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ABC Of Vaccines – 3


An article published in Family Physicians Association Magazine, Rajkot

 

BCG

Contents: Freeze dried live attenuated Chalmette Guerin strain of bovine Mycobacterium tuberculosis, o.1 to o.4 million viable bacilli per dose.

Or between 1×10⁶ and 33×10⁶ colony forming units (C.F.U.)

Age for primary immunization: At birth or earliest contact

Schedule: Single dose, may be repeated in Montaux -ve >5years

Availability: dried powder with normal saline as diluent, Multidose (1 ml=10 doses) vial.

Dose: 0.1 ml

Route: Intradermal, with TT or insulin syringe (a raised wheal of about 8mm with visible hair follicles ensures proper administration)

Site: Left upper arm at deltoid insertion.

Storage: +2˚ t0 +8˚ C in the middle compartment of refrigerator.

During immunization, keep away from light and use within 3-4

Hours as it does not contain preservative.

 

Instructions to mother: Local reaction after 3-6 weeks with nodule and or ulceration which heals by scarring.

Contraindications: Avoid for 12 weeks after measles vaccine or disease, 4 weeks after viral diseases, to patients on steroids and in immunocompromised individuals.

 Side effects: Non healing ulcer and regional suppurative lymphadenitis.

Complication: Risk of tuberculosis in immunocompromised host.

Salient features:

# Clean the skin with sterile water only.

# Don’t rub at the site after vaccination.

# Mantoux test becomes positive in 95% cases after 12 weeks.

# It can be repeated if no reaction has occurred at the site even after 12 weeks, if mantoux is non reactive (≥5mm).

# In case of preterm, the cut off limit for vaccination is 36 weeks and 2 kg weight.

 

FAQs on BCG:

  • How to manage a newborn baby delivered by a mother who is an open case of tuberculosis?

 Ans:1) Continue treatment of mother

1) Continue treatment of mother

2) Allow and promote breastfeeding as infection does not     spread through breast-milk and antitubercular drugs are not excreted in sufficient amounts in breast milk to cause any toxicity to the newborn.

3) Rule out congenital tuberculosis in the baby.

 

4) Start INH prophylaxis (10 mg/kg) to the baby for three months.

5) If child remains healthy at the end of three months, give Montoux, if –ve, give BCG vaccine

If +ve, investigate for tuberculosis and treat with multidrug regime accordingly.

6) If child shows symptoms during the three months, investigate early and treat accordingly.

 

  • Does an unvaccinated child need BCG vaccine after being infected with tuberculosis and completing the treatment?

Ans: No, this child does not require BCG vaccination because the primary infection itself has induced tuberculin hypersensitivity which was to be induced by BCG vaccine.

 

  • Which vaccines can be given along with BCG vaccine?

Ans:  OPV and DPT can be given along with BCG vaccine as OPV works on gut immunity whereas DPT acts by humoral immunity while BCG act buy cell mediated immunity. They do not interfere with each other.

 

  • Which vaccines should be avoided with BCG?

Ans: Measles and MMR vaccine depress cell mediated immune response. Hence they should not be administered along with BCG and a minimum gap of 6 weeks should be kept between the two vaccines.

 

  • What is the treatment of recurrent or non healing ulceration at the site of BCG vaccination?

Ans: It is a normal phenomenon and does not require any treatment. In fact parents should be informed beforehand of such incidence.

Antibiotics are necessary only if there is evidence of secondary infection like cellulites or abscess formation, where the drug of choice is oral erythromycin for 7to 10 days.

No antitubercular treatment is required for such cases.

 

  • How to manage post BCG axillary lymphadenitis?

Ans:

1) It is also a part of BCG uptake and requires no treatment if the size is less than 1.5 cm and nonsuppurating.

2) If there is increase in the size and/or evidence of suppuration,      INH (10 mg/kg) should be given for 3 months.

3) Rarely excision may be required when there is a danger of sinus formation.

 

  • What can happen if BCG is given subcutaneously instead of intradermal?

Ans: The uptake of the vaccine will be reduced and there will be greater chances of BCG adenitis.

 

  • How to proceed with a child whose parents are not sure about BCG vaccination or who has been vaccinated but no scar is seen?

Ans: In both the cases vaccination should be done if the Montoux test is non reactive.

 

  • What should be done if a child develops measles within 10 days of BCG vaccination?

Ans: In cases where a child develops measles or whooping cough within 6nweeks of vaccination with BCG, an INH (10 mg/kg/day) prophylaxis for 12 weeks should be given to prevent possible dissemination.

Later on montoux conversion should be ensured.

 

  • What is the status of BCG in patients on long term steroids, on chemotherapy, immunoglobulins, chickenpox, measles, congenital (TORCH) infections, and Hepatitis B infection?

Ans :

1) BCG can be given after 4-6 weeks of immunoglobulin therapy and chickenpox

2) It can be administered after 6-8 weeks of stoppage of steroids or chemotherapy.

3) It can be given 12 weeks after measles infection but should be avoided in patients with TORCH infection.

4) Only exception is Hepatitis B infection where BCG vaccination may be in fact helpful as an immunomodulator

 

 PS: This article was part of series of articles on practical points on vaccination in FPA times, 2013-14.

 

Dr. Neema Sitapara

MD (Ped), PGDip. (Adolescent Pediatrics)