Children and the global tuberculosis situation

The current global strategy for control of tuberculosis, Directly Observed Treatment, Short-course (DOTS) focuses, as a priority, on the management of patients with sputum smear positive tuberculosis. As tuberculosis in children is rarely sputum smear positive, this has led many to believe that children are not important in tuberculosis control. This is a misconception. The ultimate goal of tuberculosis services should be the eradication of Mycobacterium tuberculosis. To date, only diseases for which effective vaccines are available have been eradicated. Vaccination aims to protect the population (and especially vulnerable groups, such as children) from the disease against which it is applied. Presently, there is no vaccine able to prevent infection with Mycobacterium tuberculosis. Protection against infection must be achieved in other ways. Thus, early identification and successful treatment of the most infectious cases of tuberculosis has become the focus of attempts and is presently the most effective means to protect children from infection with M. tuberculosis. This is the theory; does it really work? Evidence put forward to support this position has come primarily from industrialised countries where tuberculous infection was already on the decline before any substantial public health activities had been instituted. What of the situation in low income countries where the highest proportion of the tuberculosis patients live at the present time? There is very little evidence available to address this question. The most convincing information published to date comes from the Beijing Municipality of China where the DOTS strategy has been implemented since 1978. Progressive expansion of the strategy occurred over the first five years after which a very high proportion of all tuberculosis patients were managed by this means. The major impact was to progressively and rapidly reduce the prevalence of tuberculosis in the community. The incidence was only more slowly diminished over the same period, primarily because cases continued to arise from the large proportion of the population previously infected. Over the same period, tuberculous meningitis virtually disappeared and the prevalence of tuberculous infection declined to very low levels. This appears to confirm the impact of efficient management of adult tuberculosis patients as a means to protect children from infection. This, while effective, clearly is not sufficient. Every effort is required to develop an effective vaccine that is capable to preventing infection in children. Only then will the disease be eradicated.