BCG vaccination in patients with severe combined immunodeficiency: complications, risks, and vaccination policies

Abstract

Background: Severe combined immunodeficiency (SCID) is a syndrome characterized by profound T-cell deficiency. BCG vaccine is contraindicated in patients with SCID. Because most countries encourage BCG vaccination at birth, a high percentage of patients with SCID are vaccinated before their immune defect is detected.

Objectives: We sought to describe the complications and risks associated with BCG vaccination in patients with SCID.

Methods: An extensive standardized questionnaire evaluating complications, therapeutics, and outcomes regarding BCG vaccination in patients given a diagnosis of SCID was widely distributed. Summary statistics and association analysis was performed.

Results: Data on 349 BCG-vaccinated patients with SCID from 28 centers in 17 countries were analyzed. Fifty-one percent of the patients had BCG-associated complications, 34% disseminated and 17% localized (a 33,000- and 400-fold increase, respectively, over the general population). Patients receiving early vaccination (≤1 month) showed an increased prevalence of complications (P = .006) and death caused by BCG-associated complications (P < .0001). The odds of experiencing complications among patients with T-cell numbers of 250/μL or less at diagnosis was 2.1 times higher (95% CI, 1.4-3.4 times higher; P = .001) than among those with T-cell numbers of greater than 250/μL. BCG-associated complications were reported in 2 of 78 patients who received antimycobacterial therapy while asymptomatic, and no deaths caused by BCG-associated complications occurred in this group. In contrast, 46 BCG-associated deaths were reported among 160 patients treated with antimycobacterial therapy for a symptomatic BCG infection (P < .0001).

Conclusions: BCG vaccine has a very high rate of complications in patients with SCID, which increase morbidity and mortality rates. Until safer and more efficient antituberculosis vaccines become available, delay in BCG vaccination should be considered to protect highly vulnerable populations from preventable complications.

Keywords: BCG; Primary immunodeficiency; hematopoietic stem cell transplant; immune reconstitution syndrome; mycobacteria; newborn screening; severe combined immunodeficiency; vaccine.

Figure 1

BCG-vaccinated SCID patients, epidemiologic characteristics A) Age at SCID diagnosis; B) SCID diagnosis and BCG complications (No manifestations, Localized, Disseminated); C) Age at BCG vaccination and BCG complications (No manifestations, Localized, Disseminated) distribution; D) BCG vaccine strain and BCG complications (No manifestations, Localized, Disseminated); E) Age at onset of BCG complications (Localized, Disseminated); F) Site of involvement of Disseminated BCG complications. X axis, number of patients.

Figure 2

Time-to-event analysis by age at BCG vaccination and age at HSCT. A) Kaplan-Meier curves for the time from vaccination to death due to BCG complications comparing early (≤ 1 month of age, dashed line) vs. late (> 1 month of age, solid line) vaccination (p<0.0001). B) Kaplan-Meier curves for the time from vaccination to death within 24 months of age before HSCT comparing early (≤ 1 month of age, dashed line) vs. late (>1 month of age, solid line) vaccination (p=0.01). C) Kaplan-Meier curves for the time from HSCT to death comparing early (≤ 1 month of age, dashed line) vs. late (> 1 month of age, solid line) vaccination (p=0.96). D) Kaplan-Meier curves for the time from HSCT to death comparing early (≤ 3 months of age, dashed line) vs. late (> 3 months of age, solid line) transplant (p=0.33).