title: Testing the hypothesis that diphtheria-tetanus-pertussis vaccine has negative non-specific and sex-differential effects on child survival in high-mortality countries.
abstract: BACKGROUND
  Measles vaccines (MV) have sex-differential effects on mortality not explained by protection against measles infection.
  
  
  OBJECTIVE
  The authors examined whether whole-cell diphtheria-tetanus-pertussis (DTP) vaccine has sex-differential and non-specific effects.
  
  
  METHODS
  Following previous reviews and a new search, the effect of DTP on mortality up to the next vaccination was assessed in all studies where DTP was given after BCG or DTP was given after MV and there was prospective follow-up after ascertainment of vaccination status.
  
  
  METHODS
  High-mortality countries in Africa and Asia.
  
  
  METHODS
  The initial observation of negative effect of DTP generated six hypotheses, which were examined in all available studies and two randomised trials reducing the time of exposure to DTP.
  
  
  RESULTS
  Consistency between studies.
  
  
  RESULTS
  In the first study, DTP had negative effects on survival in contrast to the beneficial effects of BCG and MV. This pattern was repeated in the six other studies available. Second, the two 'natural experiments' found significantly higher mortality for DTP-vaccinated compared with DTP-unvaccinated children. Third, the female-male mortality ratio was increased after DTP in all nine studies; in contrast, the ratio was decreased after BCG and MV in all studies. Fourth, the increased female mortality associated with high-titre measles vaccine was found only among children who had received DTP after high-titre measles vaccine. Fifth, in six randomised trials of early MV, female but not male mortality was increased if DTP was likely to be given after MV. Sixth, the mortality rate declined markedly for girls but not for boys when DTP-vaccinated children received MV. The authors reduced exposure to DTP as most recent vaccination by administering a live vaccine (MV and BCG) shortly after DTP. Both trials reduced child mortality.
  
  
  CONCLUSIONS
  These observations are incompatible with DTP merely protecting against the targeted diseases. With herd immunity to whooping cough, DTP is associated with higher mortality for girls. Randomised studies of DTP are warranted to measure the true impact on survival.
authors.affiliation: Bandim Health Project, INDEPTH Network, Statens Serum Institut, Bissau, Guinea-Bissau.
authors.forename: Peter
authors.initials: P
authors.lastname: Aaby
authors.forename: Christine
authors.initials: C
authors.lastname: Benn
authors.forename: Jens
authors.initials: J
authors.lastname: Nielsen
authors.forename: Ida Maria
authors.initials: IM
authors.lastname: Lisse
authors.forename: Amabelia
authors.initials: A
authors.lastname: Rodrigues
authors.forename: Henrik
authors.initials: H
authors.lastname: Ravn