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Factors influencing BCG immunization since the end of compulsory vaccination in France.L. Rossignol1,2*, J.-P. Guthmann3, S. Kernéis1,2, I. Aubin-Auger4, A. Lasserre1,2, P. Chauvin1,2, C. Pelat1,2, T. Hanslik2,5, D. Lévy-Bruhl3, T. Blanchon1,2.1 UPMC Université Paris 06, UMR S707, F-75012, Paris, France ; 2 INSERM, U707, F-75012, Paris, France; 3 Institut de VeilleSanitaire, F-94415 Saint-Maurice, France; 4 Université Paris Diderot, Paris 7, UFR de Médecine, site Bichat, F-75018, Paris, France; 5 Université Versailles Saint Quentin en Yvelines, F-78000, Versailles, France. *[email protected]
  • French recommendations:
  • Various depending on place of residence
  • Children eligible for BCG vaccination according to French recommendations (BEH, 2010):
    • Resident in a region with high incidence of tuberculosis (Paris and suburbs, and Guyana)
    • Born in tuberculosis endemic countries
    • Parents born in tuberculosis endemic countries
    • Expected travel in a high endemic country, for at least one month
    • Family history of tuberculosis
    • Unfavorable living conditions


In January 2006, the BCG vaccination multipuncture device has been replaced in France by intradermal vaccination. This event occurred when public health authorities were re-assessing the routine mandatory vaccination strategy. In July 2007, compulsory BCG vaccination has been replaced by selective vaccination targeted to children considered at high risk of tuberculosis. However, several health indicators have shown, since those events, a decrease of the immunization coverage among the target population.

  • Dissemination of recommendations different by place of residence

How to improve vaccination coverage among children targeted by BCG vaccination?



  • Cross-sectional study, in 2009, GPs of the French metropolitan Sentinel Network. Each GP was asked to include 3 children.
  • Children’s criteria for inclusion:
    • Last seen at their office, and
    • Usually followed by the GP, and
    • Born after the end of compulsory vaccination (July 2007).
  • The main outcome was targeted children’s BCG immunization status. Factors associated to vaccination status were identified using an alternating logistic regression (ALR) model to account for the association of children of a same doctor, univariate and then multivariate analyses have been performed.
  • In order to assess factors associated with BCG immunization among eligible children with a odds ratio of 2, 300 GPs were required.
  • Improve dissemination of recommendations
  • Specific training on vaccinology
  • Promote vaccination to general population through public campaign
  • Main objective :
  • To assess factors influencing BCG vaccination among targeted children
  • Secondary objectives:
  • To describe French GP’s practices about BCG vaccination
  • To assess the proportion of children eligible for BCG vaccination
  • To assess the vaccine coverage of children born after the end of compulsory vaccination
  • Medical staff:
  • Failure to identify children targeted by BCG vaccination
  • Lack of confidence in BCG vaccination
  • Parents:
  • Refusal to vaccine their child


Factors associated with BCG immunization among eligible children (N=255)

Overall, 358 GPs enrolled 920 children.

In the targeted children’s population, 7 variables were independently associated with the immunization status (table 1).

Eligibility for BCG vaccination

Table 1: Factors associated with BCG immunization among eligible children (N=255) (n(%), mean ± SD)

Of the 920 children included in the study, 261 (31%) were identified to be at risk for tuberculosis (i.e. having at least one of the 6 criteria).

Figure 1 : Proportion of children for each criteria of eligibility

Reasons for not being immunized with BCG vaccine

  • Of the 142 children not vaccinated but eligible (56%), reasons for not being immunized with BCG vaccine were:
    • Failure to identify children targeted (34%)
    • Parental refusal (14 %).
    • Others (52%)

BCG vaccination coverage

Of the 261 children (31%) identified to be at risk for tuberculosis, only 113 (44 %) were vaccinated. Median age of vaccinated children was 2 months [IQR=1-3 months] and 59% of those were vaccinated by their usual GP. The other vaccination places were mainly maternal and child health clinics or pediatricians.


Figure 2 : Age at BCG vaccination