MJA: Isaacs et al., Tuberculosis in children in Australia: strategies for control

Tuberculosis in children in Australia: strategies for control

David Isaacs and Craig M Mellis, on behalf of the Paediatric Special Interest Group of the Australasian Society for Infectious Diseases* and the Australasian Paediatric Respiratory Group**

MJA 1998; 168: 121-124

Introduction - Epidemiology - Childhood tuberculosis - Child advocacy - Control of tuberculosis - Acknowledgements - References - Paediatric Special Interest Group of ASID - Australasian Paediatric Respiratory Group - Authors' details
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Introduction
Globally, tuberculosis (TB) is responsible for more deaths per year than any other infection. The World Health Organization estimated that in 1990 there were 7.5 million new cases of TB; 1.3 million were in children under 15 years of age, of whom 450 000 died.¹ TB is relatively rare in Australian children, but, because of the associated high morbidity and mortality and the risk of later reactivation of disease, it should not be neglected. This paper outlines strategies to control paediatric TB.
Tuberculosis in childhood is different from that in adults, and requires different expertise. This position paper, a consensus by paediatric infectious disease and respiratory specialists, outlines strategies for managing childhood TB in Australia. A companion paper, in preparation, will address strategies applicable to New Zealand. A further paper will deal with specific details of management of paediatric tuberculosis, including diagnosis and treatment.
Epidemiology
While the incidence of TB in industrialised countries has fallen to very low levels with improving living conditions, in the United States the steady decline in incidence of TB has halted. From 1985 to 1992 there was a 20% increase in reported cases in both adults and children^1-4 (although this situation has now improved⁵). Further, the US has experienced an increase in the prevalence of infection with multidrug-resistant strains of TB.^2,4 This increase was the result of an association of HIV infection and TB, increasing poverty, immigration from countries with high TB prevalence, and decreased public health funding.^4,5 The re-emergence of TB as a problem in the USA has caused other industrialised countries to re-examine policies for the prevention and management of this disease.
Tuberculosis is not presently a major problem in Australia. Its incidence has remained stable since 1986 at 5.5-6.0 cases per 100 000 population per year.^6-9 The number of notified cases in children aged 0-14 years has fallen from 70 in 1991, to 45 in 1992, 37 in 1993, and 33 in 1994.^7-9 Two childhood deaths from TB were notified in 1992; none have been notified since.
While most TB notifications are made from New South Wales and Victoria, the rate of notifications is highest in the Northern Territory. The notification rate is lowest in non-indigenous Australian-born people (1.5-2.0 per 100 000), while Aboriginality is associated with a higher incidence (10-13 per 100 000).^8,9 However, being born overseas is associated with an even higher incidence, which has been consistently reported at around 15 per 100 000 for the past three years.^7-9
Childhood tuberculosis
Starke¹⁰ has emphasised the differences between paediatric and adult tuberculosis. Children generally have a much smaller bacterial population and there is less secondary resistance. Cavitary lesions are very rare, but children have a greater propensity for extrapulmonary disease. While children tolerate higher doses of medication relative to body weight, with lower rates of adverse reactions, paediatric formulations (syrups or soluble powders) are not always available. Paediatric tuberculosis is usually acquired from contact with an infected adult, and children with TB are generally at low risk of infecting others.
Child advocacy
In Australia, children with suspected or proven tuberculosis may be managed by paediatricians, at adult chest clinics, or by specialists in paediatric or adult infectious diseases.⁹ Given the low incidence of childhood cases, this variety of attending specialists is not surprising and does not necessarily mean that current management of paediatric TB is inappropriate. In large cities there may be enough children with TB or receiving preventive therapy to warrant specialised paediatric TB clinics that combine both paediatric and public health expertise. However, in many parts of Australia, children with TB or TB contact are managed in chest clinics by chest physicians who are expert in tuberculosis, but may lack paediatric knowledge and skills. On the other hand, the regional paediatrician, with experience in examining and managing children, may have little knowledge and experience of childhood tuberculosis.
Although paediatric TB is rare, child contacts of adults with TB are much less rare, and preventive therapy of children requires expert knowledge and supervision.^3,10 Guidelines on tuberculosis concentrate on adult aspects of TB, and tend to neglect paediatric aspects.^11-13 As paediatricians are child advocates and experts in child health, they should be more involved in the care of children with TB,¹⁴ not necessarily as sole carers, but at least in consultation. Paediatricians can provide clinical expertise and advice in areas such as compliance with medication, particularly for very young children.
Recommendation:
Paediatricians should be consulted and involved in the management of TB in children whenever possible.
[Consensus view, not addressed by the NHMRC TB Working Party.¹¹]
Control of tuberculosis
The most critical aspect of control of tuberculosis is the existence of appropriate public health programs. The important strategies in TB control are:
BCG vaccination;
Screening of children at high risk;
Contact tracing; and
Appropriate duration of drug therapy.

BCG vaccine
Bacille Calmette-Guerin (BCG) vaccine was first used in humans in 1921, and few attempts have been made since then to develop improved vaccines against TB. BCG vaccine is moderately effective: a recent meta-analysis¹⁵ gave its protective efficacy as 50% against any TB disease, 64% against TB meningitis, and 71% against death from TB. Occasional cases of TB meningitis occur in children in Australia^6-9 and might be prevented by BCG vaccination.
The NHMRC TB Working Party currently recommends BCG vaccination for three groups of children:¹¹
Aboriginal and Torres Strait Islander neonates in regions of high incidence;
Neonates born to patients with leprosy (because of cross-protection by BCG against leprosy); and
Children under the age of five years who will be travelling to live in countries of high TB prevalence for long periods.

The NHMRC TB Working Party¹¹ states that BCG vaccine should be considered for:
Neonates who will be living in a household which includes immigrants or visitors recently arrived from countries of high TB prevalence (and neonates in families who have returned to visit the homes of relatives in countries of high prevalence); and
Children and adolescents aged less than 16 years who continue to be exposed to a patient with active TB, and where the child or adolescent cannot be given preventive isoniazid therapy, or the person with active disease has organisms resistant to both rifampicin and isoniazid.
We believe these latter two "considerations" should be changed to "recommendations" to prevent occasional, but devastating, cases of tuberculosis in these children. In particular, neonates whose parents are from South-East Asia or the Indian subcontinent should be given BCG at birth.
There is currently no information on how many children receive BCG vaccine in Australia each year, either as an absolute number or as a proportion of those eligible. Clearly, such information would be a great advantage in analysing BCG vaccine efficacy, and thus in evaluating the current NHMRC recommendations. The Australian Childhood Immunisation Register, implemented in 1996, monitors compliance with some vaccines, but not with BCG as yet. Studies are needed on the proportion of eligible children who receive BCG vaccine, and on side effects of BCG vaccination.
Recommendations:
We support the indications for BCG vaccination as recommended by the NHMRC TB Working Party, but feel that BCG should be recommended in all five situations detailed above.
[Consensus opinion based on the high rate of TB in children exposed to adults with TB. This recommendation has also been made in the Australian immunisation procedures handbook,¹⁶ but not by the NHMRC TB Working Party,¹¹ in 1989.]
We strongly urge the Federal Government to put in place mechanisms to audit the number of children vaccinated with BCG vaccine each year.
[Consensus opinion.]
Mantoux screening
In Australia, Mantoux skin testing is usually performed with 10 tuberculin units of purified protein derivative (PPD), although one unit only may be used if there is a high risk of TB.¹⁶ In the United States,¹⁷ Mantoux skin testing is performed with five tuberculin units of PPD. US authorities' interpretation of a positive Mantoux skin test is shown in the Box; there is currently no recognised Australian interpretation of skin test positivity.

At present, the Committee on Infectious Diseases of the American Academy of Pediatrics (the "Red Book" committee)¹⁷ recommends annual tuberculin testing of children at high risk, but not of children at low risk. Six months of isoniazid preventive therapy is recommended for children who are Mantoux positive without disease,¹² as this is as effective as nine months' duration of therapy¹⁸ and has a better risk-benefit analysis.¹⁹
While Australian children are not routinely tested with tuberculin, two recent surveys of the Mantoux status of 13-year-old²⁰ and six-year-old²¹ Sydney schoolchildren showed t hat being born overseas was the major risk factor for being Mantoux-positive. In addition, the later the child left the country of birth, the greater the risk of being Mantoux- positive. Australian-born children with one or both parents born overseas were not at increased risk of being Mantoux- positive compared with Australian-born children of Australian-born parents.
As most Mantoux-positive children in Australia were born overseas, it is important to screen children who are migrating to Australia from countries with a high prevalence of TB. Short visits (e.g., holidays) overseas are associated with a low risk of becoming infected with TB.
Although short term visitors to Australia occasionally transmit TB, screening them would be extremely difficult, and this is not done routinely. However, screening might be indicated in special circumstances (e.g., a visitor from a high endemic area with chronic respiratory symptoms). Routine annual Mantoux screening is not justified by the available data.
Recommendations:
Children born overseas who are migrating to Australia from a country with a high prevalence of tuberculosis should be screened by Mantoux testing with or without a chest x-ray on entry into Australia.
[Based on evidence,^20,21 but not currently recommended by the NHMRC TB Working Party.¹¹]
Children born in Australia should not be screened annually by Mantoux testing.
[Based on evidence^20,21 and consistent with NHMRC TB Working Party recommendations.¹¹]
Visitors to Australia from areas of high TB incidence should not be routinely screened, but neonates exposed to such visitors should be vaccinated with BCG.
[Consensus opinion, consistent with Australian immunisation procedures handbook.¹⁶]
Mantoux-positive children with no evidence of TB disease should be given preventive therapy with isoniazid for six months.
[Based on evidence^18,19 and consistent with NHMRC TB Working Party recommendations.¹¹]
Contact tracing
Diligent tracing of the adult source of paediatric TB infection through public health networks continues to be an important step in preventing the spread of TB.
Appropriate duration of drug therapy
The emergence of highly resistant and multiply resistant strains of M. tuberculosis has re-emphasised the importance of good management of TB, and the development of innovative management and control strategies. The emergence of resistant strains is thought to be the result of failure of patients with TB to complete courses of chemotherapy. In New York, this was a consequence of failure to supervise patients' therapy as a result of cuts in health funding in the 1980s.^4,5
In Australia, some States supervise all antituberculous therapy, while others use targeted supervision of patients considered to be at risk of being non-compliant. In general, there are insufficient public health staff to ensure supervision of preventive therapy with isoniazid. Continued supervision of therapy (either full or targeted supervision) is important to prevent the emergence of resistant strains in Australia, and requires funding.
Recommendation:
Specifically funded TB control programs need to be maintained in each State and Territory in Australia.
[Consensus opinion.]

This document has been discussed by the Writing Panel of the Paediatric Special Interest Group of the Australasian Society for Infectious Diseases (ASID), circulated to all members, and ratified by the ASID Council. It was discussed at the 1996 meeting of the Australasian Paediatric Respiratory Group, and circulated to all members for comment. It was sent to Dr Greg Stewart, Chair of the NHMRC Working Party on Towards elimination of tuberculosis II. Guidelines and protocols for controlling tuberculosis disease in Australia, and to the Public Health Association of Australia.

Acknowledgements
Helpful comments were received from Dr T Konstantinos, Dr Graeme Oliver, Dr Graham Simpson and Professor Louis Landau.
References

Raviglione MC, Snider DE, Kochi A. Global epidemiology of tuberculosis. Morbidity and mortality of a worldwide epidemic. JAMA 1995; 273: 220-226.
Report from the Centers for Disease Control and Prevention: tuberculosis morbidity, United States, 1992. JAMA 1993; 270: 1525.
Starke JR, Jacobs RF, Jereb J. Resurgence of tuberculosis in children. J Pediatr 1992; 120: 839-855.
Drucker E, Alcabes P, Bosworth W, Schell B. Childhood tuberculosis in the Bronx, New York. Lancet 1994; 343: 1482-1485.
Frieden TR, Fujiwara PI, Washro RM, Hamburg MA. Tuberculosis in New York City -- turning the tide. N Engl J Med 1995; 333: 229-233.
Cheah D. Tuberculosis notification rates, Australia, 1991. Commun Dis Intell 1992; 16: 398-400.
Hargreaves J. Tuberculosis notifications in Australia, 1992. Commun Dis Intell 1994; 18: 330-337.
Hargreaves J. Tuberculosis notifications in Australia, 1993. Commun Dis Intell 1995; 19: 332-341.
Oliver G. Tuberculosis notifications in Australia, 1994. Commun Dis Intell 1996; 20: 108-115.
Starke JR. Multidrug therapy for tuberculosis in children. Pediatr Infect Dis J 1990; 9: 785-793.
National Health and Medical Research Council. Tuberculosis in Australia and New Zealand into the 1990s. Canberra: AGPS, 1989.
Grossman M, Hopewell PC, Jacobs RF, et al. Consensus: management of tuberculin-positive children without evidence of disease. Pediatr Infect Dis J 1988; 7: 243-246.
NSW Health Department. Controlling tuberculosis in New South Wales. Sydney: NSW Health, 1993.
Forfar JO. Child health in a changing society. Oxford: Oxford University Press, 1988.
Colditz GA, Brewer TF, Berkey JCS, et al. Efficacy of BCG vaccine in the prevention of tuberculosis. JAMA 1994; 271: 698-702.
National Health and Medical Research Council. The Australian immunisation procedures handbook. 6th ed. Canberra: AGPS, 1997.
American Academy of Pediatrics. Report of the Committee on Infectious Diseases. 23rd ed. Illinois: The Academy, 1994.
Comstock GW, Baum G, Snider DE Jr. Isoniazid prophylaxis among Alaskan Eskimos. Am Rev Respir Dis 1979; 119: 827-830.
International Union Against Tuberculosis, Committee on Prophylaxis. Efficacy of various durations of isoniazid preventive therapy for tuberculosis. Five years of follow-up in the IUAT trial. Bull World Health Organ 1982; 60: 555-564.
Alperstein G, Fett MJ, Reznik R, et al. The prevalence of tuberculosis infections among Year 8 school children in inner Sydney in 1992. Med J Aust 1994; 160: 197-201.
Alperstein G, Morgan K, Fett MJ, et al. Prevalence of tuberculosis infection among primary school entry children in Sydney. Aust J Pub Health 1996; 20: 123-128.

*Paediatric Special Interest Group of ASID

R Benn, MA Burgess, D Burgner, D Caplan, J Carapetis, P Collignon, R Doherty, G Eagles, J Faoagali, M Ferson, K Forsyth, S Garland, GL Gilbert, D Gordon, K Grimwood, J Hanna, D Hansman, G Hogg, D Holdaway, M Holloway, D Isaacs, H Jeffery, C Jones, A Kakakios, A Kesson, D Lennon, D McCrossin, P McIntyre, A McGregor, D McIntosh, M Nissen, D Roberton, R Robins-Brown, J Robson, J Royle, L Voss, S Wesselingh, J Whitson, B Wild, A Yung.
The writing panel of the Paediatric Special Interest Group of ASID comprised GL Gilbert, MA Burgess, M Ferson, S Garland, K Grimwood, G Hogg, D Isaacs, and P McIntyre.

**Australasian Paediatric Respiratory Group

H Allen, I Asher, P Van Asperen, G Bowes, B Clements, D Cooper, P Cooper, K Dawson, P Field, P Francis, N Freezer, J Gillies, M Haifer, M Harris, R Henry, A Isles, A Kemp, D Kennedy, L Landau, J Martin, CM Mellis, S Sawyer, B Masters, J Morton, T Olinsky, P Pattemore, P Phelan, C Robertson, P Robinson, P Sly, G Smith, P Le Souef, R Staugas, S Stick.

Authors' details

Australasian Society for Infectious Diseases, Sydney, NSW.
David Isaacs, FRACP, Member of the Paediatric Special Interest Group;
Craig M Mellis, FRACP, Member of the Australasian Paediatric Respiratory Group.

Reprints will not be available from the authors.
Correspondence: Associate Professor D Isaacs, Department of Immunology and Infectious Diseases, Royal Alexandra Hospital for Children, Westmead, NSW 2145.
E-mail: davidi AT rich.edu.au

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Introduction	Globally, tuberculosis (TB) is responsible for more deaths per year than any other infection. The World Health Organization estimated that in 1990 there were 7.5 million new cases of TB; 1.3 million were in children under 15 years of age, of whom 450 000 died.¹ TB is relatively rare in Australian children, but, because of the associated high morbidity and mortality and the risk of later reactivation of disease, it should not be neglected. This paper outlines strategies to control paediatric TB. Tuberculosis in childhood is different from that in adults, and requires different expertise. This position paper, a consensus by paediatric infectious disease and respiratory specialists, outlines strategies for managing childhood TB in Australia. A companion paper, in preparation, will address strategies applicable to New Zealand. A further paper will deal with specific details of management of paediatric tuberculosis, including diagnosis and treatment.
Epidemiology	While the incidence of TB in industrialised countries has fallen to very low levels with improving living conditions, in the United States the steady decline in incidence of TB has halted. From 1985 to 1992 there was a 20% increase in reported cases in both adults and children^1-4 (although this situation has now improved⁵). Further, the US has experienced an increase in the prevalence of infection with multidrug-resistant strains of TB.^2,4 This increase was the result of an association of HIV infection and TB, increasing poverty, immigration from countries with high TB prevalence, and decreased public health funding.^4,5 The re-emergence of TB as a problem in the USA has caused other industrialised countries to re-examine policies for the prevention and management of this disease. Tuberculosis is not presently a major problem in Australia. Its incidence has remained stable since 1986 at 5.5-6.0 cases per 100 000 population per year.^6-9 The number of notified cases in children aged 0-14 years has fallen from 70 in 1991, to 45 in 1992, 37 in 1993, and 33 in 1994.^7-9 Two childhood deaths from TB were notified in 1992; none have been notified since. While most TB notifications are made from New South Wales and Victoria, the rate of notifications is highest in the Northern Territory. The notification rate is lowest in non-indigenous Australian-born people (1.5-2.0 per 100 000), while Aboriginality is associated with a higher incidence (10-13 per 100 000).^8,9 However, being born overseas is associated with an even higher incidence, which has been consistently reported at around 15 per 100 000 for the past three years.^7-9
Childhood tuberculosis	Starke¹⁰ has emphasised the differences between paediatric and adult tuberculosis. Children generally have a much smaller bacterial population and there is less secondary resistance. Cavitary lesions are very rare, but children have a greater propensity for extrapulmonary disease. While children tolerate higher doses of medication relative to body weight, with lower rates of adverse reactions, paediatric formulations (syrups or soluble powders) are not always available. Paediatric tuberculosis is usually acquired from contact with an infected adult, and children with TB are generally at low risk of infecting others.
Child advocacy	In Australia, children with suspected or proven tuberculosis may be managed by paediatricians, at adult chest clinics, or by specialists in paediatric or adult infectious diseases.⁹ Given the low incidence of childhood cases, this variety of attending specialists is not surprising and does not necessarily mean that current management of paediatric TB is inappropriate. In large cities there may be enough children with TB or receiving preventive therapy to warrant specialised paediatric TB clinics that combine both paediatric and public health expertise. However, in many parts of Australia, children with TB or TB contact are managed in chest clinics by chest physicians who are expert in tuberculosis, but may lack paediatric knowledge and skills. On the other hand, the regional paediatrician, with experience in examining and managing children, may have little knowledge and experience of childhood tuberculosis. Although paediatric TB is rare, child contacts of adults with TB are much less rare, and preventive therapy of children requires expert knowledge and supervision.^3,10 Guidelines on tuberculosis concentrate on adult aspects of TB, and tend to neglect paediatric aspects.^11-13 As paediatricians are child advocates and experts in child health, they should be more involved in the care of children with TB,¹⁴ not necessarily as sole carers, but at least in consultation. Paediatricians can provide clinical expertise and advice in areas such as compliance with medication, particularly for very young children. Recommendation: Paediatricians should be consulted and involved in the management of TB in children whenever possible. [Consensus view, not addressed by the NHMRC TB Working Party.¹¹]
Control of tuberculosis	The most critical aspect of control of tuberculosis is the existence of appropriate public health programs. The important strategies in TB control are: BCG vaccination; Screening of children at high risk; Contact tracing; and Appropriate duration of drug therapy.
BCG vaccine	Bacille Calmette-Guerin (BCG) vaccine was first used in humans in 1921, and few attempts have been made since then to develop improved vaccines against TB. BCG vaccine is moderately effective: a recent meta-analysis¹⁵ gave its protective efficacy as 50% against any TB disease, 64% against TB meningitis, and 71% against death from TB. Occasional cases of TB meningitis occur in children in Australia^6-9 and might be prevented by BCG vaccination. The NHMRC TB Working Party currently recommends BCG vaccination for three groups of children:¹¹ Aboriginal and Torres Strait Islander neonates in regions of high incidence; Neonates born to patients with leprosy (because of cross-protection by BCG against leprosy); and Children under the age of five years who will be travelling to live in countries of high TB prevalence for long periods. The NHMRC TB Working Party¹¹ states that BCG vaccine should be considered for: Neonates who will be living in a household which includes immigrants or visitors recently arrived from countries of high TB prevalence (and neonates in families who have returned to visit the homes of relatives in countries of high prevalence); and Children and adolescents aged less than 16 years who continue to be exposed to a patient with active TB, and where the child or adolescent cannot be given preventive isoniazid therapy, or the person with active disease has organisms resistant to both rifampicin and isoniazid. We believe these latter two "considerations" should be changed to "recommendations" to prevent occasional, but devastating, cases of tuberculosis in these children. In particular, neonates whose parents are from South-East Asia or the Indian subcontinent should be given BCG at birth. There is currently no information on how many children receive BCG vaccine in Australia each year, either as an absolute number or as a proportion of those eligible. Clearly, such information would be a great advantage in analysing BCG vaccine efficacy, and thus in evaluating the current NHMRC recommendations. The Australian Childhood Immunisation Register, implemented in 1996, monitors compliance with some vaccines, but not with BCG as yet. Studies are needed on the proportion of eligible children who receive BCG vaccine, and on side effects of BCG vaccination. *Recommendations:* We support the indications for BCG vaccination as recommended by the NHMRC TB Working Party, but feel that BCG should be recommended in all five situations detailed above. [Consensus opinion based on the high rate of TB in children exposed to adults with TB. This recommendation has also been made in the Australian immunisation procedures handbook,¹⁶ but not by the NHMRC TB Working Party,¹¹ in 1989.] We strongly urge the Federal Government to put in place mechanisms to audit the number of children vaccinated with BCG vaccine each year. [Consensus opinion.]
Mantoux screening	In Australia, Mantoux skin testing is usually performed with 10 tuberculin units of purified protein derivative (PPD), although one unit only may be used if there is a high risk of TB.¹⁶ In the United States,¹⁷ Mantoux skin testing is performed with five tuberculin units of PPD. US authorities' interpretation of a positive Mantoux skin test is shown in the Box; there is currently no recognised Australian interpretation of skin test positivity. At present, the Committee on Infectious Diseases of the American Academy of Pediatrics (the "Red Book" committee)¹⁷ recommends annual tuberculin testing of children at high risk, but not of children at low risk. Six months of isoniazid preventive therapy is recommended for children who are Mantoux positive without disease,¹² as this is as effective as nine months' duration of therapy¹⁸ and has a better risk-benefit analysis.¹⁹ While Australian children are not routinely tested with tuberculin, two recent surveys of the Mantoux status of 13-year-old²⁰ and six-year-old²¹ Sydney schoolchildren showed t hat being born overseas was the major risk factor for being Mantoux-positive. In addition, the later the child left the country of birth, the greater the risk of being Mantoux- positive. Australian-born children with one or both parents born overseas were not at increased risk of being Mantoux- positive compared with Australian-born children of Australian-born parents. As most Mantoux-positive children in Australia were born overseas, it is important to screen children who are migrating to Australia from countries with a high prevalence of TB. Short visits (e.g., holidays) overseas are associated with a low risk of becoming infected with TB. Although short term visitors to Australia occasionally transmit TB, screening them would be extremely difficult, and this is not done routinely. However, screening might be indicated in special circumstances (e.g., a visitor from a high endemic area with chronic respiratory symptoms). Routine annual Mantoux screening is not justified by the available data. *Recommendations:* Children born overseas who are migrating to Australia from a country with a high prevalence of tuberculosis should be screened by Mantoux testing with or without a chest x-ray on entry into Australia. [Based on evidence,^20,21 but not currently recommended by the NHMRC TB Working Party.¹¹] Children born in Australia should not be screened annually by Mantoux testing. [Based on evidence^20,21 and consistent with NHMRC TB Working Party recommendations.¹¹] Visitors to Australia from areas of high TB incidence should not be routinely screened, but neonates exposed to such visitors should be vaccinated with BCG. [Consensus opinion, consistent with Australian immunisation procedures handbook.¹⁶] Mantoux-positive children with no evidence of TB disease should be given preventive therapy with isoniazid for six months. [Based on evidence^18,19 and consistent with NHMRC TB Working Party recommendations.¹¹]
Contact tracing	Diligent tracing of the adult source of paediatric TB infection through public health networks continues to be an important step in preventing the spread of TB.
Appropriate duration of drug therapy	The emergence of highly resistant and multiply resistant strains of M. tuberculosis has re-emphasised the importance of good management of TB, and the development of innovative management and control strategies. The emergence of resistant strains is thought to be the result of failure of patients with TB to complete courses of chemotherapy. In New York, this was a consequence of failure to supervise patients' therapy as a result of cuts in health funding in the 1980s.^4,5 In Australia, some States supervise all antituberculous therapy, while others use targeted supervision of patients considered to be at risk of being non-compliant. In general, there are insufficient public health staff to ensure supervision of preventive therapy with isoniazid. Continued supervision of therapy (either full or targeted supervision) is important to prevent the emergence of resistant strains in Australia, and requires funding. *Recommendation:* Specifically funded TB control programs need to be maintained in each State and Territory in Australia. [Consensus opinion.]
	This document has been discussed by the Writing Panel of the Paediatric Special Interest Group of the Australasian Society for Infectious Diseases (ASID), circulated to all members, and ratified by the ASID Council. It was discussed at the 1996 meeting of the Australasian Paediatric Respiratory Group, and circulated to all members for comment. It was sent to Dr Greg Stewart, Chair of the NHMRC Working Party on Towards elimination of tuberculosis II. Guidelines and protocols for controlling tuberculosis disease in Australia, and to the Public Health Association of Australia.

Acknowledgements	Helpful comments were received from Dr T Konstantinos, Dr Graeme Oliver, Dr Graham Simpson and Professor Louis Landau.
References	Raviglione MC, Snider DE, Kochi A. Global epidemiology of tuberculosis. Morbidity and mortality of a worldwide epidemic. JAMA 1995; 273: 220-226. Report from the Centers for Disease Control and Prevention: tuberculosis morbidity, United States, 1992. JAMA 1993; 270: 1525. Starke JR, Jacobs RF, Jereb J. Resurgence of tuberculosis in children. J Pediatr 1992; 120: 839-855. Drucker E, Alcabes P, Bosworth W, Schell B. Childhood tuberculosis in the Bronx, New York. Lancet 1994; 343: 1482-1485. Frieden TR, Fujiwara PI, Washro RM, Hamburg MA. Tuberculosis in New York City -- turning the tide. N Engl J Med 1995; 333: 229-233. Cheah D. Tuberculosis notification rates, Australia, 1991. Commun Dis Intell 1992; 16: 398-400. Hargreaves J. Tuberculosis notifications in Australia, 1992. Commun Dis Intell 1994; 18: 330-337. Hargreaves J. Tuberculosis notifications in Australia, 1993. Commun Dis Intell 1995; 19: 332-341. Oliver G. Tuberculosis notifications in Australia, 1994. Commun Dis Intell 1996; 20: 108-115. Starke JR. Multidrug therapy for tuberculosis in children. Pediatr Infect Dis J 1990; 9: 785-793. National Health and Medical Research Council. Tuberculosis in Australia and New Zealand into the 1990s. Canberra: AGPS, 1989. Grossman M, Hopewell PC, Jacobs RF, et al. Consensus: management of tuberculin-positive children without evidence of disease. Pediatr Infect Dis J 1988; 7: 243-246. NSW Health Department. Controlling tuberculosis in New South Wales. Sydney: NSW Health, 1993. Forfar JO. Child health in a changing society. Oxford: Oxford University Press, 1988. Colditz GA, Brewer TF, Berkey JCS, et al. Efficacy of BCG vaccine in the prevention of tuberculosis. JAMA 1994; 271: 698-702. National Health and Medical Research Council. The Australian immunisation procedures handbook. 6th ed. Canberra: AGPS, 1997. American Academy of Pediatrics. Report of the Committee on Infectious Diseases. 23rd ed. Illinois: The Academy, 1994. Comstock GW, Baum G, Snider DE Jr. Isoniazid prophylaxis among Alaskan Eskimos. Am Rev Respir Dis 1979; 119: 827-830. International Union Against Tuberculosis, Committee on Prophylaxis. Efficacy of various durations of isoniazid preventive therapy for tuberculosis. Five years of follow-up in the IUAT trial. Bull World Health Organ 1982; 60: 555-564. Alperstein G, Fett MJ, Reznik R, et al. The prevalence of tuberculosis infections among Year 8 school children in inner Sydney in 1992. Med J Aust 1994; 160: 197-201. Alperstein G, Morgan K, Fett MJ, et al. Prevalence of tuberculosis infection among primary school entry children in Sydney. Aust J Pub Health 1996; 20: 123-128.