Childhood

MDR TB for Healthcare Workers: Course Guide

This course guide contains information about diagnosing, treating, and
preventing MDR TB in children. You will use this guide throughout the
course, and you may want to refer to it as an ongoing resource.

However, particularly when looking at specific regimens and doses,

please understand that the best practices for managing childhood MDR
TB evolve as new research is conducted and data emerge.

You can use this guide as a resource, but only in conjunction with
your national guidelines and current, research-based best
practices.

Much of the material in this guide is reused with permission from the
Sentinel Projects Management of Drug-Resistant Tuberculosis in Children:
A Field Guide. Boston, USA: The Sentinel Project for Pediatric Drug-Resistant
Tuberculosis; April 2014, Second edition.

General Values Used in Examinations

In some activities in the course, you will need to identify whether a child has an elevated
respiratory rate or temperature.

A child has an elevated respiratory rate if breaths per minute exceed those shown
below:

Age Breaths per minute (bpm)

01 month >= 60
211 months >= 50
1259 months >= 40
511 years >= 30
12 years or older >= 20

Elevated temperature: greater than 38 degrees Celsius

1
Diagnosis
Algorithm for Suspected MDR TB in a Child

Criteria for Suspected MDR TB

History of previous treatment within the past 612 months

Close contact with a person known to have MDR TB, including
household and school contacts
Close contact with a person who has died from TB, failed TB
treatment, or is non-adherent to TB treatment
Failure to improve clinically after 23 months of first-line TB treatment,
including persistence of positive smears or cultures, persistence of
symptoms, and failure to gain weight (radiological improvement is
frequently delayed)

Yes No Continue evaluation

for drug-susceptible
TB
Clinical assessment and MDR TB
diagnostic workup including collection of
the relevant specimens to test for
M.tuberculosis.

Results of diagnostic workup available No

Yes

MDR TB DS TB No diagnosis Clinically stable Concerning signs

confirmed confirmed confirmed without concerning and symptoms
signs or symptoms present (temp.>40,
hypoxia, respiratory
distress,
Treatment First-line hemoptysis, severe
based on TB anorexia, indicators
DST treatment of meningeal or
disseminated TB)

Await diagnosis and Consider initiating

monitor closely MDR TB therapy
while awaiting
diagnosis

2
Practical considerations for optimal sample collection in children*

Overall principles

Despite, challenges in children of obtaining specimens for Mycobacterium

tuberculosis diagnostic testing, it is possible and important
The quality of specimens is critical for M. tuberculosis diagnostic testing in
children, as there is often a low burden of organisms

Prepare yourself and your team

Choose the procedure most appropriate to your setting, stick with it and become
good at it
o Older children may be able to expectorate
o Younger children may require gastric aspiration or induced sputum
collection for respiratory samples
o Dont forget about Fine Needle Aspiration (FNA) from lymph nodes
What equipment do you have available? Sputum induction requires some
special equipment, but gastric aspiration only requires widely available supplies.
What human resources/ skills? Train your team on the procedure of choice.
Be safe insure you have proper infection control in place
Develop a strategy: prepare, train your team, try your strategy, adapt as needed

Prepare the patient and caregiver

Fasting period - Sample collection early morning after an overnight fast is ideal;
otherwise attempt to collect after a 3-6 hour fast
Explain the procedure to older children to get cooperation
Immobilise the young child adequately

Collecting samples

Take your time and do the procedure well

For gastric aspiration:
o Collect as large a volume sample as you can 2mL is almost always
possible and should be considered a minimum
o Avoid gastric lavage (i.e. flushing saline through the nasogastric tube and
then aspirating), unless after reasonable attempts the sample volume is
<2mL; gastic lavage will dilute the sample and may reduce the likelihood
of a positive test
o Neutralise the pH of the gastric aspirate
Consider repeating the procedure if the sample is insufficient
Limit contamination of samples
o Get to the lab as quickly as possible.

3
 o After sample collection store the specimen in a cool place, ideally in a
cool box at 2-8 C, and for a maximum of 72 hours before processing
Splitting a single sample for multiple tests risks reducing its yield
Collect more than one high-quality sample when possible, as this may increase
the likelihood of a positive test result and allows multiple testing (such as Xpert
for a rapid result AND culture as the most sensitive test)

*Adapted from materials developed by Elisabetta Walters, Desmond Tutu TB Centre, Faculty of
Medicine and Health Sciences, Stellenbosch University

4
Treatment
Abbreviations for drugs used in this handbook

INH isoniazid ETO ethionamide

RIF rifampicin PTO prothionamide
EMB ethambutol LVX levofloxacin
PZA pyrazinamide MFX moxifloxacin
SM streptomycin OFX ofloxacin
CM capreomycin CS cycloserine
KM kanamycin TZD terizidone
AMK amikacin PAS para-aminosalicylic acid
DLM delamanid BDQ bedaquiline
CFZ clofazimine LZD linezolid

Guidance for Creating Regimens

Reproduced and modified with permission from the Sentinel Project

Children with MDR TB should be managed according to the same principles that guide
adult therapy. These include:

Use any first-line medication to which susceptibility is documented or likely (pilot

studies suggest that given the low risk of adverse events and potential benefit,
high-dose INH could be included routinely, unless high-level INH resistance or
Kat-G mutation is documented).
Use at least four second-line drugs to which the strain is likely to be sensitive;
one of these agents should be an injectable, one a fluoroquinolone (preferably a
later-generation quinolone if available), and PZA should be continued.
Use high-end dosing when possible.
All doses should be given using DOT.
Treatment duration should be for 924 months. Most patients will be treated with
an intensive regimen that includes injectables for 56 months, followed by 1218
months of treatment without injectables.

Treatment is usually recommended based on the resistance pattern of the most likely
source case, although we know that close contacts do not always share the same
resistance pattern as the source case (Cohen, T. et al., 2011). The following are
recommended as pragmatic guidance:

A strong regimen consisting of at least four new second-line medications to

which the strain is likely to be susceptible should be used in presumptive therapy
of probable MDR TB. If needed, it can be tailored back based on drug-
susceptibility testing (DST) or the development of adverse events.
Balance must be achieved between an effective MDR TB regimen and the
development of adverse events (see Section 3), whereby weighing the morbidity

5
 and mortality of under-treated TB with the morbidity and mortality of various
adverse events is taken into consideration.
Finally, children on MDR TB therapy should have weight gain and height gain;
these should be monitored monthly, and adjustments to medication doses made
accordingly.

Standard Regimen
If you do not have DST results from either the patient or the patients contact, consider
beginning the following standard regimen for patients being treated for 1824 months:
KM, ETO, CS, LVX, PZA, and vitamin B6. Generally, KM can be stopped after 56
months.

Shortened Regimen
If a patient does not meet any of the criteria below, he or she may qualify for a 912-
month shortened regimen:

Confirmed resistance or suspected ineffectiveness to a medicine in the shorter MDR TB

regimen (except isoniazid resistance)
Exposure to one or more second-line medicines in the shorter MDR TB regimen for
greater than one month
Intolerance to one or more medicines in the shorter MDR TB regimen or risk of toxicity
(e.g., drug-drug interactions)
Pregnancy
Extrapulmonary disease
At least one medicine in the shorter MDR TB regimen not available in the program

The currently suggested shortened regimen is:

46 months KM, MFX, PTO, CFZ, PZA, INH (high-dose, 15-20 mg/kg, not to exceed
900 mg/day), and EMB

5 months MFX, CFZ, PZA, and EMB

Treatment Using DLM
DLM is indicated in any children over the age of 6 years and who weigh more than 20kg,
with resistance or intolerance to second-line drugs or any child who is at high risk of
treatment failure. For younger and lower weight children meeting this criteria, delamanid
could be considered on a case-by-case basis.

The most important potential adverse effect of DLM is QT interval prolongation. This
has been minimal in studies to date, however children should have baseline and regular
ECGs while on DLM. DLM is metabolized by albumin, and low albumin may increase
the risk of QT interval prolongation.

6
More details are available in: Rapid Clinical Advice: The Use of Delamanid and
Bedaquiline for Children with Drug-Resistant Tuberculosis. The Sentinel Project on
Pediatric Drug-Resistant Tuberculosis 2016. Data and recommendations are rapidly
developing. Ensure you are following the most up to date guidance.

For most children in need of DLM, the backbone regimen will consist of the following
agents, but will need to be adapted to the specific clinical scenario: DLM, LZD, CFZ, KM,
PZA, and CS.

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Weight-based Dosing Charts
Oral first-line anti-TB drugs

High-Dose INH Isoniazid (15-20 mg/kg) Older children who

kg 100 mg tablet weigh more than 14 kg
1.0-2.9 not recommended can use the adult
3.0-4.9 0.5 tab 300 mg tablet in
5.0-8.9 1 tab combination with the
9.0-12.9 2 tabs 100 mg tablet to reduce
13.0-20.9 3 tabs the pill count.
21.0-25.9 4 tabs
26.0-29.9 5 tabs

RIF Rifampicin (10-20 mg/kg)

kg 150 mg tablet 300 mg tablet
1.0-2.9 not recommended
3.0-3.9 0.5 tab -
4.0-4.9 0.5 tab -
5.0-7.9 1 tab -
8.0-12.9 1.5 tabs -
13.0-17.9 2 tabs 1 tab
18.0-25.9 3 tabs 1.5 tabs
26.0-40.0 4 tabs 2 tabs

EMB Ethambutol (15-25 mg/kg) Older children who weigh

kg 100 mg tablet more than 16 kg can use
1.0-2.9 not recommended the adult 400 mg tablet in
3.0-7.9 1 tab combination with the
8.0-12.9 2 tabs 100 mg tablet to reduce
13.0-15.9 3 tabs the pill count.
16.0-26.9 4 tabs
27.0-29.9 5 tabs

PZA Pyrazinamide (30-40 mg/kg)

kg 400 mg tablet 500 mg tablet
1.0-2.9 not recommended
3.0-4.9 0.25 tab 0.25 tab
5.0-5.9 0.5 tab 0.25 tab
6.0-9.9 0.5 tab 0.5 tab
10.0-11.9 1 tab 0.5 tab
12.0-14.9 1 tab 1 tab
15.0-18.9 1.5 tabs 1 tab
19.0-20.9 1.5 tabs 1.5 tabs
21.0-25.9 2 tabs 1.5 tabs
26.0-26.9 2 tabs 2 tabs
27.0-29.9 2.5 tabs 2 tabs

8
Injectable anti-TB drugs (injectable agents or parental agents)

Drugs Daily dose Maximum daily dose

SM Streptomycin 20-40 mg/kg once daily 1000 mg
AMK Amikacin 15-20 mg/kg once daily 1000 mg
KM Kanamycin 15-20 mg/kg once daily 1000 mg
CM Capreomycin 15-20 mg/kg once daily 1000 mg
*Dosing range for AMK, KM, CM based on emerging data and expert practice in the
field, and may differ from some published dosing recommendations

To illustrate dose calculation, take the example of a child who weighs 6.9 kg.

Both the low and high doses for the childs weight are calculated.
For kanamycin:
Low dose: 15 mg/kg x 6.9 kg = 103 mg
High dose: 20 mg/kg x 6.9 kg = 138 mg

A convenient dosing is then chosen between the two numbers.

Select a dose between the two numbers and toward the higher
number. In this case, choose: 125 mg per day, single dose.

Calculate the number of mL to draw up in the syringe based on the

mg/mL concentration of the preparation.

9
Fluoroquinolones

LVX Levofloxacin 15-20mg/kg/day

kg 250 mg tablet 25 mg/mL suspension
1.0-2.9 not recommended
3.0-4.9 0.25 tab 2.5 mL
5.0-8.9 0.5 tab 5 mL
9.0-11.9 0.75 tab 7.5 mL
12.0-16.9 1 tab 10 mL
17.0-24.9 1.5 tabs 15 mL
25.0-29.9 2 tabs 20 mL

MFX Moxifloxacin (7.5-10 mg/kg) The moxifloxacin

kg 400 mg tablet 20 mg/mL suspension suspension is not
1.0-2.9 not recommended available
3.0-3.9 not recommended 1.5 mL commercially and
4.0-4.9 not recommended 2 mL must be prepared.
5.0-7.9 not recommended 2.5 mL
8.0-13.9 not recommended 5 mL
14.0-14.9 0.5 tab 5 mL
15.0-19.9 0.5 tab 7.5 mL
20.0-26.9 0.5 tab 10 mL
27.0-29.9 0.5 tab 12.5 mL

OFX Ofloxacin (15-20 mg/kg) Later-generation

kg 200 mg tablet quinolones such as
1.0-2.9 not recommended levofloxacin and
3.0-7.9 0.5 tab moxifloxacin are
8.0-14.9 1 tab preferred over ofloxacin.
15.0-20.9 1.5 tabs
21.0-26.9 2 tabs
27-29.9 2.5 tabs

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Oral core regimen agents

CS Cycloserine/Terizidone (15-20 mg/kg) For older children who

kg 250 mg capsule 1 capsule in 10 mL cannot swallow capsules,
water the capsules can be
1.0-2.9 not recommended opened and dissolved in
3.0-4.9 0.25 cap 2.5 mL
10 mL water to aid
5.0-8.9 0.5 cap 5 mL
administration.
9.0-11.9 0.75 cap 7.5 mL
12.0-16.9 1 cap 10 mL
17.0-24.9 1.5 caps 15 mL
25.0-29.9 2 caps 20 mL

ETO Ethionamide/Prothionamide (15-20 mg/kg)

kg 250 mg tablet
1.0-2.9 not recommended
3.0-4.9 0.25 tab
5.0-8.9 0.5 tab
9.0-11.9 0.75 tab
12.0-16.9 1 tab
17.0-24.9 1.5 tabs
25.0-29.9 2 tabs

LZD Linezolid
10 mg/kg/dose twice daily for children <10 years of age; 300
mg daily for children 10 years of age. Also give vitamin B6.

Please note that data for the ideal dosing of LZD is still
emerging. Please consult up-to-date guidance for more
information.

CFZ Clofazimine (2-3 mg/kg)

kg 50 mg gel cap 100 mg gel cap
<12.5 1 every other day
12.6 - 25.0 1 daily 1 every other day
25.0-33.9 1 daily
34.0-49.9 2 daily
>50 use adult dose

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Drugs used in shortened regimen

Weight group1
Drug
Less than 33 kg 33 to 50 kg More than 50 kg
Moxifloxacin (MFX) 400 mg 600 mg 800 mg
Clofazimine (CFZ) 50 mg 100 mg 100 mg
Ethambutol (EMB) 800 mg 800 mg 1200 mg
Pyrazinamide (PZA) 1000 mg 1500 mg 2000 mg
Isoniazid2 (INH) 300 mg 400 mg 600 mg
Prothionamide (PTO) 250 mg 500 mg 750 mg
Kanamycin (KM) 15 mg per kg body weight (maximum 1 g)
1
Use this table, based on the WHO recommendations, for children who weigh more than 30 kg. The other dosing
charts in this resource contain doses for children who weight less than 30 kg.
2
In some settings, children will receive 15-20 mg/kg of INH per day, up to a daily max of 900 mg

New drugs

DLM Delamanid
kg Dose
<20.0 Consult an expert
20.0-34.9 50 mg twice daily
>35.0 100 mg twice daily

Additional agents

PAS P-aminosalicylic acid (150-200 mg/kg) PASER is stable for up

kg PASER granules (4 g sachet) to eight weeks at 40C
Daily Twice daily and 75% humidity, and
1.0-2.9 not recommended therefore can be
3.0-3.9 500 mg 250 mg distributed to the patient
4.0-5.9 1000 mg 500 mg on a monthly basis in
6.0-8.9 1500 mg 750 mg
most environments with
9.0-12.9 2000 mg 1000 mg
no cold chain. If storage
13.0-15.9 2500 mg 1250 mg
16.0-20.9 3000 mg 1500 mg of longer than eight
21.0-24.9 4000 mg 2000 mg weeks is needed,
25.0-28.9 5000 mg 2500 mg refrigeration below 15C
29.0-29.9 6000 mg 3000 mg is required.

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Treatment Monitoring Schedule
Month
All children Baseline Ongoing
1 2 3 4 5 6 9 12 15 18
HIV status !
Toxicity (symptoms,
! ! ! ! ! ! ! ! ! ! ! !
signs)
Height and weight ! ! ! ! ! ! ! ! ! ! ! !
1
Audiology ! ! ! ! ! ! !
2
Color vision testing ! ! ! ! ! ! ! ! ! ! ! !
3
Chest x-ray ! ! !
4
TB culture and DST ! ! ! ! ! ! ! ! ! ! !
Creatinine and
1 ! ! ! ! ! ! !
potassium
5
TSH, T4 ! ! ! ! ! ! ! !
Hematology (FBC,
6 ! ! ! ! ! ! ! ! ! !
diff)
LFTs ! ! ! ! ! !
HIV-infected children
7
Cholesterol ! ! ! !
CD4 count and viral
! ! ! !
load

1
Monthly while on injectable and at 6 months following termination of injectable
2
If on ethambutol
3
If any pulmonary involvement
4
Monthly if old enough to expectorate; if unable to expectorate and initially smear or culture
positive, monthly until culture-converted then every three months; if initially smear and culture
negative, perform if clinically indicated. The frequency of sending samples for culture will depend
on the policies of a location. However, in children who were initially smear or culture positive,
attempts should be made to have three or more consecutive cultures taken at least 30 days apart
that are negative after the intensive phase, so that the child can be considered cured under
WHO recommendations.
5
If on ethionamide, prothionamide, or PAS
6
If on linezolid or HIV-infected
7
For patients on ART, depending on the regimen

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Identification and Management of Adverse Events

Type of adverse Likely culprit Identification Management

event drugs

Hepatotoxicity INH, PZA, RIF, Tender liver, visible Stop all drugs;
ETO, PAS, jaundice
Clofazimine Wait for liver function to
(CFZ) return to normal;

Re-introduce drugs
one-by-one
sequentially, every two
days, with monitoring
of liver function before
introducing the next
drug.

Visual problems EMB, LZD Regular testing with Stop EMB and/or LZD,
Ishihara chart or substitute for
alternative drug.

Hearing problems AMK, KM, CM Identified through Consider stopping the

audiometry or injectable drug,
problems in substituting for an
communication. alternative drug,
reducing dose or
increasing dose
interval.

Thyroid ETO, PAS Regular blood Consider thyroxine

dysfunction testing, clinical supplementation (0.05
hypothyroidism or mg daily) if (a) clinical
goiter hypothyroidism, or (b)
raised TSH and
decreased fT4;

If raised TSH and

normal fT4, repeat test
in one month.

14
Renal impairment AMK, KM, CM Regular blood If creatinine rises or
testing, symptoms potassium is elevated,
of high potassium stop injectable,
substitute for
alternative drug, dose
three times a week or
reduce dose.

Severe rash Any drug Severe rash, Stop all drugs;

(Stevens-Johnson peeling mucus
Syndrome) membranes, child Wait until clinical
unwell condition has
improved;

Re-introduce drugs
one-by-one
sequentially, every two
days, monitoring
clinically.

Nausea and ETO, EMB, Clinically Consider separating

vomiting PAS the dosing of ETO from
the other drugs by
giving it in the evening;

Consider reducing the

dose of ETO and
building the dose up to
full dose over two
weeks.

Diarrhea PAS Clinically Split dose of granules

to give small doses
throughout day;

Reduce dose;

Consider loperamide.

Peripheral INH, LZD Clinically Give or increase

neuropathy pyridoxine; reduce
dose of LZD.

If persistent or severe,
stop INH and/or LZD.

15
Neuropsychiatric INH, OFX, LVX, Seizures, Verify correct dosing;
problems MFX, TZD, CS headache, behavior
changes, sleep Stop likely culprit drug;
disturbances
If symptoms persist,
reintroduce and stop
next most likely drug;

If symptoms severe or
persistent, stop all
likely drugs or reduce
dose.

Joint problems PZA, OFX, Clinically Verify correct dosing;

LVX, MFX
Consider reducing
dose/stopping possible
culprit drug;

Consider trial of
allopurinol.

Painful injection AMK, KM, CM Clinically Add local anesthetic to

sites drug in equal volumes;

Vary site of injection on

a daily basis;

If severe, consider
splitting dose and
giving half into two
different sites.

16
Additional Resources for Treatment
We are in the process of creating additional resources to help with common treatment
questions and issues, including videos of pharmacists creating child-size doses of
second-line medications and an audiologist performing a screening.

Links to these videos will be added to this guide when they are available.

17
Programmatic Considerations
Checklist of Symptoms that Suggest MDR TB
Below are some common signs and symptoms of TB and MDR TB in children. Of note,
young children may have more atypical symptoms. If any one of these symptoms is
present for two weeks or more, the child should be further assessed for active MDR TB
disease:

1) Weight loss or failure to gain weight

2) Falling off their growth curve
3) Cough
4) Fever
5) Decreased playfulness, lethargy, or fatigue
6) Swollen glands or lumps in the neck or other areas of the body
7) Headache
8) Vomiting without other gastrointestinal symptoms (this is an indication for urgent
referral)

Suggested Measures for Household Infection Control

Although most transmission of MDR TB occurs in the household prior to a confirmed
diagnosis being made, there are important steps that can be taken to decrease the risk
of transmission. The most important thing to do is make sure all household members
who have been diagnosed with TB or MDR TB are able to take their treatment daily and
are supported in their treatment journey so they can achieve the best possible
outcomes. Other household infection control measures include:

1) Providing separate sleeping quarters/space, or at least a separate bed, for

persons who have been diagnosed with MDR TB;
2) Opening curtains and windows to allow for maximum sunlight and ventilation in
the household;
3) Spending as much time outdoors as possible when weather permits;
4) Using fans or other measures to increase ventilation in the home;
5) Improving the nutritional status of the household, with assistance from
organizations working in the community if necessary;
6) Having the person with MDR TB wear a mask is not necessary once that person
has a negative smear, provided that he or she is able to remain on effective
therapy; in some potentially high-risk situations (e.g., during breastfeeding if the
mother has MDR TB), masks could be worn by the person infected with MDR TB
to limit the risk of transmission.

All measures aimed at decreasing the risk of infection should be done with a sense of
compassion for the household member or members with MDR TB. Having MDR TB can
be an isolating experience, and people often blame themselves (or are blamed by
others) for exposing the household to this disease. While it is important to minimize
actual risks of transmissionagain, which are highest before the diagnosis and initiation

18
of therapyit is also important to ensure that undue stress is not placed on the family
during this difficult time.

Activities to Take Place at Screening Visits

Ongoing household screening and assessments are recommended after an MDR TB
exposure has been documented. This is because there may be people in the household
who have been exposed to and infected with MDR TB but who have not yet become
sick. Ongoing screening should be part of all post-exposure interventions, taking place
every three months if possible (or more frequently if there are high-risk individuals in the
home). The following activities are recommended for each screening visit:

Initial screening visit

Verify names and ages of all persons living in the household;

Ask about any additional people who are living in the household or who were
living in the household when the person(s) with MDR TB were sick;
Complete the contact log/register;
Perform symptom screening for each household member;
Plan for referral for persons with symptoms or signs of TB;
Provide (or refer) for HIV counseling and testing;
Review symptoms that should prompt immediate referral to a healthcare center;
Discuss plans for how family members will get to a healthcare center if symptoms
develop;
Review household measures that could be taken to decrease risk of infection in
the household;
Review community resources that could support the family if they need
nutritional, psychological, or economic support;
Assess the therapeutic journey of any persons in the household on treatment and
plan for referral if any problems are detected;
Plan for next visit.

Visit 2

Ask about any additional persons who may have joined the household;
Ask about follow-up/results for each household member who was referred;
Perform symptom screening for each household member;
Assess the health books/cards for any children in the household to see if they
have fallen off of their growth curve;
Plan for referral for persons with symptoms or signs of TB;
Provide (or refer) for HIV counseling and testing;
Review symptoms that should prompt immediate referral to a healthcare center;
Discuss plans for how family members will get to a healthcare center if symptoms
develop;

19
 Review household measures that could be taken to decrease risk of infection in
the household;
Review community resources that could support the family if they need
nutritional, psychological, or economic support;
Assess the therapeutic journey of any persons in the household on treatment and
plan for referral if any problems are detected;
Plan for next visit.

Visit 3 (and any additional visits prior to the final visit)

Ask about any additional persons who may have joined the household;
Ask about follow-up/results for each household member who was referred;
Perform symptom screening for each household member;
Assess the health books/cards for any children in the household to see if they
have fallen off of their growth curve;
Plan for referral for persons with symptoms or signs of TB;
Provide (or refer) for HIV counseling and testing;
Review symptoms that should prompt immediate referral to a healthcare center;
Discuss plans for how family members will get to a healthcare center if symptoms
develop;
Review household measures that could be taken to decrease risk of infection in
the household;
Review community resources that could support the family if they need
nutritional, psychological, or economic support;
Assess the therapeutic journey of any persons in the household on treatment and
plan for referral if any problems are detected;
Plan for next visit.

Final visit

Ask about any additional persons who may have joined the household;
Ask about follow-up/results for each household member who was referred;
Perform symptom screening for each household member;
Assess the health books/cards for any children in the household to see if they
have fallen off of their growth curve;
Plan for referral for persons with symptoms or signs of TB;
Provide (or refer) for HIV counseling and testing;
Review symptoms that should prompt immediate referral to a healthcare center;
Discuss plans for how family members will get to a healthcare center if symptoms
develop;
Review household measures that could be taken to decrease risk of infection in
the household;
Review community resources that could support the family if they need
nutritional, psychological, or economic support;

20
 Assess the therapeutic journey of any persons in the household on treatment and
plan for referral if any problems are detected;
Review with family members how to contact the TB care team if any concerns or
problems arise in the future.

21