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Schaltz-Buchholzer F, Nielsen S, Sørensen MK, Stjernholm EB, Fabricius RA, Umbasse P, Monteiro I, Cá EJC, Aaby P, Benn CS. Effects of Neonatal BCG-Japan Versus BCG-Russia Vaccination on Overall Mortality and Morbidity: Randomized Controlled Trial From Guinea-Bissau (BCGSTRAIN II). Open Forum Infect Dis 2024; 11:ofae057. [PMID: 38500576 PMCID: PMC10946234 DOI: 10.1093/ofid/ofae057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/29/2024] [Indexed: 03/20/2024] Open
Abstract
Background Vaccination with the Danish strain of bacille Calmette-Guérin (BCG) has been associated with pronounced reductions in all-cause neonatal mortality and morbidity. Developing a skin reaction postvaccination is associated with markedly reduced mortality risk. It is unknown whether the beneficial nonspecific effects are maintained across different BCG strains. Methods This was an open-label randomized controlled trial in Guinea-Bissau, comparing BCG-Japan (n = 8754) versus BCG-Russia (n = 8752) for all-cause hospital admission risk by 6 weeks of age (primary outcome) and 6 months of age. Additional secondary outcomes were in-hospital case-fatality risk (CFR), all-cause mortality, and BCG skin reaction prevalence. Participants were followed through telephone calls at 6 weeks and 6 months, with a subgroup also visited at home. We assessed admission and mortality risk in Cox models providing incidence rate ratios (IRRs) and mortality rate ratios. CFR and skin reactions were assessed by binomial regression providing risk ratios. Analyses were done overall and stratified by sex. Results BCG strain was not associated with admission risk, the BCG-Japan/BCG-Russia IRR being 0.92 (95% confidence interval [CI], .81-1.05) by 6 weeks and 0.92 (95% CI, .82-1.02) by 6 months. By 6 months of age, there were significantly fewer BCG-Japan infants with no skin reaction (1%) than for BCG-Russia (2%), the risk ratio being 0.36 (95% CI, .16-.81). BCG-Japan skin reactions were also larger. Conclusions Both vaccines induced a skin reaction in almost all participants. The BCG strains had comparable effects on morbidity and mortality, but BCG-Japan was associated with more and larger skin reactions that are indicators of lower mortality risk. Clinical Trials Registration NCT03400878.
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Affiliation(s)
- Frederik Schaltz-Buchholzer
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, Odense Patient Data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - Sebastian Nielsen
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, Odense Patient Data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | | | | | | | - Paulo Umbasse
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Ivan Monteiro
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | | | - Peter Aaby
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Christine Stabell Benn
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, Odense Patient Data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
- Danish Institute of Advanced Study, University of Southern Denmark, Odense, Denmark
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Rubio-Casillas A, Rodriguez-Quintero CM, Redwan EM, Gupta MN, Uversky VN, Raszek M. Do vaccines increase or decrease susceptibility to diseases other than those they protect against? Vaccine 2024; 42:426-440. [PMID: 38158298 DOI: 10.1016/j.vaccine.2023.12.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/16/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
Contrary to the long-held belief that the effects of vaccines are specific for the disease they were created; compelling evidence has demonstrated that vaccines can exert positive or deleterious non-specific effects (NSEs). In this review, we compiled research reports from the last 40 years, which were found based on the PubMed search for the epidemiological and immunological studies on the non-specific effects (NSEs) of the most common human vaccines. Analysis of information showed that live vaccines induce positive NSEs, whereas non-live vaccines induce several negative NSEs, including increased female mortality associated with enhanced susceptibility to other infectious diseases, especially in developing countries. These negative NSEs are determined by the vaccination sequence, the antigen concentration in vaccines, the type of vaccine used (live vs. non-live), and also by repeated vaccination. We do not recommend stopping using non-live vaccines, as they have demonstrated to protect against their target disease, so the suggestion is that their detrimental NSEs can be minimized simply by changing the current vaccination sequence. High IgG4 antibody levels generated in response to repeated inoculation with mRNA COVID-19 vaccines could be associated with a higher mortality rate from unrelated diseases and infections by suppressing the immune system. Since most COVID-19 vaccinated countries are reporting high percentages of excess mortality not directly attributable to deaths from such disease, the NSEs of mRNA vaccines on overall mortality should be studied in depth.
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Affiliation(s)
- Alberto Rubio-Casillas
- Autlan Regional Hospital, Health Secretariat, Autlan 48900, Jalisco, Mexico; Biology Laboratory, Autlan Regional Preparatory School, University of Guadalajara, Autlan 48900, Jalisco, Mexico.
| | | | - Elrashdy M Redwan
- Biological Science Department, Faculty of Science, King Abdulaziz University, P.O. Box 80203, Jeddah 21589, Saudi Arabia; Therapeutic and Protective Proteins Laboratory, Protein Research Department, Genetic Engineering and Biotechnology Research Institute, City for Scientific Research and Technology Applications, New Borg EL-Arab, Alexandria 21934, Egypt.
| | - Munishwar Nath Gupta
- Department of Biochemical Engineering and Biotechnology, Indian Institute of Technology, Hauz Khas, New Delhi 110016, India.
| | - Vladimir N Uversky
- Department of Molecular Medicine and USF Health Byrd Alzheimer's Research Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA.
| | - Mikolaj Raszek
- Merogenomics (Genomic Sequencing Consulting), Edmonton, AB T5J 3R8, Canada.
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Stougaard SW, Benn CS, Aaby P, Nielsen S, Schaltz-Buchholzer F. Using real-life data to model the impact of increasing BCG vaccination coverage and scar prevalence on all-cause infant mortality. Ann Epidemiol 2023; 86:90-97.e7. [PMID: 37479121 DOI: 10.1016/j.annepidem.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/22/2023] [Accepted: 07/17/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE Estimating the potential impact on infant mortality of increasing Bacille Calmette-Guérin (BCG) vaccination coverage and BCG scar prevalence. METHODS Guinea-Bissau Health and Demographic Surveillance System data on BCG vaccination coverage, scar status, and all-cause mortality were used for this study. Mortality risk (MR) by scar status was assessed in Cox models providing adjusted mortality rate ratios (aMRRs). Distributions were fitted for survival, vaccination coverage, and scar prevalence. Models for 12-month mortality were calculated. We utilized World Bank data on birth rates and mortality rates to assess the potential global impact of optimizing BCG vaccination programs. RESULTS BCG coverage was 81% and scar prevalence 42% among 2-month-old infants, and the 1- to 12-month scar/no scar aMRR was 0.40 (0.22, 0.76). Modeling 2-month 99% vaccination coverage with 95% developing scars would change the 1- to 12-month MR by -8% (-21%, +12%). Globally, the reduction in the MR between 1- and 12-month would be -14% (-14%, -15%), corresponding to -208,075 (-214,453, -204,023) fewer infant deaths/year. CONCLUSIONS We confirmed previous observations: having a BCG scar markedly reduces infant MR. Increasing current global 2-month BCG vaccination coverage from 76% to 99%, and scar prevalence among vaccinated infants from 52% to 95% might reduce global infant mortality by >200,000 deaths/year. Thus, optimizing BCG vaccination programs to focus on increasing early BCG vaccination coverage and the overall scar prevalence would have major public health benefits.
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Affiliation(s)
- Sarah W Stougaard
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Christine S Benn
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; Bandim Health Project, OPEN, Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark; Danish Institute of Advanced Science, University of Southern Denmark, Odense, Denmark
| | - Peter Aaby
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Sebastian Nielsen
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; Bandim Health Project, OPEN, Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - Frederik Schaltz-Buchholzer
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; Bandim Health Project, OPEN, Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
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Theilmann M, Geldsetzer P, Bärnighausen T, Sudharsanan N. Does Early Childhood BCG Vaccination Improve Survival to Midlife in a Population With a Low Tuberculosis Prevalence? Quasi-experimental Evidence on Nonspecific Effects From 32 Swedish Birth Cohorts. Demography 2023; 60:1607-1630. [PMID: 37732832 DOI: 10.1215/00703370-10970757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
The Bacillus Calmette-Guérin (BCG) vaccine for tuberculosis (TB) is widely used globally. Many high-income countries discontinued nationwide vaccination policies starting in the 1980s as the TB prevalence decreased. However, there is continued scientific interest in whether the general childhood immunity boost conferred by the BCG vaccination impacts adult health and mortality in low-TB contexts (known as nonspecific effects). While recent studies have found evidence of an association between BCG vaccination and survival to ages 34-45, it is unclear whether these associations are causal or driven by the unobserved characteristics of those who chose to voluntarily vaccinate. We use the abrupt discontinuation of mandatory BCG vaccination in Sweden in 1975 as a natural experiment to estimate the causal nonspecific effect of the BCG vaccine on cohort survival to midlife. Applying two complementary study designs, we find no evidence that survival to age 40 was affected by the discontinuation of childhood BCG vaccination. The results are consistent among both males and females and are robust to several sensitivity tests. Overall, despite prior correlational studies suggesting large nonspecific effects, we do not find any population-level evidence for a nonspecific effect of the BCG vaccine discontinuation on survival to age 40 in Sweden.
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Affiliation(s)
- Michaela Theilmann
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Professorship of Behavioral Science for Disease Prevention and Health Care and Institute for Advanced Study, Technical University of Munich, Munich, Germany
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub San Francisco, San Francisco, CA, USA
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Harvard Center for Population and Development Studies, Cambridge, MA, USA
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Nikkil Sudharsanan
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Professorship of Behavioral Science for Disease Prevention and Health Care and Institute for Advanced Study, Technical University of Munich, Munich, Germany
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Benn CS, Amenyogbe N, Björkman A, Domínguez-Andrés J, Fish EN, Flanagan KL, Klein SL, Kollmann TR, Kyvik KO, Netea MG, Rod NH, Schaltz-Buchholzer F, Shann F, Selin L, Thysen SM, Aaby P. Implications of Non-Specific Effects for Testing, Approving, and Regulating Vaccines. Drug Saf 2023; 46:439-448. [PMID: 37074598 PMCID: PMC10116894 DOI: 10.1007/s40264-023-01295-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 04/20/2023]
Abstract
The current framework for testing and regulating vaccines was established before the realization that vaccines, in addition to their effect against the vaccine-specific disease, may also have "non-specific effects" affecting the risk of unrelated diseases. Accumulating evidence from epidemiological studies shows that vaccines in some situations can affect all-cause mortality and morbidity in ways that are not explained by the prevention of the vaccine-targeted disease. Live attenuated vaccines have sometimes been associated with decreases in mortality and morbidity that are greater than anticipated. In contrast, some non-live vaccines have in certain contexts been associated with increases in all-cause mortality and morbidity. The non-specific effects are often greater for female than male individuals. Immunological studies have provided several mechanisms that explain how vaccines might modulate the immune response to unrelated pathogens, such as through trained innate immunity, emergency granulopoiesis, and heterologous T-cell immunity. These insights suggest that the framework for the testing, approving, and regulating vaccines needs to be updated to accommodate non-specific effects. Currently, non-specific effects are not routinely captured in phase I-III clinical trials or in the post-licensure safety surveillance. For instance, an infection with Streptococcus pneumoniae occurring months after a diphtheria-tetanus-pertussis vaccination would not be considered an effect of the vaccination, although evidence indicates it might well be for female individuals. Here, as a starting point for discussion, we propose a new framework that considers the non-specific effects of vaccines in both phase III trials and post-licensure.
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Affiliation(s)
- Christine Stabell Benn
- Bandim Health Project, Open Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark.
- Danish Institute for Advanced Study, University of Southern Denmark, Copenhagen, Denmark.
| | | | - Anders Björkman
- Department of Global Public Health, Karolinska Institutet Stockholm, Stockholm, Sweden
| | - Jorge Domínguez-Andrés
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Eleanor N Fish
- Department of Immunology, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Katie L Flanagan
- Tasmanian Vaccine Trial Centre, Clifford Craig Foundation, Launceston General Hospital, Launceston, TAS, Australia
- School of Medicine, Faculty of Health Sciences, University of Tasmania, Launceston, TAS, Australia
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Kirsten Ohm Kyvik
- Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Naja Hulvej Rod
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Frederik Schaltz-Buchholzer
- Bandim Health Project, Open Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Frank Shann
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Liisa Selin
- Department of Pathology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Sanne M Thysen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Peter Aaby
- Bandim Health Project, Open Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
- Bandim Health Project, Apartado 861, 1004, Bissau Codex, Guinea-Bissau
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Trunk G, Davidović M, Bohlius J. Non-Specific Effects of Bacillus Calmette-Guérin: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Vaccines (Basel) 2023; 11:vaccines11010121. [PMID: 36679966 PMCID: PMC9866113 DOI: 10.3390/vaccines11010121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/23/2022] [Accepted: 12/26/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Vaccines induce antigen-specific immunity, which provides long-lived protection from the target pathogen. Trials from areas with high incidence rates for infectious diseases indicated that the tuberculosis vaccine Bacillus Calmette-Guérin (BCG) induces in addition non-specific immunity against various pathogens and thereby reduces overall mortality more than would have been expected by just protecting from tuberculosis. Although recent trials produced conflicting results, it was suggested that BCG might protect from non-tuberculosis respiratory infections and could be used to bridge the time until a specific vaccine against novel respiratory diseases like COVID-19 is available. METHODS We performed a systematic search for randomized controlled trials (RCTs) published between 2011 and December 9th, 2022, providing evidence about non-specific effects after BCG vaccination, assessed their potential for bias, and meta-analyzed relevant clinical outcomes. We excluded RCTs investigating vaccination with an additional vaccine unless outcomes from a follow-up period before the second vaccination were reported. RESULTS Our search identified 16 RCTs including 34,197 participants. Vaccination with BCG caused an estimated 44% decrease in risk for respiratory infections (hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.39-0.82) with substantial heterogeneity between trials (I2 = 77%). There was evidence for a protective effect on all-cause mortality of 21% if follow-up was restricted to one year (HR 0.79, 95% CI 0.64-0.99). We did not find evidence for an effect when we considered longer follow-up (HR 0.88, 95% CI 0.75-1.03). Infection-related mortality after BCG vaccination was reduced by 33% (HR 0.67; 95% CI 0.46-0.99), mortality for sepsis by 38% (HR 0.62, 95% CI 0.41-0.93). There was no evidence for a protective effect of BCG vaccination on infections of any origin (HR 0.84, 95% CI 0.71-1.00), COVID-19 (HR 0.88, 95% CI 0.68-1.14), sepsis (HR 0.78, 95% CI 0.55-1.10) or hospitalization (HR 1.01, 95% CI 0.91-1.11). CONCLUSIONS According to these results, depending on the setting, vaccination with BCG provides time-limited partial protection against non-tuberculosis respiratory infections and may reduce mortality. These findings underline BCG's potential (1) in pandemic preparedness against novel pathogens especially in developing countries with established BCG vaccination programs but limited access to specific vaccines; (2) in reducing microbial infections, antimicrobial prescriptions and thus the development of antimicrobial resistance. There is a need for additional RCTs to clarify the circumstances under which BCG's non-specific protective effects are mediated.
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Affiliation(s)
- Gerhard Trunk
- Independent Researcher, 3007 Bern, Switzerland
- Correspondence:
| | - Maša Davidović
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4123 Allschwil, Switzerland
- University of Basel, 4001 Basel, Switzerland
- Graduate School of Health Sciences, University of Bern, 3012 Bern, Switzerland
| | - Julia Bohlius
- University of Basel, 4001 Basel, Switzerland
- Department for Education and Training, Swiss Tropical and Public Health Institute, 4123 Allschwil, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, 3012 Bern, Switzerland
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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.
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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
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Quinn MK, Edmond KM, Fawzi WW, Hurt L, Kirkwood BR, Masanja H, Muhihi AJ, Newton S, Noor RA, Williams PL, Sudfeld CR, Smith ER. Non-specific effects of BCG and DTP vaccination on infant mortality: An analysis of birth cohorts in Ghana and Tanzania. Vaccine 2022; 40:3737-3745. [PMID: 35618557 PMCID: PMC9194613 DOI: 10.1016/j.vaccine.2022.04.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vaccines may induce non-specific effects on survival and health outcomes, in addition to protection against targeted pathogens or disease. Observational evidence suggests that infant Baccillus Calmette-Guérin (BCG) vaccination may provide non-specific survival benefits, while diphtheria-tetanus-pertussis (DTP) vaccination may increase the risk of mortality. Non-specific vaccine effects have been hypothesized to modify the effect of neonatal vitamin A supplementation (NVAS) on mortality. METHODS 22,955 newborns in Ghana and 31,999 newborns in Tanzania were enrolled in two parallel, randomized, double-blind, placebo-controlled trials of neonatal vitamin A supplementation from 2010 to 2014 and followed until 1-year of age. Cox proportional hazard models were used to estimate associations of BCG and DTP vaccination with infant survival. RESULTS BCG vaccination was associated with a decreased risk of infant mortality after controlling for confounders in both countries (Ghana adjusted hazard ratio (aHR): 0.51, 95% CI: 0.38-0.68; Tanzania aHR: 0.08, 95% CI: 0.07-0.10). Receiving a DTP vaccination was associated with a decreased risk of death (Ghana aHR: 0.39, 95% CI: 0.26-0.59; Tanzania aHR: 0.19, 95% CI: 0.16-0.22). There was no evidence of interaction between BCG or DTP vaccination status and infant sex or NVAS. CONCLUSION We demonstrated that BCG and DTP vaccination were associated with decreased risk of infant mortality in Ghana and Tanzania with no evidence of interaction between DTP or BCG vaccination, NVAS, and infant sex. Our study supports global recommendations on BCG and DTP vaccination and programmatic efforts to ensure all children have access to timely vaccination. CLINICAL TRIALS REGISTRATION Ghana (Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12610000582055) and Tanzania (ANZCTR: ACTRN12610000636055).
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Affiliation(s)
- M K Quinn
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Karen M Edmond
- Department of Women and Children's Health, Kings College London, United Kingdom
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Lisa Hurt
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Betty R Kirkwood
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Sam Newton
- Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti, Ghana; Kintampo Health Research Centre, Kintampo, Ghana
| | - Ramadhani A Noor
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Paige L Williams
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Emily R Smith
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, USA; Department of Exercise and Nutrition Sciences, George Washington University Milken Institute School of Public Health, Washington, DC, USA.
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Schaltz-Buchholzer F, Aaby P, Silva I, Monteiro I, Kollmann TR, Amenyogbe N, Bjerregaard-Andersen M, Benn CS. Mortality risk among frail neonates might be associated with maternal BCG scar status: Observational study from Guinea-Bissau. J Infect Dis 2022; 227:1237-1244. [PMID: 35417538 DOI: 10.1093/infdis/jiac140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 03/24/2022] [Accepted: 04/08/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Maternal priming with Bacille Calmette-Guérin (BCG) has been associated with reduced offspring mortality. We investigated this association in a cohort of frail neonates. METHODS We performed an observational study within a randomized BCG trial conducted at the Neonatal Intensive Care Unit (NICU) in Guinea-Bissau from 2015-2017. At NICU admission and following informed consent, the maternal scar status was evaluated by visual inspection before neonates were randomized 1:1 to receive BCG + Oral Polio Vaccine (OPV) immediately versus BCG + OPV at hospital discharge. Stratified by maternal scar status, we assessed overall in-hospital and post-discharge mortality up to 42 days of age in Cox Proportional Hazards models providing adjusted Mortality Rate Ratios (aMRRs). RESULTS 62% (903/1451) of mothers had a BCG scar. During NICU admission, the mortality risk was 1.7% (15/903) for neonates born to mothers with a scar vs 3.3% (18/548) for those born to mothers with no scar, the maternal scar/no scar aMRR = 0.53 (0.26-1.05); the aMRR was 0.39 (0.13-1.05) for unvaccinated neonates and 0.70 (0.26-1.87) for vaccinated neonates. CONCLUSION This small study indicates that maternal BCG might be associated with reduced all-cause NICU mortality. If confirmed elsewhere, this finding would have substantial ramifications for global health.
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Affiliation(s)
- Frederik Schaltz-Buchholzer
- Bandim Health Project, INDEPTH Network, postal code 8611004, Bissau, Guinea-Bissau.,Bandim Health Project, OPEN, Department of Clinical Research, Uni. Southern Denmark and Odense University Hospital, postal code 5230 Odense, Denmark
| | - Peter Aaby
- Bandim Health Project, INDEPTH Network, postal code 8611004, Bissau, Guinea-Bissau
| | - Isaquel Silva
- Bandim Health Project, INDEPTH Network, postal code 8611004, Bissau, Guinea-Bissau.,Bandim Health Project, OPEN, Department of Clinical Research, Uni. Southern Denmark and Odense University Hospital, postal code 5230 Odense, Denmark
| | - Ivan Monteiro
- Bandim Health Project, INDEPTH Network, postal code 8611004, Bissau, Guinea-Bissau
| | - Tobias R Kollmann
- Telethon Kids Institute, 15 Hospital Avenue, Nedlands, postal code 6009, Australia
| | - Nelly Amenyogbe
- Telethon Kids Institute, 15 Hospital Avenue, Nedlands, postal code 6009, Australia
| | - Morten Bjerregaard-Andersen
- Bandim Health Project, INDEPTH Network, postal code 8611004, Bissau, Guinea-Bissau.,Department of Endocrinology, Hospital of Southwest Denmark, postal code 6700, Esbjerg, Denmark.,Steno Diabetes Center, Odense University Hospital, postal code 5000, Odense, Denmark
| | - Christine Stabell Benn
- Bandim Health Project, INDEPTH Network, postal code 8611004, Bissau, Guinea-Bissau.,Bandim Health Project, OPEN, Department of Clinical Research, Uni. Southern Denmark and Odense University Hospital, postal code 5230 Odense, Denmark.,Danish Institute of Advanced Science, Uni. Southern Denmark, postal code 5230, Odense, Denmark
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10
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Schaltz-Buchholzer F. Are Bacille Calmette-Guérin Skin Reactions the Most Important Correlates of Bacille Calmette-Guérin's Specific and Nonspecific Effects? Am J Respir Crit Care Med 2022; 205:748-750. [PMID: 35100521 PMCID: PMC9836211 DOI: 10.1164/rccm.202112-2863ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Frederik Schaltz-Buchholzer
- Bandim Health ProjectINDEPTH NetworkBissau, Guinea-Bissau,Institute of Clinical ResearchUniversity of Southern Denmark and Odense University HospitalOdense, Denmark
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