SELECTED ARTICLE
Author
Alla Gordina, MD, FAAP 
Article Title
What are the ramifications of Tuberculosis in Developing Countries? 
Posted Date
12/19/2005 
 

I will try to clarify here mysteries regarding tuberculosis in general, its testing and treatment with the help of the so called RED BOOK 2003, the report of the Committee on Infectious Diseases (American Academy of Pediatrics, 25th edition) and the MMWR (Morbidity and Mortality Weekly Report) by the CDC, published on 02.08.2002

1. Tuberculosis infection in developing countries and BCG vaccination. Tuberculosis (TB) is an infectious disease, caused by the Mycobacterium Tuberculosis (M. Tuberculosis) and it is extremely common in the developing countries and in the republics of the former Soviet Union. Most of the newly diagnosed TB cases in the United States are in foreign-born persons (California, Hawaii, Massachusetts, Minnesota, and New Hampshire had >70% of their annual total of cases attributed to foreign-born persons).

The disease is usually transmitted by the infected adults with the open pulmonary process. An affected child can have no signs and/or symptoms at all (TB infection) or suffer from such serious complications, as pulmonary TB, TB meningitis and so on. Tuberculosis is usually defined as an infection (positive skin testing and normal chest X-rays of the chest in a healthy child) or disease (positive skin testing and changes on the CXR or other symptoms of active TB). Negative skin testing can not rule out TB disease.

Prevention of TB includes active surveillance (TB skin testing) of populations at risk, treatment of contacts and affected individuals, as well as, in some countries, BCG vaccination. BCG vaccination is not protecting from the TB infection. BCG vaccine is given in order to protect a person from complications of the TB infection. BCG vaccine is routinely given in over 100 countries, including the republics of the former Soviet Union. Usually the vaccine is administered on the 5th day of life. Sometimes the vaccination is deferred because of the child's condition (sick and/or premature) and given later, at 6-12 months of age. Re-vaccinations of BCG vaccine can be given at 7 and 15 years of age.

If the BCG vaccine is given to a child outside the immediate newborn period, it is supposed to be given after the negative tuberculin test. The scar from the BCG vaccine is usually located on the upper left arm and, when given at birth, this scar is usually healed by one year of age. Presence of the scar itself does not exclude the possibility of the TB infection. TB testing of the newly adopted child has to be deferred if the scar is not healed completely (see below).

2. Testing for tuberculosis Testing for TB includes skin testing for people at risk, and, in the case of the disease - cultures for M. tuberculosis. There is no blood test for TB yet. Skin testing (Mantoux or PPD only, no prick or Tine test) a test for exposure to tuberculosis and in the former Soviet Union it is usually done annually and before BCG re-vaccinations. In the United States PPD testing should be performed twice on all adoptive children - as soon after adoption as possible and, if the first test is negative or inconclusive, 6-9 months after adoption, at the same time with repeat testing for HIV, hepatitis B and C.

Skin testing should be performed before or at the same time with the live virus vaccinations (MMR or its components - measles, mumps and/or rubella, and Varivax) or at least 4 weeks after such vaccinations. Skin testing is considered positive if INDURATION (swelling) is noticed 48 to 72 hours after placement. Test results should be read only by the health professional and recorded in mm. If parents are not able to see a medical professional for the reading (for example, if testing is done on Thursday and should be read on Saturday or Sunday), testing has to be deferred.

Skin test should be read as positive if induration is equal or over 5 mm - in contacts with active or previously active TB, in children suspected to have tuberculosis disease or in children with any immune deficiencies; 10 mm - in children with increased risk for disseminated disease (any child less than 4 years of age and children with chronic medical conditions, including malnutrition); children with increased exposure to tuberculosis disease (born or whose parents were born in high prevalence regions of the world or travel and exposure to those regions) 15 mm - in children over 4 years of age without any risk factors.

False positive results are theoretically possible, but taking in consideration that adopted children are coming from the extremely high risk areas and environments, erring of the side of caution will help us to protect our children from having the disseminated disease. The only valid cause of the false positive skin testing can be testing done when the scar from the BCG vaccination is not healed well. In this situation testing should be repeated 6-9 months later. False negative results are much more common and can be caused by many factors.

Tuberculosis can be an extremely slow developing disease and the conversion from the negative to positive skin test can occur weeks after exposure with the highest risk for the developing the disease 6 month-2 years (or even longer) after infection. Malnutrition, chronic diseases, and immune deficiencies of different origin are known to cause so-called "anergy" - the inability of the body to build the immune response. For those reasons skin testing should be repeated 6-9 months after initial negative post-adoption evaluation in all healthy children. In sick children with negative TB skin test and suspected TB disease placement of so called "anergy panel" is recommended.

3. Treatment of Tuberculosis infection/disease Treatment of TB infection can be supervised by the primary care provider and usually does consist of 9 months of the ISONIAZID or INH - a special TB antibiotic. The risk of the side effects of the INH therapy is usually so low, that in otherwise healthy infants, children and adolescents the routine determination of the liver enzymes is not recommended. Taking into consideration that every newly adopted child is a "terra incognita" for parents and medical professionals, the bloodwork is routinely recommended before initiation of treatment, monthly for the first 3 months, and then every 1-3 months during the course of the therapy.

Children and adults with the TB infection are not contagious and they can attend the day care and other activities as long as they are/were appropriately treated. Treatment of the TB disease is more complicated, and should be provided or supervised by medical professionals trained in pediatric infection diseases or pediatric pulmonology. Children with TB disease can attend the child care or school as long as they are receiving the appropriate therapy.

The information appearing here is intended for educational purposes only. It should not be used as a substitute for professional medical advice tailored to your child's individual needs. If you have questions or concerns regarding your child's physical or mental health, please seek assistance from a qualified healthcare provider.

References
GLOBAL PEDIATRICS is an international adoption medical support service that has specialized in assisting families adopting from the Former Soviet Union through every step of the adoption process for the past ten years. Dr. Gordina's unique professional background and attention to detail ensure the highest possible level of service. She is recognized by her patients and peers as a leader and pioneer in the field and has presented her adoption-related research at sessions of the AAP, JCICS, NACAS and other meetings. Dr. Gordina has both participated in and organized several humanitarian missions to pediatric clinics and orphanages in the Former Soviet Union.For all questions regarding our services please check www.globalpediatrics.net 
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