Remarks:

• These recommendations relate to TB services along the full range of care with a focus on case detection and provision of TPT.
• The recommendations apply to children and adolescents with signs and symptoms of TB in terms of the impact on case detection. They also concern children and adolescents who are exposed to TB (i.e. TB contacts), and who are eligible for TPT, in terms of the impact on provision of TPT. Children and adolescents with signs and symptoms who need evaluation for TB disease may also have a history of exposure to TB (i.e. TB contacts). Children and adolescents who are TB contacts and who do not have signs and symptoms should be evaluated for TPT eligibility.
• The recommendation on decentralized services refers to enhancing child and adolescent TB services at peripheral levels of the health system where they are closer to the community, and not to replacing specialized paediatric TB services at higher levels of the health system.
• Decentralization should be prioritized for settings and populations with poor access to existing services and/or in high TB-prevalence areas.
• Family-centred, integrated approaches are recommended as an additional option to standard TB services (e.g. alongside specialized services that may have a limited level of integration with other programmes or links to general health services).
• Family-centred care is a cross-cutting principle of child care at all levels of the health system.

Subgroup considerations Adolescents have a disease presentation that is similar to that of adults and therefore may need different interventions than those for young children. Additional subgroup considerations for adolescents are included in the WHO operational handbook, taking into account their specific healthseeking behaviour and the need for adolescent-friendly services. TB contacts: Provision of TPT has for many years focused mainly on children under five years of age. In 2018, target groups for the provision of TPT were expanded to include contacts of all ages (160). Available data from the global TB database (161) show that coverage of TPT in household contacts is poor – especially in contacts over five years of age. In children with common illnesses with overlapping signs and symptoms of TB, approaches that integrate TB services in their care can improve case detection and provision of TPT. These subgroups include:

• children with SAM;
• children with severe pneumonia;
• children living with HIV; and
• children with other chronic diseases.

Implementation considerations Health system requirements: Training of health-care workers at peripheral levels of the health system is a critical requirement for ensuring that decentralized approaches are implemented adequately. Similarly, resources are needed at the peripheral level – especially initially to establish services. It is expected that, as services are established and effectively implemented, the long-term impact will result in a decrease in TB incidence with an associated reduction in resource requirements. A phased approach may be applied if this is most appropriate in the country or area, depending on the local burden of TB, the availability of domestic or donor funding and the amount of technical and programmatic support. Factors to consider in decentralizing child and adolescent TB services include: the existing infrastructure (such as baseline health infrastructure, needs for expansion or upgrading); an applicable regulatory framework; financing; the choice between an operational research setting or programmatic implementation; human resource issues (including staffing requirements and human resources development, such as capacity-building/training and consultation skills); monitoring and evaluation; qualitative research into community needs; perceptions (including views on stigma); and suggestions. Decentralization of services to the PHC level requires that child and adolescent TB services are integrated within general PHC services, resulting in possible significant overlap between decentralization and family-centred, integrated approaches. Contact investigation: Active contact investigation at community and household level is a critical intervention for enhancing both case-finding and the provision of TPT to children and adolescents. Task-shifting: Decentralization not only concerns the levels of the health system but should ideally also take place within the same structure, by training all health-care providers of all child and adolescent care services in the recognition and management of TB. This so-called task-shifting was mentioned by the GDG as an important implementation factor. Family-centred and integrated care: Although in child health, care evolves around the family, the concept of family-centred care has not been well defined. Family-centred care is related to the more common concept of patient-centred care. The End TB Strategy (162) states: “Patient-centred care involves systematically assessing and addressing the needs and expectations of patients. The objective is to provide high-quality TB diagnosis and treatment to all patients – men, women and children – without their having to incur catastrophic costs. Depending on patients’ needs, educational, emotional and economic support should be provided to enable them to complete the diagnostic process and the full course of prescribed treatment.” Multiple descriptions exist that include components of support and education based on individual needs, building a patient–provider partnership and participatory decision-making. Family-centred care also includes interventions at household level to identify members of the household requiring evaluation for TB disease, TPT, treatment support and so on. As the concept of family-centred, integrated care may be specific to the setting, one of the first steps in implementation includes clarifying which definition applies to the setting in which the care is to be implemented. Similarly, the implementation strategy varies by setting and needs to be country- or region-specific and informed by social, cultural and societal values. The package of TB services to be provided should be defined and developed by the national TB programme in close coordination with other relevant programmes, such as through an existing child and adolescent TB technical working group. This package should seek to identify and address capacity needs for national programmes interested in the uptake of proposed interventions, and should ideally be based on family and community perceptions of the ideal family-centred model of care. The package could include community-based models for active contact investigation, identifying children with TB signs and symptoms or exposure as part of routine growth-monitoring services, or an integrated model for IMCI integration, starting with the sick child and identifying signs and symptoms pointing to a high likelihood of TB. Integration can start within the family by equipping family members with the knowledge to recognize signs and symptoms in order to understand the importance of a history of contact, to know when to seek help at the health-care facility and how to minimize stigma related to TB. High-yield entry points provide a good place to start within the health system. For instance, child and adolescent TB services can be integrated with malnutrition clinics, ANC, the Expanded Programme on Immunization, inpatient sites, adult TB and chest clinics, HIV and general paediatric clinics. TB care should ideally be integrated into general health services rather than being limited to enhanced coordination between two programmes. However, defining an optimal patient flow between services and creating strong links between child health entry points and TB clinics remains essential, especially in facilities where services are physically separated. This is critical for enhancing the quality of services, including the follow-up of persons with TB during the diagnostic evaluation, and also for ensuring the accuracy of recording and reporting. In the early phase, pilot programmes could be considered, and should be evaluated and adjusted as needed and then scaled up. Factors to consider in designing an integrated approach to child and adolescent TB care include: the existing infrastructure (e.g. baseline health infrastructure, need for expansion or upgrading); the applicable regulatory framework; financing; the choice between an operational research setting or programmatic implementation; human resource issues (including staffing requirements and human resources development such as capacity-building/training and consultation skills); monitoring and evaluation; qualitative research into community needs; perceptions (including views on stigma; and suggestions. Differentiated service delivery (DSD): DSD is a person-centred approach developed in the HIV programme that simplifies and adapts HIV services across the range of care in ways that both serve the needs of people living with and vulnerable to HIV and optimize the available resources in health systems. The principles of DSD can be applied to prevention, testing, linkage to care, ART initiation and follow-up, as well as to the integration of HIV care, co-infections and co-morbidities (163). This approach is based on the principle that when families are given the choice to interact with the health system, this provides a possible mechanism for integration of child and adolescent TB services within PHC or other programmes. Examples of implementing DSD for children and adolescents with or at risk of TB are provided in WHO’s operational handbook.