Journal of Public Health Advance Access originally published online on March 20, 2006
Journal of Public Health 2006 28(2):133-136; doi:10.1093/pubmed/fdi078
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Implementing the new BCG vaccination guidelines—a maternity hospital-based clinic approach
Deepa Athavale, Senior House Officer1
Sarah McCullough, Information Officer2
Helen Mactier, Consultant Neonatologist1
1 Neonatal Unit, Princess Royal Maternity, 8-16 Alexandra Parade, Glasgow G31 2ER, UK
2 Public Health Protection Unit, Dalian House, 350 St Vincent Street, Glasgow G3 8YU, UK
Address correspondence to Helen Mactier, E-mail: helen.mactier{at}northglasgow.scot.nhs.uk
Background With the recent changes to the UK BCG vaccination programme, the emphasis on childhood immunisation changes to identification and immunisation of at risk neonates. We report our experience of improving the system for provision of early BCG immunisation to high-risk infants born in the east of Glasgow.
Methods A maternity hospital-based BCG clinic was established, together with a programme designed to increase awareness among midwifery and junior medical staff.
Results Neonatal identification of at risk infants increased by 300% and was associated with high rates of clinic attendance and a 93% uptake of BCG immunisation in early infancy. Almost all infants were immunised within the first three months of life.
Conclusion Targeting parents prior to discharge from the maternity unit is an effective means of implementing BCG immunisation guidelines. The clinic model described is a successful and easily implemented example of co-operation between acute and community services.
Keywords: immunisation, newborn, tuberculosis, BCG
 |
Introduction |
|---|
 TOP Introduction MethodsResultsDiscussionConflict of interestsAcknowledgementsReferences |
|---|
Tuberculosis (TB) is a major problem worldwide and a re-emerging problem here in the UK.1,2 BCG immunization in infancy is up to 70 per cent effective in prevention of TB and its complications,3,4 and the World Health Organization advises that neonatal services should provide BCG immunization as soon as possible after birth in high-risk populations.5 The latest revised guidelines from the Department of Health6 include discontinuation of the existing school BCG immunization programme and place a greater importance on selective infant BCG immunization. Neonatal BCG immunization is recommended when there is a family history of TB, for infants born to parents from countries with a high prevalence of TB or when travel to a high-risk country is planned.2,7 Despite clear guidelines, implementation of neonatal BCG immunization in the UK has been poor to date, with up to 60 per cent eligible infants not receiving immunization.8–10 Reasons for this include lack of awareness among parents and health care providers, poor rates of identification of infants at higher risk of TB, language and communication barriers and subsequent poor attendance at clinics. In order to comply with the revised guidelines, there is a pressing need for an efficient system of providing early BCG immunization to high-risk infants.
Princess Royal Maternity (PRM), the largest of the maternity units in Glasgow, has around 5200 deliveries per year and serves one of the most deprived areas in the UK with a large immigrant and asylum-seeking population. Infants born to parents of ethnic minority groups (largely Asian) were traditionally offered early BCG immunization prior to discharge from the postnatal wards, but a shortage of vaccine together with lack of awareness amongst midwifery and junior medical staff had contributed to a marked fall off in neonatal immunization rates. Local audit revealed that in the year from April 2002 to March 2003, only five infants received BCG immunization prior to discharge from the postnatal ward. Identification of at-risk infants and subsequent BCG administration were primarily a community responsibility, administered either by the general practitioner (GP) or, more commonly, in specially designated community clinics. Unfortunately, for various reasons including staffing problems and poor rates of clinic attendance, this system was failing, and a large backlog of immunizations had accrued.
To address this problem, a new, maternity hospital-based BCG clinic was established together with a programme designed to increase awareness among midwifery and junior medical staff. Repeat audit demonstrated marked improvement in the identification of at-risk infants and very high rates of immunization. This model is presented here as a successful and easily implemented example of co-operation between acute and community services.
|
Methods |
|---|
|
TOPIntroductionMethodsResultsDiscussionConflict of interestsAcknowledgementsReferences |
|---|
Pilot project
Between March 2003 and June 2003, junior medical staff were individually advised of the indications for BCG immunization and were encouraged to identify and offer immunization to infants considered to be at higher risk of TB infection. During this 3.5-month period, 39 infants were recognized to be eligible for BCG immunization (mean 11 infants per month). The mother was informed of the recommendation for immunization and subsequently given details of a clinic appointment by letter, by telephone or via her Health Visitor. Thirty-six families (92 per cent) were successfully contacted, of whom 31 attended one of three clinics (86 per cent attendance). One infant was known to have been immunized in the community, giving an 82 per cent immunization rate for infants identified to be at higher risk for TB. Language barriers and problems contacting families after discharge from the maternity unit were highlighted during this period and addressed in the revised protocol, implemented in July 2003.
Revised BCG immunization protocol
Identification of eligible infants
Clear guidelines for infants at risk of TB are made available to the postnatal ward staff, including an up-to-date list of countries at high risk,11 and specific questions regarding family history of TB and parental ethnicity are encouraged during the routine pre-discharge baby check (Fig. 1).
|
Communication
A verbal explanation of the BCG immunization policy is given to the mother at the routine pre-discharge baby examination. If she agrees to immunization of her baby, a handwritten appointment card for the next BCG clinic (within the following month) is given immediately, together with a leaflet explaining BCG immunization. For non-English-speaking mothers, the baby examination is conducted in the presence of an interpreter, allowing fully informed consent for BCG immunization to be obtained. Information leaflets are currently available in Urdu and Punjabi and are being developed in other languages.
Clinic
This is held in the maternity hospital out-patient area on a monthly basis and is staffed by a staff grade paediatrician, a community nurse trained to administer BCG vaccine and an auxiliary nurse. A member of the junior paediatric staff attends on a rotational basis. Administrative support is provided by a public health officer who is responsible for notifying community services of all immunized infants and arranging reappointments for defaulting infants. After two defaulted appointments, the infant’s GP is informed and immunization referred to the community services (Fig. 2).
|
|
Results |
|---|
|
TOPIntroductionMethodsResultsDiscussionConflict of interestsAcknowledgementsReferences |
|---|
Over the period of 18 months immediately following implementation of the revised policy, 606 infants were identified at the routine pre-discharge baby check to be at higher risk of TB infection (mean of 33 infants per month). A further two infants were given BCG clinic appointments but upon review had been incorrectly identified (non-recent family history of TB), and after discussion with their parents, they were not immunized. Only one family declined immunization. Thirty-nine infants failed to attend on two occasions, with no reason given for non-attendance, and a further nine infants were known to have been immunized in the community. Excluding two clinic attendance rates of 60 per cent (falling on the Muslim festivals of Eid and Ramadan, respectively), initial BCG clinic attendance varied from 74 to 90 per cent (mean 82 per cent). With reappointments, the overall BCG clinic attendance rate was 92 per cent. Five hundred and fifty-seven infants in total, including 59 infants immunized prior to discharge, were immunized during 19 designated hospital-based BCG clinics (mean 29 babies per clinic). Including the nine infants known to have been immunized in the community, the overall BCG immunization rate of infants identified to be at higher risk of TB infection was 93 per cent.
|
Discussion |
|---|
|
TOPIntroductionMethodsResultsDiscussionConflict of interestsAcknowledgementsReferences |
|---|
Implementation of a new BCG policy within a large inner city maternity hospital has achieved increased early identification of infants at higher risk of TB and 93 per cent uptake of BCG immunization. Many factors have contributed to this success, including increased awareness among midwifery and medical staff and improved communication with families. We have demonstrated that simple measures such as providing clear, written guidelines for staff and encouraging questions about parental ethnicity can improve neonatal identification of infants at higher risk by 300 per cent.
Our BCG policy is now included in the junior doctor induction programme at the start of every 6-month rotation, and the availability of an up-to-date list of at-risk countries further heightens awareness amongst midwifery and medical staff.
The routine pre-discharge check offers a unique opportunity to ascertain the TB risk status of every infant and to discuss BCG immunization with the parents. It is important to properly address the language and communication problems highlighted in the pilot study; for example, many asylum-seeking families do not have the English language skills necessary to answer the telephone. In our hospital, every non-English-speaking mother is offered an interpreter visit prior to being discharged home with her baby. This expensive service is utilized to ensure that the parents are properly advised regarding BCG immunization and are able to give fully informed consent. Where this service cannot be provided, information leaflets can be prepared and distributed in a variety of languages appropriate to the local population.
The administration of BCG vaccine in the clinic setting ensures efficient use of multidose vials of vaccine, avoids wastage and affords teaching and supervision in the administration of the intradermal BCG vaccine. Our designated BCG clinic within the maternity hospital is set in a familiar environment within the local catchment area, facilitating access to families, the majority of whom rely on public transport. Furthermore, we are able to offer immediate paediatric and/or obstetric advice when problems are identified. The importance of being culturally aware and not scheduling clinic dates on religious festivals is highlighted with a marked fall off in clinic attendance during Muslim festivals. Public health support with access to up-to-date patient databases is vital, facilitating both correct identification of infants (most of whom have changed their name since birth) and prompt and effective communication with the GP and community services.
Our policy emphasizes the importance of not giving BCG vaccine to infants of HIV-positive mothers until they have tested negative at 3 months. This has also served to increase awareness of maternal HIV status in general within the hospital. Infants born to HIV-infected mothers are, however, often also at high risk of TB and are therefore offered BCG immunization at the clinic immediately following confirmation of HIV-negative status at 3 months.
We acknowledge that the maternity hospital-based clinic is relatively well resourced and that it is difficult to predict whether similar immunization rates could be achieved in an equally well-resourced community clinic. The maternity hospital-based clinic has, however, proved to be very popular with an initial attendance rate of 82 per cent. This compares favourably with average attendance rates of 68 per cent for general neonatal follow-up clinics within the same maternity hospital and with 52 per cent attendance rates at community BCG clinics over the same period. Only a few parents offered an appointment for the maternity hospital-based clinic subsequently chose to have their child immunized in the community, the majority of these living more than 10 miles from the maternity hospital.
Direct comparison between this clinic and community-based clinics within the city is complicated by incomplete data collection and inclusion of older infants and children. During the 12-month period from January 2004, 365 infants were immunized in 12 maternity hospital-based clinics (mean of 30.4 infants per three clinics), of whom 347 (95 per cent) were aged under 2 months and only two aged greater than 3 months. By comparison, 51 BCG community clinics were held in Glasgow during this period, immunizing 599 infants under 1 year (mean of 11.7 infants per clinic), of whom only 27 and 57 per cent were aged under 2 and 3 months, respectively. Early immunization obviates the need for Heaf testing and reduces the opportunity for missed clinic appointments.
Non-identification of at-risk infants is one of the key factors in poor BCG immunization uptake rates. Our audit does not determine how many eligible infants failed to be identified in the maternity hospital. Maternity case records provide some (albeit incomplete) data regarding maternal ethnicity, but paternal ethnicity, family history of TB and intended travel abroad are not documented, making complete ascertainment of missed cases impossible. Audit of infants born in our hospital and subsequently immunized in the community would partly address this issue and is being planned. Ongoing audit is essential to ensure effective implementation of immunization guidelines and to identify problems.
This audit has demonstrated how with relatively simple measures and by optimizing communication between hospital and community services it is possible to effect marked change in practice. Targeting parents prior to discharge from the maternity unit is an effective means of ensuring good follow-up. This clinic model offers an effective means of implementing recent changes in BCG immunization guidelines.
|
Conflict of interests |
|---|
|
TOPIntroductionMethodsResultsDiscussionConflict of interestsAcknowledgementsReferences |
|---|
None declared.
|
Acknowledgements |
|---|
|
TOPIntroductionMethodsResultsDiscussionConflict of interestsAcknowledgementsReferences |
|---|
We wish to thank the public health team who have helped with implementing the policy—Monica Maguire, Anne McDonald and Dr. Syed Ahmed. Our gratitude also to Nessie Fleming, Sharon Murray and Dr Nashwa Matta for their dedicated help with the BCG clinic.
|
References |
|---|
|
TOPIntroductionMethodsResultsDiscussionConflict of interestsAcknowledgementsReferences |
|---|
- Rose AMC. 1988 National TB Survey in England and Wales: final results. Thorax 1999;54(Suppl.):A5.
- Joint Tuberculosis Committee of the British Thoracic Society. Control and prevention of tuberculosis in the United Kingdom: Code of Practice 2000. Thorax 2000;55:887–901.
[Abstract/Free Full Text] - Packe GE, Innes JA. Protective effect of BCG immunisation in infant Asians: a case–control study. Arch Dis Childhood 1988; 63:277–81.
[Abstract/Free Full Text] - Colditz GA, Brewer TF, Berkey CS et al. Efficacy of BCG vaccine in the prevention of tuberculosis. Meta-analysis of the published literature. J Am Med Assoc 1994;271:698–702.
[Abstract/Free Full Text] - WHO. Immunisation, vaccines and biologicals. BCG Vaccine 1999.
- Changes to the BCG Vaccination Programme, Department of Health Correspondence July 2005.
- Department of Health, Welsh Office, Scottish Office, Department of Health, DHSS (Northern Ireland). Immunisation against infectious disease (The Green Book). London 1996.
- Chappel D, Fernandes V. Improving the coverage of neonatal BCG immunisation. J Public Health Med 1996;18:308–12.
[Abstract/Free Full Text] - Eastham KM, Wylie J. A study of neonatal BCG immunisation within an acute hospital trust. J Public Health Med 2001;23:335–8.
[Abstract/Free Full Text] - Deshpande SA. Ethnic differences in the rates of BCG immunisation. Arch Dis Childhood 2004;89:48–9.
[Abstract/Free Full Text] - Travax. http://www.travax.co.uk, July 2003.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||