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Selective or universal neonatal BCG immunization: what policy for a district with a high incidence of tuberculosis?
P D Pharoah1, J M Watson, S Sen
1PHLS Communicable Disease Surveillance Centre, London.
Insights
Bacillus Calmette-Guérin (BCG) immunization for newborns in the UK offers protection against tuberculosis. Policies vary by region, with universal BCG vaccination recommended in high-prevalence areas, while selective policies are used elsewhere.
Area of Science:
- Public Health
- Immunization Policy
- Tuberculosis Prevention
Background:
- Bacillus Calmette-Guérin (BCG) immunization provides protection against severe tuberculosis in neonates across ethnic groups in the UK.
- Serious adverse reactions to BCG are rare, but universal BCG vaccination is not currently recommended nationwide.
- Selective BCG policies target infants of immigrants from high tuberculosis prevalence countries, facing challenges in defining risk and ensuring implementation.
Purpose of the Study:
- To evaluate the effectiveness and implementation of different neonatal BCG immunization strategies in a newly formed health authority.
- To address challenges in selective BCG policies and explore the feasibility of universal vaccination in specific districts.
Main Methods:
- Analysis of tuberculosis notification rates within different geographical areas of the New River Health Authority.
- Implementation of differentiated neonatal BCG policies: universal vaccination in a high-tuberculosis rate area (former Haringey) and a selective policy in a lower-rate area (former Enfield).
- Ongoing evaluation of coverage for the selective policy in Enfield.
Main Results:
- The New River Health Authority, formed by merging high- and low-tuberculosis rate districts, adopted distinct neonatal BCG policies.
- A universal neonatal BCG policy was implemented in the main provider unit within the former Haringey district.
- A selective neonatal BCG policy, subject to evaluation, continues in the main provider unit of the former Enfield district.
Conclusions:
- Differentiated neonatal BCG immunization policies can be implemented within a single health authority to maximize coverage in at-risk neonates.
- Universal BCG vaccination may be more politically acceptable and easier to implement in districts with high tuberculosis notification rates.
- Selective policies require ongoing evaluation to ensure adequate coverage in targeted high-risk groups.
Abstract:
In the United Kingdom, BCG immunization of neonates provides good protection against military and meningeal disease, and probably against other forms of tuberculosis, in all ethnic groups. Serious adverse reactions to BCG immunization are rare. Cost-effectiveness studies of BCG immunization in neonates have not been reported and "universal' BCG immunization is not recommended in the United Kingdom. The Department of Health does recommend immunization for children and infants of immigrants from countries with a high prevalence of tuberculosis. There are problems associated with such a "selective' policy, as determining what is "high' prevalence and thus defining "at risk' groups is difficult, and there may be political and practical difficulties in its implementation. This may result in low coverage in eligible groups. A "universal' policy of BCG immunization for all neonates may be politically more acceptable and easier to implement in districts with high tuberculosis notification rates. Although there is no cost-effectiveness data to determine at what tuberculosis notification rate a universal policy should be adopted, an universal policy has been suggested for districts with overall notification rate of greater than 40 per 100,000. Within districts there may be large variations in tuberculosis notification rates between different areas. This is becoming more common with the amalgamation and merger of smaller districts into new larger purchasing organizations. New River Health Authority is such a district formed by the amalgamation of the former districts of Haringey with a high tuberculosis notification rate, and Enfield with a lower TB notification rate. In order to maximize coverage in the "at risk' neonates, a different neonatal BCG policy has been adopted in the two areas. This has been possible because of the flexibility of the mechanisms for contracting with different provider units. Although the overall notification rate was not thought to be sufficiently high to justify a "universal' neonatal policy throughout the district, a "universal' policy has been instituted in the main provider unit in the former district Haringey. A "selective' policy, subject to ongoing evaluation to ensure high coverage, continues to be operated by the main provider unit in the former district of Enfield.