title: BCG coverage and barriers to BCG vaccination in Guinea-Bissau: an observational study.
abstract: BACKGROUND
  BCG vaccination is recommended at birth in low-income countries, but vaccination is often delayed. Often 20-dose vials of BCG are not opened unless at least ten children are present for vaccination ("restricted vial-opening policy"). BCG coverage is usually reported as 12-month coverage, not disclosing the delay in vaccination. Several studies show that BCG at birth lowers neonatal mortality. We assessed BCG coverage at different ages and explored reasons for delay in BCG vaccination in rural Guinea-Bissau.
  
  
  METHODS
  Bandim Health Project (BHP) runs a health and demographic surveillance system covering women and their children in 182 randomly selected village clusters in rural Guinea-Bissau. BCG coverage was assessed for children born in 2010, when the restricted vial-opening policy was universally implemented, and in 2012-2013, where BHP provided BCG to all children at monthly visits in selected intervention regions. Factors associated with delayed BCG vaccination were evaluated using logistic regression models. Coverage between intervention and control regions were evaluated in log-binomial regression models providing prevalence ratios.
  
  
  RESULTS
  Among 3951 children born in 2010, vaccination status was assessed for 84%. BCG coverage by 1 week of age was 11%, 38% by 1 month, and 92% by 12 months. If BCG had been given at first contact with the health system, 1-week coverage would have been 35% and 1-month coverage 54%. When monthly visits were introduced in intervention regions, 1-month coverage was higher in intervention regions (88%) than in control regions (51%), the prevalence ratio being 1.74 (1.53-2.00). Several factors, including socioeconomic factors, were associated with delayed BCG vaccination in the 2010-birth cohort. When BCG was available at monthly visits these factors were no longer associated with delayed BCG vaccination, only region of residence was associated with delayed BCG vaccination.
  
  
  CONCLUSIONS
  BCG coverage during the first months of life is low in Guinea-Bissau. Providing BCG at monthly vaccination visits removes the risk factors associated with delayed BCG vaccination.
authors.affiliation: Bandim Health Project, INDEPTH network, Apartado 861, 1004 Bissau Codex, Guinea-Bissau. smthysen@gmail.com.
authors.forename: Sanne Marie
authors.initials: SM
authors.lastname: Thysen
authors.forename: Stine
authors.initials: S
authors.lastname: Byberg
authors.forename: Marie
authors.initials: M
authors.lastname: Pedersen
authors.forename: Amabelia
authors.initials: A
authors.lastname: Rodrigues
authors.forename: Henrik
authors.initials: H
authors.lastname: Ravn
authors.forename: Cesario
authors.initials: C
authors.lastname: Martins
authors.forename: Christine Stabell
authors.initials: CS
authors.lastname: Benn
authors.forename: Peter
authors.initials: P
authors.lastname: Aaby
authors.forename: Ane Bærent
authors.initials: AB
authors.lastname: Fisker
mesh_terms: D000818:Animals; D001500:BCG Vaccine / Q000627:therapeutic use*; D002417:Cattle; D005260:Female; D006169:Guinea-Bissau / Q000453:epidemiology; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D008297:Male; D009163:Mycobacterium bovis; D011203:Poverty; D012307:Risk Factors; D012424:Rural Population; D014380:Tuberculosis, Bovine / Q000517:prevention & control*
chemical_list: D001500:BCG Vaccine