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/HPSC℘not need a TST (Mantoux test) prior to receiving BCG vaccine6F 2256ii. Childr en in at-risk environments should have a TST (Mantoux test) prior to BCG.3. Unvaccinated (that is without adequate documentation or a characteristic scar) Mantoux negativeimmigrants under 16 years of age who were born or who have lived for a prolonged period (atleast three months) in a high incidence country7F3♦ OR aged 16-35 years from a sub-Saharan Africancountry or country with a TB incidence of 500 per 100,000 264. Unvaccinated Mantoux negative contacts aged 35 years and under of cases with active pulmonaryTB. Children under five years of age in contact with smear positive TB should be referred to acontact tracing clinic for investigation and then immunised with BCG as indicated.5. Members of special at-risk groups such as the travelling community due to the logistical difficultiesof providing alternative control measures and follow up of contacts6. Unvaccinated Mantoux negative persons under 16 years of age intending to live or work with localpeople in high incidence countries for more than one month 2577. BCG is indicated for unvaccinated healthcare workers (HCWs) aged
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSC7.6 InteractionsAdministration of blood or plasma transfusions, hepatitis B vaccine, hepatitis B immunoglobulin and normalimmunoglobulin are thought not to reduce the effectiveness of BCG vaccine. 258-261 A baby who has receivedblood or plasma transfusions can be subsequently immunised with BCG, after the observation period(24 hours) for transfusion reactions has ended. A baby who has received hepatitis B vaccine, hepatitis Bimmunoglobulin or normal human immunoglobulin can be subsequently immunised with BCG withoutdelay.7.7 Administration of BCG VaccinationDetailed instructions are available in chapter 2 of the Immunisation <strong>Guidelines</strong> for Ireland available atwww.immunisation.ie and also on the Staten Serum Institut (Denmark) website atwww.ssi.dk/sw4145.asp.7.8 Immunisation Reaction and Care of the Immunisation SiteThe expected reaction to a successful BCG vaccination seen in 90-95% of recipients is induration at theinjection site followed by a local lesion which starts as a papule two or more weeks after vaccination. It mayulcerate and then slowly subside over several weeks or months to heal leaving a small flat scar. It may alsoinclude enlargement of a regional lymph node to less than 1cm.It is not necessary to protect the site from becoming wet during washing and bathing. The ulcer shouldbe encouraged to dry and abrasion (for example by tight clothes) avoided. Should any oozing occur atemporary dry dressing may be used until a scab forms. It is essential that air is not excluded. If absolutelynecessary (e.g. to allow swimming), an impervious dressing may be applied but only for a short period as itmay delay healing and cause a larger scar.Further observation after routine vaccination with BCG is not necessary, other than as part of monitoring ofthe quality of the programme, nor is further tuberculin testing recommended.Severe injection site reactions, large discharging ulcers, abscesses and keloid scarring are most commonlycaused by faulty injection technique, excessive dosage or vaccinating individuals who are tuberculinpositive. It is essential that all healthcare professionals be properly trained in all aspects of the processinvolved in tuberculin skin tests and BCG vaccination.7.9 Adverse ReactionsLocal: Side effects include local induration, pain and occasionally ulceration, enlargement of a regionallymph node greater than 1cm, abscess formation, lupoid reaction and inflammatory and suppurativeadenitis. 109General: Headache, fever and generalised lymphadenopathy can rarely occur (in less than one in 1,500vaccinated). Anaphylactic reaction and disseminated BCG complications (such as osteitis, osteomyelitis ordisseminated BCG infection) are also very rare. Disseminated BCG infection occurs in approximately twoper one million persons, primarily in persons with severely impaired immune systems. 1091Management of adverse reactionsLocal adverse reactions to BCG vaccine occur in 1-2% of immunisations. Severe local reactions (ulcerationgreater than 10mm, caseous lesions, abscesses or drainage at the injection site) or regional suppurativelymphadenitis with draining sinuses following BCG vaccination should be discussed with a respiratoryphysician or consultant paediatrician. 255Most experts do not recommend treatment of draining skin lesions or chronic suppurative lymphadenitiscaused by BCG vaccine because spontaneous resolution occurs in most cases. Large needle aspiration ofsuppurative lymph nodes may hasten resolution. There is little evidence to support the use of either locallyinstilled anti-mycobacterial agents or systemic treatment of patients with severe persistent lesions.-92-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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