Tuberculosis Vaccination Recommendations
BCG vaccination is NOT recommended for routine use in the United States; instead, TB prevention relies on early identification and treatment of active TB cases, tuberculin skin testing of high-risk populations, and preventive therapy for latent infection. 1
Primary Prevention Strategy in the United States
The cornerstone of TB control in the U.S. does not involve vaccination but rather:
- Interrupting transmission by identifying and treating patients with active infectious TB 2, 1
- Identifying and treating latent infection through tuberculin skin testing of high-risk individuals followed by preventive therapy with isoniazid or rifampin 1
- BCG vaccination is explicitly NOT recommended for inclusion in routine immunization or TB control programs 2, 1
The rationale for this approach is that BCG's effectiveness in preventing infectious pulmonary TB is uncertain and variable (ranging from 0% to 80% in different studies), and post-vaccination tuberculin reactivity interferes with diagnosing TB infection 1, 3
Limited Indications for BCG Vaccination
For Infants and Children
BCG vaccination should be considered ONLY in highly specific circumstances when all three conditions are met 1:
- High likelihood of M. tuberculosis transmission and infection in the child's environment
- The child cannot be removed from the source of infection
- No other protective measures can be implemented
Specific scenarios include:
- Children who cannot be separated from adults with untreated or ineffectively treated infectious TB 1
- Children continually exposed to persons with TB caused by strains resistant to both isoniazid and rifampin (MDR-TB) 1
Important caveat: BCG provides >80% protection against serious disseminated forms of TB in children (tuberculous meningitis and miliary TB) but variable protection against pulmonary TB 1, 3
For Healthcare Workers
BCG vaccination is generally NOT recommended for healthcare workers 2, 1
The preferred strategies are 1:
- Comprehensive infection-control measures
- Regular tuberculin skin testing to identify newly infected workers
- Preventive therapy when indicated
BCG may be considered on an individual basis ONLY when 2, 1:
- A high percentage of TB patients have strains resistant to both isoniazid and rifampin
- Comprehensive TB infection-control precautions have been implemented and have failed
- The healthcare worker is not HIV-infected or otherwise immunocompromised
Absolute Contraindications
Never administer BCG to: 2, 1, 4
- Children or adults infected with HIV (risk of disseminated BCG infection)
- Immunocompromised individuals
Critical Clinical Pitfall
For BCG-vaccinated persons with tuberculin skin-test reaction ≥10 mm induration, TB preventive therapy should still be considered, especially if they 1:
- Are contacts of persons with infectious TB
- Were born in or resided in high TB prevalence countries
- Are continually exposed to high-prevalence populations
This is crucial because BCG vaccination does not provide complete protection, and a positive tuberculin test in a vaccinated person may still indicate true M. tuberculosis infection.
Consultation Requirement
Physicians considering BCG vaccine for their patients are required to consult with local TB control programs before administration 2, 1