectors, community engagement, as well as decentralization and integration of service delivery at the PHC level (10).

The Roadmap suggests actions to integrate child and adolescent TB into family- and community-centred care, including: (i) strengthening country-level collaboration and coordination across all health-related programmes engaged in woman, adolescent and child health - especially reproductive health, maternal, neonatal, child and adolescent health (MNCAH), nutrition, HIV, primary and community health - with clearly defined roles, responsibilities and joint accountability; (ii) decentralizing and integrating successful models of care for TB screening, prevention and diagnosis with other existing service delivery platforms for maternal and child health (such as antenatal care (ANC), iCCM, IMCI) as well as other related services (such as HIV, nutrition, immunization); (iii) ensuring that children and adolescents with other common comorbidities (such as meningitis, malnutrition, pneumonia, chronic lung disease and HIV infection) are routinely evaluated for TB; (iv) ensuring community health strategies integrate child and adolescent TB education, screening, prevention and case finding into the training and service delivery activities; and (v) increasing awareness of and demand for child and adolescent TB services in communities and among health workers (10).

This set of PICO questions examined the impact of: (i) decentralization and (ii) family-centred, integrated approaches of child and adolescent TB services on case detection in children and adolescents who present with signs and symptoms of TB. They also examine the impact of these approaches on coverage of TPT among children and adolescents.

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