Does the BCG Vaccine Offer Any Protection Against Coronavirus Disease 2019?

Mueez Rehman¹

Akshay Sood MD, MPH^2,3

¹University of New Mexico Main Campus, Albuquerque, NM, USA

²Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM USA

³Black Lung Program, Miners’ Colfax Medical Center, Raton, NM, USA

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-COV2), shares features with diseases caused by other coronaviruses such as influenza, the Severe Acute Respiratory Syndrome (SARS) outbreak of 2003, and the Middle East Respiratory syndrome (MERS) outbreak of 2012. COVID-19 has been a challenging and devastating pandemic, resulting in death rates of more than 1%, testing nations both rich and poor, and outlining the importance of strong public health programs. Social distancing, masking and hand washing have become the new norm. Healthcare professionals are on the front lines, risking their lives. Those with pre-existing health conditions or older individuals face a significant risk for complications.

As scientists race to understand this deadly virus and find a cure to protect millions, an unlikely ally may come in a vaccine created over 100 years ago. The Bacillus Calmette-Guérin or BCG vaccine was created in 1921 to protect against tuberculosis (TB). At the time, tuberculosis was widespread, and the BCG vaccine was quickly implemented globally. However, as tuberculosis rates declined, developed countries such as the United States and many European countries discontinued widespread BCG administration. This change in vaccination policy was due to the supply of the vaccine and concerns for its efficacy. On the other hand, countries such as India, Pakistan, Indonesia, Vietnam, Russia, Ethiopia, and many others have continued widespread administration of the BCG vaccine. Many of these countries still have high rates of tuberculosis infections, as well as a large percentage of their population live in poverty (1). When COVID-19 started to emerge as a pandemic, global leaders and public health officials feared this pandemic would have catastrophic effects on these countries, overwhelming their healthcare systems, and killing millions. Interestingly, the opposite outcome was observed as these countries reported low rates of COVID-19. Instead, Europe became the world’s first epicenter outside of mainland China, followed by the United States, both of which reported large infection rates and death tolls due to COVID-19. The hardest hit countries had a similarity in that, they did not require widespread neonatal BCG vaccination. Ultimately, it is possible that the key difference between rates of COVID-19 infections in nations lies in neonatal BCG immunization rates amongst the populations. However, these conclusions are subject to confounding variables, such as the strength of the public health programs, and testing and reporting rates for COVID-19. An interesting outlier is Iran, which implemented a nationwide BCG vaccination program late in 1984, for children less than 6 years of age, using the Pasteur strain (2). With the high rates of COVID-19 cases in Iran, further research needs to examine this outlier, to see if there is any association with the type of vaccine used, administration at a later age, or the fact that currently middle-aged and elderly Iranians are not universally vaccinated.

Another interesting observation comes from the COVID-19 racial/ethnic distribution in the United States. The Centers for Disease Control and Prevention (CDC) released the race/ethnicity data for 580 lab-confirmed COVID-19, hospitalized patients on April 8, 2020 (3). In this data, African Americans constituted 33% of patients (when compared to 18% in the catchment populations) while Asians constituted 5.5% of the patients (proportion of Asians in the catchment population was not described). In certain states, Asian American populations showed higher disease and death rates for COVID-19, when compared to the general population (4). Interpretation of this data is, however, subject to confounding variables. The racial category for the Asian population is reported differently throughout the nation. Many states have differing definitions for the Asian race, certain states fail to divide the Asian population into different subgroups, and others combine Asian populations with ‘other’ racial groups (5). Furthermore, because the US does not have a widespread COVID-19 testing program, certain communities lack access to tests, and disparities for groups may be hidden. Once comprehensive data is available, it would be interesting to examine if the Asian subgroups consisting of individuals who received the BCG vaccine from a BCG administering country, before immigrating to the US show better outcomes against COVID-19, when compared to other Asian American subgroups.

The BCG vaccine was created by Albert Calmette and Camille Guérin against a live attenuated strain of Mycobacterium bovis, a mycobacterium that is similar to the one that causes tuberculosis. The vaccine creates both specific immunity to that mycobacterium, as well as nonspecific immunity against other pathogens that cause respiratory tract infections. In a study conducted on mice, researchers found that when subjecting mice to infectious viruses such as the A0 and A2 influenza viruses, herpes simplex virus, as well as other highly infectious viruses, mice inoculated with BCG were found to exhibit a significantly higher resistance to these infections compared to control mice (6). An explanation for this finding may lie in the fact that the BCG vaccine results in innate immune memory in the host. This trained immunity works by reprogramming a host’s bone marrow hematopoietic stem cells and multipotent progenitors through epigenetic/metabolic changes, resulting in greater variability of the differentiated innate immune cells response following a pathogen (7). Ultimately, this may result in the host’s immune system being able to successfully fight off large numbers of respiratory tract infections, including possibly SARS-CoV-2.

The World Health Organization (WHO) stands firm on the stance that there is no scientific evidence as to whether the BCG vaccine actually protects against COVID-19. Furthermore, WHO mentions that BCG vaccination is particularly important for children in countries with high prevalence of tuberculosis, and if local supplies are diverted, these children will face an increase in disease and death from tuberculosis (8).

As more scientific research is being conducted, the preliminary findings may indicate BCG as a potential safeguard against COVID-19. This may be explained through the lower rates of infection in countries with widespread neonatal BCG vaccination policies. Furthermore, immigrants who come from BCG administering countries may also have this advantage against COVID-19. Currently, the US Government is working to release a racial/ethnic breakdown of COVID-19 cases. As more data is published on race and ethnicities, it will be useful to examine if fewer COVID-19 cases and deaths occur amongst immigrant populations from BCG-administering parent countries, after adjusting for confounders.

References

1. Zwerling A, Behr MA, Verma A, et al. The BCG World Atlas: A Database of Global BCG Vaccination Policies and Practices. PLoS Med. 2011 Mar;8(3):e1001012. [CrossRef] [PubMed]
2. Fallah F, Nasiri MJ, Pormohammad A. Bacillus Calmette-Guerin (BCG) vaccine in Iran. J Clin Tuberc Other Mycobact Dis. 2018;11:22. [CrossRef] [PubMed]
3. Garg S, Kim L, Whitaker M, et al. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 - COVID-NET, 14 States, March 1-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69.458-64. [CrossRef] [PubMed]
4. NYC Health. Age-adjusted rates of lab confirmed COVID-19 non-hospitalized cases, estimated non-fatal hospitalized cases, and patients known to have died 100,000 by race/ethnicity group as of April 16, 2020. Available at https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-deaths-race-ethnicity-04162020-1.pdf; Printed April 16, 2020. Accessed May 1, 2020.
5. Growing Data Underscore that Communities of Color are Being Harder Hit by COVID-19 | The Henry J. Kaiser Family Foundation. https://www.kff.org/coronavirus-policy-watch/growing-data-underscore-communities-color-harder-hit-covid-19/?utm_source=sfmc&utm_medium=email&utm_campaign=covidexternal&utm_content=newsletter. Accessed April 24, 2020.
6. Floc’h F, Werner GH. Increased resistance to virus infections of mice inoculated with BCG (Bacillus calmette-guérin). Ann Immunol (Paris). 1976;127(2):173-86. [PubMed]
7. Gursel M, Gursel I. Is global BCG vaccination coverage relevant to the progression of SARS-CoV-2 Pandemic? Allergy. 2020 Apr 27. [CrossRef] [PubMed]
8. World Health Organization. Bacille Calmette-Guérin (BCG) vaccination and COVID-19. https://www.who.int/news-room/commentaries/detail/bacille-calmette-guérin-(bcg)-vaccination-and-covid-19. Accessed April 14, 2020.

Cite as: Rehman M, Sood A. Does the BCG vaccine offer any protection against coronavirus disease 2019? Southwest J Pulm Crit Care. 2020;20(5):170-2. doi: https://doi.org/10.13175/swjpcc035-20 PDF 

2020 International Year of the Nurse and Midwife and International Nurses’ Day

Carol M. Baldwin, PhD, RN, CHTP, CT, AHN-BC, FAAN

Edson College of Nursing & Health Innovation

Arizona State University

Phoenix, AZ USA

Barbara M. Dossey, PhD, RN, AHN-BC, FAAN, HWNC-BC

Nightingale Initiative for Global Health (NIGH)

Washington, DC USA

The World Health Organization (WHO) designated 2020 as the International Year of the Nurse and Midwife to acknowledge the contributions of nurses and midwives in promoting the health and welfare of populations across the globe. This recognition is in concert with the 200^th anniversary of the birth of Florence Nightingale. Although nurses and midwives make up over half the world’s health care workforce, the WHO estimates that 2020 will see a shortage of 9 million nurses (1,2). International Nurses’ Week begins May 6^th and culminates on May 12^th, International Nurses Day, the anniversary of Nightingale’s birth with hopes of bringing greater re, cognition nurses play in local to global health.

Defying expected Victorian norms for women born to well-connected, affluent British families in the middle of the nineteenth century, Florence Nightingale chose the art and science of nursing over marriage. “Nightingale” is synonymous with the foundation of professional nursing, as well as her dedicated service as a manager and trainer of nurses during the Crimean War.

Florence Nightingale’s influence, however, encompasses so much more than establishing nursing education. Military and field medicine, epidemiology, early prefabricated hospitals, hospital supervision, community and public health, health policy, establishment of nursing schools and infirmaries, early pioneering in the concept of medical tourism, as well as social reform for women and all sections of society have benefitted from her groundbreaking achievements. Her work continues. The Nightingale Initiative for Global Health (NIGH), for example, fosters Nightingale’s activities grounded in social and environmental justice, preventive medicine, and holistic health from the local to global levels (3,4).

A keen observer of conditions that lead to poor health, Nightingale wrote extensively regarding sanitary reform. Her Notes on Nursing emphasized frequent handwashing that presaged the hygiene required during the current Covid-19 pandemic (5). Nightingale was the first woman admitted to the London Statistical Society (5). She became a member of the American Statistical Association (6). She was the first nurse to conduct and use research. Nightingale showed that physical and social factors influenced health, and that quality of care can be improved through careful data collection, visual displays that used her original “Polar-Area Diagram,” critical thinking, and practice based on evidence (7).

Florence Nightingale’s legacy endures in the face of the Covid-19 pandemic. It was announced on 24 March 2020 that the new “Nightingale Hospital” would be set up at the ExCel conference centre in East London to provide support for up to 4,000 patients with Covid-19 (8). On 3 April 2020, within two weeks of the announcement, the NHS Nightingale Hospital was officially opened by HRH Prince Charles as a coronavirus field hospital. In his remarks, Prince Charles stated, “Florence Nightingale, the lady with the lamp, brought hope and healing to thousands in their darkest hour. In this dark time this place will be a shining light” (9).

The Southwest Journal of Pulmonary and Critical Care congratulates and values the many legatees of Florence Nightingale in this 2020 International Year of the Nurse--the nurses and midwives across the globe for their unwavering dedication to education, research, practice and policy, as well as our valued interprofessional collaborations in promoting health and preventing disease.

References 

1. World Health Organization. Year of the Nurse and the Midwife 2020. Accessed 1 May 2020 from https://www.who.int/news-room/campaigns/year-of-the-nurse-and-the-midwife-2020
2. Jakel P. WHO’s International Year of the Nurse and Midwife. Accessed 1 May 2020 from https://www.oncnursingnews.com/publications/oncology-nurse/2020/april-2020/2020-whos-international-year-of-the-nurse-and-the-midwife
3. Beck DM, Dossey BM. In Nightingale's footsteps - individual to global: From nurse coaches to environmental and civil society activists. Creative Nursing: A Journal of Values, Issues, Experience and Collaboration, 2019;25(3):1-6.
4. Dossey BM, Rosa WE, Beck DM. Nursing and the sustainable development goals: From Nightingale to now. American Journal of Nursing, 2019;119(5):40-45. 
5. Bates, R. Florence Nightingale: A pioneer of handwashing and hygiene for health. Accessed 3 May 2020 from https://theconversation.com/florence-nightingale-a-pioneer-of-hand-washing-and-hygiene-for-health-134270
6. Columbia Mailman School of Public Health, Healthcare Policy. Florence Nightingale was an epidemiologist too. Accessed 4 May 2020 from https://www.mailman.columbia.edu/public-health-now/news/florence-nightingale-was-epidemiologist-too
7. Baldwin CM, Schultz AA, Barrere CC. (2016) ‘Evidence-based practice’, in Dossey BM & Keegan L., Holistic nursing: A handbook for practice. Burlington, MA: Jones & Bartlett, p. 639.
8. NHS England Website. Accessed 1 May 2020 from New NHS Nightingale Hospital To Fight Coronavirus
9. Evening Standard. NHS Nightingale officially opened by Prince Charles as coronavirus field hospital becomes world’s largest critical care unit. Accessed 2 May 2020 from https://www.standard.co.uk/news/health/nhs-nightingale-coronavirus-field-hospital-open-prince-charles-a4405796.html

2020 Año Internacional de la Enfermera y Partera y el Día Internacional de la Enfermera

Carol M. Baldwin, PhD, RN, CHTP, CT, AHN-BC, FAAN

Edson College of Nursing & Health Innovation

Arizona State University

Phoenix, AZ USA

Barbara M. Dossey, PhD, RN, AHN-BC, FAAN, HWNC-BC

Nightingale Initiative for Global Health (NIGH)

Washington, DC USA

La Organización Mundial de la Salud (OMS) designó 2020 como el Año Internacional de la Enfermera y la Partera para reconocer las contribuciones de las enfermeras y parteras en la promoción de la salud y el bienestar de las poblaciones de todo el mundo. Este reconocimiento está en concierto con el bicentenario del nacimiento de Florence Nightingale. Si bien las enfermeras y las parteras representan más de la mitad de la fuerza laboral mundial de atención de la salud, la OMS estima que en 2020 habrá una escasez de 9 millones de enfermeras (1,2). La Semana Internacional de Enfermeras comienza el 6 de mayo y culmina el 12 de mayo, Día Internacional de las Enfermeras, el aniversario del nacimiento de Nightingale con la esperanza de brindar un mayor reconocimiento a las enfermeras en la salud local y mundial.

Desafiando las normas victorianas esperadas para las mujeres nacidas de familias británicas acomodadas y bien conectadas a mediados del siglo XIX, Florence Nightingale eligió el arte y la ciencia de la enfermería en lugar del matrimonio. "Nightingale" es sinónimo de la base de la enfermería profesional, así como su servicio dedicado como gerente y formadora de enfermeras durante la Guerra de Crimea.

La influencia de Florence Nightingale, sin embargo, abarca mucho más que establecer una educación en enfermería. Medicina militar y de campo, epidemiología, hospitales prefabricados tempranos, supervisión hospitalaria, salud comunitaria y pública, política de salud, establecimiento de escuelas de enfermería y enfermerías, pioneros tempranos en el concepto de turismo médico, así como reforma social para las mujeres y todos los sectores de la sociedad se han beneficiado de sus logros innovadores. Su trabajo continúa. La Nightingale Initiative for Global Health (NIGH), por ejemplo, fomenta las actividades de Nightingale basadas en la justicia social y ambiental, la medicina preventiva y la salud holística desde el nivel local hasta el global (3,4).

Un observador entusiasta de las condiciones que conducen a la mala salud, Nightingale escribió ampliamente sobre la reforma sanitaria. Sus Notas sobre Enfermería enfatizaban el lavado frecuente de manos que presagiaba la higiene requerida durante la actual pandemia de Covid-19 (5). Nightingale fue la primera mujer admitida en la Sociedad Estadística de Londres (5). Se convirtió en miembro de la Asociación Americana de Estadística (6). Fue la primera enfermera para realizar y utilizar investigaciones. Nightingale demostró que los factores físicos y sociales influyeron en la salud, y que la calidad de la atención se puede mejorar mediante una cuidadosa recolección de datos, exhibiciones visuales que utilizaron su "diagrama de área polar" original, pensamiento crítico y práctica basada en evidencia (7).

El legado de Florence Nightingale perdura ante la pandemia de Covid-19. Se anunció el 24 de marzo de 2020 que el nuevo "Hospital Nightingale" se establecería en el centro de conferencias ExCel en el este de Londres para brindar apoyo a hasta 4,000 pacientes con Covid-19 (8). El 3 de abril de 2020, dentro de las dos semanas posteriores al anuncio, El “NHS Nightingale Hospital” fue inaugurado oficialmente por el Príncipe Carlos como un hospital de campaña de coronavirus. En sus comentarios, el Príncipe Carlos declaró: “Florence Nightingale, la dama de la lámpara, trajo esperanza y sanación a miles en su hora más oscura. En este tiempo oscuro este lugar será una luz brillante” (9).

The Southwest Journal of Pulmonary and Critical Care felicita y valora a los muchos legatarios de Florence Nightingale en este Año Internacional de la Enfermera 2020: las enfermeras y parteras de todo el mundo por su inquebrantable dedicación a la educación, la investigación, la práctica y la política, así como a nuestras valiosas colaboraciones interprofesionales en la promoción de la salud y la prevención de enfermedades.

Referencias

1. World Health Organization. Year of the Nurse and the Midwife 2020. Accessed 1 May 2020 from https://www.who.int/news-room/campaigns/year-of-the-nurse-and-the-midwife-2020
2. Jakel P. WHO’s International Year of the Nurse and Midwife. Accessed 1 May 2020 from https://www.oncnursingnews.com/publications/oncology-nurse/2020/april-2020/2020-whos-international-year-of-the-nurse-and-the-midwife
3. Beck DM, Dossey BM. In Nightingale's footsteps - individual to global: From nurse coaches to environmental and civil society activists. Creative Nursing: A Journal of Values, Issues, Experience and Collaboration, 2019;25(3):1-6.
4. Dossey BM, Rosa WE, Beck DM. Nursing and the sustainable development goals: From Nightingale to now. American Journal of Nursing, 2019;119(5):40-45. 
5. Bates, R. Florence Nightingale: A pioneer of handwashing and hygiene for health. Accessed 3 May 2020 from https://theconversation.com/florence-nightingale-a-pioneer-of-hand-washing-and-hygiene-for-health-134270
6. Columbia Mailman School of Public Health, Healthcare Policy. Florence Nightingale was an epidemiologist too. Accessed 4 May 2020 from https://www.mailman.columbia.edu/public-health-now/news/florence-nightingale-was-epidemiologist-too
7. Baldwin CM, Schultz AA, Barrere CC. (2016) ‘Evidence-based practice’, in Dossey BM & Keegan L., Holistic nursing: A handbook for practice. Burlington, MA: Jones & Bartlett, p. 639.
8. NHS England Website. Accessed 1 May 2020 from New NHS Nightingale Hospital To Fight Coronavirus
9. Evening Standard. NHS Nightingale officially opened by Prince Charles as coronavirus field hospital becomes world’s largest critical care unit. Accessed 2 May 2020 from https://www.standard.co.uk/news/health/nhs-nightingale-coronavirus-field-hospital-open-prince-charles-a4405796.html

Cite as: Baldwin CM, Dossey BM. 2020 international year of the nurse and midwife and international nurses’ day. Southwest J Pulm Crit Care. 2020;20(5):165-9. doi: https://doi.org/10.13175/swjpcc034-20 PDF