Using real-life data to model the impact of increasing BCG vaccination coverage and scar prevalence on all-cause infant mortality

Estimating the potential impact on infant mortality of increasing Bacille Calmette-Guérin (BCG) vaccination coverage and BCG scar prevalence. 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. 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. 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. •Developing a scar after Bacille Calmette-Guérin (BCG) vaccination reduces mortality.•Increasing vaccination coverage and scar prevalence reduces 1- to 12-month mortality.•Optimizing BCG programs might result in >200,000 fewer infant deaths/year.