What is the step-by-step procedure for administering the BCG (Bacillus Calmette-Guérin) vaccination?

BCG Vaccination Procedure: Step-by-Step Guide

The BCG vaccination should be administered percutaneously using a sterile, single-use multiple puncture device, with the vaccine placed on the skin in the deltoid area of the upper arm and delivered through multiple punctures. 1

Pre-Vaccination Assessment

• BCG vaccination is reserved for persons who have a reaction of less than 5mm induration after skin testing with 5 tuberculin units (TU) of PPD tuberculin 2
• Confirm absence of contraindications before administering BCG vaccine 1:
  • BCG should not be given to persons previously infected with M. tuberculosis
  • BCG is contraindicated in immunocompromised persons, including those with HIV infection 2
  • BCG is not recommended during pregnancy 2

Materials Required

• BCG vaccine vial (Tice strain is the only licensed BCG vaccine in the United States) 2
• Sterile, single-use multiple puncture device 1
• Alcohol or acetone swabs for skin preparation 1
• Sterile gauze or cotton balls 2
• Biohazard sharps container 1
• Gloves and other personal protective equipment 2

Preparation of Vaccine

1. Use appropriate hand hygiene methods before starting 2
2. Remove BCG vaccine vial from refrigeration and check label and expiration date 2, 1
3. Reconstitute freeze-dried vaccine according to manufacturer's instructions 2
4. Gently swirl the vial until a homogenous suspension is obtained (avoid forceful agitation which may cause clumping) 1
5. Protect reconstituted vaccine from direct sunlight 1
6. Use reconstituted vaccine within 2 hours and keep refrigerated when not in use 2, 1

Administration Procedure

1. Select administration site in the deltoid region of the upper arm 1
2. Position the arm to maintain a horizontal surface where the vaccine is to be placed 1
3. Clean the site with an alcohol or acetone swab using circular motion from center to outside 2, 1
4. Allow site to dry thoroughly before administering vaccine 2, 1
5. Drop the immunizing dose of 0.2–0.3 mL of BCG vaccine from the syringe onto the cleansed surface of the skin 1
6. Spread the vaccine over a 1" by 2" area using the smooth edge of the multiple puncture device 1
7. Grasp the arm firmly from underneath, tensing the skin 1
8. Center the multiple puncture device over the vaccine and apply firm downward pressure such that the device points are well buried in the skin 1
9. Maintain pressure for 5 seconds (do not "rock" the device) 1
10. Release the pressure underneath the arm and remove the device 1
11. After successful puncture, spread vaccine as evenly as possible over the puncture area with the smooth edge of the device 1
12. An additional 1–2 drops of BCG vaccine may be added to ensure a very wet vaccination site 1

Post-Vaccination Care

• Loosely cover the site and keep dry for 24 hours 1
• Advise the patient that the vaccine contains live organisms and infection of others is possible 1
• Draining lesions resulting from vaccination should be kept clean and bandaged 2
• Dispose of the multiple puncture device and all materials exposed to the product in a biohazard container 1

Expected Reaction and Follow-up

• Normal reactions include formation of a bluish-red pustule within 2-3 weeks after vaccination 2
• After approximately 6 weeks, the pustule ulcerates, forming a lesion approximately 5 mm in diameter 2
• Scabs form and heal usually within 3 months after vaccination 2
• BCG vaccination generally results in a permanent scar at the puncture site 2
• Document tuberculin reactivity by performing a tuberculin skin test 3 months after BCG administration 2, 1
• Record test results in millimeters of induration in the person's medical record 2, 1

Special Considerations for Infants

• In infants less than 1 month old, the dosage of BCG vaccine should be reduced by one-half 1
• If a vaccinated infant remains tuberculin negative to 5 TU on skin testing, and if indications for vaccination persist, the infant should receive a full dose after 1 year of age 1

Important Cautions

• Do not administer BCG intravenously, subcutaneously, intramuscularly, or intradermally 1
• BCG vaccination is rarely indicated in the United States and should only be considered in specific situations 2
• Physicians considering BCG vaccination for their patients should consult with TB control programs in their area 2