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Tuberculosis is a chronic infectious disease. Tuberculosis is often referred to as TB and may involve most organs of the body, but especially the lungs.
Tuberculosis is caused by a bacillus called Mycobacterium tuberculosis. The TB bacillus (tuberculous bacillus) is a long, thin bacteria.
Tuberculosis is usually spread when an infected person talks, coughs, spits, laughs, shouts, sings or sneezes. This sends a spray of very small droplets into the air (i.e. airborne droplet spread). Live TB bacilli (plural of bacillus) from the patient’s lungs then float in the air and may be breathed in by other people. The inhaled TB bacilli can cause an infection of the lung. Tuberculosis is usually spread from adults with untreated tuberculosis of the lungs (pulmonary tuberculosis). Therefore, a child (the contact) with tuberculosis almost always has been in close contact with an adult with pulmonary tuberculosis (the source). It is less common for a child to catch tuberculosis from another child as children usually do not cough up TB bacilli in such large numbers. Adults with untreated tuberculosis are a danger to children in the family.
Tuberculosis in children is usually spread from an adult with untreated pulmonary tuberculosis.
No. Most children infected with TB bacilli (i.e. Mycobacterium tuberculosis) do not develop tuberculosis (TB disease) because their immune system is able to control the infection and kill most of the TB bacilli. Therefore, the natural immune response protects most children with TB infection from developing tuberculosis.
Fortunately, most children infected with tuberculous bacilli (TB infection) do not develop tuberculosis (TB disease).
Infection with TB bacilli is very common, and it is estimated that almost 50% of South Africans have been infected. Most infections take place during childhood. However, only about 10% of all people with TB infection progress to tuberculosis (TB disease) during their lifetime. Therefore, TB infection is far more common than tuberculosis.
Tuberculosis is uncommon in most developed countries. However, tuberculosis is common in developing countries such as South Africa where the incidence has increased rapidly in the last few years. Tuberculosis is particularly common in the Western Cape and KwaZulu-Natal.
Most TB infection occurs during childhood.
In poor, disadvantaged communities where overcrowding, undernutrition and HIV infection are common. Tuberculosis is a disease of poverty. Tuberculosis may be spread in any overcrowded spaces such as homes, schools, churches, buses, clinics and trains. TB infection is usually caught from a family member, friend or neighbour.
Tuberculosis is usually seen in poor communities.
Because it is an important cause of illness and death in many poor countries.
A child can only develop tuberculosis if the child is exposed to TB bacilli. Therefore, the more tuberculosis there is in the community, the higher is the risk that children will become infected. However, some children are at a particularly high risk of developing tuberculosis if they become infected with TB bacilli:
Therefore, tuberculosis is most common when a child with a weak immune system is exposed to a large number of TB bacilli.
Children who have a weak immune system and are exposed to large numbers of TB bacilli have the greatest risk of tuberculosis.
Young children under 3 years have an immature (weak) immune system which is unable to control severe infections. The younger the child, the less mature the immune system.
Some older children have an immune system which has been weakened by illness, malnutrition or drugs:
Severe tuberculosis itself weakens the immune system.
Children with a weak immune system are at high risk of tuberculosis.
Tuberculous infection usually starts when TB bacilli are inhaled into the lung. During the first 6 weeks of infection the immune system is unable to control the TB bacilli, which multiply and cause a small, local area of inflammation in the lung. From here TB bacilli also spread along the lymphatics to the local lymph nodes (hilar nodes) at the place where the main bronchi divide into branches. After 6 weeks the immune system usually becomes active and kills most of the TB bacilli. As a result, the primary infection is asymptomatic in most children and does not cause clinical illness. Primary tuberculosis is common.
Inhaling tuberculous bacilli into the lung results in a primary infection.
Unfortunately, yes. Tuberculosis is a very unpredictable disease as there are a number of different ways that the primary infection can spread in the lungs:
The primary infection may spread to cause pulmonary tuberculosis.
Yes. Unlike some other infections, such as measles and mumps, a TB infection does not necessarily give immunity to further TB infections. A child with a healed primary infection can months or years later have another, new, primary infection. Therefore, pulmonary tuberculosis may be due to immediate spread from the original primary infection, reactivation of an old primary infection which had not healed, or spread from a further primary infection.
Tuberculous bacilli may spread from the lungs to other organs via the blood stream or the lymphatics.
Although the lung is the most common organ to be infected by TB bacilli, tuberculosis can involve any other organ of the body (extrapulmonary tuberculosis). The organs which are most commonly infected via the blood stream in children are:
The most common complications of primary tuberculous infection in children are:
The suspected diagnosis of tuberculosis is often difficult to prove. The following are used clinically to diagnose tuberculosis in children:
The diagnosis of tuberculosis in children usually depends on a history of contact, clinical signs, tuberculin skin test and chest X-ray.
The early signs and symptoms of tuberculosis are often vague and non-specific making the diagnosis difficult. These general signs and symptoms are caused by tuberculosis at any site in the body:
The later signs of tuberculosis usually depend on which organ or organs are infected (e.g. meningitis or abdominal distension).
Suspecting tuberculosis is the first step in making the diagnosis.
Phlyctenular conjunctivitis (a patch of conjunctivitis at the junction of the sclera and cornea) and erythema nodosum (raised , tender, purple patches on the shin) should always suggest TB.
A persistent cough lasting longer than 3 weeks is an important symptom of pulmonary tuberculosis.
A chest X-ray is very important in confirming a clinical suspicion or diagnosis of pulmonary tuberculosis. In children, tuberculosis is often diagnosed on a chest X-ray.
A chest X-ray is an important way of diagnosing pulmonary tuberculosis.
In children the following are the most common chest X-ray (radiographic) features:
In young children the interpretation of a chest X-ray may be difficult. A good chest X-ray is important to both diagnose tuberculosis and monitor the response to treatment. Some children with tuberculosis may have a normal chest X-ray, e.g. infants with tuberculous meningitis, bone tuberculosis or any other form of extrapulmonary tuberculosis.
This is a skin test done with tuberculin which contains protein from TB bacilli. Usually PPD (i.e. Purified Protein Derivative) is the form of tuberculin which is used. It does not contain live TB bacilli. The most accurate method of tuberculin skin testing is the Mantoux test, when a small amount of PPD is injected into the skin (intradermally). If a large area of swelling (induration) develops after 2 to 3 days at the injection site, the test is said to be positive. A positive skin test indicates that the child is infected, or has previously been infected with the TB bacillus, or been given BCG. As a result the child has now developed a sensitivity (an ‘allergy’) to the PPD.
The Tine test is also used but is not as accurate as a Mantoux test.
A 1 ml syringe and size 26 needle are used to inject 0.1 ml of tuberculin (PPD) into the skin (intradermally) over the inner side of the left forearm. It is very important that the tuberculin is injected into the skin and not under the skin (subcutaneously). If the tuberculin is correctly injected into the skin a raised, pale weal of 5 to 10 mm is formed. If no weal is raised, the tuberculin has been injected too deep in error.
Incorrect injection under the skin may make the result difficult to interpret.
The Mantoux skin test must be read 2 to 3 days (48 to 72 hours) after it is done. The widest transverse diameter (across the arm) of induration (raised, swollen, thickened area of skin) is measured. It is important that the induration and not the area of redness is measured. The diameter of the induration is best measured with a ruler. The result should be reported in millimeters and not simply as positive or negative. The interpretation is as follows:
A Mantoux skin test of 10 mm or more indicates tuberculous infection. However, an induration between 5 and 9 mm cannot differentiate between children who have a tuberculous infection and those who have had BCG in the past 2 years. Furthermore, a result of 10 mm or more cannot differentiate between a recent healed TB infection and active tuberculosis. It is unfortunate that BCG may confuse the interpretation of the Mantoux skin test in the first 2 years. It is important to understand that a positive Mantoux test suggest tuberculous infection but does not necessarily mean that the child has tuberculosis.
A positive Mantoux skin test indicates tuberculous infection but not necessarily tuberculosis.
No. Although a negative Mantoux test suggests that there is no tuberculosis, the test may be negative (less than 5 mm induration) in spite of active infection with TB bacilli if the child’s immune system is not reacting to the tuberculin. Therefore, the test may be falsely negative, even though the child has tuberculosis, in:
The Mantoux test may be falsely negative in children with severe malnutrition, HIV infection, severe tuberculosis or after measles.
The most accurate way of diagnosing tuberculosis is to identify TB bacilli. Unfortunately this is not always possible in a child and the diagnosis often has to be made on the history, clinical examination, chest X-ray and Mantoux skin test alone. TB bacilli may be identified by either:
In adults, TB bacilli are usually identified in a stained sample (smear and direct microscopy) of sputum (not saliva). A special stain is used to identify the bacteria as TB bacilli. The sputum is collected at a TB clinic and the test done at the nearest laboratory. The result can be obtained in a few hours. Patients who have TB bacilli identified by a ‘positive TB stain’ on a smear of their sputum are called ‘smear positive’.
TB bacilli can also be grown (cultured). Unfortunately this is more difficult and expensive and may take many weeks. Therefore, in most poor countries tuberculosis in adults is confirmed with a sputum smear. TB culture and sensitivity testing is important in communities where multidrug resistance is common.
A definite diagnosis of pulmonary tuberculosis in adults is usually made by identifying TB bacilli in their sputum.
Patients with untreated pulmonary tuberculosis (‘cavitary’ or ‘open TB’). These patients are highly infectious to others as they cough up large numbers of TB bacilli.
In older children and adults the patient can be asked to cough up a sample of sputum. However, younger children under 6 years of age are usually unable to cough up sputum to examine, as sputum is swallowed. If a sputum sample is needed in a child, it is easier to take a sample of gastric fluid which contains swallowed sputum. The gastric aspirate is best collected early in the morning before the first feed, the child having been nil per mouth for 6 hours. As gastric fluid is highly acid, 4% sodium bicarbonate in an equal volume to the gastric aspirate should be added to the specimen to neutralize the acid. Otherwise the TB bacilli will be killed before they can be cultured.
As children usually cough up or swallow far fewer TB bacilli than adults do, positive cultures are less common in children. Therefore, diagnosing tuberculosis in children is often done without obtaining a sputum sample.
If the primary tuberculous infection spreads (disseminates or seeds) into the bloodstream, TB bacilli can be carried to many organs other than the lungs. Tuberculosis affecting many different organs at the same time is called miliary tuberculosis.
Miliary tuberculosis is usually seen in young children under 2 years of age or children with a weak immune system due to HIV infection or severe malnutrition. Miliary tuberculosis presents with the general signs and symptoms of tuberculosis (fever, lethargy, weakness and weight loss). In addition these children often have an enlarged liver and spleen. Miliary tuberculosis usually develops soon after the primary infection when TB bacilli ‘seed’ to many organs. The chest X-ray shows many small spots of pneumonia (‘a snow storm’ appearance).
Tuberculous meningitis usually occurs a few months after the primary TB infection, especially in small children below 3 years of age. It is the most dangerous complication of pulmonary tuberculosis. The TB bacilli reach the meninges via the blood stream, usually from the lungs. Most children with tuberculous meningitis have a positive Mantoux skin test, an abnormal chest X-ray and a history of contact with an adult suffering from pulmonary tuberculosis, but all of these could be absent.
For the first few days and weeks the child is generally unwell with fever and lethargy. Then signs of meningitis appear (headache, irritability, vomiting and neck stiffness) followed by confusion, a depressed level of consciousness, convulsions and neurological signs (weakness or paralysis). The classical signs of meningitis are often not present for the first few days. The risk of permanent brain damage (hydrocephalus, paralysis, deafness, blindness, convulsions and mental retardation) or death is high, especially if the diagnosis is made late. However, recovery can be complete with early treatment.
Examination of the cerebrospinal fluid (CSF) obtained by lumbar puncture is helpful in making the clinical diagnosis. The diagnosis is only confirmed by finding TB bacilli (by staining or culture) in the CSF.
All children with suspected tuberculous meningitis must be referred urgently to hospital for investigation and treatment (and treatment preferably started immediately).
Abdominal tuberculosis usually results from spread of TB bacilli via the lymphatics from the chest. TB infection from the abdominal lymph nodes can then spread to the omentum, peritoneum, liver and other abdominal organs. These children present with the general signs of tuberculosis, i.e. fever, lethargy and weight loss. They may also have diarrhoea, abdominal pain and a distended (swollen) abdomen due to ascites or enlarged abdominal lymph nodes.
Peripheral lymphadenopathy (enlarged lymph nodes) is common in tuberculosis. Enlarged TB lymph nodes in the neck (cervical, submandibular) are usually due to spread of infection via the lymphatics from the chest. Axillary and inguinal lymph nodes are less commonly affected.
Peripheral TB lymph nodes are typically non tender (unless secondarily infected) and often matted (stuck together). In the neck the lymph nodes enlarge and fuse together becoming stuck to the skin. They may become fluctuant or even ulcerate through the skin to form a chronic sinus.
Enlarged lymph nodes in the neck may be caused by tuberculosis.
Tuberculosis may be the first serious infection in an HIV infected child and be the first indication that the child is HIV infected.
HIV infection weakens the immune system and allows previously dormant tuberculosis bacilli to become active, resulting in tuberculosis.
Tuberculosis is a very common complication and cause of death in children and adults with HIV infection.
HIV infection makes the diagnosis of TB more difficult. The Mantoux skin test may be falsely negative and the chest X-ray confusing. While a smear may be negative, TB bacilli can still be grown in the sputum.
Tuberculosis weakens the patient’s immune system and enables HIV infection to progress more rapidly to AIDS.
Every child with tuberculosis should be screened for HIV infection.
Immunisation with BCG gives some protection against infection with wild TB bacilli. BCG gives good protection against miliary tuberculosis and tuberculous meningitis, especially in well nourished children. Unfortunately, BCG immunisation does not give total protection against tuberculosis. BCG should be given to all infants at birth.
BCG should still be given to newborn infants who have HIV positive mothers. However, BCG should not be given to children with clinical signs of HIV infection. Side effects from BCG are more common in HIV infected children.
Immunisation against measles and diphtheria also helps reduce the risk of tuberculosis.
Unfortunately the diagnosis of tuberculosis is often only suspected or probable and cannot be confirmed. These infants need to be treated as if they had confirmed tuberculosis.
Multi-drug treatment for many months is essential to cure tuberculosis.
Because the TB bacillus rapidly becomes resistant to 1 antituberculous drug if it is given on its own, multiple drug therapy is used. Usually 3 or more drugs are given together. The drug combination usually given consists of:
All 3 drugs are usually given together before breakfast. It is very important that the drugs are taken regularly and correctly. Hospitalisation and bed rest are usually not needed. With correct treatment more than 90% of children with tuberculosis can be cured.
Children with miliary TB or TB meningitis must be hospitalised. A fourth antituberculous drug is added (preferably ethionamide, otherwise ethambutol or streptomycin). These drugs are given at higher doses in TB meningitis and miliary TB.
The cure rate of tuberculosis has improved with shorter, well monitored courses of anti-TB drugs. This method is better than previous longer courses where compliance was poor and many patients did not take their medication regularly or stopped treatment too soon. Short course treatment is more cost effective with better patient compliance. However it must be well managed.
With short course treatment from a clinic, the anti-TB drugs are usually given on 5 days of the week only (Monday to Friday). Most children can be treated with combination tablets (rifampicin, INH and pyrazinamide or rifampicin and INH alone). Usually all 3 drugs are given for 2 months (the initial phase) and then only rifampicin and isoniazid are taken for a further 4 months (continuation phase). See Table 8.1 for the usual 6 month treatment regimen.
Children older than 8 years or children weighing more than 35 kg are treated with 4 drugs (ethambutol added) in the initial phase as with the adult anti-TB treatment regimen.
Tuberculosis is usually treated with rifampicin, INH and pyrazinamide for 2 months followed by rifampicin and INH only for another 4 months.
Pretreatment body weight
5 times per week
Initial phase: RHZ 60/30/150 mg
5 times per week
Continuation phase: RH 60/30 mg
1 ½ tablets
1 ½ tablets
Once the child has been on triple drug treatment for a few weeks the signs and symptoms of TB should gradually improve and the child should start to gain weight. A definite improvement in the chest X-ray may be seen in early infections after a month. However, the X-ray changes may take months to improve in extensive pulmonary TB.
Unfortunately, all anti-TB drugs have side effects. In children these are fortunately not as severe as in adults. The organ most commonly affected by anti-TB drugs is the liver. Nausea and skin rashes may occur. The urine is often stained orange when rifampicin is given.
Failure to take the anti-TB drugs correctly as prescribed (non-compliance). If doses of the drugs are missed repeatedly, the tuberculosis will not be cured and drug resistance may develop. Resistance to both INH and rifampicin is called multidrug resistant (MDR) TB. This is very difficult to treat. In multidrug resistance, the TB bacilli continue to multiply and are not killed by the usual combination of anti-TB drugs. Multidrug resistant TB develops because of incorrect treatment or poor adherence. Multidrug resistant TB can be transmitted to close contacts, including children and is becoming a major problem in some regions.
If the treatment is stopped too soon the tuberculosis can also return (relapse). In many poor countries it is common for TB patients not to complete their full course of treatment. Once they feel well again they stop their treatment. As a result, relapse of TB occurs and many people die of TB.
Treatment of tuberculosis is difficult as it is lengthy and requires good compliance.
Adults with tuberculosis have a responsibility, not only to themselves, but also to their household and community to complete their treatment correctly.
‘DOTS’ stands for ‘directly observed treatment, short-course’. With the DOTS strategy the patient is given the anti-TB drugs by some responsible person in the community who observes the patient swallowing every dose of the medication. The treatment supporter does not have to be a health professional. With adults, it is best if the treatment supporter is not a family member. This ensures good compliance without the patient having to go to the clinic for every dose. If DOTS is correctly used, the failure rate of treatment is greatly reduced and over 85% of patients should be cured. The general public can play an important role in the control of TB by supporting DOTS (i.e. DOTS supporters). The cure rate for TB without DOTS in poor countries may be as low as 40%.
With DOTS a responsible person must see the patient take the tablets.
The following children should be given prophylactic (preventative) treatment:
Currently, prophylaxis consists of INH for 6 months. The treatment is given daily for 5 days a week using the same dose as for short course treatment. Children of 5 and older, who have been in close contact with an adult with untreated pulmonary TB, or have a positive Mantoux, are not given prophylaxis, as they are at far less risk of developing tuberculosis. However, they should be followed and treated if they develop any early signs of TB.
Prophylactic treatment is given to well children under 5 years of age who have been in close contact with someone with untreated tuberculosis.
Yes. All cases of tuberculosis must be notified to the local health authority. The health care worker who makes the diagnosis is responsible for the notification. The local health authority should now look for the person who is the source of the infection and also screen contacts for tuberculosis.
After 2 weeks of the correct treatment, patients with pulmonary tuberculosis are no longer infectious to others even though TB bacilli may still be seen on a smear. Isolation of patients with tuberculosis is, therefore, usually not necessary. Younger children usually do not develop ‘adult type tuberculosis’ with cavities and, therefore, are less infectious to others. As a result, most children with tuberculosis do not need to be isolated.
A 7-year-old child presents at a local clinic with a history of a persistent, dry cough for the past month. He has a poor appetite, has lost weight recently and reports that he sweats a lot at night. Examination reveals a thin child with an expiratory wheeze. A BCG scar is noted over his right upper arm. His mother says she and her 5 children live with her father in a 2 roomed house. The grandfather is also unwell and has been coughing and complaining of chest pain for the past few months. She is unemployed and the whole family live on the grandfather’s pension. The child is sent for a chest X-ray and Mantoux skin test.
The symptoms of chronic cough for a month, poor appetite, weight loss and night sweats are strongly suggestive of tuberculosis. They live in poor, overcrowded conditions and the grandfather’s history also suggests tuberculosis. The child has probably been infected by the grandfather who could have smear-positive pulmonary tuberculosis.
BCG immunisation gives partial protection against tuberculosis, especially tuberculous meningitis and miliary tuberculosis. However, an immunised child can still become infected particularly if they are undernourished or exposed to large numbers of TB bacilli. Therefore, this child may have tuberculosis even though he has been immunized with BCG.
A chest X-ray should be taken and a Mantoux skin test performed. The grandfather should also be investigated for tuberculosis.
Usually an area of pneumonia (consolidation) is seen together with a widened mediastinum due to enlarged hilar and mediastinal lymph nodes.
Either a wheeze or stridor can be caused by pressure of enlarged lymph nodes on the airway. This is common in children with pulmonary tuberculosis. The wheeze seldom responds to inhaled bronchodilators.
A test of 10 mm or more would indicate tuberculosis, even if the child had received BCG.
The child should be able to cough up a sample of sputum. This should be stained and then examined for TB bacilli.
Rifampicin, isoniazid and pyrazinamide are used for the first 2 months then only rifampicin and isoniazid continued for another 4 months. With short course treatment the drugs are given 5 times a week. It is very important that the drugs are given regularly and that doses are not missed.
Yes. All forms of tuberculosis are notifiable in South Africa. This enables the local health authority to look for the person who is the source of the infection and to screen contacts for tuberculosis.
An 18 month old infant is brought to hospital with a 1 week history of fever and irritability. For the last 2 days the infant has been very drowsy, refuses feeds and does not want to play with her siblings. She has also vomited a few times. The mother reports that the child has not been immunized as she was born at home and lives far from the nearest clinic. The child has received no treatment or traditional medicine. A chest X-ray done at the clinic is normal.
By examining a sample of cerebrospinal fluid (CSF) obtained by lumbar puncture. If the child has tuberculous meningitis the fluid will be abnormal. Children with TB meningitis often have a normal chest X-ray. The typical signs of meningitis are often not present during the first few days of illness.
Children under 3 years of age who have not been immunized with BCG and are exposed to large numbers of TB bacilli. It would be important to ask if there is an adult in the home who may have untreated tuberculosis.
The child may die or suffer permanent brain damage. Hydrocephalus, paralysis, deafness, blindness, convulsions or mental retardation may result, especially if the diagnosis is only made when the child already has neurological signs. If diagnosed and treated early, the child may fully recover. The clinical presentation in this child suggests an early diagnosis.
The child must be urgently referred to hospital for investigation and treatment. Treatment with anti-TB drugs will be needed for 6 months.
The lungs are the most common organs to be infected with tuberculosis. In children, tuberculous meningitis, abdominal tuberculosis, tuberculosis of the bones or joints, and tuberculous infection of the lymph nodes are less common. Almost any organ can be infected with tuberculosis.
A 16-year-old adolescent gives a history of feeling unwell and losing weight for the past 2 months. She also complains of a chronic loose cough and blood stained sputum. Her older brother was treated for tuberculosis for 2 months but stopped when the medicine ran out. He remained well for a while but is now coughing again. She has a younger brother who is well. The nurse at the clinic refers the patient to hospital for a chest X-ray as she suspects that she has tuberculosis.
Usually by breathing in TB bacilli that have been coughed into the air by an adult with untreated pulmonary tuberculosis.
HIV infection is a very important cause of damage to the immune system. Therefore children with HIV infection are at high risk of developing tuberculosis. A recent infection with measles can also damage the immune system .
She probably has adult type pulmonary tuberculosis with cavities in an upper lobe. Patients with this type of tuberculosis are highly infectious as they cough up large numbers of TB bacilli. A stain of her sputum will probably be full of TB bacilli.
She could have had an asymptomatic primary tuberculosis infection a number of years ago, but recent infection transmitted from her older brother is more likely. If her tuberculosis was the result of reactivation from previous infection, it was because her immune system was able to stop the TB bacilli from multiplying at the time of the previous infection but it was not able to kill them. A few years later the TB bacilli started to multiply again causing pulmonary tuberculosis. This resulted in her becoming ill.
DOTS (directly observed treatment, short-course). It is best if every dose of medication is carefully supervised by a responsible person. It is not necessary to admit her to hospital for treatment. With DOTS she also need not visit the local clinic daily for her treatment.
The younger brother should be screened for tuberculosis. Any child in the home who is under 5 years of age and does not have tuberculosis should receive prophylactic treatment.
A 1-year-old child is seen by a general practitioner with a short history of fever and being generally unwell. On examination the child is obviously ill with an enlarged liver and spleen. The mother is also unwell with weight loss and chronic diarrhoea.
Although a number of different infections can present in this way, miliary tuberculosis must be suspected.
With miliary tuberculosis the chest X-ray shows numerous small spots throughout both lungs indicating a widespread pneumonia.
The Mantoux skin test may be positive. However, with miliary tuberculosis the Mantoux could be negative, as the severe infection weakens the immune system.
The mother probably has tuberculosis. The story of chronic diarrhoea suggests that she may also have AIDS. Tuberculosis and HIV infection often occur together.
The infant should be started on prophylactic anti-TB treatment (usually INH alone or INH plus rifampicin) as soon as possible after delivery. Immunisation with BCG should be delayed until the treatment is completed.
Yes, provided the infant is given prophylactic treatment. The mother must take her anti-TB medication correctly and need not be separated from her infant.