10 December 1998
Inadvertent administration of BCG during Heaf testing in schools: United Kingdom
On several occasions schoolchildren in the United Kingdom (UK) undergoing preliminary Heaf testing, as part of the Schools BCG Programme, have had their forearms inoculated inadvertently with BCG vaccine instead of tuberculin purified protein derivative (PPD). Such incidents cause considerable anxiety in families and health care workers, but their management should reflect the fact that a very low dose of BCG will have been given, which makes it unlikely that children will sustain any significant side effects or mount a significant response to the vaccine.
Current UK guidelines for BCG provide for children at secondary school to receive ‘standard strength BCG’ by the intradermal route, and for infants and small children to receive percutaneous BCG vaccine (about ten times the strength of intradermal) via an 18-20 needle multipuncture head (1).
It has been shown that children of secondary school age would need about 40 needle punctures if BCG was to be given by the percutaneous route to produce a response equivalent to that from intradermal BCG (2). No percutaneous heads are manufactured with this characteristic, so this route is not regarded as practical in such children. Multipuncture Heaf heads contain only six needles, so, if normal strength BCG is given inadvertently, the dose of BCG administered is only 1/30th of that normally received. The recommended management of these incidents is therefore to:
contact and reassure the parents that significant ill effects are unlikely
arrange follow eight weeks after the incident, and provide contact phone numbers for parents to ring with queries.
in due course repeat the skin test and offer BCG vaccination to non-responders. The skin test should be repeated some months later; the exact timing can be determined according to local circumstances.
The above recommendations apply to inadvertent use during the schools programme and are not guidelines for other situations, in which the risk of recent infection is higher - e.g., Heaf testing after contact with an acute infectious case.
BCG immunisation policies vary widely between European Union countries (3). Belgium, Denmark, and Spain do not use the vaccine and it has not been used in Germany since March 1998. Primary immunisation with BCG is offered only to children at high risk in some countries - neonates (first month of life) in Austria and Luxembourg, and infants of 6 months of age in the Netherlands and Sweden. In Italy immunisation is mandatory for children living in highly endemic areas and for high risk groups. In France BCG immunisation is recommended for neonates at high risk (as in the UK), and for other children it is mandatory before entering nursery, daycare, or school and should not be given later than 6 years of age. Tuberculin tests are carried out before immunisation (except on neonates), at 3 to 12 months after immunisation, and between 11 and 13 and 16 and 18 years, and children with negative skin reactions are vaccinated. No more than two intradermal immunisations are required. Children in Finland, Portugal, and some regions of Ireland are immunised at birth, those in Greece at 6 years, and children in the UK at 12 years. In Ireland schoolchildren aged 10 to 13 years who have not been immunised before or who are tuberculin negative and have no characteristic scar are immunised. Tuberculin tests and reimmunisation of children with negative skin reactions are carried out at 13/14 years and 20 to 25 years in Greece, and 5 and 11 years in Portugal.
Members of the Eurosurveillance editorial board were asked to confirm their BCG immunisation policies, and replies received have been used to amend the paragraph above. In Denmark the Mantoux test is used for tuberculin testing, and no inadvertent administrations of BCG have been reported. In France the Mantoux test is recommended, but multipuncture tests are still widely used for young children although no similar events have occurred recently. In Germany the Mantoux test is strongly recommended, but prefilled intradermal multiple puncture tests (Stempeltests - ‘Tubergen-Test’) are sometimes used, and no incidents like those described have been reported. Some parts of Ireland use Mantoux tests, others Heaf tests. The UK policy applies in Scotland, where Heaf and Mantoux tests are used depending on the local expertise and historical practice. The Scottish guidelines recommend Heaf tests because it is technically more reproducible. No recent incidents like those described have been reported.
- Department of Health, Welsh Office, Scottish Office Department of Health, DHSS (Northern Ireland). Immunisation against infectious disease. London: HMSO, 1996.
- Griffith AH, Kinsley BJ, Anderson DJ. A comparison between multiple puncture and intradermal methods of BCG vaccination. Tubercle 1963; 44: 372-7.
- Guérin N, Roure C. Immunisation schedules in the countries of the European Union. Eurosurveillance 1995; 0: 5-7. (http://www.ceses.org/eurosurv/)
Reported by Paul Van Buynder (email@example.com) and Stuart Handysides (firstname.lastname@example.org), PHLS Communicable Disease Surveillance Centre, England; Sigrid Poulsen (email@example.com), Statens Serum Institut, Denmark; Hanna Nohynek (firstname.lastname@example.org), Kansanterveyslaitos, Finland; Jean-Claude Desenclos (email@example.com), Réseau National de Santé Publique, France; Gernot Rasch (RaschG@rki.de), Robert Koch Institut, Germany; Lelia Thornton (firstname.lastname@example.org), Eastern Health Board, Ireland; Stefania Salmaso (email@example.com), Istituto Superiore di Sanità, Italy; and Peter Christie (firstname.lastname@example.org), Scottish Centre for Infection and Environmental Health, Scotland
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