|LETTER TO EDITOR
|Year : 2017 | Volume
| Issue : 3 | Page : 257-258
Management of asymptomatic children of adult pulmonary tuberculosis patients
KC Patty Primary Health Center, Kodaikanal, Tamil Nadu, India
|Date of Web Publication||7-Aug-2017|
KC Patty Primary Health Center, NP Nagar, KC Patty, Perumparai Post, Kodaikanal - 624 212, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ramasamy R. Management of asymptomatic children of adult pulmonary tuberculosis patients. Curr Med Issues 2017;15:257-8
Ref: Verghese VP. Diagnosing pulmonary tuberculosis in children. Curr Med Issues 2017;15:106-13.
As a comment to this useful article, I would like to add a perspective from a family physician diagnosing an adult with tuberculosis (TB) who has children. My latest patient with sputum positive pulmonary TB is a 25-year-old agricultural worker living in the usual tiny home in a rural area with his wife and 2 children aged 2 and 4 years. The children are asymptomatic. What should be done for the children? The ideal of doing Mantoux tests (needs 2 visits to a health service) and chest X-rays (in this case needing 40 km travel) is often not possible when faced with an adult who is struggling to cope with the diagnosis and its difficult treatment after he has already lost many earning days due to illness.
However, as a family physician, I have the privilege to know this family through home visits by myself and through health worker colleagues. His home is a single room 12' × 10' structure and has a single window that is 1' square that is usually kept shut. It is inconceivable that the children are not infected it is as if they inhale nebulized smear positive sputum daily! This is a common scenario in many parts of rural India.
The pathophysiology of TB in children is such that the infection is asymptomatic until the enlarging peribronchial lymph nodes impinge on an adjacent airway or rupture into it or a blood vessel. So, what should we do? Over the years, we have made the following protocol that we follow when children have close contact with a sputum positive adult in a such poorly ventilated homes:
- All children under 1 year are given anti-TB treatment irrespective of nutritional status with standard multidrug regimes. Rationale: Infants may develop rapidly progressive and severe forms of TB - we cannot wait. Isoniazid (INH) alone as a prophylaxis, is in my opinion inadequate, because we need to treat active TB at a stage when it is still asymptomatic, and there is an increasing the prevalence of primary INAH resistance
- Children aged 1–5 years have a nutritional assessment. We are lucky to have maintained the road to health charts. If these charts show unexplained falling off centiles for 3 months, or where there are insufficient previous weights, the weight for height chart shows <80% standard, these children have treatment started on standard treatment. Rationale: Malnutrition markedly increases the likelihood of TB progressing, and TB causes malnutrition
- Asymptomatic children under 5 years with normal nutritional status have their notes flagged as close TB contacts. The family is educated about early signs of TB and efforts are made to ensure these children have regular weights. A very low threshold exists to start them on empirical treatment for symptoms suggestive of TB.
In our area, all children have had Bacillus Calmette-Guérin (BCG), but we ensure that they have had 2 doses of measles immunization also because measles possibly predisposes to activation of TB due to effects on cell-mediated immunity.
It is essential to have simpler protocols for asymptomatic children with close contacts of adults with TB. From an epidemiological perspective, if we are to succeed in controlling TB in India we cannot just rely on treating adults with TB because by the very nature of the disease and its socioeconomic interactions, most adults have infected many others by the time they are diagnosed. Many adult infections are also due to reactivation of infection acquired during childhood, so aggressive treatment of children of contacts is an important but much-neglected part of TB control.
(A nonprofit making and joint project of the Palani Hills Health Development Trust, a community-based organization of mainly Adivasi people in the Palani hills of Tamil Nadu and The Christian Fellowship Hospital in Oddanchatram, Dindigul District, Tamil Nadu 624619. https://sites.google.com/site/kcpphc/home).
I look forward to comments on this approach by Dr. Verghese.
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Conflicts of interets
There are no conflicts of interest.