Background. Treatment of recent tuberculosis infection in children aged ! 2 years is essential, because of high risk of progression to disease, but diagnosis is hindered by the inaccuracy of the tuberculin skin test (TST). More-accurate T cell-based tests of infection could enhance diagnosis by optimizing interpretation of the TST results. Methods. A total of 979 child tuberculosis contacts in Istanbul underwent the TST and enzyme-linked immunospot assay. Using enzyme-linked immunospot test results as a reference standard, we assessed the effect of age and bacille Calmette-Guerin ( BCG) vaccination on the sensitivity and specificity of the TST, and we computed the optimal TST cutoff points, using receiver operating characteristic curves. Results. With a TST cutoff point of >= 10 mm, the sensitivity of the TST was 66% for children aged = 2 years, and overall accuracy was low for children with 1 BCG scar. Conclusions. Negative results of the TST cannot exclude tuberculosis infection for child tuberculosis contacts aged = 2 years, the accuracy of the TST can be improved by adjustment of cutoff points for BCG-vaccinated children but remains poor for children with >1 BCG scar. This methodology can define optimal TST cutoff points for diagnosis of tuberculosis infection tailored to target populations.