Received BCG Vaccination Research Articles

Clinical manifestations and epidemiology of childhood tuberculosis in Stockholm 1976-95.

81 cases of tuberculosis infection (17) and disease (64), seen between 1977 and 1995 at St Göran's Children's hospital, Stockholm, Sweden are reviewed. The incidence of tuberculosis disease increased from 1 to 6/10(5) children/y. The increase was due to immigration from high-prevalence countries, with an incidence of 20/10(5) in a partly segregated suburb. Most of the children were foreign-born. Of the 31 0-4-y-old cases, 19 were born in Sweden, and 7 had received BCG vaccination. For Swedish-born children with Swedish-born parents, the incidence of tuberculosis disease remained stable at < 0.5. 50 patients were symptomatic when first seen (60% pulmonary tuberculosis, 8% military tuberculosis, 25%, cervical adenitis, 15% other extrapulmonary tuberculosis). There was 1 death, and in 2 children complicated tuberculosis courses. Side effects of drug therapy were seen in 5% of the children. In conclusion, tuberculosis remains an important differential diagnosis in children of immigrants from high-prevalence countries for at least 5 y after settlement in Sweden. The practice of delaying BCG vaccination of them until 6 months of age can be disputed.

Improving the coverage of neonatal BCG vaccination.

It is recommended that neonates at higher risk of contracting tuberculosis (such as in certain ethnic groups) should be vaccinated with BCG as soon as possible after birth. In Milton Keynes, during the late 1980s, there was anecdotal evidence to suggest that many higher-risk cases were not receiving BCG vaccination. The objectives of the study were to audit the neonatal BCG vaccination programme and to develop a system for improving and monitoring coverage. Two main sources of data were used: the obstetric computer, which gave the denominator of women considered to be in a higher-risk group, and the community child health computer, which gave the numerator of BCG vaccinations given. A case note audit was used to check the quality of these data. A computer-generated reminder was used to make sure that the antenatal assessment of risk was known about immediately after delivery. Estimated vaccine coverage rose from about 20 per cent (1988-1990) to 78 per cent by 1993. The audit suggested that about 8 per cent of vaccinations were not being recorded and 9 per cent were given unnecessarily. In addition, about 2 per cent were picked up postnatally and 1 per cent were missed completely. Improved coverage and adequate monitoring can be achieved using the two computerized systems. This methods has applications to other conditions where antenatal assessment can predict risk for a neonate, such as Hepatitis B or sickle cell disease.

Effect of inadvertent intradermal administration of high dose percutaneous BCG vaccine.

In the United Kingdom it is recommended that all children receive BCG vaccination to prevent development of tuberculosis.1 2 The standard route of administration is intradermal. In neonates a 10 times more potent percutaneous preparation is used, a small volume being injected to a depth of 2 mm with a modified Heaf gun. The two preparations have similar packaging and labelling and so may easily be confused.3 We report the outcome of inadvertent intradermal administration of the stronger percutaneous product and define the relation between the development of skin lesions and the dose of vaccine. Thirty two school children aged 11-14 received 0.1 …

Effect of inadvertent intradermal administration of high dose percutaneous BCG vaccine.

In the United Kingdom it is recommended that all children receive BCG vaccination to prevent development of tuberculosis.1 2 The standard route of administration is intradermal. In neonates a 10 times more potent percutaneous preparation is used, a small volume being injected to a depth of 2 mm with a modified Heaf gun. The two preparations have similar packaging and labelling and so may easily be confused.3 We report the outcome of inadvertent intradermal administration of the stronger percutaneous product and define the relation between the development of skin lesions and the dose of vaccine. Thirty two school children aged 11-14 received 0.1 …

Tuberculin Test on Infants and Children Who Had Been Given BCG Vaccination During Neonatal Period

On one hundred and seven children 3 months to 5 years old who had received BCG vaccination during neonatal period were reviewed with tuberculin test. This study were conducted at the children's and maternity Hospital Sri Ratu Medan for 4 months. They comprised 61 males and 46 females with moderate to well nou­rished. Tuberculin test was seen at 72 hours after the injection. Tuberculin test was said positive if the induration was >5 mm was found. Positive tuberculin test were found on 58 children (54.2%), out of which 49 children (84.5%) were 1 year old (p 1-2 years, >2-3 years, >3-4 years and >4-5 years old respectively (p<0.01). BCG scar did not show significant relationship with tuberculin test result and age.

Subdiaphragmatic Extralobar Pulmonary Sequestration with Granulomatous Necrotizing Reaction Simulating a Tuberculous Infection: A Case Report

Subdiaphragmatic Extralobar Pulmonary Sequestration with Granulomatous Necrotizing Reaction Simulating a Tuberculous Infection: A Case Report

Prevalence of PPD Positivity Among New Employees at a Hospital in New York City

To determine the prevalence of tuberculin reactivity among all new employees at a hospital in New York City. Prospective measurement of purified protein derivative (PPD) status in consecutive new employees at a hospital in New York City from 1991 to 1993. All employees are tested as part of a preemployment physical, assuring complete compliance. Aplisol (Parke-Davis, Morris Plains, NJ) was used in 1991 and 1992, and Tubersol (Connaught, Swiftwater, PA) in 1993. Tests were applied and interpreted by trained employee health personnel. Of 313 consecutive new employees, comprising all job categories, 40% were PPD positive at time of initial hire, including 20% of US-born and 70% of foreign-born employees. Of 114 persons who had received BCG vaccination, 67% were PPD positive. By multivariate regression analysis, age, BCG vaccination history, and foreign country of birth were independent predictors of a reactive PPD test. The high prevalence of tuberculin reactivity may reflect high rates of Mycobacterium tuberculosis infection and disease in the community, complicating interpretation of the efficacy of Centers for Disease Control and Prevention (CDC) guidelines to prevent the spread of tuberculosis in healthcare facilities.

BCG test reaction in previously BCG Moreaux-Rio de Janeiro-vaccinated healthy children

BCG-test reaction was carried out in 91 non-tuberculous children between 2 and 11 years old, who had received BCG vaccination during the first six months of life to critically evaluate the usefulness of this test in Pediatric practice. The BCG-test profile of the vaccinated group was shown to have a unimodal distribution, varying from 3 to 17 millimeters, with a median of 6 millimeters. It was demonstrated that the degree of reaction decreases with time. Nevertheless, false-positives could be expected in a significant percentage when reactions larger than 10 millimeters are considered as a cutoff. The specificity can be increased using only reactions with diameter equal or greater than 15 millimeters as an indicator of tuberculous disease.

Development of IgG responses to mycobacterial antigens.

Recent studies link mycobacterial and human heat shock protein antigens with autoimmune diseases. Little is known about the development of antibody responses to these antigens in children. IgG responses to mycobacterial antigens were studied in children living in the UK (an environment low in mycobacteria) who had not received BCG vaccination. Age curves of IgG response to sonicates from different species of mycobacteria were similar suggesting that the greater part of the developing IgG response is to the common antigens shared by all mycobacteria. The major part of the IgG response was to carbohydrate antigens: lipoarabinomannan is a mycobacterial cell wall carbohydrate and was confirmed as a major immunodominant antigen. Infants showed a marked early response to the mycobacterial 65 kilodalton (kDa) and 70 kDa heat shock proteins, but not to the human 65 kDa heat shock protein. The early IgG response to heat shock proteins may reflect cross reactivity to proteins released by a wide variety of bacteria (possibly from breakdown in the gut) or recognition of other immunodominant antigens with high levels of cross reactivity to self.

Tuberculin response in preterm infants after BCG vaccination at birth.

A total of 101 preterm infants between 26 and 37 weeks' gestation who received BCG vaccination at birth were evaluated between two and four months after vaccination. Altogether 32% of these infants had no visible BCG scar. All infants were then tested with tuberculin purified protein derivative (PPD) but only 70 returned for the test to be read 48-72 hours later. The test was negative in 22 (31%) and there was an induration of < or = 5 mm in another 26 (37%) of the infants. Of 22 infants with no BCG scar, 19 (86%) had an induration of < or = 5 mm. In infants with a positive BCG scar a significantly higher number had an induration of PPD > 5 mm. There were no significant differences between the rate of scarring and tuberculin conversion in the infants born before or after 32 weeks' gestation. It is considered that routine BCG vaccination at birth on preterm infants is not indicated until a much larger study has been performed.

Children From Romania: Testing for Tuberculosis-Reply

In Reply. —Dr Jameson's letter highlights some of the controversial issues in the diagnosis and management of tuberculin reactors, especially when testing is performed after BCG vaccination. Among the patients in our study, 41 of 65 Romanian children had been vaccinated with BCG prior to their arrival in the United States. Of the 20 vaccinated children who did not receive tuberculin testing as a part of their initial medical evaluation, two had no induration on subsequent testing by their private physicians, two refused tuberculin testing, one had received BCG vaccine 10 months prior to the clinic visit, and 15 had received BCG vaccine within the antecedent 2 to 3 months and exhibited moist, unhealed BCG vaccination sites. The pediatric literature provides ample precedent that tuberculin testing within 6 months of BCG vaccination elicits induration of at least 5 mm in 60% of children and greater than 10 mm in 30%1;

Two-year incidence of tuberculosis in cohorts of HIV-infected and uninfected urban Rwandan women.

To determine the prevalence of Mycobacterium tuberculosis infection and the incidence of tuberculosis in HIV-infected and uninfected urban Rwandan women, 460 HIV-positive and 998 HIV-negative childbearing women were recruited from pediatric and prenatal care clinics and were enrolled in a prospective study in 1988 and followed for 2 yr. Tuberculin testing was administered 12 to 18 months after enrollment. Fifty-three percent of HIV-negative women had positive tuberculin tests (induration > or = 10 mm), with higher rates among older women and among women who had received BCG vaccine. Only 21% of HIV-positive women had positive tuberculin tests, with no relationship to BCG vaccine. Follow-up was available for 93% of subjects. Tuberculosis was diagnosed in 20 HIV-positive women and in two HIV-negative women. Features associated with an increased risk of tuberculosis among HIV-positive women included: age > or = 30, body mass index in the lowest quartile, low income, erythrocyte sedimentation rate > 75, positive tuberculin test, and chronic cough, chronic fever, and weight loss. Among Rwandan women who are infected with HIV, approximately half of those who are infected with M. tuberculosis do not have positive tuberculin tests. The rate ratio for development of tuberculosis among HIV-positive women was 22 (95% CI, 5 to 92). New algorithms are needed to improve the early detection of tuberculosis among HIV-positive patients in Africa.

The significance of positive Mantoux reactions in BCG-vaccinated children

As the interpretation of tuberculin skin tests is controversial in subjects who have received BCG vaccine, we administered Mantoux tests to 2588 randomly selected Saudi children aged 5–13,1945 of whom had been vaccinated with BCG at birth and 643 were unvaccinated. Only 7.8% of the BCG-vaccinated children were Mantoux positive (⩾10 mm induration) at the age of 5 years, which was not significantly different from the unvaccinated children.The tuberculin sensitivity rose more steeply with age in the BCG-vaccinated than the unvaccinated children so that the difference between both groups became statistically significant in those aged 12 and 13 (20% versus 3.9%,15.5% versus 4.1 % respectively). These findings support the previously expressed theoretical postulates that BCG-vaccinated subjects display an increased ability to respond immunologically to encounters with environmental mycobacteria. In communities with low prevalence of environmental mycobacteria, this would result in a slow but persistent rise of skin reactivity to tuberculin which, if given time, will become greater than that of unvaccinated subjects.

Reply

Letters to the EditorReply Lalit PandyaMD, MRCP Lalit Pandya Sahary Chest Hospital, P.O. Box 7966, Riyadh 11472, Saudi Arabia Search for more papers by this author Published Online:1 May 1991https://doi.org/10.5144/0256-4947.1991.355aSectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionTo The Editor: I thank Dr. Nabi for his comments. My comments in reply are as follows: We see only adult pulmonary tubercular patients, and the youngest patient in our series was 15 years old. Regarding the low prevalence of tuberculosis in Saudi children in the Southern region, all the adverse predisposing factors like low socioeconomic conditions, not receiving BCG protection, malnutrition, and positive family contact need study. We cannot really comment on this. A low prevalence of tubercular infection in normal children from the Northern region of Saudi Arabia has been shown by Hajjaj et al[1] in a small survey. In their study in children 5 to 14 years old who had not received BCG vaccination, only 4% showed tuberculin positivity, compared with 58% positivity in the age group 45 to 64 years. This indicates a pool of infected population who can develop active pulmonary tuberculosis. Most of them must have acquired tuberculosis during childhood. The low percentage of tuberculosis in children is due to changes in the socioeconomic structure.ARTICLE REFERENCES:1. Al-Hajjaj M, El-Kassimi F, Abdullah A, Al-Orainey I. "Prevalence of tuberculosis infection in the Northern Region of Saudi Arabia (abstract)" . Proceedings of the Conference on Lung Health, Boston, Massachusetts, A801. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 11, Issue 3May 1991 Metrics History Published online1 May 1991 InformationCopyright © 1991, Annals of Saudi MedicinePDF download

Tuberculin survey in the Eastern Province of Saudi Arabia

We present the results of the Mantoux test (5 units tuberculin) survey in the Eastern Province of Saudi Arabia, which was conducted as part of a nationwide epidemiological survey of tuberculosis. A total of 1105 subjects were screened out of whom 630 gave a history of BCG vaccination in the past and 363 were BCG-negative. Among BCG-negative children aged 5-14 years, only 5% had a positive Mantoux, a rate lower than most Third World countries but higher than developed countries were under 2% of children are tuberculin reactors. This calls for continuation of free treatment of active cases and increased efforts towards screening of contacts. The results also vindicate the current policy of giving BCG vaccine at birth and probably indicates the need to revaccinate at school leaving age, in accordance with WHO recommendations. Tuberculin reactivity rose steeply with age (32% at age 15-24 and 72% at age 45-64 years) indicating the presence of a large pool of subjects at risk of breaking into active disease. Finally, 71% (201/283) of children aged 5-14 years who had received BCG vaccine at birth, reacted negatively to the Mantoux test. This supports the findings of previous studies that in the majority of subjects, BCG-induced tuberculin sensitivity fades a few years after vaccination.

Evaluation of BCG at birth in the United Arab Emirates

A total of 387 healthy full term infants who received BCG vaccination at birth were evaluated by the tuberculin PPD test at 6–8 weeks post vaccination. A total of 92% of these infants had visible BCG scars at that time. All infants were tested with PPD but only 264 returned for the test to be read. The tuberculin test was negative in 37 (14%) and of less than 5 mm induration in another 60 (23%) of the infants. The same pattern was observed in different nationalities. Of 11 infants with no BCG scar after vaccination, 3 had positive PPD reactions of more than 5 mm induration. There was a significant correlation between the size of the BCG scar and induration of tuberculin test P < 0.001. The complications of the vaccination were minimal. We have observed 3 sterile abscesses at the site of BCG vaccination which resolved spontaneously. We think the available vaccine is safe and potent, and that the rate of BCG scar formation and of tuberculin conversion is higher than in most studies.

Tuberculin response of Sri Lankan children after BCG vaccination at birth

A total of 740 healthy children aged between 3 months and 11 years who had received BCG vaccination in the first month of life were Mantoux tested in Sri Lanka. Despite 97 % having a visible scar following vaccination, 80 % showed Tuberculin anergy (0–1 mm). Those without a scar showed no response. There was no correlation between scar size and the Mantoux response.A low mean Mantoux reaction was seen at all ages: 3.5 mm at 3 months, 3.2 mm at 18 months, 1.8 mm at 5–7 years and 1.9 mm at 9–11 years. A significant waning of the Mantoux reaction occurred at 5–7 years but there was no significant change at 9–11 years. Children who had received routine revaccination at 10 years, having received the first at birth, had a significantly higher mean Mantoux reaction (9.6 mm) when tested 3 months after revaccination. In 90 bacteriologically proven tuberculous patients, there was a significantly increased Mantoux reaction compared to all other groups. 1 T.U. PPD RT 23 (with tween 80) was used in all instances for Mantoux testing.The present study shows that routine BCG vaccination at birth, using a reduced dose of 0.05 ml, is unlikely to interfere subsequently with the diagnostic value of the Mantoux test. However, revaccination at 10 years may do so.

Tuberculosis in a children's hospital.

We reviewed 26 cases of tuberculosis seen in The Children’s Hospital, Temple Street over the past 10 years by means of a retrospective study of hospital records. In all cases we specifically looked for clinical and bacteriological findings which helped lead to an early diagnosis. There were 15 cases of pulmonary tuberculosis and 11 cases of extrapulmonary disease including 7 cases of tuberculous meningitis. 36% had received BCG vaccination. 16% had positive cultures of mycobacterium tuberculosis. 86% had a positive tuberculin reaction and 73% had definite contact with open tuberculosis. 84% of patients with contacts had a positive tuberculin reaction. There was no mortality, but long-term sequelae occurred in 5 of the 7 cases of tuberculous meningitis.

The current value of tuberculin testing and BCG vaccination in school children

We have examined the value of routine tuberculin testing and BCG vaccination in Edinburgh school children from 1970 to 1983. Over 89000 children were observed for a mean period of 7 years, during which 77 new cases of tuberculosis were notified in Caucasians. The average annual incidence of tuberculosis in the 65692 children receiving BCG vaccination at school was 7/10 5, significantly less than the 19/10 5 estimated in 12987 Heaf negative children who missed BCG vaccination, and the 41/10 5 in 5308 tuberculin positive children ( P<0.001). The efficacy of BCG vaccination in this study exceeded 60%. The 5308 tuberculin positive children were offered chest radiographs with an initial yield (new cases of tuberculosis detected/radiographs taken) of 1 555 for Heaf grade II children, 1 75 for grade III, and 1 25 for grade IV ( P<0.001). During the period of this study approximately 700 BCG vaccinations were necessary to prevent one new case of tuberculosis and this represents considerably greater benefit than in England and Wales during the same period. There may be a case for continuing the schools' BCG programme in Scotland for a number of years longer than in England and Wales. A national BCG survey for Scotland would be valuable.

BCG test reaction in previously BCG vaccinated children

BCG test reactions were studied in 1095 non-tuberculous children from 6 months to 5 years of age, who had received BCG vaccination in the newborn period, in order to find out the diagnostic value of the BCG test in previously BCG vaccinated children. Previous BCG vaccination has an effect on the BCG test reaction in the form of an accelerated BCG reaction. Although the degree of reaction decreases with time, 51.4% of children still showed a strongly accelerated BCG reaction 4 1/2-5 years after BCG vaccination. It is concluded that the BCG test cannot be used as a diagnostic test for tuberculosis in children under 5 years of age who have had previous BCG vaccination.