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If in doubt always contact a senior colleague.

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July 2008

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 BCG Vaccination
A Self Directed Learning Package
Dr Michalis Yiallourides
June 2008

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Learning Objectives

Tuberculosis Recommendations

Contraindications
BCG Vaccine
Administration
Patient advise
Adverse effects
Documentation
Resources
BCG Clinic QMC
BCG Clinic NCH
 Learning Objectives
• Outline the disease process and epidemiology
of Tuberculosis
• State the recommendations and
contraindications to BCG vaccination in infants
• Demonstrate the administration of BCG
• State the adverse effects of the BCG

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 Tuberculosis-TB
• Infection by bacteria of mycobacterium complex
– M. tuberculosis
– M. bovis
– M. africanum
• Acquired through respiratory route mainly
• Prolonged close contact with an index case can
facilitate transmission
• Initial infection may remain latent or eliminated

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 BCG Vaccine
• Bacillus Calmette-Guerin
BCG Statens Serum Insitut (SSI)- available licenced vaccine

• Live attenuated vaccine derived from M. Bovis

• Shown to be 70-80% effective against more
severe forms of TB (TB meningitis in children)
• Less effective in preventing pulmonary TB

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 BCG Vaccine SSI
Sensitive to heat and cold
Stored +2oC to +8oC
Protected from light
Freeze dried powder
Reconstituted with 1ml of the
diluted Sauton SSI diluent

20 infant doses
Usable for four hours after
constitution

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 Recommendations
1. All infants (aged 0 to 12 months) living in areas of
the UK where the annual incidence of TB is
40/100,000 or greater
2. All infants (aged 0 to 12 months) with a parent or
grandparent who was born in a country where the
annual incidence of TB is 40/100,000 or greater

WHO table with TB rates sorted by country

WHO table with TB rates sorted by TB rate

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 Contraindications
• Infants born to HIV positive mothers this can be
administered after two appropriately timed
negative postnatal PCR tests for HIV infection
• Infant is having a high fever and are acutely unwell
at the time of vaccination (if the vaccine is not given
at birth)

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 Administration of BCG
• Must be administered intradermaly
• Lateral aspect of the left upper arm at the
level of insertion of the deltoid muscle (just
above the middle of the left upper arm)
• Jet injectors and multiple punctured devises
should not be used
Equipment Injection site

Procedure Video of administration

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 Equipment
1. BCG Vaccine SSI
2. 1ml diluted Sauton SSI diluent
3. 1ml graduated syringe
4. 24G & 26G (10mm) needles
5. Alcohol swab
6. Cotton wool
7. Sharps bin box

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Procedure- Preparation
1. Draw up diluent (1ml) with 25G needle
2. Transfer volume (1ml) to the vaccine vial
3. Gently invert several times (DO NOT shake)
4. Write the date and time on vaccine vial
5. MUST be used within 4 hours
6. Draw 0.05ml with 1ml syringe
7. Vaccine should be opaque but colourless
8. Change needle to 26G (small short orange)

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 Procedure- Preparation

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Procedure- Administration
1. Ensure that baby is swaddled firmly by carer
2. Swab the skin-upper left arm with alcohol wipe and allow
to dry completely
3. Stretch the skin between thumb and forefinger
4. Insert needle parallel to skin surface, bevel upwards.
Approximately 2mm into the superficial layers of dermis
(needle should be visible through the skin)
5. Inject slowly (Resistance should be felt). A raised
blanched blep should appear at the injection site

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 Deltoid
muscle

Site of
BCG blep injection

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 Administration of BCG Video

Please click the link below

The video will commence as a separate file.

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Procedure- Post Administration
1. Remove needle and dispose of syringe and needle in
sharps bin
2. Stop any bleeding with cotton wool
3. Dispose of cotton wool that has contacted vaccine in
sharps bin for incineration
4. Injection site should be left uncovered
5. No further immunisation should be given in the arm used
for BCG for at least three months because of risk of
lymphadenitis

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 Post BCG Administration
• No observation after BCG vaccination is required
• Expected reaction to successful BCG vaccination is:
– induration at the injection site (2-3 days)
– local papular lesion (2-3 weeks)
– may ulcerate and may take long to heal (weeks or months)
– small, flat scar
• Enlargement of a regional lymph node to less than 1cm
• It is not necessary to protect the site from becoming wet
• The ulcer should be encouraged to dry, and abrasion (by
tight clothes, for example) should be avoided.

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 Induration 2-3 days Papule formation 2-3 weeks

Large Papule 4-6 weeks BCG Ulcer 6 weeks BCG scar 4-6 months

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 Adverse effects
• Severe injection site reactions
– Large discharging ulcers
– Abscesses
– Keloid scarring
– Suppurative adenitis
• Caused by:
– Faulty injection technique
– Excessive dosage
– Vaccinating tuberculin positive individuals

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 Patient Advise
• Informed consent should be obtained prior
administration (ideally written)
• Discussion about indications, procedure and
possible adverse reactions
• Advise to seek medical advise if severe reaction
or any other concerns
• Information leaflets available on different
languages

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 Documentation
• Administration of BCG in an infant should be
documented in 3 places:

1.Maternal Notes
2.Baby’s notes (if any)
3.Personal Health Book (Red book)
4.Child Health Records at Linden House
5.BCG book (NCH hospital only)

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 QMC BCG Clinic
• Run every Monday afternoon at antenatal clinic
• Patients identified at postnatal discharge check
when consent is obtained
• Parents given appointment time
• Clinic run by Neonatal SHO and admin support
• Usually 20-30 infants per clinic
• Maximises use of BCG SSI vial with less wastage
• Parents should attend with Personal Health
Book (red book)
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 NCH BCG Clinic
• Infants who BCG is recommended are identified
at the baby check clinic in Bonnington ward
• Leaflet is given at the time of clinic
• BCGs administered daily by SHO/ST1-3 at the end
of the baby clinic
• Consent is obtained prior to this
• Administration is given by the bedside
• All BCGs given are documented in the BCG book

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 Resources

• Health Protection Agency

• Green Book 2006- Chapter 32

• Immunisation.nhs.uk

• WHO

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