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BCG (Bacille Calmette Guerin) is a freeze-dried live vaccine. It is made from a weakened live (attenuated) form of Mycobacterium bovis, the bacilli which causes tuberculosis in cattle and sometimes in children who drink milk that was not pasteurised. BCG is included in the expanded programme on immunisation (EPI) in children.
BCG does not prevent infection with TB bacilli but reduces the risk of TB meningitis and disseminated TB in young children by 75%. Unfortunately it is less effective in preventing pulmonary TB, especially in malnourished children and children with HIV infection. It also gives less protection in older children, adolescents and adults which makes reimmunisation at an older age unnecessary.
BCG reduces the risk of disseminated tuberculosis and tuberculous meningitis in children.
BCG vaccine should be stored in a refrigerator between 2 and 8 °C and must not be frozen. Keep it and the diluent on the middle shelf. It must also be kept out of direct sunlight. To prepare the vaccine for administration the vial of diluent should be added to the vial of dried vaccine. Do not use alcohol or ether to clean the top of the vial as it may kill the BCG. After adding the diluent, the vaccine will last for six hours if kept in a refrigerator or cool box. After six hours the vaccine must be discarded as the bacilli may be dead.
Usually BCG is given during the first few days after birth in well infants and on the day of discharge from hospital or clinic in infants who have been ill or are very preterm (less than 32 weeks gestation). If there is any doubt about whether BCG was given after birth or discharge, it should be given at six weeks with the other routine immunisations. BCG is not usually given to children older than one year and most clinics do not stock BCG.
Although, BCG immunisation can cause local (at the injection site), regional (axillary lymph node) or disseminated (distant) BCG infection in HIV-infected infants, in South Africa BCG is given to all infants after birth. However, infants known to be infected with HIV should not be given BCG if this has not already been given at birth.
BCG is given by intradermal injection over the right upper arm as follows:
It is important that BCG is given correctly.
In the majority of infants a raised nodule develops at the site of the immunisation after two to four weeks. A small crust may develop or it may ulcerate. The nodule will heal by itself and no dressing should be applied. After eight weeks the nodule starts to decrease in size and by six months a small flat scar will form. The lymph nodes in the axilla on that side may enlarge slightly, which is normal. BCG immunisation does not always leave a scar in an infant. It is not necessary to repeat the BCG immunisation if no scar is seen.
The most common adverse effects are local pain and ulceration at the site of the immunisation and enlarged lymph nodes in the axilla and sometimes the neck.
Serious adverse effects in infants who are not HIV infected are very rare. However there is a high risk of serious adverse effects in HIV-infected infants. They include:
All HIV-infected infants must be identified as early as possible and referred for investigation and treatment.
There is a high risk of infection when children come into contact with someone who has untreated smear-positive tuberculosis. This is usually an adult with a cavity on chest X-ray. They have a chronic cough but are not aware that they have pulmonary tuberculosis. The risk is the highest if the child lives in the same household (close contact). Children are also at risk if their caregivers or family members they regularly visit have tuberculosis.
This situation is far more common in poor families where there is overcrowding in inadequate, dark, poorly ventilated housing. Children may also be exposed to large numbers of TB bacilli in taxis, buses, clinics or other confined spaces.
This is the finding and screening of people (the ‘contacts’) who have been exposed to someone with tuberculosis (the ‘source’). Both adult and child contacts may have undiagnosed tuberculosis and need treatment.
Some children will have TB infection only (a positive Mantoux skin test with no symptoms or signs of disease). Infected children younger than five years of age and children of any age who also have HIV infection will benefit from TB prophylaxis.
Contact tracing of infectious people is a very important part of controlling the spread of tuberculosis in a community. The most effective public health measure to control tuberculosis is the identification and cure of infectious cases.
Contact tracing is an essential part of controlling the spread of tuberculosis.
Health workers are exposed to TB bacilli, especially while examining patients with a cough or while collecting sputum samples. Masks (N95 respirators) should be worn by healthcare workers when examining patients with pulmonary tuberculosis or suspected of having pulmonary tuberculosis and hands should be washed after the examination. Good ventilation in examination and procedure rooms is essential.
For children exposed to a contact with drug-susceptible pulmonary tuberculosis, INH for six months is used for prophylaxis against tuberculosis in children. The treatment is given daily using the same daily dose as for short-course treatment (10 mg/kg/day).
For children exposed to a contact with drug-resistant pulmonary tuberculosis prophylaxis depends on the resistance pattern of the TB bacilli:
The following children should be given prophylactic treatment:
Asymptomatic HIV-negative children of five years and older, who have been in close contact with an adult with untreated pulmonary TB, or have a positive Mantoux test, are not given prophylaxis, as they are at far less risk of developing tuberculosis. However, they should be followed and investigated for tuberculosis if they develop any early symptoms or signs of TB.
Prophylactic treatment is given to well children under five years of age, and HIV-infected children of any age, who have been exposed to someone with untreated tuberculosis.
The aim of a national tuberculosis programme is to prevent the spread of tuberculosis and to promote the accurate diagnosis and correct treatment of tuberculosis. This should reduce the mortality and morbidity due to tuberculosis and reduce the risk of drug resistance. The national tuberculosis programme in South Africa (National TB Control Programme) was started in 1996 with widespread implementation of the DOTS strategy.
Yes. All children who are treated for tuberculosis need to be recorded and reported to the local health (EPI) authority. Children are reported in two age groups, zero to four, and five to 14 years of age.
It is important that children with tuberculosis are reported and recorded for two main reasons.
It is not required at present to register these children. However it would be an advantage if each clinic knew which children were receiving prophylaxis, how many completed the course of prophylaxis, and what the outcome of these children was. This would help with the planning of the service.
In 2015 the United Nations migrated from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs). The SDGs are 17 global goals with 169 targets between them covering a broad range of development issues that include ending poverty and hunger, improving health and education, making cities sustainable and combating climate change by 2030. Goal 3 seeks to ensure health and wellbeing for all. One of the targets of this goal is to end epidemics of AIDS, tuberculosis, malaria, neglected tropical diseases and other communicable diseases by 2030.
It is important that the community in all areas is aware of the following:
In most communities there are many misunderstandings and incorrect beliefs about tuberculosis.
These false beliefs often cause a lot of unnecessary suffering. They can only be corrected by community education.
In South Africa the HIV epidemic has greatly increased the number of both adults and children with tuberculosis. HIV infection lowers the immunity and thereby increases the risk of TB infection progressing to tuberculosis, especially extrapulmonary tuberculosis. A greater number of adults with tuberculosis increases the chance that children in the family and community will be infected with TB bacilli. In addition, more women with tuberculosis increases the risk of vertical transmission to infants (mother-to-child transmission).
Reducing the spread of HIV and tuberculosis in the community is, therefore, essential if the number of children with tuberculosis is to be decreased.
A newborn infant is given BCG immunisation before discharge home from a obstetric care clinic. A month later the mother notices a lump at the site of the immunisation. On examination, the nurse notices mildly enlarged axillary lymph nodes. The child is generally well and thriving.
A weakened (attenuated) form of Mycobacterium bovis, the bacilli which causes tuberculosis in cattle and sometimes in children who drink milk that was not pasteurised. BCG vaccine is included in the expanded programme on immunisation in children.
It induces an immune response which reduces the risk that TB infection will progress to tuberculosis, especially disseminated and miliary tuberculosis in young children. However it does not reduce the risk of TB infection.
By injection into the skin (intradermal) of the right upper arm (deltoid area). It is important that BCG is stored and mixed correctly. BCG immunisation should be given directly after birth.
No, as this is a normal response to BCG.
HIV infection. These infants have a weakened immune system which can result in local BCG abscesses or even disseminated BCG.
IRIS (immune reconstitution inflammatory syndrome) due to BCG may present with markedly enlarged axillary lymph nodes a few weeks after antiretroviral treatment is started. It is due to the recovery of the immune system.
An unemployed man is diagnosed with pulmonary tuberculosis. He lives with his family, including a 4 year old son, in an overcrowded house. He is concerned that his son may be at risk of developing tuberculosis. Clinically the child is well and not malnourished.
He should be screened for tuberculosis as he is a ‘contact’ and therefore at high risk of infection.
A Mantoux skin test and a chest X-ray must be done. A sputum test must be done if the chest X-ray suggests tuberculosis.
Only if there is good evidence to suggest that he developed tuberculosis ( a positive Mantoux test and abnormal chest X-ray). If he appears well and his Mantoux skin test is negative or intermediate, he should be given TB prophylaxis.
For children exposed to a contact with drug-susceptible pulmonary tuberculosis, INH for six months is used for prophylaxis against tuberculosis. The treatment is given daily using the same daily dose as for short-course treatment (10 mg/kg/day).
For children exposed to a contact with drug-resistant pulmonary tuberculosis prophylaxis depends on the resistance pattern of the TB bacilli of the contact case.
In addition to well children under five years of age who have been in contact with an adult with pulmonary tuberculosis, children with a positive Mantoux skin test and children with HIV infection should receive INH prophylaxis if they are TB contacts.
By practising correct cough behaviour (cough etiquette) and taking their medication correctly.
Tuberculosis is common in a small rural community. The headmaster of the primary school wants to involve the whole community in reducing the risk of children developing tuberculosis.
Everyone must be educated about tuberculosis and understand the cause, clinical presentation, how it is spread and the importance of good adherence. They should understand that BCG immunisation, regular weight checks and good nutrition are important for children.
Via the print media (books, newspapers) and electronic media (radio and TV) as well as community organisations.
Include tuberculosis in the school curriculum. Education about tuberculosis can also be given to teacher and parent groups.
So that the prevalence and spread of tuberculosis in the community can be documented. This will help with planning both prevention and treatment.
The SDGs are 17 global goals with 169 targets between them covering a broad range development issues that include ending poverty and hunger, improving health and education, making cities sustainable and combating climate change by 2030. Goal 3 seeks to ensure health and wellbeing for all. One of the targets of this goal is to end epidemics of AIDS, tuberculosis, malaria, neglected tropical diseases and other communicable diseases by 2030.
Some traditional beliefs lead to misunderstanding and suffering. For example, in some communities people with tuberculosis are believed to be bewitched or are being punished for some sin. It is important for the community to understand the true cause of tuberculosis and know that it can be cured with early diagnosis and correct treatment.