0906 BCG immunization and HIV exposure – WHO guidelines followed or not?

In 2007 the WHO revised guidelines for administration of BCG to HIV-infected infants, making the infection a full contraindication to BCG vaccination. Implicit in this policy is the need to confirm infection in an infant before making the decision to withhold BCG, but is this the best policy for developing countries in which both HIV and TB may be prevalent? In a recent issue of the South African Medical Journal a group of HIV clinicians argue against the WHO recommendation while also stating that this is the opinion of a significant number of local experts and organizations. The authors lay out the factors that need to be considered in determining a policy for South Africa. Take for example some facts in favour of not delaying BCG: maternal HIV status is not always known, TB is prevalent in the country, follow-up of HIV-exposed neonates is not guaranteed and significant numbers of HIV-positive infants may not return if intervention is delayed. On the other hand, while it appears that in South Africa, HIV-infected infants have a 20-fold higher risk of acquiring TB, it is also stated that there is no evidence that BCG induces a protective effect against TB in HIV-infected infants and children. In other words, giving BCG to HIV-infected infants does not protect them, so it’s actually more about protecting others than the HIV-infected group. On the downside, the HIV-infected, immunocompromised infant may suffer adverse effects of BCG, ranging from adenitis to disseminated disease, particularly with rapidly progressive disease. However the latter complication affects some 1% of HIV-infected infants, and overall adverse effect rate is around 6%. Given these statistics, superimposing them on HIV transmission that affects the minority of newborn infants (and is falling in areas that have effective PMTCT programmes), and appreciating the significant risk of TB to HIV-unexposed and HIV-exposed but not infected infants, one begins to understand the position of those who are recommending that we in South Africa do not follow the WHO guideline.

Read more:
S Afr Med J 2009; 99: 88-91
WHO document WHO/V&B/99.23.Geneva:WHO;1999
Clin Infect Dis 2008; Dec 2 Epub