Childhood Tuberculosis

Department of Health-Central Visayas

ENRIQUE A. SANCHO, MD. Communicable Disease Section

Legal Basis
Administrative Order 178 S. 2004 Issued by Manuel M. Dayrit, MD. October 27, 2004 Subject : Guidelines for Implementing Tuberculosis Control in Children
Sections :

1. Rationale
2. Definition of Terms 3. Coverage & Scope

4. General Guidelines
5. Implementing Mechanisms 6. Effectivity

Natural History of Tuberculosis

PRIMARY INFECTION

Artificial Infection / BCG Vaccination - its effectiveness ?

1st 10-15 years preventing the severe form [Miliary & Meningitis] Modifies the course of true infection

Natural History of Tuberculosis

PRIMARY INFECTION Natural Infection
Infection from exposure to a smear positive individual Hypersensitivity to Lymphangitis tuberculin develops 4-8 weeks & may last for a lifetime Sequelae is PRIMARY COMPLEX Lymphadenopathy Primary Complex/Ghons Complex Primary Focus/Ghons Focus

TUBERCULIN SKIN TEST

TST is not a routine screening procedure

1. 2. 3. 4. 5.

Criteria for Diagnosis of TB Disease in Children (National Consensus 1997, PPS)

Epidemiologic (exposure history) Clinical (signs/symptoms) Immunologic (tuberculin test, Mantoux) Radiologic Laboratory

In the absence of bacteriologic evidence, a child is presumed to have active TB if 3 or more of these criteria are present.

Background : Tuberculin Skin Testing

TST, particularly the Mantoux test, is currently the only widely used method for identifying infection with M. tuberculosis in persons who do not have tuberculosis disease (latent TB infection or LTBI) Diagnostic Standards and
Classification of Tuberculosis in Adults and Children, Official Statement of ATS & CDC, Am J Respir Crit Care Med Vol 161, 2000

Rationale for TST

PPD reactivity is a general measure of cellular immune responsiveness Delayed (cellular) hypersensitivity, classical reaction to tuberculin injected intradermally /intracutaneously : T-cell sensitization with release of lymphokines at site of injection Reflects prior infection with M. tuberculosis or tuberculoproteins from BCG Safe and effective, monograph conditions

Features of TST
1. Delayed course, reaction starting 5-6 hrs after injection, peaking between 48 to 72 hrs & subsiding over several days 2. Induration, induced by lymphokines 3. Occasional vesiculation and necrosis

Delayed Type Hypersensitivity Reaction (Type IV) to Tuberculin

PPD INJECTED INTRACUTANEOUSLY

RELEASE OF LYMPHOKINES AT THE SITE OF INJECTION (5-6 HRS. POST INJECTION)

LOCAL VASODILATION, EDEMA, FIBRIN DEPOSITION AND RECRUITMENT OF OTHER INFLAMMATORY CELLS INTO THE AREA

INDURATION (48-72 HRS. POST INJECTION)

CHILDHOOD TB
Diagnosis in Govt Facility
Barangay level (midwife) TB symptom in 0-9 yrs.

Main Health Center

P.E. by medical officer

Tuberculin testing by nurse

District/Provincial Hospital x-ray

Casefinding
Two ways in the identification of children who might have tuberculosis
Contact tracing of children age 0-9 years old of adult TB cases
Identify children with TB symptoms and to subject these children to the different diagnostic procedures

Materials Needed for Tuberculin Skin Testing

PPD Tuberculin syringe, needle G 25-27 CB with alcohol or sterile water Cold storage/chain Mm stick Ballpoint pen Record book

The Procedure : Mantoux Test

Administration : Inject 0.1 mL PPD intradermally into volar aspect of forearm, using G 25 to 27 needle => a pale wheal 6 to 10 mm diameter. (Date & time of injection
recorded.)
1 vial of a commercial preparation (Japan freezedried tuberculin, PPD) contains 1 g of tuberculin PPD equiv to 50 TU. To make 5 TU strength, use 1 mL diluent.

PPD injection

Reading & Recording

Reading is done between 48 to 72 hours. (Date &
time of reading is recorded)

Diameter of induration, not erythema, is measured transversely to long axis. Measure & record in mm, not (+) or (-) Ballpoint pen technique : lightly sweep a distance of 5-10 mm from margins towards it until resistance is felt & intensity of mark changes
(Sokal, NEJM 1975)

Interpretation
A reliable interpretation requires knowledge 1. of antigen used (tuberculin), 2. of proper technique of administration and reading of the test, 3. of results of epidemiological studies and clinical experience with the test 4. of conditions that can bring about false positives & false negatives Based on purpose for which test is given

Factors that may cause false negative reaction

1. Factors related to person tested 2. Factors related to tuberculin used 3. Factors related to method of administration 4. Factors related to error in (inter-pretation), reading and recording

False negative rxn : person tested

Infections: certain viral, bacterial, fungal Live attenuated virus vaccinations Metabolic, nutritional factors Corticosteroids, Immunosuppressives Extremes of age, waning sensitivity Incubation pd, recent/overwhelming infxn Stresses: surgery, burns, graft vs host rxn Anergy

False negative rxn: tuberculin used

Improper storage exposure to light, heat Improper dilution Chemical denaturation Contamination Adsorption into the syringe (partially controlled by adding Tween 80)

False Negative Rxn : method of administration

Injection of too little antigen Delayed administration after drawing into syringe Too deep injection

False Negative Rxn : error in reading, recording or interpretation

Inexperienced reader (not standardized) Conscious or unconscious bias Error in recording

Factors that may cause false positive reaction:

Atypical mycobacteria (background) => cross-reactions with true TB

FAQs
Q. Can we do TST in infants?
A. Yes, at around 3 months when DTHR is developed

Q. How soon does tuberculin reactivity set in after exposure?

A. In most children, the tuberculin reaction appears 3 to 6 weeks or up to 3 months after initial exposure. This is the INCUBATION PERIOD

Q.Does repeated TST cause conversion to positive?