Preventable childhood tuberculosis in Alabama: Implications and opportunity

Childhood tuberculosis (TB) cases indicate recent community transmission an d thus reflect the effectiveness of TB control efforts, particularly the co ntact investigation. Objective. To evaluate all preventable childhood TB cases and implications in the context of TB morbidity trends. Design. Statewide morbidity trends are presented from 1983 to 1997. Since 1 992, each child TB case is classified as either preventable or not preventa ble, based on a standard definition. Main Outcome Measures. Case characteristics (preventable and not preventabl e), TB disease rates over time, and reasons for preventable case classifica tion. Setting. Alabama TB control program, from January 1, 1983 through December 31, 1997. Results. For the period 1983-1997, nonwhite children had a higher disease r ate (rate ratio: 5.7; 95% confidence interval: 4.3,7.6) than white children . Since 1990, the overall child rate has increased significantly despite a decline in the adult rate. Among 120 child cases diagnosed from 1992 to 199 7, 25 (21%) were classified as preventable. The causes were contact investi gation interview failure (12/ 25 = 48%), delay to evaluation (16%), source case noncompliance with previously prescribed preventive therapy (16%), and source case diagnosed out of state (16%) with no initial investigation per formed in Alabama. All preventable cases identified were black children; th e proportion of preventable cases did not vary by age group or sex. During 1996, the case rate for nonwhite children exceeded that of adult whites. Conclusions. Childhood TB in Alabama for nonwhites is rising despite a nati onal downward trend. TB is clearly a disproportionate disease burden for th e state's African American population, and the median case age is falling. Additional research and improved training in contact investigation are requ ired to assess this situation and effectively intervene.