Elsevier

Vaccine

Volume 26, Issue 47, 5 November 2008, Pages 5905-5910
Vaccine

Short communication
To BCG or not to BCG?: Preventing travel-associated tuberculosis in children

https://doi.org/10.1016/j.vaccine.2008.08.061Get rights and content

Abstract

With the rise in travel to countries with a high prevalence of tuberculosis (TB), the risk of travel-associated TB is of increasing concern. However, the use of Bacille Calmette–Guérin (BCG) vaccine for the prevention of travel-associated TB is a neglected area. We review and discuss national and international recommendations and guidelines for the prevention of travel-associated TB in children. Three children who developed travel-associated TB disease are described to illustrate that current recommendations, and in particular the use of pre-travel BCG immunisation, are inconsistent and controversial. The wide variation in recommendations reflects the paucity of data on the effectiveness of BCG immunisation and other preventive strategies in this setting. Until evidence-based guidelines can be produced, we believe that a low threshold for recommending BCG immunisation for travelling children is the safest strategy. A practical approach to deciding which children should be immunised with BCG prior to travel is presented.

Introduction

Global tourism is increasing rapidly: in the first 3 months of 2007 tourist arrivals rose by more than 6% worldwide [1]. South Asia, Southeast Asia and Northeast Asia are the destinations that have experienced the largest rise in international tourist arrivals, with increases between 9% and 12%. The high incidence and prevalence of tuberculosis (TB) in most of the countries in these regions has particular significance to travellers’ health (Table 1, Fig. 1). The spread of multidrug-resistant (MDR) TB (exceeding 5% in some areas) and extensively drug resistant (XDR) TB (reported in over 40 countries) constitutes an additional threat to the growing number of travellers exposed to TB [2], [3]. The risk of an individual traveller acquiring TB infection depends on several factors that include the local TB incidence, the duration of travel, the degree of contact with the local population and the susceptibility and age of the traveller. Younger children, especially those under 1 year of age, are at particular risk, as following TB infection, they are more likely to develop severe and disseminated forms of TB, including meningitis and miliary disease. We describe three children who developed TB disease following travel and review existing national and international recommendations for Bacille Calmette–Guérin (BCG) immunisation in travellers and the evidence underlying them.

Section snippets

Case 1

A 14-year-old girl, born in Australia, travelled to India for 6 weeks to visit friends and relatives (Table 2). She had visited India 2 years prior and had remained well in the interim. She had never been immunised with BCG and had never sought pre-travel medical advice. Eight months after returning from India she presented to her local hospital with a persistent cough, left-sided chest pain, night sweats and significant weight loss. A chest X-ray showed a left lower lobe opacity. She completed

Discussion

Travel-associated TB, other than acquired during air travel, has been reported infrequently although perceived as relatively common. The three children reported here were most likely infected during travel overseas as the TB prevalence in Australia is low and none of them had a known TB exposure prior to departure. Pulmonary TB was excluded in any household contacts by routine contact tracing by the local TB control program. In addition, with the exception of case 3, they were not exposed to

Acknowledgements

NR is supported by fellowship awards from the Swiss National Science Foundation, the European Society of Paediatric Infectious Diseases and The University of Melbourne. TC is supported by fellowship awards from the Nossal Institute of Global Health and The University of Melbourne.

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