Should we cancel for TB vaccine?

Does not escape any child in France from vaccination, Valtgayh tuberculosis vaccine (BCG) regularly and is compulsory. Is this procedure still justified? At a time does not stop the reflection of tuberculosis vaccine across the country to fall, keep the relative effectiveness
Completely? The status quo: the final inoculation or vaccination aimed; will not be a medical decision-making only.
Sweden abandoned in 1975 on the systematic vaccination of children using the TB vaccine, did not use no low-lying countries nor the United States has. As Germany was canceled in 2000. However, the vaccine remains mandatory in France: you must vaccinate all children, and must be renewed action in the case show that the first injection is not effective. We read in the last report
Institute (Institut Veille Sanitaire (IVS)): (1). Is it time for a change?
Perhaps one does not know yet how this can be done, but the Institute (IVS) objected primarily on the opportunity to re-vaccination.

Peace to re-vaccination

The compulsory vaccination day for children who belong to groups (nurseries and maternity), a regular at the age of six. Doctors looking after the first injection on the presence of a reaction to the tuberculin test (Tuberculinique): stiffness, and a small red stain to prove a real response to the immune system. Requires the absence of such a response for this test a second injection. However, the relationship between the tuberculin reaction test, and the effectiveness of the vaccine is not installed. There are cases where the absence of the first and attend the second. As well as he did not absolutely prove the effectiveness of re-vaccination when people who have lost the protection associated with the first vaccination (primo vaccination). Starting from 1995 concluded that the decision by the World Health Organization (OMS) to say: "I do not recommend re-vaccination of persons vaccinated at the tuberculosis vaccine, and that does not exist for any scientific result confirms the usefulness of this practice" (2). Did not cause the cessation of re-vaccination in the same year Pflanda - which were the characteristics of frequency (Incidence) TB * close in 1990 with the current French situation - in any additional cases of TB.



The original title of the article: Faut-il supprimer le BCG? , La Recherche, n ° 356, septembre 2002.
* Number of cases of disease in a given population at a particular time - the writer.
France is the only country in Europe, accompanied by Portugal, the Czech Republic are still involved in double fertilization. World Health Organization announced in a study dated 1998: "should be shut down for re-vaccination in France and Portugal, and the necessity to change the laws that relate to it." (3). This appears to be probably will fall soon, and perhaps the arguments of financial help in the decision-making, which tends to adopt the arguments of scientific and health: According to a study completed in 1996 the total cost of the French policy of vaccination vaccine TB bacillus (BCG) one million French francs per year; and go 665 million from this value, any 88% of the first vaccination, in the sense of re-vaccination in vain, or almost. > (4).
But the debate about re-vaccination drag us to the last talk, talk more complex and sensitive: it is simply talk vaccination using the TB bacillus (BCG). What are the elements of matter? Confirms (Daniel Lévy-Bruhl) on the coordinator of the study
As follows: "the decisions adopted in the field of vaccination, as is the case in any preventive strategy based on analysis of
Benefit - risk (bénéfice-risque), in other words, decisions are made on the basis of balancing the pros and cons. "


What is the strategy for poor countries?


He (Jacques Grosset) from the Faculty of Medicine (Pitié-Salpêtrière) (12) three years ago that the elimination of tuberculosis (in industrialized countries) depends in large part on the success of the struggle against tuberculosis in other countries of the world because of the number of TB cases imported> . Die of the disease each year in poor countries, nearly three million people, in spite of the existence of an effective antibiotic treatment in the proportion of almost 100% of cases. And because the mortality rate of the difficulties of early detection of the disease (dépistage), as well as it is not for the people involved always have access to medicines, but due also to the length of the treatment period using the antibiotic traditional (up duration of treatment to several months and sometimes years), and often stops the patient for treatment in the middle of the road.

Thus, the World Health Organization decided in 1994 to pursue a new strategy called the strategy (DOTS) for the "short-term treatment under observation." Comes to decrease the duration of treatment for Dat months, and make sure that patients follow him regularly. "However, these strategies necessitate the construction of facilities effective medical and sensitize governments to their responsibilities, as well as the supply of good medicine. Estimated the effectiveness of treatment in countries that apply the program (here in Bangladesh since 1993) by recovery of 78% to 45% in the event of his absence. But studies have shown that the existing funds
Still not enough significantly to be able to victory over the disease: it allows only install the number of victims. (13)

What is the balance?

Starting with the advantages of the vaccine, which vary according to our estimates of the various forms of tuberculosis, both pulmonary lung or outside (extra-pulmonaire). And cause pulmonary tuberculosis who died on Europe until the mid-twentieth century in the cough and spitting of blood, the two presentations represent the perception of the disease in the medical group. The forms outside the lung the most rare, but more surprising Fbasttaatha injuring other organs, where it causes, for instance in the meningitis is often fatal. It seems that the vaccine protects more of these diseases. According to (Christian Péronne) Chairman of the Technical Committee of the vaccines that "The vaccine protects young children from serious forms in more than 80% of cases. On the other hand does not exceed the percentage protection 50% for the forms of pulmonary disease in a senior>. Not improve us once again to emphasize that the process of demonstrate the effectiveness of the vaccine vague: Studies have shown the various completed since the end of World War II, the effectiveness of the vaccine ranged between 0% and 80%!, perhaps because the great diversity of these results to the diversity of vaccines TB bacillus. and the right that if the source of all of the original primary (souche originelle) for Calmette (a) (Calmette), and Girne (b) (Guérin) has evolved gradually since the century given to their production in the laboratory. and so confirms (Brigitte Gicquel), head of genetics


(A) 1863 to 1933: French doctor and a specialist in microbiology, participated with Camille Guérin in the invention of the TB vaccine. Developing and developed several methods of vaccination, particularly for TB vaccine. In 1927 became a member of the Academy of Sciences, and assume the position of deputy director of the Pasteur Institute - Translator

(B) 1872 to 1961: French created a world of germs in conjunction with the Calmette vaccine bacillus Calmette - Girne anti-TB - Translator
Mycobacteria (génétique mycobactérienne) Pasteur Institute, that "a comprehensive analysis of the genomes of these assets are female (souche filles) has shown that there were differences in several regions of the genome" (5). As for the number ratio of the maximum effectiveness of 0% which is not registered in South India, it seems that injects two other factors. The one hand, injects systematic errors, on the other injects the fact that people who are in regular contact with mycobacteria is very close to bleeding-heart tuberculosis bacillus (Mycobacterium tuberculosis) acquire natural protection against the latter; make the protection of the TB bacillus bacillus automatically hidden.

Still hangs on the issue is another important question, namely, the duration of protection afforded by the vaccine, which is estimated today to five years. Since it is assumed that the age of the vaccine less than six years, it means, then, that the slide that bracket are eligible for the vaccine of children and young people only. But the situation in France today shows that mainly affects adult mortality due to TB, while the available treatments with antibiotics effective in about 100% of the cases treated. However, since the problem is characterized by abundant forms outside the lung (formes extra-pulmonaire), which are often very serious, and focus - in Europe - the debate on appropriate or not to maintain appropriate vaccination. Shows the situation on the different bases in non-Western countries: China or India, for example, where TB is a major disaster. And go through the process of combating the disease in these countries through you get the best medicines, and better follow-up of treatment: It is a subject program (DOTS) of the World Organization of health (see: ), And aims of many of the research to develop a new vaccine really effective in all segments of life, but he does not expect any tangible result of several years ago.

Negatives

Let's go back to the cons in the context of the current vaccine used in France. No vaccine is completely free of damage, which causes inflammation of nodal (ganglions), or inflammation Gdda post-vaccination (adénite post-vaccinales) an average of once in a thousand cases. Must sometimes have to wait several months to heal the patient - and in some cases requiring minor surgery - although it is relatively benign infections. In contrast to these infections can lead to serious complications in people impaired immune system (immunodéprimés) (6), then we talk on the bacillus BCGite (seize the opportunity to double the germ defenses, even the immune system proliferate). For this reason, exempt children infected with the HIV (VIH) of compulsory vaccination.

Do you stop the vaccination or not?

What are the concrete aspects of the relative importance of negative and positive? Package commensurate with the incidents of vaccination of the population vaccinated, and is calculated on the basis of a fixed frequency (ie, in France, almost all children). The cause of TB vaccine hundreds of glandular infections annually, according to (Vincent Jarlier) Chairman of Microbiology and Health
Hospital (Pitié-Salpêtrière). In addition to this, the fruit derived by vaccination depends primarily on the frequency
Tuberculosis (incidence de la tuberculose), meaning the number of people who suffer from the disease. If the TB is a college in the population, the protective effect of the vaccine as an important mechanism. However, the number of TB cases averted less vulnerable countries where the disease is relative, namely what is the case in France. We can to TB vaccine a year to avoid - in children less than six years - the number of cases of meningitis, or avoid a dangerous form of tuberculosis called Algeorsa (tuberculose miliaire), depending on the analysis of the Institute (IVS). Is that the effect of the inflammation Gdda hundred more than the impact of ten cases of meningitis? See (Vincent) that a positive spin on this question is clear: . And allow the situation in France by the International Union Against Tuberculosis and Respiratory Diseases (UICTMR) b: . But not everyone understand that this
When he said a short while ago (Joël Gaudelus) the interest of the Pediatric Hospital (Jean-Verdier) in the city (Bondy), and a member of the Technical Committee of the vaccination, saying: 'It is still too early in France to stop the vaccinations using a vaccine


Tuberculosis (BCG)>. He adds: 'must first of all to have just the strict control system, and is likely to keep vaccinating meaningful (vaccin ciblé) (7). Evidenced by the bulk of supporters of abolition of vaccination (abolitionnistes) in Sweden, which stopped the systematic vaccination of 1975, which coincided in time when almost the circumstances prevailing in the country - in view of the disease - with the conditions of today's France. According to a document issued by the Institute (IVS) is . Evidence of this is not surprising (Daniel Lévy-Bruhl), which is . We conclude that tuberculosis is different from other diseases, those diseases that do not solve it but vaccination, smallpox disease (variole), or pertussis (coqueluche). However, it was observed in Sweden is always a slight rise in the number of TB cases after 1975, especially when children from families coming from countries with high incidence of tuberculosis, and likely that these were infected after spending a vacation, for example ... Thus, authorities have stepped up at the beginning of the 1980s the idea of ​​recommending vaccination of such children.

As there is in France also significant differences in the frequency of tuberculosis. Usually focus on the insemination of regular defenders on the existence of the problem of the risk groups (groupes à risque). Frequency has decreased regularly across the country for several decades, and this exception in case of slight increase recorded in the early nineties in connection with the epidemic of AIDS. But this is no longer hesitate to drop in four years: the equivalent height in some areas - mainly in Paris and Parisian crown (couronne parisienne) - continuous decline observed on the rest of the country. Perhaps counted years 2002 6714 cases of tuberculosis, any unauthorized frequency was 11.2 cases per 100,000 inhabitants. And (Bénédict Decludt) from the Institute (IVS) that this value amounted to 100 000 / 28.8 on the island of France, and 100,000 / 49.9 in Paris (8). However, according to (Laurence Zunic) in the interest of social emergency medical assistance (a) (Samu Social) is up value 100000 / 240 when those who do not have dignified housing (SDF) in Paris (9). Again, these figures is based only on cases authorized by the (TB is a disease that must be declared by the), which is estimated to cost in the range between 65% and 70% of the total cases.

The relationship between tuberculosis and poor sanitary conditions have been known for: TB a disease of poverty. It is not surprising that we find in some disadvantaged social groups centered in and around the capital, these figures exceed the national average too. Valmhajeryn coming from countries infected with the disease much more vulnerable to infection. While the frequency of the disease in people Almouliden France 68, up to the persons of a multitude Iqia 125.3 semi-desert. Thus, most countries have asked that stopped the mandatory vaccination programs, and those who live a similar situation for France, asked the children from foreign parents came from a country is a major threat to carry out vaccinations.
Can we do the same thing, or at least restrict the vaccination compulsory in some provinces? Do you accept some of the Republic Recognized (vincent Jalier) . The Institute (IVS) is suggested in his report two options below to decide on it: Total country


(A) the interest of a French hospital established a law dated 19 July 1972. Interested to take charge of the early cases of emergency medical and surgical procedures. And interest on the available means of its own to intervene in the field after the accident, or interfere with patients' houses when serious cases. Also provides for the organization of medical rescue operations in the event of a mass accident, or catastrophe - the translator


Criteria decision-making
Is not there an objective and scientific decision-making? The difficulty lies in the section than in the fact that we weigh the side of the scale in different materials. How inflammatory glands can be compared with meningitis? Is not that such tampering?
We have developed the economy, health curricula, trying to bring a variety of different injuries to the common standard. And the reference used is usually a reference (Disability adjusted life years (Dalys), a that are related to a factor of a nurse (pathologie). This is based criterion to establish a kind of transactions deficit for each patient, which allows calculating the impact of each factor of the transactions on the level of the population.

For example, if Osndna factor for patients with asthma 10%, and aware that affects 10 million people in the specified period of time fifty years, agrees asthma then fifty million years of life lost. Used the World Health Organization this methodology, it is a very complex way, and not without ambiguity, especially when it comes to identifying the deficit. Studies are still in any case studies of fragmented (parcellaire) (10). And perhaps try to understand the other of the subject to return all the reasons for the financial costs borne by society. However, we can move from an attempt to understand the other, but you can reduce the health and human well-being in just such equations?

Resistant TB vaccine

Broke many of the so-called epidemic epidemics multiple resistance (épidémies multi résistante), and short in English (MDR) in hospitals and prisons in the west end of the year 1980. The germs in people impaired immunity (due to agriculture or AIDS infection ...) I found the field preferred. And hit the epidemics of detainees who encouraged their mixing, and the cleanliness of insufficient development of the disease. Finally, a segment of people who do not have accommodation Gaara's population infected with the disease, in particular, because of their living conditions, but also it was difficult - they are disassembled socially - to convince them to address their pharmacy on a regular basis. The case according to a World Health Organization: . And could encourage the emergence of drug stop taking the assets of bacterial resistance
And require the latter to relations more in length, and in particular more expensive antibiotics at a rate ranging from 100 to 300 times. Seems that the health authorities managed to control the situation, where the number of new cases of epidemic multi-resistant MDR by the World Organization of the United States more than 1.2% cases of tuberculosis in 2000, compared to 1.6% in 1997, and about 0% in France in 2000, against 0.5% in 1997. However, the percentage of 10% city (Henan) Chinese, 14% in Estonia. Transfer of Doctors Without Borders that 20% of prisoners in the prisons of the former Soviet republics are suffering from tuberculosis of multi-resistant, too (here city of Kemerovo in Siberia in 2000). The organization asserts that spend some time behind bars and prison - sentenced to death>. The day the number of people living with multiple origins of resistance MDR epidemics in the world about 100,000 thousand people.

Social perception
Should this kind of calculations that take into account the fact that the possibility of the development of social perception of the disease. Sometimes become less risk to our society protected is relatively acceptable. Thus, at a time when France has not seen cases of meningitis in such a few, the recent cases of meningitis from
N-type (méningite de type C) * city (Puy-de-Dôme) has raised great concern, and resulted in the in the month of January of 2002 vaccination campaign is important. And probably seen dozens of cases of meningitis, which may cause additional stop the lens of compulsory vaccination completely tragic.

6714: It's authorized number of tuberculosis cases in France during 2002, of which 6539 case of aspects of the capital and 175 cases of the provinces beyond the sea. Has not seen a rate of frequency, estimated to be 11.2 cases in every 100,000 thousand inhabitants of any decline since 1997. And offset height region (Ile-de-France) decline in other regions. The young people born to countries where TB is prevalent and people in the development of economic and social ale category most affected by the disease. And can not reverse this situation: low frequency of illness City (Seine Saint-Denis), where a strict follow-up field program several years ago, at a time of rising in Paris, which had been neglected by the constructors conflict against tuberculosis (11).

The fact is, as pointed out to him (Vincent) when he said: . The (Daniel), he said: 'The problem today in taking the continuing uncertainty into account in order to achieve a strategy , as well as the definition of acceptable risk level of>. And regretted the world specialist in the epidemiology that there is no date for the collective process of preparing this strategy. He adds:
And what the emerging debate about the vaccine (BCG) only reminds us that Bam has already raised questions. But there has always been a simple way to involve the community in such a choice>. The BCG vaccination record today in the Law Department, and in this context, Parliament must then vote on the bill amending the public health policy, and it shows that such an amendment on the table. In the meantime, commissioned a research group to provide suggestions on the combat system more effectively with the need to develop the work of health for the population of immigrants and transients (11), all at the request of the Department of Public Health, and the Supreme Council of Public Health to respond to the variations recorded on the level of the frequency of the disease.

End