I read with great interest the recent communication by Vashishtha and John(1). They have documented the annual rate of Mycobacterium tuberculosis (Mtb) infection in children attending an outpatient department of a secondary level hospital in Western Uttar Pradesh. The prevalence rate of Mtb infection in different age groups are much higher than community surveys in rural Uttar Pradesh by Indian Council of Medical Research. Although findings from the study do not indicate the exact community prevalence, the implications are that a significant proportion of outpatient workload for practicing pediatricians in Western Uttar Pradesh (UP) would be children with tuberculosis. I have documented the overall prevalence of childhood (1month-18 years) tuberculosis (not infection) in out-patients at Shanti-Mangalick hospital (Agra, UP) using IAP guidelines to be 3.5% (95% CI 2.5% -4.0%)(2, 3). This concurs with the high prevalence rates of infection documented by Vashishtha and John and the natural history of tuberculosis disease in children.

The challenges noted while managing children with tuberculosis as outpatients were difficulties in demonstrating acid-fast bacilli, inability to link the children with the RNTCP program due to guidelines and logistic issues, an extremely high prevalence of extra-pulmonary tuberculosis (~ 50%), long delays in diagnosis considering the duration of symptoms at presentation (median 4.5 months, IQR 1-6.5 months), inability to do contact tracing in all children and follow up and affordability issues.

The observations made by me in 2004 and by Vashistha in 2008 indicate that little progress has happened in the control of tuberculosis in Western UP. The effectiveness of the RNTCP program in controlling tuberculosis in adults and children in this region is questionable. The role of practicing pediatricians must be appreciated for the control and management of tuberculosis in children in the region. Only with their active involvement it might be feasible to develop an integrated computerized system with a district hospital or medical school taking the lead to ensure compulsory follow up of each child with tuberculosis and attempt contact tracing using available community resources.