Original Article

SENSITIVITY OF BCG INOCULATION AND TUBERCULIN SKIN TEST IN

ACTIVE PULMONARY TUBERCULOSIS IN UNDER-5 CHILDREN
Muhammad Saleem Channer*, Muhammad Saddique Khan Qadri**, Ghulam Qasim Khan
Khichi***, Zahid Masood****, Saad AKhtar Birmani*****
*
Medicine Department, Ghazi Khan Medical College, Dera Ghazi Khan.
**
Assistant Professor, Community Medicine, Nishter Medical College, Multan.
***
Professor of Peadiatric Medicine,Quaid-e-Azam Medical College, Bahawal Pur
****
Associate Professor Community Medicine, University Medical & Dental College, Faisalabad
*****
Senior Demonstrator Community Medicine Department, Ghazi Khan Medical College, Dera
Ghazi Khan.
ABSTRACT
OBJECTIVE: To compare the sensitivity of Mantoux test versus BCG inoculation in patients of
pulmonary tuberculosis in children up to 5 Years of age.
DESIGN: Hospital based study quasi experimental study.
PLACE AND DURATION: Study was carried out in Pediatric Medicine Ward in Teaching Hospital of
Dera Ghazi Khan Medical College, over a period of two years.
SUBJECT AND METHODS: This study was carried out on 100 patients of pulmonary tuberculosis
diagnosed according to set criteria. Sample size was calculated by WHO sample size calculator at an
absolute precision of 0.08. The sample size was found to be 100. Hence 100 patients suffering from
pulmonary tuberculosis were inducted by non probability consecutive sampling technique from
February 01, 2013 to February 02, 2015. BCG inoculation and Mantoux test was done on each
patient concurrently and their response was studied.
RESULTS: Out of 100 patients 56% ware males and 44% females. In 25% of the total cases
neither BCG skin test nor Mantoux test showed positive response. Results of the 45 patients were
those in which both BCG skin test and Mantoux test were positive: 30 patients (30%) were only
BCG skin test positive, so total BCG skin test positive patients were 75%.

CONCLUSION: BCG inoculation was far more superior to Mantoux test as diagnostic tool in
pediatric age group. Pulmonary tuberculosis study conrmed that BCG skin test was much more
sensitive as well as specic as compared to Mantoux test in the detection of tuberculin allergy in
patients suffering from pulmonary tuberculosis.
KEY WORDS: 1 BCG. 2 PPD. 3 Sensitivity. 4 Tuberculosis. 5 tuberculin skin test.
INTRODUCTION:
One-third of world population has been infected
by pulmonary tuberculosis, 75% of them
belonging to developing countries
alone.Tuberculosis is highly prevalent in Asian
Countries. There are estimated 2.5 million
cases of active tuberculosis in Pakistan with
annual infectivity of 1.0-2.5% per person.2 To
get rid of this chronic infectious disease, the

26

most commonly used test is Mantoux tests,

which is unfortunately not reliable in certain
circumstances like malnutrition, post viral
diseases
for example measles, immuno
compromised patients and when patient has
Corresponding Author:
Dr. Muhammad Saleem Channer
2-A, Faisal Block, Sajid Awan Town Bahawal Pur
Email Address:saleemchanner@yahoo.com
Cell No. 0343-7180044

JUMDC Vol. 6, Issue 2, April-June 2015

CHANNER M.S., QADRI M.S.K., et al.

received BCG vaccination.3
To establish the diagnosis of all cases of
tuberculosis accelerated BCG reaction was
taken as the best diagnostic method by many
workers in India and Pakistan. 4.5
In non-immunized patients, skin response to
BCG inoculation is characterized by appearance
of indurations at 2-3 weeks, pustule formation
in 4-6 weeks and healing at 8-12 weeks after
intradermal injection.4 However, in sensitized
persons BCG skin response was peculiar due to
Koch's phenomenon and an accelerated
response was noticed where indurations
appears in 2-3 days, pustule formation in 5-8
days and healing in 2-3 weeks. This accelerated
BCG response was reported to be more useful
screening test in pediatric population as well as
in adults.4
Keeping these observations in mind, we
planned to see BCG versus Mantoux response in
cases of pulmonary tuberculosis in age group 4
months to 5 years.
PATIENTS AND METHODS:
This was a quasi-experimental study carried out
in pediatric medicine ward in the teaching
hospital of Dera Ghazi Khan Medical College,
over a period of 2 years staring from February
01, 2013 to February 02, 2015. Informed
consent of parents / attendants of the patient
was taken. Study population consisted of 100
admitted children having ages between 4
months to 5 years and suffering from
pulmonary tuberculosis. They were all nonimmunized against tuberculosis and none of
these cases had clinical signs/ symptoms of the
disease for less than two months duration.
Pulmonary tuberculosis in each case was
diagnosed on the basis of history, clinical
examination and laboratory investigation
including, TLC; DLC; ESR; chest x-ray; sputum
/ gastric aspiration for Acid Fast Bacillus (AFB).
TUBERCULIN TESTS:

SENSITIVITY OF BCG INOCULATION

derivative (PPD) was given intradermally in the
right forearm. Criteria for positive BCG
response were taken from various studies of
Udani.5 A positive BCG response meant an
accelerated reaction to complete healing in 1015 days instead of normal reaction in 7-10
weeks. Criteria used were as follows.
48-72 hours


5 mm-9 mm


Mild (+1) (non-signicant)
48-72 hours


10 mm-20 mm



Moderate (+2)
48-72 hours


21 mm-30 mm



Severe (+3)
05-08 days
Pustule formation
10-15 days
healing and scar formation
CRTERIA FOR MANTOUX TEST WITH 15
TU OF PPD6
48-72 hours


0 mm-5 mm


non-signicant
48-72 hours


5 mm-9 mm


Doubtful
48-72 hours


>10 mm



Positive
Test of signicance used was standard error of
difference between two proportions. The results
were statistically signicant at 0.05. Sensitivity
for BCG inoculation and Mantoux test was
calculated by using the following formula:
Sensitivity = a/a+cx100
SPSS version 16 for windows was used for
statistical analysis.
RESULTS:
Baseline characteristics of 100 patients
suffering from pulmonary tuberculosis are
shown in table I and II. Fifty-six percent cases
were males and remaining were females.
Twenty-ve percent of the cases were nonresponsive to both BCG as well as tuberculin
inoculation (Table 2 and 3). It is evident from
the Table 2 that sensitivity of BCG in rest of the
cases is signicantly higher than that of
Mantoux test.

Mantoux text and BCG inoculation were done

concurrently in the same patient. For BCG test,
0.1 ml of fresh solution of frozen, dried BCG
vaccine was inoculated intradermally in the left
deltoid region and for Mantoux test 0.1 ml of
5TU (tuberculin units) of Puried
Protein

JUMDC Vol. 6, Issue 2, April-June 2015

27

CHANNER M.S., QADRI M.S.K., et al.

SENSITIVITY OF BCG INOCULATION

neonates.
4.
BCG could be given to any child at risk of
tuberculosis without prior Mantoux test.
5.
Even in vaccinated children, BCG can be
given safely as a diagnostic tool to look for
accelerated allergic response in disease.
REFERENCES

DISCUSSION:
High prevalence of pulmonary tuberculosis in
the community may be a factor responsible for
its high incidence in pediatric age group
patients. 5,7,8,9 Pulmonary tuberculosis is mainly
primary focus of the disease whereas
tuberculous meningitis, be post-primary. These
ndings are similar to those of the earlier
researchers who carried out their surveys
nationally as well as internationally.9-12
Of the total patients studied, a majority of them
(56%) were males and the rest 44% were
females. This high prevalence among male
population of children is explained by the fact
that they may have more chances of exposure
to tuberculous patients in their surroundings
due to their more freedom of movement as
compared to the female patients who are
mainly conned within their homes. These
results are supported by previous studies. 3,5,7,8
This study conrms that BCG skin text is much
more sensitive as compared to the Mantoux
test in the detection of tuberculin allergy in
patients suffering from pulmonary
tuberculosis.
Our observations are exactly in line with those
made in earlier studies carried out at
Peshawar5, and India.4,5,6
On the basis of our observations, it is concluded
that BCG skin test is far more superior to
Mantoux test as a diagnostic tool in
pediatric age group patients suffering
from pulmonary tuberculosis. It is
therefore, recommended that:
1.
BCG should be preferred as a diagnostic
test for the diagnosis of childhood tuberculosis
as compared to Mantoux test.
2.
Besides its diagnostic value, BCG still
continues to be the only effective preventive
weapon against tuberculosis.
3.
Being safe, BCG could be given even to
28

1. Petal YG. The biological and clinical basis on

infectious diseases. 2nd edi. Philadelphia:
WB Saunders. 1980
2. Bokhari S N H. Accelerated BCG response:
diagnostic value among adults in an
endemic area. Pak J Med. Sci. 2011;
15:181-4.
3. WHO Expert Committee on Tuberculosis.
81st report WHO technical report series 290.
Geneva: WHO; 1964
4. Imran M. BCG a diagnostic tool in
childhood tuberculosis. J Post grad Med Insl
2012; 2: 181.
5. Udani PM. Tuberculosis in children. Pediatr
Clin India 2010; 18:143-56
6. Ciesilski SD. BCG vaccination and PPD test:
what the clinician needs to know? J Fam
Pract 2013; 40: 76-80.
7. Park K, Park's text-book of preventive and
social medicine. 22 n d ed. Jabalpur:
Banarsidas Bhanol 2013.
8. B e g u i n T., K h a t t a k A A , K h a n F M ,
Tuberculosis: a major threat to child health.
Pak Pediatr J 2012; 3: 28-30
9. BCG in cancer. (Editorial). Br Med J 2011; 1:
1987
10. Frappier A, Guay RA. New and practical BCG
skin test for the detection of total
tuberculous allergy. Can J Public Health
2013; 44: 78
11. Colelitz GA, Berkey CS. Mosteller F, Brewer
TF, Wilson ME, Burdick E, et al The efcacy
of BCG calmette-guerin vaccination of
newborns and infants in the prevention of
t u b e r c u l o s i s . M e t a -a n a l y s e s o f t h e
published literature Pediatrics 2010; 96
(1pt): 29-35
12. Datt T. Sen K. BCG vs tuberculin test in the
diagnosis of childhood tuberculosis. Indian
Pediatr. 2010, 19:141-6

Submitted for publication:

06-02-15

Accepted for publication:

11-04-15

JUMDC Vol. 6, Issue 2, April-June 2015