title: Surgical complications of bacille Calmette-Guérin (BCG) infection in HIV-infected children: time for a change in policy.
abstract: OBJECTIVE
  Bacille Calmette-Guérin (BCG) immunisation is well established as part of the South African national expanded programme for immunisation (EPI). The World Health Organization (WHO) currently recommends that BCG be given to all asymptomatic infants irrespective of HIV exposure at birth but does not recommend BCG vaccination for children with symptomatic HIV infection. This approach, however, has led to HIV-infected neonates who are asymptomatic at birth, developing severe vaccine-related complications. We present a surgical case series, representative of a minority of the cases in circulation, in support of a change to the timing of BCG administration to HIV-exposed neonates.
  
  
  METHODS
  A case series of 17 HIV-infected patients with surgical complications of BCG vaccination.
  
  
  RESULTS
  Seventeen patients are presented. The first two illustrate disseminated systemic BCG infection, resulting in BCG infection of the lymph nodes, liver, spleen and tibia, and the second with gastrointestinal involvement causing bowel obstruction. The other 15 patients represent a series of severe ulcerating lymphadenitis secondary to BCG.
  
  
  CONCLUSIONS
  The risks of BCG in HIV-infected infants are significant. Current recommendations are not satisfactory, and a change in policy is required to prevent the harmful effects of this vaccine in a high-risk group of patients. We believe that there is sufficient need to adequately stratify patients and vaccinate them according to a protocol that takes impaired immunity into consideration.
authors.affiliation: Division of Paediatric Surgery, Red Cross War Memorial Children's Hospital and University of Cape Town. jonathan.karpelowsky@uct.ac.za
authors.forename: J S
authors.initials: JS
authors.lastname: Karpelowsky
authors.forename: A G
authors.initials: AG
authors.lastname: Alexander
authors.forename: S Dix
authors.initials: SD
authors.lastname: Peek
authors.forename: A J W
authors.initials: AJ
authors.lastname: Millar
authors.forename: H
authors.initials: H
authors.lastname: Rode
mesh_terms: D001500:BCG Vaccine / Q000009:adverse effects*; D002675:Child, Preschool; D015331:Cohort Studies; D000075202:Contraindications; D015658:HIV Infections / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D006801:Humans; D017589:Immunization Programs; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009163:Mycobacterium bovis; D015997:Neonatal Screening; D012189:Retrospective Studies; D013019:South Africa; D014376:Tuberculosis / Q000139:chemically induced* / Q000175:diagnosis* / Q000628:therapy
chemical_list: D001500:BCG Vaccine