Research Open Access
Like 1



In 2006, the Calmette–Guérin (BCG) vaccination policy in Finland changed from universal to selective.


We assessed the impact of the policy change on tuberculosis (TB) morbidity in children under 5 years and epidemiological trends of paediatric TB in Finland.


We conducted a nationwide, population-based, retrospective registry study of all newly diagnosed active TB cases younger than 15 years in Finland from 1995 to 2015 by linking data from the National Infectious Diseases Register, Finnish Care Register for Health Care, medical patient records and Finnish Population Information System. We compared the TB incidence rate ratio of under 5 year-olds with universal and selective BCG vaccinations with a Poisson log-linear model and analysed incidence trends among those younger than 15 years with a negative binomial model.


We identified 139 paediatric TB cases: 50 native (including 24 second-generation migrants) and 89 foreign-born children. The TB rate of under 5 year-olds remained stable after changing to selective BCG vaccination (incidence rate ratio (IRR): 1.3; 95% confidence interval (CI): 0.7–2.3). TB rate in the native population under 15 years increased slightly (IRR = 1.06; 95% CI: 1.01–1.11).


Paediatric TB cases in Finland were concentrated in families with migrant background from high-TB incidence countries. The native TB morbidity in under 5-year-olds did not increase after the BCG policy revision, suggesting that selective vaccinations can prevent TB in the most vulnerable age group in low-incidence settings. Second-generation migrants under 15 years in Finland with high TB risk are probably increasing.


Article metrics loading...

Loading full text...

Full text loading...



  1. World Health Organization (WHO). Global tuberculosis report 2019. Geneva: WHO; 2019. Available from: https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-report-2019
  2. Perez-Velez CM, Marais BJ. Tuberculosis in children. N Engl J Med. 2012;367(4):348-61.  https://doi.org/10.1056/NEJMra1008049  PMID: 22830465 
  3. Sloot R, Schim van der Loeff MF, Kouw PM, Borgdorff MW. Risk of tuberculosis after recent exposure. A 10-year follow-up study of contacts in Amsterdam. Am J Respir Crit Care Med. 2014;190(9):1044-52.  https://doi.org/10.1164/rccm.201406-1159OC  PMID: 25265362 
  4. Colditz GA, Berkey CS, Mosteller F, Brewer TF, Wilson ME, Burdick E, et al. The efficacy of bacillus Calmette-Guérin vaccination of newborns and infants in the prevention of tuberculosis: meta-analyses of the published literature. Pediatrics. 1995;96(1 Pt 1):29-35. PMID: 7596718 
  5. Dierig A, Tebruegge M, Krivec U, Heininger U, Ritz N, Paediatric Tuberculosis Network European Trials group (ptbnet). Current status of Bacille Calmette Guérin (BCG) immunisation in Europe - A ptbnet survey and review of current guidelines. Vaccine. 2015;33(38):4994-9.  https://doi.org/10.1016/j.vaccine.2015.06.097  PMID: 26151543 
  6. Criteria for discontinuation of vaccination programmes using Bacille Calmette-Guerin (BCG) in countries with a low prevalence of tuberculosis. A statement of the International Union Against Tuberculosis and Lung Disease. Tuber Lung Dis. 1994;75(3):179-80.  https://doi.org/10.1016/0962-8479(94)90003-5  PMID: 7919307 
  7. World Health Organization. BCG vaccine: WHO position paper, February 2018 - Recommendations. Vaccine. 2018;36(24):3408-10.  https://doi.org/10.1016/j.vaccine.2018.03.009  PMID: 29609965 
  8. Faust L, Schreiber Y, Bocking N. A systematic review of BCG vaccination policies among high-risk groups in low TB-burden countries: implications for vaccination strategy in Canadian indigenous communities. BMC Public Health. 2019;19(1):1504.  https://doi.org/10.1186/s12889-019-7868-9  PMID: 31711446 
  9. Romanus V, Svensson A, Hallander HO. The impact of changing BCG coverage on tuberculosis incidence in Swedish-born children between 1969 and 1989. Tuber Lung Dis. 1992;73(3):150-61.  https://doi.org/10.1016/0962-8479(92)90149-E  PMID: 1421348 
  10. Trnka L, Danková D, Svandová E. Six years’ experience with the discontinuation of BCG vaccination. 2. Cost and benefit of mass BCG vaccination. Tuber Lung Dis. 1993;74(4):288-92.  https://doi.org/10.1016/0962-8479(93)90056-4  PMID: 8219182 
  11. Räisänen PE, Soini H, Vasankari T, Smit PW, Nuorti JP, Ollgren J, et al. Tuberculosis in immigrants in Finland, 1995-2013. Epidemiol Infect. 2016;144(2):425-33.  https://doi.org/10.1017/S0950268815001508  PMID: 26135388 
  12. Salo EP. BCG in Finland: changing from a universal to a selected programme. Euro Surveill. 2006;11(3):607.  https://doi.org/10.2807/esm.11.03.00607-en  PMID: 16567879 
  13. Hersh AL, Tala-Heikkilä M, Tala E, Tosteson AN, Fordham von Reyn C. A cost-effectiveness analysis of universal versus selective immunization with Mycobacterium bovis bacille Calmette-Guérin in Finland. Int J Tuberc Lung Dis. 2003;7(1):22-9. PMID: 12701831 
  14. Kontturi A, Soini H, Ollgren J, Salo E. Increase in childhood nontuberculous mycobacterial infections after Bacille Calmette-Guérin coverage drop: a nationwide, population-based retrospective study, Finland, 1995-2016. Clin Infect Dis. 2018;67(8):1256-61.  https://doi.org/10.1093/cid/ciy241  PMID: 29584893 
  15. Smit PW, Haanperä M, Rantala P, Couvin D, Lyytikäinen O, Rastogi N, et al. Genotypic characterization and historical perspective of Mycobacterium tuberculosis among older and younger Finns, 2008-2011. Clin Microbiol Infect. 2014;20(11):1134-9.  https://doi.org/10.1111/1469-0691.12725  PMID: 24944074 
  16. Sund R. Quality of the Finnish Hospital Discharge Register: a systematic review. Scand J Public Health. 2012;40(6):505-15.  https://doi.org/10.1177/1403494812456637  PMID: 22899561 
  17. Finnish National Infectious Diseases Register. Helsinki: National Institute for Health and Welfare. [Accessed: 15 Oct 2018]. Available from: https://thl.fi/en/web/infectious-diseases-and-vaccinations/surveillance-and-registers/finnish-national-infectious-diseases-register
  18. Official Statistics of Finland (OSF). Tilastot. [Statistics]. Helsinki: Statistics Finland. [Accessed: 12 Sep 2018]. Finnish. Available from: http://www.stat.fi/til/
  19. BCG- eli tuberkuloosirokote [BCG, or tuberculosis vaccine]. Helsinki: Terveyden ja hyvinvoinnin laitos [Finnish institute for health and welfare]; 2013. Finnish. Available from: https://thl.fi/fi/web/infektiotaudit-ja-rokotukset/rokotteet-a-o/bcg-eli-tuberkuloosirokote#kenelle
  20. Van Bui T, Lévy-Bruhl D, Che D, Antoine D, Jarlier V, Robert J. Impact of the BCG vaccination policy on tuberculous meningitis in children under 6 years in metropolitan France between 2000 and 2011. Euro Surveill. 2015;20(11):21064.  https://doi.org/10.2807/1560-7917.ES2015.20.11.21064  PMID: 25811645 
  21. Guthmann JP, Antoine D, Fonteneau L, Che D, Lévy-Bruhl D. Assessing BCG vaccination coverage and incidence of paediatric tuberculosis following two major changes in BCG vaccination policy in France. Euro Surveill. 2011;16(12):19824. PMID: 21457685 
  22. Erkens CG, de Vries G, Keizer ST, Slump E, van den Hof S. The epidemiology of childhood tuberculosis in the Netherlands: still room for prevention. BMC Infect Dis. 2014;14(1):295.  https://doi.org/10.1186/1471-2334-14-295  PMID: 24885314 
  23. Tiittala P, Tuomisto K, Puumalainen T, Lyytikäinen O, Ollgren J, Snellman O, et al. Public health response to large influx of asylum seekers: implementation and timing of infectious disease screening. BMC Public Health. 2018;18(1):1139.  https://doi.org/10.1186/s12889-018-6038-9  PMID: 30249224 
  24. Brantsaeter AB, Romanus V, Andersen PH, Heldal E. Evidence of protective effect of BCG vaccination in persons at low risk of tuberculosis in Nordic countries. Int J Tuberc Lung Dis. 2009;13(4):440-5. PMID: 19335948 
  25. Mohiyuddin T, Seddon JA, Thomas HL, Lalor MK. The changing landscape of childhood tuberculosis in the United Kingdom: a retrospective cohort (2000-2015). Pediatr Infect Dis J. 2019;38(5):470-5.  https://doi.org/10.1097/INF.0000000000002200  PMID: 30256311 
  26. Marx FM, Fiebig L, Hauer B, Brodhun B, Glaser-Paschke G, Magdorf K, et al. Higher rate of tuberculosis in second generation migrants compared to native residents in a metropolitan setting in western Europe. PLoS One. 2015;10(6):e0119693.  https://doi.org/10.1371/journal.pone.0119693  PMID: 26061733 
  27. Kunkel A, Abel Zur Wiesch P, Nathavitharana RR, Marx FM, Jenkins HE, Cohen T. Smear positivity in paediatric and adult tuberculosis: systematic review and meta-analysis. BMC Infect Dis. 2016;16(1):282.  https://doi.org/10.1186/s12879-016-1617-9  PMID: 27296716 
  28. European Centre for Disease Prevention and Control (ECDC)/World Health Organization Regional Office for Europe. Tuberculosis surveillance in Europe 2007. Stockholm: ECDC; 2009. Available from: https://www.ecdc.europa.eu/en/publications-data/tuberculosis-surveillance-europe-2007
  29. Dodd PJ, Yuen CM, Sismanidis C, Seddon JA, Jenkins HE. The global burden of tuberculosis mortality in children: a mathematical modelling study. Lancet Glob Health. 2017;5(9):e898-906.  https://doi.org/10.1016/S2214-109X(17)30289-9  PMID: 28807188 
  30. Teo SS, Alfaham M, Evans MR, Watson JM, Riordan A, Sonnenberg P, et al. An evaluation of the completeness of reporting of childhood tuberculosis. Eur Respir J. 2009;34(1):176-9.  https://doi.org/10.1183/09031936.00031808  PMID: 19251788 
  31. Morales-García C, Rodrigo T, García-Clemente MM, Muñoz A, Bermúdez P, Casas F, et al. Factors associated with unreported tuberculosis cases in Spanish hospitals. BMC Infect Dis. 2015;15(1):295.  https://doi.org/10.1186/s12879-015-1047-0  PMID: 26220420 
  32. van Hest NA, Smit F, Baars HW, De Vries G, De Haas PE, Westenend PJ, et al. Completeness of notification of tuberculosis in The Netherlands: how reliable is record-linkage and capture-recapture analysis? Epidemiol Infect. 2007;135(6):1021-9.  https://doi.org/10.1017/S0950268806007540  PMID: 17156496 

Data & Media loading...

Supplementary data

Submit comment
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error