House Call - January, 2003
~ Tuberculosis
International Adoption Physician
Alla Gordina, MD FAAP
Global Pediatrics
International Adoption Medical Support Services
7 Auer Ct., East Brunswick NJ 08816
Tel. 732-432-7777 Fax. 732-432-9030
E-mail:drgordina@globalpediatrics.net
Website: http://www.globalpediatrics.net
"What are the ramifications of Tuberculosis in Developing Countries?
I will try to clarify here mysteries regarding tuberculosis
in general, its testing and treatment with the help of the so
called RED BOOK 2000, 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.
* Note:
The information and advice provided is intended to be general information, NOT as
advice on how to deal with a particular child's situation and or problem. If your
child has a specific problem you need to ask your pediatrician about it -- only
after a careful history and physical exam can a medical diagnosis and treatment
plan be made.
Have a question you would like answered?
Email: Press Here
View the Medical Library Archives:
This work product is subject to copyright and may not be reprinted
without permission of The Welcome Garden and physician/author.
View MAIN PAGE here.
The Welcome Garden, ©1999-2004. All Rights Reserved. All images, text, graphics,
and designs are track-coded and protected by Copyright #169; and may not be copied,
duplicated, modified, or redistributed.
Content Creation - Garden Associates
|
