The incidence of tuberculosis in our country is
on the rise. A child who has been administered BCG vaccine during
the neonatal period or infancy is mostly confined to the indoors
during early childhood. The protection provided by BCG vacine
declines over the period of time. A child after admission to the
school may be exposed to a person with tuberculosis in infective
stage. Perhaps ideal would be the periodic screening of the school
staff for tuberculosis.
Should Mantoux testing be done at the time of
admission? What other measures should be taken for safeguard of
the school going children?
A-D-7, Devi Marg,
Jaipur 302 016, India.
Dr. Yash Paul cautions that the incidence of
tuberculosis (presumably in adults) in our country is rising
(presumably due to the HIV epidemic). How should we, as
pediatricians, safeguard school-going children from the
anticipated increase in risk of infection? He argues that the ‘protection’
provided by the BCG vaccine would have declined by the time the
child is sent to school and that the child now comes in contact
with more adults in the new environment of the school. Dr. Yash
Paul’s suggestions are, periodic screening of school staff for
tuberculosis (and early diagnosis and treatment) and Mantoux
testing of all children at school entry.
Let us accept that the prevalence of adult open
tuberculosis might be increasing. Do we have to modify our
practice in order to safeguard the well being of children? We must
examine the issue in two ways. First, what should we do in our
role as pediatricians, to individual children? Second, is there a
need to modify the public health approach to protect children?
What is the role of BCG? It does not protect
the immunized child from getting infected with the tubercle
bacilli, but it protects from the infection spreading within the
body via hematogenous route, particularly to the meninges and
brain. This lesson must be clearly understood.
The August 1999 issue of Indian Journal of
Medical Research has a very important paper from the ICMR
Tuberculosis Research Centre, Chennai(1). The incidence rates of
tuberculosis in unimmunized and the immunized were no different,
in the 15 years of follow up of the famous BCG trial. The recorded
overall protection in children was only 27%. In short, BCG has no
role in ‘public health’ for the reduction in incidence of
tuberculosis, nor for the reduction of infection. Children will
conti-nue to be susceptible to infection, early lung tuberculosis
and also secondary tuberculosis, as they grow older.
Is it realistic to screen all school staff to
reduce risk of infection to children? Do we have any evidence that
school staff are the source of infection in school children, or
for that matter, evidence that there is increased risk for
school-going children? It is obvious that we do need detailed
information on the epidemiology of infection by the tubercle
bacilli in children before we can design any interventions.
Targetting school staff does not seem to be an important step,
unless we can have systematic screening of all adults.
Will Mantoux test at school entry help? It will
help to detect the individual children who have already been
infected with tubercle bacilli either in the absence of BCG scar
or history, or even in the event of BCG immunization in infancy.
What should we do if the child is Mantoux reactive with over 10 mm
induration? Are we willing to treat all such children with INH and
Rifampicin for at least 6 months? If this could become a universal
practice in our country, we will have the hope that the prevalence
of adult tuberculosis will decline in these persons as they are in
their adulthood. It is my personal belief that the present
national tuberculosis control will not succeed since it targets
only adults and not children. It must be pointed out here that the
Working Group Consensus on treatment of tuberculosis, quoted in
the IAP Textbook of Pediatrics(2) recom-mends such treatment only
for Mantoux positive children below 3 years, undernourished
children below 5 years and recent tuberculin converters. Dr. Seth
recommends tuberculin surveys in under-fives to describe the
Good quality primary health care every-where,
rural and urban, is the foundation for the safeguarding of our
children’s health, particularly from adult-to-child transmitted
infections (such as tuberculosis).
T. Jacob John,
Emeritus Medical Scientist (ICMR),
439, Civil Supplies Godown Lane,
Vellore 632 002, India.
1. Tuberculosis Research Center, Chennai.
Fifteen year follow up of trial of BCG vaccines in south India for
tuberculosis prevention. Indian J Med Res 1999; 110: 56-69.
2. IAP Working Group. Treatment of childhood
tuberculosis: Consensus statement. In: IAP Textbook of
Pediatrics. Eds. Parthasarathy A, Menon PSN, Nair MKG Lokeshwar MR,
Srivastava RN, Bhave SY, Hathi GS, Sachdev HPS, Nammalwar BR. New
Delhi, Jaypee Brothers, 1999; pp 199-201.
3. Seth V. National tuberculosis control program. In:
IAP Textbook of Pediatrics. Eds. Partha-sarathy A, Menon PSN, Nair
MKC, Lokeshwar MR, Srivastava RN, Bhave SY, Hathi GS, Sachdev HPS,
Nammalwar BR, New Delhi, Jaypee Brothers, 1999; pp 8-10.