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Childhood Tuberculosis with Reference to the Ameriean Indian

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Childhood Tuberculosis with Reference to the Ameriean Indian Childhood Tuberculosis 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 isoniazid was a decrease of 76 percent in census from the and streptomycin. 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. Tuberculin 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 Mantoux test. 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 tuberculins 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.
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