Screening for Tuberculosis in Infants and Children

In 1992 the reported number of cases of tuberculosis (TB) was increased to 26 673 in the United States, an increase of I .5% from 1991 . Although a decline of approximately 5% to 6% occurred from 1981 to 1984, during the period of 1985 to 1992 the number of reported cases increased by 20.1 %. The largest increase in TB cases by age group occurred in the 25to 44year-old cohort (54.5% increase in 1985 to 1992), whereas cases increased 36.1 % among children 0 to 4 years old and 34.1 % among children 5 to 14 years old.1 This recent increase in the number of reported cases of tuberculosis and the changing epidemiology of this disease in children have necessitated a reevaluation of the appropriate use and type of skin test for the diagnosis.2 Within the general population there are groups at varying risk for infection and for progression to disease (Table 1). To achieve significant progress toward reducing the number of future cases of TB, it is necessary to have the following: 1) identification of highrisk groups, with Mantoux tuberculin skin testing of persons in those groups; 2) evaluation to determine the actual presence of disease in those persons identified as infected; and 3) provision of appropriate therapy for both those with positive Mantoux tests and those with active disease.3 Therefore, the emphasis should be to identify targeted high-risk populations for annual skin testing rather than routinely screening all persons. Routine screening would indude a vast number of individuals at low risk. More than two thirds of reported TB cases now occur in nonwhite racial and ethnic groups. Approximately one quarter of all cases in the United States occur in foreign-born persons. The majority of adult cases reported annually in the United States comes from a group of persons who have been infected in the past. Infants and children who are exposed to adult contacts with infectious TB comprise a group of individuals at high risk for recent infection. Other highrisk groups include persons with human immunodeficiency virus (HIV) infection; substance abusers; lowincome populations; residents of correctional facilities; and persons with specific medical risk factors such as diabetes mellitus, chronic renal failure, and immunosuppressive disorders.1 Because of current variability in incidence of TB in different regions of the United States, effective strat-