• All babies (aged ≤12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is ≥40/100,000
• All babies (aged ≤12 months) living in areas of the UK where the annual incidence of TB is ≥40/100,000
• PHE TB Official Statistics 2020 (publishing.service.gov.uk)

BCG vaccine to be given to eligible baby

• Once aged 28 days
• On receipt of screen negative severe combined immune deficiency (SCID) result (or ‘SCID not offered’ result)

Countries with incidence of TB ≥40/100,000

https://www.gov.uk/government/publications/tuberculosis-tb-by-country-rates-per-100000-people

Tuberculin testing not necessary aged <6 yr unless baby has been in recent contact with TB or has resided in high-incidence country for >3 months

• SCID screen positive or screen performed and result pending
• Temperature >38°C or acutely unwell
• Severe eczema (give at suitable lesion-free site)
• Baby in household where an active TB case suspected or confirmed, see Tuberculosis (investigation and management following exposure in pregnancy) guideline
• Immunodeficient or on high-dose corticosteroids
  • defer BCG until 3 months after stopping corticosteroids if given prednisolone 1 mg/kg/day for >2 weeks, 2 mg/kg/day for 1 week, (or equivalent doses of another corticosteroid, e.g. dexamethasone 150 micrograms = prednisolone 1 mg)
• Maternal immunosuppressive treatment during pregnancy or breastfeeding 
  • biologicals e.g. anti-TNFα, postpone BCG until aged 6 months
  • immune-modulation therapy for treatment of COVID in pregnancy e.g. tocilizumab and sarilumab, postpone BCG until aged 6 months
• HIV positive, living in UK
  • if mother HIV positive and high risk of HIV transmission [see Human immunodeficiency virus (HIV) guideline] and exclusively formula feeding, give vaccine only after baby is confirmed HIV uninfected at aged 12–14 weeks
  • if mother HIV positive and very low risk or low risk of HIV transmission [see Human immunodeficiency virus (HIV) guideline] BCG can be given to baby when indicated
  • if high risk of TB exposure and maternal HIV viral load <50 copies/mL after 36 weeks’ gestation, BCG can be given at birth
  • encourage maternal HIV testing but do not withhold BCG if mother declines testing unless mother from sub-Saharan Africa, in which case refer to HIV team for counselling about testing

• No need to delay routine vaccinations
  • BCG can be given simultaneously with other vaccines [including rotavirus vaccine oral or palivizumab (Synagis®) (IM but not in same arm)]
  • no further immunisation should be given in arm used for BCG immunisation for ≥3 months due to risk of regional lymphadenitis
  • if not given at same time, leave 4 weeks before giving other injectable live vaccines

• Dose: 0.05 mL (Note: vial contains 20 doses)
• Only to be given by health professional trained in giving BCG vaccine

Consent

• Midwife to record at booking if risk factor present
• Postnatal check for risk factor
• Ensure baby within inclusion group
• Give mother information on vaccine
• Give appropriate language leaflet TB, BCG vaccine and your baby, available from https://www.gov.uk/government/publications/tb-bcg-and-your-baby-leaflet order line: 0300 123 1002 
• Department of Health guidelines state written consent is not required but follow local practice

Injection

• Hold arm at 45° to body 
• At insertion of deltoid muscle near middle of left upper arm
• If skin is clean, no further cleaning is necessary
• If skin is visibly dirty, clean with soap and water
• Stretch skin between thumb and forefinger
• Introduce needle bevel upwards approximately 3 mm into superficial layers of dermis almost parallel to skin
• If considerable resistance not felt, remove needle and reinsert before giving more vaccine
• Correctly given intradermal injection results a tense blanched bleb

• Enter on BCG page in online Child Health Record or in Red Book and tear out yellow copy for Child Health 

• Scar
  • within 2–6 weeks a small papule will appear
  • sometimes this ulcerates and can ooze 
  • site need not be protected from water
  • do not cover with an impervious dressing
  • can take several months to heal 
  • occasionally persists as keloid (particularly if given superior to insertion of deltoid)
• Adenitis:
  • a minor degree of adenitis can occur in the weeks following BCG
  • no treatment indicated
• Rare sequelae:
  • local abscess 
  • chronic suppurative lymphadenopathy 
  • disseminated disease, if immunocompromised
  • osteitis, refer to infectious diseases specialist 

Refer to paediatric TB team if

• Severe local reactions 
  • abscesses or drainage at the injection site or
  • regional suppurative lymphadenitis with draining sinuses