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Vol. 68, No. 1

Mycobacteriosis: Incidence in Jamaican Basic School Children* BASSEY WILLIAMS, M.D., Fellow in Infectious Diseases, and MARGARET E. GRIGSBY, M.D., Professor of Medicine, Howard University Hospital Washington, D.C.

TH IS project was carried out in order to determine the prevalence of delayed skin sensitivity to both the human tuberculin (PPD-S) and the more common atypical mycobacterial antigens (PPD-G, PPD-B, and PPD-Y), to determine which of the atypical mycobacterial antigens would be the best companion antigen to PPD-S in a dual skin-testing program in Jamaica and to administer BCG to the negative reactors with respect to PPD-S. MATERIALS AND METHODS

This work was done among children aged seven years and younger in August Town, a rural community in the outskirt of Kingston but only a few miles from the University of the West Indies. This community was selected because it has never been involved in any similar survey and the particular age group had not yet been vaccinated with B.C.G. Two hundred and eighty-one boys and girls in five basic schools were involved in the program, but 20 of these children were above the age of seven and were excluded in the analysis of the results. The mycobacterial antigens-PPD-S, PPD-G, PPD-B and PPD-Y, were obtained from The National Institutes of Health, United States Public Health Service, Bethesda, Maryland. B. C. G. was supplied by the Kingston Chest Clinic. Disposable tuberculin syringes and 26 gauge needles were obtained locally in Kingston. An experienced school nurse from Kingston Chest Clinic assisted in the skin-testing *This project was undertaken at the University of the West Indies, Department of Social and Preventive Medicine, Kingston, Mona, Jamaica. NIH Grant No. A10042-03.

and she administered the B. C. G. Consent of parents was obtained well in advance by letters and through the teachers of the schools. The mycobacterial antigens were kept in cold storage all the time until the actual skin-testing started in any school. After warming up, the antigen was actually drawn into the syringe at the time it was about to be administered to each child. The antigen, 0.1 ml (5 tuberculin units) was given intradermally in the forearm about 4cm. below the cubital fossa. PPD-S was always given in the right forearm and an atypical antigen in the left. In each occasion one antigen4 was handled by one operator. This was to eliminate error. While PPD-S was given to every child in the study, the children were divided for the atypical antigen. That is, two schools received PPD-S and PPD-B, two schools received PPD-S and PPD-Y and the largest school received PPD-S and PPD-G, so that approximately equal number of children shared the atypical antigens. This arrangement was satisfactory because the community has the same environment. The skin test was examined and measured on the third day (after 48 hours) and B. C. G. was administered at this visit to any child with a reaction size less than 10mm. to PPD-S and who had not been recently vaccinated. Almost all of this age-group in this community had not yet been vaccinated with B.C.G. B.C.G. was not given to any child who did not appear well. In Table 1, the reaction sizes for PPD-S and an atypical antigen in each school are compared. The children are divided into

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

40

three groups: Those with reaction size less than 10mm., those with reaction size equal to 10mm. and those with reaction size greater than 10mm. This table shows grossly that the reaction sizes to PPD-S and PPD-Y are about equal whereas the reaction sizes to both PPD-B and PPD-G are greater than those due to PPD-S. Table I. REACTION SIZES TO PPD-S AND ATYPICAL ANTIGEN COMPARED IN EACH OF THE FIVE BASIC SCHOOLS IN AUGUST TOWN Number of Children ReacReacReaction tion tion size size size School PPD 10mm. Good Hope

S Y

26 26

0 0

0 0

A.T.I.C. S Y

37 37

0 0

0 0

Hermitage

S B

59 55

0 0

0 3

S.D.A.

S B

58 52

0 3

0 3

Bronx

S G

64 58

0 3

0 3

Remarks Reaction size to PPD-Y and PPD-S are similar. Reaction size to PPD-Y and PPD-S are similar. Reaction size to PPD-B greater than that to PPD-S. Reaction size to PPD-B greater than that to PPD-S. Reaction size to PPD-G greater than that to PPD-S.

Table 2 shows the number of children within each reaction size range for both PPD-S and the atypical antigen used in that school. Here one can easily discern that the reaction size response to both PPD-B and PPD-G is considerably greater than the response to PPD-S and PPD-Y. In Figure 1, the number of children (in percentage) within each reaction size range (frequency distribution) is depicted graphically. In greater detail one can set the negligible reaction to PPD-S in this community, a slightly higher response to PPD-Y and the comparatively marked responses to PPD-B and PPD-G, the latter greater than the former. DISCUSSION

Jamaica is a Caribbean developing country of about two million people, 99% of which are of African descent while the rest is comprised of East Indians, Chinese and a few whites. The school system is based on age

JANUARY, 1976

group, the basic school for ages two through seven, the primary school for ages six through 1 1, the junior secondary school for ages 11-15 and the secondary schools for ages 11-19. Every child has access to a medical facility. Besides the general and special hospitals and clinics, there are special health centers for schools, not only for the purpose of examination and innoculation for school entry, but for regular checks thereafter. Besides the school health system mentioned, August Town is not far from the University of the West Indies, and the public transport is adequate for every child to attend the University Hospital and clinics as the need arises. The environment is naturally healthful and beautiful for this community mainly because of its backyard of the Blue Mountains. It is not surprising then to find that the incidence of infection due to the human tubercle bacillus is very low among the age group in this study-as indicated by the insignificant reaction to the human tuberculin (PPD-S). This is in marked contrast, however, to the incidence of infection due to some of the atypical mycobacteria-as Table 2. NUMBER OF CHILDREN WITHIN EACH REACTION SIZE FOR BOTH PPD-S AND THE COMPANION ATYPICAL MYCOBACTERIAL ANTIGEN Reaction

Size

in No. of Children No. of Children No. of Children Millimeter PPD-S PPD-G PPD-S PPD-B PPD-S PPD-Y 0

1-2 3-4 5-6 7-8 9-10 11-12 13-14 15+ Total

61 0 1

2 0 0 0 0 0 64

35

0 7

115 0

11

1 1

5 3 2 1 0 64

0 0 0 0 0 117

71 6 10 14 6 4

3 1 2 117

56 1 5 1 0 0 0 0 0 63

54

0 4 2 3 0 0 0 0 63

shown by their reaction to PPD-Gause and PPD-Battey. The incidence of infection due to Mycobacterium kansasii is just as low as that due to Mycobacterium tuberculosis in this area and it would be reasonable to say that skin testing with PPD-Y is not necessary

Vol. 68, No. 1

for this population in terms of large scale programs in preventive medicine. The incidence of infection due to M. battey and M. gause is high and similar. Therefore it would be difficult to choose between these two in selecting a companion antigen to PPD-S for dual skin-testing in this area. Should we then revolve to triple skintesting, using PPD-S, PPD-B and PPD-G, in order to solve this problem? Besides the difficulty in practice, the dilemma would increase in interpreting the results especially with respect to cross-reactions between mycobacterial antigens and other antigens used in clinical medicine. ,00

90

80 -PPD

z

70 I a

-G

PPO -8

---PPD

60

I

z

-PP

-S y

-

0400

z

adenopathies and suppurating lymph nodes and BCGosis. An incidental but very important price has been the elimination of the tuberculin reaction as a diagnostic tool. Another serious limitation to the most effective application of BCG is the absence of yardsticks for determinlng how long effective protective immunity persists after initial vaccination. Who should be revaccinated, if anybody, and when?"5 SUMMARY

Two hundred and eighty-one children between the ages of 3 and 7 years had dual skin-testing with PPD-S and an atypical mycobacterial antigen: The results showed that the incidence of infection due to Mycobacterium tuberculosis was as low as in the United States, if not lower. Infection rate due to M. kansasii was equally negligible but it was much higher for M. battey and M. gause. Dual skin-testing as a public health routine was therefore not advisable, and the continued usefulness of BCG vaccination in this population becomes questionable. ACKNOWLEDGEMENT

3020-

II ':

41

Myebacteriosis

3-4 5-6 7-8 9-10 -12 13-14 REACTION SIZE IN MILLIMETERS

15 +

Since the source of atypical mycobacteria is not clear at this stage2, it would not be wise to embark upon dual skin-testing for purpose of diagnosis in mycobacteriosis as recently suggested.3 This would cause more confusion than there is at present, especially as newer mycobacterial pathogens continue to come to light.4 An important conclusion from this particular study is that BCG vaccination, as a public health measure, is of questionable value in this population since the incidence of infection due to M. tuberculosis is so low. BCG has several disadvantages-as noted in these remarks of Schmidt in his John Barnwell lecture: "There has been a cost for this achievement, however, namely, a fairly high incidence of reactions including lymph-

The writers thank Professor K. L. Standard and Dr. H. C. Dyer, both of the Department of Social and Preventive Medicine at the University of the West Indies in Jamaica, who provided much of the facilities for this project, Dr. L. B. Edwards of the National Institutes of Health who supplied the mycobacterial antigens used in this study and Nurse Vivette Anderson who assisted in the skin-testing and administered the BCG.

LITERATURE CITED

1. KANE R., and H. MAC VANDIVIERE. The Significance of Multiple Simultaneous Tuberculin Skin-testing in the Prediction of Various Mycobacterial Infections in the Host. Am. Rev. Resp. Dis.,

105:296, 1972. 2. LINCOLN E. M., and L. A. GILBERT. Disease in Children due to Mycobacteria Other than Mycobacterium Tuberculosis. Am. Rev. Resp. Dis., 105:686, 1972. 3. EDWARDS L. B., and F. A. ACQUAVIVA, and V. T. LIVESAY. Identification of Tuberculous Infected: Dual Tests and Density of Reaction. Am. Rec. Resp. Dis., 108:1334, 1973. 4. SCHOEFER W. B. and E. WOLINSKY, P. A. JENKINS and J. MARKS. Mycobacterium Szulgai-A New Pathogen. Serologic Identification and (Concluded on page 33)

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Idiopathic Clubfoot

Vol. 68, No. I

at 10-12 years if tarsal symptoms are disabling. Tendon transfers will never correct existing bony deformity. CASE REPORT L.B. was treated from birth with plaster cast for a bilateral idiopathic clubfoot deformity. At age 12 months, bilateral posteromedial releases were performed one week apart (Fig. 1). Plaster casts were discontinued after seven months postoperative. At age three years, the child re-presented to the clinic, having kept no appointments for more than six months, with an equinovarus deformity. Corrective casting and cabletwisting long-leg braces were all tried and found to be totally ineffective. At age five years, bilateral Evans operations were performed (Figs. 2 & 3). Two a a half years post-surgery, the feet remained corrected with dorsiflexion 20 degrees bilaterally and 30 degrees of plantarflexion possible in both feet. Invertion of each heel was possible to 10 degrees and eversion of five degrees bilaterally. Both heels were in slight valgus. There was no pain, and the mother indicated that the child physically competed in running activities with other children.

SUMMARY

Approximately one-half of patients seen with a diagnosis of idiopathic clubfoot will require surgical intervention to correct their deformities. This surgery should consist of a complete posteromedial release not to be performed under one year of age. No better results should be anticipated under the age of one year, and in my opinion is contraindicated. Beyond the age of two years, most certainly three years, there should be decreasing optimism towards adequate correction with soft tissue release alone. The Evans operation is the procedure of choice for recurrent deformity or residual deformity from ages four to eight years. Without resection of the lateral column of the foot at the calcaneal cuboid-joint, posteromedial release at these ages, will be ineffectual in correcting hind foot varus and the medial displacement of the navicular upon the talar head and neck. There is insufficient evidence to suggest that a surgical caleaneo-cuboid coalition will necessarily require eventual triple arthrodesis for

disabling symptoms. Roentgenographic assessment of postoperative posteromedial release operation is mandatory. The surgeon must know whether postoperative deformities are truly recurrent or the result of an inadequate surgical release. Without this type of proper assessment, it seems conceivable that with the wave of enthusiasm towards early surgical correction of clubfoot deformity, the return of notoriety and crippling results is an eminent possibility. LITERATURE CITED

1. HERSH, A. J. The Role of Surgery in the Treatment of Clubfeet. J. Bone & Joint Surg., 55a: 1377, 1973. 2. IRANI, R. N. and M. D. SHERMAN. The Pathological Anatomy of Clubfoot. J. Bone & Joint Surg., 45a:45-52, 1963. 3. KITE, T. H. Nonoperative Treatment of Congenital Clubfeet: A Review of One Hundred Cases. South. Med. J., 23:334-345, 1930. 4. BOST, F. C. and E. R. SCHOTTSTEADT, and L. J. LARSEN. Plantar Dissection. An Operation to Release the Soft Tissues in Recurrent or Recalcitrant Talipes Equinovarus. J. Bone & Joint

Surg., 42a:151-164, 1960. 5. TURCO, F. J. Surgical Correction of the Resistant Clubfoot. One-stage Posteromedial Release with Internal Fixation: A Preliminary Report. J. Bone & Joint Surg., 53a:477, 1971. 6. BEN-MENACHEN, Y. and J. E. BUTLER. Arteriography of the Foot in Congenital Deformities. J. Bone & Joint Surg., 56a:1625, 1974. 7. BEATSON, T. R. and J. R. PEARSON. A Method of Assessing Correction in Clubfeet. J. Bone & Joint Surg., 48b:40-50, 1966. 8. ASHBY, M. E. Roentgenographic Assessment of Soft Tissue Medial Release Operations in Clubfoot Deformity. Clin. Orthop., 90: 146-149, 1973. 9. ABRAMS, R. C. Relapsed Clubfoot: A Study of the Dillwyn Evans Operation. J. Bone & Joint Surg., 51a:270, 1969. 10. EVANS, D. Relapsed Clubfoot. J. Bone & Joint Surg., 43b:722-733. 11. LICHTBLAU, S. A Medial and Lateral Release Operation for Clubfoot. A Preliminary Report. J. Bone & Joint Surg., 55a: 1377, 1973. 12. HARRIS, R. I. Retrospect: Peroneal Spastic Flatfoot (Rigid Valgus Foot). J. Bone & Joint Surg., 47a: 1657, 1965.

(Williams and Grigsby, from page 4 1) Improving Existing Methods of Control of TuberReport of Five New Cases. Am. Rev. Resp. Dis. culosis: A Prime Challenge to the Experimentalist. 108:1320, 1973. Am. Rev. Resp. Dis., 105:183, 1972. 5. SCHMIDT L. H. The John Barnwell Lecture.

Mycobacteriosis: incidence in Jamaican basic school children.

39 Vol. 68, No. 1 Mycobacteriosis: Incidence in Jamaican Basic School Children* BASSEY WILLIAMS, M.D., Fellow in Infectious Diseases, and MARGARET E...
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