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Clin Infect Dis. 2018 Nov 20. doi: 10.1093/cid/ciy987. [Epub ahead of print]

High Prevalence of Active and Latent Tuberculosis in Children and Adolescents in Tibetan Schools in India: The Zero TB Kids Initiative in Tibetan Refugee Children.

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Center for TB Research, School of Medicine Division of Infectious Diseases, Johns Hopkins University, Baltimore, USA.
Division of Tuberculosis, Tibetan Delek Hospital, Dharamsala, India.
Tibetan Children's Village School, Dharamsala, India.
Department of Health, Central Tibetan Administration, Dharamsala, India.
Department of Family Medicine, University of Wisconsin, Wisconsin, USA.



Tuberculosis prevalence is high among Tibetan refugees in India, with almost half of cases occurring in congregate facilities, including schools. A comprehensive program of tuberculosis case-finding, and diagnosis and treatment of TB infection (TBI) was undertaken in schools for Tibetan refugee children.


Under the Zero TB Kids program, schoolchildren and staff in Tibetan schools in Himachal Pradesh, India, were screened for tuberculosis with an algorithm using symptom criteria, chest radiography, molecular diagnostics, and tuberculin skin tests. Individuals with active TB were treated and those with TBI were offered isoniazid-rifampicin preventive therapy for 3 months.


From April 2017-March 2018, 5391 schoolchildren (median age: 13 years) and 786 staff in 11 Tibetan schools-7 boarding- and 4 day-schools-were screened for TB. Forty-six TB cases, including one multidrug resistant, were found in schoolchildren, for a prevalence of 853/100,000. Extensively drug resistant-TB was diagnosed in one staff member. The majority of cases (66%) were subclinical. TBI was detected in 930/5234 (18%) schoolchildren and 334/634 (53%) staff who completed testing. Children in boarding-schools had a higher prevalence of TBI than children in day-schools [915/5020 (18%) vs 15/371 (4%), p<0.01]. Preventive therapy was provided to 799 of 930 (86%) schoolchildren and 101 of 334 (30%) staff with TBI; 857 (95%) people successfully completed therapy.


TB prevalence is extremely high among Tibetan schoolchildren. Active case finding using radiography, skin-testing, and molecular diagnostics is effective. A high uptake and completion of preventive therapy for children was achieved. With leadership and community mobilization, TB control is implementable on a population level.


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