|ASSESSMENT OF BCG VACCINATION IN INDIA; THIRD REPORT
|Kul Bhushan: Indian J Med Res 1960, 48, 406-17.
Under the auspices of the Indian Council of Medical
Research, a third assessment of the mass BCG campaign in
India was carried out from 1955-58. It is a continuation
of the work started by the WHO, of evaluating the level of allergy
among groups vaccinated in the campaign. WHO team used 5 TU RT 14,
20, 21, while the present assessment team used 5 TU RT 22.
A total of 18,367 school children distributed over 262 schools in
169 different localities were retested for post-vaccination tuberculin
sensitivity. The groups were vaccinated in mass BCG campaign
with 91 different batches of vaccine produced in Madras. The interval
between vaccination and retest varied from 1½ to 42 months.
The mean size of reactions varied from 8.3 to 16.6
with overall mean of 12.5 mm. Less than 10% of the mean values
were under 10 mm and less than 10% over 15 mm. Analysis also showed
that BCG vaccination was responsible for an increase of 6-7 mm
in the mean size of reaction over the pre-vaccination level of the
non-infected. One third of the groups had their sensitivity increased
upto 6 mm and two third by 7-11 mm. Comparing with the highest attainable
degree of tuberculin sensitivity in the infected 1/3rd of the vaccinated
group fell short of it by 5-9 mm, whereas 2/3rd were within 4 mm
of this level. There is no appreciable difference in the post-vaccination
allergy according to the state and prevalence of non- specific tuberculin
sensitivity. However, there is an increase in allergising capacity
of the BCG vaccine after introduction of modifications in the production
procedures in 1955 and again in 1956 in the BCG Laboratory at Madras.
Waning of allergy upto 20 months after vaccination and boosting
thereafter probably due to super infection was also observed. Findings
show that a large proportion of the vaccinated groups retested have
achieved attainable allergy with the vaccine used. In view of the
above, there is an urgent need to produce Freeze-Dried vaccine than
the present liquid vaccine for achieving high levels of allergy.
Freeze-Dried vaccine holds out promise for
use in the mass BCG campaign. A continued and expanded research
is needed into the protective value of BCG vaccination with the
level of allergy which the mass campaign can produce under the epidemiological
circumstances existing in India and other technically developed
|KEY WORDS: BCG VACCINATION, ASSESSMENT, TUBERCULIN
SENSITIVITY, TUBERCULIN ALLERGY, LIQUID BCG, FREEZE-DRIED BCG.
|TECHNICAL ASPECTS OF BCG VACCINATION CAMPAIGN
|Kul Bhushan: Bull Dev Prev TB 1965, 11, 31-35.
During the 7th All India BCG Conference held at
Ahmedabad in February 1965 various points regarding the technical
aspects of BCG Campaign were put forward by the author of this article.
The issues discussed were related to specific age group to be vaccinated;
direct vaccination; vaccination of new-borns; techniques of testing,
reading and vaccination; preservation of biologicals, Freeze-Dried
vaccine; pilot and research studies; assessment and training.
Some of the suggestions given on the above aspects
described briefly were: (1) Only 0-20 years might be taken up because
that was the most vulnerable age group for infection from the natural
sources. (2) Direct BCG vaccination in 0-20 years age group
could be carried out in the first round followed by vaccination
of population below 7 years of age (0-6 years) in the subsequent
rounds. (3) Infant vaccination practiced at that time in some of
the major cities only, would not contribute greatly to the control
of tuberculosis unless it is extended to the rural areas also. (4)
Results of vaccination should be exceedingly good provided vaccine
was maintained properly, used within 2 weeks of manufacture, shaken
well before opening, a drop ejected out before vaccination and proper
dosage injected correctly. (5) The vaccine must be kept under refrigeration
during storage, transport and use. (6) The personnel engaged in
the use of Freeze-Dried vaccine had to be trained properly
in its aseptic reconstitution. (7) Operational studies in respect
of BCG work in cities; practicability and feasibility of setting
up training centres in the states, assessment of programme by the
states etc., were required to be undertaken. (8) Uniformity of techniques
and procedures of BCG vaccination and proper assessment of Mass
BCG Campaign by an independent agency would be required. The author
in his article also stressed that no changes should be brought into
operation without assessment.
|KEY WORDS: BCG VACCINATION, MASS BCG CAMPAIGN,
DIRECT BCG VACCINATION.
|INTEGRATION OF BCG VACCINATION IN GENERAL HEALTH
SERVICES IN RURAL AREAS
|Baily GVJ, Kul Bhushan, GE Rupert Samuel & BK Keshav
Murthy : Indian J TB 1973, 20, 155-60.
BCG vaccination is being conducted as a mass campaign.
It is difficult to maintain a high coverage of the population at
risk i.e., new borns. This can best be done by integrating the BCG
vaccination services with the general health services. The present
investigation was planned to study the feasibility of routine BCG
vaccination of the new borns by the Primary Health Centre
personnel using the normal records maintained by them. In a rural
population of 33,128 persons (1971 census), served by PHC Bettahalasur
of Bangalore district, BCG vaccination was administered to 0-15
months old children by 2 Block Health Workers (BHWs) and 3 Auxiliary
Nurse Midwives (ANMs) after training them for about 3 weeks. They
used a compact specially designed BCG kit and employed a conventional
intradermal technique for BCG vaccination. Routine work was not
to be disturbed in any way. Each worker prepared a list of children
eligible for BCG vaccination from the register of unprotected children
and updated the list for those not found registered. National Tuberculosis
Institute (NTI) field staff registered a sample population, allotted
to each worker for estimation of eligibles. Three months later they
also examined BCG vaccination lesions in a sample of children. BHWS
and ANMS were interviewed by a medical officer from NTI regarding
their opinion on integrated work.
The findings showed that the ANMS and BHWS had already registered
nearly 50% of the new borns in their records with variation in registration
from 21 to 80% by the field workers; ANMS understandably having
registered lesser numbers. All of them were, however, able to update
the registrations to a level of 82%. They could pick up the BCG
vaccination technique easily. Of the total eligibles, ANMS and BHWS
could contact 86.4% and vaccinate 77%; remaining 23% either refused
or were excluded from vaccination. In the total eligibles registered,
however, the vaccination coverage was 66.6%. Of the children reported
vaccinated, 96% had evidence of BCG vaccination indicating a high
degree of reliability of reporting. The opinion of all the
5 field workers on integration was favourable. All the ANMS and
BHWS workers, on interview, stated that they had done BCG work without
detriment to their other duties and would be easily able to do so
in future. The field workers can accumulate the new borns for a
year and vaccinate them during a month. This has mainly operational
advantages including less vaccine wastage. For urban areas a
different operational design with the same principles may become
|KEY WORDS: INTEGRATION, BCG VACCINATION, HEALTH
SERVICES, RURAL POPULATION.
|BCG VACCINATION INDURATION SIZE AS AN INDICATOR
OF INFECTION WITH MYCOBACTERIUM TUBERCULOSIS
|GD Gothi, SS Nair, Kul Bhushan, GVJ Baily & GE
Rupert Samuel: Indian J TB 1974, 21, 145-51.
After the introduction of direct BCG vaccination,
assessment of post-vaccination allergy and information about prevalence
of infection could not be obtained. Few methods were tested i.e.,
i) retesting of persons with 0-13 mm reaction at site of vaccination
on 4th day of vaccination, ii) retesting of all vaccinated persons
of age 0-10 years. It is not only necessary to find out the size
of BCG lesion that could separate them but also the day after vaccination
on which the tuberculin reaction size best correlates with the BCG
vaccination size. With this in view, two studies with regard to
direct BCG vaccination done in India have been examined further.
In Study I, 816 eligible persons were tested with 1 TU RT
23 read on 3rd day and vaccinated with either Indian or Danish vaccine.
The vaccination lesions were examined on the 3rd, 6th and 90th day
of vaccination. On the 90th day post-vaccination tuberculin test
was done and read on 3rd day. In Study II, a total of 691
who had no previous BCG scar were simultaneously tuberculin tested
with 1 TU RT 23 and vaccinated with either Indian or Danish vaccine.
The BCG lesions were examined every day and on 39th and 90th day.
The correlation of pre-vaccination tuberculin
test and BCG lesion size showe d that sixth day in first study
and fifth day in second study was the highest. Tuberculin reaction
size of 10 mm or more correlated well with 14 mm or more induration
size of BCG in classifying the persons as infected and non-infected.
Correlation between the size of BCG scar at 3 months and size of
pre-vaccination tuberculin reaction was poor. Considering the two
studies together vaccination induration of 14 mm or more on 5th
or 6th day appears to be the best criterion for demarcating the
infected from non-infected. Some other choices are 12 or 14 mm levels
on 2nd day, 10 and 12 mm levels on 5th day and 10 mm levels on 8th
day seems to be nearly as good and operationally useful.
A BCG Vaccination induration size of 14 mm and
above between 5th and 6th day of vaccination, for all practical
purposes may be considered satisfactory for demarcating persons
infected with M.tuberculosis from those non-infected. It can
be concluded that estimation of prevalence of infection,
when BCG vaccination is given to all without prior tuberculin testing,
can be made on the basis of BCG vaccination induration size of 14
mm or more.
|KEY WORDS: BCG VACCINATION, M.TUBERCULOSIS,
INFECTION, TUBERCULIN INDURATION, RURAL POPULATION.
|PRIMARY COMPLEX AND BCG VACCINATION
|Kul Bhushan: Souvenir of Shri A.V.Jasani TB Hospital,
Kotharia: 1978, 1-7.
The article deals with primary complex and BCG
vaccination. Lodgement or implantation of tubercle bacilli, at any
site, in the body of an animal or human being is called primary
infection. The tissue response by accumulation of polymorphonuclear
leucocytes at the site of primary infection is termed as primary
focus. The tubercle bacilli are transported from the primary
focus to the lymph node through lymphatics. The primary focus,
the lymphangitis and regional lymphadenitis together constitute
primary complex. In 95% of cases it occurs in the lung: the initial
polymorphic leucocytic reaction in the primary focus and
the lymph nodes are soon augmented by large monocytes then epitheloid
cells and the Langhans' giant cells. In about 2-4 weeks the
reticuloendothehal system develops cell mediated immunity and tuberculo
hypersensitivity. Most of the primary complexes (lesions) become
innocuous after a short time harbouring the tubercle bacilli with
arrested activity, but live and potentially virulent. There is always
a lurking danger of these bacilli flaring up in the future to progressive
tuberculous disease. BCG vaccination is aimed at establishing a
controlled primary complex by intradermal injection of attenuated
(harmless) live, bovine strain of tubercle bacilli in an attempt
to forestall the infection with virulent tubercle bacilli among
the uninfected persons. At the site of vaccination, the lower half
of the left deltoid region, a primary focus is created from where
some bacilli are transported to axillary lymph node through the
lymphatics and complete the formation of primary complex. In 2-4
weeks time cell mediated immunity and delayed hypersensitivity are
initiated and is completed in about 6-8 weeks time and the vaccinated
persons show positive reaction to tuberculin test. The BCG lesion
heals in 4-6 weeks time.
The advantages of primary complex established
with BCG vaccination prior to a chance of natural infection
are: i) primary tuberculosis disease caused by it can be ruled out;
ii) there is no chance of spread of disease to adjoining parts i.e.,
haematogenous dissemination of disease leading to milliary, meningeal,
bone tuberculosis etc., is prevented; iii) also the danger of future
local flare up and thereby chances of disease after infection are
reduced. To obtain maximum advantage from the BCG vaccination, it
should be given at the earliest possible time in life of an individual.
|KEY WORDS: PRIMARY COMPLEX, BCG VACCINATION.