Childhood With Reference to the Ameriean Indian

HELEN M. WALLACE, M.D., M.P.H.

PROGRESS has been made in times that of the United States as a whole. Of GREATreducing deaths from tuberculosis in the the total cases reported in 1964, nearly 38 per¬ United States over the past decades, but the cent were in persons less than 20 years old greater challenge of eradication remains. From (table 2). 1900 to 1960 the tuberculosis death rate declined Since 1956 fewer patients with tuberculosis from 194.1 to 6.1 per 100,000 persons (1). have been hospitalized and their hospital stays Striking decreases in the rate occurred during have been shorter. In 1965 the tuberculosis the early years of the 20th century and in the patient census constituted about 17 percent of years 1946-55 following discovery of the chemo- the total census for all types of patients. This therapeutic and antibiotic compounds was a decrease of 76 percent in census from the and . peak in 1956 (3). The ambulatory chemo- For many decades the rate of deaths due to therapy program contributed to a marked de¬ tuberculosis has been higher among the non- cline in hospitalization, and the use of drugs white than in the white population. In 1960 also helped to reduce the length of stay of among white infants, children, and youth, mor¬ patients requiring hospitalization. tality rates from tuberculosis were low; for the comparable nonwhite age groups mortality Mortality Among Indians rates were significantly higher (table 1). The The highest tuberculosis death rate in the ratio of deaths of nonwhite to white persons United States has been among Ameriean In¬ from tuberculosis in 1960 was 2.8 to 1. dians. During 1961-63, it was 11 times that for the total population in 1962 (table 3). Morbidity Among Indians In 1964 tuberculosis ranked ninth among the The reported incidence of tuberculosis among causes of death of Indians, while among the Ameriean Indians in 1962 was 263.4 per 100,000 total U.S. population it was no longer among population compared with 37 for the entire U.S. the first 10 causes (3). population.or approximately seven times that The high rate of death caused by tuberculosis of the non-Indian population (2). This was among Indians and the high risk of illness from a decline from 284.8 in 1961 and 292.3 in 1960. tuberculosis encountered by many Indian chil¬ 80 or 647 of the total of 844 Nearly percent, dren strongly suggest a grave need to prevent cases in were classified as active reported 1962, further of tuberculosis in Indian com¬ or active cases. the 1950's spread probably During munities. Any tuberculosis program for In- there had been a reduction of 54 percent in the reported incidence of tuberculosis among Dr. WaUace is professor and chairman, Division of Indians. Matemal and Child Health, University of California In 1964 a total of 578 new active cases of School of Public Health, Berkeley. This paper is tuberculosis were reported among the Indians based on material presented at a medical staff meet- (3). This was a reduction of 3 percent from ing, at the Public Health Service Indian Hospital, 1963, but the rate of incidence was still seven Gallup, N. Mex., December 16, 1965.

30 Public Health Reports dian children should be an integral part of the given to those for whom it is considered appro- health services for their entire families. priate. Persons with the disease should be Furthermore, thegeneral health needs ofIndian treated. children should be given high priority. testing should be routine for adults in close contact with children. Mothers Suggested Program for Children The specifics in a program for Indian chil¬ dren include (a) casefinding and data collec¬ Table 1. Death rates x from tuberculosis, by tion, (b) followup of the child and his contacts, age groups, raee, and sex, United States, (c) diagnosis and treatment, (d) prevention, 1960 and (e) evaluation of data. Casefinding. Tuberculosis morbidity is three to five times higher among children who react positively to the tuberculin test than among those who do not. This susceptivity applies to immediate oomplications and to laterbreakdown into endogenous pulmonary disease. The prob- ability of developing progressive disease and extrapulmonary oomplications within a year is 1 Rates are for children 4 old or and per 100,000 persons. high years younger, Source: 1. this risk is multiplied many times for reactors Reference under 1 year of age. Tuberculin testing of children should be part Table 2. Reported eases of tuberculosis of the general plan for supervising their health. among Ameriean Indians,1 by age groups, It can be included routinely in a well-child con- 1964 ference; school health, day care, or hospital clinic programs; or the procedures followed by a private physician. In areas with high incidence of tuberculosis, testing should be done at 6 months of age, an- nually until 1 year after admission to school, at ages 9 and 12, and again annually through high school. All hospitalized children should be tuberculin tested, and all children attending a hospital clinic should be skin tested yearly. If the reaction to the tuberculin test is positive, 1 Exchides Alfialrfl. natives. the child should receive a standard diagnostic X-ray. Extent of followup is determined by Source: Reference 3, p. 41. clinical findings (length and extent of infection, presence or absence of calcification, or discovery Table 3. Age-specific death rates from of any pulmonary disease), the child's associa¬ tuberculosis tion with persons having active tuberculosis, and his age. If a child has tuberculosis, it is imperative to identify and control the source of infection. This should include a tuberculin test for mem¬ bers of his family, or household, and his close associates. Positive tests of contacts should be followed by a diagnostic chest X-ray. Persons at special risk should be re-examined periodi- cally, and prophylactic chemotherapy should be Source: Reference 3, p. 20.

VoL 82, No. 1, 1967 31 237-827.67- should be given a tuberculin test during preg- determining a rough index of tuberculous infec¬ nancy and another at 3 months postpartum. tion. Unless there are too many persons with School employees, personnel of day care centers, small skin indurations or questionable reactions, nursery schools, summer camps, children's insti- all such persons should be retested with the tutions, and baby sitters should be tested an- standard . nually. If the results of the tests are negative, 4. For differential diagnosis when tuberculo¬ persons working with preschool and primary sis is suspected, the multiple-puncture test is an grade school children should be tested annually. acceptable initial test. If a negative or equivo¬ If the results of their tuberculin tests are posi¬ cal reaction is obtained, a Mantoux test, using tive, people working with children of any age 5 tuberculin units of PPD, should be given. If should have a chest X-ray immediately and the reaction is still negative, a stronger dose each year thereafter. should be used in an effort to rule out tuber¬ The tuberculin test. The kind of tuberculin culous infection. test to be used merits some discussion. Eegardless of the test used, the size of all 1. The Mantoux test permits administration reactions should be recorded in quantitative of accurately measured amounts of tuberculin. terms so that an excess number of small skin The materials and equipment are readily avail- indurations will be detected. A skin induration able, and the reactions can be read and recorded of more than 10 mm. in reaction to 0.0001 mg. quantitatively. However, skillful administra¬ PPD should be considered an indication of tu¬ tion of the Mantoux test is required for best berculous infection until proved otherwise. results, techniques associated with its use are An induration of 5-10 mm. should be considered cumbersome, and there are psychological objec- as questionable and the test should be repeated. tions to use of a hypodermic needle (If). An induration of 0-5 mm. should be considered 2. The multiple-puncture test can be adminis- a negative reaction. tered by persons with minimal technical skill. In the tine test, a skin induration of 2 mm. Concentrated tuberculin punched into the skin or more is considered positive. If the results is essentially a strong dose, a factor which mini- of the tine test are questionable, the Mantoux mizes the number of false negative results. The test should be given. materials for this test are stable at room temper- ature. Disadvantages include the fact that the Followup Procedures are not well standardized, the dose The tuberculin test is of little value unless of antigen retained in the skin is unknown, and appropriate followup programs are planned in an excess of false positive reactions is produced advance and accurate records are kept. Pri¬ by concentrated tuberculin. Quantitative meas¬ mary emphasis in followup should be placed on urements of reactions can be only approximate persons who have larger skin indurations. guides to degrees of sensitivity in view of the Children who react positively should be re- variables affecting the dose (4). ferred promptly for diagnostic study. The The following recommendations have been study should include obtaining a complete his¬ made (4). tory (with emphasis on contact with persons 1. For screening and diagnostic purposes, the with active tuberculosis), physical examina- intracutaneous injection (Mantoux test) with tion, and chest X-ray. a standard dose of 5 tuberculin units Factors predisposing active disease. Once (0.0001 mg.) of purified protein derivative infection has occurred, morbidity rates are four (PPD) is the most accurate test. Skillful ad¬ times higher among persons who are 15 percent ministration and careful reading are essential. or more underweight for their height than in 2. For clinical screening when tuberculosis is those who are overweight (5). not suspected, a multiple-puncture test is ac- Substandard living conditions, especially ceptable. If an equivocal reaction is obtained, poor and crowded housing, can increase the risk give a Mantoux test using 5 tuberculin units. of contact with a patient with active disease. 3. For large-scale screening, multiple-punc¬ Exposure carries an unusually high risk for ture tests are acceptable for casefinding and for young children. The severity of primary dis-

32 Public Health Reports ease is related directly to the intimacy of the most serious complication in children, 80 per¬ contact and the amount of tubercle bacilli being cent have been reported to survive when ther¬ released. apy is initiated early and includes isoniazid. Surveillance of adult associates. Children Good prognosis depends on early diagnosis, ade- in contact with anyone who has active tuber¬ quate treatment, and the age of the child. culosis should be tuberculin tested. Because of Children seriously ill with tuberculous men¬ the high degree of tuberculin reactivity in such ingitis, miliary disease, or rapidly progressive a group of contacts, a Mantoux test using first- pulmonary disease must be hospitalized and strength (0.00002 mg.) PPD should be given. treated vigorously with antituberculosis drugs. If the first test is negative after 48 to 72 hours, Children with nonprogressive pulmonary dis¬ intermediate strength (0.0001 mg.) PPD should ease are not dangerous to other children and be administered. Positive reactors are referred should be allowed to attend school and pursue promptly for diagnostic study. Adults with their usual activities if they are free from tuberculin-positive sputum should be removed symptoms. from further contact with children. Treatment with isoniazid for 1 year should be Chemoprophylaxis and chemotherapy. In given to positive reactors under 4 years of age 1955, the Public Health Service initiated a study and recent converters, especially adolescents and to determine the efficiency of isoniazid in pre- those in contact with active tuberculosis, who venting oomplications of primary tuberculosis had Mantoux tests. (6). A total of 2,750 children who had posi¬ Treatment with isoniazid and para-amino- tive reactions to tuberculin tests were followed. salicylic acid (PAS) for 18 months or longer is The study was limited to children under 3 years indicated for children clinically ill with pro¬ of age with asymptomatic primary tuberculosis. gressive pulmonary disease, pulmonary infil- For 1 year, half received isoniazid and the trates, or pleural effusion. A similar regimen others received placebo. During the first year should be prescribed for children who have lost 27 children in the control group developed weight or who have fever and those with non- definite extrapulmonary complications, includ¬ pulmonary, bone, or renal disease; cervical node ing five cases of meningitis and one of miliary involvement; or large hilar nodes, with or with- tuberculosis. The study group had two chil¬ out atelectasis. dren with definite complications. Frequent observation, not necessarily with For infants less than 1 year of age who were X-ray, every 2 to 3 months is indicated for nega¬ tuberculin reactors, the risk of developing ex¬ tive reactors over 4 years old who are in contact trapulmonary complications within 2 years af¬ with patients who have active tuberculosis and ter diagnosis was 1 in 11. For tuberculin re¬ recent converters between 4 years and adoles- actors 1 to 4 years of age, the risk was found cence who have no signs of disease and who are to be substantial only if the roentgenograph not in contact with a patient with active disease. showed definite tuberculosis. The rate of risk Observation every 6-12 months is indicated was 1 in 14 if the involvement was parenchy- for positive reactors over 4 years of age who are mal, 1 in 36 if the involvement was hilar or known to have converted more than 1 year in the paratracheal (6*). Therefore, the Ameriean past, or whose chest films show good calcification Academy of Pediatrics recommends that all or no signs of tuberculosis, and who are not in children under 4 years of age who react posi- contact with active tuberculosis. tively to tuberculin should receive isoniazid for 12 months in a daily dose of 10 to 20 mg. per Prevention kilogram of body weight (6*). Preventive measures include improving nu- Treatment. Present-day drug therapy is tritional status and general health, the standard highly effective in the treatment of pulmonary of living (especially housing), and education. tuberculosis. Ninety-five percent of all pa¬ These measures constitute the long-range ap- tients with active disease who receive appropri- proach to most problems encountered with a dis- ate drug therapy from the time of diagnosis advantaged, culturally different group. can recover. In , the More specific preventive measures include

YoL 82, No. 1, 1967 33 those already mentioned: early casefinding, mass testing or confine their efforts to certain treatment of recent converters, adequate follow- age groups or specific areas. up of close contacts of recent converters, prompt Tlle number of positive reactors X-rayed and treatment and management of persons with the results of the examinations will show the active disease, and separation of patients from effectiveness of followup and the number and children. percent of positive reactors with active tuber- Although Bacillus Calmette-Guerin (BCG) culosis. Information obtained by the followup vaccine has not been recommended for general of contacts of positive reactors will yield the use in the United States, it lhas been recom- same kind of data about them. mended for persons exposed to greater than Furthermore, the total analysis will tell the average risk of infection (7). It slhould be number of active cases found per total children administered only to persons who are tuberculin tested. It will reveal the productivity in test- negative. BCG has been recommended for ing Indian children-both in positive reactors tuberculin-negative children unavoidably ex- found and in cases of active tuberculosis found. posed to infectious disease in the home and for Also, a record of expenditures in the program tuberculin-negative infants and adolescents who will show the cost of finding a positive reactor live under substandard conditions in high- and of finding an active case. incidence areas. American Indian clhildren Only by careful recording of events and steps may be in either of these groups. BCG vaccine taken can it be determined whether a program is recommended for employees of tuberculosis is carrying out its objectives. sanitoriums, student nurses, and medical students. Conclusion Newborn infants who are to be given BCG In the past decade much progress has been vaccine do not require tuberculin testing before made in coping with tuberculosis in the Ameri- vaccination. Children in contact with tubercu- can Indian. It is clear, however, that tubercu- losis should be followed as carefully as the un- losis is still a major problem in this group. An vaccinated. BCG is not a substitute for otlher antituberculosis program, including casefind- control measures: it is only an additional ing, diagnosis, treatment, continuous super- method for use under special conditions. vision, prevention, and evaluation, should con- tinue to be a major part of any general public Records and Evaluation health program for the American Indian. In any tuberculosis control program at least two kinds of records should be kept. REFERENCES In order to follow and (1) Doege, T. C.: Tuberculosis mortality in the United Family folders. States, 1900 to 1960. JAMA 192: 1045-1048, supervise the health care of families at higlh risk June 21, 1905. to tuberculosis, a family folder is necessary. (2) U.S. Public Health Service: Illness among In- All family (or household) members and otlher dians, 1964. U.S. Government Printing Office, close contacts should be viewed as an entity. Washington, D.C., '96.. Each step planned or taken for an individual (3) U.S. Public Health Service: Indian health high- lights. U.S. Government Printing Office, family member should be considered part of the Washington, D.C., 1906. total family health plan. Both a tuberculosis (4) CoInmittee on Diagniostic Skin Testing: Tuberculin case register and a family folder system are skin-testing techniques: Current status. Amer essential. Rev Resp Dis 87: 607-610, April 1963. Service statistics. Some system of determin- (5) Palmier, C. E., Jablon, S., and Edwvards, P. Q.: Tuberculosis morbidity of young men in relation ing its effectiveness must be an integral part of to tuberculin sensitivity and body build. Amer any public health program. Records of mass Rev Tuberc 76: 517-539, October 1957. tuberculin testing of children slhould enable de- (6) Coiiuiniittee on Selection of Diseases of the Chest: termination, by age and geograplhic area, of the Isonlazid treatment for tuberculin reactors. number of children tested and the number of Pediatrics 27: 179-180, February 1901. (7) Tuberculosis Advisory Commiiittee to the Public positive reactors. These two factors will en- Health Service: Use of BCG vaccine. Public able planners to determine whether to continue Health Rep 77: 680-681, August 1962.

34 Public Health Reports