The beta version of the Atlas went live in the fall of 2008 with completed
questionnaires on BCG vaccination from 62 countries. Since that time, more data have
been added and several improvements have been made. As of October 2010, we have
collected data concerning BCG vaccination policies and practices for 180 of 209
(86%) countries worldwide that we approached. The database is available as an
interactive Web site at http://www.bcgatlas.org/
information for a particular country's BCG policy, along with its estimated
World Health Organization (WHO) TB incidence statistics, can be viewed alongside a
graphical map. Among the 180 countries with available data, 157 countries currently
recommend universal BCG vaccination, while the remaining 23 countries have either
stopped BCG vaccination (due to a reduction in TB incidence), or never recommended
mass BCG immunization and instead favored selective vaccination of “at
risk” groups ().
Complete questionnaire data were available for 77 countries, while remaining data
were extracted from published sources.
Map displaying BCG vaccination policy by country.
Many countries began BCG vaccination programs in the 1940s–1980s, though some
countries such as Romania and Uzbekistan report vaccination campaigns as early as
1928 and 1937, respectively, while some sub-Saharan African nations such as Nigeria
and Sierra Leone only began BCG vaccinations in 1991 and 1990. Nine countries have
ceased universal BCG vaccination programs; Spain and Denmark were among the first,
stopping in 1981 and 1986, respectively, while Austria and Germany had stopped by
1990 and 1998. The remaining countries, including the Isle of Man, Slovenia, UK,
Finland, and France, all ceased their BCG vaccination campaigns between 2005 and
2007. While these countries may have ceased mass universal vaccination programs,
many do continue to provide BCG vaccination selectively to high-risk individuals,
including those involved in high TB risk occupations and/or travel, and infants born
into high TB risk environments.
We identified 49 countries that reported changes to their BCG vaccination policy in
the past 20 years. Twenty-seven countries reported major changes to their BCG policy
within the last 10 years. Of particular interest is the large number
33) of countries that had multiple
vaccination programs in the past, but have since ceased revaccination, and now use a
single BCG vaccination schedule (). These revaccination policy changes were as recent as 2007.
Sixteen countries continue to give an additional BCG vaccination after the initial
BCG, known as a booster vaccination (), while Kazakhstan, Belarus, Uzbekistan, and Turkmenistan
continue to recommend three BCG vaccinations, with the third given between the ages
of 12 and 15. Multiple revaccinations may lead to a delayed hypersensitivity
reaction also known as the Koch response (phenomenon), where a person previously
infected with M. tuberculosis
is reinfected intracutaneously,
resulting in a local inflammatory reaction marked by necrotic lesions that develops
rapidly and heals quickly 
Changes in vaccine strain were the most frequent type of change reported
42), and many countries have employed
several strains over the course of their BCG vaccination program's existence,
with countries reporting strain changes as recently as 2008.
Additional variations in BCG vaccination administration are seen across countries.
Currently, eight countries recommend TST post–BCG vaccination, and two other
countries had this policy but have since ceased. Estimated national BCG coverage
ranged from 70% to 100%; however, frequently these estimates were not
available or were several years out of date. Finally, 19 countries that did not
recommend universal BCG vaccination did report BCG vaccination for certain at-risk
groups, most frequently health care workers and infants living in high-risk TB
settings. These variations highlight the importance of mapping these differences
across regions both for clinical purposes and research.