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correspondence

Indian Pediatr 2013;50: 802-803

Reply

 

Varinder Singh and BN Sharath

Email: [email protected]

 


In reference to letter received from Kumar and Patwari, we would like to add that:

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.

References

1. Kumar A, Gupta D, Sharath BN, Singh V, Sethi GR, Prasad J. Updated national guidelines for pediatric tuberculosis in India, 2012 Indian Pediatr. 2013;50:301-6.

2. Rapid advice: Treatment of TB in children. WHO 2010.

3. Thee S, Seddon JA, Donald PR, Seifart HI, Werely CJ, Hesseling AC, et al. Pharmacokinetics of isoniazid, rifampin, and pyrazinamide in children younger than two years of age with tuberculosis: evidence for implementation of revised World Health Organization recommendations. Antimicrob Agents Chemother. 2011;55:5560-7.

4. Menzies Dick,  Al Jahdali H, Al Otaibi B. Recent developments in treatment of latent tuberculosis infection Indian J Med Res. 2011;133:257-66.

 

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