The article by Neil Heywood and associates1 draws attention to an important aspect of the health management of adult immigrants and refugees. However, the authors do not make clear that infants and young children (those under 5 years of age) who have been exposed to TB should be managed differently, as they are at much higher risk of progression to active disease. In contrast to adults with recent latent TB infection, among whom the risk for progression to active disease within 5 years is less than 2%, the likelihood of such progression in an infant is up to 40%.2 Furthermore, infants and young children are much more likely than older children and adults to experience life-threatening forms of TB such as TB meningitis and miliary TB.2 TB meningitis occurs in approximately 0.5% of children with untreated primary infection;3 if left untreated this condition is often fatal. In contrast, TB meningitis in adults is much rarer after untreated primary infection.
I am curious as to why young children were omitted from the discussion (in the first full paragraph on page 1564) of giving greater priority for identification and management to those at greater risk of progression to active disease; young age is not even mentioned as a major risk factor for progression.
Readers might be left with the erroneous impression that these guidelines are appropriate for immigrants and refugees of all ages, whereas they really apply only to adults. Nonetheless, physicians also need information about the management of TB in young immigrants and refugees.
Noni MacDonald Professor of Paediatrics and Microbiology Dalhousie University Halifax, NS