Abstract
BackgroundTuberculosis (TB) transmission rates are exceptionally high in endemic TB settings. Adolescence represents a period of increasing TB infection and disease but little is known as to where adolescents acquire TB infection. We explored the relationship between residential exposure to adult TB cases and infection in children and adolescents in a South African community with high burdens of TB and HIV.MethodsTB infection data were obtained from community, school-based tuberculin skin test (TST) surveys performed in 2006, 2007 and 2009. A subset of 2007 participants received a repeat TST in 2009, among which incident TB infections were identified. Using residential address, all adult TB cases notified by the community clinic between 1996 and 2009 were cross-referenced with childhood and adolescent TST results. Demographic and clinic data including HIV status were abstracted for TB cases. Multivariate logistic regression models examined the association of adult TB exposure with childhood and adolescent prevalent and incident TB infection.ResultsOf 1,100 children and adolescents included in the prevalent TB infection analysis, 480 (44%) were TST positive and 651 (59%) were exposed to an adult TB case on their residential plot. Prevalent TB infection in children aged 5–9 and 10–14 years was positively associated with residential exposure to an adult TB case (odds ratio [OR]:2.0; 95% confidence interval [CI]: 1.1-3.6 and OR:1.5; 95% CI: 1.0-2.3 respectively), but no association was found in adolescents ≥15 years (OR:1.4; 95% CI: 0.9-2.0). HIV status of adult TB cases was not associated with TB infection (p = 0.62). Of 67 previously TST negative children, 16 (24%) converted to a positive TST in 2009. These incident infections were not associated with residential exposure to an adult TB case (OR: 1.9; 95% CI: 0.5-7.3).ConclusionsTB infection among young children was strongly associated with residential exposure to an adult TB case, but prevalent and incident TB infection in adolescents was not associated with residential exposure. The HIV-status of adult TB cases was not a risk factor for transmission. The high rates of TB infection and disease among adolescents underscore the importance of identifying where infection occurs in this age group.
Highlights
Tuberculosis (TB) transmission rates are exceptionally high in endemic TB settings
We have previously suggested that age-specific interventions may be required for TB control, and this is applicable in the context of Mycobacterium tuberculosis (Mtb) transmission
It is well documented that Mtb transmission to children occurs predominantly in households [4,5,6], and household-based interventions may be most appropriate for young children [7]
Summary
Tuberculosis (TB) transmission rates are exceptionally high in endemic TB settings. In order to achieve TB control, it is necessary for an increasing proportion of the population to remain free of infection [2]. Reaching this goal in Africa will require the development and implementation of strategies adjunctive to Directly Observed Treatment Short-course (DOTS) that reduce TB transmission. While it is recognized that Mycobacterium tuberculosis (Mtb) transmission rates are exceptionally high [3], there are few data on the drivers and determinants of Mtb transmission in high HIV burdened communities. Studies from sub-Saharan Africa report high prevalence [3] and incidence [9] of TB infection in this age group, and adolescents are increasingly recognized as a key target group for future TB prevention initiatives [10]
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