Guidelines on the Prevention and Control of Tuberculosis in Ireland

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<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCor• The average annual notification rate of TB meningitis in children under five years of age should beless than one case per ten million general population over the previous five yearsor• The average annual risk of TB infection should be 0.1% or less. This is not applicable to Ireland.The national rate for sputum smear positive pulmonary TB has been under 5 per 100,000 for the threeyears prior to 2006. In 2005 the rate was 3.3 per 100,000, while in 2004, 2003 and 2002, the rates were3.5 per 100,000, 3.7 per 100,000 and 3.1 per 100,000 respectively. However, data from between 2001 and2006 indicate that there were four cases of TB meningitis notified in children aged less than five years, ofwhom two were culture positive and three had not received BCG vaccine. 20When considering the importance of neonatal BCG vaccination, it is worth considering the practice inother European countries. For example, Sweden discontinued routine neonatal BCG vaccination in 1975when they had a total notification rate of 20 per 100,000 population and an age-specific incidence ratefor children aged 0-14 years of 0.3 per 100,000. While the national crude rate in Ireland is less than 20 per100,000 population, the 2006 age-specific incidence rate for children 0-14 years was 2.4 per 100,000, eighttimes the rate recorded in Sweden when they discontinued neonatal BCG vaccination. In 2005, 2004, 2003,2002, 2001 and 2000, the age-specific incidence rate for children aged 0-14 years was 3.0 per 100,000,1.2 per 100,000, 2.9 per 100,000, 2.2 per 100,000, 1.9 per 100,000 and 1.9 per 100,000 respectively. In1999, the age-specific incidence rate for children aged 0-14 years was 5.1 per 100,000 population, almostseventeen times the rate recorded in Sweden. In 1998, the corresponding figure was 3.5 per 100,000population almost twelve times the rate recorded in Sweden when they discontinued BCG. 20It is also notable that Finland who moved from a universal newborn BCG vaccination programme to atargeted risk group programme in September 2006 had only five notified cases of TB in the 0-2 year oldsbetween 1997 and 2001 and no cases of TB meningitis in the 0-14 year olds notified in this period. Since1970, only two cases of TB meningitis have been notified nationally in Finland. The national incidencerate for TB is 11 per 100,000 and 65% of cases occur in those aged over 60 years. Foreign-born patientsrepresent 6 to 9% of the total. 253When Canada discontinued universal BCG in 2002, the national TB notification rate was 5.2 per 100,000and the notification rate was 1.6 per 100,000 in 0-14 year olds. 254Also, rates of TB notifications in 1998 in the following Nordic countries that have discontinued neonatalBCG programmes are much lower than in Ireland and among the best in the world as outlined below:• Sweden = 5.0 per 100,000• Norway = 5.0 per 100,000• Denmark = 9.6 per 100,000• Iceland = 5.8 per 100,000.As well as the IUATLD criteria, there are additional considerations which should also be reviewed whendeciding to modify or stop a universal BCG programme as outlined below:• Costs• Adverse reactions to BCG• Risk groups: In the event of discontinuation of the BCG vaccination programme for the generalpopulation, it may be advisable to continue it in certain well-defined population groups with aknown high notification rate of active TB. 253While Ireland meets the IUATLD criteria on the basis of overall smear positive pulmonary TB reportingrates, the number of TB meningitis cases in children and general rates of TB in children remain a concern.Also, the TB control programme is currently under review and it is likely that recommendations will bemade for strengthening the programme. In light of these findings, the continuation of the universalprogramme of neonatal BCG vaccination is recommended in Ireland at this time.-89-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCRecommendation:The continuation of a universal programme of neonatal BCG vaccination is recommended inIreland at this time.7.3 Dose and Route of AdministrationBCG Vaccine Statens Serum Institut (SSI) is the only available licensed BCG vaccine in Ireland. It containsthe Danish strain 1331. It does not contain thiomersal or any other preservatives. It may be givenconcurrently with another live vaccine, but if they are not given at the same time an interval of at least fourweeks should be allowed between such vaccines. It can also be given at the same time as killed vaccinese.g. DTaP/IPV/Hib/Hepatitis B, PCV (pneumococcal conjugate vaccine) or Men C.Recommendation:When BCG is given to infants there is no need to delay the primary immunisations. No furtherimmunisation should be given in the arm used for BCG immunisation for at least three monthsbecause of the risk of regional lymphadenitis.Infants under 12 months of ageThe recommended dose is 0.05ml by intradermal injection of the reconstituted vaccine at one site over themiddle of the deltoid muscle.Adults and children 12 months and overThe recommended dose is 0.1ml by intradermal injection of the reconstituted vaccine and given at onesite over the middle of the deltoid muscle.Although the protection afforded by BCG vaccine may wane with time, there is no evidence that repeatvaccination offers significant protection and repeat BCG is not recommended. If re-immunisation with BCGis being considered expert advice should be sought.Detailed instructions including illustrations are available from the Immunisation <strong>Guidelines</strong> for Irelandprepared by the National Immunisation Advisory Committee. 2557.4 Indications for BCG VaccineRecommendation:Training for health professionals in the correct administration of BCG vaccine is recommended.Those administering vaccine should be aware of indications, contraindications, immunisationand adverse reactions associated with BCG.Groups in whom BCG vaccine is indicated:1. Newborn babies2. Unvaccinated children aged one to 15 years (i.e. those with no documented evidence of BCG orwithout a characteristic scar)i. Children aged three months to less than six years who are not in an at-risk environment5F1∏ do1 ∏ Children in at-risk environments include those who are contacts of a pulmonary TB case, who are from an area of high endemnicity(annual TB rates of ≥ 40/100,000) or whose parents are from an area of high endemnicity or who have household contacts who belongto an at-risk group for TB-90-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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