Missed opportunities for preventing tuberculosis among children younger than five years of age.

OBJECTIVES: Childhood tuberculosis (TB) is an important indicator of public health success in interrupting and preventing TB transmission. To determine the frequency and types of missed opportunities for preventing TB among children <5 years of age.
METHODS: We collected data from the public health records of child TB cases and their adult source cases. These children were from health jurisdictions where TB case rates in children were higher than the California average for this age group.
RESULTS: We reviewed the records for 165 children reported with TB (20% confirmed by culture). These children were evaluated for TB because of signs or symptoms of illness (32%), a contact investigation (26%), screening (22%), a source case investigation (4%), and unknown reasons (16%). Excluding 4 children infected by Mycobacterium bovis, only 59 of 161 children (37%) had a source case found. Children found in a contact investigation, born in the United States, <1 year of age, or who were black were more likely to have a source case found than children who did not have one of these characteristics. Of 43 children found in a contact investigation, improvements in contact investigations may have prevented TB in 17 of these children (40%). Among the 43 adult source cases, factors that may have facilitated transmission include delayed reporting in 23%, a delayed contact investigation in 21%, and delayed or nondocumented bacteriologic sputum conversion in 42% of culture-positive cases.
CONCLUSIONS: Important missed opportunities to prevent TB in children include the failure to find and appropriately manage adult source cases and failure to completely evaluate and properly treat children exposed to TB. Improvements in case detection, case management, and contact investigations are necessary to eliminate TB in children.