Appendix 1

Croydon Borough Team

BCG VACCINATION POLICY FOR CROYDON

Date approved: Date for Review: May 2011 (extended to August 2012) Lead Director: Director of Public Health Lead Clinician: Consultant Paediatrician, Immunisation Coordinator Date for next review – April 2014

NOTE: This is a CONTROLLED Document. Any documents appearing in paper form are not controlled and should be checked against the server file version prior to use.

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Appendix 1

Policy Statement/Summary

On 6th July 2005, a letter from the Chief Medical Officer, Chief Nursing Officer and Chief Pharmaceutical Officer (PL/CMO/2005/3) detailed changes in the national BCG vaccination policy. Children are no longer vaccinated at school during year 9 (age 14 years) but receive vaccination at the earliest opportunity preferably during the first 12 months of their lives if they have been identified as being at risk of tuberculosis (TB). The May 2007 version of this policy originally addressed the implementation of the new national BCG vaccination policy in Croydon. This current policy, dated November 2012 supersedes the May 2010 policy. It has been updated following a review of the previous policy to ensure that eligibility criteria are in line with NICE guidance and Immunisation Against Infectious Disease, The Green Book, and that all vaccination pathways are robust. This policy is applicable to all health professionals working in NHS health care in Croydon. Information within the policy is relevant to all professionals who may be consulted for advice relating to BCG vaccination.

CMO letter July 2005: http://www.dh.gov.uk/assetRoot/04/11/49/98/04114998.pdf (click on underlined words to go to this document online) Operational note August 2005: http://www.dh.gov.uk/assetRoot/04/11/81/35/04118135.pdf (click on underlined words to go to this document online)

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Appendix 1

Table of Contents 1.

Introduction.................................................................................................................... 5 1.1

National Policy Prior to September 2005 ................................................................. 5

1.2

National Policy from September 2005 ..................................................................... 5

2.

Scope ............................................................................................................................ 5

3.

Key Principles ................................................................................................................ 6

4.

Statement of Objectives ................................................................................................ 6 4.1

Risk groups eligible for BCG vaccination................................................................. 7

4.1.1

Infants (0 to 12 months) .................................................................................... 7

4.1.2

Children (aged 1 year to 16th birthday ) and unaccompanied minors (UAMs)

(aged 1 year to 18th birthday) ..................................................................................... 7 4.1.3

Adults ................................................................................................................ 8

4.1.4

Individuals at occupational risk of TB ................................................................ 8

4.2 5.

6.

Previous BCG vaccination ....................................................................................... 8

Responsibilities ............................................................................................................. 9 5.1

Co-ordination and Quality Assurance ...................................................................... 9

5.2

Service provision and process ................................................................................. 9

5.3

Referral.................................................................................................................. 10

The procedure ............................................................................................................. 10 6.1

Identification of individuals at risk .......................................................................... 10

6.1.1. Infants ............................................................................................................. 10 6.1.2

Children and young people aged 1year to 16th birthday and unaccompanied

minors aged 1year to 18th birthday ............................................................................. 10 6.1.3

Other Adults .................................................................................................... 11

6.1.4

Refugees and Asylum Seekers (referral pathway from the Homeless Team) . 11

6.2

Referral and vaccination ........................................................................................ 11

6.3

Mantoux testing ..................................................................................................... 12

6.3.1 6.4 7.

Interpretation of Mantoux test ......................................................................... 13

Individuals not at risk ............................................................................................. 14

Training Needs Assessment ........................................................................................ 14

3

Appendix 1 8.

Consent and Documentation ....................................................................................... 14

9.

Record retention and quality assurance ...................................................................... 15

10.

Distribution List ......................................................................................................... 16

11.

Glossary of Terms .................................................................................................... 17

12.

References ............................................................................................................... 18

Appendices ..................................................................................................................... 19 Appendix 1: Reference list of high TB prevalence countries.............................................. 19 Appendix 2: Referral guidelines for BCG immunisation .................................................. 20 Appendix 3: BCG assessment questionnaire ................................................................... 21 Appendix 4: Care of the BCG site...................................................................................... 24 Appendix 5: Certificate of BCG .......................................................................................... 25 Appendix 6: Private travel clinics near Croydon ................................................................ 26

4

Appendix 1

1. Introduction 1.1

National Policy prior to September 2005

BCG vaccination was introduced in the UK in the 1950s when there were approximately 50,000 cases of tuberculosis (TB) every year. It was given at school leaving age (then 14 years) because most cases of TB occurred in young adults in the workplace. The approach of vaccinating at secondary school age was unique to the UK with most other countries vaccinating babies. In the 1960s, selective immunisation of neonates born to new entrants to the UK from countries with high rates of TB was also introduced. The situation today has changed considerably and there is no longer a peak incidence of TB seen in young adults born in the UK. The epidemiology of TB in the UK also changed from a disease of the general population to one of predominantly high-risk groups. 1.2

National Policy from September 2005

As from 1st September 2005, the universal schools vaccination programme ceased. A targeted, risk based programme primarily aiming at infants under the age of 1 year has replaced the schools’ programme. In areas with an incidence of TB of 40 per 100,000 or greater all infants now receive BCG. In areas, such as Croydon, where the incidence of TB is lower, BCG vaccination is offered to certain risk groups. (See 4.1. for a definition of risk groups) As the standard method of tuberculin testing prior to vaccination, the Mantoux test has replaced the Heaf test.1

2. Scope This policy is applicable to health professionals in Croydon Health Services NHS Trust, General Practice, the Directorate of Public Health, and the Health Informatics Team. The information within this policy is relevant to all professionals who may be consulted for advice relating to BCG vaccination.

5

Appendix 1

3. Key principles The key principles underlying the national policy2 are:  The main role of BCG vaccination is to protect individuals at high risk of exposure to TB  BCG vaccination does not have a significant impact on the incidence of disease in the population 

BCG vaccination is most effective at preventing severe disease in infants and young children

 The policy is a targeted programme for individuals in certain risk groups and replaces the schools’ programme for older children  The use of targeted BCG vaccination means that the majority of children at high risk of TB will be vaccinated in early life.

4. Statement of Objectives The objectives of this policy are:  To provide an on-going BCG vaccination programme for those infants (0 to 12 months) in Croydon who are most at risk of contracting TB as defined by risk groups  To provide BCG vaccination for un-immunised children aged 1 year to 15 years inclusive (up to their 16th birthday) who belong to identified risk groups 

To provide BCG vaccination for un-immunised unaccompanied asylum-seeking children under the care of the London Borough of Croydon’s Unaccompanied Minors (UAMs) service, who are aged 1 year to 17 years inclusive (up to their 18th birthday) who belong to identified risk groups



To provide opportunistic BCG vaccination for other young people and adults aged 16 years and over who belong to the identified risk groups* or to refer those individuals appropriately where vaccination is not covered by the NHS.

*

There are few data on the protection afforded by BCG vaccine to adults and BCG is usually not recommended for adults unless the risk of exposure is great (e.g. healthcare or laboratory workers at occupational risk or where indicated for travel).

6

Appendix 1 4.1

Risk groups eligible for BCG vaccination

For a list of countries with a TB rate of 40 per 100,000 population or greater, see Appendix 1 of this policy or the hpa website7. 4.1.1

Infants (0 to 12 months)



Infants with a parent or grandparent who was born in a country with a TB rate of 40 per 100,000 population or greater 3,4



Infants intending to visit or live in a country with a TB incidence of 40 per 100,000 or greater for a period of three months or more 3,4



Infants who were born in or who have lived for a prolonged period (at least three months) in a country with an annual TB incidence of 40 per 100,000 population or greater 4



Previously unvaccinated, tuberculin-negative infants in recent close contact (within the last 12 months) with an individual with respiratory TB 3,4



Previously unvaccinated, tuberculin negative infants with a family history of TB in the past year3

4.1.2 Children (aged 1 year to 16th birthday ) and unaccompanied minors (UAMs) (aged 1 year to 18th birthday ) 

Previously unvaccinated children with a parent or grandparent who was born in a country with a TB rate of 40 per 100,000 population or greater. 3,4 Note: children aged one to five years can normally be vaccinated without tuberculin testing. Children aged 6 to 15 years inclusive (up to their 16th birthday) should be tuberculin tested and vaccinated if negative



Previously unvaccinated children intending to visit or live in a country with a TB incidence of 40 per 100,000 or greater for a period of three months or more 3,4



Previously unvaccinated children under 16 years of age (under 18 years of age if unaccompanied minor) who were born in, or who have lived for a prolonged period (at least three months), in a country with an annual TB incidence of 40 per 100,000 population or greater 4



Previously unvaccinated, tuberculin-negative children under 16 years of age (under 18 years of age if an unaccompanied minor) in recent close contact (within the last 12 months) with an individual with respiratory TB. 3,4



Previously unvaccinated, tuberculin negative children with a family history of TB in the past 5 years.

7

Appendix 1 4.1.3

Adults



Individuals under 35 years of age who are intending to live or work with local people in a country with a TB incidence of 40 per 100,000 or greater for a period of three months or more3



Mantoux/tuberculin negative individuals between the ages of 16 years and 35 years inclusive who are new entrants from sub-Saharan Africa or any country with a TB incidence of 500 per 100,000 population or greater3 should be screened for symptoms. Those who are registered with a local GP should be screened symptomatically.

4.1.4

Individuals at occupational risk of TB



Healthcare workers who will have contact with patients or clinical material



Laboratory staff who will have contact with patients, clinical materials or derived isolates



Veterinary and staff such as abattoir workers who handle animal species known to be susceptible to TB, e.g. simians



Prison staff working directly with prisoners



Staff of care homes for the elderly



Staff of hostels for homeless people and facilities accommodating refugees and asylum seekers.

4.2

Previous BCG vaccination

BCG should not be administered to previously vaccinated individuals as there is an increased risk of adverse reactions and no evidence of additional protection. Evidence of a previous BCG vaccination includes documentary evidence; a clear reliable history of vaccination or evidence of a characteristic scar4. Although the protection afforded by BCG vaccine may wane with time, there is no evidence that repeat vaccination offers significant additional protection and repeat BCG vaccination is not recommended.

8

Appendix 1

5. Responsibilities 5.1

Co-ordination and Quality Assurance

It is the responsibility of the Director of Public Health to ensure that their population is covered by an appropriate BCG immunisation programme and that quality assurance is in place. It is the responsibility of the Childhood Immunisation Steering Group to plan for and oversee the delivery of the programme and to monitor its quality. This group is co-chaired by the Croydon Immunisation Coordinator and the Consultant in Public Health. It is the responsibility of the Health Informatics Team to inform the quality monitoring process and to provide annual reports. Reporting should meet Department of Health requirements.

5.2

Service provision and process

It is the responsibility of the Willows at Croydon University Hospital to immunise infants (0 to 12 months) referred to them who belong to the defined risk groups for TB and to provide appropriate clinical supervision. This responsibility is to confirm eligibility of referrals for vaccination, to arrange appointments for those individuals identified as being at risk and to include follow up for defaulters. Neonatal BCG data is entered onto the Patient Administration System (PAS), and paper copies are sent to Child Health Record Department (CHRD) for entry onto ePEX. Training and quality control of the Willows’ immunisation nurses is the responsibility of Willows’ clinical lead† and service manager in partnership with the chest clinic. It is the responsibility of the Croydon Health Services’ (CHS) Immunisation Team to immunise children aged between 1 and 15 years inclusive and unaccompanied minors 117 years inclusive, who belong to the defined risk groups. The routine immunisation of this age group takes place at the Community Clinic within CHS. Part of this responsibility is to send out risk assessment questionnaires (Appendix 3), to assess eligibility for vaccination, to arrange appointments for those individuals identified as being at risk and to document data on ePEX. Training and monitoring of quality standards of the CHS Immunisation Team is the responsibility of the CHS Immunisation Team Lead, in partnership with the Chest Clinic at Croydon University Hospital whose role is support with training and competency levels. It is the responsibility of the community and chest clinics to ensure Mantoux tests and vaccine supplies are ordered and kept at the correct temperature in the vaccine fridge, to ensure the cold chain is maintained6. It is the responsibility of the Community Paediatricians to give medical advice to patients and health professionals when required. In particular, it is their responsibility to give medical advice to providers of Mantoux testing and BCG vaccination. †

Dr Jenny Handforth, consultant paediatrician lead for infectious diseases

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Appendix 1

5.3

Referral

It is the responsibility of all health professionals working within Primary Care to be aware of the BCG policy for Croydon and of risk groups for TB and to refer un-immunised or at risk individuals. It is the responsibility of midwives, health visitors, school nurses, school staff nurses, practice nurses and general practitioners to undertake a risk assessment with their clients and send the completed BCG vaccination assessment questionnaire (Appendix 3) to the appropriate clinic or team. It is the responsibility of London Borough of Croydon’s Unaccompanied Minors’ Service to identify those unaccompanied minors within Croydon aged 1 – 17 years inclusive, who belong to the defined risk groups for TB screening, during the initial health assessment process. These children should be referred to the CHS Immunisation Team, Community Clinic, Lennard Road, Croydon.

6. The procedure 6.1

Identification of individuals at risk

The BCG vaccination assessment questionnaire should be used to identify those individuals who are at risk using the appropriate criteria (see Appendix 3). As part of the targeted programme BCG vaccination will be offered to eligible individuals.

6.1.1. Infants Assessment and eligibility should be carried out antenatally at Croydon University Hospital. Midwives, health visitors, practice nurses and general practitioners should also use the BCG vaccination assessment questionnaire (Appendix 3) to identify infants (0 to 12 months) at risk. Infants in risk groups should be assessed by community midwives and referred to the Willows for vaccination. (See Appendix 2 for referral guidelines) 6.1.2 Children and young people aged 1 year to 16th birthday and unaccompanied minors aged 1 year to 18th birthday Health visitors, school nurses, school staff nurses, practice nurses, general practitioners and Looked After Children (LAC) team health services should have access to, and use, the BCG vaccination assessment questionnaire to identify children at risk and to refer to the CHS Immunisation Team, Community Clinic, Lennard Road. (See Appendix 2 for referral guidelines)

10

Appendix 1 6.1.3

Other Adults

GPs, practice nurses, the Homeless Health Team and other health professionals involved in patient contact should refer eligible individuals to the appropriate place for vaccination: 

The Chest Clinic for individuals in recent contact (during the last 12 months) with cases of TB



Individuals intending to travel or live for extended periods (more than three months) in high risk countries for TB are generally not covered by the NHS for vaccination. Travel immunisation advice for adults is available at travel clinics. (See Appendix 6 for clinics providing BCG vaccination near Croydon).

Individuals of any age requiring BCG for visa purposes or university entrance, who do not belong to the identified risk groups are not covered by the NHS for vaccination and should be referred to providers outside the NHS. (See Appendix 6 for clinics providing BCG vaccination near Croydon)

6.1.4 Refugees and Asylum Seekers (referral pathway from the Homeless Team) Adults: All adults are symptom screened for TB. Adults who are symptomatic are referred to the chest clinic at CUH. All adults are checked for the presence of a BCG scar and a record is made of whether one is visible or not. Infants (0-12 months): All infants are checked for the presence of a BCG scar. If there is no visible scar identified the infant should be referred to the Willows, Woodcroft Wing, CUH. Children 1 year up to16th birthday : All children up to their 16th birthday are checked for the presence of a BCG scar. If there is no visible scar the child should be referred to the CHS Immunisation Team, Community Clinic, Lennard Road, Croydon.

6.2

Referral and vaccination

The completed BCG vaccination assessment questionnaires should be returned to the Willows (for 0 to 12 months old) or the CHS Immunisation Team, Community Clinic, Lennard Road (for 1 to 15 year olds (to 16th birthday) and 1 to 17 year olds (up to 18th birthday) for UAMs) for assessment of eligibility and appointments (see contact details Appendix 2). This enables infants, children and young people who are deemed to be at risk to be vaccinated at the earliest opportunity.

11

Appendix 1 Individuals of any age who are identified as having symptomatic TB: persistent cough; fever; night sweats; weight loss; fatigue; enlarged lymph nodes should be referred to the chest clinic at Croydon University Hospital (CUH) for assessment. 6.3

Mantoux testing

The Mantoux skin test is given at the first clinic appointment with a return visit 2-3 days later (maximum 96 hours) to read the test and give BCG if required. The Mantoux test is not currently licensed in the UK. Mantoux testing should be performed in line with the Green book.4 A tuberculin skin test is necessary prior to BCG vaccination for:  All individuals aged over 6 years  Infants and children under six years of age with a history of residence or prolonged stay (more than three months) in a country with an annual TB incidence of 40/100,000 or greater  Those who have had close contact with a person with known TB  Those who have a family history of TB within the last five years

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Appendix 1 6.3.1

Interpretation of Mantoux test

Infants and children up to 16th birthday AND unaccompanied minors up to 18th birthday Diameter

Positivity

Interpretation

Less than 6mm

Negative – no significant hypersensitivity to tuberculin protein

Previously unvaccinated individuals may be given BCG provided there are no contraindications

6mm or greater but less than 15mm

Positive – hypersensitive to tuberculin protein

Should not be given BCG. No further action is needed in the presence of a BCG scar. Refer any individual with a hypersensitive Mantoux test to the chest clinic at Croydon University Hospital (CUH) Ask about TB symptoms (persistent cough; fever; night sweats; weight loss; fatigue; enlarged lymph nodes). If TB symptoms are present refer to the chest clinic at Croydon University Hospital (CUH)

15mm and above

Strongly positive – strongly hypersensitive to tuberculin protein

13

Suggests tuberculosis infection or disease. Refer to the chest clinic at Croydon University Hospital (CUH) for further investigation and treatment.

Appendix 1 6.4

Individuals not at risk

Individuals requesting BCG vaccination who do not belong to risk groups should be given advice regarding the national policy and telephone contact number for the Immunisation Coordinator at NHS South West London, Croydon Borough Team or the South West London Health Protection Unit. Croydon Immunisation Coordinator: South West London Health Protection Unit:

020 8274 6369/6374 020 8812 7850

7. Training needs assessment All staff administering Mantoux skin tests and BCG vaccination should have received training and should be assessed as competent to: 

administer intra-dermal injections, the technique used for Mantoux testing and BCG vaccination



read and record Mantoux tests



identify and respond to all levels of results of the Mantoux test



recognise and manage anaphylaxis



all staff should follow CHS infection control policy and guidelines to maintain standard infection control procedures and ensure sharps and vials are disposed of appropriately.

8. Consent and Documentation Valid consent should be obtained from either the adult with legal parental/carer responsibility or the patient themselves, if 16 years of age and over. A separate consent should be obtained for both the Mantoux skin test and the BCG vaccination. A written set of instructions about the care of vaccination site should be given to the individuals or a responsible carer, to confirm verbal instructions & information. (See Appendix 4) Any suspected adverse effect of Mantoux testing or BCG vaccination should be documented, reported to the patient’s GP and reported to the Medicines and Healthcare products Regulatory Agency (MHRA) by completing and sending a yellow card. http://yellowcard.mhra.gov.uk/

14

Appendix 1

9. Record retention and quality assurance Records should be kept of the date of both Mantoux test & BCG vaccination, batch numbers and expiry date, staff member’s name and title. Site of injection is recorded on paper notes only. Records for children and young people should be retained until the patient’s 25th birthday or 26th if the young person was 17 at conclusion of treatment. All others should be retained for 10 years after conclusion of treatment. 5 A written record of test and vaccinations done (Certificate of BCG vaccination) should be given to the individual to keep for future reference. (See Appendix 5) If a patient does not attend a prearranged appointment twice, the patient’s GP should be informed in writing. All data on Mantoux tests and BCG vaccinations should be collected on the ePEX system. The Immunisation Team at the Community Clinic, Lennard Road enter data directly on ePEX, and the Willows enter data onto the Patient Administration System (PAS) and send paper copies to the CHRD for entry onto ePEX. GPs are informed by letter once the BCG is given. Information entered on ePEX includes:           

NHS number Patient registration information Attendance for vaccination Date of attendance Criteria leading to decision to immunise or not Name of health professional administering test and/or vaccination BCG vaccination batch number and expiry date Mantoux batch number and expiry date if given Mantoux test result if given Non-attendance if Mantoux test given but patient not returned for vaccination Refusal to be immunised

The Governance process for this policy is via Croydon Borough Team’s Childhood Immunisations Steering Group, and NHS SWL Croydon Borough Team Clinical Leadership Group.

15

Appendix 1

10.

Distribution List

NHS SWL, Croydon Borough Team/Primary Care Trust: Director of Public Health - Dr Mike Robinson Consultants in Public Health – Dr Sarah Nicholls/Dr Sara Corben Public Health nurse and midwives - Elaine Trainor/Dawn Cox/ Alison Miller Chief Pharmacist – Eileen Callaghan Croydon Childhood Immunisations Steering Group Croydon Health Services NHS Trust Croydon University Hospital Chest Clinic Physician – Dr Anne Dunleavy, Rosemary Khan, Anne Smith Director of Nursing – Zoe Packman Director of Midwifery – Ann Morling Clinical Midwifery Managers – Beverly Reyes-Roberts Antenatal and Newborn Screening Co-ordinators – Angela Gentles/Stella Sebuwufu/Jane Smaldon The Willows Clinic and Service Manager – Dr Jennifer Handforth, Anne-Marie Baker Children’s Universal Services Manager and Immunisation Lead – Audrey Adamah Homeless Health Team – Paul Coleman Principal Pharmacist – Barbara Adie Clinical Nurse Trainer – Claudia Foster Croydon Immunisation Coordinator, CHS – Dr Joy Okpala Health Informatics – Derek Gooch Croydon Health Service – Tina Hickson, Associate Director of Nursing for Children, Young People, Family Health and Wellbeing Directorate and Alison Markwell, General Manager of Therapies and Children’s Services Looked After Children Services - Eileen Lawrence (UASC), Alison Brett (to June 2012) Croydon General Practice (on completion of policy) General Practitioners –Dr Farhhan Sami and Dr Brian Okumu Practice Nurse Lead – Catherine Wallace South West London Health Protection Unit Consultant in Communicable Disease Control - Barry Walsh Health Protection Nurse Specialist - Emma Dapaah

16

Appendix 1

11.

Glossary of Terms

Anaphylaxis

An immediate and severe allergic reaction to a substance requiring emergency medical intervention.

BCG

BCG stands for Bacille Calmette Guérin. BCG is a weakened (attenuated) version of a bacterium called Mycobacterium bovis, which is closely related to Mycobacterium tuberculosis, the agent responsible for TB. Effective immunisation against TB

ePEX

A community information system with child health module used by NHS Croydon provider services for recording information about patient care. ePEX-3 supplied by Ascribe Ltd.

Heaf Test

Former tuberculin test used in the UK, replaced by Mantoux test in 2005.

Infant

Child under the age of 1 year

Intra-dermal injection

Injection technique within the layers of the skin used for both Mantoux test and BCG vaccination.

Mantoux Test

Test in which a small amount of tuberculin is injected under the skin. Standard method of tuberculin testing.

TB/Tuberculosis An infection causing symptoms, due to the bacterium called Mycobacterium tuberculosis. Infection can occur at many sites in the body. Infection of the lungs can be passed on to other people through, for example, excessive coughing. Unaccompanied These are children under the care of London Borough of Minor Croydon’s Unaccompanied Minors service. They are children under 18 years of age who are seeking asylum in the UK and are not accompanied by a parent or guardian.

17

Appendix 1

12.

References

1. From the Chief Medical Officer, the Chief Nursing Officer and the Chief Pharmaceutical Officer. Changes to the BCG Vaccination Programme, Department of Health, 6th of July 2005, PL/CMO/2005/3. 2. Operational note to profession Changes to the BCG Vaccination Programme in England. Department of Health August 2005. 3. Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control. NICE clinical guideline CG117. National Collaborating Centre for Chronic Conditions March 2011. http://publications.nice.org.uk/tuberculosis-cg117

4. Immunisation against Infectious Disease – “The Green book”, Department of Health, August 2006. Updated Nov 2011 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131000.p df

5. Records Management: NHS code of practice (2nd Edition). Department of Health. January 2009. http://www.southwestlondon.nhs.uk/About/NHSCroydon/NHS%20Croydon%20policies/records_mana gement_annex_D1_D2.pdf

6. Guidelines on cold chain storage and safe handling of vaccines and medicines requiring refrigeration. Croydon Health Services 2010 http://nhscroydonintranet/policy/Documents/guidelinescurrent/Cold%20chain%20guidelines%20final%20version%20February%202010.pdf

7. World Health Organization (WHO) estimates of tuberculosis incidence by country, 2010 http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733758290

Web links accessed November 2012

18

Appendix 1

Appendices Appendix 1

Reference list of high risk countries7 - incidence of TB 40 per 100,000; updated June 2012 A E M S Afghanistan Ecuador Madagascar Sao Tome & Algeria Equatorial Guinea Malawi Principe Angola Eritrea Malaysia Senegal Armenia Ethiopia Mali Sierra Leone Azerbaijan Marshall Islands Solomon Islands F Mauritania Somalia B Micronesia (Federated South Africa Bahrain G States of) Sri Lanka Bangladesh Gabon Mongolia Sudan Belarus Gambia Morocco Suriname Belize Georgia Mozambique Swaziland Benin Ghana Myanmar Bhutan Guam T Bolivia Guatemala Tajikistan N Bosnia Herzegovina Guinea Thailand Namibia Botswana Guinea-Bissau Timor-Leste Nauru Brazil Guyana Togo Nepal Brunei Darussalam Turkmenistan Nicaragua Bulgaria H Tuvalu Niger Burkina Faso Haiti Nigeria Burundi Honduras U Northern Mariana Uganda Islands C I Ukraine Cambodia India United Republic of O Cameroon Indonesia Tanzania Cape Verde Iraq Uzbekistan P Central African Republic Pakistan Chad V J Palau China Vanuatu Panama China, Hong Kong SAR Vietnam K Papua New Guinea China, Macao SAR Kazakhstan Paraguay Columbia W Kenya Peru Comoros Wallace and Kiribati Philippines Congo Futuna Islands Kuwait Cote d’Ivoire Kyrgyzstan Q Y D Yemen L R Democratic People’s Lao People’s Republic of Korea Republic of Korea Z Democratic Republic Republic of Moldova Democratic People’s Zambia Lesotho Romania Republic of Congo Zimbabwe Lithuania Russian Federation Djibouti Libyan Arab Jamahiriya Rwanda Dominican Republic Liberia

Appendices correct at date of document approval November 2012

19

Appendix 1

Appendix 2 Referral Guidelines for BCG immunisation Infants 0 – 12 months:

Refer to the Willows at Croydon University Hospital 530 London Road, Croydon CR7 7YE, Tel: 0208 401 3177

Children and young people 1– up to 16th birthday, resident in Croydon, attending schools in Croydon or registered with a Croydon GP: Refer to the CHS Immunisation Team Community Clinic 12-18 Lennard Road, Croydon, CR9 2RS Telephone: 020 8274 6343, Fax 020 8666 0495 Unaccompanied Minors 1- up to 18th birthday: Refer to the CHS Immunisation Team Community Clinic 12-18 Lennard Road, Croydon, CR9 2RS Telephone: 020 8274 6343, Fax 020 8666 0495 Other at risk groups: Refer to Chest Clinic Croydon University Hospital Mayday Road Tel: 0208 401 3135 Referral Criteria3 : 

Children with a parent or grandparent who was born in a country with a high level of TB (see Appendix 1)



New entrants from high-incidence countries: offer BCG vaccination to Mantoux-negative new entrants who: • are from high-incidence countries, and • are previously unvaccinated (that is, without adequate documentation or a characteristic scar), and • are aged 16 to 35 years from sub-Saharan Africa or a country with a TB incidence of 500 per 100,0004*

 Children who are to visit or live in a country with high level of TB for more than 3 consecutive months during the following 2 years (see Appendix 1)  Symptomatic TB: the following are common symptoms of TB and may indicate a positive diagnosis: Persistent cough, fever, night sweats, weight loss, fatigue, enlarged lymph nodes. Refer directly to the Chest Clinic at Croydon University Hospital.  Contacts of TB: Refer directly to the Chest Clinic at Croydon University Hospital. *The Green Book recommends BCG for new entrants only up to the age of 16 years. However, in this pathway BCG is recommended for those up to 35 years who come from the countries with the very highest rates of TB because there is some evidence of cost effectiveness.

Appendices correct at date of document approval November 2012

20

Appendix 1

Appendix 3

Please return to Children’s Immunisations clinic, 12-18 Lennard Road, CR0 2RS. BCG Vaccination Assessment Questionnaire To be completed by the parent/carer for children aged 15 years and younger AND a health professional. Child’s Family Name____________

First Name_________________

NHS number (if known) ________________________ Date of birth___________________

Male / Female _________________

Country of birth

_________________

Date of Entry to UK (if applicable) _________________

Home address

_______________________________________________

Post code

________________

Telephone number ______________________

Name of additional contact person / Interpreter ____________________ Address__________________________________________ Telephone number _________________________

Name of GP _________________________________ Address ________________________________________________________ Telephone number ________________________

Please answer the following questions about you or your child. 1

Please name the country where the child’s father was born

2

Please name the country where the child’s mother was born Please name the country where the child’s father’s parents were born Please name the country where the child’s mother’s parents were born Has your child lived in any country in the following areas for three months or more? A) S.E Asia B) South America C) Africa D) Eastern Europe E) Bahamas F) Far East G) Middle East (See attached list) Is your child likely to travel to any country in the following areas and stay there for three months or more during the next two years?

3 4 5

6

Appendices correct at date of document approval November 2012

21

Yes / No If yes give name of country

Yes / No

Appendix 1 A) S.E Asia B) South America C) Africa D) Eastern Europe E) Bahamas F) Far East G) Middle East (See attached List) Have you or any member of your family ever lived in A) SE Asia B) South America C) Africa D) Eastern Europe E) Bahamas F) Far east G) Middle East (See attached List) As far as you are aware has your child ever been in contact with any person who might have had TB?

If yes give name of country

9

Has your child ever been treated for TB? If yes do not give Mantoux or BCG vaccination

If yes give date

10

Has your child been given any recent immunisations? If so, please state which.

If yes give date

11.

Does your child have any special physical or educational needs? If so, please specify.

7

8

To be completed by Health Professional This individual has symptoms of TB (persistent cough; fever; night sweats; weight loss; fatigue; enlarged lymph nodes)

Yes / No If yes give name of country

If yes give date

Yes / No If yes, refer directly to the chest clinic at CUH Yes / No

This individual requires BCG vaccination What are the reasons for requesting BCG vaccination?

The individual has risk factors (eg, HIV, receiving cortico steroids / immunosuppressants / pregnancy)

Yes / No Specify

For referral to Chest Clinic (check with Chest Clinic referral criteria)

Yes / No

Refer to Community BCG clinic

Yes / No

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Appendix 1 Form completed by

________________________________ Health Professional

Signature

________________________________

Designation

________________________________

Date

________________________________

A list of high risk countries is attached to this questionnaire.

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Appendix 1

Appendix 4

Care of the BCG vaccination site If you look after the BCG vaccination site it should heal up neatly and cleanly and leave a tidy scar. The time it takes for the BCG site to heal up varies from person to person, but do not be surprised if it takes between two and three months to heal. Sometimes it takes longer. In a few people the pink spot does not appear, but you will still gain protection from the vaccination. If you follow a few simple guidelines any problems should be reduced.

BCG Day Following the BCG vaccination, take care; do not knock as vaccination site will be delicate. For the rest of the day try and refrain from games which will knock the site. The vaccine will gradually absorb into the skin during the day and the raised area will usually disappear.

After this time the following tips should help It usually takes one to two weeks for the spot to appear. Over a period of time it will develop a scab on top. You may bath and shower as usual. Shower gel is ok to use, but do not put creams and lotions on the site afterwards. Do not scratch, pick or intentionally knock any scab off the site. Leave the site exposed as much as possible whilst you have the spot, the principle is the same as for any healing wound, allow it to dry undisturbed. The less you disturb it the neater the scar will be. If the blister oozes try to leave it alone, but you may cover it with a waterproof plaster for swimming, but always remove this plaster after the swim. For contact / dirty sports and activities cover it with a dry non-stick dressing to keep dirt out. Do not have any other injections in the same arm for three months as this could lead to an interaction between the vaccines resulting in a sore arm. It is important to wait four weeks before you have any live vaccines such as Yellow Fever or MMR (Measles, Mumps, Rubella) And finally Do not lose the certificate; it may be needed sometime in the future.

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Appendix 1

Appendix 5

Children’s Universal Services BCG Clinic Community Children’s Immunisations clinic 12-18 Lennard Road CR9 2RS Tel: 020 8274 6343 E-mail: [email protected] www.croydon.nhs.uk CERTIFICATE OF BCG VACCINATION AGAINST TUBERCULOSIS

Name _____________________________________ D.O.B_____________ Date of vaccination

___________________________

Vaccine Batch No.

___________________________

Diluent Batch No.

____________________________

Given by

_________________________________

Print

______________________

Designation __________________________________

Please keep this certificate safe; you may need it in the future. You may wish to tell your GP you have received this vaccination so it can be put on your records.

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Appendix 1

Appendix 6 Private travel clinics near Croydon:

MASTA Travel Clinic - Gatwick Airport Rooms 1-3 Jubilee House Furlong Way North Terminal, Gatwick Airport RH6 0JN  0330 100 4174 http://www.masta-travel-health.com/travelclinic/gatwickairporttravelclinic

MASTA Travel Clinic - Fulham Basuto Medical Centre 29 Basuto Road Fulham London SW6 4BJ 0330 100 4239 http://www.masta-travel-health.com/clinic_searches/87592

MASTA Travel Clinic - Tower Hill Tower Hill Medical Centre 10 Lloyds Avenue London EC3N 3AJ 0330 100 4251 http://www.masta-travel-health.com/clinic_searches/87594

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