BCG immunisation in the newborn

Human tuberculosis (TB) is caused by infection with bacteria of the Mycobacterium tuberculosis complex (M. tuberculosis, M. bovis or M. africanum) and may affect almost any part of the body. The most common form is pulmonary TB, which accounts for almost 60% of all cases in the UK. Non-respiratory forms of TB are more common in young children in communities with connections to areas of the world with high prevalence, and in those with impaired immunity.

The UK BCG immunisation programme is now a selective risk-based programme, the key part being a neonatal programme targeted at protecting those children most at risk of exposure to TB, particularly from the more serious childhood forms of the disease

BCG vaccine contains a live attenuated strain derived from M. bovis. It does not contain thiomersal or any other preservatives. It contains live organisms that have been attenuated (modified).

Meta-analyses of BCG vaccine efficacy have shown the vaccine to be 70 to 80% effective against the most severe forms of the disease, such as TB meningitis in children. It is less effective in preventing respiratory disease, which is the more common form in adults.

Current guidance from the JCVI is that BCG immunisation should be offered to:

• All infants (aged 0 to 12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater (see the table below or the posters on the postnatal wards)
• All infants (aged 0 to 12 months) living in areas of the UK where the annual incidence of TB is 40/100,000 or greater (Edinburgh and the Lothians have a lower incidence than this, as does the rest of Scotland, however a few areas of England exceed this threshold- they are listed below)
• Newly born babies who are contacts of a TB case that is not smear positive should be immunised with BCG immediately.
• Infants in whom there is a close family history of TB in the last 5 years
• Infants who are likely to be living in a high prevalence area for more than 3 months

In addition:

• Newly born babies who are contacts of a smear-positive case should not be tested or immunized immediately but should be given prophylactic isoniazid chemotherapy and tuberculin tested after three to six months. If the skin test is positive, chemotherapy is continued; if negative, BCG vaccine is given provided the infant is no longer in contact with infectious TB. It is not necessary to use isoniazid-resistant BCG. This is organised by referring to Dr Laura Jones, consultant in paediatric infectious diseases, RHSC.

In many cases the nursery nurses and midwives on the postnatal wards will have noted those at risk and put them in the ward workbook. However information on ethnicity may not always be available so it is always worth asking during the babycheck.

Requests for immunisation

• Occasionally families request BCG for their baby despite not being in any of the above groups. It is not recommended that BCG is given in these circumstances and this should be explained to the family. This is still the case if the family is originally from a country that has universal BCG immunisation but is not on the list of high risk countries below, as the UK immunisation programme should be followed.

The vaccine should not be given to:

• Neonates in a household where an active TB case is suspected or confirmed
• People who are immunocompromised by virtue of disease or treatment, e.g.: patients receiving corticosteroid or other immunosuppressive treatment, including general radiation. (inhaled steroids are not a contraindication), and those suffering from a malignant condition such as lymphoma, leukaemia, Hodgkin’s disease or other tumour of the reticuloendothelial system.
• BCG is contraindicated in symptomatic HIV-positive individuals. In countries such as the UK where the risk of TB is low, it is recommended that BCG is also withheld from all those known to be or suspected to be HIV positive, regardless of clinical status. In infants born to HIV-positive mothers, BCG can be administered after two appropriately timed negative postnatal PCR tests for HIV infection

BCG is not a universal immunisation in NHS Lothian but is offered to babies most at risk of exposure to TB ie born to families from high risk TB countries.

Currently in Lothian BCG is not offered on the postnatal ward routinely. In Lothian new born infants who are eligible for BCG vaccination are identified through information gathered by the health visitor at the 10 day postnatal baby check.  Details of the countries of birth of both parents and grandparents is collected and sent back to Child Health and if any of these countries have high rates of TB (set by the WHO as >40 per 100,000 population) then the child is eligible for BCG and an invitation for BCG is sent out to the child's parents as soon as possible.

Currently BCG clinics are run by the Community Vaccination Team/Specialist TB nurses and held at the RIE or in the community around Edinburgh and West Lothian.

There is no need to delay BCG immunisation in preterm babies. Individual cases should be discussed with the attending consultant to decide on the appropriate timing of immunisation based on their clinical status.

These are available in English on the postnatal wards, and in a number of other languages via the following websites:

• http://www.healthscotland.com/documents/3932.aspx
• http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/
  PublicationsPolicyAndGuidance/DH_082947

Please give appropriate information when giving the leaflet re. phoning for an appointment.

Countries

This is a list of countries with an incidence of TB >40/100000. It is compiled using Health Protection Agency data 2006 (see http://www.hpa.org.uk, accurate 08/09).

(see DOH Green Book https://www.gov.uk/government/publications/tuberculosis-the-green-book-chapter-32 )

Regions within UK

These are all English Primary Care Trusts with incidence of TB over 40/100,000.
This list is compiled using HPA data from 2005. Available at http://www.hpa.org.uk (accurate 08/09).

Blackburn  with Darwen PCT
Brent Teaching PCT
Camden PCT
City and Hackney Teaching PCT
Ealing PCT
Hammersmith and Fulham PCT haringey Teaching PCT
Harrow PCT
Heart of Birmingham Teaching PCT
Hillingdon PCT
Hounslow PCT
Islington PCT
Lambeth PCT
Leicester city PCT
Lewisham PCT
Luton PCT
Newham PCT
Redbridge PCT
Sandwell PCT
Southwark PCT
Tower Hamlets PCT
Waltham Forest PCT
Wandsworth PCT