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?

Yash Paul,
A-D-7, Devi Marg,
Bani Park,
Jaipur 302 016, India.

Reply

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 changing epidemio-logy(3).

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,
Kamalakshipuram,
Vellore 632 002, India.
E-mail: [email protected]

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.