AN INVESTIGATION INTO SPECIFIC AND NON-SPECIFIC TUBERCULIN SENSITIVITY IN SCHOOLCHILDREN IN FIFTEEN COUNTRIES
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- Title
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AN INVESTIGATION INTO SPECIFIC AND NON-SPECIFIC
TUBERCULIN SENSITIVITY IN SCHOOLCHILDREN IN
FIFTEEN COUNTRIES - extracted text
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* * **
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AN INVESTIGATION INTO SPECIFIC AND NON-SPECIFIC
TUBERCULIN SENSITIVITY IN SCHOOLCHILDREN IN
FIFTEEN COUNTRIES
Dr
^7
M.A. Bleiker
a
AN INVESTIGATION INTO SPECIFIC AND NON-SPECIFIC
TUBERCULIN SENSITIVITY IN SCHOOLCHILDREN IN
FIFTEEN COUNTRIES
<
by
Dr. M.A. Bleiker
-
I
1
nr 1
AN INVESTIGATION INTO SPECIFIC AND NON-SPECIFIC TUBERCULIN
SENSITIVITY IN SCHOOLCHILDREN IN FIFTEEN COUNTRIES.
Introductiono
As mortality and incidence of tuberculosis decrease in many coun
tries, the tuberculin test is likely to become of increasing import
ance, primarily in estimating the infection transmission and secondly
in the detection of cases of tuberculosis.
Although tuberculin sensitivity has been extensively investigat
ed in many countries, it would be useful to compare data from several
countries as to the epidemiological and clinical significance of a
standard test with mammalian tuberculin,.
The subject of ’’non-specific1’ tuberculin sensitivity also de
serves attention in an international context. Investigators from
several countries report cases of diseases resembling tuberculosis
but caused by mycobacteriae other than the tubercle bacilluso It is
possible that low grade tuberculin sensitivity as found in a healthy
population, may be due to infection with these other mycobacterial
dia 1
organismso Studies of the prevalence of low grade sensitivity to mam
malian tuberculin in different environments and in different coun
tries, and its relationship to sensitivity to avian tuberculin, may
well contribute to our knowledge of its origin and significance.
To obtain information about the prevalence of specific and non
specific tuberculin allergy in schoolchildren in various countries,
a co-ordinated international tuberculin survey is carried out under
the auspices of the International Union against Tuberculosis, in co
operation with the World Health Organization.
A working protocol for this study was prepared which was approv
ed by the Committee on Epidemiology and Statistics in September 1965 «>
In 19 countries groups of children of similar age have been test
ed intradermally with a low dose of a mammalian and an avian P.P.Do
These tests were followed by high dose tests if the low dose tests
showed no or only small reactions. Each of the two tuberculins is
drawn from a single large batch and is administered in all countries
throughout the survey.
TNO
The
2
The present report deals with preliminary results obtained
dia 2
in about 50»000 children, born between 1952 and 1959, divided into
30 groups in 15 countries; in alphabetical order: Algeria, Belgium,
Canada, Czechoslovakia, France, Gabon, Great Britain, Israel, Italy,
The Netherlands, Poland, Portugal, Spain, Surinam and Yugoslavia.
The study was carried out during the last quarter of 19&5
during 1966 and 19^7•
dia 3
The following maps show the areas in the respective countries
dia 4
where the study was carried out, or is in progress, as well as the
dia 5
numbers of children tested in each area.
Selection of the groups to_be tested
The groups of children tested in each country form by no means
representative samples of the school population.
The only reason for participation in this international
survey was the existing possibility in the regions concerned, The
kind co-operation of the respective authorities is acknowledged.
Material and methods.
The W.H.O standard Mantoux-test was performed throughout
the study. Omega Passaic tuberculin syringes were used and Eisele
platinum needles.
The technicians, who injected the tuberculin and who read the
tests, were all trained for a short period in the reference team of
nurses, be it in the Netherlands, or in their own country. In the
latter case a nurse from the Dutch reference team assisted them in
starting the study.
Two tests were given to each child simultaneously; one test was
dia 6
made with 2 T.U. P.P.D. Rt 23 + Tween 80, whilst the second test was
made with 2 I.U. P.P.D.-avian (Weybridge *65) + Tween 80 (the socalled low dose tests). P.P.D. Rt 23 was produced in the State Serum
Institute in Copenhagen, Denmark (Ir. M. Magnusson). The P.P.D.-
avian was produced at the Central Veterinary Laboratory in Weybridge,
England (Dr. I. Lesslie).
TNO
The
- 3 The high dose tests (20 T.U. P.P.D. Rt 23 + Tween 80 and
20 I.U. P.P.D.-avian Weybridge *65 + Tween 80) were given on the
day of reading of the low dose tests to those children who reacted
with indurations smaller than 11 mm to both low dose tests.
The reactions were read after 72 hours, a.o. by measuring and
recording the transverse diameter of the indurations in mm. For
each individual a separate card was filled in, which besides personalia,
included information about previous B.C.G.-vaccination.
Results*
Of all results obtained, only a few will be presented in this
report.
1) B.CoG.-vaccination.
The percentages of the children, who previously had been
vaccinated with B.C.G. varied from country to country. Some
countries have compulsory B.C.G.-vaccination, others advocate
B.C.G.-vaccination on a voluntary basis; a few countries practice
dia 7
B.C.G.-vaccination on special indication only.
The next map shows the percentages of children who had been
previously vaccinated with B.C.G. in the respective groups.
2) Tuberculin indices.
For the children without previous B.C.G.-vaccination in each
region the percentages of those, who reacted with indurations
of 6 mm and more to the low dose tests of mammalian and avian PPD
were calculated.
Furthermore for each region the percentages of children who
reacted with a larger induration to avian P.P.D. than the corresponding
induration to human P.P.D. were calculated.
The following maps show these results.
Map III shows the percentages of children (without previous
dia 8
B.C.G.-vaccination) with indurations of 6 mm and more to 2 T.U.
P.P.D. Rt 2J + Tween 80.
In Great Britain regional differences are seen, ranging from
0.6 to 3»9» The overall percentage for the children tested in
Great Britain is 1.5*
TNO
In
- 4 In the Netherlands in the city of Delft a percentage of 3.1
reactors to Rt 23 was found. In Hilversum this percentage was 2.4,
whereas the percentage representative for the Netherlands in
total is 1.3*
In Belgium in two small areas the percentages turned out to be
2.8 (in Louvain) and 4.1 (in Courtray).
In France the percentages of reactors to P.P.D. Rt 23,
2 Units were 9*4 in Cote d’Or (result obtained in a pilot study)
and 11.7 in Gironde. (A percentage of 31*5 was found in Tourcoing.)
(Gabon 42$.)
In Spain studies were made in two areas, being Alicante on
the Mediterranean coast 10.0% and Castro Urdiales (Laredo),
Atlantic coast 14.4.
Portugal, also two areas, the Algarve on the south coast
6.0$ and in Sabugal in the central part of Portugal: 5«0$o
Sicily: Messina city: 14$; surrounding area 10$. Little
island Lipari: 7$»
Crossing the Mediterranean in Algeria, three areas from north to
south: coastal 39»O$, intermediate 18.3$ and the southern part
(dessert): 9-0$.
Further to the east: Israel with 2.5$ reactors in Jerusalem
(west) and 10.4 in Ramleh, an urban center between Jerusalem
and Tel Aviv.
Going to the north again: Yugoslavia with respectively 48.1
and 47.4$ of reactors to Rt 23 in Sarajevo and Velica Gorica
(rural area near Zagreb).
In Czechoslovakia, children were tested in three areas;
Prague, 54.6$, a rural area near Prague, 61.1$ and a village
Ivanka on Danube, near Bratislava, 54.2$.
In the south of Poland in Nowi Saez the percentage of reactors
was 29.6.
When considering the percentages in Yugoslavia, Czechoslovakia
and Poland, it has to be kept in mind that these percentages were
calculated from the not previously B.C.G.-vaccinated children, and
that in these countries respectively about 70.95 and 50$ of the
children tested has been previously vaccinated.
Overseas in Surinam former Dutch Guyana the percentage of reactors
was 23o9 and in Vancouver (Canada) 1.4.
TNO
Skin -
- 6 e. The group of reactors to human P.P.D. in which the phenomenon
of reacting with larger indurations to avian P.P.D. than to
human P.P.D. is present} the non-reactors (negatives), the low
grade reactors (e.g. 6-12 mm), the positive reactors (> 12 mm).
Thus it was possible to calculate for each group of non
B.C.G.-vaccinated children tested, the percentage of children
which reacted with indurations to avian P.P.D. which were at least
6 mm larger than the corresponding indurations to human P.P.D.
The reason we put this difference at 6 mm will be given later
on.
dia 10
The next map shows in each area the percentages of children
in whom the indurations to 2 U P.P.D.-avian WA’65 + Tween 80
were at least 6 mm larger than the corresponding indurations to
2 U P.PoD. Rt 23 + Tween 80.
Only in the Netherlands and in Spain this percentage is 3 or
more. This may indicate that skin sensitivity to avian P.P.D. is
definitely present in these areas.
Low grade sensitivity and
specific sensitivity.
Low grade sensitivity can be defined as the phenomenon of
reacting with a small induration (e.g. between 6-12 mm) to a
low dose of P.P.D. (2 units).
The presence of low grade sensitivity can be demonstrated
in the tuberculin histogram. This gives graphically the
dia 11
distribution of the number of indurations per mm. Low grade
sensitivity is then visually demonstrated as a proportion of the
histogram.
dia 12
The origin of low grade sensitivity is at least twofold:
Firstly : as the individual physiological response in t.b.
infected persons to a standard tuberculin test.
Secondly: as a cross reaction evoked by e.g. human P.P.D. in a
person infected with atypical mycobacteriae .
To distinguish physiological low grade sensitivity from cross
reaction low grade sensitivity (or non-specific sensitivity)
additional tests with sensitins prepared from e.g. avian Myco
bacteriae are given in addition to the tests with human P.P.D.
TNO
As
- 7 As we have learned originally from the veterinarians: tests
with homologous PoP.D. elicit indurations of wider diameter than
evoked by heterologeous P.P.D.
Generally speaking, it may be concluded that in case the
induration to human PjP.Dj is larger than the corresponding
induration to avian P.P.D. low grade sensitivity is considered
as being physiological.
In case the induration to avian _P_._P«JD
is larger than the
corresponding induration to human j?_.P_.D. the low grade sensitivity
is considered as being non-specific.
With these rules in mind, the prevalence of non-specific
tuberculin sensitivity can be estimated in the groups of nonB.CeG.-vaccinated children in each region.
First the percentage of reactors with indurations of e.g.
6-12 mm can be calculated in each group of reactors of 6 mm
and more.
Secondly in this group the percentages of physiological low
grade sensitivity and of non-specific sensitivity can be calculated.
Non-B.C.G.-vaccinated children tested in Delft are taken as
an example.
Total number of non-B.C.G.-vaccinated boys tested: 3108.
Number of indurations of 6 mm and more: 70. Of them between 6 and
12: 51. This is 73%. If from a total of positive reactors
(6-2^ mm) 73% is in the range of 6-12 mm, it can be stated that
there is an excessive amount of low grade sensitivity. It can be
supposed that this group of children is composed of physiological
low grade reactors and of non-specific reactors. If it is accepted
that children in which the induration to avian P.P.D. is at least
6 mm larger than the corresponding induration to human P.P.D. are
to be considered as non-specific reactors, the number of physiological
low grade reactors is brought back from 51 to ^-2, which means a
reduction of 18% being the percentage of non-specific reactors.
The results of a similar calculation for the non-B.C.G.dia 13
vaccinated children in all areas is given in the next map. Only
those figures are given which are large enough to be statistically
reliable, the Netherlands, France, Spain, Algeria, Poland, Surinam.
TNO
- Again -
- 8 Again the difference of 6 mm and more between avian and human
induration was taken as a condition for non—specificity of a given
particular induration.
Non-specific low grade sensitivity is also demonstrated in the
histograms.
dia 14
For comparison the histograms are given from the non-B.C.G.vaccinated children tested in Delft (the Netherlands) and Surinam
as areas with a high amount of non-specific reactions and from
the children in Poland and Yugoslavia as areas with none or little
non-specific tuberculin sensitivity.
It can be seen that in Delft and Surinam the ndipn in the
histogram has gone, whilst in Poland and in Yugoslavia this "dip”
is apparent.
A few words about the 6 mm difference limit between indurations
to avian and to human P.P0D. in individuals in the correlation
tables.
As can be seen in the correlation table of indurations to
human and to avian P.P.D. in 2038 schoolgirls in the Medoc area
dia 15
in France there are three groups of children: One group is
situated on the diagonal, which means that the indurations to
human P.P.D. are equal in size to the corresponding indurations
to avian P.P.D. The second group is on the left side of the
diagonal, which indicates that the indurations to human P.P.D.
are bigger than the corresponding indurations to avian P.P.D.
The third group is on the right side of the diagonal, indicating
that the indurations to avian P.P.D. are of wider diameter than
the corresponding indurations to human P.P.D.
Let us concentrate on this last group. Is it true that all
these children are not infected with human tubercle bacilli but
with other anonymous mycobacteriae, which are antigenically more
related to avian bacilli than to human tubercle bacilli? For,
as we know from experimental studies in animals tuberculin tests
with homologeous P.P.D. elicit indurations of wider diameter than
heterologeous P.P.D. does.
The answer is negative: as we know the phenomenons of the cross
sensitivity and of the technical errors.
TNO
The
- 8 Again the difference of 6 mm and more between avian and human
induration was taken as a condition for non-specificity of a given
particular induration.
Non-specific low grade sensitivity is also demonstrated in the
histograms.
dia 14
For comparison the histograms are given from the non-B.C.G.vaccinated children tested in Delft (the Netherlands) and Surinam
as areas with a high amount of non-specific reactions and from
the children in Poland and Yugoslavia as areas with none or little
non-specific tuberculin sensitivity.
It can be seen that in Delft and Surinam the ’’dip11 in the
histogram has gone, whilst in Poland and in Yugoslavia this ndipu
is apparent.
A few words about the 6 mm difference limit between indurations
to avian and to human P.P.D. in individuals in the correlation
tables.
As can be seen in the correlation table of indurations to
human and to avian P.P.D. in 2038 schoolgirls in the Medoc area
dia 15
in France there are three groups of children: One group is
situated on the diagonal, which means that the indurations to
human P.P.D. are equal in size to the corresponding indurations
to avian POPOD. The second group is on the left side of the
diagonal, which indicates that the indurations to human P.P.D.
are bigger than the corresponding indurations to avian P.P.D.
The third group is on the right side of the diagonal, indicating
that the indurations to avian P.P.D. are of wider diameter than
the corresponding indurations to human P.P.D.
Let us concentrate on this last group. Is it true that all
these children are not infected with human tubercle bacilli but
with other anonymous mycobacteriae, which are antigenically more
related to avian bacilli than to human tubercle bacilli? For,
as we know from experimental studies in animals tuberculin tests
with homologeous P.P.D. elicit indurations of wider diameter than
heterologeous P.P.D. does.
The answer is negative: as we know the phenomenons of the cross
sensitivity and of the technical errors.
TNO
The -
- 9 The question now arises which should be the smallest mm
difference between an induration with wider diameter to avian
P.P.D. than to human P.P.D*, should groups of children be
considered as suspect for an infection with other mycobacteriae
than the human tubercle bacillus.
A study executed in Tourcoing in France may give some information
on this problem. 195 non-vaccinated children showed zero-reactions to
2 and 20 units of P.P.D. Rt 2J and also zero-reactions to 2 and
20 units of avian P.P.D. In my opinion these children can be considered
as not infected with human tubercle bacilli and not infected with
any other mycobacteriae. After these tests the children were
vaccinated with B.C.G. 8 weeks after the vaccination tuberculin
tests were made with 2 units of human P.P.D. and with 2 units of
avian P.P.D. The correlation table of the indurations shows that
most of the children are situated on the left side of the diagonal,
dia 16
but also 20 others showed indurations which are of wider diameter
to avian P.P.D. than to human P.P.D.
Thus it seems to be possible that persons who were infected
with Bovine-B.CoG.-bacilli react with indurations of wider diameter
to avian P.P.D. than to human P.P.D.
This study provided the information to put the difference
between the indurations to human and to avian P.P.D. at an
arbitrary limit of 6 mm.
Summary and preliminary conelusions»
1. In total 50.000 children were tested with human and avian P.P.D.
in eleven countries. A uniform technique was applied throughout
the study. Uniform were also syringes, needles, tuberculins and
recording cards.
2. The percentages of children previously vaccinated with B.C.G.
varied from region to region. No B.C.G.-vaccination was found
in Spain and southern Algeria, a low percentage of vaccinees.was
found in Great Britain, the Netherlands, Portugal, Jerusalem and
Surinam.
A high percentage was found in Yugoslavia, Czechoslovakia and
Poland and West-France.
TNO
- 3.
10
J. The percentage of reactors to 2 U of P.P.D. Pt 2J in children
without previous B.C.G.-vaccination was lowest in the Netherlands,
Vancouver (Canada) and Great Britain (1.3, 1.4 and 1.5). Higher it
was in Belgium (2.8 and 4.1). Still higher in France (9.4 and 11.7)
and in Spain (10.0 in Alicante and 14.4 in Castro Urdiales). In
Portugal the index was a little lower, 5.0 and 6.1. Still higher
it was in Algeria (and Surinam) and Poland and highest in
Yugoslavia and Czechoslovakia.
4. The percentages of children with reactions, which were at least
6 mm wider in diameter to avian P.P.D. than to human P.P.D., were
highest in the Netherlands,5 in Medoc area in France, in Alicante
in Spain and in Surinam.
5* Non-specific tuberculin sensitivity was found in the Netherlands,
France, northern Algeria and Surinam with certainty. Probably
non-specific sensitivity was found in Alicante (Spain), Jerusalem
(Israel), southern Algeria. An absence of non-specific sensitivity
was found in Yugoslavia and Czechoslovakia.
The study has not yet been completed and more data are
coming forward.
Further analysis of the results is in progress, in which a.o.
responses to low and high doses of P.P.D. will be discussed, as
well as tuberculin sensitivity in previously B.C.G.-vaccinated
children.
My sincere respect goes to all our co-workers in the study
who without exception have been and still are helping to complete
this work.
Special acknowledgement to all participating collegues for
their gracious and continuous co-operation.
Thanks to Dr. Lesslie for the avian P.P.D. and to Ir. Magnusson
for the human P.P.D. both products were in due time in the respective
areas.
My sincere thanks to the International Union against
Tuberoulosis, who took this study under their auspices, to W.H.O.
for their continuous stimulation and to the Organization for Health
Research TNO and the Royal Netherlands T.B.-association for their
material support.
I hope that this progress report has provided some preliminary
information on the prevalence of tuberculin sensitivity in
comparable groups in various areas, using standard methods.
TNO. 22-9-196?. MS.
i nto
Invest i gat ion
Specific and non- specific
tuberculin sensitivity in
‘
schoolchildren in 19 countries
u
£3
Study
population:
± 50.000 chi Idren
age : 6_ 12 years .
Groups
of children were tested
(alphabetical order )
Algeria
Belgium
Canada
Czechoslovakia
France
Gabon
Great Britain
Israel
Italy
the Netherlands
Poland
Portugal
Spain
Surina m
Yugoslavia
In :
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W A 65+Tween 80
tests^ 2 0 U. PPD. Rt 23 +Tween
80
20 U. PPO_ovion Weybridge
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Percentages of children
previously vaccinated with B.C.G.
0.4
• 67
91
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12
74
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61
Percentoge of indurotions of 6 mm ond more to 2 T.U PPD.Rt23+Tween 80
(wi t h out
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6
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III
19 84 44 8 256 W 76 5 8 27 2 0 2 5 15 11 9 6 9 11 '7 7
3 6 5 5 4 3
2
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3108
Percentoge of reoctors
6 mm
larger
than to
with
ind urotions
to avian
PPD. at least
human PPD.
0.0
0.8
,0.4
2.8
0.0
0.0
0.8
0.7
0.0
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Table 13
France . medoc
girls
non B.C.G.-vaccinated
avian WA '6 5 + Twe e n
2 LU. PPD
o
o 165
1
4
5
6
7
8
9
10 11
9 10 6
6
2
2
1
2
2
2
3
1
<90
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29>30
3
5
4
1
1
1
1
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2
1
1
1
1756
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7
1
2
3 15
3
4
2 1
2
1
2
1
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10216.pdf
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