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While clinical diagnosis remains valuable, improving access to laboratory-based diagnosis for children with presumptive tuberculosis (TB) is critical to increase diagnostic certainty and ensure timely initiation on effective treatment, even more so in settings with high transmission of drug-resistant TB. Laboratory-based diagnosis in children is hampered by challenges in obtaining adequate specimens and sub-optimal performance of existing tests on pauci-bacillary specimens. Recently the World Health Organization recommended stool as a useful specimen to diagnose pulmonary paediatric TB and urine-based LF-LAM for children living with HIV. This session will review the latest evidence on the role of those alternative sample types for childhood TB.  

15:00 - 15:05: Introduction

15:05 - 15:15: Closing the case detection gap in children with TB: WHO updatesOver 1.1 million children (aged under 15 years) were estimated to have fallen ill with tuberculosis (TB) in 2018 and over 200,000 of them died, the majority before their 5th birthday. The case detection gap was estimated at 54% and was highest (63%) in children under five, due to -among others - the paucibacillary nature of TB, the lack of a sensitive point-of-care test and the challenges in collecting a respiratory sample for bacteriological testing in young children. This presentation will set the scene covering the latest epidemiological data on TB children as well as progress towards the United Nations High-Level Meeting on TB targets for children. Updated World Health Organization policy recommendations, relevant to the diagnosis and management of TB in children, will be discussed.
Sabine Verkuijl

15:15 - 15:25: Utility of stool samples for microbiological confirmation of TB in childrenIn January 2020 the World Health Organization published a Rapid Communication on the use of molecular assays as initial tests for the diagnosis of tuberculosis (TB). The conclusions support the continued use of Xpert MTB/RIF and Xpert Ultra in children including stool samples. 
Following up on last year’s symposium, two parallel evaluations of centrifuge-free stool processing methods are underway, including the Stool Processing Kit (FIND), Simple One-Step (KNCV) and Sucrose Flotation (TB-Speed) methods, in combination with Xpert Ultra. 
The head-to-head comparison includes an assessment of the performance for TB detection as well as the ease of use of the three methods.
Pamela Nabeta

15:25 - 15:35: Update on simple one step stool testing method and practical guidance on the best placement of this test in the diagnostic algorithmTo assess the accuracy, feasibility and acceptability of the KNCV SOS stool method as compared to Xpert on a gastric aspirate or an induced sputum specimen, the SOS stool method is being implemented in parallel to the routine algorithm in Ethiopia and Indonesia. This will provide more precise accuracy estimates and valuable lessons for scale-up. Modelling studies are underway to provide more insights into the best placement of the method in the diagnostic algorithms. This presentation will outline key lessons learned to be addressed for scale-up of stool processing in countries and provide insights on how it can best be placed in the diagnostic algorithm for childhood tuberculosis.
Edine Tiemersma

15:35 - 15:45: Accuracy of a novel urine test, Fujifilm SILVAMP TB LAM, for the diagnosis of pulmonary TB in childrenAn accurate point-of-care test for tuberculosis (TB) in children remains an elusive goal. A novel urinary lipoarabinomannan (LAM) test, Fujifilm SILVAMP TB LAM (FujiLAM) showed superior sensitivity to Alere Determine TB LAM (AlereLAM) in HIV-infected adults. We compared the accuracy of FujiLAM and AlereLAM in children with suspected pulmonary TB presenting to hospital in Cape Town, South Africa. There were 204 children enrolled who had valid results from index and sputum tests. Using a microbiological reference standard, sensitivities of FujiLAM and AlereLAM were similar (42% and 50% respectively), but lower than Xpert MTB/RIF of sputum (74%).   However, specificity of FujiLAM was substantially higher than AlereLAM (92% vs. 66%), suggesting that non-specific detection accounted for the apparent higher sensitivity of AlereLAM. Sensitivity of FujiLAM was higher in HIV-infected and malnourished children. The high specificity of FujiLAM suggests utility as a ‘rule-in’ test for TB in children, particularly those who are HIV-infected.
Mark Nicol

15:45 - 15:55: Keynote : overview of where we are in childhood TB diagnosisThis presentation will discuss the role of the  sample types and tests recently recommended for tuberculosis (TB) diagnosis in the context of clinical and programmatic management of childhood TB and summarise remaining challenges to be addressed to close the gap in paediatric TB case finding
Ben Marais

15:55 - 16:20: Q&A session