What is the recommended tuberculosis (TB) vaccine in America?

BCG Vaccination in the United States

BCG vaccination is not routinely recommended in the United States and is reserved only for select high-risk individuals in specific circumstances. 1, 2

Current U.S. Recommendations

The Centers for Disease Control and Prevention (CDC) limits BCG vaccination to very specific situations:

For Children

• BCG vaccination should be considered only for infants and children who:
  • Reside in settings with high likelihood of M. tuberculosis transmission
  • Have continuous exposure to untreated or ineffectively treated TB patients
  • Cannot be separated from the infectious person
  • Cannot receive long-term preventive therapy
  • Are exposed to TB strains resistant to both isoniazid and rifampin 1, 2

For Healthcare Workers

• BCG may be considered on an individual basis only when:
  • Working in settings with high multidrug-resistant TB transmission
  • Comprehensive infection control measures have been implemented but failed
  • Risk of infection with multidrug-resistant TB strains is high 1, 2

Primary TB Prevention Strategy in the U.S.

Instead of routine BCG vaccination, the U.S. employs a two-pronged approach:

1. Early identification and treatment of active infectious TB cases to minimize transmission
2. Screening and preventive therapy for those with latent TB infection:
   • Isoniazid (10 mg/kg/day, max 300 mg/day) for 6-9 months for drug-susceptible TB exposure
   • Rifampin for 4 months for isoniazid-resistant TB exposure
   • Specialist consultation for MDR-TB exposure 1, 2

Limitations of BCG Vaccination

Several factors limit BCG use in the United States:

• Variable efficacy: While highly effective (80-100%) for preventing serious forms of TB in children (meningeal and miliary TB), efficacy for preventing pulmonary TB in adults is inconsistent (0-80%) 1, 2, 3
• Interference with TB screening: BCG vaccination causes tuberculin reactivity, complicating future TB screening efforts 1, 2
• Contraindications: Not recommended for immunocompromised individuals, including those with HIV infection 1, 2

Special Considerations

Travel to High TB Prevalence Countries

While some countries recommend BCG for travelers to high-prevalence regions, U.S. guidelines do not routinely recommend this practice 4. Consultation with a TB specialist or travel medicine expert is advised for those planning extended stays in high-prevalence areas.

Common Pitfalls to Avoid

1. Assuming BCG is part of routine U.S. immunization: Unlike many other countries, the U.S. does not include BCG in standard vaccination schedules due to the low overall TB risk in the general population 1, 2

2. Misinterpreting positive TB skin tests: Healthcare providers should be aware that prior BCG vaccination can cause false-positive tuberculin skin test results, though this reactivity typically wanes over time 1, 2

3. Overlooking the need for TB screening: Even in BCG-vaccinated individuals, regular TB screening is still recommended when risk factors are present 2

Future Directions

Research continues on developing more effective TB vaccines beyond BCG. Current strategies include:

• Recombinant BCG vaccines
• Attenuated M. tuberculosis strains
• Subunit boosting vaccines designed to enhance BCG protection 5

However, until new vaccines are approved, the U.S. approach remains focused on targeted use of BCG only in specific high-risk situations, with greater emphasis on early detection and treatment of active TB and preventive therapy for latent infection.