BCG Immunisation in High Risk Infants

1. BCG Immunisation in High Risk Infants Dr Dominik Zenner Dr P Chandrasekar

2. Objectives To audit the local guideline:

3. Objectives And the ‘infant-BCG part’ of the local

4. Objectives Based on the national (BTS) guideline:

5. Background and rationale • BCG is a live attenuated vaccine with the Bacillus Calmette-Guérin • derived from an isolate of Mycobacterium bovis at the Institut Pasteur in Lille • first given to humans in 1921 orally • One of the most widely used vaccines globally, (partial) protection against TB and Leprosy (also Mycobacterium)

6. Background and rationale • Infant vaccination said to be most effective mode • Particularly in preventing TB Meningitis • And to a slightly lower extend Pulmonary TB • ‘…hence the case for giving BCG is stronger in children than in adults’ (BTS guideline p895)

7. Background and rationalePH aspects • Despite modern antibacterial treatment, TB has significant morbidities • and mortalities (globally estimated 2 million deaths yearly) • TB is widespread, about 2 billion are infected (prevalence), the global incidence was estimated at 8.46 million cases in 2003 (WHO, 2003:10) • The share is unequal: most cases are found in 22 ‘high burden countries’ (6.77 million; ibid.) • TB benefits from poor immune status; the incidence increases alongside HIV in particularly affected areas (i.e. Sub-Saharan Africa) • TB is on the increase: the worldwide growth rate is 0.4%, and significantly higher in Sub-Saharan Africa

8. Estimated TB Incidence Rates, 2001 per 100 000 pop < 10 10 - 24 25 - 49 50 - 99 100 - 299 300 or more No estimate

9. 1 India 2 China 3 Indonesia 4 Bangladesh 5 Nigeria 6 Pakistan 7 South Africa 8 Philippines 9 Russian Federation 10 Ethiopia 11 Kenya 12 DR Congo 13 Viet Nam 14 UR Tanzania 15 Brazil 16 Thailand 17 Zimbabwe 18 Cambodia 19 Myanmar 20 Uganda 21 Afghanistan 22 Mozambique Background and rationale‘High-burden countries’** These countries account for 80% of the new TB cases/year

10. Background and rationale • Incidence in the British population: • White English 4.4/100000 • Black Caribbean 26/100000 Indian 121/100000 • Black African 210/100000

11. Background and rationale • Most Babies in the area are born to white British or white Irish mothers and therefore not eligible for BCG vaccination as an infant • Out of 514 babies born between 1 April and 30 June 2003, only 17 were born to mothers of high risk countries

12. Background and rationaledistribution of our foreign babies

13. Background and rationalebabies from ‘high burden countries’

14. Methodology Data sources: • Computer based Patient Database • Central Delivery Birth Register • Maternal patient records • Baby’s patient records (if applicable) • BCG forms (from Dr Chandrasekar)

15. Methodology Inclusion Criteria: • All live babies born to parents eligible for BCG vaccination • In particular: all live babies born to mothers of foreign descent • between 1 April 2003 until 30 June 2003 (3 months)

16. Methodology

17. Referral process

18. Audit criteria • Criterion 1: Parents from ‘high risk countries are offered BCG immunisation for their baby. • 1.1 Families are successfully identified • 1.2 A BCG form is filled in • 1.3 The form is transferred to Chandra • 1.4 The baby is vaccinated within 3 months

19. Audit criteria • Criterion 2: Parents who are likely to be travelling to a high risk country are offered BCG immunisation for their baby.

20. Audit criteria • Criterion 3: Parents who had a history of TB or who have frequent visitor with a history of TB in the last five years are offered BCG immunisation for their baby • This guideline is only found in the Paediatric Tuberculosis Guideline

21. Criterion 1: successful referral 1

22. Criterion 1: successful referral 2

23. Criterion 1: successful referral 3

24. Criterion 1.4: Successful BCG vaccination within 3 months 1

25. Criterion 1.4: Successful BCG vaccination within 3 months 2

26. Criterion 1.4: additional information ‘No BCG vaccination within 3 months’ but belated BCG vaccination ( after 3 months)

27. Criterion 1.4: additional information ‘No BCG vaccination within 3 months’ but belated BCG vaccination ( after 3 months)

28. Criterion 1: BCG vaccination not performed 1

29. Criterion 1: BCG vaccination not performed 2

30. Appendix to Criterion 1: • Currently not in the BCG guideline, • However the Paediatric Tuberculosis Guideline states: ’infants born to families where one or both parents originate from continents with a high prevalence of tuberculosis … should be offered vaccination shortly after birth And the BTS guidelines state ‘babies born to immigrants…’ and does not classify mother or father (p899). • Out of the ethnically mixed children within our period, only one had a British mother and a foreign father (Spanish). The child did not receive vaccination.

31. Criterion 2: Traveller immunisation • 100% non-performance • Some babies are vaccinated at parental request (n=2 in this period), but it’s ‘up to them’ • The number of eligible babies is therefore unknown

32. Criterion 3: TB contact vaccination • Maternal TB will be identified in the antenatal history. • One case has been identified within this period, the child has been successfully referred to Chandra, but not been immunised yet. • TB contacts are currently not routinely identified. • We therefore do not know, how many babies were eligible for vaccination • Discussion: should we offer vaccination to babies born to foreign fathers?

33. Recommendations: • Transfer problem: • in-transfers should have a completed JPH antenatal record not merely ‘see N+N notes’ (loss of information), and the nationality should always be recorded • Out-transfers should have a clear statement ‘for BCG’ in the notes +/- transfer letter • Discussion: possibly facilitating referral process to Chandra ?computer based tagging system etc.

34. Literature • Baker J. (2002) ‘Policy and Procedure for ensuring that babies born to mothers from countries of high incidence of Tuberculosis receive BCG immunisation at, or soon after birth’ (local guideline) at Jpaget Intranet http://lighthouse/guidelines/WoChHealth/BCGVaccination.htm • Chapman J. (2001) ‘Paediatric Tuberculosis Guidelines’ (local guideline) at Jpaget Intranet http://lighthouse/guidelines/ • Fine P.E.M., Carneiro I.A.M., Milstien J.B. Clements C.J. (1999): Issues relating to the use of BCG in immunization programmes: A discussion document, WHO (Geneva), 1999 • Joint Tuberculosis Committee of the British Thoracic Society (2000): ‘Control and prevention of tuberculosis in the United Kingdom: Code of Practice 2000’ Thorax 2000;55:887–901 • Rose AMC (1998) ‘National TB Survey in England and Wales: final results’ Thorax 1999; 54(Suppl 3):A5.

35. Recommendations: • The two current guidelines must agree with each other (i.e. re: TB contacts): BCG guideline review date April 2004 • Potential travellers should be identified at the booking visit and informed about BCG • The antenatal history should contain information regarding TB contacts, if appropriate: offer BCG • For the latter two: ?information leaflet • The antenatal history must contain nationality of both, mother and father • World Health Organisation (2002): ‘Tuberculosis. Fact Sheet 104’ at www.who.int • World Health Organisation (2003): WHO Report 2003. Global Tuberculosis Control: Surveillance, Planning, Financing, WHO (Geneva), 2003 at www.who.int/gtb/publications/globrep/index.html • World Health Organisation (2004): ‘Tuberculosis’ at who web pageshttp://www.who.int/vaccine_research/diseases/tb/en/

36. Thank you! 