Tuberculosis Looms

Tuberculosis continues to be an important cause of morbidity, mortality and health care cost in the U.S. TB cases declined 6% annually until 1985 when they leveled off. Now we seem poised for a slow rise again due to immigration, HIV infection, spread among the homeless , resistant strains, and other factors.

The author emphasizes these points:

1. The majority of tuberculosis cases in children are from high-risk populations, that is, immigrants, and those living in poverty and in the inner cities.

2. The preferred tuberculin skin test is the intradermal Mantoux test with purified protein derivative (PPD); two levels of positivity now are accepted. Children exposed to active disease who have findings suggestive of tuberculosis or who have human immunodeficiency virus (HIV) infection are positive at 5 to 9 mm; other high-risk groups are positive at 10 mm.

3. Diagnosis of childhood tuberculosis depends on a high index of suspicion coupled with suggestive epidemiologic data, tuberculin skin test results, and chest x-rays. Cultures are not routinely positive in children, and results are available only after treatment must be started.

4. Treatment is a course of isoniazid, rifampin, and pyrazinamide for 2 months followed by 4 months of isoniazid and rifampin daily (sometimes twice weekly). Additional drugs are needed in cases of drug resistance.

5. Chemoprophylaxis (usually isoniazid alone for nine months) for all children who have a positive tuberculin reaction will prevent future disease

(Abernathy R. Tuberculosis: an update. Pediatrics in Review. 1997;18(2):50-57.)

Comment: Schools will undoubtedly be impacted by an increasing number of skin test positive students on medication. It will be in everyone’s best interest for school nurses to participate or to allow health department staff into school for directly observed therapy programs (DOT). Although many school districts already do this, others refuse to give meds that can be given outside school hours (2-3 times weekly antibiotics for TB fall in this category). - R.A.