Tuberculosis Ward

(This is the first of two blogs exploring why the US is the only country - besides the Netherlands - that doesn’t vaccinate against tuberculosis)

One side of the vaccine controversy Americans are extremely unlikely to hear about concerns the safest, cheapest and most widely used vaccine in the world - against tuberculosis (TB). Every country in the world, except the US and the Netherlands (where TB is extremely rare), uses or has used the TB vaccine (known as Bacillus Calmette Guerin or BCG) in public vaccination programs. The BCG controversy was my first introduction (in 1971) to the US government propensity to engage in conspiracies and cover-ups. This happened during my second year of medical school, in the TB module taught by University of Wisconsin infectious disease researcher Dr Donald Smith.

Prior to World War II, TB epidemics infected industrialized countries at levels comparable to the current rate of clinical depression. Roughly one out of three families had at least one family member who had died of TB or been sent to a TB sanatorium. Once a leading cause of death in the US, TB is very much a disease of poverty. Healthy subjects can carry the tubercular bacillus for years and only develop active illness if poor nutrition – or stress – lowers their natural immune state (see http://www.annals.org/content/124/7/673.abstract).

With the post World War II boom and vastly improved nutrition and living standards, the incidence of TB declined drastically in industrialized countries. However in the large disadvantaged urban centers that characterize US society, rates of TB infection continue at pre-World War II rates. This is of particular concern with the emergence of “drug resistant” TB, related to a surge of new cases in AIDS and other immune-compromised patients.

History of the BCG

Albert Calmette and Camille Guerin first began work on the BCG vaccine at the Pasteur Institute in 1908. They developed their vaccine from the bacillus that produces bovine tuberculosis, based on Edward Jenner’s discovery that vaccinating people with “cowpox” produced immunity against smallpox, a far more virulent disease. The BCG was first used in humans in 1921. In 1928 the Health Committee of the League of Nations (precursor to WHO) recommended its use in mass immunization campaigns to prevent TB.

There was strong opposition to the vaccine, particularly in the US and Britain, which delayed global acceptance till after World War II. It was first widely used in Eastern Europe between 1945 and 1948. The vaccination of eight million babies with BCG prevented the anticipated TB epidemic, which always accompanies the massive poverty and deprivation that occurs when a society’s economic and social infrastructure is destroyed by war. The BCG’s success in war torn Eastern Europe led Britain to begin using it in 1953. Between 1956-63, they enrolled 54,239 children in a randomized control study, in which BCG proved to be 84% effective in preventing TB (see http://www.bmj.com/content/2/6082/293).

More recent studies show that BCG is much less effective in preventing pulmonary (lung) tuberculosis in the third world, where patients are often too malnourished to develop sufficient antibodies to give them full protection. However the BCG is still widely used in India and other third world countries, owing to its efficacy in preventing fatal complications of TB, when it spreads to the brain, liver, spleen and other vital organs (http://www.ncbi.nlm.nih.gov/pubmed/7744445).

How the US “Prevents” TB

Unlike every other country in the world (except the Netherlands), the US still resists the use of BCG to control the spread of TB in our inner cities. Instead the CDC recommends routine skin testing (known as the Mantoux or PPD) of high risk groups. A patient who has been exposed to the tubercular bacillus (mycobacterium tuberculosis) has a positive reaction. They are then given four to nine months of drug treatment (depending on the medication used – see http://www.cdc.gov/mmwr/preview/mmwrhtml/00041047.htm).

I can personally attest that mycobacterium tuberculosis is alive and well in American ghettos. At age forty, my mother developed a positive skin test within six months of transferring to an inner city school and had to undergo twelve months of treatment with the antituberculosis drug isoniazid.

To be continued, with a discussion of the scandal and cover-up that led BCG to be suppressed in the US.