A CAJM article on tuberculosis testing among Zimbabwean  black African children.In African countries tuberculosis remains one of the major health problems. Tuberculin testing is widely used as a screening test for its detection and B.C.G. vaccination is one of the means for its control. The present investigation was undertaken in order to determine in one area of Rhodesia the extent of B.C.G. vaccination, and also toy means of the Heaf Test to compare tuberculosis in the vaccinated and the un-vaccinated and the degree to which tuberculin sensitivity as measured by this test and in this particular population is modified by malnutrition

Kendall, A.C.

Mackintosh, Mary

Central African Journal of Medicine

English

IDS OpenDocs

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Tuberculin Testing in 
African Children
BY
' MARY MACKINTOSH
AND
A. C. KENDALL*
Department of Paediatrics, University of Rhodesia.
In African countries tuberculosis remains one of 
the major health problems. Tuberculin testing is 
widely used as a screening test for its detection 
and B.C.G. vaccination is one of the means for its 
control. The present investigation was undertaken 
in order to determine in one area of Rhodesia the 
extent of B.C.G. vaccination, and also toy means 
of the Heaf Test to compare tuberculosis in the 
vaccinated and the unvaccinated and the degree 
to which tuberculin sensitivity as measured by this 
test and in this partcular population is modified 
by malnutrition.
M ethods
A total of 1,036 children whose ages were from 
birth to 14 years were observed. These children 
were those attending schools or well baby clinics 
in the Wedza district, but were otherwise un­
selected. Each child was Heaf tested using 
undiluted P.P.D. and the reaction was inspected 
three days later. The result was recorded by grade 
of reaction as originally proposed by Heaf 
(1951):
. Grade 0 =  No induration.
Grade 1 =  Induration around at least 
four punctures.
Grade 2 =  Coalescence of induration to 
form a ring.
Grade 3 =  As Grade 2 but also with in­
duration within the ring.
; Grade 4 =  As Grade 3 but also with 
blistering.
The child’s age, sex and weight were recorded and 
also the presence or absence of a B.C.G. scar. 
Table I shows the age distribution of the children 
examined and the numbers at each age who had 
previously received B.C.G. vaccine. Table II gives 
the numbers and percentages in each Heaf grade 
in the vaccinated as compared with the unvaccin­
ated; Columns A and B refer to post-vaccinal 
Heaf reactions recorded by other observers which 
will toe mentioned during the discussion. Table III
* Present address, Coventry and Warwickshire Hospital, 
England.
Vol. 17. N o. 11. N ovember, 1971. T h e  Central African
J ournal of M edicine
Table I
T otal N umber of Children at Each Age Showing the 
N umbers and P ercentages Previously Vaccinated w ith  
B.C.G.
Age Group Total No.
B.C.G.
Pos.
B.C.G. Pos. 
% of Total
0-11/12 Mths. 41 0 0
1-1 11/12 Mths. 23 2 8
2-2 11/12 Mths. 34 2 5
3-3 11/12 Mths. 24 1 4
4 Years 23 2 8
5 Years 24 2 8
6 Years - 20 4 20
7 Years 118 15 . 13
8 Years 118 13 11
9 Years 141 32 23
10 Years 140 44 32
11 Years 139 36 26
12 Years 88 26 29
13 Years 81 19 23
14 Years 22 1 5
1,036 199 11.5
gives a breakdown of Table II into the age groups 
0-4 years, 5-9 years and 10-14 years. In Table IV 
in the vaccinated and unvaccinated separately a 
comparison is made between the nutritional status, 
the weight of the child being expressed as a per­
centile on the Boston Growth Charts and the Heaf 
Grade.
R esults and  D iscussio ns
Of a l  children examined, 11.8 per cent, showed 
evidence of B.C.G. vaccination, a figure which was 
lower than had been anticipated. Table II shows 
the Heaf reaction in the vaccinated as compared 
with the unvaccinated children. In those who had 
not received B.C.G., 40.5 per cent. Showed no sensi­
tivity to tuberculin, while from Table III it will be 
seen these negative reactors comprise a diminish­
ing percentage with advance in age. In the 0-4 year 
group 81 per cent, at that age were non-reactors, 
while of the age group 10-14 years, 21 per cent, 
were non-reactors. Over the same age ranges the 
percentage of children reacting at- each Heaf grade 
increased, so that with increase in age there was 
an increase in tuberculin sensitivity.
However, even in the 10-14 year group 91 per 
cent, had a Heaf reaction of Grade 2 or less and 
71 per cent, a Grade 1 or 0 reaction. This low 
grade sensitivity to tuberculin has been investig­
ated in many countries by means of' differential 
Mantoux testing in which the response to tuber­
culin prepared from Mycobacterium tuberculosis 
is compared with the response to tuberculin pre­
pared from a number of different atypical myco­
bacteria. Ogbuni (.1969) carried out such a study 
in Nigeria using antigens obtained from nine types
229
N ovember, 1971. TUBERCULIN TESTING T h e  Central African
J ournal of Medicine
Table II
H eaf Reactions in  the B.C.G. Vaccinated and 
U nvaccinated
(C olumns A & B R eports of Previous I nvestigators)
B.C.G. Positive B.C.G. Negative
Grade No. % A B No. ■ %
0 33 16.5 1.1 57 339 40.5
1 93 46.7 77.8 18 334 39.9
2 50 25.1 17.8 22 121 14.4
3 18 9.0 3.3 3 36 4.3
4 5 2.5 0 0 7 0.8
of atypical mycobacteria and was able to demon­
strate that low grade reactors to tuberculin de­
rived from M. tuberculosis showed a greater 
degree of sensitivity to one or more tuberculins 
derived from atypical mycobacteria. There is now 
general agreement that in persons who have not 
received B.C.G. vaccine, low grade sensitivity to 
tuberculin 'is usually the result of a previous and 
in most cases a subclinical infection with these 
atypical mycobacteria.
The degree of tuberculin sensitivity following 
vaccination with B.C.G. has been studied by many 
investigators. For comparison with our results the 
figures obtained by the British B.C.G. Control 
Centre for 1967 (Irvine, 1969) are shown in Table 
II Column A and in Column B the results obtained 
by Carruthers working in Australia (Carruthers, 
1969). Both these investigations show that tuber­
culin sensitivity following B.C.G. vaccination is 
almost always of low grade. In neither of these
series was a Grade 4 reaction recorded and only 
three per cent, showed a Grade 3 reaction. In our 
series the B.C.G. vaccinated children showed a 
similar preponderance of low grade reactors and, 
as in the case of the unvaccinated group, there was1 
an increase in tuberculin sensitivity with increase 
in age as shown in Table III.
The reasons for this observed increase in tuber­
culin sensitivity with increase in age are similar in 
the two groups; with increasing age there will be 
an increase in tuberculin sensitivity because of in­
fections with M. tuberculosis and atypical myco­
bacteria. Although B.C.G. vaccination confers an 
80 per cent, protection against alinicai tuberculosis 
(British Medical Research Council, 1963), it does 
not prevent infection which will be manifest by a 
sharp increase in tuberculin sensitivity (Springett, 
1969). Thus when B.C.G. vaccinated persons are 
infected with M. tuberculosis there will be an in­
crease in tuberculin sensitivity both in the 80 per 
cent, who show no evidence of cilinical disease and 
the 20 per cent, who do. Sensitivity to M. tubercul­
osis and the sensitivity due to B.C.G. are therefore 
additive and the same applies to allergy to atypical 
mycobacteria. Thus in a particular child the degree 
of reactivity to tuberculin may be the result of pre­
vious B.C.G. vaccination, infection with M  tuber­
culosis and infection with atypical mycobacteria 
singly or. in combination.
Various conditions may cause a depression of 
sensitivity to tuberculin. These include the effects 
of malnutrition which has been studied by Har-
• Table III
H eaf R eactions According to Age in  th e  B.C.G. Vaccinated as Compared w ith  the U nvaccinated
B.C.G. POSITIVE
Age Group
Grade 0 Grade 1 Grade 2 . Grade 3 Grade 4
TotalNo. . % No. % No. % No. % No. %
04 2 28.0 5 71.0 — — — — — — 7
5-9 16 24.6 25 38.0 16 24.6 7 10.7 2 1.5 66
10-14 ' 15 11.9 63 50.0 34 . 26.9 11 8.0 3 ' 2.3 126
Total 33 93 50 18 5 199
B.C.G. NEGATIVE
Age Group
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4
TotalNo. % No. % No. % No. ' % No. %
04 112 81.1 23 .13.8 3 2.1 — — — — - 138
5-9 155 43.6 136 38.3 48 13.5 14 3.9 2 0.5 355
10-14 72 20.9 175 50.8 70 20.0 22 6.5 5 1.4 344
Total 339 334 121 36 7 837 .
230
November, 1971. TUBERCULIN TESTING T h e  Central AfricanJournal of M edicine
land and Brown (1965) and Harland (1965). 
These observers studied children up to the age of 
three years and reported a reduction in the size 
of induration occurring in response to Mantoux 
testing in previously B.C.G. vaccinated children 
who showed no evidence of malnutrition other 
I than that they were below 80 per cent, of their ex- 
| peoted weights. Table IV shows the grade of Heaf 
] reaction' correlated with the nutritional state, the 
j children being grouped into those below the third 
j percentile, from the third to twenty-fifth percent- 
j ile to the fiftieth percentile and above the fiftieth 
percentile. In the previously vaccinated group 
there are no differences between the percentages 
in each group who show a strong (Grade 3 or 4 
reaction) to Heaf testing. However, in those who 
had not received B.C.G. vaccination there is a pro­
gression from the children below the third per­
centile, three per cent, of whom had a Heaf re­
action of Grades 3 or 4, to seven per cent, in those 
over the fiftieth percentile who showed this degree 
of sensitivity. This finding, however, does not 
reach the level of statistical significance as it did in 
the series reported by Harland and Brown. These 
latter observers, however, showed that the reduc­
tion in tuberculin sensitivity in malnourished 
children was not absolute, but could be overcome 
by increasing the intradermal dose of tuberculin 
from 2 T.U. to 20 T.U. Heaf testing is known to
be of about the same degree of sensitivity as this 
higher dosage of tuberculin used in the intra- 
dermai test, so that a maximal reaction would be 
expected to occur in children in our series and 
thus the effect of malnutrition would not be ap­
parent.
In a particular child the observed degree of 
sensitivity to tuberculin is the result of those fac­
tors which bring about tuberculin sensitisation on 
the one hand, and on the other hand those factors 
which are capable of causing a depression of re­
sponse. Tuberculin sensitivity may result from 
B.C.G. vaccination, infection with M. tuberculosis 
and also atypical mycobacteria either singly or in 
any combination. Factors which depress tuberculin 
sensitivity include malnutrition, recent infection 
with measles and to a lesser extent poliomyelitis 
and chicken pox, hypothyroidism, Hodgkin’s dis­
ease and sarcoidosis, treatment with glucocorti- 
costeroids and overwhelming tuberculous infec­
tion. It also suggested that non-spedifie anergy 
may exist since occasionally known cases of tuber­
culosis other than Chose with the above-mentioned 
complications may show a failure to react to 
tuberculin (Rosenberg and Gottlieb, 1968).
Summary
In 1,036 children Heaf testing was carried out 
and the result related to age, nutritional status and 
the presence or absence of previous B.C.G. vac-
Table IV
H eaf R eaction R elated to N utritional Status 
B.C.G. NEGATIVE
Nutritional
Status
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Total
Grade 3 & 4 
Combined
No. % No. % No. % No. ' % No. % Number No. %
3% 94 44.0 77 ' 36.0 34 16.0 6 2.0 i 0.4 212 7 3.0
/■  3-25% 87 42.0 78 38.0 31 15.0 7 3.0 i 0.4 204 8 3.0
25-50% 82 38.0 95 44.0 25 11.0 10 4.0 3 1.3 215 13 6.0
. 50+% 76 36.0 84 40.0 31 15.0 13 6.0 2 0.9 206 15 7.0
Total 339 40.5 334 39.9 121 14.4 36 4.3 7 0.8 837 43 5.0
B.C.G. POSITIVE
Nutritional
Status
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Total
Grade 3 & 4 
Combined
No. % No. % No. % No. % No. % Number No. %
3% 6 10.0 34 57.0 13 22.0 4 , 6.0 2 3.0 59 6 10.0
3-25% 6 11.0 25 49.0 14 27.0 6 11.0 0 0.0 51 6 11.0
- 25-50% 11 28.0 12 30.0 10 25.0 3 7.0 3 7.0 39 6 15.0
50+% 10 20.0 22 44.0 13 26.0 5 10.0 0 0.0 50 5 10.0
Total 33 16.5 93 46.7 50 25.1 18 9.0 5 2.5 199 23 11.0
V ol . 17."No. 11. N ovember, 1971. T h e  Central African
J ournal of M edicine
cination. The observed pattern of tuberculin sensi­
tivity is described, compared with the reports of 
previous investigations and discussed in the light 
of factors known to promote and depress tuber­
culin sensitivity. The Heaf test when recorded by 
grade of reaction and related to those factors 
known to induce or diminish tuberculin sensitivity 
remains a valuable diagnostic investigation both 
in children who have received B.C.G. vaccine and 
in the unvaccinated.
REFERENCES
British Medical Research Council (1963). Brit. med. J„
1, 973.
Carruthers, K. J. M. (1969). Tubercle, Lond., 50,
22.
Harland, P. S. E. G., and Brown, R. E. (1965).
E. Afr. med. J., 42, 233.
H arland, P. S. E. G. (1965). Lancet. 2, 719.
H eaf, F . (1951), Lancet, 2; 151.
I rvine, K. N. (1969). Tubercle, Lond. 50, 177.
Ogbuni, O. (1969). Tubercle, 50, 356.
R osenberg, M., and Gottlieb, R. P. (1968). Pediat.
Clin. N. Amer., 15, 513.
Springett, V. H. (1969). Tubercle., Lond., 50, 159.
Acknowledgment
These investigations were carried out under the 
direction of one of us (M.M.) by the following 
students during their period of study at Wedza: 
B. L. Holt (now Dr.), Miss S. A. Henry (Mrs. 
D. C. Emmanuel), O. S. Chidede and M. F. M. 
James, and to whom we express our grateful 
thanks. We are also grateful to Dr. W. M. Castle 
for her help with the statistical analysis.
Swimmer’s Nose
BY
J. C. J. STOKE
Department of Social and Preventive Medicine, 
University of Rhodesia.
I ntroduction
One of the great delights found in the study of 
occupational health is the variety of descriptive 
terms which so eloquently link an occupation with 
its disability. Terms such as jeep’s bottom, writer’s 
cramp and arc welder’s eye come readily to mind.
In the sphere of athletic endeavour, however, 
there is a paucity both of eponyms and recorded 
disability except for tennis elbow and athlete’s 
foot.
Recently I had the privilege of acting as honor­
ary physician to the Midland’s team competing in 
the Rhodesian Swimming Championships. Follow­
ing a study of the team, I wish to draw attention 
to a condition which, in the Rhodesian context, 
I believe potentially to be of great importance — 
that of “Swimmer’s Nose”.
T he Study
The team consisted of 16 Europeans, of whom 
five were girls. Their ages ranged from 12 to 19 
years. Although all had been swimming since the 
beginning of summer, for the month prior to the 
championships they had been training daily, some 
for as many as five hours a day. I examined the 
skin of the nose of each swimmer and catergor- 
ised the results as shown in the following table: 
It is interesting to record that all three swim­
mers in Category 4 specialised in backstroke 
where, of course, exposure to the isun is maximal. 
Moreover, one backstroke swimmer who at the 
time of this survey was placed in Category 3 had 
presented earlier with a Category 4 nose which, 
however, had quickly regressed with treatment.
Table I
Exam ination  of Sk in  of N ose 
N umber of Sw im m ers  S urveyed: 16
Category Condition of Skin of Nose Swimmers
1 Normal 0
2 Erythema only 6
3 Erythema and desquamation 7
4 More severe than Category 3 
with the presence of pits or 
nodules.
3
D iscussion
Considerable publicity has recently been given 
to the risk of skin cancer developing in those con­
tinuously exposed to the sun. It has been sug­
gested that young people should be encouraged 
either to avoid direct sunlight or to wear hats 
when exposed to it. For swimmers this is, of 
course, impossible. All of them, and particularly 
those specialising in backstroke, must, during 
their training, spend considerable time directly 
exposed to the rays of the sun.
It is, however, possible to minimise the effects 
of this exposure in two ways. In the first place, 
swimmers whilst resting during training should 
not be directly exposed to the sun. In particular, 
the skin of the nose should be in the shade. Sec­
ondly, it is my experience that the regular use of 
a sun barrier cream provides not only good pro­
tection for the nose, but that with its constant 
use regression of swimmer’s nose will quickly 
occur.
Conclusion
Although swimmer’s nose is an entity found 
dn only a small group of people, because of the 
undoubted potentially severe sequela of skin 
cancer, considerable attention should be paid to 
its treatment and, above all, its prevention.
232
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Tuberculin Testing In African Children

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Tuberculin Testing In African Children

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