BCG Scar Recognition

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BCG Scar RecognitionPlease read through the following module. Further information can be obtained via the reference

sites at the end of the module. Complete the quiz once ou have read through the module.

!ims and "b#ectives

B the end of this module$ ou will%

&. 'ave (nowledge and understanding of the BCG vaccine

). *now how the vaccine is administered and the process of scar formation.

+. *now how to identif BCG scars and the process for chec(ing scars

,. *now how to distinguish between BCG scars and small po- scars

Bac(ground nformation

What is TB?

/uberculosis 0/B1 is caused b the bacterium$ 2cobacteria tuberculosis$ which is mainl transmitted

via respirator droplets i.e. through coughing$ sneezing. t is the second greatest (iller due to a single

infectious agent worldwide 0after '31. /he 4'" estimates that one third of the world5s population

have latent /B 0infection without smptoms1. /he highest rates of infection are found in South and

South 6ast !sia and Sub Saharan !frica.

n the 7*$ the highest ris( of /B is in people born in countries with high incidence.

n adults$ /B of the lung is the commonest 0and most infectious1 form$ but /B can a8ect an organ of

the bod.


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BCG Vaccine

Bacillus Calmette9Guerin 0BCG1 contains a live$ attenuated strain of 2cobacterium bovis$ which

provides cross immunit to 2cobacterium tuberculosis and 2cobacterium leprae 0causes lepros

in humans1. /he vaccine has been in e-istence since &:)& and was introduced into the 4'"6-panded Programme on mmunisation in &:;,$ leading to global coverage of over in endemic

countries.

/he vaccine was introduced in the 7* in &:?+ when school children were routinel vaccinated.

'owever$ as the incidence of /B declined in the indigenous population$ the vaccine was removed

from the childhood immunisation programme. t is now onl administered to babies born to parents

from high prevalence countries.

/he e8ectiveness of the vaccine varies in di8erent studies. 'owever$ meta9analsis shows that the

vaccine is ;=9 e8ective against the most severe forms of /B such as /B meningitis$ which tends

to occur in children. t is less e8ective against the respirator form of the disease. Protection is

thought to be between &= to&? ears@ data after this time is limited and it is thought protection is

li(el to wane.

Administration and Local Reactions

/he BCG vaccine should be administered intradermall onl to the deltoid insertion region of the left

upper arm. /he left arm is the 4'" recommended site and is therefore$ the internationallrecognised site of the BCG scar. Sites other than the arm are not recommended due to increased

ris( of /B lmphadenitis 0/B infection of the lmph nodes1. Some countries administer the vaccine

percutaneousl and it is thought that this might a8ect the scar formation.

4hen the vaccine is administered intradermall$ a tense$ blanched$ raised bleb forms at the site.

/his$ then becomes a small papule 0raised red spot1 in :=9:?> of cases ) or more wee(s later. /his

ma ulcerate and then subsides over several wee(s or months to heal$ leaving a small$ Aat scar$

often with a raised central area when palpated 0see gure &1.

ndividuals ma have severe local reactions to the vaccine$ including abscess$ large ulcers and (eloid

formation$ which will a8ect the eventual scar formation.

Identifcation o BCG scars


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Screening for or evidence of /B immunit is required for all health care wor(ers due to the increased

ris( of e-posure.

6vidence of BCG vaccination includes the following

• ocumentar evidence of vaccination

• Clear and reliable histor of vaccination

• 6vidence of characteristic scar 0gure &1.

deall$ all three are required for evidence of vaccination and documentar evidence should alwas

be sought in all cases when clients attend for BCG scar chec(. 'owever$ clients might not have

documentar evidence of vaccination$ particularl if the were born overseas and were vaccinated

as infants 0as is the case in most endemic countries1. n these circumstances$ the might not be able

to reliabl recall the vaccination. Providing a clear and reliable histor of vaccination is not enough in

the absence of documentar evidence and a visible scar$ /herefore$ often the presence of the

characteristic scar is the onl evidence that BCG vaccination has been performed.

Scar Check

!s( the client if the have a BCG scar and follow the procedure outlined below.

• Chec( the scar under good lighting

•

nitiall inspect the scar%

o Position9 should be left upper arm$ either centrall or the posterior lateral or anterior

medial aspect of the arm. Dess commonl$ the scar might be located in the right upper arm and rarel

thigh or forearm.

o !ppearance9usuall circular in shape$ but can be oval or even linear. /he scar is

tpicall raised.

• Palpate the scar to feel the central raised area$ either central region or uniforml.

f the client is unsure if the have a BCG scar$ then%

• Chec( both upper arms and then the thigh for characteristic features as above.

Reasons or absence o characteristic scar:


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• Scar not formed following intradermal in#ection 0unusual1.

• 3accine administered percutaneousl 0some countries such as Eapan prefer this route1$

therefore characteristic scar not formed.

• on standard administration site used 0i.e. site other than upper arm and tpicall the leftarm1.

4hen there is an unclear vaccination histor and no characteristic scar$ further BCG vaccination

must not be administered as this increases the ris( of adverse reactions. n these individuals$ the

should be referred rst for 2antou- testing or uantiferon Gold /esting.

Figure &% BCG Scar

istinguishing BCG from Small po- scar

/he smallpo- vaccine is routinel given in the deltoid region of the arm and also leaves a scar.

/herefore$ it can be confused for the BCG vaccine. Clients ma also have been immunised with both

vaccines and have the individual scars on the same arm. /he smallpo- vaccine is given in an entirel

di8erent manner to the BCG vaccine. /he vaccine is given using a bifurcated 0two9pronged1 needle


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that is dipped into the vaccine solution. 4hen removed$ the needle retains a droplet of the vaccine.

/he needle is used to pric( the s(in a number of times in a few seconds. /he pric(ing is not deep$

but it will cause a sore spot and one or two droplets of blood to form. /his method givens the scar

its tpical appearance with a central depression and lines radiating out 0similar to a biccle wheel1.

/he di8erences between the scars of the small po- vaccine and the /B vaccine can be seen in Figure

) and +. /he small po- vaccine is no longer routinel administered following the eradication of small

po- in &:;:.

Figure )% Small Po- Scar

Figure +% BCG scar versus Smallpo- Scar


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Figure ,% BCG scar versus Smallpo- scar%


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ow complete the uiz on BCG Scar Recognition

below

References

&1 epartment of 'ealth% mmunisation against nfectious isease$ Chapter +)9/uberculosis$

accessed via https%HHwww.gov.u(HgovernmentHcollectionsHimmunisation9against9infectious9disease9

the9green9boo(

)1 'ealth Protection !genc% /uberculosis Fact sheet$ accessed via www.hpa.org.u(

+1 4orld 'ealth "rganisation9mmunological Basis for mmunisation Series 2odule /B )=&&$

accessed via www.who.int

,1 4orld 'ealth "rganisation9BCG vaccination$ accessed via www.who.int

?1 4orld 'ealth "rganisation9/uberculosis Fact sheet accessed via www.who.int

I1 Centre for isease Control 0CC19/uberculosis vaccination$ accessed via www.cdc.gov

BCG Scar Recognition uiz• Jour ameK

• Clinic DocationK

• ate "f BirthK


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22

JJJJ

• &1 /he 4'" recommends that the BCG vaccine should be administered in the left upper

arm%K

o /rue

o False

• )1 /o conrm whether a BCG vaccination as been given$ the following information is required

0tic( all that appl1K

o 'ave documentar evidence of the BCG vaccination

o 'ave the characteristic scar identiable

o 3erbal evidence of BCG vaccination

• +1 /he Characteristic BCG scar has a depressed central region%K

o /rue

o False

• ,1 /he following picture shows a Smallpo- scar%K

o

/rue

o False


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•

• ?!1 /he following pictures are characteristic of BCG scars%K

o /rue

o False

•

•

?B.Ko /rue

o False


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•

• ?C.K

o /rue

o False

•


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• ?.K

o /rue

o False

•

• ?6.K

o /rue

o False


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•

6A) Identify the correct BCG and Smallpox scars on the following

pictures:

• /op ScarK

Enter either "BCG" or "Smallpox" in both felds

• Bottom ScarK


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•

6B

• Bottom Deft ScarK


• /op Right ScarK


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•

6C

• /op ScarK


• Bottom ScarK


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•

Contact 7s

Submit Your Answers


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City of ondon ! Central ondon

2oorgateH"-ford Circus

=)=+ &+& +)


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BCG Scar Recognition

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