Editorial Comment regarding BCG Vaccine use in the United States
The BCG vaccine is not recommended in the United States for several reasons. The Center for Disease Control (CDC) states the criteria for BCG immunization in this country. While opinion varies throughout the world, the United States, along with Sweden, Czech Republic and Slovakia, recommend vaccination only in specific high-risk individuals. The decision of a country to endorse the widespread use of the vaccination is based on numerous factors. According to a document published by the World Health Organization (WHO) on the BCG vaccine, the "policy differences [between countries] are based upon regional differences in patterns and perspectives of tuberculosis, regional variations in health systems (economics, relative emphasis on preventive and curative services, manpower), and local history (personalities and "schools” of opinion). Justifications for the various policies are embedded in the medical and public health teaching and traditions of the countries involved.” Furthermore, the WHO recommends vaccinating children either at birth, or in young childhood. It has generally been shown that revaccination does not significantly increase the effectiveness of the vaccine, although this continues to be the policy in some Eastern European countries.
There are numerous contraindications provided by the WHO and the CDC, and individuals with "impaired immunity, with malignant conditions such as lymphoma, leukemia, Hodgkin’s disease, or who are HIV positive, pregnant, tuberculin positive, febrile, or with a generalized septic skin condition should not be vaccinated.” Additionally, it has been found that the vaccine typically has only a 50% effectiveness rate in immunized individuals. This may be due to the fact that BCG vaccines may vary from country to country, and there may be numerous different strains of M. tuberculosis that are differentially affected by environmental and genetic conditions experienced by individuals. Additionally, a further area of concern in the effectiveness of the BCG vaccine is that it is typically administered to children. However, the majority of tuberculosis cases are present in adults and are spread from adult pulmonary cases. Currently, it is believed that the BCG vaccine given in childhood is ineffective in preventing the development of adult pulmonary tuberculosis.
Finally, only TB experts should be advising and performing the immunization. It is not surprising that a family physician would have a difficult time obtaining the vaccine and performing the immunization. In the case presented, if the family visited a TB specialist, the specialist would be able to discuss their options and to get the vaccine administered timely and properly, if that is what the specialist deemed to be the best option. Although TB incidence is rising in the USA, it is the authors’ belief that there is not a need for BCG immunization to become popular yet, nor is there sufficient evidence to support its efficacy.
For individuals seeking further information on the BCG vaccine, the CDC website provides significant information: http://www.cdc.gov/tb/pubs/tbfactsheets/BCG.htm.
- Fine PEM, Carneiro IAM, Milstien JB, Clements CJ. Issues relating to the use of BCG in immunization programmes. A discussion document. World Health Organization (WHO) document no. WHO/V&B/99.23. Geneva: WHO; 1999.
- Colditz GA, Brewer TF, Berkey CS, Wilson ME, Burdick E, Fineberg HV, Mosteller F. Efficacy of BCG vaccine in the prevention of tuberculosis, JAMA. 1994 Mar 2;271(9):698-702.
- Giri, PK, Khuller, GK. Is intranasal vaccination a feasible solution for tuberculosis? Expert review of vaccines, 2008, 7(9):1341-56.
Shamus E, Cohen G, Lou J. Editorial Comment regarding BCG Vaccine use in the United States. The Internet Journal of Allied Health Sciences and Practice. 2009 Jan 01;7(1), Article 6.