The global nature of childhood tuberculosis.

After several decades of neglect, childhood tuberculosis (TB) is receiving some of the attention it deserves. Although the common perception is that TB has disappeared from the United States, there are almost 10 000 cases annually, with.1000 occurring in children. There are many thousands of children with untreated latent TB infection (LTBI) at risk of developing TB disease, who either were missed during contact investigation of adults with TB disease in the United States or who were not tested during immigration to the United States. Pang et al describe the epidemiology of TB in preschool-aged US children. They highlight and quantify a recently described risk factor for childhood TB in a low-incidence setting: parental foreign birth. A 2012 Pediatrics article found that two-thirds of all children and adolescents with TB in the United States had at least 1 foreign-born parent, and only one-quarter of children with TB lacked an international connection. Before 2009, children immigrating to the United States were not routinely tested for LTBI or TB disease. The 2009 Centers for Disease Control and Prevention (CDC) Technical Instructions for children immigrating to the United States endorse testing children ages 2 to 14 years for LTBI and treatment of infected children after arrival in the United States. The hope is that this immigration screening protocol will decrease the reservoir for future cases among the foreign-born. However, some US-born children with LTBI are not detected by existing screening algorithms. Having a foreign-born parent is not currently included as a risk factor in the American Academy of Pediatrics–endorsed LTBI screening questionnaire and is not included in most state and local public health questionnaires. It is unclear why having a foreign-born parent is a risk factor. The parent may develop infectious TB, but this also may be a marker that foreign visitors to the home, who are not screened for TB before entry to the United States, may have undetected infectious TB. One study from California showed that having an adult foreign visitor in the home was an independent risk factor for a child developing LTBI. The results of the Pang et al study lead one to question if TB can be eliminated domestically solely by focusing within our own borders. Rates of TB in US-born adults are at an all-time low and are 11 times lower than TB rates in foreign-born persons, who now comprise almost two-thirds of US cases. We cannot eradicate TB domestically until better TB control is attained in high-prevalence nations, especially those from which the United States receives many immigrants and visitors. The CDC Technical Instructions endorse screening for TB disease by chest radiograph for immigrants older than 14 years of age and do not emphasize testing for LTBI in this population. The result is that many adolescent immigrants have LTBI that goes undetected. Although immigrant children ages 2 to 14 years are tested for LTBI, many do not receive immediate treatment in the United States because they lack health insurance or medical homes, and local public health departments AUTHORS: Jeffrey R. Starke, MD, and Andrea T. Cruz, MD, MPH