Meta-Analysis

. 2022 Sep;10(9):e1307-e1316.

doi: 10.1016/S2214-109X(22)00283-2.

Infant BCG vaccination and risk of pulmonary and extrapulmonary tuberculosis throughout the life course: a systematic review and individual participant data meta-analysis

Leonardo Martinez¹, Olivia Cords², Qiao Liu³, Carlos Acuna-Villaorduna⁴, Maryline Bonnet⁵, Greg J Fox⁶, Anna Cristina C Carvalho⁷, Pei-Chun Chan⁸, Julio Croda⁹, Philip C Hill¹⁰, Elisa Lopez-Varela¹¹, Simon Donkor¹², Katherine Fielding¹³, Stephen M Graham¹⁴, Marcos A Espinal¹⁵, Beate Kampmann¹², Arthur Reingold¹⁶, Helena Huerga¹⁷, Julian A Villalba¹⁸, Louis Grandjean¹⁹, Giovanni Sotgiu²⁰, Uzochukwu Egere²¹, Sarman Singh²², Limei Zhu³, Christian Lienhardt²³, Justin T Denholm²⁴, James A Seddon²⁵, Christopher C Whalen²⁶, Alberto L García-Basteiro²⁷, Rina Triasih²⁸, Cheng Chen³, Jitendra Singh²⁹, Li-Min Huang³⁰, Surendra Sharma³¹, Djohar Hannoun³², Helena Del Corral³³, Anna M Mandalakas³⁴, LaShaunda L Malone³⁵, Du-Lin Ling³⁶, Afrânio Kritski³⁷, Catherine M Stein³⁸, Richa Vashishtha³⁹, Fadila Boulahbal⁴⁰, Chi-Tai Fang⁴¹, W Henry Boom³⁸, Eduardo Martins Netto⁴², Antonio Carlos Lemos⁴², Anneke C Hesseling⁴³, Alexander Kay⁴⁴, Edward C Jones-López⁴⁵, C Robert Horsburgh⁴⁶, Christoph Lange⁴⁷, Jason R Andrews⁴⁸

Affiliations

¹ Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA. Electronic address: leomarti@bu.edu.
² Center for Animal Disease Modeling and Surveillance, School of Veterinary Medicine, University of California, Davis, Davis, CA, USA.
³ Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China.
⁴ Section of Infectious Diseases, Department of Medicine, Boston University Medical Center, Boston, MA, USA.
⁵ Université de Montpellier, IRD, INSERM, TransVIHMI, Montpellier, France.
⁶ Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Woolcock Institute of Medical Research, Glebe, NSW, Australia.
⁷ Laboratory of Innovations in Therapies, Education and Bioproducts, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
⁸ Division of Chronic Infectious Disease, Taiwan Centers for Disease Control, Taipei, Taiwan; Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
⁹ Oswaldo Cruz Foundation Mato Grosso do Sul, Campo Grande, Brazil; Federal University of Mato Grosso do Sul, Campo Grande, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.
¹⁰ Centre for International Health, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
¹¹ Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.
¹² Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia.
¹³ Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
¹⁴ Centre for International Health, University of Melbourne Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC, Australia.
¹⁵ Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization, Washington, DC, USA.
¹⁶ Division of Epidemiology, University of California, Berkeley, Berkeley, CA, USA.
¹⁷ Epicentre, Paris, France.
¹⁸ Laboratorio de Tuberculosis, Instituto de Biomedicina, Universidad Central de Venezuela, Caracas, Venezuela; Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
¹⁹ Department of Infection, Inflammation and Immunity, Institute of Child Health, University College London, London, UK.
²⁰ Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy.
²¹ Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
²² Department of Microbiology, All India Institute of Medical Sciences, Bhopal, India; Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India; Medical Science and Engineering Research Centre, Indian Institute of Science Education and Research, Bhopal, India.
²³ Université de Montpellier, IRD, INSERM, TransVIHMI, Montpellier, France; Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
²⁴ Victorian Tuberculosis Program, Melbourne Health, Melbourne, VIC, Australia; Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, VIC, Australia.
²⁵ Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa; Department of Infectious Disease, Imperial College London, London, UK.
²⁶ Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA; Global Health Institute, University of Georgia, Athens, GA, USA.
²⁷ Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Barcelona, Spain.
²⁸ Department of Pediatrics, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada and Dr. Sardjito Hospital, Yogyakarta, Indonesia.
²⁹ Department of Microbiology, All India Institute of Medical Sciences, Bhopal, India; Translational Medicine Centre, All India Institute of Medical Sciences, Bhopal, India; Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India.
³⁰ Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
³¹ Department of Molecular Medicine, Jamia Hamdard Institute of Molecular Medicine, New Delhi, India; Department of General Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, India; Department of Respiratory Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, India.
³² Department of Information, National Institute of Public Health, Algiers, Algeria.
³³ Grupo de Inmunología Celulare Inmunogenética, Facultad de Medicina, Sede de Investigación Universitaria, Universidad de Antioquia, Medellin, Colombia; Grupo de Epidemiologıa, Universidad de Antioquia, Medellin, Colombia.
³⁴ The Global TB Program, Texas Children's Hospital, Houston, TX, USA; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Division of Clinical Infectious Diseases, Medical Clinic, Research Center Borstel, Borstel, Germany; Tuberculosis Unit, German Center for Infection Research, Borstel, Germany.
³⁵ Uganda-CWRU Research Collaboration, Kampala, Uganda; Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
³⁶ Taichung Regional Center, Taiwan Centers for Disease Control, Taipei, Taiwan.
³⁷ Tuberculosis Academic Program, Medical School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
³⁸ Uganda-CWRU Research Collaboration, Kampala, Uganda; Tuberculosis Research Unit, Case Western Reserve University, Cleveland, OH, USA; Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
³⁹ Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India.
⁴⁰ Groupe de recherche sur la tuberculose latente, Laboratoire National de Référence pour la Tuberculose, Institut Pasteur d'Algérie, Algiers, Algeria.
⁴¹ Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
⁴² Medicine Department, University Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Brazil.
⁴³ Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa.
⁴⁴ The Global TB Program, Texas Children's Hospital, Houston, TX, USA; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
⁴⁵ Division of Infectious Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
⁴⁶ Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA.
⁴⁷ Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Division of Clinical Infectious Diseases, Medical Clinic, Research Center Borstel, Borstel, Germany; Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany; Tuberculosis Unit, German Center for Infection Research, Borstel, Germany.
⁴⁸ Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.

PMID: 35961354
PMCID: PMC10406427
DOI: 10.1016/S2214-109X(22)00283-2

Meta-Analysis

Infant BCG vaccination and risk of pulmonary and extrapulmonary tuberculosis throughout the life course: a systematic review and individual participant data meta-analysis

Leonardo Martinez et al. Lancet Glob Health. 2022 Sep.

. 2022 Sep;10(9):e1307-e1316.

doi: 10.1016/S2214-109X(22)00283-2.

Authors

Affiliations

¹ Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA. Electronic address: leomarti@bu.edu.
² Center for Animal Disease Modeling and Surveillance, School of Veterinary Medicine, University of California, Davis, Davis, CA, USA.
³ Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China.
⁴ Section of Infectious Diseases, Department of Medicine, Boston University Medical Center, Boston, MA, USA.
⁵ Université de Montpellier, IRD, INSERM, TransVIHMI, Montpellier, France.
⁶ Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Woolcock Institute of Medical Research, Glebe, NSW, Australia.
⁷ Laboratory of Innovations in Therapies, Education and Bioproducts, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
⁸ Division of Chronic Infectious Disease, Taiwan Centers for Disease Control, Taipei, Taiwan; Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
⁹ Oswaldo Cruz Foundation Mato Grosso do Sul, Campo Grande, Brazil; Federal University of Mato Grosso do Sul, Campo Grande, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.
¹⁰ Centre for International Health, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
¹¹ Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.
¹² Vaccines and Immunity Theme, Medical Research Council Unit The Gambia, Banjul, The Gambia.
¹³ Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
¹⁴ Centre for International Health, University of Melbourne Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC, Australia.
¹⁵ Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization, Washington, DC, USA.
¹⁶ Division of Epidemiology, University of California, Berkeley, Berkeley, CA, USA.
¹⁷ Epicentre, Paris, France.
¹⁸ Laboratorio de Tuberculosis, Instituto de Biomedicina, Universidad Central de Venezuela, Caracas, Venezuela; Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
¹⁹ Department of Infection, Inflammation and Immunity, Institute of Child Health, University College London, London, UK.
²⁰ Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy.
²¹ Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
²² Department of Microbiology, All India Institute of Medical Sciences, Bhopal, India; Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India; Medical Science and Engineering Research Centre, Indian Institute of Science Education and Research, Bhopal, India.
²³ Université de Montpellier, IRD, INSERM, TransVIHMI, Montpellier, France; Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
²⁴ Victorian Tuberculosis Program, Melbourne Health, Melbourne, VIC, Australia; Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, VIC, Australia.
²⁵ Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa; Department of Infectious Disease, Imperial College London, London, UK.
²⁶ Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA; Global Health Institute, University of Georgia, Athens, GA, USA.
²⁷ Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Barcelona, Spain.
²⁸ Department of Pediatrics, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada and Dr. Sardjito Hospital, Yogyakarta, Indonesia.
²⁹ Department of Microbiology, All India Institute of Medical Sciences, Bhopal, India; Translational Medicine Centre, All India Institute of Medical Sciences, Bhopal, India; Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India.
³⁰ Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
³¹ Department of Molecular Medicine, Jamia Hamdard Institute of Molecular Medicine, New Delhi, India; Department of General Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, India; Department of Respiratory Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, India.
³² Department of Information, National Institute of Public Health, Algiers, Algeria.
³³ Grupo de Inmunología Celulare Inmunogenética, Facultad de Medicina, Sede de Investigación Universitaria, Universidad de Antioquia, Medellin, Colombia; Grupo de Epidemiologıa, Universidad de Antioquia, Medellin, Colombia.
³⁴ The Global TB Program, Texas Children's Hospital, Houston, TX, USA; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Division of Clinical Infectious Diseases, Medical Clinic, Research Center Borstel, Borstel, Germany; Tuberculosis Unit, German Center for Infection Research, Borstel, Germany.
³⁵ Uganda-CWRU Research Collaboration, Kampala, Uganda; Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
³⁶ Taichung Regional Center, Taiwan Centers for Disease Control, Taipei, Taiwan.
³⁷ Tuberculosis Academic Program, Medical School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
³⁸ Uganda-CWRU Research Collaboration, Kampala, Uganda; Tuberculosis Research Unit, Case Western Reserve University, Cleveland, OH, USA; Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
³⁹ Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India.
⁴⁰ Groupe de recherche sur la tuberculose latente, Laboratoire National de Référence pour la Tuberculose, Institut Pasteur d'Algérie, Algiers, Algeria.
⁴¹ Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
⁴² Medicine Department, University Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Brazil.
⁴³ Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa.
⁴⁴ The Global TB Program, Texas Children's Hospital, Houston, TX, USA; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
⁴⁵ Division of Infectious Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
⁴⁶ Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA.
⁴⁷ Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Division of Clinical Infectious Diseases, Medical Clinic, Research Center Borstel, Borstel, Germany; Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany; Tuberculosis Unit, German Center for Infection Research, Borstel, Germany.
⁴⁸ Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.

PMID: 35961354
PMCID: PMC10406427
DOI: 10.1016/S2214-109X(22)00283-2

Abstract

Background: BCG vaccines are given to more than 100 million children every year, but there is considerable debate regarding the effectiveness of BCG vaccination in preventing tuberculosis and death, particularly among older children and adults. We therefore aimed to investigate the age-specific impact of infant BCG vaccination on tuberculosis (pulmonary and extrapulmonary) development and mortality.

Methods: In this systematic review and individual participant data meta-analysis, we searched MEDLINE, Web of Science, BIOSIS, and Embase without language restrictions for case-contact cohort studies of tuberculosis contacts published between Jan 1, 1998, and April 7, 2018. Search terms included "mycobacterium tuberculosis", "TB", "tuberculosis", and "contact". We excluded cohort studies that did not provide information on BCG vaccination or were done in countries that did not recommend BCG vaccination at birth. Individual-level participant data for a prespecified list of variables, including the characteristics of the exposed participant (contact), the index case, and the environment, were requested from authors of all eligible studies. Our primary outcome was a composite of prevalent (diagnosed at or within 90 days of baseline) and incident (diagnosed more than 90 days after baseline) tuberculosis in contacts exposed to tuberculosis. Secondary outcomes were pulmonary tuberculosis, extrapulmonary tuberculosis, and mortality. We derived adjusted odds ratios (aORs) using mixed-effects, binary, multivariable logistic regression analyses with study-level random effects, adjusting for the variable of interest, baseline age, sex, previous tuberculosis, and whether data were collected prospectively or retrospectively. We stratified our results by contact age and Mycobacterium tuberculosis infection status. This study is registered with PROSPERO, CRD42020180512.

Findings: We identified 14 927 original records from our database searches. We included participant-level data from 26 cohort studies done in 17 countries in our meta-analysis. Among 68 552 participants, 1782 (2·6%) developed tuberculosis (1309 [2·6%] of 49 686 BCG-vaccinated participants vs 473 [2·5%] of 18 866 unvaccinated participants). The overall effectiveness of BCG vaccination against all tuberculosis was 18% (aOR 0·82, 95% CI 0·74-0·91). When stratified by age, BCG vaccination only significantly protected against all tuberculosis in children younger than 5 years (aOR 0·63, 95% CI 0·49-0·81). Among contacts with a positive tuberculin skin test or IFNγ release assay, BCG vaccination significantly protected against tuberculosis among all participants (aOR 0·81, 95% CI 0·69-0·96), participants younger than 5 years (0·68, 0·47-0·97), and participants aged 5-9 years (0·62, 0·38-0·99). There was no protective effect among those with negative tests, unless they were younger than 5 years (0·54, 0·32-0·90). 14 cohorts reported on whether tuberculosis was pulmonary or extrapulmonary (n=57 421). BCG vaccination significantly protected against pulmonary tuberculosis among all participants (916 [2·2%] in 41 119 vaccinated participants vs 334 [2·1%] in 16 161 unvaccinated participants; aOR 0·81, 0·70-0·94) but not against extrapulmonary tuberculosis (106 [0·3%] in 40 318 vaccinated participants vs 38 [0·2%] in 15 865 unvaccinated participants; 0·96, 0·65-1·41). In the four studies with mortality data, BCG vaccination was significantly protective against death (0·25, 0·13-0·49).

Interpretation: Our results suggest that BCG vaccination at birth is effective at preventing tuberculosis in young children but is ineffective in adolescents and adults. Immunoprotection therefore needs to be boosted in older populations.

Funding: National Institutes of Health.

PubMed Disclaimer

Conflict of interest statement

Declaration of interests We declare no competing interests.

Figures

**Figure 1:. Study selection**
Excluded articles could have more than one reason for exclusion. Only one reason for exclusion is listed for each excluded article.

**Figure 2:. BCG vaccination at birth and the risk of all tuberculosis, stratified by infection status and age**
Each stratified model used separate, mixed-effects, binary, multivariable logistic regression analyses with study-level random effects. We assumed a conditional Bernoulli distribution of the response given the random effects. Models were adjusted for the variable of interest, baseline age, sex, previous tuberculosis, and whether data were collected prospectively or retrospectively. Age was adjusted within each age stratum. Analysing raw numbers might not translate well into adjusted odds ratios due to the mixed-effects model. IGRA=IFNγ release assay. TST=tuberculin skin test.

**Figure 3:. BCG vaccination at birth and the risk of death, stratified by age**
Each stratified model used separate, mixed-effects, binary, multivariable logistic regression analyses with study-level random effects. We assumed a conditional Bernoulli distribution of the response given the random effects. Models were adjusted for the variable of interest, baseline age, sex, previous tuberculosis, and whether data were collected prospectively or retrospectively. Age was adjusted within each age stratum.

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Comment in

Infant BCG vaccination is beneficial, but not sufficient.
Hatherill M, Cobelens F. Hatherill M, et al. Lancet Glob Health. 2022 Sep;10(9):e1220-e1221. doi: 10.1016/S2214-109X(22)00325-4. Lancet Glob Health. 2022. PMID: 35961334 No abstract available.

References

1. Lange C, Aaby P, Behr MA, et al. 100 years of Mycobacterium bovis bacille Calmette-Guérin. Lancet Infect Dis 2022; 22: e2–12. - PMC - PubMed
1. WHO. Weekly epidemiological record. July 14, 2017. https://apps.who.int/iris/bitstream/handle/10665/255870/WER9228.pdf (accessed May 1, 2021).
1. Rieder HL. BCG vaccination. In: Davies P, Barnes P, Gordon S, eds. Clinical tuberculosis, 4th edn. London: Hodder Arnold, 2008: 411–27.
1. Trunz BB, Fine P, Dye C. Effect of BCG vaccination on childhood tuberculous meningitis and miliary tuberculosis worldwide: a meta-analysis and assessment of cost-effectiveness. Lancet 2006; 367: 1173–80. - PubMed
1. Fine PE. BCG: the challenge continues. Scand J Infect Dis 2001; 33: 243–45. - PubMed

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Infant BCG vaccination and risk of pulmonary and extrapulmonary tuberculosis throughout the life course: a systematic review and individual participant data meta-analysis

Affiliations

Infant BCG vaccination and risk of pulmonary and extrapulmonary tuberculosis throughout the life course: a systematic review and individual participant data meta-analysis

Authors

Affiliations

Abstract

Conflict of interest statement

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