The permissible mantoux rate in children is 7 years old. Tuberculosis vaccination for children: vaccination and Mantoux test

Modern parents, caring for the health of their babies, are ready to abandon all vaccinations conducted under the auspices of mass immunization. The mantoux test also falls into the abandoned group, although the injection does not belong to the vaccination process at all. Having determined what size the mantle should be, the doctor checks the reaction of the baby's immunity to the introduction of tuberculin, a kind of antigen of the causative agent of tuberculosis infection. It can be infected in any crowded place, but the body of the vaccinated person will be reliably protected by strong immunity against the harmful Koch wand.

Important: a mantoux test, as a common method for diagnosing tuberculosis, is given to children under 14 years old annually. Only the reaction to tuberculin and its dynamic assessment can detect whether tubercle bacillus is present in the body and whether there is a threat of predisposition to a dangerous disease.

Features of a tuberculosis test

The Mantoux test is not a vaccination in its classical sense, but a variant of a test diagnosis to detect tuberculosis at an early stage. In order to form anti-tuberculosis immunity, they are vaccinated with BCG, which is given to the child in the first week of his life. The first tuberculin test is put at the age of one year, before the procedure is not carried out due to the characteristics of the growing organism and the threat of unexpected reactions.

The study is carried out by piercing the skin and injecting the drug into the arm - between the elbow and wrist, which leads to swelling of the skin in the form of a button. This is the Mantoux reaction, the size assessment and appearance of which show whether the child’s body is infected with a Koch wand. The procedure is carried out in a clinic.

Advice to parents: do not give up tuberculin testing, this is the most reliable and safest way to determine infection at the very beginning. For adults, X-ray diagnostics are performed, and radiation is harmful to a growing body even in small doses.

Mantoux reaction is a kind of breakdown to allergies. Therefore, within three days after the procedure, to ensure a correct interpretation of the test results in a child, he needs special care for the injection site. What can not be done:

• comb and rub the injection site;
• glue and bandage his hand, pinch clothes;
• nothing to lubricate the wound, this applies to peroxide and brilliant green;
• soak with water or other liquid.

Tip: to ensure the correct conclusions of the control check, allergy-causing products should be excluded from the diet of children, and also refuse to take any medications.

What should be the norm of mantoux

As a result of the introduction of tuberculin subcutaneously, a papule forms on the skin area, and around a few cm of redness. This will be the reaction of the body if microbacteria of tuberculosis are present in it, since lymphocytes sensitive to the Koch bacillus are activated at the injection site. If there is no infection, and the baby was not given a BCG vaccine, then there will be no answer. An increase in the size of the button indicates the contact of the body with a tuberculosis infection, which causes an immune and allergic response.

After three days, the result of the injection should be indicated. The doctor’s task is to correctly evaluate him, armed with a transparent ruler that has millimeter divisions. The dimensions of the seal (papule) are measured, redness is not taken into account, it is evaluated only in the absence of a button - this is an ideal negative type of reaction, indicating that the child’s body is not familiar with tuberculosis or the immunity is greatly weakened.

How does the mantoux size estimation procedure go?

1. Visual inspection of the injection site to determine if there is a reaction - hyperemia, swelling in the diameter of several cm around the injection.
2. Feeling the injection site carefully to determine the thickness of the skin in order to measure the size of the button.
3. Measurement of the amount of compaction to compare them with the norm.

Important: tuberculosis infection occurs through contact-domestic means, which increases the role of personal hygiene, especially after visiting places with a large crowd of people. In addition, doctors recommend a safe distance when communicating with a sick person, it is 70 centimeters.

What does the Mantoux test look like?

In the absence of papules and redness, or when the compaction size is not more than one mm, the answer is considered negative, which means that the child has no microbacteria of a dangerous disease. If the button has increased to 4 mm, and the size of the redness can be any, this indicates a dubious reaction. Plaque sizes up to 17 mm indicate a positive result of the tuberculosis test, which requires additional diagnosis and treatment of the disease.

The main criteria for evaluating tuberculin test

Type of reaction to tuberculin	How much can the diameter of the papule be	Seal characteristic	Reaction, its meaning
Negative	0-1 mm	No buttons, only an injection wound	The body of the child is free from pathogens of tuberculosis (normal test)
Doubtful	2-4 mm	The plaque may be absent in the presence of redness of any size	Pathogens are present, but in a small amount or the incorrectness of the result was influenced by other reasons
Positive	5 mm and more	The seal is particularly noticeable	Full leukocyte infection with Koch's stick with a high risk of tuberculosis infection
Hyperergic	More than 17 mm	Pronounced injection response	The condition is considered dangerous, especially with the appearance of pustules with traces of tissue necrosis

Features of a positive test in children, it can be:

• weakly positive (0.5-0.9 cm);
• moderate (1.0-1.4 cm);
• very pronounced (up to 1.6 cm).

Advice to parents: if you increase the size of the plaque by several mm, you should not immediately panic, it can just be an allergy - the child’s body response is not to the tubercle bacillus, but to the composition of the drug. Either heredity is to blame.

It is necessary to consult a doctor for additional diagnostics, because in the absence of BCG, a positive reaction can indicate infection with tuberculosis. However, it is not necessary for the child to get sick; microbacteria can be present in the body of children and adults all their lives, but under certain conditions, Koch’s wand can be activated, especially when it comes in contact with patients.

What diagnostic results should trigger an alarm:

• if the permanent negative version of the result turns into positive when there is no BCG vaccination (turn);
• hyperergic type of mantle reaction, accompanied by edema and inflammation of the lymph nodes;
• button sizes within 12 mm hold for four years.

In these cases, further testing of children for tuberculosis is necessary with the help of additional studies and tests in order to start treating the disease with modern methods leading to a complete recovery.

Important: no matter how many times each year the mantle is placed, the papule should decrease in size by several millimeters, and by the age of seven years become almost invisible. This is a signal for re-vaccination with BCG. However, if after the first normal reactions the plaque sizes increase sharply, we are talking about turbo-circulation of the mantoux sample.

Mantoux test features

1. Turn of results - the diameter of the papule increases compared to last year’s size. Such a reaction is possible with infection over the past year, if other causes of a sharp change in the size of the seal are excluded.
2. The booster (enhanced) effect is an increase in the diameter of the sample with its frequent conduct (several times a year). This indicates the sensitivity of lymphocytes to the introduction of tuberculin. In addition, this effect indicates the extinction of the injection reaction in infected adolescent children and adults.

Tip: Doubtful cases require a second test in a year, and sometimes in six months. In case of confirmation of a tuberculosis infection, children need observation in the dispensary and the appointment of preventive treatment.

When you can not conduct a mantoux test:

• with intolerance to tuberculin;
• in case of acute or chronic infections;
• with colds;
• in case of allergies, as well as epilepsy.

An allergy to the tuberculin test manifests itself in children similar to the common cold symptoms - fever, skin rashes, general weakness, there is a threat of anaphylactic shock. The appearance of adverse reactions is an occasion to call a doctor.

If the rules for conducting tuberculin diagnostics are fully observed, and the drug is administered intradermally, and not to a depth, then this eliminates the appearance of blood at the injection site and does not cause an incorrect interpretation of the results of testing for tuberculosis.

Cones after injections or postinjection infiltration

The Mantoux test is the main method of preventive examination of children for tuberculosis, an immunological test that shows whether there is a tuberculosis infection in the body.

The Mantoux reaction is the body's reaction to the introduction of tuberculin. Specific inflammation occurs at the injection site of the skin, caused by lymphocyte infiltration - specific blood cells responsible for cellular immunity (as opposed to antibody-based immune responses, in which antibody antibodies play a major role). Fragments of mycobacteria seem to attract lymphocytes from the nearby blood vessels of the skin. But not all lymphocytes enter the game, but only those that are already fully or partially “familiar” with Koch’s wand. If the body already had a chance to "get acquainted" with the real mycobacterium of tuberculosis, then there will be more such lymphocytes, the inflammation is more intense, and the reaction will be "positive" (there is an infection with Koch's bacillus). Naturally, a positive reaction means that the inflammation exceeds that caused by the injection itself and a certain diagnostic threshold. By measuring the diameter of the papule (an inflammatory “plaque” or “button”) with a ruler, one can assess the intensity of immunity to tubercle bacillus.

Strictly speaking, the body's reaction to tuberculin is one of the varieties of allergies (because tuberculin itself is not a complete antigen, but rather an allergen).

Is tuberculin test harmless?

Despite the long-term use of tuberculin for diagnostic purposes, the nature and mechanism of its action remains controversial. The mechanism of the interaction of tuberculin with the immune system is still not known exactly. Tuberculin is not a genuine toxin, it cannot be called an antigen, since after its introduction specific antibodies are not formed in the body. Most researchers see it as an incomplete antigen. It is able to cause a response only in people previously sensitized with mycobacterium tuberculosis or BCG vaccine. In these patients, at the site of intradermal administration of tuberculin, a specific delayed type reaction develops in the form of an infiltrate. Tuberculin does not cause the formation of immunity. But this point of view does not explain the amplification, as with vaccination, of the reaction with frequent sampling - the so-called "Booster effect" of the Mantoux test.

Most likely, tuberculin can be characterized as a heterogeneous mixture of organic substances of varying degrees of complexity, obtained from mycobacteria. Tuberculin does not carry a tubercle bacillus, as the name might suggest. It contains only the products of her life.

The modern tuberculin preparation, in addition to tuberculin itself, contains salts of a phosphate buffer solution, sodium chloride, the stabilizer Tween-80, and phenol as a preservative. Basically, the drug is free from ballast impurities, however, it can contain them in trace amounts, which can affect the result of the reaction.

The first Mantoux is set per year

Practically healthy children and adolescents from the age of 12 months, irrespective of the results of the previous test, are subject to annual examination using the Mantoux intradermal test.

And here the contradictions begin. It is proved that the test does not make sense in children younger than 12 months, because the test result will be unreliable or inaccurate, due to age-related features of the development of the immune system - the reaction can be false negative. Children under 6 months of age are unable to adequately respond to the Mantoux test. But there is the following practice: for children not vaccinated during the neonatal period, the Mantoux test is given 2 times a year, starting from 6 months of age, before the child is vaccinated with BCG vaccine.

Button Care

After the introduction of tuberculin, a specific swelling of the upper layer of the skin is formed, better known as the “button”.

Improper handling of the sample location may affect the result of the reaction, and neither the patient nor the doctor need this. Until the moment of evaluating the results, it is not necessary to smear the button with green, peroxide. It is very important that the sample is not exposed to water or other liquids. No need to stick the wound with adhesive tape - under it, the skin can sweat. Do not let the child comb the injection site of tuberculin. After evaluating the results, if an abscess or ulcer has formed, it can be treated like any other wound, using all traditional means.

What can affect the Mantoux reaction?

The reaction of the body to tuberculin is one of the varieties of allergies. That is why existing allergic diseases can affect the result of the Mantoux test - this is both food or drug allergy, and allergic dermatitis. Recently transmitted infections, chronic pathology, immunity to non-tuberculous mycobacteria, age can affect the result of the reaction. Not the last role is played by other concomitant factors: individual characteristics of skin sensitivity, phase of the menstrual cycle in girls, balanced nutrition of the child. Even worms contribute to a positive Mantoux reaction. Unfavorable environmental factors influence the sample results: increased radiation background, harmful emissions from chemical plants.

Various violations in the methodology for its implementation can also affect the results of tuberculin diagnostics: transportation and storage of tuberculin, when using non-standard and low-quality instruments, and when there are errors in the technique for setting up and reading Mantoux reactions.

The Instructions also indicate possible individual intolerance to tuberculin, in which, logically, the Mantoux reaction is simply contraindicated (this is what I try to prove to doctors regarding my child - the temperature rises, tuberculin is injected, general lethargy, feeling unwell, upset stomach intestinal tract).

Given the above factors, in an isolated form, the positive Mantoux test alone is not 100% evidence of tuberculosis infection.

Contraindications to the Mantoux test:

• skin diseases
• acute and chronic infectious and somatic diseases in the acute stage (the Mantoux test is placed 1 month after the disappearance of all clinical symptoms or immediately after removal of the quarantine)
• allergic conditions
• epilepsy.

The test is not allowed in those teams where there is a quarantine for childhood infections - the Mantoux test is placed 1 month after the disappearance of all clinical symptoms or immediately after removal of the quarantine.

Due to the fact that the immunity generated as a result of vaccinations can affect the result of the Mantoux test, its formulation should not be carried out on the same day with any vaccinations. Otherwise, the risk of false positive reactions increases. In cases where, for one reason or another, the Mantoux test is performed not before, but after various preventive vaccinations, tuberculin diagnostics should be carried out no earlier than 1 month after vaccination.

Evaluation of the results

After the introduction of tuberculin, a specific skin tightening is formed on day 2-3. In appearance, it rises above the skin, a little reddened rounded area of \u200b\u200bthe skin, which differs from ordinary reddening to the touch by a slight seal. The more immune cells in the body that know about the tubercle bacillus, the larger the compaction will be.

The result of the Mantoux test is evaluated after 72 hours. Start with an external examination of the injection site of tuberculin. In this case, it is possible to establish the absence of a reaction, hyperemia or infiltration. You must be able to distinguish between infiltration and hyperemia. For this, the thickness of the skin folds over a healthy area is palpated, then at the injection site of tuberculin. With infiltration, the skin fold is thickened compared with a healthy area, with hyperemia the same. Then, a transverse (with respect to the axis of the arm) size of the infiltrate is measured and recorded with a transparent colorless millimeter ruler. It is not allowed to use a thermometer and other “improvised materials” for measuring, such as graph paper and home-made rulers from an X-ray film. Carefully make sure that your child is not neglected, and the evaluation of the test results was carried out by a specialist in a well-lit room, a strictly transparent ruler!

Only the size of the seal is measured. Redness around the seal is not a sign of immunity to tuberculosis or infection, but it is recorded when there is no papule.

The reaction is considered:

• negative  - in the complete absence of compaction or in the presence of only injection prick (0-1 mm);
• doubtful  - with a “button” of 2-4 mm in size and with redness of any size without compaction;
• positive  - in the presence of a pronounced seal with a diameter of 5 mm or more. Reactions with a button size of 5–9 mm in diameter are considered weakly positive; medium intensity - 10-14 mm; pronounced - 15-16 mm;
• very pronounced  in children and adolescents, a reaction with a seal diameter of 17 mm or more is considered.

When is it necessary to consult a TB specialist?

A positive Mantoux test in itself is not 100 percent evidence of tuberculosis. However, there are moments that indicate a danger:

• sensitivity to tuberculin increases from year to year;
• a sharp “jump” in which the seal increases by 6 mm or more (for example, last year the “button” was 10 mm in size, and this year it was 16);
• recent stay in a region with increased tuberculosis circulation;
• even temporary contact with a patient with open tuberculosis;
• the presence in the family of relatives who were sick or infected with tuberculosis.

In such cases, the child is referred for consultation with a pediatric TB specialist.

The reaction is considered negative in the complete absence of infiltrate (hyperemia) or in the presence of an injection reaction (0-1 mm); doubtful - with an infiltrate (papule) of 2-4 mm in size with only hyperemia of any size without an infiltrate; positive - in the presence of a pronounced infiltrate (papule) with a diameter of 5 mm or more. Reactions with an infiltrate size of 5–9 mm in diameter are considered weakly positive; medium intensity - 10-14 mm; pronounced - 15-16 mm. Hyperergic reactions in children and adolescents are considered to be reactions with an infiltrate diameter of 17 mm or more, in adults - 21 mm or more, as well as vesiculonecrotic reactions, regardless of the size of the infiltrate, lymphangitis, daughter screenings, regional lymphadenitis.

If your child has a positive Mantoux test

Under conditions of compulsory vaccination and revaccination of BCG, positive reactions to the Mantoux test can be a consequence of both infectious and post-vaccination allergies. Therefore, before deciding on the nature of the allergy, it is necessary to establish the presence and size of the skin scar at the injection site of the BCG vaccine; the time elapsed since the moment of vaccination (revaccination) and compare them with the size of the infiltrate and previous results of tuberculin tests.

A positive reaction to tuberculin in a two-to-three-year-old child may be a manifestation of post-vaccination allergy. Depending on the individual reactivity of the body, the reaction to the Mantoux test 1-1.5 years after BCG vaccination can be negative, dubious and 60% of children are positive. Positive reactions as manifestations of a post-vaccination allergy develop 6-8 weeks after vaccination and reach their greatest intensity by 1-2 years. This is due to the fact that post-vaccination immunity reaches its maximum severity by this period. Therefore, in the first two years of life after BCG vaccination, positive reactions to the Mantoux test can be from 5 to 16 mm in diameter. With a 2-4 mm scar, the duration of post-vaccination immunity is 3-4 years. It is recommended that these children be given Mantoux while taking desensitizing agents for 7 days (5 days before staging and 2 days after it).

If the Mantoux test showed a positive result, the pediatrician will refer you to a TB consultation. All influencing factors must be excluded: vaccination with BCG and other vaccines, recent infection, allergy to the components of tuberculin, allergy of unknown etiology.

The conclusion "an allergy of unclear etiology" is made in the case when it is impossible to solve the question of the nature of the allergy (infectious or post-vaccination). To clarify the etiology of allergies, children are sent to the PDD, where, after the examination, they are registered with the “O” dispensary observation group. After 6 months, the Mantoux test is repeated. If the size of the reaction remains the same or increases, the allergy is considered contagious. A decrease in sensitivity to tuberculin indicates a post-vaccination allergy.

An important sign that allows to distinguish between post-vaccination immunity and infection, as the causes of a positive reaction, is the presence of pigmentation (brownish staining of the place where the papule was) 1-2 weeks after the Mantoux test. The papule that appears after vaccination usually does not have clear contours, is pale pink and does not leave pigmentation. The post-infectious papule is more intensely colored, has clear contours and leaves pigmentation lasting about 2 weeks.

Duration after BCG vaccination	Scar size after BCG vaccination	The size of the papule when setting the Mantoux test
		Post-vaccination immunity	The reason is unclear.	Infection
				more than 17 mm
				more than 16 mm
		Doubtful		more than 12 mm
	Irrelevant	Downsizing or Old Size	2-5 mm increase in size if previous result was positive	Change to positive or increase by 6 mm

"Turn" Mantoux test  - change (increase) in the result of testing the diameter of the papule) compared with last year's result. It is a very valuable diagnostic feature. The bend criteria are:

• the appearance for the first time of a positive reaction (papule 5 mm or more) after a previously negative or doubtful one;
• strengthening the previous reaction by 6 mm or more;
• hyperergic reaction (more than 17 mm) regardless of the duration of vaccination;
• reaction more than 12 mm 3-4 years after BCG vaccination.

It is the bend that makes the doctor think about the infection that has occurred over the past year. For example, if the result of a sample over the past three years looked like 12, 12, 12, and in the fourth year a result of 17 mm was obtained, then with a high degree of probability we can talk about the infection that occurred. Naturally, in this case, all influencing factors must be excluded - an allergy to the components of tuberculin , allergy to other substances, a recent infection, the fact of recent vaccination with BCG or another vaccine for less than 1 month. back, etc.

Booster effect  Mantoux tests  - gain effect (boost (English) - gain), i.e. increasing the diameter of the papule with frequent (often more than once a year) formulation. Despite the fact that tuberculin is not a full-fledged antigen and cannot cause the formation of immunity, the effect is most likely associated with an increase in the sensitivity of lymphocytes to tuberculin. The booster effect also has a downside - individuals infected with tuberculosis bacillus lose their ability to respond to tuberculin over the years and, in the end, the test result becomes false negative. The booster effect (in both its manifestations) occurs in adolescents and adults, which is apparently due to a higher degree of development of the immune system. In children, this effect is less pronounced, however, the formulation of the Mantoux test more often than once a year without obvious necessity is not desirable. An exception to this is the need for a repeated Mantoux test (in doubtful and critical cases), which, according to Russian regulatory documents, is carried out after 3 months. from the first.

To exclude the booster effect in those infected with mycobacteria (in the presence of obvious risk factors for infection and the absence of a reaction to the Mantoux test) in the USA, it is recommended to re-test the sample after 1-3 weeks. In tuberculosis, the reaction becomes sharply positive, as if the body “remembers” its sensitivity to tuberculin.

If registered and prescribed preventive treatment

Children and adolescents with newly diagnosed tuberculosis infections have an increased risk of developing clinically severe tuberculosis - it is estimated that 7-10% of these children may develop primary tuberculosis with all its inherent symptoms. Therefore, such children are subject to observation in a TB dispensary for a year. Chemoprophylaxis with isoniazid is carried out for three months. At the end of this period, the child is placed under the supervision of a local pediatrician as "infected for more than one year."

If such a child after a year does not show signs of increased sensitivity to tuberculin and a hyperergic reaction, then he is observed by a pediatrician on "common grounds." In these children, the result of the annual Mantoux test is carefully monitored. An increase in reactions of 6 mm or more in such children indicates activation of the infection.

Those infected for more than one year with a hyperergic reaction to tuberculin and an increase in reaction of 6 mm or more are observed in the TB dispensary. Chemoprophylaxis is carried out for 3 months.

If the result of the test in a child is positive, but the previous test was carried out not one, but two or more years ago, the child is considered "infected with an unknown period of limitation." A repeat test is recommended after 6 months. According to the results of the second test, the question of the need for observation in a TB dispensary and chemoprophylaxis is resolved.

The placement of children for dispensary registration with a TB specialist is determined by the provisions of the Instructions for the organization of dispensary observation and registration by the contingent of tuberculosis institutions (Appendix No. 7 to the Order of the Ministry of Health of Russia dated March 21, 2003 No. 109, part III of the Group for dispensary observation and registration of children and teenage contingents of TB institutions) .

I especially note here that, according to the “Instructions for the Use of Tuberculin Samples,” registration of children under three years of age in Group VI (in fact, by which the treatment with special drugs is determined) is generally excluded! I quote: “All children (older than three years) who have undergone the transition of previously negative tuberculin reactions to positive ones, as well as children with increasing sensitivity to tuberculin in the presence of contact with a patient with tuberculosis, after exclusion of active tuberculosis process, are taken into account PDD for group VI ". Over three years old! This rule is specifically stipulated in the instructions, but is often violated in practice.

Let me remind you that the Mantoux test is not a 100% reliable means of diagnosing tuberculosis, and on the basis of a positive reaction alone, the diagnosis of tuberculosis cannot be made!

At the first visit to a TB doctor, you will be prescribed the following examinations - chest x-ray, microbiological sputum culture, examination of family members.

If you are prescribed a prophylactic course of isoniazid or other drugs, then require the full range of examinations required by the “Instructions for chemotherapy for tuberculosis patients”: a study of sputum and other available diagnostic material for mycobacterium tuberculosis at least three times, a blood test for antibodies to HIV, viruses hepatitis, ECG, tuberculin diagnostics (determination of the threshold of sensitivity to tuberculin, cutaneous graduated test) and a number of others.

Drugs against tuberculosis bacillus are very toxic, even in “preventive doses”, which are calculated on the weight of the child. You understand what it means to “calculate the weight” of a drug with a lot of side effects, children - they are not the same mechanisms, therefore, the risk of preventive treatment for a healthy child is very high!

The regimen and technique of chemotherapy are determined individually, taking into account risk factors. Demand a reliable assessment of your child’s health status. Check your doctor’s recommendations for taking vitamins, hepatoprotectors (drugs that protect the liver) and a special diet regimen.

Other diagnostic methods

Test Pirke  - a skin test carried out by applying a drop of old Koch tuberculin (ATK) to the skin of the inner surface of the forearm and scarifying the skin through the applied drop. After 48-72 hours, a local reaction is evaluated. Currently, the sample is practically not used due to the low standard in the formulation of the sample (different droplet size, different lengths and depths of scratches, etc.).

Graduated test Pirke  - a modified test of Pirke. 4 different solutions of tuberculin are applied dropwise to the skin of the inner surface of the forearm or the anterior surface of the thigh: 100%, 25%, 5% and 1%, and as a control, a fifth drop of 0.25% solution of carbolic acid in 0.9% NaCl solution, on which tuberculin solutions are prepared. Scarification of the skin through the applied drops is carried out, starting with the control solution and ending with 100% tuberculin. Reading the local reaction is carried out after 48-72 hours. Most often this test is used in pediatric practice.

Among other methods for diagnosing tuberculosis, some regions use   linked immunosorbent assay  (IFA), which carries information not about the disease, but about infection. ELISA detects antibodies to mycobacterium tuberculosis. Its information content is high only in countries with low morbidity and infection of the population. Sensitivity ranges from 68 to 90%, therefore, a sufficiently large percentage remains undiagnosed.

Serological studies for tuberculosis are based on the recognition of serum immunoglobulins G (IgG) - antibodies specific for mycobacterial antigens. Methods using enzyme-linked immunosorbent (ELISA) are used.

Polymerase chain reaction (PCR) technique, which has an extremely high sensitivity (about 1-10 microorganisms) and high specificity. The PCR method can improve the diagnosis of tuberculosis, make it quick and cheap, and also removes dubious diagnoses in overdiagnosis. A significant advantage of this reaction is the ability to work with a small amount of pathological material and obtain analysis results within one working day. Especially strong is the advantage of the PCR method for extrapulmonary infections. Paradoxically, the PCR method is still not accepted in phthisiology as an official diagnostic method. Unfortunately, to date, the situation is such that the results of PCR must necessarily be confirmed either by one of the officially accepted methods, or clinically.

In Yekaterinburg, the PCR method is so far only applicable to the diagnosis of tuberculosis of urogenital localization (on a fee basis in medical centers). However, you can request a referral from your phthisiatrician to the Ural Scientific Research Institute of Phthisiopulmonology (UrNIIF of the Ministry of Health of the Russian Federation), which is a co-executor of the program "Development and implementation of accelerated methods of diagnosis and early detection of tuberculosis, new technologies for treating tuberculosis patients with various localizations, reliable ways to control epidemiology »And undergo modern diagnostics for tuberculosis.

Instead of a conclusion.

This material does not pretend to be a medical scientific article, but is written as an “educational program according to the Mantoux test” by an ordinary parent on the basis of their own experience in communicating with medical specialists, as well as in the study of regulatory documents governing the scope of TB services.

Taking into account the stressful nature of the situation in which the child’s parents are diagnosed with primary tuberculosis, I urge you to weigh the pros and cons of refusing preventive treatment and follow-up care at the TB doctor. Russia, alas, a country where a virtually undeclared epidemic of tuberculosis ...

If you do not agree with the diagnosis, or have come under the case of overdiagnosis, simply reinsurance the specialist, first, connect the pediatrician to the situation. It is better if it is a highly qualified pediatrician who determines that the child is developing normally, the results of a general examination are normal, and there is no reason to suspect extra pulmonary tuberculosis (and the pulmonary is excluded according to fluorography). Second, according to the law, you have the right to refuse any treatment (Article 7, part 3 of the Law "On the prevention of the spread of tuberculosis in the Russian Federation" - on the provision of anti-tuberculosis care to minors only with the consent of their legal representatives). And the third - if a specialist refuses you for additional research (violates other provisions of the Instruction), or simply refuses to give you advice and dialogue, you can appeal against his actions in an administrative order by writing to the management of a medical institution or territorial office (department) of the Ministry of Health RF

Documents:

1. Instructions for the use of tuberculin samples (Appendix N 4 to the Order of the Ministry of Health of Russia dated March 21, 2003 N 109)
2. Dispensary observation and registration groups for children and teenage contingents of tuberculosis institutions (Instruction for the organization of dispensary observation and contingent registration of anti-TB institutions, Appendix No. 7 to Order of the Ministry of Health of Russia dated March 21, 2003 No. 109, part III).

Mantoux test is carried out in schools and kindergartens regularly. But are we all
  do we know about the “buttons” that our children put? What size should a healthy child have, and which one speaks of a positive reaction and what to do in this case?

When is the Mantoux test

The Mantoux reaction is one of the methods of screening for the presence of tuberculosis bacteria (Koch sticks) in the body and their activity.

The essence of the test is simple: a small amount of tuberculin, an extract of tuberculosis bacteria, is injected under the skin.

When the Mantoux reaction is carried out, the size of the papule formed on the third day of the tubercle indicates the presence or absence of infection in the body.

With the help of Mantoux tests, almost all healthy children and adolescents are examined every year, starting from 1 year.

Moreover examination is carried out regardless of the result of the previous test. Children who were not immediately vaccinated against tuberculosis immediately after birth are given a test twice a year, starting from six months of age. Only after the test they begin to conduct once a year.

What size should be Mantoux

If the baby is healthy, his immune system did not interfere with Koch’s wand, then the injection site (papule) will be small, no more than 5 millimeters.

If the body for some reason vulnerable  for tuberculosis, the papule may be from 5 to 10 millimeters.

Well, when is the size of the papule 15 millimeters and more, or when an ulcer appears at the injection site - most likely a person with tuberculosis.

The size of the papule after a Mantoux test in a healthy child should not be more than 5 mm. But if the result turned out to be different - this is not a reason to panic. There can be many reasons.

The reaction rate for the sample in children of different ages

Many parents whose children have a tuberculin test try to find out what size the mantle should be for the child and independently evaluate the results.

For most children  and adolescents older than 7 years of papule size after a Mantoux test no more than 5 millimeters  clearly indicates the absence of tuberculosis. But in children at an earlier age, the size of the papule can fluctuate. This is due to the fact that the immune system of a child under 7 years old is only being formed and often reacts to tuberculin more actively than in older children.

The table shows that with a negative test result, the size of the papule is 5 millimeters in children only by 7 years. And from this age, an increase in the trace of injection becomes an indicator of the presence of infection in the body.

Thus, if we evaluate, for example, the Mantoux size a child is 4 years old, the norm will be 8 mm. And such a large papule will not be an occasion to see a doctor. And if you evaluate the size of the Mantoux the child is 3 years old, the norm is already 10 mm.

Child age	Papule size with a negative Mantoux test
1 year	5-10 mm
2-3 years	5-10 mm
4 years	5-8 mm
5-6 years	5-6 mm
from 7 years old	no more than 5 mm

How to independently determine the results

If parents are worried about their child’s health and cannot wait for the doctors to examine the results of the test, they can do it themselves.

The papule is measured on the third day after the injection using a standard ruler.. The classification of test results depending on the size and nature of the papule is given above.

When measuring, it is also important to know what size Mantoux is considered the norm in children of this particular age.

Parents can independently measure the size of the papule, but in order to evaluate the result, this is not enough - you need medical experience.

Is there an allergy to Mantoux

Mantoux test may in some cases cause an allergic reaction.. An allergy to tuberculin is no different from other types of individual intolerance - it is accompanied by symptoms:

• redness and rash at the injection site and in other parts of the body;
• fever, chills (most often - in the evening after an injection);
• general weakness and loss of appetite.

  Allergy after the introduction of tuberculin into the body may occur in the evening, on the day of the injection. An allergy may be because, in addition to tuberculin, phenol is also present in the substance that is introduced into the body. If your child has intolerance to this substance, you are provided with an allergy

When such symptoms appear, the child must be shown to the doctor.

If an allergy to tuberculin is confirmed, this should first be known to the medical worker of the educational institution where the child goes.

An established allergic reaction is a contraindication to a Mantoux test, and screening for tuberculosis is carried out in other ways - through a fluorographic examination or sputum analysis.

How to care for the “button”

When conducting the test, it is very important to follow the rules for caring for the injection site. These rules are simple:

• Papule should be clean and dry.
• It is unacceptable to lubricate the injection site with iodine, brilliant green or other disinfectants, bandage or glue with a band-aid.
• It is strictly forbidden to wet the injection site  water (or other liquids) and comb to avoid introducing additional infection into weakened tuberculin tissues.

From the moment of the injection and until the result is measured, keep the injection site clean and dry, without processing or sticking.

Positive reaction what to do

If the child’s Mantoux test yields a positive result, the school or kindergarten medical officer passes this information to the local doctor, who sends the child to the clinic for analysis.

Akhmeddibirova Zulkhizhat Rasulovna, Makhachkala, TBUZ TB, Republican Dispensary, head of the children's and adolescent department, doctor of the highest qualification category.

No diagnosis is made based on the results of a single Mantoux test. And on this basis no one also takes them to a TB dispensary. If tuberculosis is suspected, then four mandatory measures are taken:

1. Analysis of the results of previous Mantoux tests.
2. Blood and urine tests.
3. X-ray examination of the child himself.
4. Fluorographic examination of the immediate environment of the child: parents, grandparents.

Tuberculosis is a serious disease, and with its treatment, strong drugs are used. Therefore, treatment can be started only on the basis of the positive results of several types of tests, in the first place, a smear for the presence of Koch's bacillus in sputum and fluorographic examination.

Side effects and complications

When carried out correctly, the Mantoux reaction does not give side effects. Complications can occur either with an allergy to tuberculin, or as a result of non-compliance with the rules for caring for the injection site.

Three main causes of complications can be distinguished.  (excluding allergies):

• combing the injection site;
• infection;
• moistening (washing or fogging as a result of gluing with a plaster).

Contraindications to the test

Like any medical intervention, mantoux test has a number of contraindications.

These include:

• skin diseases;
• any acute infectious diseases;
• an allergic reaction to tuberculin;
• allergic condition at the time of the test;
• epilepsy.

Also, contraindications to the Mantoux test include any vaccinations given on the same day for which the examination is scheduled.

Besides, mantoux test not quarantined. It must take at least a month after the cancellation of quarantine measures in order to schedule an examination.

When should I contact a TB doctor?

A positive Mantoux test is not absolute evidence of tuberculosis in a child. However, in combination with one of several factors, it becomes an occasion to visit a TB specialist. These factors are:

• gradual, from test to test, or sudden (by 6 millimeters or more) increase in papule;
• stay in an unsuccessful area for tuberculosis;
• any contact with a person with an open form of tuberculosis;
• the presence in the family or immediate environment (colleagues, neighbors in the apartment) of those who are sick or have had tuberculosis;
• non-specific symptoms of tuberculosis: night sweats, weight loss, general weakness.

If, along with a positive Mantoux reaction, at least one condition is present, you need to see a doctor.

Whatever the result of the Mantoux test, only a general practitioner can send a phthisiatrician - a general practitioner.

Murzaeva Irina Aleksandrovna, Irkutsk, MBUZ City Clinical Hospital No. 8, infectious diseases doctor.

Any infectious disease, acute or in the stage of exacerbation, is a reason to refuse to conduct the Mantoux reaction. Therefore, the doctor must measure the temperature before the test.

If the child does not feel well, and a tuberculin test is planned in the institution, parents need to warn the teacher or teacher about the condition of the child in advance.

  (one of the ways to prevent tuberculosis) is a kind of test with which it is possible to detect the presence / absence of an infection in the child's body.

The Mantoux test is carried out annually, starting from the first year of the baby's life.  This is necessary in order to ensure constant monitoring of the Koch stick, which can be activated at any time.

The specifics of the

The first Mantoux test is performed 1 year after the introduction of the vaccine (BCG) and then every year. If BCG was delayed for any reason, the Mantoux test is done longer every six months.

Sometimes, when surrounded by a year old crumbs, infected patients are present, a test is placed several times a year (at least 2 times).  How many times they will put it depends on the results of the tests and diagnostics that the baby has to go through.

If the baby is not yet one year old, it is pointless to vaccinate. This is due to the fact that under the age of 1 year, an unstable reaction to Mantoux is observed in babies, which means that it is highly likely that the result will be false. In the first years of life, immunity is formed in children, so a number of individual characteristics can affect the result of a test.

How many times do you need to put a sample? It all depends on individual characteristics, as well as on how the body responds to the drug. However, most often enough once a year.

Why vaccinate a child?

Perhaps many parents wondered if Mantoux should be done.

In fact, the introduction of tuberculin is not a vaccine, since it does not cause persistent immunity to the causative agent of the disease. A sample should be made to determine whether the body is familiar with Koch's bacillus or not.

Tuberculin is administered to:

• determine whether BCG is valid and what its capabilities are;
• identify the causative agent of tuberculosis;
• get additional information about the state of health (vaccination acts as a diagnostic test).

Technique of introduction and care

Where is the drug administered? Mantas for a child are made as follows: tuberculin is injected with a disposable syringe under the skin on the inside of the hand, from the wrist to the elbow. A papule is formed at the injection site, the diameter of which is measured using a standard ruler after 72 hours. To correctly determine the reaction to Mantoux, it is necessary after the test to follow certain rules.

Within 72 hours, after Mantoux was made in 1 year, you should adhere to some recommendations:

After the results were recorded by a doctor, you can treat the injection site with peroxide / green.

Attention! If the injection site is wet, inform the doctor who will take the measurement in advance.

Interpretation of results: norm and deviations

The first time Mantoux is done in 1 year of life, then it is repeated at 2 years of age and then every year. By this time, the vaccine (BCG) should take root, and the body to develop the required number of antibodies.

For the results in children to be accurate, you should not change the diet usual for the baby for four weeks.  It will not be superfluous to check the baby for allergens. If the results of Mantoux have raised doubts among doctors, the child will be sent to a TB dispensary to undergo a full examination.

It should also be noted that in children at this age, immunity has not yet been formed, so the reaction to the Mantoux test at 1 year may not occur.

So, what size should a papule be in children aged 1-2 years? Dimensions and reaction:

1.   in children in the first year of life - the absence of redness and seals at the injection site. For the Mantoux reaction, the norm is also the presence of a seal with a size / diameter not exceeding 1 mm.
2.   . It is characterized by the presence of clearly defined boundaries of the infiltrate - redness and swelling. The size of the papule is in the range of 2-4 mm. With this result, the presence of infected people in the environment of the child is detected. You will also need to visit the TB specialist with a crumb.
3. Positive reaction to Mantoux.  It is characterized by the presence of a tubercle with a height of more than 5 mm. As a rule, after obtaining such results, you need to do the test again.
4. Hyperergic reaction.  It is characterized by the presence of a seal with a diameter of more than 17 mm or an ulcer and an abscess. Such a Mantoux per year indicates that a large number of bacteria enter the body and there is a likelihood that a person is infected.
5. False positive reaction.  The reason may be improper care of the vaccine or the characteristics of the body.

By the nature of severity, a positive reaction to Mantoux can be:

If the tubercle is practically invisible on the skin, then in children under three years of age you can feel it. This is due to the presence of delicate skin in the child.

At this age (if Mantoux was made in 1 year of a baby's life), the vaccination result is evaluated taking into account the presence / absence of a scar after BCG vaccination. If a scar is present at the injection site, it is highly likely that the Mantoux in the child will show a positive result and this will be normal. You should consult a doctor if it is observed - the diameter of the papule will be more than 16 mm.

If there is no scar, then the vaccine did not work. In this case, if a positive Mantoux reaction is observed, it is necessary to consult a doctor.

Naturally, the Mantoux reaction in 1 year also depends on the individual immune characteristics of the baby. Sometimes it is considered normal when after the injection there is only a trace of the needle (that is, there is no redness or papules).

Negative consequences and how to avoid them

The negative consequences of the sample can be triggered by some factors. First of all, they include:

To avoid possible negative consequences from the sample, you need to know in which cases it should not be done to a child at 1 year old.

Contraindications to Mantoux:

• skin problems
• infectious diseases (especially the acute stage of the disease);
• an allergic reaction (when the baby already has an allergy to cat / dog hair, some foods and more);
• rheumatism;
• epilepsy;
• bronchial asthma;
• colds / runny nose.

It should also be noted that the reaction of the sample is influenced by:

• vaccine storage and transportation;
• individual sensitivity of the child's body;
• taking medication;
• radiation background;
• baby contact with allergens.

Like any Mantoux vaccine, it puts a strain on the immune system, which can weaken or cause complications.

Many parents are interested in the question, what is the Mantoux reaction in children 1 year old? Their excitement is understandable, because at this age the first Mantoux is made for children. Why do I need a Mantoux test in 1 year? This procedure is very important for the baby, as it allows you to control the presence of mycobacteria in the body, which are the causative agents of such a terrible disease as tuberculosis. What are the features of the Mantoux test for one-year-old children, will be discussed further.

Mantoux test in 1 year is not accidental. The fact is that at an earlier age it is useless to do it. In a child under 1 year old, the immune system is still very unstable. Accordingly, it is impossible to predict her response to the delivered test, since the probability of a false reaction is very high. In addition, in the first days of life, a child is vaccinated with BCG. One of the main goals of conducting a Mantoux test in 1 year is to control how the child develops immunity to tuberculosis after vaccination. The first such control is carried out one year after vaccination and then repeated every year.

In addition to the above goals, the Mantoux test is set in order to:

• identify children who do not have a response to the sample in order to vaccinate them in the future;
• to identify cases of a pronounced reaction that indicate that the child needs a more in-depth examination for tuberculosis.

If the vaccination with BCG was postponed, then the Mantoux test is put later and done every 6 months. In cases where in the immediate environment of the baby there are people infected with Koch's wand, the frequency of samples is also increased.

How to prepare your baby for Mantoux

The Mantoux vaccine is considered harmless to the child and relatively painless. However, in a baby with an unformed psyche, this procedure can cause serious psychological shock. Therefore, you need to carry out some preparation for Mantoux so that everything goes smoothly.

In order to prepare well for the vaccine, it is recommended:

• tell the child in an accessible form about the upcoming procedure, explaining why it is needed;
• play with the child in the hospital, simulating various medical manipulations using game medical kits;
• never scare the child with doctors, the hospital and what they can do with it;
• not to show the child his excitement, to emphasize with his whole appearance that this procedure is a completely ordinary event;
• immediately before and during the test, constantly provide the child with all-round psychological support, showing his concern for him.

In addition to the psychological aspect, preparation for Mantoux should include ensuring the normal nutrition of the child, walking in the fresh air and a benevolent emotional background, so that by the time of the procedure he would be absolutely healthy and in a good mood.

Compliance with these rules will help the baby overcome the fear of injections, which can greatly simplify visits to medical facilities in the future.

Holding Mantoux and caring for a child after her

  The Mantoux test is put by introducing a small amount of tuberculin under the skin - a drug containing neutralized fragments of tuberculosis pathogens. An injection is made on the inside of the forearm. When doing Mantoux, the child should be in a sitting position.

After the Mantoux is done to the child, to ensure maximum accuracy of the result, it is necessary to adhere to the following rules:

1. The injection site cannot be wetted. This is the main thing that can not be done after the injection. You can also not bathe in the bath, take a shower or go to the bath. But this does not mean that you do not need to follow the rules of personal hygiene.
2. Do not bandage or seal the injection site with a band-aid.
3. It is not necessary to give the child a scratch in the place where the test was placed and in the adjacent area. It is necessary in every way to distract his attention from this.
4. The child must not be allowed to come into contact with pets.
5. Do not give the baby citrus fruits, as well as fruits and vegetables that are red.

These restrictions must be valid for three days from the date of the test. It is such a period of time that must elapse before it can be evaluated. After the doctor fixes it, the sample site can be treated with hydrogen peroxide or glossed over with green.

Mantoux score in children 1 year old

The result of the Mantoux test is determined by examining the injection site. Usually there is redness and a papule is formed that resembles a button. The conclusion of doctors depends on its size. The more immune cells that are familiar with the causative agent of the disease, the more pronounced the reaction will be. Papules diameter should be measured only with a transparent ruler with a centimeter scale. The redness that occurs around the papule is usually not taken into account. It is taken into account only in cases where the papule is absent.

There are such types of Mantoux reactions:

• negative - redness and papule at the injection site are absent;
• doubtful - there is redness, but there is no papule. The diameter of the redness is from 2 to 4 mm;
• positive - there is redness and papule. Seal size - from 5 to 10 mm.

There is also a type of Mantoux reaction that is called false positive when the test gives positive results, but in fact there is no pathogen in the body. Such a reaction occurs in cases where there is an infection with mycobacterium of another species, or if the rules for the formulation of the sample are not observed.

To understand what the Mantoux reaction should be in 1 year, the size of the papule is also compared with the size of the scar that occurs on the skin after BCG vaccination.

Interpretation options for this comparison for children one year old are displayed in the table below:

The size of the scar from BCG	Mantoux papule diameter
	Vaccine response	Incomprehensible reason	Child is infected
6 to 10 mm	5 to 15 mm	16 mm	Over 17 mm
2 to 5 mm	5 to 11 mm	12 to 15 mm	Over 16 mm
There is no scar	2 to 4 mm	5 to 11 mm	Over 12 mm

Thus, the Mantoux norm in children is displayed in the second column. With the indicators displayed in the last column of the table, the patient is sent for a deeper examination for tuberculosis.

It should be borne in mind that a negative reaction in a one-year-old child does not mean that the Mantoux is normal. If it is observed in a previously vaccinated baby, then the vaccination did not give a result and there is still no immunity to the causative agent of tuberculosis. The negative reaction becomes normal only after 4 years.

You can learn more about what Mantoux should be in a year by contacting a TB doctor. He can tell about it taking into account the individual characteristics of the baby.

What you need to know about the effects of Mantoux in children 1 year old

Despite the fact that Mantoux is considered a safe event, its implementation can have certain negative consequences.

These include:

1. Low accuracy of the test result. Because of this, additional procedures can be prescribed to the patient, in particular, fluorography, which affects the child’s body not in the best way. In addition, due to a distorted test result, therapy may be prescribed that is not really necessary.
2. Poor quality of the drug. It is primarily affected by storage and transportation conditions. Not the last role is played by the manufacturer of the drug. The use of such a tool also leads to a distortion of the result with all the negative consequences. If there are doubts about its quality - three days after the introduction, the sample must be repeated at another medical institution. This will avoid unnecessary treatment.
3. Individual intolerance to the components of the drug. It can cause allergies, which can also be misinterpreted as a positive test result.

Children at the age of one year are very sensitive to various chemical compounds and additives. Many parents are concerned about phenol, which is used as a preservative in tuberculin. Sodium chloride is also not universally tolerated by everyone.

Therefore, the Mantoux test for one-year-old children is not done in such cases:

• in the presence of skin diseases;
• in cases of the presence of infectious diseases, especially in the acute stage, or if the child tolerated them less than two weeks before the procedure;
• tendency to allergies;
• with rheumatism, asthma and epilepsy;
• with problems with the immune system.

Parents should also keep in mind that Mantoux can cause side effects. The possibility of developing allergies has already been mentioned above.

In addition, the following phenomena may occur:

• temperature rise;
• general weakness;
• skin rash;
• digestive disorders;
• cough.

Knowledge of contraindications and possible side effects is mandatory for each parent. If available, you can refuse the Mantoux test. Currently, there are a number of alternative methods for diagnosing tuberculosis. Instead of a Mantoux reaction, you can do a Diaskintest or a blood test for tuberculosis.