TB Control and Quality BCG Vaccination
- Nawaraj Subba, MPH
|
ABSTRACT |
Background
Tuberculosis is a highly communicable and fatal disease. People of
all ages can contract it. Children have higher risks from tuberculosis.
Therefore to protect them from contracting this disease all children should
preferably be given BCG vaccination immediately after birth or as soon as possible
within the first 12 months of birth. The percentage of children receiving BCG
vaccine within their first month of birth is very low in Nepal.[1]
The population pyramid of Nepal (2001) or age composition of the country suggests that the percent of 00-04 years age group (12.12%), 05- 09 Years (14.12%), 10-14 years (13.11%) and 15-19 years (10.51%).[2] Therefore the proportion of less than 19 years is 49.86% of total population.
The duration of protection is from 15 to 20 years by BCG.[3] Studies have shown that the range of protection offered by BCG varied from 0 to 80 per cent in different parts of the world.[4] There is large body of evidence, which supports the conclusion that BCG gives appreciable degree of protection against childhood tuberculosis. The WHO, on the basis of an extended review of BCG including the South Indian trial holds that it would seem unreasonable to stop the use of BCG should be continued as an anti-tuberculosis measure.[5]
Literature Review and Discussion
Tuberculosis (TB) control program and Immunization program cannot be
imagined separately. In other words immunization is one of the means of TB
control program. The Expanded Program on Immunization (EPI) was established in
1979 and is currently one of the priority programs of His Majesty's Government
(HMG). DHS surveys[6]
conducted in 1991, 1996, and 2001 indicate that there has been a significant
improvement in EPI coverage. BCG coverage in 2001 was 84%, suggesting that
about 16% of infants in Nepal are still not reached by routine EPI activities.
The results, however, also show that there is still an issue of access to
routine EPI services. BCG coverage in 2001 was 84%, suggesting that about 16%
of infants in Nepal are still not reached by routine EPI activities. While the
EPI in Nepal has made significant progress over the last decade, there is
clearly a need to further improve routine immunization coverage as part of a
systematic effort to further strengthen the program.[7]
HMG now buys all vaccines for routine EPI, with the exception of BCG.
According to Annual report[8] 2058/59, every year 44,000 people develop active TB, of whom 20,000 have infectious pulmonary disease. The number of TB patients attending OPD new visits found to be fluctuating around 20,000 at national level. At regional level, this is found less than 5000 in eastern development region observed over last eight years. [9] Although the trend of BCG vaccination coverage is increasing, the incidence of TB patients is not found to be declined substantially. Socio-economic, cultural and behavioral factors are considered as motivational factors of the problem. Malnutrition, Poor sanitation, Population movement, etc have accelerated TB infection and transmission. Newly emerging disease HIV/AIDS has put challenge forward on the way of TB control. WHO has also warned that poorly managed TB programmes are threatening to make TB incurable.
Quality assurance of BCG vaccination and shortage in supplying BCG vaccine is not merely a concern of EPI programme. NTP does take into account of impact (herd immunity) while setting and achieving its targets. There are so many issues, which usually do rise by number of managers and health workers during EPI review meetings. It is often reported that there is still number of unfulfilled posts of VHWs in hill and mountain districts and also growing in number of VHWs who are unable to give vaccination due to their old age. MCHWs and AHW/ANM are being used in their jobs during out reach EPI clinics. But most of these health workers are not trained enough with skill to give BCG vaccination properly as reported.[10] And that AHW/ANM is not getting TADA due to the provision of working in the same VDC would not be offered TADA.[11]
Conclusion
Since BCG vaccination is one of the preventive approaches for TB control, it demands to be included as subsequent review and evaluation during regular National Tuberculosis Programme (NTP) review meetings. Question of quality assurance is increasing year by year. Country does not achieve successes in the endeavor of TB control until and unless coverage and quality of BCG vaccination ensured.
Recommendation
Morbidity and Mortality of Tuberculosis need to be correlated and evaluated with immunization and other related attributes along with service coverage. Comprehensive prospective is required to address TB, which should be regarded as a public health problem not merely a medical problem.
© 2004, Nawaraj Subba