Bacille de Calmette-Guérin, or BCG Vaccine for Tuberculosis

BCG Vaccine

BCG Vaccine

By Maureen Lux

Haven’t got your BCG vaccine against tuberculosis?  Fortunately, most Canadians don’t need to worry about that one.[1]  Though BCG was never widely used in Canada, until very recently most Aboriginal infants were routinely administered the vaccine.   The difference has something to do with higher levels of tuberculosis in some, though certainly not all, northern communities; but it has a lot to do with history. 

The BCG vaccine, developed in the 1920s by French researchers Calmette and Guérin, found little acceptance in North America or Britain.   But beginning in 1928 the Canadian government funded research into BCG led by Dr. R. George Ferguson, director of Saskatchewan’s Fort Qu’Appelle Sanatorium.  Ferguson lived at the sanatorium, literally surrounded by poverty-stricken Treaty Four reserves. But Ferguson, like many of his time, saw what he termed a “primitive” people, prone to tuberculosis, and who could only develop resistance through the long process of evolution to ‘civilization’.   And until they caught up to the “white races” they were a disease menace to the population.  He hoped to prove that BCG could provide the means to drag the “less evolved races” across the evolutionary divide, at very little cost.[2]

But he had his doubts about the controversial vaccine.  Would BCG, prepared from a strain of the attenuated (weakened) live bovine tuberculosis, regain its virulence?  In 1930 in Lubeck, Germany 249 infants were given oral doses of BCG and within months 71 were dead.  The Lubeck disaster shook confidence in BCG even after an investigation determined that the vaccine had been contaminated with live tuberculosis bacillus.   In 1933 Ferguson, funded by Indian Affairs and the National Research Council, began an experimental vaccine trial on local Aboriginal infants. His twelve-year study was an apparent success: only six of the 306 children in the vaccinated group developed tuberculosis and two died; while 29 of the 303 in the control group developed tuberculosis and nine died.  But Ferguson’s research also revealed that 77 of the 609 children in the trial, or more than 12 percent, died before their first birthday, while only four of these were tuberculosis deaths (two in each of the vaccinated and control groups.)  In all, nearly one-fifth of the children in the trial died from other diseases, mostly gastroenteritis and pneumonia.[3]  Poverty posed the greatest threat to children, but unlike tuberculosis, it did not spread to white communities.  BCG lived up to its promise to control tuberculosis while leaving untouched the socio-economic conditions that led to its rise.

Dr. RG Ferguson (1883-1965) conducted a trial of BCG on First Nations infants

Dr. RG Ferguson (1883-1965) conducted a trial of BCG on First Nations infants

Most provinces, except Quebec, rejected systematic BCG vaccination because of concerns about efficacy (revaccination was necessary every two years), but especially because it created false positives for the simple diagnostic Mantoux skin test that indicated exposure to tuberculosis.[4]   Nevertheless, Ferguson’s BCG trial convinced the Indian Health Service (IHS) of the utility and economy of the vaccine for Aboriginal communities.  By 1954 IHS adopted a policy of mass BCG vaccination and annual (at least) chest x-rays.[5]   But it was unsafe to vaccinate anyone already exposed to the disease (verified by the Mantoux test).[6]  That test took up to three days to indicate exposure, a decided impediment to hurried vaccinators in Aboriginal communities.  Instead, Armand Frappier, director of Montreal’s Institute of Microbiology and Hygiene and the driving force behind BCG distribution in Canada, devised a simpler scratch test using a diluted dose of BCG that produced an immediate reaction.  When, in 1952, two schoolgirls developed tuberculosis after re-vaccination with BCG, the federal deputy minister of health, Dr. GDW Cameron, advised keeping the affair quiet lest it raised questions about the method.[7]  Despite concerns about safety, the vaccine and the BCG skin test continued to be used in Aboriginal communities into the late 1960s, in conjunction with annual x-ray examinations.[8]

The incidence of tuberculosis in Canada fell steadily throughout the twentieth century, meaning many Canadians were never exposed to the disease.  By the 1950s effective drugs allowed outpatient treatment, though for decades Aboriginal people continued to be institutionalized.  At the same time, provincial health authorities warned that due to the hazards of ionizing radiation, children in particular should not have routine chest x-rays, unless they first showed a positive Mantoux test. [9]   But the continued BCG use in Aboriginal communities rendered the Mantoux test useless, necessitating chest x-rays.  The damage caused by serious BCG reactions and the long-term impact of 30 to 40 or more years of x-rays beginning in early childhood may never be known, though the risks to white Canadians were deemed too great.

Ferguson’s study, suffused with 1930s race science, cast a long shadow indeed.  In light of international studies that questioned BCG’s effectiveness, a 1982 call for a randomized controlled study of BCG vaccination of Aboriginal people was deemed politically and ethically unacceptable. [10]  A 2007 study recommending termination of the widespread BCG vaccination in Alberta First Nations communities cited Ferguson’s study as the only estimate of annual risk of infection.[11]

The deaths between the 1990s and 2003 of six vaccinated Aboriginal infants with underlying immunodeficiency disorders led to the discontinuation of routine immunization in some Canadian provinces and territories.[12]  Yet, in 2012 routine BCG vaccination continued in Aboriginal communities in Alberta, Manitoba, Northwest Territories, Northern Ontario, and Nunavut; its use in Saskatchewan was discontinued in 2011, in Quebec in 2005.[13]  The vaccine continues to be used in the global fight against tuberculosis, but questions about its effectiveness and utility continue.[14]

Maureen K. Lux teaches Canadian and Aboriginal history at Brock. Her book, Medicine That Walks: Medicine, Disease and Canadian Plains Native People, 1880-1940 (University of Toronto Press 2001) won the Canadian Historical Association Clio Prize as well as the Royal Society of Canada’s Hannah Medal for the History of Medicine.

References

Fort Qu’Appelle Indian Hospital where many infants were vaccinated with BCG. [Ft Qu’Appelle Hospital Accession no. R96-472, Saskatchewan Archives Board.]

Fort Qu’Appelle Indian Hospital where many infants were vaccinated with BCG. [Ft Qu’Appelle Hospital Accession no. R96-472, Saskatchewan Archives Board.]

[1] Tuberculosis is an infectious disease spread through coughing or sneezing that often affects the lungs but can involve almost any organ of the body. Unlike other infectious diseases, tuberculosis is acutely environmental-specific; it continues to stalk the world’s undernourished and overcrowded poor, particularly those living with HIV/AIDS.  In 2013, 9 million people, many in Africa and Southeast Asia, were ill with the disease and 1.5 million died, http://www.who.int/mediacentre/factsheets/fs104/en/ accessed 22 March 2015

[2] RG Ferguson, Tuberculosis among the Indians of the Great Canadian Plains (Reprint, London: Adlard and Son, 1928); Ferguson and Simes, “BCG Vaccination of Indian Infants in Saskatchewan” Tubercle 30, 1 (1949): 5-11

[3]see MK Lux, “Perfect Subjects: Race, Tuberculosis and the Qu’Appelle BCG Vaccine Trial” Canadian Bulletin of Medical History 15 (1998): 277-296; of the vaccinated group, 39 of 306 children died in the first year, and 38 of 303 controls died within the first year, Ferguson and Simes, “BCG Vaccination”, 5

[4] Tuberculin, a solution containing substances extracted from the tubercle bacillus, became by the early twentieth century a simple skin test where a positive reaction indicated exposure to the disease, not disease itself.  The Mantoux Test (purified protein derivative, or PPD) continues to be used to infer exposure to the disease.

[5] WJ Wood, regional superintendent IHS, “Survey of BCG Vaccinated Indians in Manitoba” 13 June 1955, RG29 (records of National Health and Welfare) v 2868, file 851-1-4 part 2, Library and Archives Canada (LAC)

[6] Armand Frappier, “Report on the opportuneness [sic], possibility and practical means of applying routine preventive BCG vaccination” 11 Jan 1947, RG29 v 2868, file 851-1-4, part 1a, LAC

[7] GDW Cameron to Moore, 10 Oct 1952, RG29 v 2868, file 851-1-4, part 2, LAC

[8] Dr. M Matas, “Tuberculosis Programs of the Medical Services, Department of National Health and Welfare” in “Proceedings of the Third National Tuberculosis Conference” Medical Services Journal Canada, v 22 (1966): 881-82

[9] Stewart Murray, Metropolitan Health Committee (Vancouver) to Mr. HPJ Gunn, Administrator Children’s Hospital, 17 Dec 1957, GR-0129, Tuberculosis Control Division, Box 39, file 1, British Columbia Archives

[10] Raj Narian, “Need for a BCG Trial in Canada’s Native Populations” Canadian Medical Association Journal, 15 July, v 127 (1982): 101-02; and exchange with T. Kue Young, “A BCG Trial in Canada’s Native Populations” Ibid. 15 Dec (1982): 1166-67

[11] Sandy Jacobs et al, “Mycobacterium tuberculosis Infection in First Nations

Preschool Children in Alberta Implications for BCG (bacille Calmette-Guérin) Vaccine Withdrawal” Canadian Journal of Public Health v 98, 2 (March-April 2007):116-120

[12] Public Health Agency of Canada, Canadian Immunization Guide http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-bcg-eng.php#clae accessed 22 March 2015

[13] Public Health Agency of Canada, “BCG Vaccine use in Canada – Current and Historical” http://www.phac-aspc.gc.ca/tbpc-latb/bcgvac_1206-eng.php accessed 16 April 2013

[14] http://www.who.int/biologicals/areas/vaccines/bcg/Tuberculosis/en/ accessed 24 Mar 2015

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