CONTENTS




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Introduction
Tuberculosis is one of the oldest infectious diseases and was first described during the 3rd century B.C. by a Chinese doctor. New knowledge was rapidly acquired during the 20th century about the cause of this disease, its mode of transmission and treatment.

Although many centuries have passed since tuberculosis was first described, this disease continues to exist as a serious public health problem globally. A large number of children become sick from tuberculosis each year even in developed countries such as Greece. The need to provide specialized care forthese children was recognized early on and for this reason a tuberculosis (T.B.) clinic was established at our Pediatric Department by Associate Professor P. Spyridis in 1980. Since then about 3,500 children with tuberculosis or tuberculous infection have been examined. In addition, more than 10,000 children were seen at the clinic because of a falsely positive skin test for tuberculosis. The latter may have resulted from a previous BCG vaccination or because of infection with nonpathogenic (innocuous) environmental mycobacteria. A large number of children who developed BCG complications have also been examined at the Clinic during the 22 years it has been functioning.

In addition to clinical care the T.B. clinic provides telephone consultations about tuberculosis to primary care physicians and other health professionals as well as to patients and their families.

The need for the introduction of a tuberculosis screening program was realized by the staff working in the clinic in the early years of its operation. Physicians working in the clinic made a strong effort through their educational activities to promote the development and implementation of such a program. Since the early 1990’s T.B. screening has been widely accepted and applied by most pediatricians and primary health care services throughout the country. During the past decade this clinic has become a national childhood tuberculosis reference center.

The number of children of immigrant families who attend our T.B. clinic has increased considerably in recent years. It is estimated that about 47% of the patients examined at the clinic belong to immigrant families who do not have an adequate knowledge of the Greek language. Communication problems may therefore frequently arise and they may be a handicap to patient education and to compliance. It was for these reasons that the clinic took the initiative inprintingthis leaflet in different languages so that all the information about this disease as well as the instructions to patients are given in each patient’s native language.

This is a true indication of the care and interest of our Pediatric Department for the health and welfare of all children regardless of race and country of origin. I congratulate Professor Spyridis who is the Head of this Clinic for taking the initiative and I am sure that it will contribute to the earlier diagnosis and more successful treatment of tuberculosis among Greek as well as minority populations.

Andreas Konstantopoulos Professor of Paediatrics

Dear parents,
The aim of this leaflet is to answer all your questions about childhood tuberculosis. In these pages we will try to inform you about the cause of tuberculosis, mode of transmission, seriousness of this disease, diagnosis and treatment. We believe that this knowledge will contribute to your better cooperation and finally to a better end result.

The tuberculosis (T.B.) clinic of the Second Department of Pediatrics of the University of Athens operates every Thursday from 9.00 a.m. to 13.00 p.m. at the "P. and A. Kyriakou" Children’s hospital. The clinic established in 1980 and since then more than 3,500 children with a problem related to tuberculosis have been examined. The clinic is staffed by four pediatricians, Dr Mariza Tsolia, Dr Anna Yelesme, Dr Pipina Bonou, Dr Mina Valianatou and myself. The students of the Nursing School with the supervision of Mrs Maria Dagli, Professor in Nursing, provide the nursing care of our little patients.

In our hearts there is no difference if a child lives temporarily or permanently in Greece, legally or illegally. We are all ready and willing to help you solve any problem, which may be directly or indirectly related to the follow-up and treatment of your child.

If you have any questions related to the care of your child please do not hesitate to contact us on 210-7726448, every Thursday from 9.00 a.m. to 13.00 p.m and ask for the physician who is looking after your child. In case of an emergency your family physician can contact me personally, any day of the week, during working hours on 210-7726348.

Enjoy reading!
Best regards

Panayotis Spyridis
Associate Professor of Paediatrics

What is tuberculosis?
Tuberculosis is an infectious disease as old as mankind. It can attack all human body organs and causes more deaths than any other infectious disease. Tuberculosis causes about three to four million deaths each year around the world out of which 500,000 are among children.



Despite the recent progress in medicine, tuberculosis re- emerged as a global public health problem especially since 1985. The expansion of tuberculosis is more serious in Africa, Asia, S. America, the former Soviet Union and in most of the Eastern European countries. Tuberculosis is transferred from developing to developed countries mainly through immigrants who are already ill or who have been infected in their country of origin and then develop tuberculosis in the new country where they settle and live. Hardships of life, malnutrition, physical and psychological stress from leaving their country and trying to adjust to a new life are all factors that increase the risk for the development of tuberculosis in adult immigrants.

The cause and transmission of tuberculosis
Tuberculosis is not inherited but is caused by a bug called mycobacterium tuberculosis. Unlike other bacteria that cause disease right away, mycobacterium tuberculosis proliferates very slowly and for this reason once a person gets infected he/she may become ill long after transmission occurred. Although it can live for a few hours in the soil, on the floor of a room or on utensils and dishes, infection occurs through the inhalation of droplets produced by a sick adult.



Transmission to children always occurs from an adult who is sick and has active tuberculosis. Such a person produces droplets that contain a large number of mycobacteria while coughing, sneezing, talking or singing. Closed, dark rooms that are not well ventilated and have no sunlight are the ideal place for infection to occur. About 75% of children are infected from other family members while in the other 25% transmission of tuberculosis occurs after contact with friends, visitors or on public transportation. Transmission from family members is more likely to occur in young children whereas school age children are often infected from outside home contacts. Children who have tuberculosis do not transmit the disease to other children or adults. Therefore, there is no need for protective measures to be taken. The affected child can sleep, eat and play together with other children. Transmission may occasionally occur from a sick adolescent, but on this rare ocasion your doctor will warn you about the possible risk.

From tuberculous infection to tuberculosis
Once transmission of tuberculosis occurs from an adult to a child it takes about 11-12 weeks for the mycobacteria to settle in the human body. This may be shown by apositive skin test (Mantoux test or PPD test) on the forearm of the child. When the test is positive a red indurated area may be seen at the site of the injection 48- 72 hours later and its size is equal or larger than 1cm. Once a person is infected with mycobacteria these microorganisms remain in the body almost forever in a dormant state. However, they can be activated any time and overcome the immune system causing disease. If a child or adult is infected but does not receive any preventive treatment he or she may become sick from active tuberculosis during the following months or years while a low risk remains for the entire life. Children who are younger than 5 years and especially infants under one year of age have the highest risk of developing tuberculosis in the lungs or other organs. They are also more likely than older children, adolescents and adults to develop severe forms of tuberculosis such as disease of the central nervous system (tuberculous meningitis), bones and kidneys or dissemination to many organs at the same time (miliary tuberculosis). Fortunately, these severe forms of tuberculosis are very rare in Greece and account for only 6% of all tuberculosis cases. In the remaining 94% of the cases the lungs or the pulmonary lymph nodes are affected. Once preventive treatment is given to a child or adult who has been infected with tuberculous bacteria but does not have disease, the risk of becoming sickdrops to almost zero for his/her entire life. This happens if this person takes the medications without missing doses for the whole duration of treatment, as prescribed. In the case of pulmonary disease the child may have low-grade fever that usually lasts more than a week, a mild cough, anorexia, weight loss and fatigue. Such symptoms can be seen in several other diseases. More than 50% of the children appear to be well with the exception of infants who almost always develop most of the symptoms mentioned. The diagnosis of tuberculosis is made from the Mantoux skin test, the chest-x-ray and discovering an adult who is sick from tuberculosis in the child’s environment.

The search for the infected adult who transmitted tuberculosis to the child
The search for the adult with tuberculosis needs to be done with great care and thoroughness. The child’s parents must contribute to this effort. It has been estimated that it usually takes about 6-8 months before an adult with tuberculosis becomes sick and develops symptoms, however, he/she transmits the disease to others during this time. For this reason, if a child has been infected or is sick from tuberculosis all adults in the environment need to be checked with a chest-x-ray. All children and adolescents need to have a mantoux skin test. If it’s negative it has to be repeated 3 months later because they may have been infected from the same source but later than the index patient.



The search for the source of infection is critical for tuberculosis control. It is very important that once the diagnosis is made the sick person should be offered treatment. This way we help the sick individual and at the same time we interrupt the transmission of infection to other children and adults. In addition to adults who are family members other persons who have regular contact with the child need to be checked. Persons with chronic respiratory or heart problems, those with diabetes or with a history of stomach resection, patients suffering from cancer and those with AIDS are susceptible to tuberculosis. If there is a positive finding in this search please call us, so that we can advise you properly onwhat needs to be done. When treatment is given to adults with tuberculosis transmission of infection is usually interrupted within 2-3 weeks.

It must be noted that if an adult immigrant has a license to stay in the country, the diagnosis of active tuberculosis is not a reason for deportation. Health services are involved only on issues related to the patient’s treatment.

Preventive treatment and therapy
Children who have only been infected as well as children who are sick with tuberculosis need to receive treatment. The medications that are available for the prevention and treatment of tuberculosis are very effective. One of our main goals is to use safe combinations of medications and at the same time we try to keep the duration of treatment as short as possible. The medications are given all together at the same time. Some children find it fairly difficult to take drugs but most, if not all, are finally convinced to do so depending on parental efficiency and persistence. If you have difficulties with this issue, please do not hesitate to contact us.



Avoid making any changes in the medication or their dosage without first consulting a physician from our clinic. On the rare occasion that a child vomits after taking the medications or develops a rash we would like to know as well. If during our discussion at the clinic you forgot to mention that a child is taking other medication on a regular basis please call and let us know.

It is worth noting that adherence to the instructions given at the clinic will decrease the risk that your child may have from tuberculosis to almost zero. However, missing doses and non-adherence to treatment is worse than no treatment. The bacteria become resistant to the antibiotics which are no longer effective and the control of the disease becomes difficult. Compliance is of equal or even higher importance when adults are treated and for this reason we urge you to encourage them to follow their physicians instructions closely.

Tuberculous infection and tuberculosis may be cured completely if treatment is given by experienced doctors and the patients comply with their instructions.

The child’s life during treatment
With the exception of severe cases, which are uncommon, most children will have a normal life during the entire duration of treatment. He/she may eat, sleep, play and participate in sports as usual.



  • If the child becomes sick from another illness other medication can be given without interruption of the tuberculosis treatment. If the child gets sick from another serious illness please let us know.
  • The child who receives treatment for tuberculous infection or disease can usually be immunized like any other child of the same age. In case it is necessary to interrupt immunizations for one or two months we will let you know.
  • Please keep your clinic appointments as they are written on the white card you were given and do not forget to bring all previous chest-x-rays with you.
  • You do not have to make an appointment to come to the clinic. Your next appointment is written on the small white card you were given during your last visit.
  • If you had any questions about the instructions you were given at the clinic please do not hesitate to discuss it with us until everything is clear.
  • If you have problems taking the day off from work we can assist you by examining your child first. Finally, if its difficult to find your child’s medication at your local pharmacy, you can ask anyone from our staff for advice.

  • The vaccine against tuberculosis (BCG vaccine)
    The complications of BCG vaccine are not serious or life threatening. Occasionally a little sore may appear on the arm at the site of injection that may fail to heal for more than 6-7 weeks or swollen lymph nodes may be palpated in the underarm region or above the collar bone at the same side. It must be noted that the vaccine does not provide full protection like other vaccines. A vaccinated child may become sick from tuberculosis if he or she comes in contact with an adult who suffers from the disease. For this reason, vaccinated children who come in contact with an infected adult must be examined and checked.

    Protection of children who have had contact with tuberculosis
    These instructions concern children who may have come in contact with a patient who has active tuberculosis and is transmitting the disease but they have a negative mantoux skin test. In this case the Mantoux skin test needs to be repeated in three months to see if the child was actually infected or not. The reason is that it may take up to three months for this test to become positive since infection was transmitted. The child should not be vaccinated with BCG because vaccination itself may turn the skin test positive. Thank you for your cooperation

    Images from Greece...