BCG/MMR injections

[pommie]

Our little one will be 1 on saturday and I know that the BCG injection should be given to them before they are 1. She is also going to be due to have her MMR injection at the age of 1. just wondered how long i have to wait after one injection before she can have the other one

[etta166]

The BCG doesn't have to be given before the age of 1. It is more effective in older children (in fact there is little published evidence of long-term effectivness when givent to infants) and is also frequently given to adults. Whether you want to give it depends on where you live and the prevelance of TB in the area. It's not a recommended vaccine in all London boroughs and it is rarely given to infants outside of cities in the UK. Most people have it as teenagers.

On the other hand, there's absoluetly no reason not to have the BCG and MMR in the same visit if that's what you want to do. You can do the MMR at 12 months and the booster at 15 months, saving the need to do it again at pre-school age. Southwark did a study on this a few years ago and found that the protection was better for measles if you had the booster sooner.

[pommie]

i was told that my daughter has to have the BCG before she is 1.

With regards to having the BCG and MMR at the same time, this wouldnt be possible as i have to go to a BCG drop in clinic so wouldnt be able to have the MMR also.

[Saffron]

The NHS has a mandate to vaccinate under-1s with BCG, and it's no longer routinely given to teens. The vaccine itself only has between 60-80% efficacy, with decreasing efficacy in older children and adults (that's why the age was moved down from teens to under-1s). One reason for this may be that increasing environmental exposure to mold/fungus with age develops an immune response that has some overlap with TB immunity.

Many countries do not give the BCG at all, and instead rely on latent TB testing. However, due to the presence of TB in some London populations (mostly the homeless and chronic drug users), the BCG is being offered by the NHS to under-1s in order to provide protection against miliary TB, a particularly damaging form of TB in infants. This vaccination is at your dr's discretion, and you can still have it given to your child, even if she's a little older than one-year. You can also choose not to have this vaccine, if your child is not in contact with any high risk populations.

xx

[Digbina]

The information I received from the Nunhead clinic responsible for administering the BCg in Southwark specifically said that the BGC should NOT be given within one month of receiving the MMR vaccine as it is a live vaccine.

[pommie]

ok so looks like i need to get the BCG done tomorrow and wait a few weeks to get the MMR done

[etta166]

Although some PCTs have decided to engourage the BCG in infants, my friends living in Croydon are not being offered it. It seems like only Lambeth and Southwark are pushing for it to be done before the age of 1. When I spoke to my GP about it, he thought that there was no real medical reason for giving the BCG before the age of 1 if you are in a low-risk population. He also wasn't able to point to any information showing that you get long-lasting immunity from infant vaccination.

I'd be more keen to get the MMR sooner, because there have been a number of measles outbreaks in South London recently.

[Piaf]

In Islington where we were living, my daughter had the BCG done at four weeks! The policy in Islington and Hackney was (and is) for the BCG vaccination to be given ahead of all the others... I think because there is a higher incidence of TB in the area than elsewhere. Interesting the different approaches

[etta166]

It is really interesting how much variation there can be in such a small area. When I was considering the BCG for my children, Southwark and Lambeth were very close to the lower threshold to not even offer the BCG and Croydon was just under, so it didn't! It seemed odd to me, because they are right next to each other...

[Saffron]

Lewisham has also been offering the BCG to under-1s, but I'm not surprised that not everywhere is offering it b/c it isn't the best way to fight TB on a population basis. As of a couple years ago, the stats were such that ~10,000 children needed to be vaccinated with the BCG to prevent 1 case of TB. However, research has shown that the far more effective way to control TB is to target it at its source by improving housing and hygeine for vulnerable populations, eg the homeless or people living in overcrowded unsanitary conditions, as well as chronic drug users.

The medical reasons for giving the BCG to infants are that it protects against miliary TB (a particularly damaging and difficult to treat form of TB infection where TB spreads outside the lungs to other organs of the body), and that it protects again TB-related menigitis: both of which are life-threatening conditions for infants. This is common medical knowledge, which can be found in many places including the WHO website, so it's a little surprising than a GP would not be aware of this.

The BCG gives 60-80% protection (depending on which studies / what populations you observe) that lasts for ~15 years. This is also common medical knowledge.

So even if you had the BCG as a child or teen, if as an adult you have been in direct contact with TB infected individuals, you should have a Mantoux test which is diagnostic of TB. Indeed many coutries rely only on Mantoux testing and do not offer the BCG. This appears to work well incombination with improved living conditions and hygeine for vulnerable populations in first world countries. However, for many poor countries where TB is endemic, the BCG though not fully effective is still the best line of defense for preventing miliary TB and TB menigits in infants.

[KattyKit]

Saffron that is not quite correct - A mantoux test for adults over 35 doesn't diagnose TB particularly well and is not recommended - it's a chest x ray and possibly a blood test, depending on the results.

Testing for TB if you have been in contact with someone with TB is only done after a careful risk assessment of degree of contact, how infectious they are etc.

[etta166]

I feel the need to defend my GP a bit Saffron. His view was better informed than you seem to assume. His advice is based on the fact that Lambeth and Southwark as a whole are very close to 40 per 100,000 cases of TB in the population, which is the threshold for routine infant TB vaccination. If you look in more detail at the information from the HPA about TB incidence, the rate is extremely low for people born in the UK, but higher for those from areas with high rates of endemic TB. So a child of parents born in the UK who is also born in the UK, even if they live in Southwark or Lambeth, is not actually in an at-risk population.

Added to that, as you said, immunity is thought to last about 15 years, but this is only known for some populations. It is well known that the BCG has a highly variable rate of inducing immunity in different ethnic groups and in different geographical locations. No one really knows why. Because the shift to infant vaccination in the UK is only recent, we don't really know if immunity will persist for as long as 15 years in this population, as BGC immunity s very variable so you can't really extrapolate from the data collected in other countries that have used infant vaccination for longer.

Exposure to TB, according to the HPA data on incidence of TB with age, is thought to be low in infancy and to start to climb around the teenage years. Even a vaccinated infant who did get 15 years immunity might well be susceptible again by that point.

So overall, the advice I had was to wait and vaccinate later, either before school age or a bit later.

As to the OP's question, on balance I wouldn't delay the MMR in favour of the BCG, just because the MMR is more effective and the risk of contracting measles in our local area is higher than TB. I'd probably still try to get both done, because I'm massively in favour of vaccination in general.

[Saffron]

Perhaps there was something lost in translation here? I did not assume your GP was ill informed. I was merely surprised by your statement that "When I spoke to my GP about it, he thought that there was no real medical reason for giving the BCG before the age of 1 if you are in a low-risk population."

The medical reason for giving it remains the same in any population. It's the risk assessment that changes with population. Whether in a low or high risk, the vaccine provides protection from milliary TB and TB menigitis.

I'm not disputing any of the threshold data or age-related immunity you discuss either, quite the contrary. Indeed the madate to vaccinate under-1s in high-risk areas may be misplaced (or out of proportion to age-related risk). However, there is no longer a mandate to vaccinate teens, that I'm aware http://www.nhs.uk/Conditions/vaccinations/Pages/bcg-tb-vaccine-questions-answers.aspx#teenagers. And the NHS website on BCG says that if your child has not been automatically offered a BCG, then you'll have to pay for it privately https://www.nhs.uk/Conditions/vaccinations/Pages/bcg-tuberculosis-TB-vaccine.aspx. (Possibly different practices are handling this differently, with some offering uptake later, and others not??? We actually didn't do the BCG for Little Saff, and our practice nurse was quite clear that if we did not take this imm at or around 1 yrs old, then we'd have to have it done privately later.)

Regarding BCG and MMR, I found this website useful and easy to navigate: http://surreydockshc.co.uk/child_imms_links.htm#BCG_for_babies_and_children_under_6_years_old

Should other immunisations be delayed if my child is going to receive the BCG vaccine?

Diphtheria, tetanus, whooping cough, Haemophilus influenza type b (Hib), Polio, meningitis C, pneumococcal and Hepatitis B immunisations can be given at any time, regardless of when the BCG was given.

If for any reason MMR vaccine needs to be given at the same time as BCG, it should be given on the same day or four weeks apart. The Mantoux test needs to be done with a four week gap from a live vaccine.

BCG vaccination will be given on the upper part of the left arm. This arm must NOT be used for any further injections for at least three months after BCG vaccine has been given.

Other vaccines can be given in the other arm or in the thighs.

[Saffron]

KattyKit Wrote:

-------------------------------------------------------

> Saffron that is not quite correct - A mantoux test

> for adults over 35 doesn't diagnose TB

> particularly well and is not recommended - it's a

> chest x ray and possibly a blood test, depending

> on the results.

Quite right. I should have said Mantoux and associated tests.

>

> Testing for TB if you have been in contact with

> someone with TB is only done after a careful risk

> assessment of degree of contact, how infectious

> they are etc.

In Britain.

Different countries approach this differently.

[Saffron]

Pommie, hope you were able to schedule your LO's imms ok in the end. xx

[KattyKit]

Saffron Wrote:

-------------------------------------------------------

> KattyKit Wrote:

> --------------------------------------------------

> -----

> > Saffron that is not quite correct - A mantoux

> test

> > for adults over 35 doesn't diagnose TB

> > particularly well and is not recommended - it's

> a

> > chest x ray and possibly a blood test,

> depending

> > on the results.

>

> Quite right. I should have said Mantoux and

> associated tests.

>

> >

> > Testing for TB if you have been in contact with

> > someone with TB is only done after a careful

> risk

> > assessment of degree of contact, how infectious

> > they are etc.

>

> In Britain.

>

> Different countries approach this differently.

Yes Saffron I am aware of that. I was referring to the UK. Sorry thought that was obvious.

[pommie]

saffron

yes my little one had her BCG and she has to wait 4 months before she can have her MMR booster. She was fine with her BCG and at the moment doesnt have the usual blister that comes up but was told if this doesnt happen it means her immune system is high

[TE44]

Its still early days for a reaction pommie.

I have never heard that no scaarring or blister shows a highh

immunity, many countries including uk would re vaccinate if there was no reaction.

I believe this has not been the practice in this country for many years.but believe

this was stilll happening quite recently elsewhere in world. World Health Organisation

advised agains it. Sorry cant check or put up link now.

[etta166]

pommie Wrote:

-------------------------------------------------------

> at the moment doesnt

> have the usual blister that comes up but was told

> if this doesnt happen it means her immune system

> is high

That's the opposite of what I was told. I was borderline positive on my Heaf test but had a BCG as a teenager anyway. I was told I'd get a huge scar because of my high TB immunity. I didn't though, I hardly have a scar at all...

[crystal7]

I was told that too etta166, the bigger the blister the higher the level of immunity. No idea if it's true, my daughter had a really nasty pus filled blister for ages after having her BCG and 3 years on has a visible mark, son had no reaction at all.

[buggie]

The scar thing is a myth - it's not something which proves the effictiveness of the immunisation & shouldn't be trusted as such. The reaction varies from person to person.

As an interesting aside the pus that often comes from the injection site in the months following is due to the white blood cells over reaction to the immunisation & doesn't contain any of the vaccine as its been long absorbed by the body.

[TE44]

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001012

Link to bcg global database, at the end of link "implications for immunisation strategies".

[TE44]

http://m.ije.oxfordjournals.org/content/34/3/540.long

Link above says scar could bbe used as a marker, I don't know how old this is,

Maybe newer studies show diffrent. These findings were takken from studie done

in Guinea-Bissau, one of the poorest countries.

I know not related to bcg, although some vert

contraversual trials been done there, but that's

a bigger picture, As regards the scar,

Is it a case of conflicting views with science

or are parents being given wrong or old information,

[buggie]

My info came from the Lewisham immunisation programme lead when I had training on how to give BCG's last month - unfortunately I don't have the ref's to hand as I've got it at work.

For reasons unknown to even the top boffins, particular population cohorts are more resistant than others, which could explain the figures on the Malawi study you found TE44.

[TE44]

I think so many organisations involved with

trials in poorer countries where safety for the

people involved in these trials, has not been put

in place.below is a study on effect on bcg re vaccination

which shows how safety was lost.

http://www.bmj.com/content/340/bmj.c671

Below is some background and looking in parts at lessons

to be learned. Its an interesting read and at times seems

a breakthrough for communication, where many people felt they

had no voice.

http://www.health-policy-systems.com/content/10/1/5