Fever and or cough > 2 weeks with loss of weight and recent contact with infectious case should arouse suspicion of TB. Chest Xray and trial with broad-spectrum antibiotic for 7-10 days is justified. In case of clinical and radiological non-response, Mantoux test and sputum or gastric aspirate for AFB is recommended. If AFB is positive, diagnosis is confirmed. If AFB is negative but chest Xray is suggestive and Mantoux test is positive, it is a probable case and if these tests are negative, alternate diagnosis must be sought and referral made to an expert. Ideally it is recommended to use 1TU of PPD for Mantoux test but 2 or 5 TU may be acceptable (but less preferred). Cut-off point of 10 mms for natural infection may be used for test done with 1, 2 or 5 TU. There is no linear relation of reaction to tuberculin strength and so no more than 5 TU should be used. BCG test is not recommended. Diagnosis must not be made without an attempt to look for AFB in gastric aspirate or sputum, as it is possible to get AFB even in primary complex. Elisa and PCR tests for TB are not recommended. There is no place for trial of anti tubercular therapy. Lymphnode enlargement > 2 cm with or without typical findings suggestive of TB and failure of antibiotic response demands FNAC for histopathology and bacteriology. Clinical suspicion of tubercular meningitis (TBM) should be confirmed by CSF examination and CT scan though none of these investigations are confirmatory and hence should not be considered in isolation. CSF tests for TB antibody and PCR are not recommended for routine use. Diagnosis of abdominal TB is made on circumstantial evidence and there are no standard guidelines. For treatment, disease is divided into three categories. The Category I and III are recommended for different types of new cases i.e. those who have received treatment for not more than 4 weeks. Category III includes primary pulmonary complex, one site peripheral lymphadenitis and pleural effusion, while all other forms of TB are included in Category I, that corresponds to smear positive TB in adults. This is because AFB is often found in many Category I disease in children. Category II includes defaulters, relapses and failure cases irrespective of the site of disease. Standard protocol is followed for each of these categories. Intermittent thrice weekly therapy with higher dose has been found to be equally effective as daily therapy and so is recommended in DOTS Direct Observed Therapy Short term. Compliance of treatment must be ensured. Repeat chest X-ray is ideal at the end of therapy. Liver function tests are not routinely recommended. Recommendations are also made for special situations such as MDRTB, TB and HIV and neonate born to mother suffering from TB.
PCV13 has immunogenicity similar to PCV7 in response to the 7 common serotypes, and has generally higher immunogenicity in response to the 6 additional serotypes. PCV13 may provide added protection against pneumococcal disease caused by the additional 6 serotypes and does not interfere with immune responses to whole-cell pertussis and oral poliovirus vaccines. PCV13 has an acceptable safety profile in both infants and toddlers, comparable with that of PCV7.
Enteric fever is responsible for significant morbidity in South Asia and high prevalence of severe disease is seen in children under two years of age. Effective typhoid vaccines are available, but they cannot be used for children under two years of age and also have some limitations in older age groups. Participants supported development of a Salmonella Typhi conjugate vaccine able to induce effective, long-lasting immunity in young children. The role of Salmonella Paratyphi A as a cause of enteric fever was discussed and consensus reached that a bivalent S. Typhi-S. Paratyphi A conjugate vaccine is highly desirable; however, considering disease epidemiology and the advanced status of vaccine development, rapid introduction of monovalent S. Typhi conjugate vaccine into vaccination programs of South Asia was recommended. Prevention should be emphasized, available vaccines used, and efforts toward improving sanitation continued. Success of the new vaccine will depend on several factors, including delivery costs and governmental ability to adopt and implement suitable immunization programs. To ensure good immunization coverage, the conjugate vaccine could be administered either to young infants, concomitantly with infant EPI vaccines, or to older infants, concomitantly with measles vaccine, currently given at 9 to 12 months. The need for new combination vaccines, containing both EPI and typhoid antigens, was discussed as a tool to increase coverage and reduce the number of injections and priority conflicts in a crowded infant vaccination schedule. However, stand-alone enteric fever conjugate vaccines would allow more flexibility to immunize different age groups and therefore should be rapidly developed.
Spirometry is indicated in all the children with clinical diagnosis of asthma, chronic/recurrent cough or wheeze, exercise induced cough or breathlessness and with recurrent respiratory manifestations. Mid expiratory How 25-75% (MEF 25-75) is an important diagnostic parameters in children due to its effort independence, high sensitivity in bronchodilator reversibility test and also because it represents smaller airways and is likely to be affected in mildest obstruction. The base line spirometry, bronchodilator reversibility and histamine challenge are diagnostic of hyper reactive airway with 98% sensitivity. Flow volume loops hardly add to the diagnosis and also need more co-operation from the subject. Therefore it is not useful in children. PEFR monitoring constitutes an important part of the followup care of asthma patients.
Isolation of mycobacterium tuberculosis is the gold standard in the diagnosis of childhood tuberculosis. However, it has inherent limitations due to paucibacillary nature of the disease in children and technical difficulties encountered in collection of appropriate sample. Thus, diagnosis is dependent on circumstantial evidence at best supported by conventional tests such as tuberculin test and chest radiograph. Several new tests are being developed but they lack ideal sensitivity and specificity. Hence, it is important to optimise use of current diagnostic tests. Clinical suspicion based on protocol developed by IAP is a pre-requisite of ordering tests and it is only then that proper interpretation is possible. Tuberculin skin test is still a useful screening test. It does help in establishing presence of infection though not necessarily disease. Attention must be paid to ideal test solution, proper technique and cautious interpretation. BCG test is not recommended. Miliary shadows and fibrocaseious cavitary lesions in chest radiograph are highly suggestive of tuberculosis in our epidemiology. CT scan is rarely necessary and is not cost and radiation-effective. It is ideal to attempt bacteriological examination in every suspected case of childhood tuberculosis. Most practical method is collection of gastric aspirate for smear and culture. It is possible to carry out this procedure in out-patient clinic. Better yield is likely with increasing expertise especially in extensive disease. Bronchoalveolar lavage is an invasive test and bacterial yield is comparable to that of gastric aspirate. Tissue collected for histopathological examination must be submitted for bacteriological tests. PCR is not easily available. It has high sensitivity but lower specificity and thus, is not routinely recommended. Serology has no place in diagnosis of tuberculosis. Interferon gamma release assays are also now available. Sensitivity and specificity of Quantiferon Gold and T-spot tests have not been studied in children and hence are not recommended in routine practice. Instead of trying newer tests, it may be best to avail an expert advice in difficult cases.
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