Map displaying BCG vaccination policy by country.
A: The country currently has universal BCG vaccination program. B: The                         country used to recommend BCG vaccination for everyone, but currently does                         not. C: The country never had universal BCG vaccination programs.

Map displaying BCG vaccination policy by country. A: The country currently has universal BCG vaccination program. B: The country used to recommend BCG vaccination for everyone, but currently does not. C: The country never had universal BCG vaccination programs.

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Madhu Pai and colleagues introduce the BCG World Atlas, an open access, user friendly Web site for TB clinicians to discern global BCG vaccination policies and practices and improve the care of their patients.

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Citations

... In 2011, among the 180 countries with available data, 157 countries recommended universal BCG vaccination (Zwerling et al., 2011). BCG vaccine efficiency is limited, as reflected by the number of tuberculosis cases worldwide. ...
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Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium tuberculosis. According to the WHO, the disease is one of the top 10 causes of death of people worldwide. Mycobacterium tuberculosis is an intracellular pathogen with an unusually thick, waxy cell wall and a complex life cycle. These factors, combined with M. tuberculosis ability to enter prolonged periods of latency, make the bacterium very difficult to eradicate. The standard treatment of TB requires 6–20months, depending on the drug susceptibility of the infecting strain. The need to take cocktails of antibiotics to treat tuberculosis effectively and the emergence of drug-resistant strains prompts the need to search for new antitubercular compounds. This review provides a perspective on how modern -omic technologies facilitate the drug discovery process for tuberculosis treatment. We discuss how methods of DNA and RNA sequencing, proteomics, and genetic manipulation of organisms increase our understanding of mechanisms of action of antibiotics and allow the evaluation of drugs. We explore the utility of mathematical modeling and modern computational analysis for the drug discovery process. Finally, we summarize how -omic technologies contribute to our understanding of the emergence of drug resistance.
... This is presumed to be the case in Europe where the nations most affected by the pandemic have abandoned the application of BCG for decades. 95 BCG vaccination reduces infant mortality from infections other than TB due to a potential heterologous effect. 96 It has been determined that the population previously immunized responds more effectively against nonmycobacterial diseases, such as influenza A, as it produces a high antibody response. ...
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Currently, a battle against the clock has been unleashed to deal with SARS-CoV-2, which to date has caused approximately nine hundred thousand deaths. Science has made significant efforts to characterize the COVID-19 virus and understand it from its origin to its transmission. Goals of the scientific community include controlling the propagation of the disease by developing hundreds of diagnostic tools and the future generation of a vaccine for this recent infection. Its counterpart, the Mycobacterium tuberculosis bacillus, causes more than 1.5 million deaths a year despite being an ancient disease. Its diagnostic methods are debatable due to the scarcity of effective options. Consequently, tuberculosis has spread mainly in developing countries that are not currently able to mitigate the infection. This paper compares two infectious diseases through a global narrative review and comprehensively describes what is known to date about two global health emergencies: tuberculosis and COVID-19.
... This study used BCG vaccination rates from Our World in Data [10], with the rates averaged for all the years with available data (1980-2019) for each country, and these were further verified with data from The BCG World Atlas [11]. Although the world health organization (WHO) started recording BCG coverage data only after 1980, most countries with BCG policy started immunization before 1980 [11]. ...
... This study used BCG vaccination rates from Our World in Data [10], with the rates averaged for all the years with available data (1980-2019) for each country, and these were further verified with data from The BCG World Atlas [11]. Although the world health organization (WHO) started recording BCG coverage data only after 1980, most countries with BCG policy started immunization before 1980 [11]. The average BCG vaccination rates over all the years show highly significant inverse correlation with COVID-19 deaths by two statistics methods (Tables 1, 3). ...
... las.org/index .php) [11]. ...
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Purpose The coronavirus disease 2019 (COVID-19) pandemic has spread to all countries in the world, and different countries have been impacted differently. The study aims to understand what factors contribute to different COVID-19 impacts at the country level. Methods Multivariate statistical analyses were used to evaluate COVID-19 deaths and cases relative to nine other demographic and socioeconomic factors in all countries and regions of the world using data as of August 1, 2020. The factors analyzed in the study include a country’s total COVID-19 deaths and cases per million population, per capita gross domestic product (GDP), population density, virus tests per million population, median age, government response stringency index, hospital beds availability per thousand population, extreme poverty rate, Bacille Calmette–Guérin (BCG) vaccination rate, and diphtheria–tetanus–pertussis (DTP3) immunization rate. Results The study reveals that COVID-19 deaths per million population in a country most significantly correlates, inversely, with the country’s BCG vaccination rate (r = − 0.50, p = 5.3e-5), and also significantly correlates a country’s per capita GDP (r = 0.39, p = 7.4e-3) and median age (r = 0.30, p = 0.042), while COVID-19 cases per million population significantly correlate with per capita GDP and tests per thousand population. To control for possible confounding effects of age, the correlation was assessed in countries propensity score matched for age. The inverse correlation between BCG vaccination rates and COVID-19 case (r = − 0.30, p = 0.02) and death (r = − 0.42, p = 0.0007) remained significant among the top 61 countries with the highest median age. Conclusion This study contributes to a growing body of evidence supporting the notion that BCG vaccination may be protective against COVID-19 mortality.
... Another study reported the significance of BCG vaccination in reducing the COVID-19 related mortality [19]. In most of the countries with high COVID-19 case fatality rate (European countries, the USA, and Iran), Universal BCG vaccination was either never implemented or abandoned long before [20]. In contrast heavily populated countries like India, Pakistan, Russia, and others, the case fatality rate is relatively low though the number of confirmed cases are more [12]. ...
... Surprisingly, Japan, though has the highest old age population, hit early by COVID-19 and not having adopted more restrictive measures found to have very low COVID-19 related mortality in contrast to Italy and other European countries. This might be due to their extensive universal BCG vaccination and their cultural behavior [20]. ...
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... Telemedicine offers various solutions depending upon the use-case scenario. There are several aspects of telemedicine as shown in Fig. 1 [53]. Firstly, there are various modes of telemedicine including real-time, store and forward, remote patient monitoring, and mobile health. ...
... In many countries such as China, Japan, and Taiwan where TB is very prevalent or where there is a high possibility of exposure to tuberculosis, worldwide vaccination is recommended at birth with a single dose of Bacillus Calmette-Guerin, whereas other countries like Switzerland, France, and Spain have withdrawn their vaccine policies since the incidence of the infection of tuberculosis has declined. Some countries like Italy, the USA, and Netherland have yet to accept vaccine policies [53]. The vaccination of BCG has been shown to induce non-specific or heterologous effects against the nonmycobacterial pathogens, and this property is termed as trained immunity (which is the capability of the innate immunity memory to provide an enhanced response against diverse microbes) [54]. ...
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... With over 4 billion administered doses worldwide, and an additional 100 million newborns being vaccinated annually, BCG is currently the most widely used vaccines in the world; however, there exists no universal or global BCG vaccination policy, as various countries have taken differing approaches to vaccinating their populations [4]. While countries like the United Kingdom as well as most countries in Africa and Asia have employed universal BCG vaccination schemes, others such as the United States of America (USA), Canada, Italy, Belgium and the Netherlands, have either recommended BCG vaccination for high-risk demographics, or have never had any form of BCG vaccination policy in place [5]. ...
... They also showed that this effect was strongly influenced by the time of implementation of the policy, with nations like Iran, whose BCG vaccination policy started in 1984, having a higher mortality rate of 19.7 deaths per million, compared with Japan, whose policy started in 1947, having a lower mortality rate of 0.28 deaths per million [52]. Hegarty et al. [60] analyzed and matched the case incidence and mortality data from 178 countries with information about their BCG vaccination policies obtained from the BCG world atlas [5], and they reported that those with long-standing BCG vaccination policies had a significantly lower case incidence and mortality rate than those without such policies (38.4 vs. 358.4 cases per million of the population). ...
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Background: The Bacillus Calmette-Guerin (BCG) vaccine has been in use for 99 years, and is regarded as one of the oldest human vaccines known today. It is recommended primarily due to its effect in preventing the most severe forms of tuberculosis, including disseminated tuberculosis and meningeal tuberculosis in children; however, its efficacy in preventing pulmonary tuberculosis and TB reactivation in adults has been questioned. Several studies however have found that asides from its role in tuberculosis prevention, the BCG vaccine also has protective effects against a host of other viral infections in humans, an effect which has been termed: heterologous, non-specific or off-target. Objectives: As we approach 100 years since the discovery of the BCG vaccine, we review the evidence of the non-specific protection offered by the vaccine against viral infections, discuss the possible mechanisms of action of these effects, highlight the implications these effects could have on vaccinology and summarize the recent epidemiological correlation between the vaccine and the on-going COVID-19 pandemic. Results: Several epidemiological studies have established that BCG does reduce all-cause mortality in infants, and also the time of vaccination influences this effect significantly. This effect has been attributed to the protective effect of the vaccine in preventing unrelated viral infections during the neonatal period. Some of such viral infections that have been investigated include: herpes simplex virus (HSV), human Papilloma virus (HPV), yellow fever virus (YFV), respiratory syncytial virus (RSV) and influenza virus type A (H1N1). These effects are thought to be mediated via induction of innate immune memory as well as heterologous lymphocytic activation. While epidemiological studies have suggested a correlation, the potential protection of the BCG vaccine against COVID-19 transmission and mortality rates is currently unclear. Ongoing clinical trials and further research may shed more light on the subject in the future. Conclusion: BCG is a multifaceted vaccine, with many numerous potential applications to vaccination strategies being employed for current and future viral infections. There however is a need for further studies into the immunologic mechanisms behind these non-specific effects, for these potentials to become reality, as we usher in the beginning of the second century since the vaccine's discovery.
... From 1996 to 2018, it was recommended to vaccinate BCG only for very specific groups such as newborns and infants under 12 years of age, months at risk of infection and whose parents feed them in areas where the incidence and return of tuberculosis are high and children born prematurely (VLBW), children less than 33 weeks or less than 1500 kg if people under 24 years have not been vaccinated with BCG, except for the groups indicated. [14,15,16]. Finally, according to the 2019 vaccination plan in Switzerland [16], BCG vaccination for premature babies has been canceled. ...
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Vaccines are designed to train the immune system in a highly targeted way that leaves lasting protection against one particular infection. But this process also causes widespread changes in the immune system. This seems to heighten the response to other infections and scientists hope it may even give our bodies an advantage against coronavirus. In this article, we raise the thesis of a possible correlation between the Bacille Calmette-Guérin (BCG) vaccine and the community immunity observed during the first wave of covid-19 contamination. We propose to study the figures associated with the number of contaminated cases as well as the mortality rate in two countries with different vaccination policies, namelyTunisia and Switzerland. This work points, only from a static point of view, to a possible link between the use of the BCG vaccine and a low rate of contamination.
... A few unpublished ecological studies have suggested that there may be an association between BCG and the SARS-CoV2 epidemic [10,11], while others have discredited its link to mortality and morbidity [12]. Countries with and without BCG vaccination policy tend to differ markedly in terms of their economies, health systems and exposure to infectious diseases [13]. In addition, these studies all assessed BCG association very early in the pandemic and likely underestimated confounding, particularly differences in the timing of the epidemic and temporal responses at a country-level [9]. ...
... Information on BCG vaccination policies were obtained from the World BCG Atlas which is an online BCG database that is hosted by McGill University [13,17]. Where these data were not available on the BCG atlas, we searched immunization schedules of countries for information, and if BCG was not currently universally used (for five countries), we assumed that it had never been part of their schedule [18]. ...
... BCG status was categorized to current BCG policy, previous BCG policy (where it was in place for greater than 30 years) and no BCG policy (where it was never used or used for less than 30 years) [13]. The overall proportion smoking was determined by using the proportions of males and females in the population and the proportion of smokers in each gender group. ...
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As the SARS-CoV2 pandemic has progressed, there have been marked geographical differences in the pace and extent of its spread. We evaluated the association of BCG vaccination on morbidity and mortality of SARS-CoV2, adjusted for country-specific responses to the epidemic, demographics and health. SARS-CoV2 cases and deaths as reported by 31 May 2020 in the World Health Organization situation reports were used. Countries with at least 28 days following the first 100 cases, and available information on BCG were included. We used log-linear regression models to explore associations of cases and deaths with the BCG vaccination policy in each country, adjusted for population size, gross domestic product, proportion aged over 65 years, stringency level measures, testing levels, smoking proportion, and the time difference from date of reporting the 100th case to 31 May 2020. We further looked at the association that might have been found if the analyses were done at earlier time points. The study included 97 countries with 73 having a policy of current BCG vaccination, 13 having previously had BCG vaccination, and 11 having never had BCG vaccination. In a log-linear regression model there was no effect of country-level BCG status on SARS-CoV2 cases or deaths. Univariable log-linear regression models showed a trend towards a weakening of the association over time. We found no statistical evidence for an association between BCG vaccination policy and either SARS-CoV2 morbidity or mortality. We urge countries to rather consider alternative tools with evidence supporting their effectiveness for controlling SARS-CoV2 morbidity and mortality.
... Mycobacterium (M.) bovis bacillus Calmette-Guérin (BCG) is a live attenuated strain of M. bovis and the only licensed vaccine against tuberculosis (TB). It is one of the most widely used of all current vaccines, reaching >80% of neonates and infants in countries where it is part of the national childhood immunization program [1]. While BCG confers protection from the severe forms of TB in children, such as TB meningitis and miliary disease, protection against pulmonary TB in adolescents and adults is considerably variable [2]. ...
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Clinical and experimental evidence suggests that the tuberculosis vaccine BCG offers protection against unrelated pathogens including the malaria parasite. Cerebral malaria (CM) is the most severe complication associated with Plasmodium falciparum infection in humans and is responsible for most of the fatalities attributed to malaria. We investigated whether BCG protected C57BL/6 mice from P. berghei ANKA (PbA)-induced experimental CM (ECM). The majority of PbA-infected mice that were immunized with BCG showed prolonged survival without developing clinical symptoms of ECM. However, this protective effect waned over time and was associated with the recovery of viable BCG from liver and spleen. Intriguingly, BCG-mediated protection from ECM was not associated with a reduction in parasite burden, indicating that BCG immunization did not improve anti-parasite effector mechanisms. Instead, we found a significant reduction in pro-inflammatory mediators and CD8+ T cells in brains of BCG-vaccinated mice. Together these data suggest that brain recruitment of immune cells involved in the pathogenesis of ECM decreased after BCG vaccination. Understanding the mechanisms underlying the protective effects of BCG on PbA-induced ECM can provide a rationale for developing effective adjunctive therapies to reduce the risk of death and brain damage in CM.
... The potential protective effect of neonatal BCG vaccination on COVID-19 severity was suggested due to the lower COVID-19 mortality in some European and Asian countries (China, South Corea, India, Russia and Japan), where the vaccination is mandatory [5,6]. Additionally, COVID-19 mortality is higher where BCG vaccination has been discontinued for more than 20 years [7]. ...
... Additionally, COVID-19 mortality is higher where BCG vaccination has been discontinued for more than 20 years [7]. France, for instance, registered lower COVID-19 mortality than Italy, where the vaccination is no longer mandatory [5][6][7][8]. However, there is conflicting data on the protective effect of BCG vaccination. ...
... However, there is conflicting data on the protective effect of BCG vaccination. In Italy, BCG vaccination was interrupted in 2001 and COVID-19 mortality rates were high among elders [5][6][7][8]. In the UK, where BCG vaccination was recently restarted for TB high-risk groups such as migrants and individuals living in social deprived conditions, COVID-19 mortality rates were higher in these groups than in the overall population [5][6][7][8]. ...
Article
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Abstract Bacillus Calmette-Guérin (BCG) vaccination is routine and near-universal in many low- and middle-income countries (LMIC). It has been suggested that BCG can have a protective effect on COVID-19 morbidity and mortality. This commentary discusses the limitations of the evidence around BCG and COVID-19. We argue that higher-quality evidence is necessary to understand the protective effect of the BCG vaccine from existing, secondary data, while we await results from clinical trials currently conducted in different settings.