All issues > Volume 10(5); 1967

Original Article

J Korean Pediatr Soc. 1967;10(5):247-260. Published online May 31, 1967.

A Clinical and Statistical Analysis of Tuberculosis in Children from Poor Families in Pusan Area of Korea

S.T. Kim¹, J.S. Bae¹, C.D. Cho¹, D.S. Kim¹, J.J. Cho¹, C.Y. Kim¹

¹Dept, of Pediatrics, Pusan National Univ. Hosp.

Abstract

Introduction At present the infection rate of tuberculosis in Korea is 65% of total population according to the survey of Korean National Tuberculosis Association in 1965, and the morbidity rate is 5.1% of total population, roughly numbering 1. 24 million with tuberculosis and 24,000 people are dead each year from this disease. The source of tuberculous infection in children is mostly from open tuberculosis in adults who infect their household contacts, as described in most texts and articles. The authors tried to find such children infected or suffering from tuberculosis in poor families in the Pusan area, and gave treatment at S.C.F. clinics. Here we report the clinical characteristics and source of tuberculous infection whenever found among household contacts. Study Material and Method A total of 830 cases of tuberculosis, under 15 years, from poor families were subjected to study; they were registered at 2 S.C.F. clinics for tuberculosis, between Jan. 1964 and June 1966. Diagnostic procedures included tuberculin testing, radiography, gastric lavage, and sputum examination. And for many of those children diagnosed as having tuberculosis mass x-rays, tuberculin testings and sputum examinations were used for household contacts, as much as possible. Home visiting was done by a qualified nurse before or during treatment to evaluate economic and environmental condition, and to find household contacts. The classification of tuberculosis used was according to that in Nelson’s textbook of pediatrics. The media used for AFB culture was that of Ogawa, and the criteria of drug resistance was determined, as resistant strain when more than 50% of colonies were grown in the media of INH 5.07*/mU PAS 10r/ml, SM 10r/ml, Thiacetazone 5.0 r/ml, comparing with those of control media. Results and Discussion 1) Incidence 830 patients with tuberculosis were found among a total of 14, 205 children attending out-patient clinics, so that 5.8% were tuberculous. This rate is a little higher than the 4.3% of tuberculosis in adults attending out-patient clinics in Korea, but much higher than the 1.2% of total out-patients in Japan, 1960. Among these 830 cases of tuberculosis, 91 children (11%) were discovered as having tuberculosis by positive reading after routine tuberculin testing at Dong offices. Doing such simple routine tuberculin testing is a very important way of finding early tuberculosis. Also 13 cases (1. 56%) infected with tuberculosis were found among children previously receiving B.C.G. vaccination. This is in agreement with Hatcher’s report in which tuberculosis was found in 1 % (3 out of 309 children) after B.C.G. vaccination. Without doubt a B.C.G. vaccination does a great deal to prevent tuberc- ulosis in young children at present in Korea. Assuming that children from poor families in urban areas have much chance to be in contactwith heavy sources of infection, it is probably best to do B.C.G. vaccination immediately after birth or during the first month of life. 2)Age hnd Sex distribution 95 cases (11.4%) were under 1 year and 385 cases (46.4%) between 1 and 3 years; 57.8% of total number were under 3 year and 78.2% were under 6 year. 450 children (54.2%) were male and 380 children were female, showing slight sexual difference， perhaps due to mothers, greater concern for male babies. The majority of primary tubercluosis was found in younger children； 95 cases of active tuberculosis were found in infants suggesting that there might be many open tuberculosis cases in poor family households who were infecting their close contacts. 3) Classification according to lesions 151 patients (18.1%) out of the total of 830 cases had multiple tuberculous lesions more than 2 sites in the same patient. Dividing the cases into intrathoracic and extrathoracic lesions, 69% were intra and 31% extrathoracic cases. This showed a remarkable difference from the findings in a Japanese report, in which 5.6% were extrathoracic lesions. The difference may be due to different intake policy at the two centers. The most common intrathoracic lesions were (1) hilar adenitis alone (33.5%) (2) children under 3 years with positive tuberculin tests only (9. 8%) (3) non-calcified pulmonary focus only (8.5%). All of the lesions were primary tublerculosis in the under 6 year age group. Miliary tuberculosis and tuberculous meningitis were found more often in younger children from 1 to 6 year of age. In infants 3 cases of miliary tuberculosis and 7 cases of tuberculous meningitis were detected. Adult type of lesions such as apical tuberculous lesions and extensive pulmonary infiltrations were found not only in the older children but also in early childhood (See Table 3). Many cases of multiple tuberculous lesions occurred in the same child, frequently observed conversion from tuberculin negative to tuberculin positive in infants and younger children and common miliary tuberculosis and tuberculous meningitis in these children, indicated that heavy tuberculous infection occurred in the family and household contacts in early life, especially in families with poor nutrition and living close together in small houses under unhygienic conditions. 4)Positive AFB cultures AFB was found by cultures from gastric lavage, sputum, and other specimens from 115 children out of 492 children from whom specimens for culture were obtained, revealing 23.4%. The culture of gastric lavage material was attempted in 200 cases under the age of 9 and positive results were obtained in 28 cases (14%). This result was similar to the 13.8% of Pratt, but much higher than Roye’s,who got positive results^in only 8 out of 1207 cases. And Choi, in Korea, reported 20% of positive results from culturing gastric lavage material in tuberculous children in 1966. Of the 28 cases with positive AFB culture from gastric lavage material, 17 (70.8%) had heavy infection such as extensive pulmonary infinltration, miliary tuberculosis or bronchopneumonia; 11 (29.2%) had mild infection such as a non-calcified pulmonary focus ;some children aged 3 and under with positive tuberculin tests and hilar adenitis, had positive cultures showing the importance of culturing gastric lavage material (See Table 4). Positive culture for AFB in sputum was obtained in 28 out of 134 sputums examined (20.9%). Sputum culture for AFB was positive in adult cases collected and reported by Song in 32.6%, and by Pratt in 65.4%, but Roye found only 10 positive results out of 1297 sputums cultured. Among those 28 cases with positive sputum culture, 22 cases (78.6%) were very severely infected and had extensive pulmonary infiltrations, apical lesions, miliary tuberculosis or ronchopneumonia. AFB were also found in the sputum of 5 cases (21.4%) in which the infection was mild, such cases as non-calcifie pulmonary focus, hilar adenitis and pleurisy (See Table 5)» Other cultures of specimens from abscesses or draining sinuses, pleural effusion and urine showed positive results for AFB in 59 out of 158 patients (7.1%). Of these, 19 (32.2%) were from joint effusion, 16 (27.1%) from iliac fossae, and 16 (27.1%) from tuberculous abscesses following lym- phadenitis (See Table 6). 5)The occurrence of resistant strains to anti-tuberculous drugs. 76 cultures were put through sensitivity testing and 9 (11.8%) revealed resistant strains. Namely 5 (5.7%) to SM, 2 (2.7%) to PAS, 1 to INH, and 1 to INH and to Thiacetazone. The amount of resistance to INH, PAS, and Thiacetazone is slightly lower in our series than that of Song (13.6%) and Kim (17.8%), but the resistance to SM in our series is slightly higher than that of the others’ series. Among the 5 cultured organisms, that showed resistance to strepto- mycin, 2 were from children under 4 years with primary tuberculosis. These resistant strains might have some close relationship with those in another tuberculous adult in the family, but this was not proved. 6)Mass x-ray examination of household contacts 507 household contacts of the 830 cases of tuberculous children, were investigated by mass x-ray or sputum tests or both (61.1%). Among 2036 people who were household contacts 1722 had mass x-ray examinations (84.6%). Source of Infection: Of 513 cases investigated, 213 (42%) had a definite source of infection in the family. This is much less than Huston’s 78% (59 out of 74 cases) which were obtained after a detailed examination, but is higher than that of Kurihara’s 23%. The source of infection in the family was fond to be the father 55.3%, the mother 31.7%, and so from either parent in 87% of cases. But Huston reported 27.2% from father, 12.2% from mo- ther, 39.4% from a parent. Kurihara also reported 13.6% from father, 5.3% from mother, 18.9 % from a parent. Again Yamasaki reported 46.3% from father, 36.1% from mother, 72.4% from a parent. Our x-ray data suggests that either parent is frequently found to be the source of infection in the family. Concerning the age of the parents, 45.1% were in the 4th decade of life and 23.9% in the 5th decade; 69% were in the 4th and 5th decades, and tuberculous infection was commonest in middle-aged parents (See Table 9). Adult open tuberculosis cases in the family were found in 59 (24%) out of 246 patients, of which 34.7% were one of the parents whose ages were mostly 4th decade (father) and 3rd decade (mother). Therefore the source of infection was most commonly found in the parents before, during or sooajority of cases, in the young middle aged parents, infants and younger children, having close contact with their parents, were exposed to tuberculosis, and easily got heavy infections, and far advanced disease with poor prognosis. ConclusionFor 2 and a half year since Jan. 1964, 830 cases of tuberculosis in children from poor families in Pusan area were studied clinically and statistically, and mass x-ray examinations were done on many household contacts； the following results were obtained;1)Among 14,205 out-patients from poor families 5.8% had tuberculosis, 11.4% of these were infants and 57. 8% under the age of 3 years. 2)Classifying the lesions of primary tuberculosis, hilar adeniti (33. 5%) was most common, and severe infections such as miliary (4.3%) and tuberculous meningitis (4. 8%) were also not uncommon in infants and younger children. 18.1% had multiple tuberculous lesions and 18. 9% had bone and joint tuberculosis. 3)AFB were found in 23.4% of cultures from gastric lavage, sputum, etc. AFB were positive in cultures from gastric lavage material in 28 out of 200 cases (14%), these were not only from children with severe infection but also from 3 cases under 3 year with just a positive tuberculin test, and in 4 cases of hilar adenitis only. 4)Sensitivity tests for anti-tuberculous drugs were done on 76 positive cultures:5.7% were found to show some resistance to streptomycin, 2.7% to INH and 2.7% to PAS. Two of the cultures showing resistance to streptomycin were from cases of apparently uncomplicated primary tuberculosis of the lung in children under 4 years. 5)The infectious source was found to be the father in 55. 3% of these cases, and the mother in 31. 7%, therefore one of the parents were found as source case in 87%. The infective parents were found most commonly to be in the 4th decade, and next most commonly in the 6th decade, and then in the 3rd decade. Our thanks are due to Dr. J. Adams who gave us a good advice and permission to use the S.C.F. clinic records.

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