What is the primary recommendation for Tuberculosis (TB) vaccination?

Tuberculosis Vaccination Recommendations

BCG vaccination in the United States is rarely indicated and is reserved only for selected high-risk individuals who meet specific criteria, as the primary strategy for TB control focuses on early identification and treatment of active cases and preventive therapy for latent infections. 1

General Recommendations

• The primary strategy for preventing and controlling TB in the United States is minimizing transmission risk through early identification and treatment of patients with active infectious TB 1
• The second most important strategy is identifying persons with latent M. tuberculosis infection and providing preventive therapy with isoniazid or rifampin 1
• BCG vaccination is not recommended for inclusion in routine immunization or TB control programs in the United States 1
• BCG vaccine use has been limited because its effectiveness in preventing infectious forms of TB is uncertain and post-vaccination tuberculin reactivity interferes with TB infection diagnosis 1

Specific Recommendations for BCG Vaccination

For Children:

• BCG vaccination should be considered for infants and children who:

  • Reside in settings with high likelihood of M. tuberculosis transmission and subsequent infection 1
  • Cannot be removed from the source of infection 1
  • Have no other protective measures that can be implemented 1

• Specific indications include children who:

  • Cannot be separated from adults with untreated or ineffectively treated infectious TB 1
  • Are continually exposed to persons with infectious TB caused by M. tuberculosis strains resistant to both isoniazid and rifampin 1

• BCG vaccination is not recommended for children infected with HIV due to potential adverse reactions 1

For Healthcare Workers (HCWs):

• BCG vaccination of HCWs should be considered only on an individual basis in settings where: 1

  • A high percentage of TB patients are infected with M. tuberculosis strains resistant to both isoniazid and rifampin 1
  • Transmission of such drug-resistant strains to HCWs is likely 1
  • Comprehensive TB infection-control precautions have been implemented but have not been successful 1

• BCG vaccination should not be used as a primary strategy for HCWs because: 1

  • The protective efficacy in HCWs is uncertain 1
  • Even if effective for an individual HCW, it doesn't protect others in the healthcare facility 1
  • It interferes with tuberculin skin test interpretation for infection surveillance 2

• The preferred strategies for TB prevention in healthcare facilities are: 1

  • Comprehensive infection-control measures 1
  • Regular tuberculin skin testing to identify newly infected HCWs 1
  • Preventive therapy when indicated 1

• BCG vaccination is not recommended for HCWs who are infected with HIV or otherwise immunocompromised 1

Effectiveness of BCG Vaccination

• Meta-analyses have confirmed that BCG provides high protective efficacy (>80%) against serious forms of TB in children, including tuberculous meningitis and disseminated TB 1
• The protective efficacy for preventing pulmonary TB in adolescents and adults is variable and equivocal 1
• Protection from BCG vaccination has been shown to last at least 10 years in some populations 3
• Regional differences in protection exist, with one case-control study in Alberta, Canada showing 57% protection in Treaty Indians 4

International Perspective

• BCG vaccination is still considered an important strategy in National Tuberculosis Programs of countries with a high burden of TB 2
• Recommendations for BCG vaccination vary widely between countries 3
• For travelers to high TB prevalence countries, pre-travel BCG immunization should be considered for children, though recommendations are inconsistent 5

Important Considerations

• BCG vaccination does not prevent transmission of infection to the individual 2

• BCG vaccination affects the response to tuberculin skin tests for at least 6 years 3

• TB preventive therapy should be considered for any BCG-vaccinated person with a tuberculin skin-test reaction ≥10 mm of induration, especially if they: 1

  • Are a contact of a person with infectious TB 1
  • Were born or resided in a high TB prevalence country 1
  • Are continually exposed to high-prevalence populations 1

• Physicians considering BCG vaccine for their patients should consult with local TB control programs 1