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Meta-analysis of the Published Literature

Graham A. Colditz, MD, DrPH; Timothy F. Brewer, MD, MPH; Catherine S. Berkey, DSc, MA; Mary E. Wilson, MD; Elisabeth Burdick, MSc; Harvey V. Fineberg, MD, PhD; Frederick Mosteller, PhD

JAMA. 1994;271(9):698-702.

Abstract
Objective.
—To quantify the efficacy of BCG vaccine against tuberculosis (TB).

Data Sources.
—MEDLINE with index terms BCG vaccine, tuberculosis, and human. Experts from the Centers for Disease Control and Prevention and the World Health Organization, among others, provided lists of all known studies.

Study Selection.
—A total of 1264 articles or abstracts were reviewed for details on BCG vaccination, concurrent vaccinated and unvaccinated groups, and TB outcome; 70 articles were reviewed in depth for method of vaccine allocation used to create comparable groups, equal surveillance and follow-up for recipient and concurrent control groups, and outcome measures of TB cases and/or deaths. Fourteen prospective trials and 12 case-control studies were included in the analysis.

Data Extraction.
—We recorded study design, age range of study population, number of patients enrolled, efficacy of vaccine, and items to assess the potential for bias in study design and diagnosis. At least two readers independently extracted data and evaluated validity.

Data Synthesis.
—The relative risk (RR) or odds ratio (OR) of TB provided the measure of vaccine efficacy that we analyzed. The protective effect was then computed by 1 —RR or 1 —OR. A random-effects model estimated a weighted average RR or OR from those provided by the trials or case-control studies. In the trials, the RR of TB was 0.49 (95% confidence interval [Cl], 0.34 to 0.70) for vaccine recipients compared with nonrecipients (protective effect of 51%). In the case-control studies, the OR for TB was 0.50 (95% CI, 0.39 to 0.64), or a 50% protective effect. Seven trials reporting tuberculous deaths showed a protective effect from BCG vaccine of 71% (RR, 0.29; 95% Cl, 0.16 to 0.53), and five studies reporting on meningitis showed a protective effect from BCG vaccine of 64% (OR, 0.36; 95% Cl, 0.18 to 0.70). Geographic latitude of the study site and study validity score explained 66% of the heterogeneity among trials in a random-effects regression model.

Conclusion.
—On average, BCG vaccine significantly reduces the risk of TB by 50%. Protection is observed across many populations, study designs, and forms of TB. Age at vaccination did not enhance predictiveness of BCG efficacy. Protection against tuberculous death, meningitis, and disseminated disease is higher than for total TB cases, although this result may reflect reduced error in disease classification rather than greater BCG efficacy.

(JAMA. 1994;271:698-702)

Author Affiliations
From the Technology Assessment Group, Harvard School of Public Health (Drs Colditz, Berkey, Fineberg, and Mosteller and Ms Burdick); the Channing Laboratory, Brigham and Women's Hospital and Harvard Medical School (Dr Colditz); the Infectious Disease Unit, Massachusetts General Hospital (Dr Brewer), Boston; and the Infectious Disease Unit, Mount Auburn Hospital (Dr Wilson), Cambridge, Mass. Dr Brewer is the recipient of an Alfred L. Frechette Postdoctoral Research Fellowship in Public Health from the Massachusetts Health Research Institute, Boston, Mass, and a grant from the Potts Foundation, Hudson, NY.

Footnotes
Reprint requests to the Technology Assessment Group, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 (Dr Colditz).

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