1
|
Emilie Hartvig Rasmussen C, Odgaard Vedel J, Møller Jensen A, Da Silva Borges I, Furtado O, Wolf Meyrowitsch D, Bærent Fisker A. Implementation of the vaccination program in Guinea-Bissau: Coverage and missed opportunities for BCG at birth. Vaccine 2024:S0264-410X(24)00697-2. [PMID: 38871573 DOI: 10.1016/j.vaccine.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND The Bacillus Calmette-Guérin (BCG) vaccine is recommended at birth in Guinea-Bissau but often given with delay. Delays are not evident in routine coverage estimates since coverage is measured by 12 months of age. Studies show that BCG protects against other infections than tuberculosis and lowers neonatal mortality. Hence, the timing of BCG is important since the children should benefit from these non-specific effects as early as possible. METHODS Using data from a nationally representative health and demographic surveillance system in Guinea-Bissau, we assessed BCG coverage at birth (within the first 3 days of life), 1 month, and 12 months for children born in 2013-19. We measured the proportion of children who had a documented health system contact within the first 3 days of life, thus an opportunity for BCG at birth, and whether the opportunities were utilized. In binomial regression models, we investigated factors associated with missed opportunities for vaccination. RESULTS Among the 22,178 children only 19 % were vaccinated at birth. By 1 month and 12 months, BCG coverages were 64 % and 93 %. The timeliness of BCG improved over time, with coverage at birth increasing from 16 % in 2013 to 25 % in 2019 and 1-month coverage from 63 % in 2013 to 75 % in 2019. If all vaccination opportunities had been utilized, the BCG coverage at birth could have reached 45 % (in the 1-month cohort) instead of the actual coverage of 19 %, as only 40 % of the vaccination opportunities were utilized. Region of residence was associated with having a missed opportunity for vaccination. CONCLUSION The high coverage estimates at 12 months falsely imply that the vaccine is being administered according to the recommended schedule. Our findings suggest that early coverage could be markedly improved by ensuring that children are vaccinated at their first contact with the health system.
Collapse
Affiliation(s)
| | - Julie Odgaard Vedel
- Bandim Health Project, Bissau, Guinea-Bissau; OPEN, University of Southern Denmark/Odense University Hospital, Denmark.
| | - Andreas Møller Jensen
- Bandim Health Project, Bissau, Guinea-Bissau; OPEN, University of Southern Denmark/Odense University Hospital, Denmark
| | | | | | - Dan Wolf Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Denmark
| | - Ane Bærent Fisker
- Bandim Health Project, Bissau, Guinea-Bissau; OPEN, University of Southern Denmark/Odense University Hospital, Denmark
| |
Collapse
|
2
|
Thysen SM, Møller Jensen A, Vedel JO, da Silva Borges I, Aaby P, Jensen AKG, Benn CS, Fisker AB. Can BCG vaccination at first health-facility contact reduce early infant mortality? Study protocol for a cluster-randomised trial (CS-BCG). BMJ Open 2022; 12:e063872. [PMID: 36410811 PMCID: PMC9680145 DOI: 10.1136/bmjopen-2022-063872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Increasing evidence suggests that the BCG vaccine has non-specific effects, altering the susceptibility to non-tuberculous infections. Thus, early BCG vaccination may reduce mortality. BCG is recommended at birth but is often delayed. Vaccination opportunities are missed due to multidose vials not being opened for a few children. We will assess the effect of making BCG available at the first health-facility contact on early infant mortality and morbidity in a rural setting in Guinea-Bissau. METHODS AND ANALYSIS In a cluster-randomised crossover trial, we randomise 23 health centres to two different treatment groups. In half of the health centres, BCG is provided as per current practice; in the remaining health centres, we make BCG available everyday to allow opening a vial of BCG if there is just one eligible child present. The randomisation of centres will be crossed over after 12 months and enrolment will continue for another 12 months.We will use logistic regression models with adjustment for village to assess the effect of making BCG available at the first health-facility contact. The main outcome is non-accidental mortality between day 1 and day 42 after birth. We will adjust for sex, health centre, period (before/after crossover) and level of surveillance (level 1 or level 2). Further analyses include assessment of the effect on hospital admission and a cost-effectiveness evaluation. ETHICS AND DISSEMINATION If BCG vaccination reduces early infant mortality, missed opportunities and delays of vaccinations expose infants in several low-income countries to unnecessary excess mortality risk. The present trial will provide information on the effect of implementing a feasible intervention, where all children receive BCG at their first health-facility contact. Consent is obtained from all pregnant women registered as part of the trial. The results of the study will be published and communicated to the National Institute of Public Health in Guinea-Bissau. TRIAL REGISTRATION NUMBER NCT04658680; Clinicaltrials.gov.
Collapse
Affiliation(s)
- Sanne Marie Thysen
- Bandim Health Project, Bissau, Guinea-Bissau
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Center for Clinical Research and Prevention, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Andreas Møller Jensen
- Bandim Health Project, Bissau, Guinea-Bissau
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Julie Odgaard Vedel
- Bandim Health Project, Bissau, Guinea-Bissau
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Peter Aaby
- Bandim Health Project, Bissau, Guinea-Bissau
| | | | - Christine Stabell Benn
- Bandim Health Project, Bissau, Guinea-Bissau
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ane Bærent Fisker
- Bandim Health Project, Bissau, Guinea-Bissau
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
3
|
Thysen SM, Fisker AB, Byberg S, Aaby P, Roy P, White R, Griffiths U, Harris RC. Disregarding the restrictive vial-opening policy for BCG vaccine in Guinea-Bissau: impact and cost-effectiveness for tuberculosis mortality and all-cause mortality in children aged 0-4 years. BMJ Glob Health 2021; 6:bmjgh-2021-006127. [PMID: 34344667 PMCID: PMC8336130 DOI: 10.1136/bmjgh-2021-006127] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/02/2021] [Indexed: 11/16/2022] Open
Abstract
Objective BCG vaccination is frequently delayed in low-income countries. Restrictive vial-opening policies, where a vial of BCG vaccine is not opened for few children, are a major reason for delay. During delays, children are unprotected against tuberculosis (TB) and deprived of non-specific effects of BCG. We assessed the potential effect and cost-effectiveness of disregarding the restrictive vial-opening policy, on TB and all-cause mortality, in children aged 0–4 years in Guinea-Bissau. Methods Using static mathematical models, we estimated the absolute and percentage change in TB and all-cause deaths, in children aged 0–4 years, between the current BCG vaccine restrictive-opening policy scenario, and a non-restrictive policy scenario where all children were vaccinated in the first health-facility contact. Incremental cost-effectiveness was estimated by integration of vaccine and treatment costs. Findings Disregarding the restrictive BCG vial-opening policy was estimated to reduce TB deaths by 11.0% (95% uncertainty range (UR):0.5%–28.8%), corresponding to 4 (UR:0–15) TB deaths averted per birth cohort in Guinea-Bissau, resulting in incremental cost-effectiveness of US$ 911 per discounted life-year gained (LYG) (UR:145–9142). For all-cause deaths, the estimated reduction was 8.1% (UR: 3.3%–12.7%) corresponding to 392 (UR:158–624) fewer all-cause deaths and an incremental cost-effectiveness of US$ 9 (UR:5–23) per discounted LYG. Conclusions Disregarding the restrictive BCG vial-opening policy was associated with reductions in TB deaths and all-cause deaths and low cost-effectiveness ratios. Our results suggest that it would be cost-effective to disregard the restrictive vial-opening policy. Other settings with similar practice are also likely to gain from disregarding this policy.
Collapse
Affiliation(s)
- Sanne M Thysen
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark .,Bandim Health Project, Bissau, Guinea-Bissau.,Research Centre for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark.,Center for Global Health (GloHAU), Aarhus University, Aarhus, Denmark
| | - Ane Baerent Fisker
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.,Bandim Health Project, Bissau, Guinea-Bissau.,Research Centre for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | - Stine Byberg
- Bandim Health Project, Bissau, Guinea-Bissau.,Research Centre for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | - Peter Aaby
- Bandim Health Project, Bissau, Guinea-Bissau.,Research Centre for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | - Partho Roy
- TB Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Population Health, London, UK
| | - Richard White
- TB Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Population Health, London, UK
| | | | - Rebecca C Harris
- TB Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Population Health, London, UK
| |
Collapse
|