Management of TB Contact: 1-Year-Old Breastfeeding Infant (India / NTEP Guidelines)

Step 1 - Rule Out Active TB Disease First

• Clinical assessment: Cough >2 weeks, fever >2 weeks, weight loss/failure to thrive, lymphadenopathy, poor feeding
• Chest X-ray (wherever available - do NOT delay TPT if CXR is unavailable)
• Tuberculin Skin Test (TST/Mantoux) - offered wherever available, but TPT must not be deferred pending the result in children <5 years
• If any signs suggest active TB - full diagnostic workup and treat as TB disease, not TPT

Step 2 - Eligibility for TPT

"Household contacts below 5 years of pulmonary TB patients - TPT to all after ruling out active TB disease"

Step 3 - TPT Regimen Choices for a 1-Year-Old in India

• Example: if child weighs 10 kg - give 100 mg daily

• Isoniazid: 10 mg/kg/day (for age <10 years)
• Rifampicin: 15 mg/kg/day
• Duration: 84 days (3 months)

Step 4 - Breastfeeding Considerations

• Isoniazid is safe in breastfeeding infants
• The amount of isoniazid passed through breast milk is insufficient to treat or cause significant drug exposure
• Breastfeeding should not be stopped

• If the child is receiving isoniazid: give pyridoxine 5 mg/day (1 mg/kg/day; for children <5 years: 5-10 mg/day per WHO/NTEP)
• This is especially important because exclusively breastfed infants have limited dietary pyridoxine sources
• Monitor for signs of peripheral neuropathy (rare at this age but possible)

Step 5 - Monitoring During TPT

• Jaundice or vomiting (hepatotoxicity - rare in children but monitor)
• Rash
• Development of TB symptoms at any point (convert to full TB treatment)
• Seizures or neurological changes (pyridoxine deficiency)

Step 6 - BCG Vaccination

• Confirm BCG vaccination status - if not already given, ensure it is administered as per India's national immunization schedule
• BCG does not interfere with isoniazid TPT

Step 7 - Index Case Management

• Ensure the index TB case (the contact source) is enrolled and receiving treatment
• Notify index case in Nikshay
• Screen all other household contacts simultaneously

Summary for This Child

Key principle from NTEP 2021: "TPT must not be deferred" in children <5 years who are household contacts of pulmonary TB patients, even if TST or CXR is unavailable.

Management of Adult Household TB Contact in India (NTEP PMTPT Guidelines 2021)

Who Qualifies?

• Bacteriologically confirmed pulmonary TB patient (smear/CBNAAT positive)
• Private or public sector - must be notified in Nikshay

Step 1 - Enumerate and Screen All Household Contacts

• Register contacts in Nikshay / Prevent TB India app
• Assess each contact with a 4-symptom screen:

Step 2 - Rule Out Active TB (Mandatory Before TPT)

Symptomatic? 
  YES → Investigate fully (CBNAAT, CXR, sputum) → If TB confirmed: start ATT (not TPT)
  NO  → Proceed to CXR + TBI testing (where available)
         CXR normal AND (TST/IGRA positive OR not available) → Start TPT
         CXR abnormal → Investigate for TB first

• Chest X-ray (CXR) - mandatory if available; normal CXR + no symptoms = eligible
• TST (Mantoux) or IGRA - TBI testing; positive result strengthens indication; but NOT a requirement to start TPT
• CBNAAT/sputum - only if symptomatic

Step 3 - TPT Regimen for Adults

3HP Dosing (Adults >14 years, by weight band):

3HP is the preferred regimen for adults because it has fewer pills overall (108 pills over 3 months vs 180 pills), is shorter, and has equivalent efficacy - but it is administered once weekly (not daily).

6H Dosing (Adults ≥10 years):

• Isoniazid 5 mg/kg/day (maximum 300 mg/day)
• Given as a single daily dose, 6 months

When to use 6H instead of 3HP:

• 3HP not yet available at the facility
• Drug interaction concerns (rifapentine interacts with several drugs)
• Patient preference for daily dosing

Step 4 - DR-TB Contact (Special Situation)

• Screen all HHC per standard algorithm
• For DR-TB contacts: no TPT is offered routinely to asymptomatic contacts (per current policy)
• Active TB is ruled out; if contact develops symptoms, investigate and treat appropriately
• Close follow-up for 2 years is recommended
• 6Lfx (levofloxacin 6 months) is considered in high-risk DR-TB contacts under programmatic settings - refer to NTEP DR-TB contact guidelines

Step 5 - Contraindications to TPT

• Active TB disease (treat with full ATT instead)
• Acute or chronic hepatitis
• Concurrent hepatotoxic medications (e.g., nevirapine-based ART - use alternative ART)
• Regular heavy alcohol consumption
• Peripheral neuropathy (if isoniazid-based regimen)
• Known hypersensitivity to drugs being used

• Pregnancy - TPT can be given; 6H is safe in pregnancy
• Previous history of TB - not a contraindication
• Elderly age - not a contraindication; monitor LFTs

Step 6 - Pre-Treatment Assessment

1. Confirm no active TB
2. Check for hepatic disease (history/examination; LFTs if clinically indicated)
3. Review current medications for interactions (especially rifapentine-based 3HP)
4. Counsel patient on:
   • Purpose of TPT (treats latent infection, prevents disease)
   • Duration and adherence
   • Side effects to watch for
   • Importance of returning if symptoms develop

Step 7 - Monitoring During TPT

• Not routinely needed for healthy adults on standard dose isoniazid
• Give 25 mg/day if: malnourished, HIV-positive, diabetic, renal failure, pregnant, breastfeeding, or alcoholic

Step 8 - Treatment Outcomes and Documentation

Summary: Adult Household TB Contact (DS-TB Index Case)

Index TB case notified in Nikshay
        ↓
List ALL household contacts
        ↓
4-symptom screen
        ↓
SYMPTOMATIC → Investigate → Treat ATT if TB confirmed
        ↓
ASYMPTOMATIC → CXR (if available) → TBI test (if available)
        ↓
No active TB → Check contraindications
        ↓
START TPT:
  Preferred → 3HP (Isoniazid + Rifapentine, weekly x 12 doses / 3 months)
  Alternative → 6H (Isoniazid 5 mg/kg/day x 6 months)
        ↓
Monitor monthly; document in Nikshay

Key NTEP principle: "All HHC of pulmonary TB patients, regardless of their age, should be given TPT after ruling out TB." TPT must not be deferred pending TBI testing or CXR if these are unavailable.