All children and adolescents initiated on TB treatment should undergo a monitoring assessment at the following intervals as a minimum:
- HIV-negative children and adolescents – 2 weeks and 4 weeks after the start of treatment, at the end of the intensive phase (after 2 months) and at completion of treatment at 4 months; and
- CALHIV – 2 weeks and 4 weeks after the start of treatment, then every month until completion of treatment at 4 months or 6 months (depending on the regimen used).
Clinical monitoring requirements for the shorter regimen are the same as for the 6-month regimen. Treatment outcomes are determined at the end of treatment; that is, at 4 months for the shorter regimen.
Monitoring should include the following as a minimum:
- assess for resolution or persistence of TB-related symptoms, symptoms of side-effects of medicines and other symptoms;
- measure weight and adjust dosages as necessary, depending on weight gain;
- assess adherence; that is, review the treatment card and discuss with the patient, carers and other treatment supporters; and
- collect follow-up sputum samples for smear microscopy 2 months after the start of treatment and at treatment completion from any child who was Xpert MTB/RIF positive, Xpert Ultra positive, smear positive or culture positive at diagnosis, if the treatment site has the capacity to perform the test.
Symptomatic improvement and weight gain are the most valuable markers of treatment success or failure (30). If a follow-up smear is positive, the patient should complete additional investigations to assess for drug-resistance (Xpert MTB/RIF or Ultra, TB culture and DST or molecular tests for drug-resistance) and other causes of poor treatment response. Possible causes of a poor response include (30):
- incorrect dosage;
- adherence being compromised by adverse events; or
- the child or adolescent:
- not taking the drugs as prescribed or having poor gastrointestinal absorption of one or more of the drugs;
- living with HIV and having developed immune reconstitution inflammatory syndrome (IRIS) or having an opportunistic infection;
- being (severely) malnourished, and SAM not being managed appropriately; or
- having another comorbidity or illness.
In children who cannot expectorate, a repeat specimen at the end of treatment is not necessary if the specimen collected at 2 months is negative. Repeat sample collection at 2 months in children with unconfirmed TB is not indicated unless there is an inadequate clinical response without symptomatic and nutritional improvement. Follow-up CXR is not needed if the child is responding well to TB treatment. Children commonly have a slow radiographic response to treatment and may have persistent radiographic abnormalities at treatment completion (30), but this does not mean they are not responding to treatment.
¹⁴ Defined as weight-for-height Z-score below −3 or mid-upper-arm circumference below 115 mm (33).