13 July 2005

Changes to the UK BCG vaccination programme and tuberculin skin testing

On 6th July 2005, the Chief Medical Officer, Sir Liam Donaldson announced changes to the BCG (Bacillus Calmette-Guerin) vaccination programme in the UK [1]. The new policy is based on targeted immunisation of neonates and others at high risk and will replace the schools' programme for older children.

This change reflects the evolving epidemiology of tuberculosis in the UK since the BCG programme was first introduced in the 1950s. At that time, 50,000 cases of TB were reported each year, affecting most groups of people in society. Around 7,000 cases now occur each year, mainly concentrated in large cities and  in specific population groups.

Following advice from the Joint Committee on Vaccination and Immunisation (JCVI), the current universal BCG vaccination programme delivered through schools will be replaced from September 2005 with a targeted programme of vaccination for the following groups who are at greatest risk;

• all babies living in areas where the incidence of TB is 40/100,000 or greater
• babies whose parents or grandparents have lived in a country with a TB prevalence of 40/100,000 or higher
• unvaccinated new immigrants from countries with a high TB prevalence

Recommendations have not changed for immunisation of contacts and those at risk occupationally or through travel. Travel medicine practitioners are reminded that BCG should be offered to those intending to live or work in high prevalence countries (tuberculosis rates of 40/100,000 or greater) for extended periods (generally one month or longer), who have not been previously vaccinated, and who have a negative tuberculin skin test (see below).

The switch from a universal to a targeted programme will have implications for the number of people who will require tuberculin skin testing and BCG vaccine pre-travel.  In the past, most travellers at risk for tuberculosis will have already received BCG via the schools programme.  However, in the future there are likely to be fewer at risk travellers who will have received BCG.  Health providers will need to consider how they will integrate a programme of screening and vaccination for travellers.  NaTHNaC and others are developing guidance in this regard.

With the change to this BCG programme, there will also be a switch from Heaf testing to Mantoux tuberculin skin testing.  The manufacturer that has supplied tuberculin PPD for both Heaf and Mantoux testing in the UK (Chiron Vaccines Evans) is ceasing production of these products and there is no other supplier of tuberculin PPD for Heaf testing.  The Department of Health (DH) has obtained alternative supplies of PPD for Mantoux testing from the Statens Serum Institute (SSI) in Denmark (summary of product characteristics at <http://www.immunisation.nhs.uk/files/

SSI_SPC.pdf>). This is currently only available as an unlicensed product in the UK. As current stocks of Heaf strength tuberculin PPD run out, services will need to change to Mantoux testing using the SSI product.

Tuberculin PPD (SSI) for routine use in the Mantoux test is the 2TU per 0.1ml dose. A summary of the differences between the tuberculin PPD products from Chiron Vaccines Evans and SSI can be found at
<http://www.immunisation.nhs.uk/files/PPD_

difference.pdf>. 

Further guidance on the new programme and on Mantoux testing is anticipated from the Department of Health shortly.

Reference

1.  Department of Health. Tuberculosis: Improvements to BCG immunisation programme ( press release ) (PL/CMO/2005/3). London : Department of Health, 6 July 2005. Available at <http://www.dh.gov.uk/AboutUs/MinistersAnd

DepartmentLeaders/ChiefMedicalOfficer/fs/en>.