Pediatric tuberculosis: What needs to be done to decrease morbidity and mortality

Objective. Tuberculosis (TB) control programs have been less successful amo ng children than among adults in the United States. Between 1992 and 1997, the rate of decline of TB cases among 0- to 14-year-old children was less t han the rate of decline among any other age group of US-born persons. Becau se of the higher prevalence of active TB among adults and their higher infe ctivity, most programs for TB in the United States have targeted adults. Th e inherent assumption has been that by targeting adults, from whom children may become infected, TB morbidity and mortality among children also will b e reduced effectively. Methods. Using a semi-Markov model that divided the US population into age groups <15 years old and greater than or equal to 15 years old and into 18 clinical states based on the risk for or presence of TB and human immunodef iciency virus infection, we developed a computer-based simulation model to examine the effect of a range of potential TB control strategies on project ed TB cases and deaths in children. We compare the impact of interventions targeted at children with the impact of interventions targeted at adults on pediatric morbidity and mortality. Results. After 10 years, a 5% increase in the number of adults with TB who enter treatment would only lead to a .05% decline in TB cases among childre n, compared with predicted cases without this intervention. Improving treat ment efficacy among those adults who are already receiving treatment for th eir TB leads to a smaller decline in cases among children of only .003%. In contrast, a 5% increase in the number of children who enter treatment lead s to a 25% decline, after 10 years, in the number of TB cases among childre n and a 16% decline in the number of TB deaths. In the presence of immigrat ion of tuberculin-positive children, the benefit of targeting programs dire ctly at children is magnified. Conclusions. Marginal changes in programs targeted directly at children are significantly more effective at further reducing pediatric TB morbidity an d mortality than the same changes in programs targeted at adults with the i ndirect goal of reducing spread to children. Marginal increases in the number of children who enter treatment are far mo re effective at decreasing morbidity and mortality than equivalent marginal increases in treatment effectiveness. Unfortunately, declining insurance c overage and increasing restrictions on services to immigrants have made it harder for those who are at greatest risk of TB to get medical care. Margin al increases in preventive therapy rates substantially reduce future pediat ric TB cases and deaths among children with TB infection and human immunode ficiency virus.