Tubercle, (1970), 51, 423

BCG VACCINATION: A COMPARISON OF POST-VACCINATION TUBERCULIN

SENSITIVITY AmER ORAL AND INTRADERMAL VACCINATION OF NEWBORN
INFANTS*

By HILDEKAHN and ROLFMEYERHEIM

from the Departamento BCG da Fundacrio Ataulpho de Paiva, Institute Viscondessa de Moraes

R.D. AZULAY
Universidade Federal Fluminense and Faculdade de Ciencias Midieas. Universidade Estado da Guanabora

ACHILLESSCORZELLI
Escola de Medicina e Cirurgia do Rio de Janeiro

SUMMARY
Two groups of newborn infants were vaccinated with BCG soon after birth, one by the oral
and the other by the intradermal route; a third group of infants were left unvaccinated.
Tuberculin tests were done two, three and five months after vaccination.
A high proportion of the infants did not have completed tests; but the losses were similar
in all three groups. All tests were completed in 148 of the oral group, 154 of the intradermal
group and 95 of the unvaccinated group.
Among the unvaccinated group 16 “/, showed tuberculin conversion during the observa-
tion period.
Among those vaccinated by the oral route 82% became tuberculin positive, compared
with 76 ‘A of those vaccinated intradermally. The difference was not significant.
The results indicate that in this study oral vaccination was as effective as intradermal
vaccination in producing tuberculin skin sensitivity.

RESUME
Deux groupes de nouveau-& ont Ctt vaccines par le B.C.G. peu de temps aprbs la nais-
sance, l’un de ces groupes, par voie orale, l’autre par voie intradermique; un troisibme
groupe n’ a pas Ctt vaccine. Des tests tuberculiniques ont tte effect&s, deux, trois et cinq
mois aprts la vaccination.
Une forte proportion d’enfant n’ont pas eu tous les tests; mais les pertes ont tte sem-
blables dans les trois groupes. Tous les tests ont CtC faits, chez 148 enfants vaccines par
voie orale, 154 vaccines par voie intradermique, et 95 non vaccines.
Dans le groupe des enfants non vaccines, I,6 % ont montre une conversion des reactions
tuberculiniques au tours de la periode d’etude envisagee.
Parmi les enfants non vaccines, 82% de ceux ayant eu le B.C.G. par voie orale ont eu
* A cooperative study by FundacBo Ataulpho de Paiva; Faculdade de Medicina, Universidade Federal Fluminense;
and Secretaria de Saude e Assistencia, Estado do Rio de Janeiro, with funds from the Comissao Central de Pesquisas,
Universidade Federal Fluminense.
Reprints can be obtained from Dr. Hilde Kahn, Fundagao Ataulpho de Paiva, 260 Avenida Pedro II, Rio de
Janeiro, Brazil.
424 KAHN AND OTHERS

des tests tuberculiniques positifs, compares a 76% de ceux ayant eu le B.C.G par voie
intradermique. La difference n’est pas significative.
Les resultats de cette etude montrent que la vaccination par voie orale a CtCaussi effi-
cace que la vaccination par voie intradermique pour produire une sensibilite cutanee a la
tuberculine.

RESUMEN
DOSgrupos de recien nacidos fueron vacunados con BCG al nacer, un grupo por via bucal
y el otro por via intradermica; un tercer grupo se deja sin vacunar. Se hicieron reacciones
tuberculinicas a 10s dos, tres y cinco meses de la vacunacion.
Una proportion elevada de niiios no pudo completar las reacciones, pero ello sucedio
por igual en 10s tres grupos. Se completaron 10s test en 148 de1 grupo bucal, 154 de1 grupo
intradtrmico y 95 de1 grupo control.
Entre 10s no vacunados el 16 % presento viraje tuberculinico en el period0 de observa-
cion.
Entre 10s vacunados por via bucal el 82 % result6 tuberculin0 positivo, comparado con
76 % de 10s vacunados por via intradermica. La diferencia no fuC significativa.
Los resultados indican que en este estudio la vacunacion bucal fuC tan efectiva coma la
intradermica para conseguir viraje tuberculinico.

ZUSAMMENFASSUNG
Neugeborene wurden kurz nach der Geburt BCG-geimpft, eine Gruppe oral, eine andere
intrakutan, eine dritte blieb zur Kontrolle ungeimpft. Zwei, drei und fiinf Monate post
vaccinationem wurden Tuberkulinpriifungen vorgenommen.
Eine grol3e Anzahl von Kindern konnte nicht hickenlos durchgetestet werden; die Fehler
verteilen sich gleichmal3ig auf alle drei Gruppen. Alle Tests erhielten 148 oral Geimpfte,
154 intrakutan Geimpfte und 95 Kontrollen.
Bei 16 % der Nichtgeimpften erfolgte eine Tuberkulinkonversion wahrend der Beo-
bachtungszeit.
Nach oraler Vakzination wurden 82 %, nach intrakutaner 76 % tuberkulinpositiv. Dieser
Unterschied ist nicht signifikant.
Nach den Erfahrungen dieser Studie kommt es nach oraler Impfung ebensooft zu einer
nachweisbaren Hautallergie gegen Tuberkulin wie nach intrakutaner Impfung.

Introduction
In developing countries the oral method of BCG vaccination is easier to perform, for these
countries generally do not have sufficient trained personnel to do intradermal vaccination. This is
true not only in the vast rural areas, in which at least half of the Latin American population lives,
but also in the urban areas.
The oral route is particularly attractive for vaccinating newborn infants, whose protection has
priority in almost all developing countries, because of the high risk of infection.
The vast experience in oral BCG vaccination in France and South America, especially in Brazil
and Uruguay, suggests that this method confers protection against tuberculosis (see de Assis, 1964;
Mande, 1966). But the reports of its use, almost all published many years ago, lack the statistical
precision that is now required. For this reason, its degree of effectiveness cannot be fully assessed.
One of the recommendations of the XVI Congress0 Latinoamericano de Tuberculosis y Enfermi-
 ORALBCG 425

dades de1 Apart0 Respiratorio held in Mexico in 1969, was as follows: ‘Taking into account the
practical advantages of the oral route, the evidence of its protective value, and the fact that it has
been widely used for many years in several countries, it is worthwhile to promote a controlled,
internationally supervised trial to elucidate the value of the oral vaccination in different age groups’.
The British Medical Research Council (1963) demonstrated the efficacy of intradermal BCG vaccina-
tion. In this study more than 50,000 participants were observed for many years and it was shown
that about 80% protection lasted for at least 10 years. For a similar trial to determine the degree
of the protective effect of oral vaccination, it has been suggested that a study population of 200,000
to 600,000 subjects and an observation time of 10 years would be necessary (see Unidade de Tuber-
culose da Divisao de Doencas Transmissiveis da O.M.S., 1968).
Such a trial could be performed only in a developing country. As the follow-up of the very
fluctuant populations in vast territories is difficult, and national or international funds for such
enormous investigations are not available, this kind of trial is impracticable.
It is, therefore, necessary to devise short-term, relatively inexpensive trials. These can compare
the degree of tuberculin sensitivity and the size of vaccination lesions produced by one method of
vaccination and one vaccine with the sensitivity and lesions produced by another method and an-
other vaccine that have been shown by long-term investigations to be protective in man.
If the study population is newborn infants, who are undoubtedly free from any tuberculous or
other mycobacterial infection before the vaccination, the numbers required can be reduced.
As tuberculous infection can evolve rapidly to disease in infants and small children, estimates of
morbidity can be obtained from a relatively short period of observation.
Investigations, including animal experiments and vaccination of newborn infants, have been
carried out using the same vaccines by oral and intradermal routes. The results of the animal
experiments have been published elsewhere (Azulay and Kahn, 1969). The present paper relates
only to the tuberculin sensitivity observed in the first five months after vaccination of newborn
infants.
As BCG vaccination is considered of value in the prophylaxis of leprosy the present study
included also investigation of the influence of the two vaccination methods on lepromin conversion.
The results will be published in a separate paper.

Methods
The study was done in the Hospital Universitario Antonio Pedro, Faculdade de Medicina da
Universidade Federal in Niteroi, Rio de Janeiro, Brazil. The maternity clinic is used by a section
of the poor population living in unfavourable conditions. The vaccinations were performed between
5th December, 1967 and 8th May, 1968 by two hospital nurses (intradermal) and two vaccinators of
the State BCG Service (oral). They were supervised by the authors.
VACCINES
For intradermal vaccination: freeze dried BCG vaccine, batch B8185, manufactured October
1967 (expiration October 1968), by Glaxo Laboratories Ltd., Greenford, England. Dose - 0.05 ml.
intradermally in the left deltoid region.
For oral vaccination: liquid BCG vaccine, prepared from the BCG-Moreau-Rio-de-Janeiro
strain by the Institute Viscondessa de Moraes of the Fundacao Ataulpho de Paiva, Rio de Janeiro,
Brazil. Seventeen different batches were used, all within three weeks of manufacture. Dose - 5 ml.
of the suspension containing 100 mg. BCG.
Sensitins
PPD RT23 received from Statens Serum Institut, Copenhagen, and diluted to 2 TU by the
Service National de Tuberculose, Rio de Janeiro.
426 KAHN AND OTHERS

Old Tuberculin produced by the Instituto Oswald0 Cruz of the Health Ministry, Rio de Janeiro,
and diluted to l/100 by the Instituto Viscondessa de Moraes.
Lepromin produced by the Service National de Lepra, Rio de Janeiro.
Apparatus
Syringes Microstat Tuberculin U.S.A. of 1 ml. capacity and needles of 18-8 stainless UNICEF
no. 26 were used for the intradermal vaccination and the post-vaccination tests.
The oral vaccine was given by nipples, fitted directly to the vaccine vials. Needles and nipples
were used only once and sterilized before further use.
Different syringes, needles and containers were used for each special purpose (intradermal
vaccination, PPD test, OT test, lepromin test).
Allocation to groups
The infants were vaccinated between 24 and 48 hours after birth. Premature and sick infants and
those who lived so far away from the hospital that follow-up observation was impossible, were
excluded. Those infants considered suitable for the trial on the first vaccination day received
intradermal BCG vaccine. The same number of children born the next day were given oral BCG
vaccine. The following day an identical number were left without vaccination. This scheme was
modified when the control group consisted of 249 children. After April 6th no more were left
unvaccinated. The vaccinations continued then on alternate days intradermally and orally.
The study population originally consisted of more than 1,000 infants; but some were withdrawn
after their first visit (14 days after birth) when conditions were discovered which would have
excluded their participation from the beginning (distance of residence, tuberculosis contact or
suspicion of contact in the control group, etc.).
There remained 989 infants, 366 in the intradermal group, 374 in the oral group and 249 in the
control group.
Observation after vaccination
All mothers were informed that their babies had been vaccinated and asked to come back to the
hospital’s outpatient clinic 14 days after the birth. On this occasion the existence and the size of
local vaccination lesions and of lymph nodes were observed; this observation was repeated each
time the children came to the clinic.
Post-vaccination tests were done between February 2nd and December 12th 1968, two, three and
five months after vaccination. With the exception of some of the first of the two-month tests all
tests were given and read by the same person, supervised by the authors. The PPD was injected
intradermally on the superior third and the OT on the middle third of the inner side of the left
forearm.
Initially 2TU PPD was injected. If the induration after 48 to 96 hours (usually 72 hours) was
less than 5 mm. diameter, a second test with 0.1 ml. of 1 in 100 OT was performed. If the induration
to this was less than 5 mm. the child had to come back one month later (i.e. three months after
birth), when the tests were repeated. If both tests were again negative, they were repeated two months
later (i.e. five months after birth).
A few children could be tested only after six to nine months after birth, because of illness or the
mother’s failure to bring them to the clinic at the appointed time.
Once a test with 2TU PPD or with 1 in 100 OT was recorded as giving induration of 5 mm. or
more, no other tests were performed.
Loss to observation
As the children had to appear many times in the hospital (the non-reactors 13 times) a relatively
small number finished the test series (397 (40%) of 989). (Table I.) The majority of losses in all
groups were due to failure to obtain one completed test, the mothers not bringing the infants to the
clinic for testing or reading.
In all groups few mothers who were requested to return for retesting after a completed test failed
 ORAL BCG 427

TABLEI.-THE NUMBERSWITH COMPLETED

TESTSIN THETHREEGROUPS

Oral / Intradermal Non-vaccinated

I
group wow grouP
- _____
Total at start of observations 314 cloo%) 366 (100 %I 249 (1000’
.o)
____ _. ..___
No. completed tests 220 (59%) 1 202 (55%) - 146 (59 %I

At least one completed test 1.54 (41%) 164 (45%) I 103 (41 O’
0)
-
Tested once but failed to complete
all tests . . 6* IO? 8
-
All tests completed . 148 (40%) 1 154 (45%) 95 (38 “)
40
I
* 3 after negative tests at two months; 3 after negative tests at three months.
t 4 after negative tests at two months: 6 after negative tests at three months.

to do so (in the oral group six -three after negative tests at two months and three after three months:
in the intradermal group 10 - four after negative tests at two months and six after three months).

Results
The analysis of the results of tuberculin testing concerns only those in whom all the required
tests were completed (oral - 148, intradermal - 154, non-vaccinated - 95).
Non-vaccinated group
Of the 95 infants with completed tests two developed reactions of 5 mm. or more to 2TU PPD
and 13 to I in 100 OT. Thus during the period of observation 15 (16 %) showed tuberculin con-
version.
Vaccinatedgroups
The comparison between the two vaccinated groups is shown in Tables II and III. Of those
tested at two months 63 % in the oral group and 49 % in the intradermal group had positive reactions
(Table II). In the oral group 73 were tested at two, two and three, two and five or two, three and
five months; 61 (84%) gave reactions of 5 mm. or more to either 2TU PPD or 1 in 100 OT (Table
III). The corresponding percentage for the 79 in the intradermal group was 747:;;. Of the total
tested, 121 (82%) of 148 in the oral and 117 (76%) of 154 in the intradermal group became positive.
None of the differences between the groups are significant.
Vaccination lesions
The vaccination site was examined in 233 infants in the intradermal group; lesions were present
in 224. Among 154 who were tuberculin tested at least once, 147 had lesions. In 33 of these the
tuberculin reaction was negative. Of the seven without lesions, four had negative reactions. All the
lesions were within the normal limits.
In both vaccinated groups there were a few infants with small increase in size of lymph nodes,
but no serious adenitis or other complications were observed.

Discussion
The present study has compared the tuberculin conversion after routine oral BCG vaccination, as
carried out in Brazil, with the conversion rate produced by an intradermal vaccine recognized as an
efficient one.
428 KAHN AND OTHERS

TABLEII.-THE RESJLTS OF TUBERCULINTESTSAT Two. THREEAND FIVE MONTHSAFTERVACC~NA-~~ON

Positive* to Positive* to Negative to

Period after Results of Vaccination Total 2TU PPD 2TU PPD or I in 100 OT;
vaccination previous test group subjects I in 100 OT to be
No. % No. % retested

2 months Not previously Oral 73 14 19 46 63 27

tested Intradermal 79 6 8 39 49 40

3 months Negative at 2 Oral 23 0 0 10 (43) 13

months Intradermal 30 0 0 10 (33) 20

Negative at 2 Oral 4 1 (25)

months, not tes- Intradermal 10 0 (01 : ii;;
ted at 3 months
5 months
Negative at 2 Oral 13 0 (01 4 (31) -
and 3 months Intradermal 20 0 (01 5 (25) -
.I=
3 months Not previously Oral 42 15 36 29 69 13
tested Intradermal 34 4 I2 24 71 10

5 months Negative at 3 Oral 13 1 (8) 6 (46)

months, not tes- Intradermal 10 0 (0) 6 (60) -
ted at 2 months
:: _=
5 months Not previously Oral 33 11 33 25 76 -
tested Intradermal 41 4 10 29 71
_
* Positive-5 mm. or more induration.
Percentages in brackets are based on less than 25 subjects.

TABLEIII.-THE RESULTSOF TUBERCULINTE.YTS

AFTERVACCINA~ON

Positive to
Vaccination Total 2TU PPD or
group tested I in 100 OT
No. %

Tested at two, two and three, two and five

or two, three and five months . .’ ) ~-z$ermal 1 ;i

Tested at three or three and five months . Oral 42 35 83

Intradermal 34 30 88

Tested only at five months Oral 33 25 76

Intradermal 41 29 71

Total tested . .

.-_-
 ORAL BCG 429

The simultaneous observation of a non-vaccinated group was considered necessary, to know the
spontaneous conversion rate in the study population. The non-vaccinated group showed 16 %
conversion, most (13 of 15) cases being observed only five months after birth, at an age a child
vaccinated at birth could have developed resistance.
The high proportion of conversions in the non-vaccinated group could raise the suspicion that the
results might have been influenced by repetition of tuberculin testing. But that did not happen, for
14 of the 15 had positive reactions at the first test. Only one became positive at the third test.
Furthermore, out of the 80 with negative tests, 36 children had been tested two or three times.
The conversion rates to 2TU PPD were very low (see Table II). This dose might not be sufficient
to demonstrate post-vaccination allergy in newborn infants.
Observation of the site of the intradermal vaccination showed that 33 (22%) of 147 children
with vaccination lesions gave no reaction to 1 in 100 OT. This is relevant to the question whether
the presence of vaccination lesions is sufficient by itself to indicate the efficacy of vaccination.

REFERENCES
Assrs, A. (1964). Passado, presente e future da vacina@o BCG. Rev&a do Servigo National de Tuberculose, 8, 7,
AZULAY, R. D. & KAHN, H. (1969). Sensibilidade leprominica e tuberculinica induzidas pelo BCG pelas vias mtra-
d&mica e oral. Boletim do Serviqo National de Lepra, 28, 15.
MANDE. R. (1966). B.C.G. Manuel Pratiaue de Vaccination. Centre International de Z’Enfance.Paris.
MEDICALRE&F.AR~H GCJNCIL (1963). B.C.G. and vole bacillus vaccines in the prevention of tuberculosis in adolescence
and early adult life. Third report to the M.R.C. by their Tuberculosis Vaccines Clinical Trials Committee.
British Medical Journal, 1, 973.
U.L.A.S.T.-XVI CQNGRESOLATINOAMERICANO DE TUBERCULOSIS Y ENPERMIDADES DELAPARATORESPIRATORIO (1969).
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Comitt Regional Latinoamericcn3, Maracaibo, Venezuela.
UNIDADE DE TUBERCULOSE DA DIVI&O DE DOENCASTRANSMISSIVEIS DA O.M.S. (1968). Revisao critica das pesquisas
sobre vacinatio corn B.C.G. oral. Revista do Servifo National de Tuberculose, 12, 273.