TUBERCULOSIS, CHILDREN - UNITED KINGDOM: USE OF BCG VACCINE
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Date: Thu 15 Jul 2010
Source: The Independent [edited]
<http://www.independent.co.uk/life-style/health-and-families/health-news/ex=perts-urge-tb-vaccine-for-all-london-children-2026878.html>

All babies born in London should be vaccinated against tuberculosis
(TB) to protect them against the growing threat from the disease, public health specialists say. Almost 45 percent of all childhood TB cases in the UK occur in the capital [London] and the rising incidence has now passed the threshold where routine immunisation should be introduced, according to experts from the Health Protection Agency (HPA).

Tuberculosis is often thought to be a disease of the past. It was a major killer until the early 20th century, but the introduction of powerful drugs in the mid-20th century was thought to have beaten it, and by the late 1980s cases had fallen to an all-time low of 5000 a year. But since then there has been a resurgence and the incidence has steadily increased. There were 9153 cases among adults and children recorded in the UK in 2009, the largest annual increase (5.5
percent) since 2005.

Nine out of 10 cases occur in ethnic minorities, and routine BCG [Bacillus of Calmette and Guerin] vaccination of school age children against TB was abandoned in 2005 in favour of a more focused campaign on children of immigrants. Current policy is to offer vaccination to children born abroad or with parents born abroad. Immunisation is also recommended for all children living in areas where the incidence of TB exceeds 40 cases per 100 000.

Writing in the Journal of Public Health, Josephine Ruwende of the HPA and colleagues say this level is now seen consistently across London.
They criticise the existing policy of targeting immigrant families because high levels of migration within the city make them difficult to trace. "With an overall TB incidence in London exceeding 40 per 100 000, universal BCG immunisation of all neonates should be considered across all London boroughs," they say.

Most children with tuberculosis are infected in this country (unlike adults, who are mostly infected abroad). Although children rarely pass on the disease to others there have been outbreaks in schools.
The study found 1370 cases of TB reported in children under 15 [?
years] in London between 1999 and 2006.

In 2004, the UK's Chief Medical Officer launched a TB Action Plan that called for a "progressive decline" in incidence rates of TB by at least 2 percent per year for everyone born in England. "Clearly, this is not being achieved among London's children," the authors write.

Tuberculosis is a global killer, claiming more than 2 million lives a year, mostly in the developing world. It is curable with drugs, but requires 6 months of treatment and the course must be completed to prevent the disease returning. The development of drug-resistant strains of TB in recent years has caused alarm. These cases are extremely difficult to treat and cost tens of thousands of pounds.

Dr Ibrahim Abubakar, a TB expert at the HPA's Centre for Infections,
said: "This increase shows we must remain vigilant in our fight against TB. This is an entirely preventable infection, but it can be fatal if prompt diagnosis and treatment are not given. People need to be aware of the main symptoms of TB, which include a fever and night sweats; a persistent cough; weight loss; and blood in your sputum (phlegm or spit). If you experience 2 or 3 of these symptoms for more than 3 weeks, you should go to your GP."

A brief history of TB

1850s One person in 4 killed by TB in Europe and America

1882 Robert Koch discovers that TB is caused by an organism, _Mycobacterium tuberculosis_

1920 The 1st human trials of the vaccine Bacille Calmette Guerin (BCG)

1944 Streptomycin discovered and the 1st patient successfully treated

1952 Isoniazid discovered to treat TB patients

1953 BCG vaccination is introduced in secondary schools in the UK

1987 TB figures in England and Wales at their lowest since records
began: 5086 cases

1987-2009 TB cases rise to reach 9153 in the UK

2004 National Action Plan, "Stopping Tuberculosis in England,"
published by Chief Medical Officer

2005 Withdrawal of the BCG school vaccination programme in the UK.
New strategy targeted at immigrant families [see <http://www.tbalert.org/tuberculosis/documents/BCGgovtrelease.pdf>]

[Byline: Jeremy Laurance]

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Communicated by:
ProMED-mail Rapporteur Mary Marshall

[BCG, or Bacille Calmette-Guerin, is an attenuated strain of the bovine tuberculosis bacillus, _Mycobacterium bovis_, developed for use as a live bacterial vaccine to prevent tuberculosis (TB) and disease due to nontuberculous mycobacteria. In addition, it is used as an immunostimulant in the treatment of superficial carcinoma of the bladder. The vaccine was 1st administered to humans in 1921 and remains the only vaccine against tuberculosis in general use.

Many persons born in countries with a high prevalence of TB have been BCG-vaccinated in infancy to prevent childhood tuberculous meningitis and miliary disease. However, vaccination with BCG is not recommended as a means to control TB in the USA, relying instead on the detection and treatment of latent TB infection (LTBI).

BCG is not recommended because of the success of other measures in reducing incidence of TB, the low risk of infection with _Mycobacterium tuberculosis_ in the U.S. (e.g., in 2003, children aged <14 years accounted for 6.2 percent of reported TB cases - <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5412a1.htm>), the variable effectiveness of the vaccine against adult pulmonary TB (Colditz GA, Brewer TF, Berkey CS, et al. Efficacy of BCG vaccine in the prevention of tuberculosis. Meta-analysis of the published literature. JAMA 1994;271:698--702), and the vaccine's potential interference with tuberculin skin test (TST) reactivity. TST is used to diagnose LTBI.

Also, BCG vaccination is not used in HIV-infected persons (WHO.
Revised BCG vaccination guidelines for infants at risk for HIV infection. Wkly Epidemiol Rec 2007; 82 (21): 193-196); disseminated disease due to BCG has been reported in HIV-infected children vaccinated at birth with BCG, and immune reconstitution inflammatory syndrome (IRIS) associated with BCG also has been reported among children initiating highly active antiretroviral therapy (HAART) for HIV infection (<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5811a1.htm>).

Children most commonly are infected with _M. tuberculosis_ from exposure in their immediate environment, usually the household.
Contact investigation of adults with infectious TB is the most important activity for early detection of TB among children. Children exposed to active TB must be evaluated for LTBI; children with LTBI are at high risk for progressing to primary TB and its sequellae.

In the U.S., infants and children are treated for LTBI if they have a positive TST or are exposed to a person who has contagious TB (after exclusion of active TB disease in the infant or child and regardless of the child's TST results). Exposed children with an initially negative TST are retested in 3 months after exposure to infectious TB has ended. If the 2nd test result is positive, treatment is continued for a full course of treatment for LTBI. If the 2nd test result is negative, treatment may be stopped (<http://www.cdc.gov/tb/publications/LTBI/treatment.htm>).

In 1996, the U.S. CDC only recommended vaccination with BCG for infants and children with exposure to _Mycobacterium tuberculosis_ in settings in which other protective measures are either inaccessible or proven to be ineffective. Specifically, "BCG vaccination should only be considered for children who have a negative tuberculin skin test and who are continually exposed, and cannot be separated from, adults who [either] are untreated or ineffectively treated for TB disease (if the child cannot be given long-term treatment for infection); or have TB caused by strains resistant to isoniazid and rifampin"
(<http://www.cdc.gov/tb/publications/factsheets/prevention/BCG.htm>).

Timely reporting and contact investigation of suspected cases of infectious TB is crucial in prevention of TB among children. The high rate of TB in the UK in children born, or with parents, born in countries with high TB prevalence suggests that detection and treatment of active TB in adults in the households of these children, targeted tuberculin skin testing of children from these households, treatment of exposed children for confirmed or suspected LTBI, or targeted tuberculin skin testing of recent immigrants from high TB prevalence countries has been inadequate.

The UK can be located via the HealthMap/ProMED-mail interactive map at <http://healthmap.org/r/01Je>. - MOD.ML] ....................ml/ejp/dk

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