Tuberculosis (TB): care of the child and protection of staff and patients

This guideline describes the procedure which must be followed whenever a diagnosis of Mycobacterium Tuberculosis (M.TB) infection is suspected or confirmed, to optimally protect staff, patients and other visitors from risk of infection and assist in the care of the child with M.TB (not including Occupational Health policy).

NOTE: We review our guidelines regularly and this guideline is now past its review date. The content of the guideline below may not reflect the most recent evidence based practice. Please use with caution.

Clinical care should be undertaken with or in conjunction with the Infectious Diseases team.

Introduction

This guideline should be read in conjunction with the NICE Clinical Guideline 117 (NICE,2006 & 2011) and Joint Tuberculosis Committee (JTC) of the British Thoracic Society (BTS) guidelines for ‘Chemotherapy and management of TB’ (1998)  and JTC BTS guidelines for the’ Control and Prevention of TB’ (2000 and 2010).

Please note: that the NICE Guidance is in the process of being updated and this is expected to be published in October 2015. Update of Clinical Guideline 117 Tuberculosis- clinical diagnosis, and measures for its prevention and control, incorporating PH37 Tuberculosis - Hard to reach Groups. Topics included Diagnostic procedures, Infectious diseases, Mental health/ behavioural conditions, Public health and, Respiratory.

M.TB is usually caused by an organism in the mycobacterium tuberculosis complex, usually mycobacterium tuberculosis (M.TB) or mycobacterium Bovis (M. Bovis). M.TB will now be referred to as TB (Tuberculosis) in this document.

There are other environmental or atypical mycobacterial species (for example, mycobacterium avium or mycobacterium maimoense), which do not have the same degree of infectivity and are therefore not covered by this guideline.

This guideline does not cover BCG vaccination, as this is not currently performed routinely within the Trust. If necessary, please refer to NICE guideline (NICE, 2011); refer to GP or local TB team. Please also note that staff pre-employment screening and immunisation is covered in the Occupational Health (OH) policy (please contact OH if need to discuss policy). 

Source and route of transmission

TB is usually spread by the airborne route from cases of pulmonary TB (PTB) disease, which is the most common form of adult and paediatric TB. People with sputum-smear-positive tuberculosis are the main transmitters of mycobacterium tuberculosis within communities.

Great Ormond Street Hospital (GOSH), however, tend to see more children/young people with complex TB affecting other systems (e.g. TB of the lymph nodes, TB Meningitis (TBM), TB of the bone, abdomen etc). Non-pulmonary TB is usually not infectious, although some clinical material may be (e.g. CSF, lymph node biopsy) (Rationale 1). 

However the child with suspected/diagnosed TB is usually accompanied by adults who may have pulmonary TB and be the source of infection. As such the adults must be treated as potentially infectious until Pulmonary TB disease can be ruled out. 

Risk factors 

Children living in areas of high prevalence, including those living in poverty, are at increased risk of exposure to TB. 

Age and additional disease or treatment 

Some children are at higher risk of developing TB disease such as those: 

  • with an immune deficiency (congenital or acquired) 
  • on steroids
  • receiving chemotherapy for cancer and/or transplant 
  • young children, especially <1 month - 5 years 

Definition of significant exposure 

For non-immune compromised individuals, eight hours of exposure to an infectious person in a confined space is considered to be a significant contact (Joint Tuberculosis Committee of the British Thoracic Society 2000).

With immune compromised individuals transmission may result from: 

  • a shorter period of exposure or 
  • exposure to less infectious cases

Detailed individual risk assessment is necessary when reviewing potential exposure in hospital. 

For HIV positive long term non-progressors who require Highly Active Antiretroviral Therapy HAART quickly due to opportunistic infections, and patients with low CD4 counts should have a baseline chest x-ray prior to commencing treatment. (Rationale 2).

Treatment  

Pulmonary TB is generally treated by a six-month course of anti-tuberculosis medication. A longer course of treatment may be prescribed for children with non-pulmonary TB. Treatment may also be given to prevent disease.

Actions to be followed when the diagnosis of M.TB is suspected 

Pre-admission

  • Prior to admission determine whether pulmonary TB is suspected/diagnosed and the results of any tests should be provided. 

  • See doctors's admission checklist Appendix 1 (Rationale 3).

  • Determine whether it is admission scenario A or B (see below), before admitting patient. 

  • NB: If in doubt treat as scenario B. 

  • Ascertain the language spoken by the family and arrange for an interpreter to be present if necessary (see Trust information for staff: communicating with non-English speaking families) (Rationales  4, 5 and  6).

  • Allocate a bed for the child and parent/carer(s) in liaison with ward staff (Rationale 7).

  • Follow admission scenario A or B below.

Admission scenario A 

  • clear chest X-ray (at local hospital/in community). 
  • pulmonary TB not diagnosed/suspected in child or parent. 

Admission scenario B  

  • pulmonary TB diagnosed/suspected in child and/or 
  • no chest X-ray and/or 
  • status of parents unknown/pulmonary TB suspected. 

Admission A: clear chest X-ray (at local hospital/in community), pulmonary TB not suspected in child or parent. 

  • Admit the child to a side room/cubicle with non-mechanical ventilation or a cubicle with air-lock and balanced or negative pressure. The door must be kept closed. NB: Not a positive pressure cubicle (contact a member of the Infection Prevention and Control Team if unsure) (Rationale 8)
  • Inform the Specialist Nurse /Clinical Nurse Specialist (CNS) for Infectious Diseases (ext. 8555/8231) (Rationales 9 and 10).

Admission B: pulmonary TB diagnosed/suspected in a child and/or no chest x-ray, or status of parents unknown/pulmonary TB suspected. 

Admit the child to one of the following: 

  • Side room/cubicle with non-mechanical ventilation or either balanced or negative pressure cubicle (Rationale 11).
  • Balanced or negative pressure cubicle with air-lock (especially if patient/carer is on a ward with immuno-compromised patients for example those on high-dose steroids, immuno-deficiencies). NB: Not a positive pressure cubicle (Rationale 8).
  • The room/cubicle door must be kept closed. 

Personal Protective Equipment (PPE) - See child/staff protection: use of PPE in addition to standard precautions section in this guideline. 

Protective face masks/respirators

  • FFP2- suspected or confirmed pulmonary TB 
  • FFP3*- suspected or confirmed multi-drug resistant TB (MDR TB), extensively drug resistant TB (XDR TB) and totally drug resistant TB (TDR TB).

*NB: Staff must be "fit tested" for FFP3 masks Appendix 2.

Inform Infection Control and Prevention Team (ext 5284 and bleep 0640)/Specialist Nurse/Infectious Disease Team CNS (ext. 8555/8231) (Rationales 9 and 12).

Until pulmonary TB is ruled out in the child and parent/carer they should be confined to the cubicle/side room. 

The child and the parents/carers should not use any communal facilities and any visitors other than the parents/carers should be restricted until pulmonary TB has been ruled out. 

Prior to pulmonary TB being ruled out when the parent/carer needs to leave the cubicle/side room in order to leave the ward and make their way out of the hospital they should wear an FFP2 mask/respirator. 

Where possible, ward staff should negotiate washing, cooking, provision of toys etc. with the child and family to minimise risk of cross infection (Rationale 11).

Parent/sibling care 

Chest X-ray (CXR) at GOSH for parents/carers should be organised (preferably via Infectious Diseases Registrar) within 24 hours of the child’s admission (Rationale 13).

The person ordering the CXR should take down the form to the X-ray department (Rationale 14) and they should discuss the request with the X-ray technicians rather than the department clerk. 

Ask the X-ray department to call the ward when the department is ready for the parent /carer. This should be out of hours (usually after 4pm) (Rationale 11).

The parent/carer should be asked to wear a facemask (FFP2) to the department, throughout the procedure and until they have returned to the cubicle on the ward (Rationale 11).

To request a Radiology test for a family member please: 

  • Do not use the child's record on PiMS to request a test for a family member.
  • The family member must be registered on PiMS (if they are not on PiMS already) to generate their own unique number. 
  • The request must be made on PiMS using the family members record.
  • Downtime forms will not be accepted by Radiology.
  • Do not enter the child’s hospital number or place the child’s PiMS label over the patient details boxes.  
  • The child’s hospital number and name should be stated clearly or a PiMS label placed elsewhere on the form, indicating that this test is on a relative and that relative’s relationship to the child.  

The parent/carer(s) should not use communal facilities on the ward, in parent accommodation or in the hospital buildings until pulmonary TB is ruled out (NICE 2011) (Rationale 11).

The ward manager or (in the absence of the ward manager) the nurse in charge should negotiate with parents/carers how laundry, meal times (making meals and clearing/cleaning dishes) and other daily activities will be achieved whilst in isolation.  

Asymptomatic family members, if available, should be recruited for help in this matter but in some circumstances ward staff may need to help. 

Used cutlery and crockery should be cleaned promptly using hot soapy water or a dishwasher. 

Chest X-ray reports for parents/carers/sibling 

Chest X-rays should be reported by a Consultant Radiologist. If CXR regarded abnormal a CT scan will normally be required (Rationale 16).

The CNS/Specialist Nurse Infectious Diseases at GOSH will liaise with UCLH or local TB services, to arrange the follow-up the parents/carers as required.  

Siblings/other family members/close contacts will be followed up by local TB services as part of contact screening. 
Chest X-ray normal. 

The parent/carer does not need to be kept in isolation and may use communal facilities (Rationale 15). The parent/carer does not need to wear a mask while not with child. 

The parent/carer should be referred to a local TB service (or UCLH if resident at GOSH and live outside London) for a skin test (Rationale 17).

Chest X-ray abnormal 

Ideally any parent/carer requiring treatment for TB should not be at GOSH but at home managed by their local service. If they are is the only available carer, the parent/carer must be kept in isolation until he/she has received two weeks of anti-TB medication (if sensitive to the medication) (Rationale 18).

If the parent/carer remains at GOSH, movement through the hospital should be limited where possible. The parent/carer should be asked to wear a facemask (FFP2) when accompanying the child to departments if necessary or when moving through the Trust when leaving the hospital (Rationale 11).

TB service at UCLH  

If the family live further away from GOSH, UCLH can perform basic screening on parents/carers. The CNS/Specialist Nurse Infectious Diseases normally arranges this (Rationale 19). The staff at UCLH must be contacted to arrange this, so that the appropriate documentation is completed:

Tel: 020 7380 9259 and Fax: 020 7380 6998 

UCLH address:

TB clinic
Ground Floor Rosenheim Buildings Grafton Way (off Tottenham Court Road)
London
WC1E 6AU  

A letter of referral including any X-ray downloaded onto a CD and any other test results should be provided. Request form for downloading CXR to CD available on PiMS. 

UCLH clinic times: Monday afternoon between 1.30-3.30pm. 

Child/staff protection: use of PPE in addition to standard precautions

When caring for a child with suspected pulmonary TB, use a mask (FFP2 or *FFP3), a visor (when performing aerosol generating procedures) and apron (Rationale 20).

  • If CXR is not normal or not yet performed. 
  • When TB status of parent/carer(s) is unknown regardless of the child’s results (Rationale 20).
  • Pulmonary disease diagnosed (e.g. lung collapse, cavitation, caseation, haemoptysis), even if the child is smear negative. 
  • If the child is sputum smear positive. 
  • For high-risk procedures such as suctioning, intubation, chest surgery, gastric washings, induced sputum (NICE 2011). 
  • *All multi-drug resistant TB cases (FFP3) (NICE, 2011). 
  • TB/HIV co-infection (Joint Tuberculosis Committee of the British Thoracic Society 1998: 2010: NICE 2011).
  • If in doubt, please contact Infection Control and Prevention Team/Specialist Nurse or CNS Infectious Diseases who will perform a risk assessment for the use of PPE for each individual case of patients with TB. 
  • If the teams are not available, use a FFP2 mask until a risk assessment has been performed, but especially in the aforementioned cases.  
  • Infectious precautions should remain in place until the infectious patient/parent/carer(s) has taken anti-TB medication for two weeks if TB sensitive to drugs (NICE 2011) (Rationale 18).
  • If smear samples for microscopy are obtainable patient should have 3x smear negative sputum samples for TB or MDR TB. 
  • If the patient presents in clinic and a  CXR/sputum is requested to rule out TB, the patient must be isolated ASAP and a mask used by the patient and attending family members (unless they have negative screening for TB) go to, and during, the CXR procedure (Rationale 21).  

Advice on the correct use of masks/respirators 

How to put on an FFP2/FFP3 mask/respirator:

  • Select an FFP2/FFP3 mask/respirator (NB staff have to be fit-tested for FFP3 respirators).
  • Place over nose, mouth and chin.
  • Fit flexible nose piece over nose bridge.
  • Secure on head with elastic.
  • Adjust to fit.
  • For non-valved masks perform a quick fit-check:
    • inhale – mask should collapse
    • exhale – check for leakage around the face 

Removing an FFP2/FFP3 mask/respirator 

  • Break ties/elastic at side to remove.
  • Pull off face without touching outside of mask (Rationale 22).
  • Discard mask in a clinical waste bin.
  • Wash hands. 

Dos and don’ts 

  • Do not hang the mask around your neck or rest in your pocket (Rationale 22).
  • Do not handle the outside of a worn mask (Rationale 22).
  • Do not re-use the mask. FFP2/FFP3 masks/respirators can be worn for eight hours continuously, but are single use only.
  • Do not give valved masks/respirators to patients/parents (Rationale 23).

Use of masks and isolation can be discontinued when (Rationales 18, 24 and 25).

  • CXR clear and where available, the sputum/gastric washings are reported to be smear negative and the patient does not have MDR TB. 
  • Please confer with the Infection Control and Infectious diseases Teams on a case by case basis if the above information is not available or the results are not reported to be clear”.

Members of staff who are immunosuppressed/post transplant should avoid contact with patient with suspected or confirmed TB. 

Staff who have not had BCG or those who are pregnant need not take further precautions than those described above. 

Contact Occupational Health for further information.

PPE (above standard precautions) is not required for non-pulmonary TB when chest status of child and parent/carer is known to be non-TB.  

Child/staff protection: isolation 

Always use 'Airborne/Droplet Isolation Precautions' door signs on the door of the cubicle if infectious TB or MDR TB is diagnosed or suspected (Rationales 26 and 27).

If the child is in a room with an air-lock, ensure that the antechamber is used correctly (Rationale 28).

Children and parent/carer(s) with suspected or proven infectious TB or MDR-TB should only be admitted into a room with an air-lock (NICE, 2011) (Rationales  26 and 29).

Visitors should be strictly limited to two carers (Rationale 30 and 31).

Siblings should also be prevented from visiting unless they are a breast feeding infant (Rationale 31).

Some basic sibling screening is performed on an individual basis but is usually referred to local TB services. 

Diagnosis 

Do not rely solely on one diagnostic result. Observe the child and family in terms of: 

  • their ethnic origin 
  • previous TB history or contact 
  • BCG history 
  • other diagnostic results 
  • clinical signs and symptoms  

NB: When collecting data in relation to household contacts, this should include all members of the extended family/close friends (residing in or staying in the home) and anyone who has been "unwell", irrespective of symptoms and existing diagnosis (Rationale 32).

Chest X-ray 

  • should always be done within 24 hours of admission (Rationales 33 and 34).
  • out of X-ray hours or mobile if urgent 
  • CXR should be undertaken for parent/carer accompanying child to rule out TB disease.

Mantoux test

Tuberculin skin test (TST)/ purified protein derivative Skin test (PPD) for TB.  

The tuberculin skin test (TST) is the standard method of determining whether a person is infected with Mycobacterium tuberculosis.  

Reliable administration and reading of the TST requires standardization of procedures, training, supervision, and practice. It should only be performed by those who have received training to do so. Prescribe 2 units (0.1ml of 20 units/ml strength) of

Tuberculin purified protein derivative (PPD) SSI intra-dermally as a once-only dose on the front of the child’s medication chart (Rationale 35).

Be aware of different strengths. 10 tuberculin units may be prescribed in some cases. NB: This should only be prescribed when advised by Infectious Diseases/Infection Control team. 

Reading the Mantoux

Induration should be measured in millimetres transversely to the long axis of the forearm with a clear, plastic, flexible ruler 48-72 hours after administration.

Please contact the Infectious Diseases team for interpretation of the result Appendix 3 (Rationale 36). 

Currently:

  • 0-5 mm negative result
  • 6-14mm positive result. 
  • ≥ 15mm strongly positive result 

NB:  The advice regarding TB exposure and interpretation of mantoux test results will vary for neonates, children older than 4 weeks but less than 2years and for children older than two years (NICE 2011).

A positive reaction indicates: 

  • infection with mycobacterium tuberculosis complex
  • infection with non-tuberculous mycobacteria
  • previous BCG vaccine 
  • ≥ 15mm is regarded to be a strong indication of infection of mycobacterium tuberculosis complex (NICE, 2006 and 2011).

Please note that the NICE guidelines are currently under review and will be updated in October 2015. The above parameters in relation to interpretzation of mantoux test results may be subject to amendment.

Heaf Test

No longer performed in the UK. 

Other tests used to confirm a diagnosis of TB

Sputum 

  • Collection of three sputum samples.
  • Send for ZN staining and Microscopy, Culture and Sensitivities (M, C &S) (TB (mycobacteria) microscopy and culture is requested on PiMS). 

Quantiferon TB test

  • At  GOSH QTB should be carried out with a mantoux skin test and CXR,
  • Important in people whose mantoux testing shows positive results and for those in whom mantoux testing may be less reliable, for example BCG-vaccinated people (NICE 2011).
  • Should be performed in discussion with the Infectious Diseases Team/Microbiology
  • Microbiology will organise sample collection bottles.  

What is Quantiferon? 

  • It is a serological test 
  • It measures amount of interferon produced by cells 
  • It detects latent/overt TB 
  • interferon from T-lymphocytes activates macrophages that kill mycobacteria 
  • it has a control and antigen tube, assisting in identifying differences between the two tubes. Positive result= >0.35lU/ml.
  • Pros: more sensitive. Useful in patients who are malnourished, HIV. Differentiates between BCG. 
  • Cons: cross reactivity with mycobacteria kanasasi.  

Gastric washings/lavage 

  • Please see microbiological specimen collection hyper link for instruction on how to perform a gastric washing/lavage for TB diagnosis (Rationale 37).
  • Not recommended in children >6 yrs depending on development (Rationale 38).
  • Send for ZN staining and Microscopy, Culture and Sensitivities (M, C &S), (TB (mycobcteria) microscopy and culture on PiMS) (Rationale 39).

Other 

There are other diagnostic tests that can be performed (e.g. TB mycobacteria PCR on PiMS). NB: These should be performed in discussion with the Infectious Diseases team/Microbiology.

Notification of TB to Consultant for CDC and entry on the London TB Register (LTBR) 

Refer to the TB Protocol and Incident Plan (Appendix 4).

It is the duty of the physician making the TB diagnosis to make a statutory notification.  

The child's medical team must inform the Consultant for Communicable Disease Control. The Specialist Nurse/CNS Infectious Diseases are responsible for ensuring that the patients are entered into the London TB Register (LTBR) and that this is kept updated. The Health Protection England (HPE) are notified by entering the child onto the LTBR.

Refer to the GOSH Infection: management of outbreaks, including diarrhoea and vomiting guideline for advice regarding outbreaks or contact tracing.

Treatment 

  • Treatment should be prescribed in accordance with NICE TB Guideline (NICE 2011, World Health organisation (WHO) 2010, 2011) and always in partnership with the Infectious Diseases team.  
  • Pyridoxine should be prescribed with Isoniazid for breast-feeding or malnourished children (Rationale 40).
  • Obtain baseline liver function tests (LFTs) prior to commencing TB medication (Rationale 43).
  • Obtain a baseline eye examination prior to commencing TB medication (Rationale 44).
  • Ensure that the parent/carer(s) and child understand the reason for treatment and the necessity for taking medication as per regime (Rationale 41).
  • Ensure that the child is tolerating each dose of medication. Take appropriate action if the child is having difficulties (tablets vs. syrups, NG tube (Barnie and Currier 1995), Directly Observed Therapy short course (DOTs)) (WHO, 2010 & 2011). 

Please note that Video Observed TB Therapy VOTT has also been used for complex TB patients i.e. those struggling with medications, multi-drug resistant TB, TB patients already on a drug regime for other long term/chronic illness. The Outreach Team at UCLH for Camden & Islington provides this service. It should be explored whether the service is offered in other areas.

  • Ensure that the parent/carer(s) and child are competent at administering TB medication prior to discharge (Rationales 41and 42).

Discharge 

  • Prior to discharge, ensure that the child is tolerating TB medication and that the parent/carer(s) are confident and competent in its administration (Rationales 41, 42, 46 and 47).
  • Organise Directly Observed Therapy Short Course (DOTs) if concerns are raised about adherence to treatment (the Specialist Nurse/CNS Infectious Diseases will usually do this).
  • Write a discharge summary as per GOSH policy and ensure that this is copied to relevant internal and external agencies (Rationale 48).
  • Book the child into the next TB clinic (Clinic Code INF3).  
  • Ensure that child is dispensed enough medication to last until Outpatient appointment. 
  • Refer the family to social services if necessary (Rationale 49).

Follow up Outpatient appointments 

Pulmonary TB patients should be isolated on first visit to clinic regardless of having three negative sputum test results whilst and inpatient. Further sputum must be sent to M. C. & S at this first clinic visit. 

If the patient remains negative then no further isolation precautions required unless the patient subsequently becomes symptomatic (Rationale 45).

Rationale

Rationale 1 Extra-pulmonary TB disease is more common in children than in adults (Shingadia and Novelli, 2003).
Rationale 2 As their CD4 falls and treatment is required, this patient group is vulnerable to reactivation of latent TB infection
Rationale 3 Guides practitioners through the process of admission.
Rationale 4 To avoid a delay in the clerking/admission processes due to language barrier.
Rationale 5 To enable the child and parent/carer(s) to voice any concerns.
Rationale 6 To ensure that the child and parent/carer(s) are fully informed regarding diagnostic procedures, treatment, etc.
Rationale 7 To ensure that the child and family are placed in an appropriate bed according to their infection control needs (see admission notes below and doctors checklist).
Rationale 8 A side room/balanced cubicle/negative pressure cubicle acceptable for suspected/diagnosed TB and whilst the team are confirming status of child/parents/caregivers. A positive pressure cubicle is never recommended for possible/diagnosed TB.
Rationale 9 To enable the CNS to commence community communication.
Rationale 10 Acts as resource to the family and ward staff.
Rationale 11 To prevent cross infection to other patients/families/staff members.
Rationale 12 To aid diagnosis of/rule out pulmonary TB in parent/carer(s) (NICE, 2011, Munoz et al, 2002).
Rationale 13 The Infectious Disease team has permission from the X-ray department superintendent for screening resident parents/carers of children suspected of having TB. X-rays on other family members within the Trust is only performed in extenuating circumstances.
Rationale 14 This exceeds NICE guidance as the Trust aims to offer the highest level of protection to children, families and staff (NICE, 2011).
Rationale 15 Once Pulmonary TB has been ruled out through CXR and the parent/carer(s) therefore pose no risk to other children, family or hospital staff.
Rationale 16  To provide expert review and reporting of CXR.
Rationale 17 To ascertain whether parent/carer(s) has had TB infection in the past, or if they have latent TB requiring prophylaxis.
Rationale 18 Patients are generally considered to be non-infectious after two to 3 weeks of medication, provided that they are fully sensitive to the medication prescribed (Joint Tuberculosis Committee of the British Thoracic Society, 1998: 2010:  NICE 2011)
Rationale 19 For further screening, diagnostic tests, treatment and follow up.
Rationale 20 Pulmonary TB is an airborne disease. Correctly fitted masks prevent cross infection.
Rationale  21 If there are investigations being undertaken due to a suspicion of TB disease, then patient needs to be treated as potentially infectious. 
Rationale  22 To avoid contaminating the face, neck and hands.
Rationale 23 Valved masks protect only the wearer of the mask. They are not suitable to be worn by infectious patients/parents with the intention to protect attending staff or the environment.
Rationale 24 Children are, generally considered to be, non-infectious, but this should not be assumed (Joint Tuberculosis Committee of the British Thoracic Society, 2000, American Academy of Pediatrics, 2000: NICE 2011)
Rationale  25 Adults tend to be infectious.
Rationale 26 Children and parent/carer(s) with suspected or proven infectious TB or MDR-TB should only be admitted into a negative pressure room.
Rationale 27 Acts as a prompt for all hospital staff that infectious precautions are necessary.
Rationale 28 To ensure that air change has occurred.
Rationale 29 To prevent airborne droplets from spreading.
Rationale 30 Family members and friends may also have infectious TB.
Rationale 31 Limiting visitors prevents cross infection to other patients/families and hospital staff.
Rationale32 The TB index case may be an extended family member/friend who is/has resided in the patient's home and in an individual with TB diseases the symptoms may not present typically.
Rationale 33 To observe for radiological signs of pulmonary TB (e.g. hilar/mediastinal lymphadenopathy, lung parenchymal changes, focal mass, miliary TB).
Rationale 34 Cavitation is rare in younger children but does occur in adolescents.
Rationale 35 The skin test shows whether the child has been exposed to TB before. This could show latent TB infection or active TB disease.
Rationale 36  It is possible to get a false positive and a false negative depending on level of infectivity and disease, BCG immunisation and immuno-suppression.
Rationale 37 Younger children with pulmonary TB rarely produce sputum.
Rationale  38 <20 per cent of children with proven TB will have a positive sputum or gastric washing result from ZN staining. This compares to 75 per cent in adults (Shingadia and Novelli, 2003).
Rationale 39 Mycobacterial culture of sputum, gastric washings and extra-pulmonary sites yields more positive results (between 30 and 70 per cent) (Shingadia and Novelli, 2003).
Rationale 40 Pyridoxine is given to prevent Isoniazid neuropathy.
Rationale 41 Failure to adhere to the prescribed treatment regime causes problems with drug resistance.
Rationale 42 In order that they can continue correct administration of the medication at home.
Rationale 43 Isoniazid, Rifampicin and Pyrazinamide are hepatoxic.
Rationale 44 Ethambutol can cause optical neuritis.
Rationale 45: To minimise the risk of there being TB contacts when child has first follow-up in outpatients
Rationale 46 To prevent the possibility of MDR TB.
Rationale 47  To effectively treat the disease.
Rationale 48 To promote communication between GOSH and local colleagues.
Rationale 49 To help with housing/income needs that are common with this patient population.

References

Reference 1:
American Academy of Pediatrics (2000) Tuberculosis Pickering LK, Peter G In: Red Book: Report of the Committee on Infectious Diseases (25th edtion). Illinois, American Academy of Pediatrics.

Reference 2:
Barnie DC, Currier J (1995) What's that GI tube being used for? RN 58 (8): 45-8; quiz 49. Viewed on 19/08/2015

Reference 3:
Joint Tuberculosis Committee of the British Thoracic Society (1998) Chemotherapy and management of tuberculosis in the United Kingdom: recommendations 1998. Joint Tuberculosis Committee of the British Thoracic Society. Thorax 53 (7): 536-48. Viewed on 19/08/2015

Reference 4:
Joint Tuberculosis Committee of the British Thoracic Society (2000) Control and prevention of tuberculosis in the United Kingdom: code of practice 2000. Joint Tuberculosis Committee of the British Thoracic Society. Thorax 55 (11): 887-901.

Reference 5: 
Joint Tuberculosis Committee of the British Thoracic Society (2010) Guidelines for the prevention and management of Mycobacterium tuberculosis infection and disease in adult patients with chronic kidney disease. Thorax 65:559-570. Viewed on 19/08/2015.

Reference 6:
Munoz FM, Ong LT, Seavy D, Medina D, Correa A, Starke JR (2002) Tuberculosis among adult visitors of children with suspected tuberculosis and employees at a children's hospital. Infect Control Hosp Epidemiol 23 (10): 568-72. Viewed on 19/08/2015

Reference 7:
National Institute of Clinical Excellence (NICE) (2006) Tuberculosis: clinical diagnosis and management of tuberculosis, and measures of its prevention and control. NICE Guidelines CG33. London, NICE

Reference 8:
National Institute of Clinical Excellence (NICE) (2011) Tuberculosis: clinical diagnosis and management of tuberculosis, and measures of its prevention and control. London, NICE. Viewed on 19/08/2015

Reference 9:
Shingadia D, Novelli V (2003) Diagnosis and treatment of tuberculosis in children. Lancet Infect Dis 3 (10): 624-32. Viewed on 19/08/2015

Reference 10:
World Health Organization (2010) Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response. WHO/HTM/TB/2010.3. Viewed on 19/08/2015

Reference 11: 
World Health Organization (2011) Global tuberculosis control: WHO Switzerland.

Document control information

Lead Author(s)

Laura Caddle, Nurse Specialist (CNS), Infectious Diseases

Additional Author(s)

Jacquie Flynn, Nurse Specialist, Infectious Diseases
John Hartley, Consultant Microbiologist/Director of Infection Prevention and Control, Microbiology/Infection Control

Document owner(s)

Jacquie Flynn, Nurse Specialist, Infectious Diseases

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
15 June 2006
Date approved: 
14 August 2015
Review schedule: 
Three years
Next review: 
14 August 2018
Document version: 
3.0
Previous version: 
2.0