We wrote a letter to the child at school refusing Mantoux. Now the child is being sent to a tuberculosis clinic.

A phthisiatrician and Mantoux are the necessary steps for a child to enter kindergarten or school if the reaction turns out to be positive or questionable. But the main thing is that the test and the specialist will help identify tuberculosis or rule out the disease. If the test is carried out once a year for vaccinated children and twice for unvaccinated children, it is negative and a specialist is not needed at all.

The pediatrician will send you to the doctor for examination and for a certificate when tuberculin was not administered to the child. You can refuse the test and the TB doctor, but it is better for the parent to make a statement in writing. True, in these cases the child will not be accepted either into school or kindergarten.

Why and when do you need a phthisiatrician after Mantoux?

After Mantoux, a phthisiatrician should not always examine the patient, but only if there are alarming signs:

• A positive reaction to the test was detected, that is, the papule formed after the test is larger than the standard size. This may mean that the body is highly susceptible to tuberculosis or already has the disease. The same thing happens with allergies, but this needs to be clarified.
• Additional increase in papule after repeated testing. This happens if the disease already exists. But this is also not observed in all cases. The real reasons for referral to a specialist may be different, and they can only be discovered after additional tests.
• The appearance of signs of suppuration and tissue necrosis at the site of the test. These phenomena in themselves require the intervention of a doctor, and parents should not doubt the need for additional examination and ask why they were sent to a TB specialist.
• A long-lasting reaction, that is, redness and elevation above the skin at the injection site for 4 years. In this case, there may be no infiltration.

Positive Mantoux test
If a child has been referred to a phthisiatrician, additional tests should be expected for the patient, as well as his family members if they live in the same apartment. And their results will not necessarily reveal tuberculosis. A non-standard reaction to the introduction of tuberculin occurs with a tendency to allergies, as a response to the BCG vaccination. It is also worth knowing that this test is not 100% informative.

And if a predisposition to tuberculosis is accurately identified, the patient is registered with a specialist and a course of therapy is prescribed. After this, it is necessary to undergo a new examination.

We recommend reading about what to do if you have made Manta, but it is not visible. From the article you will learn why a child does not have a reaction to Mantoux, what to do if Mantoux has disappeared. And here is more information about whether it is dangerous for a child to scratch Mantu.

What to do if a referral is issued

If Mantoux is suspicious, a referral to a phthisiatrician is obtained from a pediatrician at the children's clinic. Then you need to:

• make fluorography of all family members living in an apartment with a child, if the previous photographs are more than a year old;
• collect documents, that is, a statement of the results of a test for tuberculosis, vaccinations, including BCG, blood and urine tests, a medical insurance policy, a report on existing chronic diseases, fluorography results of the immediate environment of a small patient;
• make an appointment and come to the specialist with your child.

Examination of a child by a phthisiatrician
Referral to a phthisiatrician always means the subsequent conduct of Diaskintest, that is, the introduction of a tuberculosis allergen to the patient, which more accurately shows the presence or absence of bacteria in the body. If the result is positive or questionable, an appropriate diagnosis is made.

The patient is registered with a phthisiatrician, a chest X-ray, CT scan is taken, and sputum or saliva is taken for analysis. Then anti-tuberculosis treatment is prescribed in a hospital or at home. The latter depends on the form of the pathology.

Do they send without X-ray and Mantoux?

If Mantoux was not performed, an X-ray was not performed, a TB doctor, or rather a conclusion from him, may be required to register the child in a kindergarten or school. A certificate from this doctor is needed indicating that the baby does not have tuberculosis. A TB doctor without X-rays and Mantoux will be required, even if the child was vaccinated against tuberculosis at 5 days of age. After all, BCG must be repeated in the 7th year, and this is only possible if it is known for sure that the child does not have an infection.

The latter is detected by alternative methods, not necessarily with the help of an image or injection of tuberculin under the skin.

Visits to the doctor after Mantoux

What to do if you receive a referral to a phthisiatrician after Mantoux?

For certain results after Mantoux, a visit to a phthisiatrician is mandatory.

To do this, it must be revealed:

1. Positive reaction of the body to the test.
2. The body's reaction to Mantoux, which exceeds the permissible limits many times.
3. Increased size of papules after Mantoux. If the dimensions exceed 0.6 cm.

For the doctor, you need to have the following documents and test results with you:

• results of all vaccinations performed;
• the results of the Mantoux that were carried out up to this point, necessarily with dates;
• tell the doctor about contact with a patient with tuberculosis, if any;
• fluorographic examination results;
• information about all past complex diseases or allergic reactions;
• entries in the card about visiting a TB specialist earlier;
• results of urine and blood tests;
• results of consultations with a specialist, if required.

In order to make a decision about the reasons for the increase in papules after Mantoux, it is necessary:

1. Determine the intensity of the Mantoux reaction, the results are entered into the form.
2. Determine how many times BCG was done and give the results to the doctor.
3. Determine the size of scars after vaccination.
4. The time that has passed since the test and vaccination.
5. Determine whether the child has had contact with an infected person.
6. Determine what symptoms your baby has.

In what case after the Mantoux reaction can tuberculosis be diagnosed:

• there is a positive reaction to the test, in which the papule is at least 0.5 cm, provided that it was done for the first time and BCG vaccination has not been used before;
• if children with a positive reaction to the test are found to be stable in this situation for 5-6 years;
• gradual increase in papules with a tuberculin test over several years.

An increase in sensitivity in patients to a tuberculin test with their manifestation on the skin and increased allergies, the number of infectious diseases, and frequent colds may not be associated with the development of tuberculosis bacteria.

Such patients should be observed by a pediatrician. Children need to be examined periodically, but at least once every 3 months. If no changes are observed, the patient is registered at the dispensary.

Will they give me a certificate from a TB doctor without Mantoux?

A certificate from a phthisiatrician without Mantoux can be obtained if other studies have been performed to confirm that the child does not have tuberculosis. But parents will most likely have to pay for them themselves, since in medical institutions disease prevention is carried out according to a certain protocol. And expensive research methods are not prescribed simply at the request of a small patient’s representative.

Instead of Mantoux, the phthisiatrist will take into account:

• Diaskintest . This specialist himself can prescribe it, even under the policy. But the test result will be obtained only 3-4 months after it is carried out, while tuberculin provides information in 2-3 days.
• T-Spot . This method is expensive and accurate, but it is not possible to perform it in all regional and regional hospitals in Russia, not to mention city and district hospitals.

Theoretically, you can get a certificate from a phthisiatrician without Mantoux without all these studies, if the child has no symptoms of the disease and his contact with a patient with tuberculosis has not been identified. But the doctor prescribes it at his own peril and risk, because he is responsible for the possible negative consequences. In some regions of Russia this is possible.

But where the situation with tuberculosis is serious, there is a high incidence of tuberculosis, you should not count on receiving a document from the words of parents and on the basis of an examination. The doctor has the right to refuse to call an unexamined baby healthy only because he does not yet cough or have a fever.

Description of Mantoux

If Mantoux is 13 cm, is it referred to a phthisiatrician?

Mantoux is an integral part of preventive measures to detect and prevent tuberculosis. What happens in the body when tuberculin is administered?

• when tuberculin is administered, a slight inflammation begins;
• lymphocytes and antibodies are involved in this process;
• harmful microorganisms begin to attract lymphocytes, but they have a certain resistance to these bacteria;
• with a strong reaction, it can be assumed that the patient is infected with tuberculosis;
• The body's reaction is determined depending on the size of the Mantoux.

With this help, the body’s tendency to develop a complex disease is revealed.

How does the sample affect the body?

The tuberculin test has been used for a very long time. With its help, a diagnosis is made. To date, the effect of administered tuberculin on the body is still unknown.

Properties of tuberculin:

1. It is not considered a toxin.
2. It is not an antibody and does not contribute to their formation.
3. Many experts consider it an imperfect antigen.
4. A response occurs only in patients whose bodies have increased sensitivity to tuberculosis or the BCG vaccine.
5. Tuberculosis allergen in standard dilution does not contribute to the development of immunity to tuberculosis.
6. Tuberculin is a mixture of organic substances that were obtained from bacteria. It does not contain tuberculosis bacillus. It contains the substances of their vital activity.
7. It also additionally contains phosphate salts, sodium chloride, Tween-80, and phenol.
8. It is usually free of any impurities that could alter the results of the study.

The first time Mantoux should be done at the age of 1 year, but until this moment the newborn’s immunity is very weak and he can become an easy target for infection. Some experts claim that samples taken earlier will not be true. At the moment of formation of the immune system, Mantoux results are distorted.

But all the same, if the child was not vaccinated at birth, then a tuberculin test is done at the age of 6 months and one more time before vaccination against tuberculosis.

Do I need a certificate for school?

A certificate from a TB doctor for a school without Mantoux is usually required by the management of the educational institution. The school director does this on the basis of clause 5.7 of section V SP 3.1.2.3114-13 “Prevention of tuberculosis”:

Children who have not undergone tuberculin diagnostics are admitted to the children's organization if they have a phthisiatrician's conclusion that they do not have the disease.

Otherwise, the educational institution has the right to refuse to admit the child. This was confirmed by the decision of the Supreme Court of the Russian Federation.

Such a certificate from a TB doctor without performing a test and x-ray can be issued by a doctor on the basis of Diaskintest, T-Spot or without them. It is also necessary to provide the results of fluorography of the child’s relatives living with him in the same apartment. It is unlikely that a doctor would issue a conclusion without supporting documents, simply by looking at the patient or from the words of the parents.

Watch this video about whether a child can attend school without Mantoux:

Will the TB doctor give a certificate to the kindergarten without a button?

A phthisiatrician can give a certificate to a kindergarten without Mantoux if he has confirmation that the child does not have an infection or its mycobacteria:

• the little patient underwent Diaskintest, it was negative;
• with positive ATP, but good results of computed tomography of the chest.

In regions where the situation with the incidence of tuberculosis is quite favorable, a specialist can give a certificate that the child is healthy, and only on the basis of an examination, a survey of parents, and also studying the results of their fluorography. And if the baby does not have a cough, shortness of breath, fever, weakness, excessive sweating, that is, symptoms that allow one to suspect an active form of tuberculosis, a certificate will be issued. When receiving it, contact between the baby and the patient should also be excluded.

What are the consequences of refusing Mantoux and a phthisiatrician?

Refusal from Mantoux and a TB doctor must be formalized in writing; the law allows this, because medical care must be provided voluntarily. After the pediatrician explains to the parents the consequences of such a step, the document is drawn up and filed with the child’s medical record. If relatives do not allow a test for tuberculosis and do not take the baby to a specialist, but do not formalize this in writing, then a verbal refusal:

• is still recorded in the medical documents of the small patient;
• confirmed by the signatures of two employees of the medical institution.

After this, the parent may be called to a medical commission to find out the reasons for this decision and offer alternative screening methods. This is, for example, Diaskintest or T-SPOT. This algorithm is prescribed in methodological recommendations intended for specialists.

But in reality, if the child has no alarming symptoms, the family is prosperous, there are no cases of tuberculosis in the environment, everything ends with the parent’s refusal to have the child examined. There will be no sanctions, but the pediatrician will not issue a certificate for the kindergarten. He will not be able to formalize it without the conclusion of a specialist.

A parent’s refusal to see a pediatric phthisiatrician and Mantoux in case of clinical symptoms of tuberculosis in a child, poor living and material conditions of the family, or an identified disease in his environment will lead to an immediate appeal by doctors to the guardianship authorities. A minor can be seized and sent for examination without the consent of the parents, which in this case violates his rights.

Will the child be accepted into kindergarten?

They have the right not to accept a child into a kindergarten without Mantoux and a TB doctor. The possibility is specified in clause 5.7 of SP 3.1.2.3114-13 “Prevention of tuberculosis”.

After all, there are other children who go to kindergarten, who need to be protected from contact with the infection, the carrier of which may be an untested child.

Will the child be accepted to school?

They also have the right not to admit a child who has not been examined for tuberculosis to school without a certificate from a specialist. The same paragraph of the Decree applies here.

Parents will have to show their son or daughter to a doctor, perhaps perform alternative tests for MTB, in order to obtain a certificate. If they do not want to do either one or the other, they can contact the prosecutor's office with a statement that the child is not accepted into school. But they should know that there is a decision of the Supreme Court of the Russian Federation dated February 17, 2015 that the requirement of a certificate from a TB doctor by a child care institution does not contradict the law.

Watch this video about what laws protect a child’s right to attend school and kindergarten without Mantoux:

Evaluation of results

Why do they send to a phthisiatrician after Mantoux?

True results are obtained on the 3rd day after the tuberculin test. The doctor measures the size of the lump and determines whether the area with the sample has turned red, especially if a papule has not formed there. In this case, a note is made about this in the patient’s medical record.

By what criteria is Mantoux assessed and the patient is sent for consultation to a phthisiatrician?

• an increase in the papule after Mantoux, if it exceeds 1.7 cm. Even when there is tissue necrosis in this place or suppuration has appeared. Particular attention is paid to patients with any abnormal results of the tuberculin test that was done before. Perhaps during this time tuberculosis has already begun to develop in the child’s body;
• a positive reaction is considered when the lump measures from 0.5 cm to 1.6 cm. In this case, a visit to the doctor becomes mandatory. He will be able to identify the degree of predisposition to the disease;
• the results will be suspicious when the Mantoux size reaches 0.4 cm. In this case, the tuberculin test can be repeated to clarify the patient’s health status and the possibility of the presence of pathogenic bacteria in it;
• the result will be negative when the reaction reaches 0.1 cm. If there is no redness or enlargement of the papule, then a repeat test is performed. In this case, Mantoux cannot provide a protective function.

What do they do if there is a positive Mantoux reaction?

1. If a positive tuberculin test reaction is detected, measures must be taken. It means that the child has an increased susceptibility to developing tuberculosis. But this does not mean its development. In this case, you need to register with a TB doctor. The patient will belong to the zero group of dispensary registration. An infection can appear in the body due to favorable factors, such as a weakened immune system.
2. To check your health, you need to undergo an X-ray and examine your sputum.
3. If all tests do not show the presence of tubercle bacilli, it can be assumed that an allergic reaction to the test has developed.

All newborns are given BCG in the maternity hospital because they still have weak immunity and there is a high possibility of contracting tuberculosis. Children under 3 years of age are allergic to Mantoux quite often.

Testing for tuberculosis should not be neglected. The child's health depends on this.

How to correctly refuse tests for MTB and visits to a specialist

Parents have the right to refuse to have their child undergo a tuberculin test, visit a specialist, or have a chest x-ray performed, but it is better to formalize the decision in writing in the form of a statement:

• indicate where the document is addressed, that is, a children's clinic for a preschooler or a kindergarten, if attending, a school;
• leave your data and child;
• mention refusal of samples, chest x-ray;
• refer to laws that allow this to be done (Article 7, Chapter 3 of the Law “On Preventing the Spread of Tuberculosis in the Russian Federation” No. 77-FZ of June 18, 2001);
• explain the reasons for the refusal, for example, indicate that the child does not have any signs of illness (fever, cough, weakness, sweating), has not had contact with people or animals with tuberculosis, and his family has satisfactory living and material conditions.

The document is drawn up in any form, but the listed nuances should be indicated in it.

Positive reaction of Mantoux and phthisiatrician

A positive Mantoux reaction means that a phthisiatrician must examine the child, since it also occurs when there is Mycobacterium tuberculosis in the little patient’s body. And this can lead to infection, increasing the risk several times. If Mantoux is bad, they were sent to a phthisiatrician, you need to visit him before the end of 1 month. Further, more accurate studies are needed, and the first is Diaskintest. Here are the following options:

• If the test is also positive, a chest CT scan is performed to study the condition of the lymph nodes and organs of the respiratory system. Even in the absence of calcifications and enlargement, in any case, the child will be prescribed preventive chemotherapy for tuberculosis for 3-6 months.
• It may turn out to be negative. This means that the child is not infected and can go to kindergarten or school. And the fact that Mantoux was tested, and it was positive, and was sent to a phthisiatrician, may mean the body’s reaction to the BCG vaccination. You can calm down until the next test, but you shouldn’t give up on it.

It is impossible not to have your baby examined by a specialist, not only because of the increased risk of tuberculosis. With a bad test, he will not be accepted into kindergarten or school. After all, the first paragraph of clause 5.7 SP 3.1.2.3114-13 “Prevention of tuberculosis” reads:

Children sent for consultation to a tuberculosis dispensary, whose parents or legal representatives have not submitted a phthisiatrician's conclusion about the absence of tuberculosis within 1 month from the date of the Mantoux test, are not allowed into children's organizations.

Why does a reaction to Mantoux occur?

If you have immunity to tuberculosis, an allergic type reaction to the Mantoux test is observed. The size of the papule that forms on the skin at the site of drug administration is assessed 72 hours after the Mantoux test is performed. A negative test means the absence of papule, redness, or rash is considered a good result and means that the child is healthy. If the reaction is questionable or positive, an enlarged papule, redness, and pustules are recorded during testing, and the children are sent to a phthisiatrician.

Important! A questionable or positive reaction to the test does not mean that the child is infected with tuberculosis; such results can be caused by a BCG vaccination given less than a month ago, or an allergy to the administered drug. Only a TB specialist can determine exactly what is wrong with a child.

What size Mantoux is a reason to contact a phthisiatrician?

The reason for contacting a phthisiatrician is the following Mantoux sizes:

• An infiltrate of 2-4 mm without redness or a reddened area of ​​skin without a papule. This is a dubious reaction in which it is not clear whether the child is protected from infection, or whether mycobacteria are still present in his body.
• Infiltrate with a diameter of 5-16 mm. This is a positive reaction (up to 10 mm weakly positive), the cause of its occurrence may also be infection with tuberculosis in the past or present. Or the presence of an open disease.
• Papule ranging in size from 15-17 mm. This is a hyperergic reaction. In the same way, suppuration and necrosis of the skin are assessed, regardless of the size of the papule.

The time the test is carried out is also taken into account. If this is the second or subsequent cases, and the reaction has become 6 mm or higher compared to the previous case, they are referred to a phthisiatrician. With an enlarged Mantoux, a specialist prescribes tests, examines the child, and collects information about the health of his environment. And then everything happens depending on the diagnostic results. This “repeated Mantoux” is called Diaskintest, it is more informative.

We recommend that you read about the rules for drawing up a Mantoux waiver. From the article you will learn whether it is possible to refuse Mantoux in kindergarten and school, how to write a refusal, the reasons and consequences of refusal. And here is more information about the real and imagined consequences of the Mantoux test.

Some parents are fundamentally against conducting any tests for the presence of tuberculosis, as they consider them harmful to the health of their children. But they need to learn that the disease itself is much more dangerous. And it is better to treat it at the initial stage, the establishment of which is helped by early detection using Mantoux tests and methods proposed by a specialist.

Indications for referral to a phthisiatrician based on Mantoux results

The main reasons for referral to a TB specialist are a severe reaction at the injection site, hyperemia, redness, and rash. Consultation with a phthisiatrician after Mantoux is needed in the following cases:

• if the diameter of the Mantoux papule is 12 mm higher than the previous Mantoux over the last 4 years;
• if after the first Mantoux test in a child who did not receive the BCG vaccine in the maternity hospital, the diameter of the papule is larger than normal;
• after the first negative test, the second gave a positive result;
• if Mantoux increases every year instead of decreasing. The fact is that after vaccination with BCG, the child begins to develop immunity to tuberculosis. But every year it weakens, so at the age of 7 the second revaccination is carried out, and at the age of 14 - the last one. After this, it is considered that the development of the immune system is complete, and immunity to tuberculosis has already been developed. Therefore, the reaction to Mantoux should be less and less from year to year. If instead the reaction increases, there is reason to suspect infection with Koch's bacillus;
• if the tuberculin test after a long break (due to medical withdrawal or other reasons) gave a positive result. In this case, the pediatrician is not able to independently determine the presence or absence of infection based on the Mantoux results, so he will refer the child to a phthisiatrician for additional diagnostics;
• with the development of a hyperergic reaction, when the size of the papule exceeds 15 mm, there is pronounced redness, vesicular-necrotic changes in the skin around the papule. In case of an extreme reaction, the doctor may also recommend a consultation with a phthisiatrician. A turn is indicated if over the course of 6 months the Mantoux results have increased by 6 mm or more compared to the previous ones.

Signs of tuberculosis infection according to the results of tuberculin diagnostics

Signs of a tuberculosis infection in a child based on the results of a tuberculin test can be the results of a positive and questionable reaction:

• skin redness;
• formation of papules more than 2 mm in diameter;
• pustules and rashes.

In this case, any external symptoms of tuberculosis may be absent.

How to distinguish an allergy to a sample from tuberculosis

An allergy to tuberculin components may develop if the patient has previously experienced hypersensitivity to drugs or sensitivity to tuberculin after the first test. Other causes of hypersensitivity:

• use of a low-quality drug;
• violation of test technique;
• the presence of contraindications to the tuberculin test.

Important! The Mantoux test is not performed if BCG or any other vaccination was carried out less than a month ago, if any infectious process is progressing, or if the child suffered from something less than two weeks ago.

Sometimes neither the parents nor the doctor notice the symptoms of an incipient cold in the child at the time the test is performed. In this case, a severe allergic reaction to tuberculin may also occur. Only a TB specialist can accurately differentiate an allergic reaction from a TB infection with the help of additional examinations, which is why the pediatrician refers the child for additional consultation.