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effect of BCG vaccination on childhood tuberculous meningitis and miliary tuberculosis worldwide a m.pdf

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effect of BCG vaccination on childhood tuberculous meningitis and miliary tuberculosis worldwide a m

Vol 367 April 8, 2006 1173 Introduction Randomised controlled trials and case-control studies have shown consistently high effi cacy of BCG vaccination against severe forms of childhood tuberculosis, principally miliary disease and meningitis, but variable effi cacy against pulmonary tuberculosis in adults.1–5 Increases in tuberculous meningitis and mycobacterial glandular disease were reported after BCG vaccination was discontinued in Sweden and the former Czechoslovakia.6–8 BCG also prevents leprosy.9 More controversially, it might reduce childhood mortality from other causes, perhaps because BCG promotes a T-helper-1 immune response.10,11 The studies whose results showed high effi cacy against severe childhood tuberculosis have lent support to the view that BCG should continue to be used in countries where the disease remains a substantial public-health problem, and roughly 100 million doses are given to infants every year. However, the evidence for effi cacy from trials is not, on its own, suffi cient to justify BCG vaccination on its present large scale. That argument needs an assessment of the number of cases and deaths prevented in relation to eff ort and cost. We have used information about effi cacy together with data for risk of severe childhood tuberculosis to assess, for all countries and territories where BCG vaccine is routinely administered to infants, the number of cases of tuberculous meningitis and miliary tuberculosis expected, with and without BCG vaccination, in children born in 2002. This analysis leads to estimates of the numbers of cases prevented by country, by region, and for the whole world. Methods We assessed the annual risk of infection for tuberculosis by country and the risk of tuberculous meningitis and miliary tuberculosis in children after infection, and we have updated earlier meta-analyses of BCG effi cacy. To see whether BCG vaccination is good value for money in comparison with othe