Tuberculosis Transmission in a Primary School and a Private Language School. An Estimation of Infectivity.

Introduction: Belgium is a country with low incidence of tuberculosis (TB) and a very low number of TB cases in children. Children in contact with an adult smear-positive TB case are at high risk of transmission. Early diagnosis is important as young children have a significant predisposition of developing TB disease. In this paper, we describe two outbreaks after exposure to, respectively, two teachers with smear-positive pulmonary TB: one in a primary school, a nursery teacher, and another in a private language school. Methods: An exposure investigation was carried out in both index cases household and school, according to the stone-in-the-pond principle. The tuberculin skin test (TST) was used a screening tool. The time elapsed between TB diagnosis in the index case and contact investigation was, respectively, 1 and 3 weeks. If this initial test was negative, it was repeated after a "window period" of ≥8 weeks. Results: Index cases showed a transmission rate of, respectively, 13 and 40% in their classes at school, defined as casual contacts. The proximity of contact increased the risk of infection. TB disease was observed in, respectively, 4 and 11% of all the casual contacts; all of them were children younger than 5 years old. TB-infected and children with active TB disease had good compliance with recommended treatment. Uptake of chemoprophylaxis during the "window period" was poor, respectively, only 32-42%, in children under 5 years with an initially negative TST. Discussion: The World Health Organization recommends to screen all young children (<5 years old) who have close contact with a person affected by pulmonary TB and to initiate Latent tuberculosis infection treatment even before infection can be demonstrated, after ruling out active TB disease. Despite this knowledge, a small percentage of the children younger than 5 years with no proof of infection was treated with the proposed chemoprophylactic treatment, in both cases. Conclusion: This exposure investigation of two teachers detects high transmission among family contacts and school casual contacts. Recommendations for chemoprophylactic treatment in children <5 years showed low compliance, reflecting the difficulty of communication to staff, parents, and children in a school outbreak. It is essential to develop a new approach for this vulnerable group of patients. This approach could be improved, applied, and evaluated by National TB Control Programs, involving public and private health services. Public health authorities play a role in raising public awareness about the risks of TB for young children.

Paradoxical reaction during tuberculosis treatment in immunocompetent children: clinical spectrum and risk factors.

BACKGROUND: Paradoxical reaction (PR) during antituberculosis (TB) therapy, defined as clinical or radiologic worsening of preexisting TB lesions or the development of new lesions, has not been widely studied in immunocompetent children. METHODS: All children (<17 years) with the diagnosis of TB who sought care at our center between 1994 and 2007 were included in this retrospective study. Data on demographic characteristics, bacteriologic results, medical imaging, treatment regimens and outcomes were abstracted from medical records. Patients with and without PR were compared. RESULTS: Of 115 TB cases, 12 (10.3%) developed PR. Children with PR were younger than those with TB without complication: median age at diagnosis was 26 months (range, 5-148) compared with 66 months (range, 6-205) for those without complications (P = 0.013). None of the children in the PR group had received Calmette-Guérin bacillus vaccination, compared with 34 of 103 (33%) children without PR (P = 0.017). Children with a diagnosis of PR were more frequently symptomatic at diagnosis of TB disease when compared with children without PR (P = 0.028). PR occurred at a median interval of 39 days (range, 15-75) after initiation of antituberculosis treatment. The most common PR was worsening of preexisting pulmonary lesions (75%). New lesions in anatomical sites other than those observed at initial presentation developed in 3 children. CONCLUSION: Paradoxical deterioration during treatment of TB disease is common in immunocompetent children. Young age and absence of Calmette-Guérin bacillus vaccination appeared to be associated with PR.

Neonatal complications of vacuum-assisted delivery.

OBJECTIVE: To assess systematically the extent of neonatal complications in a cohort of vacuum-assisted deliveries, identify risk factors associated with the occurrence of these complications, and to evaluate the usefulness of skull X-ray and transfontanellar ultrasonography after vacuum extraction. METHODS: We reviewed a cohort of 1,123 attempted vacuum extractions of singletons performed between January 2000 and December 2004. During this period, a systematic screening using transfontanellar ultrasonography and skull X-ray was performed after vacuum extraction. RESULTS: Among 913 successful vacuum-assisted, full-term deliveries, 25.7% were admitted to the neonatal intensive care unit. Scalp edema, cephalhematoma, and skull fracture were assessed by cranial radiography and were present in, respectively, 18.7%, 10.8%, and 5.0% of cases. Intracranial hemorrhage occurred in eight cases (0.87%). Nulliparity, a vacuum attempt at mid station, an extraction requiring more than three tractions, and dislodgment of the cup were associated with these complications but had a low predictive value. CONCLUSION: Severe neonatal complications associated with vacuum extraction are uncommon. Systematic X-ray and ultrasonographic examination led to the discovery of asymptomatic complications. Because the clinical significance of these complications is unknown, we do not recommend them as routine screening tools. LEVEL OF EVIDENCE: II.

Prevalence of lipodystrophy in HIV-infected children: a cross-sectional study.

OBJECTIVE: The aim of this study was to assess the changes in body fat distribution and lipid abnormalities in a population of HIV-infected children and adolescents followed in one single centre who had been exposed, or not, to antiretroviral therapy (ART). MATERIALS AND METHODS: Patients aged between 3 and 19 years were evaluated in a cross-sectional study carried out between October and December 2002. Fat redistribution was evaluated independently by the physician and the patient. Fasting blood lipid profile, glucose, insulin and C peptide were measured. Among the 88 patients evaluated, 74 were taking ART. RESULTS: Fat redistribution was present in 20 patients, metabolic alterations alone were found in 22 children and 46 children had neither physical nor metabolic abnormalities. Patients with fat redistribution were found to have been on ART for a significantly longer period of time, with 42% of the children showing fat redistribution having been treated with antiretroviral agents for more than 5 years. These children had also been exposed to a higher number of antiretroviral agents. In contrast, metabolic alterations in the absence of fat redistribution were not related to the duration of ART nor to the number of drugs received. Treatment with stavudine or protease inhibitors was significantly associated with the presence of physical changes. CONCLUSION: Regular assessment of fat redistribution and metabolic markers should be carried out in children treated with antiretroviral agents and taken into account when adapting therapy during the long-term follow up of these children.

Tuberculosis in healthcare workers caring for a congenitally infected infant.

OBJECTIVE: To assess the extent of nosocomial transmission of tuberculosis among infants, family members, and healthcare workers (HCWs) who were exposed to a 29-week-old premature infant with congenital tuberculosis, diagnosed at 102 days of age. DESIGN: A prospective exposure investigation using tuberculin skin test (IST conversion was conducted. Contacts underwent two skin tests 10 to 12 weeks apart. Clinical examination and chest radiographs were performed to rule out disease. Isoniazid prophylaxis was administered to exposed infants at higher risk. SETTING: A neonatal intensive care unit in an urban hospital in Brussels, Belgium. PARTICIPANTS: Ninety-seven infants, 139 HCWs, and 180 visitors. RESULTS: Newly positive TST results occurred in HCWs who had been in close contact with the infant. Six (19%) of 32 primary care nurses and physicians had TST conversions and received treatment. Among the 97 exposed infants, 85 were screened and 34 were identified as at higher risk of infection. Of these, 27 received preventive isoniazid. None of the infants and none of the 93 other infants' family members evaluated were infected. CONCLUSIONS: Congenital tuberculosis in an infant poses a risk for nosocomial transmission to HCWs. Delayed diagnosis of this rare disease and close proximity are the most important factors related to transmission.