1. The current recommendations [1]
highlight that the diagnosis of TB is most reliable with
microbiological methods and in such cases the findings
on chest skiagrams usually do not help any further in
diagnosis. Chest skiagram, however, may be done, for
detailing the pulmonary disease, depending upon the
feasibility.
2. They themselves have pointed out,
the existing PCR- based tests available in most
commercial laboratories are not reliable therefore these
were clubbed with all other inaccurate diagnostic tests.
With the advancement in technologies, the guidance may
be revised in future as and when new tools or evidence
emerges. Cartridge-based nucleic amplification test is
one such test currently being evaluated.
3. DOTS for new cases does not need a
skilled person as there are only oral drugs to be
administered. School based DOTS may be an option but the
limited capacities and lack of time or motivation with
in the school staff as well as the potential risk of
stigmatisation are the likely hurdles Also, partnerships
for provision of directly supervised treatment must have
a continued link with health providers to monitor the
child for response to therapy, adverse events and
management of other co-morbidities, including
malnutrition. There is certainly a need to make DOTS
more user-friendly for children and there is a need to
pilot test to achieve innovative out of the box
alternatives (school based, home based or neighbourhood
DOTS).
4. INH prophylaxis is the only proven
and established chemoprophylactic drug for tuberculosis
[2-4]. The committee after reviewing the scientific
literature and deliberating on programmatic
implementation the committee opined that INH therapy
should continue to be the mainstay of chemoprophylaxis
in our country; albeit at a higher dosage of 10 mg/kg
body weight per day.
5. The prophylaxis is recommended for
all asympto-matic contacts (children under the age of
six years) of smear positive tuberculosis because (a)
the exposure to an infectious case (which is usually a
smear positive TB case) is one of the strongest
determinant for the risk of infection, (b) and at
a younger age the risk of developing disease after
infection is very high. Though tuberculin skin test
(TST) is performed to establish infection, it may not be
required when there is a definite exposure. The current
recommendations merely simplifies the mechanism to
clinically identify children, in the family/household,
who are likely to be recently infected.
The current evidence is for the post
exposure prophylaxis and is recommended for six months.
The benefit of a prolonged or continuous use of INH
prophylaxis for TB, in a continued state of
immunosuppression is not known. We, therefore, found it
appropriate to recommend six months prophylaxis only for
those cases who are found to be infected at the first
point when the immunosuppressive therapy is started.
6. The recommendations clearly state
the need to rule out active disease before initiating
any child on preventive therapy including suspected
perinatal cases. Congenital TB is suspected based upon
clinical examination (hepatosplenomegaly with or without
pneumonia), chest skiagrams, microbio-logical diagnosis
and ultrasonology of the abdomen for any hepatic
granulomas, particularly in a neonate born to a mother
who is suffering from active tuberculosis.