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Canadian pediatricians should be wary of TB among Aboriginal children
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Pediatricians in Canada should consider tuberculosis disease in children with epidemiologic risk factors and suggestive symptoms or signs of organ involvement, particularly among Aboriginal children, according to a recently published review.
“Tuberculosis (TB) is uncommon in children and adolescents in Canada, and diagnosis is often delayed of a lack of diagnostic suspicion,” Ian Kitai, MBBCh, a staff physician and TB specialist at The Hospital for Sick Children in Toronto, and colleagues wrote. “Social determinants of health, including poverty, underscore its incidence and prevalence in countries with high TB burden but also among indigenous peoples in Canada in whom endemic TB remains a serious problem.”
Kitai and colleagues conducted a systematic literature review using TB search terms in PubMed and the Public Health Agency of Canada website to evaluate the quality level of TB diagnostic rates in Canada from 1998 to 2015. The researchers found that pediatric TB treatment had been evaluated with inadequate observational studies, particularly among children with increased risks such as recently emigrating to Canada, having immigrant parents or being of Aboriginal descent.
The researchers noted that very young children often appear asymptomatic; however, negative results with both the tuberculin skin test and interferon gamma release assays may occur in 30% of children with TB; hence, diagnostic chest radiographs and sputum collection for TB culture are necessary to achieve accurate diagnosis.
Missed opportunities for early diagnosis of TB in Canada include failure to consider epidemiologic history; failure to consider a TB diagnosis due to a negative TB skin test result; and failure to send biopsy specimens for TB culture, according to the researchers.
Further, the researchers wrote that though screening for latent TB disease in increased risk populations is currently recommended and implemented by Canadian legislation for prevention, these groups require careful monitoring for toxicity and clinician–parent conversations on the risks and benefits of TB detection screening.
“High rates of TB among the Inuit and other Aboriginal groups in Canada deserve much greater national focus and will require coordinated public health measures and innovative programs but also substantial improvement in housing and living conditions,” Kitai and colleagues wrote. “Finally, elimination of TB in Canada also depends on a global effort to control and eliminate TB. It is in Canada’s interests to participate actively in this international effort.” – by Kate Sherrer
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Jeffrey R. Starke, MD
The WHO estimated in 2016 that 1 million children develop TB disease every year and 210,000 of these children die from the disease. Many, in fact, most of those deaths are completely preventable. However, in countries where there is a high-burden of TB, they are simply not taking the steps necessary to prevent the disease from occurring, so then they are trying to treat very sick kids, which is difficult even under the best of circumstances. The data published in this review and the emphasis on prevention are absolutely appropriate and what pediatricians, TB programs and health systems should be doing throughout the world is being more active in finding children who are at risk for TB disease and prevent it rather than waiting for kids to get sick and then try to treat them.
In both the U.S. and Canada, the children who are most at risk for developing TB disease are children whose families live in difficult social circumstances, and in both countries, Native American and Canadian Aborignal populations are at increased risk. While there may be some genetic predispositions, most of the increased risk has to do with living conditions. The fact that the organism is present in the population and has never been cleared out, so to speak, by people carrying the organism being appropriately treated so that they cannot develop TB and the past populations have been treated in that way. We know that in the U.S. as well as in Canada that 80% of U.S. born kids who develop TB disease that have international connection. Their parents are foreign-born, they have traveled abroad, they have visitors in the home from high-prevalence countries maybe who had contagious TB that was unknown. And those statistics are very similar between Canada and the U.S.
The AAP puts out recommendations and they are meant to be applied in all of North America, and the overall tone of this article indicates that things are being done in a similar way in Canada as they are in the U.S. in that we are both trying to pick out populations of children who are at the greatest risk and concentrating our efforts in identification, screening, testing and treatment at those kids who are most likely to develop TB disease. The most important activity by far is the contact investigation; that is, no matter who it is, once you have an adult with contagious TB, you make sure you identify all the children who have been in that person's environment to make sure they are appropriately evaluated and, if necessary, treated. That is the cornerstone of any TB control program, be it Canada or the U.S. Beyond that, we want to identify kids at the highest risk and in both countries, Native American kids and foreign-born kids who come from high-burden countries are going to be at the very top of the list of those kids who we would like to test and, if appropriate, treat.
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