Age and sex differences in paediatric tuberculosis care for child contacts.

Background: Childhood tuberculosis (TB) remains difficult to diagnose, even among exposed household contacts. We assessed age- and sex-specific gaps in TB screening, evaluation, diagnosis, and treatment among child contacts in a high-burden setting. Methods: As part of a large active screening program in Kotri, Pakistan, from 2014-2016, children aged 0-14 years with household TB exposure were screened for TB disease. We analysed their progression through the TB care cascade and identified factors associated with drop-off at each stage. Results: Of 3014 child contacts screened, 56.3% were males. Despite clear exposure risk, only 1608 (53.4%) were completely evaluated. Evaluated children were more likely to have lower weight percentiles and report cough, fever, and weight loss (P < 0.001). Among those evaluated, 390 (24.3%) were diagnosed with TB (25.8% males vs. 22.2% females; P = 0.103). Nearly all initiated treatment (98.7%) and completed it successfully (98.2.%) with no significant differences by sex. As age increased, symptom reporting declined into adolescence, and the percentage being evaluated and diagnosed decreased. However, males in certain age groups were significantly more likely to be diagnosed (at age six) or evaluated (at ages seven and 14) than females of the same ages. Conclusions: The largest gap occurred at the evaluation stage, despite symptoms and known exposure. While treatment initiation and completion were high, observed differences in evaluation completion across age and sex represent a critical barrier to TB elimination in children. Interventions addressing this drop-off - especially among young females - are urgently needed.