Do selective immunisation against tuberculosis and hepatitis B reach the targeted populations? A nationwide register-based study evaluating the recommendations in the Norwegian Childhood Immunisation Programme

Feiring, Berit; Laake, Ida; Molden, Tor; Håberg, Siri E.; Nøkleby, Hanne; Seterelv, Siri; Magnus, Per; Trogstad, Lill

doi:10.1016/j.vaccine.2016.02.060

Cited by 10 publications

(8 citation statements)

References 26 publications

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“…(27) Our study extends this work by also considering the age of those given BCG vaccination, although we were unable to estimate the impact of a universal neonatal scheme as this has never been implemented nationally in England. It has previously been shown that targeted vaccination programmes may not reach those considered most at risk, (28) our findings may support this view as we observed only a small decrease in incidence rates in UK born neonates after the introduction of the targeted neonatal vaccination programme. Alternatively, the effectiveness of the BCG in neonates, in England, may be lower than previously thought as we only observed a small decrease in incidence rates, whilst a previous study estimated BCG coverage at 68% (95%CI 65%, 71%) amongst those eligible for the targeted neonatal vaccination programme.…”

Section: Discussionsupporting

confidence: 85%

Estimating the effect of the 2005 change in BCG policy in England: A retrospective cohort study

Abbott

Christensen²,

Welton³

et al. 2019

Preprint

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BackgroundIn 2005, England changed from universal Bacillus Calmette-Guérin (BCG) vaccination of school-age children to targeted BCG vaccination of high-risk children at birth. MethodsWe combined notification data from the Enhanced Tuberculosis Surveillance system, with demographic data from the Labour Force Survey to construct retrospective cohorts of individuals in England relevant to both the universal, and targeted vaccination programmes between Jan 1, 2000 and Dec 31, 2010. For each cohort, we estimated incidence rates over a 5 year follow-up period and used Poisson and Negative Binomial regression models in order to estimate the impact of the change in policy on TB. ResultsIn the non-UK born, we found evidence for an association between a reduction in incidence rates and the change in BCG policy (school-age IRR: 0.74 (95%CI 0.61, 0.88), neonatal IRR: 0.62 (95%CI 0.44, 0.88)). We found some evidence that the change in BCG policy was associated with a increase in incidence rates in the UK born school-age population (IRR: 1.08 (95%CI 0.97, 1.19)) and weaker evidence of an association with a reduction in incidence rates in UK born neonates (IRR: 0.96 (95%CI 0.82, 1.14)). Overall, we found that the change in BCG policy was associated with directly preventing 385 (95% CI -105, 881) TB cases. ConclusionsWithdrawing universal vaccination at school-age and targeting BCG vaccination towards high-risk neonates was associated with reduced incidence of TB in England. This was largely driven by reductions in the non-UK born. There was a slight increase in UK born school-age cases. Key Messages •There is little existing literature on the impact of withdrawing universal school-age BCG vaccination and introducing high-risk neonatal BCG vaccination on TB incidence rates in the populations directly affected by the vaccination programmes.

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Section: Discussionsupporting

confidence: 85%

Estimating the effect of the 2005 change in BCG policy in England: A retrospective cohort study

Abbott

Christensen²,

Welton³

et al. 2019

Preprint

View full text Add to dashboard Cite

show abstract

“…Norway d 2Mass vaccinationTargeted2009At birthNewborns with parents from high prevalence countries5.6NRTargeted vaccination of high-risk groups recommended over universal vaccination due to high number of vaccinations needed to prevent one case in low-risk groups [34]. Due to concerns of incomplete coverage of risk groups after discontinuation of universal vaccination policy, improvements are needed in the identification of children considered high risk [35]. Australia3Mass vaccinationTargetedMid-1980sPreviously at school age, currently at birth• Newborns in high-incidence Aboriginal and Torres Strait Islander communities• Newborns in families with leprosy,• Newborns and children otherwise at risk (e.g.…”

Section: Resultsmentioning

confidence: 99%

“…Notably, among studies in countries that have shifted from universal to targeted vaccination, all found this change in policy appropriate and did not recommend re-introduction of universal vaccination, however, possible dangers of withdrawal of mass vaccination were also highlighted. These included not only a potential rise in TB cases, (as occurred, for example, in the Czech Republic, where a rise in TB incidence was observed in the region in which mass vaccination was discontinued in 1986 [9]), but also the concern of incomplete coverage of risk groups after discontinuation of universal vaccination [35]. It was therefore generally agreed that for successful withdrawal of universal vaccination, effective identification of high-risk children and strict adherence to guidelines regarding their vaccination is needed [14, 35], and a strong TB control program (including sufficient screening and diagnostic strategies) must be in place prior to withdrawal [19, 32].…”

Section: Resultsmentioning

confidence: 99%

“…Specifically, the continuation of targeted vaccination in new-borns of parents from TB endemic countries (WHO-estimated incidence > 50 /100.000 population) is recommended. [61], 2008NeRCTNewborns with a family history of allergic disease (asthma, allergicrhinitis, eczema or food allergy)BCG given at 6 weeks and repeated if BCG scar absent and TST negative at four monthsPlacebo6154Asthma attackMedication use for eczema8/54 (15%)23/54 (43%)11/61 (18%)RR: 1.22 (0.5–2.8) p value: ns15/61 (25%)RR: 0.58 (0.3–1.0) p value = 0.04BCG may be beneficial in reducing allergic disease, however, there was no significant difference in occurrence of asthma, although there was significantly lower medication use for eczema in the BCG group. Larger studies are needed however in order to confirm the effect of BCG on allergic disease. [35], 2016NorCSNorwegian ChildrenUniversal vaccination of children aged 13–15 until 2009Targeted vaccination shortly after birth of children with at least one parent born in a country with high burden of TB (83.60%)Total: 240,484Children of parents from high-burden countries.This study found that coverage of BCG vaccination, which was targeted, was lower than coverage of vaccines that are offered under a universal vaccination program, and suggests that improvements in the identification of children eligible for vaccination is needed, including the appropriate informing of healthcare professionals regarding the new guidelines. [9], 2014S. ArCSChildren diagnosed with BCG lymphadenitisMandatory BCG vaccination since 1968, mainly using Pasteur 1173 P2 and Tokyo 172–1.…”

Section: Resultsmentioning

confidence: 99%

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A systematic review of BCG vaccination policies among high-risk groups in low TB-burden countries: implications for vaccination strategy in Canadian indigenous communities

Faust

Schreiber

Bocking³

2019

BMC Public Health

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BackgroundBacille Calmette-Guérin (BCG) vaccination against tuberculosis (TB) is widespread in high-TB-burden countries, however, BCG vaccination policies in low-burden countries vary. Considering the uncertainties surrounding BCG efficacy and the lower likelihood of TB exposure in low-incidence countries, most have discontinued mass vaccination, choosing instead a targeted vaccination strategy among high-risk groups. Given the increased risk of TB infection in Canadian Indigenous communities compared to the general Canadian population, these communities are a pertinent example of high-incidence groups in an otherwise low-burden country, warranting particular consideration regarding BCG vaccination strategy. This systematic review aims to synthesise and critically appraise the literature on BCG vaccination strategies in high-risk groups in low-incidence settings to provide policy considerations relevant to the Canadian Indigenous context.Methods: A literature search of the Medline and Embase databases was conducted, returning studies pertaining to BCG vaccine efficacy, TB incidence under specific vaccination policies, BCG-associated adverse events, and vaccination policy guidelines in low-burden countries. Study screening was tracked using the Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia), and data pertaining to the above points of interest were extracted.ResultsThe final review included 49 studies, spanning 15 countries. Although almost all of these countries had implemented a form of mass or routine vaccination previously, 11 have since moved to targeted vaccination of selected risk groups, in most cases due to the low risk of infection among the general population and thus the high number of vaccinations needed to prevent one case in the context of low-incidence settings. Regarding identifying risk groups for targeted screening, community-based (rather than individual risk-factor-based) vaccination has been found to be beneficial in high-incidence communities within low-incidence countries, suggesting this approach may be beneficial in the Canadian Indigenous setting.ConclusionsCommunity-based vaccination of high-incidence communities may be beneficial in the Canadian Indigenous context, however, where BCG vaccination is implemented, delivery strategies and potential barriers to achieving adequate coverage in this setting should be considered. Where an existing vaccination program is discontinued, it is crucial that an effective TB surveillance system is in place, and that case-finding, screening, and diagnostic efforts are strengthened in order to ensure adequate TB control. This is particularly relevant in Canadian Indigenous and other remote or under-served communities, where barriers to surveillance, screening, and diagnosis persist.

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“…Despite newborn vaccination of children having at least one parent from a highly endemic country, the incidence rate in this group is 27 times higher than in children whose parents are both Norwegian-born. In recent years, approximately one-sixth of the birth cohorts have received BCG vaccination as neonates [8].…”

Section: Tb Epidemiologymentioning

confidence: 99%

Bacille Calmette–Guérin vaccination of healthcare personnel: changing epidemiology calls for new recommendations in Norway

2019

Self Cite

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]. Until 2018, bacille Calmette-Guérin (BCG) vaccination was strongly recommended for all unvaccinated personnel and students in the healthcare sector in Norway. From June 2018, only a select group of students and healthcare personnel have been targeted for BCG vaccination, i.e. previously unvaccinated healthcare workers and students under 35 years of age who are caring for adult patients with pulmonary tuberculosis (TB) in hospitals or involved with mycobacterial culture in laboratories. What was the rationale behind this policy change? A short history of BCG in Norway In 2009, Norway was one of the last Western European nations to abandon universal BCG vaccination [1]. Until then, all tuberculin-negative schoolchildren were vaccinated at the age of 12-14 years. In addition, both before and after 2009, vaccination was recommended for newborns with parents from high-incidence countries, for all students and employees <35 years of age in the healthcare sector, and for individuals <35 years of age planning a long-term stay in a country with high incidence of TB (table 1) [2]. Norway's extensive BCG vaccination policies may have been influenced by pioneer studies in the 1920s and 1930s conducted by the physicians Johannes Heimbeck and Olaf Scheel at Ullevål Hospital in Oslo [3]. At a time when Norway had very high TB prevalence, they found that one-half of nursing school students were tuberculin-negative when they started their studies, and all were positive after 3 years, indicating high rates of new infection [4]. Out of 284 tuberculin-negative students who were not vaccinated, 97 fell ill with TB during their studies and 10 died [3]. By administering BCG to volunteer tuberculin-negative nursing and medical students, Heimbeck and Scheel observed a protective effect against TB of ∼80% [2]. Need to revaluate BCG vaccination recommendations for healthcare personnel In 2014, 5 years after routine adolescent BCG vaccination was discontinued, the first cohort of unvaccinated individuals started healthcare studies. Practical difficulties related to BCG vaccination of healthcare employees and students had been anticipated, and indeed soon appeared. A main obstacle was

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Do selective immunisation against tuberculosis and hepatitis B reach the targeted populations? A nationwide register-based study evaluating the recommendations in the Norwegian Childhood Immunisation Programme

Cited by 10 publications

References 26 publications

Estimating the effect of the 2005 change in BCG policy in England: A retrospective cohort study

Estimating the effect of the 2005 change in BCG policy in England: A retrospective cohort study

A systematic review of BCG vaccination policies among high-risk groups in low TB-burden countries: implications for vaccination strategy in Canadian indigenous communities

Bacille Calmette–Guérin vaccination of healthcare personnel: changing epidemiology calls for new recommendations in Norway

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