Pediatric Tuberculosis

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Abstract
The articles prior to January 2008 are part of the back file collection and are not available with a current paid subscription. To access the article, you may purchase it or purchase the complete back file collection here Kwabena Krow Ampofo, MD; Lisa Saiman, MD, MPH EPIDEMIOLOGY Tuberculosis (TB) remains one of the most devastating infectious diseases in the world. The World Health Organization (WHO) estimates that approximately one-third of the world's population is infected with Mycobacterium tuberculosis, with 88 million new cases from 1990 to 1999. Thirty million people worldwide died of TB during this period, including 2.9 million persons coinfected with human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS). Between 1990 and 1999, the incidence worldwide increased from 143 cases per 100,000 persons to 163 cases per 100,000 persons.1 Factors contributing to the global increase in TB included population growth and the emerging HIV epidemic. The WHO and the international public health community have prioritized the control, prevention, and treatment of TB during this millennium. During a resurgence in the United States that peaked in 1992,2 the incidence of TB reached 10.4 per 100,000 persons. Case rates were highest in ethnic minorities, with highs of 46.6 and 31.7 per 100,000 persons for Asians and non-Hispanic blacks, respectively. Non-Hispanic whites had the lowest case rate of 4.0 per 100,000 persons. Several factors contributed to this resurgence, including a large influx of foreign-born persons during the late 1970s, the HIV epidemic, homelessness, crowded living conditions, and the dismantling of the public health structure for TB care. In addition, there was an increase in multidrug-resistant TB, denned as resistance to isoniazid and rifampin. This included both primary acquisition of multidrug-resistant strains attributed to health care-associated infection and overcrowding in homeless shelters and secondary cases due to nonadherence to TB therapy. Multidrug-resistant TB is also associated with higher mortality rates and costs. Since 1992, case rates, including cases of multidrug-resistant TB, have steadily fallen in the United States because of a huge influx of financial and technical support to health departments and hospitals. The case rate of TB dropped by 38% from 1992 to 1997.2 Foreign birth remains the major risk factor for TB in the United States.2 During the 1990s, the case rates of pediatrie TB, defined as TB occurring among children younger than 15 years, also increased, although the total number of cases was a fraction of those in adults. TB in adults may be primary or reactivation disease, whereas TB in children is a sentinel event indicating recent transmission of M. tuberculosis from an infected adult or adolescent source. Thus, risk factors for TB in children reflect contact with adults who are at risk for TB (Table 1). Table Pulmonary Tuberculosis During the past two decades, studies have evaluated shorter multidrug regimens that take into account local resistance patterns. Short-course studies show the successful use of isoniazid, rifampin, and pyrazinamide in both adults and children for pansusceptible TB (Tables 5 and 6). Patients initially receive all three drugs for 2 months and pyrazinamide is discontinued after 2 months. Isoniazid and rifampin are continued for 4 more months. After 2 to 4 weeks of daily therapy, intermittent therapy (ie, twice or thrice weekly) is as effective as daily therapy if provided by directly observed therapy to ensure adherence. Some physicians are more comfortable with thrice-weekly therapy for very young children because of the high rates of emesis after drug ingestion. Isoniazid tablets, rifampin capsules, or pyrazinamide tablets can be crushed and added to juice or foods. More recent recommendations for empiric therapy include isoniazid, rifampin, and pyrazinamide plus ethambutol in locales with high rates (> 4%) of resistance to isoniazid. Once susceptibilities are known, ethambutol can be discontinued if the organism is pansusceptible. However, if the susceptibility of the source case is unknown and the child's cultures remain negative, four drugs (isoniazid, rifampin, pyrazinamide, and ethambutol)… 10.3928/0090-4481-20020201-07