CORRESPONDENCE

Selective neonatal BCG vaccination: Specialist BCG clinics arean alternative

Dear Sir,

We read with interest the article by Bakshi and

Sharief [1]. Selective neonatal BCG vaccination is

currently recommended in the United Kingdom for

infants “at risk” of tuberculosis (TB). Most health

trusts have local guidelines based on an accepted

national policy of selective immunization as recom-

mended by the Department of Health [2] and the

British Thoracic Society [3]. Audits are mostly local,

limited to a health authority area, as there are no

studies done on a national basis.

The authors of the cited paper [1] have shown an

85% vaccination rate in Basildon, Essex, which is quite

encouraging. We would like to discuss a few issues that

have surfaced in recent times in our experience

regarding this issue. Defining “risk” of TB based only

on ethnicity of either parent excludes white British

children with family and/or contact history of TB,

asylum seekers of any ethnic origin and children of

travelling families among others who are perceived to

be at risk of TB as well. Surveillance of childhood TB

from September 1996 to December 1999 conducted

through the Welsh Paediatric Surveillance System

(WPSS) reported 38 cases of TB and 59 children on

chemoprophylaxis. The majority of cases were noted to

be in the white population, and most had not received

BCG [4]. This was consistent with a previous study

conducted in Wales [5]. Therefore, what constitutes

“risk” will have a significant bearing on the inter-

pretation of these results. Another issue is regarding

the exclusion of infants born to parents who had

not visited their home country for more than 5 y.

Reactivation of TB in their parents as well as exposure

to TB from visiting relatives will remain a possibility

in such cases. We agree that the major bulk of the

infants at risk do come from well-defined foreign

ethnic groups, but the above exclusions are clearly

important. Regarding the conclusion that neonates at

risk of TB rarely get immunized in the community, one

has to interpret this finding in light of the process

adopted to vaccinate these subjects. The authors are

testing their existing process of ensuring BCG vacci-

nation prior to hospital discharge, but not a process

designed for post-discharge vaccination in the

community.

In our experience, lack of junior doctor familiarity

with performing intradermal injections, lack of single

dose ampoules and vaccine availability over consider-

able periods of time in recent years (second half of

2002) make such a process of pre-discharge vacci-

nation difficult. Many health trusts now adopt a policy

of appointing these infants to specialist BCG clinics

manned by trained nursing teams experienced in

administering BCG vaccine. The advantage of such a

system is not only reliable vaccination technique, but

also review facilities with strong community links

which help in tracking defaulters and reappointing

them. This also gives TB prevention a holistic and

family-oriented dimension.

It has always been regarded ideal to catch the

“at risk” babies before their discharge, but the salient

issues are availability of vaccine and cost effectiveness

of using multidose vials on an ad hoc basis, thus regu-

larly wasting vaccine, as opposed to using full resources

by organizing “baby clinics” after discharge. More

importantly, the dubious efficacy of immunization

given by rather “unpractised” health professionals

(doctors or midwives) simply by virtue that they do not

get the opportunity to regularly practice the skill should

be borne in mind as well. Arguably, babies will benefit

more from having a BCG from someone who is

consistently administering the vaccine. The benefits

from having such a custom-built service will have a

broader applicability, considering that the issues

discussed are not peculiar to our local area in the UK.

References

[1] Bakshi D, Sharief N. Selective BCG vaccination. Acta Paediatr

2004;93:1207–9.

[2] Department of Health, Welsh Office, Scottish Office Depart-

ment of Health, DHSS (Northern Ireland). Immunization

against infectious disease. London; 1996.

[3] Control and prevention of tuberculosis in the United Kingdom:

Code of Practice 2000. Joint Tuberculosis Committee of the

British Thoracic Society. Thorax 2000;55:887–901.

[4] Sastry J, Alfaham M, Evans M. Surveillance of childhood

tuberculosis through the Welsh Paediatric Surveillance System

(WPSS). Thorax 2000;55 Suppl 3:A56.

[5] Mathew V, Alfaham M, Evans MR, Adams H, Verrier Jones R,

Campbell I, Jenkins T. Management of tuberculosis in Wales:

1986–92. Arch Dis Child 1998;78:349–53.

Acta Pædiatrica, 2005; 94: 634–637

ISSN 0803-5253 print/ISSN 1651-2227 online # 2005 Taylor & Francis Group Ltd

DOI: 10.1080/08035250510025833

RAMESH SRINIVASAN1 & PATRICIA STEVENS2, 1Depart-

ment of Child Health, Llandough Hospital, Cardiff, UK, and 2TB

Control Service, Llandough Hospital, Cardiff, UK. Correspondence:

R. Srinivasan, Department of Child Health, Llandough Hospital,

Penlan Road, Penarth, Cardiff CF64 2XX, UK. Tel: +44 2920

715353. Fax: +44 2920 716048. E-mail: ramesh.srinivasan@

cardiffandvale.wales.nhs.uk

Received 31 August 2004; accepted 12 October 2004

Bilateral panuveitis and optic neuritis following BacillusCalmette-Guerin (BCG) vaccination

Sir,

Uveitis and associated arthritis have been reported

following intravesical and intradermal BCG vaccine

[1]. Yen and Liu reported the first case of bilateral optic

neuritis in a young girl following BCG vaccination [2].

We would like to describe a case of simultaneous

uveitis and optic neuritis following intradermal BCG

vaccination in a girl with immunoglobulin (IgA and

IgM) deficiency. To the best of our knowledge, we are

unaware of similar observations.

A 14-y-old girl was examined at an eye clinic for

bilateral sore and red eyes. Her presenting visual

acuity was 6/9 in the right and 2/60 in the left. On

examination of the left eye, positive findings were:

cells in the anterior chamber and a vitreous, relative

afferent pupilary defect and swollen optic disc. The

right eye also demonstrated few cells in aqueous and

vitreous with swollen optic disc. The retina looked

healthy in both eyes. Colour vision was reduced in

both eyes. Goldman visual field demonstrated gener-

alized constriction in either eye. She also complained

of accompanying sore wrists, which subsided with

oral non-steroidal anti-inflammatory tablets. Family

history revealed her brother as having a mild deficiency

of IgA and IgM. Five weeks prior to the sore eyes,

she had received BCG vaccination, as she was found

negative for tuberculin skin test. An investigation of

the brain and optic nerves with magnetic resonance

imaging scan was normal. Full blood count, serum

electrolytes, erythrocyte sedimentation rate (ESR),

C-reactive protein (CRP), serum calcium (Ca++),

serum angiotensin-converting enzyme, fluorescent

treponemal antibody test, viral serology, urinalysis,

chest X-ray, antinuclear antibodies and cerebro spinal

fluid analysis were normal. She was HLA-B27 and

rheumatoid factor negative. Her immunoglobulin assay

also showed low IgA (0.59 g/l) and IgM (0.29 g/l)

levels. She received 3 d of intravenous methyl predni-

sone (500 mg/d) followed by a tapering dose of oral

prednisolone (60 mg/d). She also received topical

prednisone (1%) QID and cyclopentolate (1%) BID to

both eyes. Both optic neuritis and uveitis resolved

completely with improvement in vision to 6/5 in both

eyes. Currently, she is on methotrexate (10 mg/wk)

with visual acuities of 6/5 in both eyes and almost full

recovery of visual fields.

A case of arthritis and iritis has been reported 3 wk

after BCG therapy for bladder cancer [3]. Our case

developed eye symptoms and arthritis 5 wk after the

BCG vaccination. Up to 25% of patients may have

ocular inflammation following BCG immunotherapy

in bladder cancer [1]. Arthritis following BCG vacci-

nation is mainly of the small joints (90%), consistent

with the sore wrists in our case [1]. The dose of BCG

vaccination is 0.05–0.1 ml; however, BCG immu-

notherapy for bladder cancer is between 50–120 mg

[4,5]. This dose difference may contribute to more

systemic side effects following BCG immunotherapy.

The amplification of the systemic side effects follow-

ing a BCG vaccine in our case has probably been

contributed by immunoglobulin deficiency. The

pathogenesis of complications following BCG immu-

notherapy is thought to be T-cell mediated, and the

role of HLA-B27 is debatable [1,6].

In the absence of other demonstrable aetiologies

and considering the close proximity to BCG vacci-

nation, we think the panuveitis and optic neuritis

is probably secondary to her vaccination. This

case suggests a strong causal relationship between

panuveitis and optic neuritis with BCG vaccination.

There is no definitive test to confirm this, and only

similar observations in the future can substantiate our

hypothesis.

References

[1] Buchs N, Chevrel G, Miossec P. Bacillus Calmette-Guerin

induced arthritis: an experimental model of reactive arthritis.

J Rheumatol 1998;25:662–4.

[2] Yen MY, Liu JH. Bilateral optic neuritis following Bacillus

Calmette- Guerin vaccination. J Clin Neuroophthalmol

1991;11:246–9.

[3] Price GE. Arthritis and iritis after BCG therapy for bladder

cancer. J Rheumatol 1994;21:564–5.

[4] Lamm DL. Optimal BCG treatment of superficial bladder

cancer as defined by American trials. Eur Urol 1992;21 Suppl

2:12–6.

[5] Issues relating to the use of BCG in immunization programmes.

WHO/V&B/99. 23 November 1999.

Correspondence 635

ISSN 0803-5253 print/ISSN 1651-2227 online # 2005 Taylor & Francis Group Ltd

DOI: 10.1080/08035250510029514