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Table 2 Overview of Vaccination Policies in Countries of Conduct of Included Studies, by TB Incidence

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

Country

#S

Prior Vaccination

Policies

Current Vaccination Policy b

As of

(Year)

Age at Vaccination

Currently Targeted Risk Groups (TRG)

Nat. TB Inc. a c

TB Inc. a in TRG

Summary of Policy Recommendations or Concerns Based on Results of the Included Studies (see Tables 3 and 4 for specific results regarding vaccine efficacy and adverse events)

UAE d

1

Mass vaccination

No change - Mass vaccination

NA

At birth

NA

0.7

NA

Low number of adverse events suggests vaccine is safe and current policy of mass vaccination is acceptable [28].

USA d

3

Targeted

No change - Targeted

NA

NR

Children residing in contexts in which risk of TB infection is high (detailed cut-offs unspecified)

2.9

NR

Mass vaccination remains unnecessary [29]. Regarding high-risk groups, BCG vaccination among the homeless has been shown to be effective [30], and the protective efficacy of the vaccine among Native American communities has been shown to persist up to 50–60 years post-vaccination, suggesting a long-term benefit of vaccination among this risk group [8].

Finland

2

Mass vaccination

Targeted

2006

At birth (and previously, re-vaccination at school age)

• Children of immigrant families from high-incidence countries,

• Children living with relatives with TB

• Children staying in high-incidence countries for a prolonged period

• Children whose families request BCG

• Children from high-incidence countries who have not yet entered school.

4.3

NR

In Finland, most TB cases are among seniors (65 or older) and the Indigenous population (rather than among immigrants, as is the case in many other European countries). However, recommended target groups remain immigrant and other at-risk children (see targeted risk groups) [31]. Before routine vaccination was discontinued in 2004, it was emphasized that the following criteria (set by the International union against TB and lung disease) should be met before discontinuation:

• Strong established TB control program

• Knowledge of impact of HIV prevalence in the population on TB transmission

• Incidence of smear-positive TB no more than 5 / 100,000 in the past 3 years, or

• Less than 1 case per 10,000,000 of TB meningitis in children under 5 in the last 5 years, or

• Annual risk of TB 0.1% or less [32].

Czech Republic

2

Mass vaccination

Targeted

2010

Between birth and 6 weeks of age (and previously, re-vaccination at 11 years)

Newborns from high-risk families

4.7

NR

Although TB incidence increased in the region where mass vaccination was stopped [10], risk of infection was low, so re-introduction of mass vaccination was not deemed necessary [11]. Overcrowded living conditions were associated with a higher risk of infection, which is also a relevant consideration in the Canadian Indigenous context, however, no specific risk groups or criteria for targeted vaccination were identified, except neonates from families at “high risk” of infection [11].

Canada

3

Routine vaccination among Indigenous communities

Targeted (see currently targeted risk groups)

2003–2005 (Varies by community)

Within 1 year of birth

• Infants in some Indigenous Communities,

• Infants in populations with an annual risk of TB infection > 0.1%

4.8

26.6

As recommended by the National Advisory Committee on Immunizations, vaccination should continue in:

• Infants in First Nations and Inuit communities with an average annual rate of smear-positive pulmonary TB greater than 15 per 100,000 population in the past 3 years, or

• Infants residing in populations with an annual risk of TB infection greater than 0.1% [33].

Where vaccination is withdrawn, it should be ascertained that a strong surveillance system is in place before withdrawal [19].

Netherlands

2

Targeted vaccination of children with parents from endemic countries

Targeted

2005

NR

Children with one or both parents born in a country with TB incidence > 50/100000 (as per WHO estimate)

5.2

NR

Issues of incomplete coverage (39% of at-risk children not vaccinated in a 2014 study) suggest that further cases could be prevented through stricter adherence to vaccination of high-risk children. Specifically, the continuation of targeted vaccination in new-borns of parents from TB endemic countries (WHO-estimated incidence > 50 /100.000 population) is recommended [14].

Norway d

2

Mass vaccination

Targeted

2009

At birth

Newborns with parents from high prevalence countries

5.6

NR

Targeted 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].

Australia

3

Mass vaccination

Targeted

Mid-1980s

Previously 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. those who will be travelling to high TB prevalence countries

5.7

Foreign-born pop.: 15.5–21.0 (1992–2012)

Aboriginal pop.: 5.9 (2008)

As most TB cases (80–90%) in the country are among immigrants from high-prevalence countries, selective vaccination is efficient [36]. Increased surveillance of adverse events is needed during vaccine shortages and consequent use of unregistered vaccines [37, 38].

Denmark

4

Mass vaccination

Targeted

1986

At birth

• Children traveling to endemic countries

• Children with a family history of TB

5.8

NR

Targeted vaccination continues to be recommended. No significant negative effects of BCG were found on child psychomotor development [39], occurrence of inflammatory bowel disease [40], or other adverse events [41].

Ireland d

1

Mass vaccination (in some regions)

No change - Mass vaccination in some regions

NA

At birth (and previously, re-vaccination at 11–12 years)

NA

6.8

NA

A 1997 study in Ireland showed the number of vaccinations needed to prevent one case had decreased over time, suggesting that continuing the policy of routine neonatal BCG vaccination is beneficial [42], however, this policy may need to be updated based on the current situation.

Sweden

3

Mass vaccination

Targeted

1975

At 6 months - 1 year (and previously, re-vaccination at 7 years)

High risk infants, i.e. those with:

• Family history of TB,

• Close contact to TB case

• Parents from endemic countries

• Plans to travel to endemic countries [43]

7.4

NR

Targeted vaccination of high-risk groups should continue, however, the age at vaccination should be postponed from at birth to 6 months of age, to allow the detection of immune-compromising conditions prior to vaccination (thereby avoiding serious adverse events) [44].

France

6

Mass vaccination

Targeted

2007

Before hospital discharge or entry into daycare

• Children with parents from endemic countries

• Children with a family history of TB

7.6

NR

No significant difference in incidence of TB meningitis before and after the changes in vaccination policy, suggesting that targeted screening is sufficient for TB control. However, given the possibility of incomplete coverage of high-risk children after suspension of mass vaccination, surveillance efforts should be strengthened [12].

Egypt d

1

Mass vaccination

No change - Mass vaccination

NA

At birth

NA

8.6

NA

Routine vaccination at birth continues to be considered beneficial (based on the significant correlation of BCG vaccine coverage with reduced TB incidence and TB-associated mortality) [45].

Saudi Arabia d

1

Mass vaccination

No change - Mass vaccination

NA

At birth

NA

9.3

NA

Routine vaccination continues, however, given the change of strains used for vaccination (from Pasteur 1173 P2 and Tokyo 172–1 to the Danish 1331 strain in 2005), more detailed population-based studies are recommended before the introduction of new strains in the future, with particular attention to the prevalence of host risk factors that contraindicate vaccination, such as immunodeficiency [9].

UK

6

Mass vaccination

Targeted

2005

At birth in at-risk neonates and opportunistically in older children [46] (previously at 12–13 years)

Children from high-risk families (see recommendations for details)

9.4

NR

Re-introduction of routine vaccination is not recommended [13]. Instead, targeted vaccination is recommended among the following groups:

• Infants attending primary care organisations with a high incidence of TB,

• Infants in low-incidence communities meeting the following criteria:– those born in an area with a high incidence of TB, or– those with one or more parents or grandparents who were born in a high-incidence country (> 40 cases per 100,000 per year), or– those with a family history of TB in the past 5 years.

• Children younger than 16 who also meet these risk criteria should be opportunistically vaccinated [47].

  1. #S Number of included studies from this country in this review, Cont Control, Inc Incidence, Int Intervention (or case group, for case-control studies), NA Not applicable, Nat National, NR Not reported, Pop population, TB Tuberculosis, TRG Targeted Risk Groups
  2. a Cases per 100,000 population per year
  3. b As the included studies report different policies as current or prior depending on publication date (as shown in later tables), current policies in this summary table are extracted from the BCG World Atlas, which was last updated 2017, unless otherwise indicated
  4. c National incidence rates per 100, 000 population were calculated based on 2016 WHO incidence estimates
  5. d Policy information last updated 2011