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Indian Pediatr 2011;48: 387-389 |
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Significance of Family Survey of Index Case
for Detection of Tuberculosis |
Nishikant Dahiwale, Sunil Rao, Jyoti Singh and AK Rawat
From the Department of Pediatrics, Gandhi Memorial
Hospital and SS Medical College, Rewa,MP, India.
Correspondence: Dr AK Rawat, D-2, Doctors’ Colony, Rewa,
MP, India.
Email:
[email protected]
Received: May 19, 2009;
Initial review: June 12, 2009;
Accepted: September 21, 2010.
Published online 2011 Feb 28.
PII: S097475590900347-2
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Abstract
Tuberculosis is highly prevalent amongst children in
India. Contact survey has not received much attention in the Revised
National Tuberculosis Control Program guidelines. This study was
conducted to look for tuberculosis in asymptomatic family members of
pediatric tuberculosis patients at a government hospital attached to a
medical college in Central India. 168 siblings and 162 parents of 86
index cases of tuberculosis were studied. 64 tuberculosis infected
siblings and 7 sputum positive parents were identified.
Key words: Contact survey, Index case, Tuberculin Skin Testing
(TST), Tuberculosis.
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In 1993, WHO declared tuberculosis as to be global public health
problem. 1.8 million new tuberculosis cases occur every year in India and
0.8 million of these are infectious sputum positive cases [1]. Of the
total TB case load, around 10% are found amongst children according to
estimates, amounting to 1.5 million new cases and 1.30 lakh deaths due to
TB every year [2]. According to the pyramid of childhood tuberculosis,
those with serious disease constitute only the apex of the problem and are
admitted in hospitals [3]. Bacteriogical confirmation of tuberculosis is
difficult in children due to paucibacilliary nature of the disease. The
importance of case contact investigation cannot be overemphasized as up to
50% of children are diagnosed as a result of contact investigation [4,5]..
RNTCP guidelines at present do not recommend ascending, descending and
horizontal survey of tuberculosis patients. This study has been carried
out to find evidence of tuberculsis in asymptomatic family members of
pediatric tuberculosis patients.
Methods
This was a prospective hospital based study conducted
in a total of 168 siblings of 86 index cases admitted in the Department of
Pediatrics at our institution from August 2007 to July 2008. Siblings of
the index case between age group 1month to 12 years were enrolled.
Exclusion criteria included siblings previously treated for tubercular
infection or disease; those with medical condition like HIV infection,
hematological or reticuloendothelial system malignancy; and those who were
previously or currently on immuno-suppressive drugs. Parents of index
cases were also included to detect tuberculous infection but the data is
not presented here. Index cases were diagnosed on the basis of history,
general and systemic clinical examination, and investigations including
X-ray chest. Sputum examination of their parents was done for
detection of acid fast bacilli by trained personnel at the DOTS center in
the hospital. Siblings were subjected to detailed history regarding
history of fever and/or cough, weight loss, loss of appetite, previous
history of infectious disease (measles and pertussis), immunization
status, history of contact with a case of tuberculosis and history
regarding housing condition and education of parents. Detailed general and
systematic examination was done. Tuberculin skin testing (TST) was
performed by intradermal injection of 0.1 mL of 1 TU of PPD into the volar
surface of left forearm and was read 48 to 72 hours later. Induration was
measured in mm by Pen method and read as negative <5 mm, doubtful
³5-10mm and positive
>10mm. X-ray chest PA view of all children was taken and additional
investigations were done if required. All proportions were compared by
Chi-square test. The level of significance for all tests was 0.05.
Analysis was conducted using the SPSS version 10.0 software.
Results
Of the 86 index cases, 60% were <5 year of age, male to
female ratio was 1.09:1, 44% had severe grade malnutrition (III and IV)
and only 8% had normal nutrition. The commonest form of tuber-culosis
between age 1month and 12 years was pulmonary tuberculosis (40%).
Disseminated tuberculosis was most common under 5 years of age: pulmonary
tuberculosis (n=22), tubercular meningitis (n=18) and
military tuberculosis (n=7).
Out of 168 siblings, 30% had severe malnutrition, 55%
had no BCG scar and 39.2% had history of contact. 32 (19.0%) had positive
tuberculin reaction and 62 (36.9%) had induration between ≥ 5–10 mm. Amongst
those having induration ³5–10
mm, 18 (out of 62) had risk factors making TST positive. Thus 50 siblings
were diagnosed with hidden tubercular infection by TST, 23 out of these
had tubercular disease. The total number of siblings infected with
tuberculosis were 64 (Table I). Among 162 parents, 7 (4.3%)
parents were newly detected as sputum positive and 20 (12.3%) parents had
X-ray chest suggestive of healed or active tuberculosis.
TABLE I
Distribution of Siblings with Positive Tubercular Reaction and Chest X-Ray
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Severe Malnutrition |
BCG Scar |
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Present |
Absent |
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Present |
Absent |
|
|
n=51 |
n=117 |
P value |
n=76 |
n=92 |
P value |
Positive tubercular skin test (n=32) |
11 |
21 |
0.58 |
12 |
20 |
0.36 |
Positive chest X-ray (n=19) |
11 |
8 |
0.006 |
4 |
15 |
0.025 |
Both positive (n=13) |
9 |
4 |
0.002 |
1 |
12 |
0.005 |
Discussion
In this study, family survey of 168 siblings and
162 parents of 86 index cases of tuberculosis has resulted in detection of
tuberculosis in 64 siblings and 27 parents. Severe disease like tubercular
meningitis and disseminated tuberculosis were common in under 5 years
index cases. Benakappa, et al. [6] had also reported nearly same
incidence of tubercular meningitis. As positive TST indicates tubercular
infection, in our study 32 (29.7%) siblings were found to be having
tubercular infection on the basis of TST. Tuberculin positivity of our
study (29.7%) is also comparable to previous studies [7-9]. We conclude
that history of contact is very important in diagnosis of childhood
tuberculosis. Earlier studies have also noted history of contact in 37-55%
cases [7-11].
Contributors: All authors contributed to study design,
concept, execution and writing.
Competing interests: None stated.
Funding: None.
What This Study Adds?
• Family surveys are important in early detection
of hidden tuberculosis.
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