Variation in policy and practice of adolescent tuberculosis management in the WHO European Region.

To the Editor:

Tuberculosis (TB) is a major public health concern worldwide. The World Health Organization (WHO) estimates that 9.6 million people fell ill with TB and 1.5 million people died of TB in 2014. Of an estimated total of 1 million children with TB, 140 000 children died [1]. The risk of progression to TB is highest for children <5 years of age. There is a comparatively low risk for those 5–10 years of age, after which the risk of progression to TB increases at the onset of puberty to an adult level of 5–10% [2] as well as the chance of developing an adult-type TB accompanied by increased infectiousness [3]. However, adolescents form a particularly vulnerable group with psychosocial challenges distinct from adults and the usual challenges of transition from paediatric to adult health service provision. Puberty may affect health behaviour and have a significant impact on therapy compliance [4], requiring specific approaches usually not provided by paediatric or adult health services [5].

The current guidelines for childhood TB cover children from 0 to 14 years of age but do not specifically deal with adolescents aged 10–18 years [5, 6]. WHO surveillance guidelines recommend to record and report two age bands (0–4 years and 5–14 years) [5], and thus specific epidemiological information on adolescents is lacking. To gain more insight in TB management among adolescents, the WHO European Regional Task Force on childhood TB conducted a survey among the 53 member states of the WHO European Region [7]. In January 2015, all national TB programme managers and designated childhood TB focal points were asked to provide information on the existence and nature of policies and practical management of adolescents with TB in their country. Responses received by April 30, 2015 were analysed using Excel 2010 (Microsoft, Redmond, WA, USA). 28 (53%) countries responded to the first part of the questionnaire on policy and 20 countries also completed the questions on management of adolescents with TB. The relevant results are summarised in table 1.

TABLE 1

Results from the questionnaire on the sections policy, treatment and prevention

	High-burden countries	Low-burden countries	Total countries
Country income group
Middle income	7/9 (78%)	5/19 (26%)	12/28 (43%)
High income	2/9 (22%)	14/19 (74%)	16/28 (57%)
Policy#
Countries with specific TB care policy for adolescents	4/9 (44%)	2/19 (11%)	6/28 (21%)
Countries that expect adolescents to have increased risk of getting TB	4/9 (44%)	3/19 (16%)	7/28 (25%)
Countries that feel the need for specific guidelines for adolescents	3/9 (33%)	5/19 (26%)	8/28 (29%)
Adolescents with drug-susceptible TB that are allowed to attend school  when smear and culture negative	2/9 (22%)	15/19 (79%)	17/28 (61%)
Practice¶
Countries that initiate ambulatory treatment for adolescents as soon  as possible	2/8 (25%)	5/12 (42%)	7/20 (35%)
Countries that hospitalise adolescents during entire treatment period	2/8 (25%)	0/12 (0%)	2/20 (10%)
Preventive therapy for exposed adolescents	7/8 (88%)	10/12 (83%)	17/20 (85%)
Preventive therapy for adolescents in contact with a DR index case	1/8 (13%)	1/12 (8%)	2/20 (10%)
Routine screening of TB disease in asymptomatic adolescents	3/8 (38%)	3/12 (25%)	6/20 (30%)

TB: tuberculosis; DR: drug-resistant. #: replies from Andorra, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, the Czech Republic, Denmark, Estonia, Finland, Georgia, Germany, Greece, Hungary, Ireland, Luxembourg, Macedonia, Monaco, the Netherlands, Norway, the Russian Federation, Serbia, Slovakia, Sweden, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan; ¶: replies from Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, the Czech Republic, Denmark, Estonia, Georgia, Germany, Greece, Macedonia, Monaco, Norway, the Russian Federation, Serbia, Slovakia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan.

Six (21%) countries reported a designated policy on adolescent TB. The age bands defining adolescents in these countries ranged between 14 and 19 years. In nine (32%) countries, adolescents are managed as children and in 13 (46%) countries as adults from the average age of 15 years (range 14–16 years). Only 25% of the countries perceive adolescents as a specific group with a high risk of TB and only 29% express a need for specific guidance.

All countries treat adolescents with the standard regimen (2 months of isoniazid, rifampicin, pyrazinamide and ethambutol, followed by 4 months of isoniazid and rifampicin) [5] for drug-susceptible TB and second-line drugs for confirmed drug-resistant (DR)-TB. Eight (42%) countries also treat adolescents with clinical TB and recent contact with a DR-TB index case with second-line drugs.

Seven (35%) countries provide early ambulatory care. Six (30%) countries hospitalise adolescents for an average period of 45 days (118 days for DR-TB), five (25%) while the adolescent is infectious and two (10%) countries during the entire treatment period. When ambulatory care is provided, treatment supervision during the intensive phase is often the combined responsibility of caretakers and nurses who provide support through home or school visits. The responsibility is often shifted to the caretaker during the continuation phase. In 17 (61%) countries, adolescents with noninfectious TB can attend school while still on treatment, five countries provide education on hospital or sanatorium premises and in three countries, no arrangements are made to continue school education.

Most countries follow WHO recommendations for contact investigation [6, 8]. Adolescents in the household of an index case (100%), close nonhousehold contacts (95%) and casual contacts (80%) were eligible for contact investigation in most countries. 17 (85%) countries test adolescent TB contacts for latent tuberculosis infection (LTBI) and provide preventive therapy to adolescents with LTBI or exposed to TB.

Six countries conduct routine screening for TB disease in asymptomatic adolescents starting at the average age of 15 years (range 11–18 years) while WHO recommends routine screening only for high-risk groups and geographically defined subpopulations with extremely high levels of undetected TB (1% prevalence or higher) [5, 9].

The specific challenges relating to the management of TB in adolescents mentioned by the respondents are: lack of awareness in healthcare workers of the particular needs of adolescents with TB resulting in poor treatment adherence; diagnosis and follow-up of TB in adolescent migrants; inappropriateness of paediatric or adult TB facilities for adolescents; and lack of knowledge of the safety and effectiveness of second- and third-line drugs in adolescents with DR-TB.

This is the first survey of the current policies and practices on TB management in adolescents in the WHO European Region. The overall response rate in this survey was 53%. Response rates from high-burden countries and low-burden countries were 64% and 49%, respectively. Response rates from high-income and middle-income countries were 47% and 63%, respectively [1, 10]. The results show that practices vary, few countries have specific policies and guidelines for the management of TB in adolescents, and those that have may not be adequate for addressing the particular challenges. Most countries did not express a need for policies and guidelines for adolescents, because of a perceived low incidence and because they apply similar main principles for case management in adults or children.

We conclude that access to diagnosis and treatment is available for all adolescents with TB in the countries responding to our survey but there is a lack of policies that adequately deal with the unique challenges related to adolescence such as age group-sensitive support. In some countries, adolescents are still kept away from their families and friends for prolonged periods, thereby inducing stigma and social isolation. Adolescents should be treated in an ambulatory fashion and be allowed to continue their education as soon as can be allowed in view of infection control, their clinical condition and the availability of treatment support, as recommended by current international guidelines [5, 11, 12]. Evidence is needed on conditional or compassionate use of new medicines (bedaquiline and/or delamanid) for children including adolescents with extremely severe clinical conditions and when to recourse to other second-line drugs [13, 14].

The challenges and needs of adolescents with TB are similar worldwide, and must be addressed more effectively by all stakeholders [15]. Countries should be encouraged to monitor and evaluate the TB situation and case management of adolescents as a specific group. Specific epidemiological information on the occurrence and management of TB in the age group of 10–18 years, on a global as well as a country level, would provide more insight in the particular challenges and can contribute to guidance for age group-sensitive approaches to adolescents with TB.