[ Routine BCG vaccination to newborns- Future challenges Prof. Fahad Abdullah Al Zamil Professor and Consultant, Pediatric Infectious Diseases Head of Infectious Diseases Unit College Of Medicine King Saud University 2 nd Middle East Vaccination Congress Abu Dhabi, United Arab Emirates December 14-15, 2012 Jean Marie Camille Guerin

Tuberculosis Epidemiology WHO Surveillance Data Case / 100,000No. (million) Incidence Smear (+)623.9 HIV (+) Prevalence Death Latently Infected33% of people2 billions

Age-Age-specific risk of progression to TB disease after primary infections Age at primary infection No disease(%)Pulmonary(%)Miliary/CNS(%) ˂1 year years years years982˂0.5 ˃10 years ˂0.5 Marais, et al. Am J Respir Crit Care Med 2006; 173:1078

TB Epidemiology About 11% of world new TB cases occurred in children <15 years old (884,000 of 8.3 million in 2000), with variability among countries (3- 6% developed,15-20% developing countries) Children receive less attention in TB control program because of paucibacillary disease 60% among infant and children <5 years

TB remains a major public health problem in KSA Incidence is not significantly decreasing in the last 10 yeas 46% of incident cases were among Non-Saudis with twice the rate, but not clear if due to reactivation of LTB or infection after arrival

% of MDR-TB among new TB cases

TB-KSA

TB trend, KSA-Saudi

TB trend-KSA-Non Saudi

Source: Annals of Saudi Medicine, Volume 32, Issue 1, January 2012

Source: Indian Journal Of Pathology and Microbiology, Vol. 55; Issue 2, April-June 2012

Severe suppurative adenopathy post-BCG vaccination.

Inoculation site abscess post-BCG vaccination.

Suppurative BCG lymphadenitis in right axillary region. The lymph node measures 5 cm in diameter, and is fluctuant in centre and the overlying skin is inflamed

Outbreak of BCG related lymphadenitis in Saudi children at a university hospital after a change in BCG vaccine Abdulkarim Al Rabiaah, Sarah Alsubaie, Elham Bukhari, Fahad Al Zamil, Ashry, Gad a Department of Pediatrics, College Of Medicine, King Saud University, Saudi Arabia. Conclusion: We conclude that increased susceptibility to the BCG SSI vaccine might have contributed to the increased incidence of lymphadenitis in these children. Hence, caution should be exercised in switching from one vaccine to another, as is often done in developing countries. Source: Annals of Saudi Medicine, Volume 32, Issue 1, January 2012

BCG Lymphadenitis: A 6 year experience in two Saudi hospitals Conclusion: An increase in BCG lymphadenitis was observed in our population, with an incidence higher than expected. The cause of this increase is likely secondary to changes in the vaccine strain. Medical treatment appears to be effective when used in conjunction with needle aspiration for enlarged lymph nodes. Further research is needed to clarify the exact incidence, etiology and optimal management of BCG lymphadenitis. Source: Indian Journal Of Pathology and Microbiology, Vol. 55; Issue 2, April-June 2012

Treatment of Calmette-Guérin bacillus adenitis: a metaanalysis Abstract Various treatments have been used to decrease the risk of suppuration; the most troublesome complication of Calmette-Guerin bacillus adenitis, but results are controversial. Metaanalysis of four randomized controlled trials revealed no significant difference in the frequency of suppuration between the treatment and control groups for all treatments [relative risk (RR), 1.10; 95% confidence interval (CI), 0.88 to 1.38], erythromycin (RR 1.04; 95% CI 0.79 to 1.37) and isoniazid (RR 1.35; 95% CI 0.84 to 2.18). Therefore medical treatment does not reduce the frequency of suppuration in Calmette-Guerin bacillus adenitis. Goraya JS, Virdi VS Source: Pediatr Infect Dis J Jun;20(6):632-4

Safety of Intradermal Bacillus Calmette-Guerin vaccine for neonates in Eastern Saudi Arabia Ahmed R. Alsuwaidi Department of Pediatrics United Arab Emirates University Al Ain, United Arab Emirates We have observed a similar high incidence (4.3) per 1000 among children in Al Ain, United Arab Emirates where the same strain is currently used. Correspondence Source: Saudi Medical Journal Vol. 33, July 2012;

Why the world failed to control TB? Nature of organism leading to latency with huge pool of people with LTBI acting as reservoir for TB disease if reactivated Prolonged treatment course TB not priority, disease of the poor Lack of new drugs, vaccine development except recently

Research and development New diagnostics New medications (10 new or repurposed) under trials/ new regimens with short duration New vaccines ( 9 candidate vaccine in phase 1 or 2 trials)

Conclusions TB remains global health threat TB control is hampered by lack of effective vaccine, prolonged treatment course emergence of MDRTb, HIV epidemic and availability of affordable treatment The near future will witness major breakthrough in TB therapy in the form of novel drugs and shorter duration of therapy Caution should be exercised in switching from one vaccine to another, as is often done in developing countries. An increase in BCG lymphadenitis was observed in our population, with an incidence higher than expected. The cause of this increase is likely secondary to changes in the vaccine strain. Medical treatment appears to be effective when used in conjunction with needle aspiration for enlarged lymph nodes.

C Giving BCG at birth to our newborn babies, is it the ideal time????????????????????????? Conclusions (Continue)