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Since that time, more data have been added and several improvements have been made. Complete questionnaire data were available for 77 countries, while remaining data were extracted from published sources. A: The country currently has universal BCG vaccination program.

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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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Many countries began BCG vaccination programs in the s—s, though some countries such as Romania and Uzbekistan report vaccination campaigns as early as and , respectively, while some sub-Saharan African nations such as Nigeria and Sierra Leone only began BCG vaccinations in and Nine countries have ceased universal BCG vaccination programs; Spain and Denmark were among the first, stopping in and , respectively, while Austria and Germany had stopped by and 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. These revaccination policy changes were as recent as Sixteen countries continue to give an additional BCG vaccination after the initial BCG, known as a booster vaccination Table 2 , while Kazakhstan, Belarus, Uzbekistan, and Turkmenistan continue to recommend three BCG vaccinations, with the third given between the ages of 12 and Multiple revaccinations may lead to a delayed hypersensitivity reaction also known as the Koch response phenomenon , where a person previously infected with M.

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. 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.

The Atlas is an interactive Web site that allows users to select and view information concerning a country's past and current BCG vaccination policy either by clicking on an interactive map or by selecting the country of interest from a drop-down list Figure 1.

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The Web site is available to the public and is free of charge. Over the past year during its beta phase , we have recorded over 6, visits to the site, with a steady increase in traffic over time. False positives can occur in BCG-vaccinated individuals, complicating interpretation of test results [21]. However, research suggests the timing of vaccination plays an important role [9] , [10] ; in a meta-analysis, Farhat et al. The Atlas may help clinicians interpret TST by providing the information necessary to assess whether the TST is a valid diagnostic tool in a particular patient, or when alternative diagnostics may be preferable.

Recent meta-analyses show that the specificity of IGRA is high in all populations, and will be of greatest utility in BCG-vaccinated populations [19] , [23]. Conversely, the TST should not suffer from non-specificity in India, for example, where BCG is given once at birth, as has been borne out by research studies [26] — [28].

One of the applications of this database is its ability to identify populations where repeated BCG immunizations were administered or where BCG was administered after infancy, as these populations are most likely to benefit from the use of highly specific IGRAs for the diagnosis of LTBI Figure 3 and Box 1. The six bolded countries have either recommended booster BCGs in the past or currently doing so, while the remaining 16 countries have not recommended booster BCG vaccinations. One of the applications of this database is its ability to identify populations where repeated BCG immunizations were administered or where BCG was administered after infancy, as these populations are most likely to benefit from the use of highly specific IGRAs for the diagnosis of LTBI.

Along with novel approved diagnostics such as the IGRAs, there exist other novel diagnostics in research and development stages that use antigens that vary across BCG strains.

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These include, for example, the MPB64 patch test and serological tests for the diagnosis of TB [30] — [32]. The BCG policies and practices of a particular country may influence the use and utility of these tests in the future. Recently there has been renewed interest in developing novel vaccines for TB. In , at least six different vaccine candidates completed Phase I clinical trials, and three are currently in Phase II [18].

Novel vaccine candidates include both live and sub-unit vaccines. Different vaccines are being developed that could be administered in infants and young children pre-exposure, and others as adjuvants to chemotherapy post-exposure. Similarly, we may be concerned that antigens from the primary vaccination with BCG may affect the booster vaccine.

Policies, strategies and interventions

Therefore, in countries where revaccination with BCG was practiced, we might expect higher rates of Koch response, or delayed hypersensitivity response. As countries respond to these new global recommendations, changes in vaccination policies because of the HIV epidemic should be captured in future updates of the Atlas. Despite nearly a century of use, the BCG vaccine continues to be controversial, and policies and practices vary widely across the world.

Many countries have experienced major changes in regards to revaccination over the past 20 years.

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The BCG World Atlas: A Database of Global BCG Vaccination Policy and Practices is an interactive Web site that attempts to provide the clinician, researcher, and pubic health practitioner alike with resources and information necessary to interpret current and novel TB diagnostics and conduct fruitful research on novel vaccines. Most critically, this is a useful resource for the TB community and is publicly available free of charge through an easy-to-use Web site.

The authors are grateful to a large number of colleagues from around the world for their contributions to this BCG Atlas. The authors welcome input that will help improve the Atlas, especially from countries that are currently not covered.

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The Tobacco Atlas is a resource to help us understand both the problems and their solutions. These firms have automated and consolidated their own factories, steadily driving down the number of employees.

Effective taxation drives up prices on tobacco products, thereby driving down consumption. Unfortunately, it is also one of the least implemented tools. We have proven interventions to affect all stages of the tobacco cycle. It is now a question of using them decisively. Tobacco control wants to prevent tobacco marketing from taking the focus away from death and disease. Despite overall prevalence declines in many countries, there are alarming increases among youth and in low-HDI countries.

Tobacco use damages the whole body and a regular smoker typically loses more than a decade of life. Tobacco use significantly worsens other major health challenges such as tuberculosis, HIV infection and mental illness. The site is secure. The vast majority of mangrove research programs are modest in size and limited in funding. Nonetheless, much knowledge has been gained since the last atlas, including a potential role for mangroves in storm protection, proactive adjustment of soil surface elevation with sea-level rise, coastal water conservation, economic importance locally, etc.

Furthermore, by documenting what can be lost, this book allows the reader to imagine what a world without mangroves might look like see also Science , 41— If the first atlas established a mere image of an important wetland community type in peril, then this current edition paints a picture rivaling what an artist may have envisioned.