Original Article

Ind. J. Tub., 1992, 39, 177

A STUDY OF CHILDHOOD TUBERCULOSIS

V.A. Kakrani and A.K. Pratinidhi (Original received on 6.11.91; Accepted on 7.5.92)

Summary. The clinical profile of 170 children diagnosed to be suffering front tuberciilosisv pulmonary as Well as extra-pulmonary, at the Pediatric OPD of Sassoon General Hospital, Pune is; presented to help in the stil1 problematic process of reaching the correct diagnosis. The crucial importance of tuberculin test is discussed.

Introduction Tuberculosis remains one of the major public health problems in our country inspite of the spectacular developments in the field of science and medicine. Childhood tuberculosis is one of the six vaccine preventable diseases under universal immunization programme (UIP) for which continuous surveillance activities are going on. Nearly 1.8 per cent population above 5 years in age is suffering from radiologically active tuberculosis of lungs of which 25% are sputum positive and infectious to others1. Further, 2.8% of the children below 5 years in age are infected with tubercle bacilli. The annual incidence rate of infection in the 0 to 4 years age group is 0.8%. Though the acute forms of tuberculosis have been largely controlled due to improved coverage by BCG vaccination, there is no dent yet on chronic pulmonary disease. It was decided to study the children diagnosed as cases of tuberculosis at Sassoon General Hospital, Pune to understand the epidemiological aspects of childhood tuberculosis. Material and Methods Information was collected on a pretested prof or ma on cases of childhood tuberculosis from Pediatric OPD of Sassoon General Hospital which has been identified as the sentinel surveillance centre under UIP. The study included 170 children diagnosed over a period of

6 months, from March to September 91. Information comprised family history of tuberculosis, any death suggestive of tuberculosis, the type of tuberculosis, symptoms, BCG status along with the methods of diagnosis. The results of tuberculin test were recorded and correlated with the type of tuberculosis. Categorization of the cases was done as pulmonary tuberculosis, tuberculous meningitis, miliary tuberculosis, and tuberculosis of other sites. Results There were 135 (80%) children belonging to urban areas, and 35 (20%) from rural areas; 114 (67.0%) had a strong family history of tuberculosis out of which 20 (17.5%) had death in the family suggestive of tuberculosis. The age and sex distribution of the children is shown in Table 1. More than 50% of children belonged to the age group above 5 years. Although, overall, sex distribution did not show any difference, the proportion of boys was more in under fives, with reversal of sex ratio in age group of 6-12 years. The distribution of cases according to the type of tuberculosis showed that there were 120 (70.7%) cases of pulmonary tuberculosis, 20 (11.7%) of tuberculous meningitis, 2 (1.1%) of miliary tuberculosis while 28 (16.5%) had tuberculosis at other sites. There was no sex difference according to type of tuberculosis, except that a higher proportion of males had tuberculous meningitis (Table 2). Only 150 cases were given tuberculin test. It was found that out of 113 cases of pulmonary tuberculosis, 90% had induration size above 10 mm (Table 3). Out of total 170 cases, 94 were immunized (55.2%). It was seen that 72 out of 120 (60%) cases of pulmonary tuberculosis had BCG scar, both the cases of miliary tuberculosis were

Correspondence: Dr. VA. Kakrani, 10, Rhea Apartments, 5, Aundh Road, Khadki, Pune-3.

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V.A. KAKRANI AND A.K. PRATINIDHI Table 1 Age and sex distribution of tuberculous children

Age/sex

Male No. (%) 60.0 62.5 39.1 49.4

Female No. 12 18 56 86 (%) 40.0 37.5 60.9 50.6

Total No. 30 48 92 170 (%) 17.6 28.3 54.0 100.0

0 2 years 3-5years 6- 12 years Total

18 30 36 84

Table 2 Distribution of cases according to type of tuberculosis and sex Male No. Pulmonary tuberculosis Tuberculous meningitis Miliary tuberculosis Others Total 86 50.5 58 12 16 (%) 48.3 60.0 57.2 No. 62 8 2 12 84 Female (%) 51.7 40.0 42.8 49.5 No. 120 20 2 16.5 170 100.0 Total (%) 70.7 11.7 1.1 28

Induration size (mm)

Table 3 Distribution of tuberculin indurations according to type of tuberculosis Others Total Pulmonary TuberMiliary tuber-. culous tuberculosis meningitis culosis No % 4.4 5.3 28.3 62.0 100.0 No. 3 4 5 % 25.0 33.4 41.6 No. 1 1 2 % 50.0 50.0 100.0 No. 7 3 3 10 % 30.5 13.0 13.0 43.5 No. 15 10 40 85 150 % 10.0 6.6 26.7 56.7 100.0

0-5 6-10 11-15 Above 15 Total

5 6 32 70 113

12 100.0

23 100.0

unimmunized, while only 7 (35%) cases out of 20 of tuberculous meningitis had the BCG scar (Table 4).

Discussion

Symptom of presentation and duration in respect of cases of pulmonary tuberculosis revealed that 70% of them had fever with or without cough of long duration (more than 15 days) Table 5.

Among the six vaccine preventable diseases under surveillance, all others are showing a declining trend except the unabated childhood tuberculosis2. Adults in the family or neighbourhood who are suffering from tuberculosis are usually the source

A STUDY OF CHILDHOOD TUBERCULOSIS

179

Table 4 Type of tuberculosis according to immunization status of tuberculous children Type of tuberculosis Immunized No. Pulmonary tuberculosis Tuberculous meningitis Miliary tuberculosis Others Total % Unimmunized No. % No. Total

72 7

60.0 35.0

48 13 2 13 76

40.0 65.0

120 20 2 28 170

100 100 100 100 100

15 94

55.3
55.3

46.5
44.7

Table 5 Con-elation of symptoms with duration in pulmonary tuberculosis Symptom 1-15 days No. Fever with cough Fever with vomiting and loose motions Others No symptoms 24 16-30 days No. 35 Total 30+ days No. 39 No. 98 81.5 %

1 2 6

3 2 -

5 3 -

9 7 6

7.6 5.8 5.0

of infection for children. In our study, 67% of the children had strong family history of tuberculosis, as reported in other studies3'4. A history of direct or indirect contact with a case of tuberculosis often supports the diagnosis of tuberculosis, as suggested in an ICMR study5 where 47% of patients had a positive history of contact. In our study, 50% of the children were above 5 years in age whereas the hospital study conducted at Madras6 showed 64% of children below 5 years in age and the rest were 5-10 years old. In our study, pulmonary tuberculosis formed the bulk of the patients, followed by tuberculous meningitis, similar to the study done in Eastern Maharashtra7'8 The proportion of vaccinated children among cases of pulmonary and other type of tuberculosis was higher compared with 68% non-vaccinated in disseminated tuberculosis. A retrospective study8 of six vaccine preventable diseases had also

revealed that immunization status in pulmonary cases (48.6%) was higher than in extra pulmonary cases (26.8%). In the present study, among 170 cases the presenting symptom of pulmonary and extrapulmonary tuberculosis has been fever along with symptoms suggestive of the site affected. In all types of tuberculosis, thus, the common denominator appears to be fever of variable duration : 80% of cases had fever of more than 15 days duration. Therefore fever can be used as an indicator of suspicion of tuberculosis to be investigated for confirmation of the diagnosis. Of the 150 cases in which tuberculin test was done, 125 (83.3%) could have been diagnosed if the test had been performed earlier i.e., before the development of disseminated and other severe forms of tuberculosis. Since radiological diagnosis is not only costly but mostly nonspecific in children, it may be used only for those who

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VA. KAKRANI AND A.K. PRATINIDHI

cannot be diagnosed by tuberculin testing. High tuberculin positively was reported in the study6 conducted at Madras Institute of Child Health where 80% showed tuberculin positively whereas field surveys conducted at Madras9 showed 24% of children below 4 years and 40% of children below 12 years had positive tuberculin reaction. Diagnosis of childhood tuberculosis still presents a problem because of paucity of specific signs and symptoms, clinical evidence and difficulty in sputum collection. Tuberculin testing seems to be an important diagnostic tool. Though available and routinely done in hospital setting, the test is never used in Primary Health Centres. Since a majority of our population is rural, making this diagnostic tool available at Primary Health Centres can go a long way in the early diagnosis and prompt treatment of cases of childhood tuberculosis. Whether used in hospital or health centre, the test needs careful training of personnel and adoption of a precise and sophisticated technique. References
1. National Programme for control of tuberculosis. National Health Programme series No. 10 by

National Institute of Health and Family Welfare page 9. 2. Target diseases included in UIP : Monograph on Integrated training on National Programmes for Mother and Child development; 1990; page 111. 3. Chandra P : Tuberculosis in BCG vaccinated and unvaccinated children, Ind. Ped.; 1975,12, 424. 4. Bhandari B, Mandoruare S.L. : A study of tuberculosis in BCG vaccinated children Ind. Ped; 1982, 19, 865. 5. Padma Ramchandran, Duriapandian M, Nagarajan M : TB Research Centre (ICMR) 3 Chemotherapeutic studies of TBM in children : Tubercle; 1986, 67,17. 6. Parthasarthy A, Narmada R, Krishnamoorthy K.A. Tuberculosis in BCG vaccinated children Ind. Ped; 1982,19, 785. 7. Rao K.N. : Text book of Tuberculosis; 2nd edition Bombay 1982. 8. Rao S.P., Bharambe M.S : Vaccine preventable diseases in Eastern Maharashtra - A hospital based analysis, Ind. Ped; 1991, 28, 629. 9. Udani P.M. Bhatt S., Bhare S.K. : Problem of tuberculosis in India : Epidemiology, morbidity mortality and control programme, Ind. Ped; 1976, 13, 891.