Introduction

  • Formerly Revised National TB Control Programme (RNTCP); renamed NTEP in 2020 under National Health Mission
  • National Strategic Plan (NSP) 2017-2025: “TB Mukt Bharat” – TB elimination by 2025 (incidence <1/1,00,000)
  • Strategy: Detect – Treat – Prevent – Build (DTPB)
  • Paediatric TB accounts for 6–7% of total notified cases (~3.42 lakh children 0–14 years estimated annually; ~1 lakh 0–14 years + 1.4 lakh 15–18 years reported)

Burden & Challenges in Children

  • Higher proportion of extrapulmonary TB (EPTB) and severe disseminated forms (miliary, TB meningitis) compared to adults
  • Paucibacillary disease → lower yield of conventional smear microscopy
  • Diagnostic difficulties: Non-specific symptoms, inability to expectorate sputum, overlap with malnutrition/pneumonia
  • High under-diagnosis & under-reporting; significant contribution to under-5 mortality
  • Risk factors: Household contact, severe acute malnutrition, HIV, immunosuppression

Diagnosis

  • Presumptive Paediatric TB: Persistent fever/cough >2 weeks, unexplained weight loss (>5% in 3 months) or failure to gain weight, TB contact history (last 2 years)
  • Microbiological confirmation prioritised – Universal Drug Susceptibility Testing (U-DST)
  • Preferred specimens: Gastric aspirate (overnight fasting), induced sputum, sputum (older children), BAL if required
  • First-line test: CBNAAT (GeneXpert MTB/RIF) or Truenat for MTB detection + rifampicin resistance
  • Chest X-ray (frontal): Highly suggestive – hilar/mediastinal lymphadenopathy, miliary shadows, fibrocavitary lesions; non-specific findings → trial of antibiotics then re-evaluate
  • Supportive: TST (≥10 mm) or IGRA (not diagnostic alone)
  • EPTB: Site-specific (FNAC/biopsy/CSF analysis, USG/CECT/MRI as indicated)
  • Algorithm: Clinical suspicion → CXR → CBNAAT on appropriate sample → clinically diagnosed TB if microbiology negative but strong evidence

Case Definitions

  • Bacteriologically confirmed TB: Positive smear/NAAT/culture
  • Clinically diagnosed TB: Strong clinical/radiological evidence + response to ATT after ruling out alternatives
  • Drug-resistant TB: RR/MDR/Pre-XDR/XDR based on DST

Treatment – Drug-Susceptible TB (DS-TB)

  • Daily weight-band paediatric Fixed-Dose Combinations (FDC) dispersible tablets (preferred)
  • Standard regimen: 2HRZE (Intensive phase) / 4HRE (Continuation phase) – total 6 months
  • Extension of continuation phase to 7–10 months in TB meningitis, osteoarticular, disseminated TB
  • Doses (mg/kg/day): H 7–15 (avg 10), R 10–20 (avg 15), Z 30–40 (avg 35), E 15–25 (avg 20)
  • Pyridoxine supplementation: 10 mg/day (<5 years), 25 mg/day (>5 years) for all INH-containing regimens
  • Nutritional support: Nikshay Poshan Yojana (₹500/month to all notified patients)

Treatment – Drug-Resistant TB (DR-TB)

  • All-oral shorter regimens preferred; avoid injectables wherever possible
  • MDR/RR-TB: Bedaquiline-containing shorter oral regimen (eligible ≥5 years, ≥15 kg)
  • INH mono/poly-resistant: Levofloxacin-based regimen
  • Longer oral M/XDR-TB regimen (18–20 months) using Group A/B/C drugs based on DST
  • Delamanid approved for ≥6 years in selected cases
  • Pre-treatment evaluation & monthly monitoring (ECG, LFT, hearing)

TB Preventive Therapy (TPT)

  • All household contacts <5 years of pulmonary TB Index active TB ruled out (CXR + clinical evaluation)
  • Preferred regimens:
    • 3HP (Isoniazid + Rifapentine weekly × 3 months) – >2 years
    • 6H (Isoniazid daily × 6 months)
  • TPT for older children with positive TST/IGRA or high-risk groups (HIV, malnutrition, immunosuppression)
  • DR-TB contacts: Levofloxacin-based TPT (6Lfx)

Programmatic Aspects & Integration

  • Mandatory notification through Ni-kshay portal (public & private sectors)
  • Strong collaboration with RBSK & RKSK – active case finding, screening of school children & adolescents, referral to DEIC
  • Private sector engagement: Paediatric Centres of Excellence (pCoE-TB), IAP-MoHFW MoU for training
  • Adherence support: 99DOTS, family observed therapy, video observed treatment
  • Incentives: Nikshay Mitras for nutritional & social support

Monitoring, Follow-up & Outcomes

  • Monthly clinical monitoring: Weight gain, symptom resolution, adherence
  • End of intensive phase: Repeat CBNAAT/CXR if required
  • Treatment outcomes: Cured, Treatment completed, Failure, Died, Lost to follow-up
  • Post-treatment follow-up: 6-monthly for 2 years (detect relapse/recurrence)
  • Management of paradoxical reactions, adverse drug reactions & treatment interruptions