Selective BCG vaccination in a country with low incidence of tuberculosis

In 1975 the BCG vaccination policy in Sweden changed from routine vaccination of all newborn infants to selective vaccination of groups at higher risk. This report aims to evaluate the present BCG policy, with focus on the tuberculosis situation in Sweden during the period from 1989 to 2005. The population structure in Sweden has changed, with increasing numbers and proportions of people who were born outside Sweden, especially in countries with high prevalence of tuberculosis. BCG vaccination coverage fell from more than 95% before 1975 to less than 2% in 1976 to 1980, and then again increased to around 16 % (corresponding to about 88% of the risk group recommended for vaccination). The increasing proportion of foreign born tuberculosis patients among all tuberculosis cases of illness in Sweden, and the high age-specific incidence of tuberculosis in the childbearing age groups in the foreign-born population, indicate the need to continue selective vaccination of children in families originating from countries with high tuberculosis incidence. The cumulative incidence of tuberculosis in the 30 cohorts born in Sweden after 1974 and observed to the end of 2004 was estimated at 0.5 cases per 100 000 person-years. Sweden still has one of the lowest incidences of tuberculosis in the world, which means a minimal average risk of infection for the majority of children born to Swedish parents. The observed increase of tuberculosis in 2005, partly attributed to an outbreak at a day nursery, is a reminder of the serious consequences of delayed diagnosis. Intensified active case finding is the most important action to prevent childhood tuberculosis, by means of eliminating the sources of infection to prevent transmission to the child population. Early detection and treatment of infected children is necessary to prevent development of serious disseminated tuberculosis.