Elsevier

Vaccine

Volume 29, Issue 32, 18 July 2011, Pages 5232-5237
Vaccine

Barriers to implementation of the new targeted BCG vaccination in France: A cross sectional study

https://doi.org/10.1016/j.vaccine.2011.05.020Get rights and content

Abstract

The aim of the study was to assess factors influencing BCG vaccination among targeted children after the end of universal and mandatory BCG vaccination in France. A cross-sectional study was conducted in 2009 among general practitioners (GPs) of the French Sentinel Network. With the participation of 358 physician-investigators, 920 children were included. Of the 261 children (31%) identified to be at risk of tuberculosis, only 113 (44%) were vaccinated. The median number of French criteria for BCG vaccination correctly cited by the GPs was 3 of the existing 6. Of the 10 proposed, a median number of 5 regions in the world according to their level of tuberculosis risk were correctly classified by GPs. After adjustment using an alternating logistic model, 7 variables were found to be associated with the immunisation status of the target population. Six of these increased the probability of being vaccinated: children older than 6 months (OR = 3.4 (CI 95% [1.4–8.6])), residents in central Paris or its suburbs (OR = 14.7 [4.4–49.5]), children expected to travel to highly endemic regions (OR = 3.5 [1.4–8.6]), those living in unfavourable conditions (OR = 19.9 [6.2–63.9]), the GP's good knowledge of vaccination guidelines (OR = 1.4 [1.1–1.9]) and the GP's perception of tuberculosis as a common disease (OR = 2.2 [1.1–4.5]). Surprisingly, GPs with university training on infectious diseases tended to be more reluctant to follow vaccination guidelines (OR = 0.14 [0.1–0.4]). Actions targeted at these factors could contribute to improving BCG immunisation coverage.

Introduction

Incidence of tuberculosis gradually decreased in France from 60.3 to 9 cases per 100,000 between 1972 and 2008 [1]. The epidemiology of tuberculosis in France, together with increasing concerns about the adverse effects of Bacille Calmette-Guérin (BCG) vaccination as well as the replacement of the multipuncture device by the intradermal BCG in January 2006 [2], [3], [4], led to the suspension of universal mandatory BCG vaccination in 2006. Based on studies estimating the effects of discontinuing or changing the BCG vaccination strategy [5], [6], [7], [8], [9], the French Health authorities recommended targeting children considered to be at risk of tuberculosis [10], [11], i.e., those (i) living in the region of Paris or French Guyana, (ii) born in a country with a high incidence of tuberculosis, (iii) with at least one parent born in such a country, (iv) planning to stay at least one month in such a country, (v) with a history of tuberculosis in his/her close family, or (vi) any other situation considered to be at risk of exposure to tuberculosis by the physician.

In 2005, Infuso et al. led a survey on BCG vaccination in children in all 25 EU countries, as well as Andorra, Bulgaria, Norway, Romania and Switzerland [12]. BCG was recommended nationally for children under 12 months in 12 countries, in older children in five countries and in children at risk (from origin, contact or travel) in 10 countries. Seven countries did not use BCG systematically. There were a wide variation among BCG recommendations in Europe, and nearly half the countries surveyed were considering revisions, at a time when the European Centre for Disease Prevention and Control were advocating for harmonised vaccine strategies. Two first experiences of discontinuing BCG vaccination in children gave major data. In April 1975, the Swedish authorities replaced the mass vaccination of newborn against tuberculosis by selective vaccination of groups at risk [13], [14], [15]. It caused a decrease in BCG coverage of the risk group recommended for vaccination, resulting in an increased incidence of tuberculosis and other mycobacterial diseases in children. After the end of mass BCG vaccination in a selected area of the Czech Republic in 1986, benefit analysis proved that the advantages and disadvantages of BCG vaccination were in balance [16], [17]. The number of nonvaccinated children developing tuberculosis was so small that mass application of BCG has been found to be redundant. In 2005, United Kingdom replaced BCG vaccination by selective vaccination of newborn in group at risk [18]. They have described difficulties in the implementation of the new policy. Due to those difficulties and the risk of increased incidence of tuberculosis, changing BCG vaccination has to be associated with strengthening tuberculosis control, surveillance, and information to health care provider.

Since the withdrawal of the BCG multipuncture device and the end of compulsory vaccination 18 months later in France, several health indicators have shown a decrease in the immunization coverage among the target population [19], [20].

This study aimed to: (i) assess factors influencing rate of BCG vaccination in the target population, (ii) describe French general practitioners’ (GPs) practices regarding BCG vaccination and (iii) quantify the immunisation coverage of children born after the end of compulsory vaccination.

Section snippets

Study population and data collection

Between June and September 2009, we led a cross sectional study among GPs of the French Sentinel Network. The Sentinel Network is a computerised system comprising 1298 volunteer GPs located throughout France and participating in the ongoing surveillance of 10 health indicators and in epidemiological studies [21]. GPs of the Sentinel Network are considered to be similar to the population of French GPs regarding regional distribution, proportion of GPs working in rural practices and age [22].

All

Results

Overall, 358 GPs participated in the survey (i.e., 119% of the expected). Individual and occupational characteristics of the GPs are detailed in Table 1. More than half (59%) reported not having seen tuberculosis patient in consultation since 2006. GPs’ perception of tuberculosis incidence and BCG vaccination are detailed in Table 2. The median number of French criteria for BCG vaccination correctly cited by the GPs was 3 of the existing 6; details of each criterion are presented in Table 2 and

Discussion

The aims of this study were to assess the factors associated with the BCG immunisation status of children born after the suspension of universal mandatory BCG vaccination in France and targeted by BCG, and to describe French GP practices about BCG vaccination.

The seven factors associated with the immunisation status of target children can be grouped into two main points of discussion: GP's knowledge of recommendations, and perceived risk of infection and vaccination. These factors may partly

Conclusion

Two years after the end of universal and mandatory BCG vaccination, the targeted vaccination policy had some difficulties in its implementation in France. With less than half (44%) of the children eligible for BCG vaccination actually vaccinated, there is a risk of recurrence of severe forms of tuberculosis in children. Therefore, improving tuberculosis diagnosis, investigating cases as well as epidemiological surveillance are necessary, together with a better dissemination of vaccine

Acknowledgements

We thank all the GPs who participated in the survey as well as the Scientific Committee. Funding and support: French Institute for Public Health Surveillance (Institut de Veille Sanitaire, InVS) and National Health Insurance Fund for Salaried Employees (CNAMTS). We thank the Editor in Chief and the three anonymous reviewers for helpful comments and remarks.

References (28)

  • D. Antoine et al.

    Epidemiology of tuberculosis in France: cases reported in 2008

    BEH

    (2010)
  • D. Levy-Bruhl et al.

    Recent changes in tuberculosis control and BCG vaccination policy in France

    Euro Surveill

    (2007)
  • Groupe de travail du Conseil Supérieur d’Hygiène Publique de France

    Prévention et prise en charge de la tuberculose en France. Synthèse et recommandations du groupe de travail du Conseil Supérieur d’Hygiène Publique de France (2002–2003)

    Rev Mal Respir

    (2003)
  • Expertise collective Inserm

    Tuberculose

    (2004)
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