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Incidence of BCG Vaccine-Related Lymphadenopathy in HIV-Infected Children in Malawi

This study investigates the incidence and clinical course of Bacillus Calmette-Guérin (BCG) vaccine-related lymphadenopathy among HIV-infected children at Baylor College of Medicine in Lilongwe, Malawi. From July 2005 to February 2007, data on children diagnosed with HIV and related conditions like axillary lymphadenopathy were collected. The prevalence of BCG disease was found to be 1.46%, with many cases presenting within weeks of ART initiation. Most patients showed recovery after three months, highlighting critical considerations for BCG vaccination strategies in this vulnerable population.

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Incidence of BCG Vaccine-Related Lymphadenopathy in HIV-Infected Children in Malawi

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  1. Case Series of HIV-infected children with Bacillus Calmette-Guérin Vaccine Related Lymphadenopathy in Lilongwe, Malawi John Midturi Kazembe, PN., Schutze, GE., Kline, MW

  2. Background-Malawi • Population of 13 million • HIV prevalence 14% (15-49yr) • 30,000 children infected with HIV • 125,000 individuals have been started on ART (Sept 2007) • children 8%

  3. Background-Malawi (2) • BCG incorporated into EPI schedule in 1974 • Administered within 1st week of life • 99% coverage • Danish 1331

  4. Background-Baylor COE • Baylor COE- established officially in November 2006 • Provision of pediatric HIV care, treatment and training • 3612 patients • 2155 active patients • ~50% on ART • Enroll ~100 new clients/month • Average age at enrolment • 4.56 years

  5. Background-BCG vaccine • Live attenuated vaccine • Adverse reactions • Injection site ulceration • Lymphadenitis • Disseminated disease • Dependent on strain, administration method, bacillary load, host immunity, and physical-chemical property • Incidence 0-17%

  6. True Incidence, unknown: Under-reported 0% to 30% Frequency similar to uninfected population Turnbull CID 2002 HIV-negative: 2.5% vaccine site abscess & 1.7% lymphadenitis HIV-Infected: 2.7% vaccine site abscess & 0.7% lymphadenitis Adverse reactions to BCG in HIV infected infants

  7. Objective • Identify incidence of BCG Disease in children infected with HIV at Baylor COE • Determine clinical course of BCG disease

  8. Retrospective chart review July 2005 through February 28th, 2007 All children diagnosed as HIV-infected at the Baylor COE. Data gathering: Computerized medical record chart Diagnosis of axillary lymphadenopathy, axillary lymphadenitis, BCG reaction, TB lymphadenitis, or right axillary adenopathy Methods

  9. Methods • Diagnosis: • BCG disease (EPI): • ipsilateral axillary lymph node enlargement of >15x15 mm, suppurative ipsilateral axillary lymphadenitis, injection site abscess of 10 mm, or a clinically significant or non-resolving BCG papule • BCG disease IRIS: • Temporal association of ARV initiation and development of right axillary adenopathy • CD4/CD4% increase >5%

  10. 13 cases:13/958, prevalence of 1.46% in HIV-infected children 10 BCG Disease IRIS (1.04%) Age: Range 4 months to 18 months Median 9 months WHO Stage: 8 Stage III (PTB/thrush/diarrhea) 5 Stage IV (PCP/severe malnutrition) Follow-up time: Range 2 weeks to 37 weeks Median 20 weeks Results

  11. Median CD4% 13%, (2.2%-23.4%)

  12. Median 3.5 weeks, (1-11weeks)

  13. 69.2% Spontaneously ruptured Median time to rupture 9.2 weeks, (2-14 weeks)

  14. Median 3 months, (1-4 months)

  15. Management • Treatments: • 8 TB therapy, 6 started TB meds prior to BCG Disease • 6 antibiotics • All Started ART • No surgical intervention • Outcome: • 11 alive • 2 died • both had BCG disease prior to ART • 1 on TB therapy • Mortality 3.2 per 100 weeks follow-up

  16. Conclusions • Prevalence of 1.46% in our HIV-infected pediatric population • Most develop BCG Disease IRIS 3-4 weeks after ART • ~70% of them rupture 9 weeks after ART • Most cases resolved after 3 months • Most of our patients were already on TB therapy when they developed BCG Disease

  17. Future • Complete analysis of our data • Potentially will become a more significant issue with the proposed universal treatment for all HIV-positive children under 12 months of age • Prospective study: • Role of INH prophylaxis to see if it decreases incidence of BCG disease • Delaying BCG vaccination in HIV-infected infants

  18. Acknowledgments • Dr. Peter Kazembe • BIPAI • Dr. Mark Kline • Dr. Gordon Schutze • Dr. Mark Kabue • All the patients and families from the Baylor COE-Malawi

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