Udani P M
Postgraduate Institute of Medical Sciences, Bombay Hospital.
Indian J Pediatr. 1994 Sep-Oct;61(5):451-62. doi: 10.1007/BF02751703.
With the extended programme of immunisation and since 1985 the universal programme of immunisation and the coverage status of BCG vaccination in India has been very good, although it is still unsatisfactory in the eastern states. It is emphasized that BCG vaccination cannot prevent natural tuberculous infection of the lungs and its local complications, although it reduces the haematogenous complications of primary infection. However, this is not true for malnourished children who, inspite of BCG vaccination, develop serious, and often fatal types of tuberculosis such as miliary, meningitic and disseminated tuberculosis. The tuberculin anergy in malnourished children, is mainly responsible for high morbidity and mortality. BCG vaccinated, well-nourished children manifest modified patterns of tuberculous disease, following infection. The most important manifestation is the increased incidence of intrathoracic tuberculosis, specially enlargement of the various groups of mediastinal nodes and their local complications. Localisation of the disease by T cell immunity, due to BCG vaccination is responsible for this and the much lower incidence of haemotological complications such as neurotuberculosis and disseminated disease. In these children, the clinical picture of neurotuberculosis is also modified, with a tendency for more localised involvement of the brain and meninges. Similarly, vaccinated children may present with hepatomegaly, splenomegaly or isolated organ disease. It is important to relearn the new patterns of tuberculosis disease seen in vaccinated, non-malnourished children, and to a lesser extent in children with grade 1 to 2 protein energy malnutrition (PEM). With these limitations of BCG vaccination, other strategies like chemoprophylaxis need multicentric trials in high risk children, in different parts of the country.
自1985年以来，随着扩大免疫规划的实施，印度的常规免疫规划以及卡介苗接种的覆盖情况一直非常良好，尽管在东部各邦仍不尽人意。需要强调的是，卡介苗接种虽可减少原发性感染的血行并发症，但无法预防肺部的自然结核感染及其局部并发症。然而，对于营养不良的儿童而言并非如此，尽管接种了卡介苗，他们仍会患上严重且往往致命的结核病类型，如粟粒性、结核性脑膜炎和播散性结核病。营养不良儿童的结核菌素无反应主要是导致高发病率和高死亡率的原因。接种卡介苗且营养良好的儿童在感染后会表现出结核疾病的改良模式。最重要的表现是胸内结核发病率增加，特别是纵隔各组淋巴结肿大及其局部并发症。卡介苗接种通过T细胞免疫使疾病局限化，这导致了血行并发症如神经结核和播散性疾病的发病率大大降低。在这些儿童中，神经结核的临床表现也有所改变，脑部和脑膜的局部受累倾向更大。同样，接种疫苗的儿童可能会出现肝肿大、脾肿大或孤立器官疾病。重新认识接种疫苗、非营养不良儿童以及程度较轻的1至2级蛋白质能量营养不良（PEM）儿童中出现的结核病新模式非常重要。鉴于卡介苗接种存在这些局限性，像化学预防这样的其他策略需要在该国不同地区的高危儿童中进行多中心试验。
