Implementing changes in Cornwall
Objectives of the session
Describe the background to
the change in programme
Put this into a local context
Explain the new programme
Highlight the local
WHAT IS BCG?
BCG – Green Book says..
•BCG vaccine contains a live attenuated strain derived from
M. bovis. BCG Vaccine Statens Serum Institut (SSI) is the
only available licensed vaccine in the UK.
•Studies of the effectiveness of BCG vaccine have given
widely varying results,between countries and between
studies, ranging from no protection to 70–80% protection in
•However, meta-analyses have shown the vaccine to be 70–
80% effective against the most severe forms of the disease,
such as TB meningitis in children.
BCG Green Book says…
•It is less effective in preventing respiratory disease, which
is the more common form in adults.
•Protection has been shown to last for at least 10–15 years.
•There are few data on the protection afforded by BCG
vaccine when it is given to adults (aged 16 years and over),
and virtually no data for persons aged 35 years and over.
•BCG is not usually recommended for people aged over 16
years, unless the risk of exposure is great (e.g. healthcare
or laboratory workers at occupational risk or where indicated
WHY CHANGE THE PROGRAMME?
The International Union against
Tuberculosis and Lung Disease
…published their criteria for discontinuation of BCG
programmes in countries of low prevalence in 1993
● there is a well functioning TB control programme
● there has been a reliable monitoring system over the
previous five years or more enabling the estimation of the
annual incidence of TB by age and risk groups, with
particular emphasis on TB meningitis and sputum smear-
positive pulmonary TB
● due consideration has been given to the possibility of an
increase in the incidence of TB resulting from HIV infection.
NICE guide explains
Whilst BCG in school-age children has a protective
efficacy of 75–80% lasting 10–15 years, the incidence
of active TB in those at low risk is now in the order of
1 case per 100,000, with a continuing downward trend.
England and Wales meet the accepted international
criteria for the cessation of universal BCG vaccination
in a low-prevalence country,291 and have done so at
least since 2000.
The schools programme becomes cost-effective only if
15% or more of the children included are at higher risk
and previously unvaccinated.
For these reasons, it was felt that routine BCG
vaccination of children aged 10 to 15 in schools should
Department of Health Press release
6th July 2005
Changes to the BCG vaccination programme were
announced today by the Chief Medical Officer, Sir Liam
Following advice from the Joint Committee on Vaccination
and Immunisation (JCVI) the current universal BCG
vaccination programme delivered through schools will be
replaced with an improved programme of targeted
vaccination for those individuals who are at greatest risk.
This decision did coincide with
•problems in manufacturing of Heaf Heads
•Problems in the production of Heaf strength PPD
Making this a particularly good time to make the change.
WHO IS AT GREATEST RISK?
We are now targeting risk groups so who are they?
Back to the Green Book
• all infants (aged 0 to 12 months) living in areas of the UK
where the annual incidence of TB is 40/100,000 or
• All infants (aged 0 to 12 months) with a parent or
grandparent who was born in a country where the
annual incidence of TB is 40/100,000 or greater
• Previously unvaccinated children aged 1-5 years with a
parent or grandparent born in a country where the
annual incidence of TB is 40/100,000 or greater. (identify
at suitable opportunities, normally vaccinate without
•Previously unvaccinated, tuberculin-negative children aged
from 6 – under 16 years with a parent or grandparent born
in a country where annual TB incidence is 40/100,000 or
greater. (Identify at suitable opportunities – Mantoux & BCG
•Previously unvaccinated tuberculin negative contacts of
cases of respiratory TB. (see NICE guide 2006)
•Previously unvaccinated, tuberculin negative new entrants
under 16 years born in or having lived for at least three
months in a country with an annual TB incidence of
40/100,000 or greater.
BCG for occupational risk
•Healthcare workers who will have contact with patients or
•Laboratory Staff who will have contact with patients, clinical
materials or derived isolates
•Veterinary and staff such as abattoir workers who handle
animal species known to be susceptible to TB
•Prison staff working directly with prisoners
•Staff of care homes for the elderly
•Staff of hostels for homeless people/refugees/asylum
•Unvaccinated, tuberculin-negative individuals aged under
35 years in these occupations are recommended to receive
•There are no data on the protection afforded by BCG
vaccine when it is given to adults aged 35 years or over.
•Not all healthcare workers are at an equal risk of TB. There
are likely to be categories of healthcare workers who are at
particular risk of TB, and should be part of the clinical risk
assessment when the use of BCG is being considered for a
healthcare worker over 35 years of age.
Health Clearance Guide
In accordance with guidelines from the National
Institute for Health and Clinical Excellence (NICE),13
health checks should include the following:
• Employees new to the NHS who will be working with
clinical specimens should not start work until they have
completed a TB screen or health check, or until
documentary evidence is provided of such screening
having taken place within the preceding 12 months.
Health Clearance Guide cont
•Employees new to the NHS who will not have
contact with patients or clinical specimens
should not start work if they have signs or
symptoms of TB.
• Health checks for employees new to the NHS
who will have contact with patients or clinical
materials should include:
– assessment of personal or family history of
– symptom and signs enquiry, possibly by
Health Clearance Guide cont
documentary evidence of tuberculin skin testing (or
interferon gamma testing) and/or BCG scar check by
health professional, not relying on the applicant’s
– tuberculin skin test (or interferon-gamma test) result
last five years, if available.
Hand Out 1.
Why is testing one-off and not
Professional codes of practice from regulatory bodies
require healthcare workers who may have been
exposed to infection with a serious communicable
disease, in whatever circumstances, promptly to seek
and follow confidential professional advice about
whether to undergo testing. Failure do so may breach
the duty of care to patients.
BCG FOR TRAVELLERS
The vaccine is
recommended for those
under 35 years who are
going to live or work with
local people for more than
three months in a country
where the annual incidence
of TB is 40/100,000 or
People seeking vaccination
for themselves or their
children should be assessed
for specific risk factors for
TB. Those without risk
factors should not be offered
BCG vaccination but should
be advised of the current
policy and given written
IMPLEMENTING CHANGES IN CORNWALL
TB ADVISORY GROUP ATTENDED BY;
Chaired by HEALTH Respiratory Physician
Occupational Health Physician
Neonatal Nurse Specialist
County Immunisation Lead
State Veterinary Service
Neonates – ensuring the target group are identified
School Entry- identifying children in risk group who
would not have been assessed at birth
School- identifying children in risk groups
New Immigrants- ensuring new arrival register with a
GP and that their risks are assessed.
Neonates & School Entry
NEONATES SCHOOL ENTRY
We now have an agreed policy to The school entry questionnaire
ensure that neonates at risk are now asks if the child has already
identified early. had a BCG vaccination and
includes questions to assess the
risk group of those who have not.
Available in several languages
Tel: 08701 555 455
Parents of children already in school who would have
been due to receive a BCG under the old system should
be sent a risk assessment by the PCT.
This has been delayed whilst the TB Key-workers have
undertaken Mantoux Training
A system already exists at Heathrow and Gatwick to
identify new entrants from high risk areas who are
coming to stay for more than six months.
Local strategies are not finalised and this is our next
Lynne Heard should be presenting a session on
Immigrant Health and TB to this group soon.
Also available in several
•Department of Health
Tel: 08701 555 455
TB in Cornwall 2006
7 cases – 4 born overseas
1 case in Kerrier
1 case in Restormel
5 cases in NCDC
Cornwall TB cases 2006