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Human rights and bioethics updates

A blog dedicated to updating you upon legislation and ethical debates around human rights (principally under the angle of law-enforcement forces) and bioethics (under the angle of the protection of vulnerable persons). You are welcome to leave your comments on any of the posts!

Wednesday, July 19, 2006

Prevention of tuberculosis and discrimination : an opinion of the French national consultative committee for bioethics

A recent question that arose with the regression of tuberculosis as a pathology and at the same time its apparition under more virulent forms in a pauperized population brought up the question of the use of continuing preventive vaccination of the whole infantile population with BCG.

The French committee for bioethics, the Comité Consultatif National d’Ethique pour les sciences de la vie et de la santé (CCNE) thus requested to give an opinion by the General Director for Public Health in France.

The question was formulated in these terms :

Suppression of the obligatory nature of the vaccination of children by BCG in order to reserve this vaccination to the risk populations exclusively

Systematic detection of tuberculosis through intradermic reaction to tuberculine, targeted on some children at school.

Systematic detection of tuberculosis by radiography and intradermic reaction to tuberculine when any person is hired who has to work with those children concerned by the tracking and the vaccination.



Specifically, we are talking here of children mainly from immigrant populations, in areas with endemic tuberculosis.

The CCNE answered by considering five points : the epidemiology of tuberculosis, detection of tuberculosis, vaccination, public health and ethical questions.

Epidemiology :

The CCNE recalls the available medical data, i.e. that there is an incidence of 10 new cases of tuberculosis per 100.000 inhabitants per year, since 1997. Actually there is a disparity in the presence of tuberculosis according to the nationality : about 5.7 cases per 100.000 inhabitants for French nationals, and much higher figures for foreign nationals : 74.2 cases per 100.000 inhabitants, this figure rising to 114.3 per 100.000 inhabitants in the region of Paris.

The CCNE thus found that there is a serious risk of contamination for fragilized populations.

Detection :

A systematic detection of tuberculosis is slowly disappearing. Mostly there are radiographies taken when hiring for some forms of employment or at the entrance in prison. Detecting persons affected by tuberculosis is all the more difficult since the tuberculine test reacts just as well to BCG as to tuberculosis. While fragilized populations would be the most in need of such detection, they are also those who have the least access to these procedures. Reserving detection to these populations might also end up by causing ethical problems as the CCNE examines further in its opinion.

Vaccination :

The coverage rate by BCG vaccination is of about 95 % at the age of six years, which is considered as excellent. With the change in furnisher of the BCG, the technique of vaccination also changed. Whereas before it was applied by a « multipuncture » ring, now it will have to be injected through intradermic injection. The problem being that many doctors do not have the necessary skills for practicing such injections (incidentally, that says a lot of the GP’s in France!). Secondary effects might be suppurations, and the presence of a scar. The CCNE finds that while the secondary effects and the low practicability of the new vaccination form are elements to be considered in favour of abandoning systematic vaccination, without a generalised detection of tuberculosis it may be discriminating without being efficient.

Public health:

The CCNE here starts examining the foundations of prevention, and notably recalls that protecting a group necessarily means limiting the freedom of the individual. However, to approach this problem, the CCNE recalls again that it had emitted the idea of a “debt of the society” towards the person having to be treated, in order that this person may gain more rights towards the society through its illness, than the society has on her.

Ethical questions:

This is the most interesting part, since this blog is concerned with bioethical questions. The CCNE signals before anything that the use of the verb “to target” is not innocent.

With a targeted vaccination, the CCNE signals that it might be considered as discriminating against, even if it is explained as being a “positive discrimination”. And the risk is very present of having to use force and policing to enforce this vaccination. In addition, one day, this “targeted” vaccination may become “segregative” in the terms of the CCNE.

More fundamentally, the ethics committee recalls that the problem of tuberculosis is also that of accessing the health structures without fear. Fear might bring up strategies of avoidment which might be counter-productive for the public health objective.

Recommandations:

The CCNE makes several recommandations (it only has a consultative nature, it cannot take decisions). Considering previous epidemiological studies, notably in Sweden where BCG was stopped several years ago (although the CCNE does not refer explicitly to these), the CCNE warns against a possible interruption of the BCG vaccination.

Any change in the vaccination policies should be accompanied by an increase in the generalised detection effort, especially with people coming from zones where tuberculosis is endemic...

At the same time, any specific attention to exposed populations should ensure that the detection and vaccination efforts be not transformed into a general policy against such or such population; exclusively basing these efforts on socio-economic considerations might be a way to exercise a disguised adverse discrimination.

The CCNE concludes by recommending an increased effort in the training of school physicians, GP’s etc, in order to sensibilise them to the aid to vulnerable persons.
You may download the whole opinion (in French) here.