Treatment of TB

What if my child had a positive PPD and Chest X-ray –your child has TB which will need treatment. Since TB is such a hard bacteria to kill your doctor will recommend six months of treatment with four different medications. Four in the first two months to really start to get ahead of the infection and two the last four months.

Why did they make my child give sputum samples for three days? This is one of the ways to diagnose active TB. If the samples are negative they may either delay treatment until you leave China or start treatment in China before letting you fly. The reason is even if a child has the positive X-ray the abnormalities are usually small, children don’t cough up sputum (and the TB bacteria) as much as adults and when they do there are few bacteria in it. rea

 Why does the doctor want to see my child take the medicine? -The biggest cause for people not completing their treatment successfully is folks/parents forgetting to give the medicine therefore physicians usually recommend directly observed treatment. A trained health professional other than the parents will need to see the child take each and every dose of medicine- a major hassle but TB is bad and can easily spread so killing the bacteria effectively is critical.

My child’s chest x-ray was normal but they still want to treat?  If the PPD was positive, particularly in a child coming from China, your child was exposed to TB and has some hibernating (called latent) TB in the lungs that is just too small for an X-ray to see. Even a CT scan, which can see even smaller abnormalities, will not see it but it is most likely there. Since TB can be so dangerous it should be treated. The treatment is called INH and it is taken for 9 months daily but, unlike the children with a positive X-ray the doctor doesn’t need to see your child take each dose- count your blessing where they come. In studies of children who were treated for latent TB almost 100% didn‘t have TB occur in 20 years. Some doctors will elect to watch a patient without treatment if they were in a low risk environment but China is not low risk- it is near the top of the World Health Organizations top 20 list for TB. If they do treat, they will consider also giving vitamin B6 because INH can deplete this important vitamin; in well-nourished children it is not usually given but with your child coming from a Chinese orphanage, the assumption will be that he or she is not well nourished.

What on earth IS the BCG??

This is one of the burning questions you will have when looking over your child's immunization record. The BCG is a vaccination for tuberculosis given to babies to help prevent tuberculosis. Tuberculosis itself is a very common and difficult to treat infection spread by coughing, usually involving the lungs but occasionally spreading out to the brain and other organs-- it is one of the number one killers of all time and is particularly dangerous in young children who are even more likely to have it spread out of the lungs if they are malnourished. China is on the WHO (World Health Organization) top 20 lists of countries where tuberculosis is most common.

The BCG is given to prevent any infection from getting out of the lungs and causing the worst types of TB infections in infants. The immunization itself is a live weakened TB bacteria and the children are immunized as infants. In most cases if the child was immunized, you will see a small round scar on their left or right upper outer arm. It protects 80 out of 100 children from TB spreading out of the lungs but isn’t particularly effective at preventing the lung version of TB. 

Young children have weak immune systems and so the effectiveness of BCG wears off with time which then means the child may get lung TB even though they have had the vaccine. In older children and adults here in the US, physicians perform skin testing to see if someone has been exposed to TB. This is done by injecting a small amount of tuberculin (PPD) under the skin and measuring the size of the bump, not the red area at the site in 48-72 hours. All of you adoptive parents had this done for your initial medicals for your dossiers.

If the test is positive we usually follow this with a chest X-ray to see if there is any evidence of TB in the lungs hibernating (called latent infection). In addition, all children at least two years old in China are tested for TB with this skin test before the US consulate can issue a visa. This requires an additional 2-3 days in Guangzhou waiting for the PPD to be read. If the PPD is positive, a chest xray will be required, and this is a US government requirement. It's a good requirement. It protects you, the parents, and your children and everyone one else on the plane breathing the same recycled air for 14 hours.

What confuses things further is that the BCG, because it is tuberculosis, can cause the skin testing for TB  to be positive even if the child doesn’t have real TB! If a child is coming from an area like China where TB is so common and tests positive with the skin test they are assumed to have been exposed and possibly have lung TB and will be required to get the X-ray. The assumption is that the BCG has worn off,  the child was exposed to TB, and has possible become infected.
What if my child had the BCG, had a PPD test and it is negative? Does she have TB? Not likely. The immunity from the BCG has worn off and your child has not been exposed to TB. Exceptions would be if they are very malnourished or the test was interpreted wrong.

What if the PPD is positive? Should she have a PPD in the future? No. Once it is positive, it is considered positive forever and retesting can cause a severe reaction at the test site.

Stay tuned for further discussions of treatment.