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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.
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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
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Thysen SM, da Silva Borges I, Martins J, Stjernholm AD, Hansen JS, da Silva LMV, Martins JSD, Jensen A, Rodrigues A, Aaby P, Stabell Benn C, Fisker AB. Can earlier BCG-Japan and OPV vaccination reduce early infant mortality? A cluster-randomised trial in Guinea-Bissau. BMJ Glob Health 2024; 9:e014044. [PMID: 38350670 PMCID: PMC10862335 DOI: 10.1136/bmjgh-2023-014044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/20/2023] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE To assess the effect of providing BCG and oral polio vaccine (OPV) at an early home visit after delivery. DESIGN Cluster-randomised trial, randomising 92 geographically defined clusters 1:1 to intervention/control arms. SETTING Bandim Health Project Health and Demographic Surveillance System, Guinea-Bissau. PARTICIPANTS 2226 newborns enrolled between July 2016 and August 2019. INTERVENTIONS In both arms, newborns received a home visit within 72 hours after birth. In intervention clusters (n=46), BCG and OPV were provided at the home visit. MAIN OUTCOME MEASURE Rates of non-accidental mortality were compared in Cox proportional hazards models from (last of) day 1 or enrolment, until (first of) day 60 or registration of non-trial vaccines. RESULTS A total of 35 deaths (intervention: 7, control: 28) were registered during the trial. Providing BCG and OPV reduced non-accidental early infant mortality by 59% (8-82%). The intervention also reduced non-accidental hospital admissions. The intervention had little impact on growth and BCG scarring and tended to increase the risk of consultations. CONCLUSIONS The trial was stopped early due to lower-than-expected enrolment and event rates when 33% of the planned number of newborns had been enrolled. Despite the small size of the trial, the results support that early BCG and OPV vaccinations are beneficial and reduce early child mortality and morbidity. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT02504203).
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Affiliation(s)
- Sanne Marie Thysen
- Bandim Health Project, Bissau, Guinea-Bissau
- Bandim Health Project, Research unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | | | | | | | | | - Aksel Jensen
- Bandim Health Project, Bissau, Guinea-Bissau
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | | | - Peter Aaby
- Bandim Health Project, Bissau, Guinea-Bissau
- Bandim Health Project, Research unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christine Stabell Benn
- Bandim Health Project, Bissau, Guinea-Bissau
- Bandim Health Project, Research unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Danish Institute for Advanced Study, University of Southern Denmark, Copenhagen, Denmark
| | - Ane Baerent Fisker
- Bandim Health Project, Bissau, Guinea-Bissau
- Bandim Health Project, Research unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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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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Fisker AB, Jensen KJ. On the investigation of non-specific effects of BCG: Interpreting global vaccine data. EBioMedicine 2021; 66:103321. [PMID: 33857901 PMCID: PMC8050847 DOI: 10.1016/j.ebiom.2021.103321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Ane Bærent Fisker
- Bandim Health Project, OPEN, University of Southern Denmark, Copenhagen, Denmark; Bandim Health Project, Bissau, Guinea-Bissau.
| | - Kristoffer Jarlov Jensen
- Bandim Health Project, OPEN, University of Southern Denmark, Copenhagen, Denmark; Copenhagen Phase IV Unit, Center for Clinical Research and Prevention, Frederiksberg and Bispebjerg Hospital, Frederiksberg, Denmark
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Thysen SM, Benn CS, Gomes VF, Rudolf F, Wejse C, Roth A, Kallestrup P, Aaby P, Fisker A. Neonatal BCG vaccination and child survival in TB-exposed and TB-unexposed children: a prospective cohort study. BMJ Open 2020; 10:e035595. [PMID: 32114478 PMCID: PMC7050365 DOI: 10.1136/bmjopen-2019-035595] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To assess the association between neonatal BCG vaccination and mortality between 28 days and 3 years of age among tuberculosis (TB)-exposed and TB-unexposed children. DESIGN Prospective cohort study. SETTING Bandim Health Project runs an urban Health and Demographic Surveillance site in Guinea-Bissau with registration of mortality, vaccination status and TB cases. PARTICIPANTS Children entered the analysis when their vaccination card was inspected after 28 days of age and remained under surveillance to 3 years of age. Children residing in the same house as a TB case were classified as TB-exposed from 3 months prior to case registration to the end of follow-up. METHODS Using Cox-proportional hazards models with age as underlying time scale, we compared mortality of children with and without neonatal BCG between October 2003 and September 2017. MAIN OUTCOME MEASURE HR for neonatal BCG compared with no neonatal BCG by TB-exposure status. RESULTS Among the 39 421 children who entered the analyses, 3022 (8%) had observation time as TB-exposed. In total, 84% of children received neonatal BCG. Children with neonatal BCG had lower mortality both in TB-exposed (adjusted HR: 0.57 (0.26 to 1.27)) and in TB-unexposed children (HR: 0.57 (95% CI 0.47 to 0.69)) than children without neonatal BCG. Children exposed to TB had higher mortality than TB-unexposed children if they had not received neonatal BCG. CONCLUSION Neonatal BCG vaccination was associated with lower mortality among both TB-exposed and TB-unexposed children, consistent with neonatal BCG vaccination having beneficial non-specific effects. Interventions to increase timely BCG vaccination are urgently warranted.
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Affiliation(s)
- Sanne M Thysen
- Bandim Health Project, OPEN, University of Southern Denmark, Odense, Syddanmark, Denmark
- Bandim Health Project, Bissau, Guinea-Bissau
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
- Center for Global Health (GloHAU), Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Christine Stabell Benn
- Bandim Health Project, OPEN, University of Southern Denmark, Odense, Syddanmark, Denmark
- Bandim Health Project, Bissau, Guinea-Bissau
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | | | - Frauke Rudolf
- Bandim Health Project, Bissau, Guinea-Bissau
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Wejse
- Bandim Health Project, Bissau, Guinea-Bissau
- Center for Global Health (GloHAU), Department of Public Health, Aarhus University, Aarhus, Denmark
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Adam Roth
- Department of Communicable Disease Control and Health Protection, Public Health Agency of Sweden, Solna, Stockholm, Sweden
- Department of Translational Medicine, Lund University, Lund, Sweden
| | - Per Kallestrup
- Center for Global Health (GloHAU), Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Peter Aaby
- Bandim Health Project, Bissau, Guinea-Bissau
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | - Ane Fisker
- Bandim Health Project, Bissau, Guinea-Bissau
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
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Wedlock PT, Mitgang EA, Oron AP, Hagedorn BL, Leonard J, Brown ST, Bakal J, Siegmund SS, Lee BY. Modeling the economic impact of different vial-opening thresholds for measles-containing vaccines. Vaccine 2019; 37:2356-2368. [PMID: 30914223 PMCID: PMC6467546 DOI: 10.1016/j.vaccine.2019.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/07/2019] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The lack of specific policies on how many children must be present at a vaccinating location before a healthcare worker can open a measles-containing vaccine (MCV) - i.e. the vial-opening threshold - has led to inconsistent practices, which can have wide-ranging systems effects. METHODS Using HERMES-generated simulation models of the routine immunization supply chains of Benin, Mozambique and Niger, we evaluated the impact of different vial-opening thresholds (none, 30% of doses must be used, 60%) and MCV presentations (10-dose, 5-dose) on each supply chain. We linked these outputs to a clinical- and economic-outcomes model which translated the change in vaccine availability to associated infections, medical costs, and DALYs. We calculated the economic impact of each policy from the health system perspective. RESULTS The vial-opening threshold that maximizes vaccine availability while minimizing costs varies between individual countries. In Benin (median session size = 5), implementing a 30% vial-opening threshold and tailoring distribution of 10-dose and 5-dose MCVs to clinics based on session size is the most cost-effective policy, preventing 671 DALYs ($471/DALY averted) compared to baseline (no threshold, 10-dose MCVs). In Niger (median MCV session size = 9), setting a 60% vial-opening threshold and tailoring MCV presentations is the most cost-effective policy, preventing 2897 DALYs ($16.05/ DALY averted). In Mozambique (median session size = 3), setting a 30% vial-opening threshold using 10-dose MCVs is the only beneficial policy compared to baseline, preventing 3081 DALYs ($85.98/DALY averted). Across all three countries, however, a 30% vial-opening threshold using 10-dose MCVs everywhere is the only MCV threshold that consistently benefits each system compared to baseline. CONCLUSION While the ideal vial-opening threshold policy for MCV varies by supply chain, implementing a 30% vial-opening threshold for 10-dose MCVs benefits each system by improving overall vaccine availability and reducing associated medical costs and DALYs compared to no threshold.
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Affiliation(s)
- Patrick T Wedlock
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; Global Obesity Prevention Center (GOPC) at Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Elizabeth A Mitgang
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; Global Obesity Prevention Center (GOPC) at Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Assaf P Oron
- Institute for Disease Modeling, Bellevue, WA, United States
| | | | - Jim Leonard
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; Pittsburgh Supercomputing Center, Carnegie Mellon University, Pittsburgh, PA, United States
| | - Shawn T Brown
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; McGill Centre for Integrative Neuroscience, McGill Neurological Institute, McGill University, Montreal, Canada
| | - Jennifer Bakal
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; Pittsburgh Supercomputing Center, Carnegie Mellon University, Pittsburgh, PA, United States
| | - Sheryl S Siegmund
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; Global Obesity Prevention Center (GOPC) at Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Bruce Y Lee
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; Global Obesity Prevention Center (GOPC) at Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
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