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Rural Health and Demographic Surveillance System (HDSS)—A Nationally Representative HDSS in Guinea-Bissau

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Rural Health and Demographic Surveillance System (HDSS)—A Nationally Representative HDSS in Guinea-Bissau Open access Cohort profile BMJ Open: first published as 10.1136/bmjopen-2018-028775 on 11 June 2019. Downloaded from Cohort profile : Bandim Health Project’s (BHP) rural Health and Demographic Surveillance System (HDSS)—a nationally representative HDSS in Guinea-Bissau Sanne Marie Thysen, 1,2,3,4 Manuel Fernandes,2 Christine Stabell Benn,1,2,3 Peter Aaby,1,2 Ane Bærent Fisker 1,2,3 To cite: Thysen SM, ABSTRACT Strengths and weaknesses Fernandes M, Benn CS, et al. Purpose Bandim Health Project (BHP) monitors health Cohort profile : Bandim Health and survival of women and children in a nationally ► The Bandim Health Project rural Health and Project’s (BHP) rural Health representative rural Health and Demographic Surveillance and Demographic Surveillance Demographic Surveillance System (HDSS) is a na- System (HDSS) in Guinea-Bissau. The HDSS was set up System (HDSS)—a nationally tionally representative HDSS covering women and in 1989–1990 to collect data on health interventions and representative HDSS in children below the age of 5 years in 182 village clus- child mortality. Guinea-Bissau. BMJ Open ters all over Guinea-Bissau. 2019;9:e028775. doi:10.1136/ Participants The HDSS covers 182 randomly selected ► Since the inception of the HDSS, registration of clusters across the whole country. The cohort is open, bmjopen-2018-028775 pregnancies and follow-up for birth outcomes have and women and children enter the cohort, when they Pre-publication history and been at the core of the data collection. ► move into the selected clusters, and leave the cohort, Additional material is published ► Vaccination data are collected at all visits allowing when they move out or die, or when children reach 5 online only. To view please visit for assessment of the real-life effects of vaccines years of age. Data are collected through biannual or more the journal online (http:// dx. doi. and changes in vaccination policies. org/ 10. 1136/ bmjopen- 2018- frequent household visits. At all village visits, information ► Six-monthly visits and individual follow-up means on pregnancies, vital status, vaccination status, arm 028775). that hard endpoints like deaths are not missed but circumference, use of bed nets and other basic information http://bmjopen.bmj.com/ the precision of dates may be limited to month of Received 22 December 2018 is collected for women and children. Today, more than event. Revised 25 March 2019 25 000 women and 23 000 children below the age of 5 ► Cause of death is established based on an interview Accepted 15 May 2019 years are under surveillance. conducted at the time of registering the death, thus Findings to date Research from the BHP has given rise to classified causes must be interpreted with caution. the hypothesis that vaccines, in addition to their targeted effects, have important non-specific effects altering the susceptibility to other infections. Initially, it was observed (HDSS) in Guinea-Bissau, a small West African that mortality among children vaccinated with the live BCG country located at the coast to the Atlantic on September 29, 2021 by guest. Protected copyright. © Author(s) (or their or measles vaccines was much lower than the mortality Ocean. Guinea-Bissau borders Senegal in employer(s)) 2019. Re-use among unvaccinated children, a difference, which could permitted under CC BY-NC. No not be explained by prevention of tuberculosis and measles the north and Guinea to the east and south. commercial re-use. See rights infections. In contrast, mortality tended to be higher for The climate is tropical with an annual rainfall and permissions. Published by of approximately 1500 mm1 during a single BMJ. children who had received the non-live Diphtheria-Tetanus- Pertussis vaccine compared with children who had not rainy season (June to November). 1OPEN, Department of Clinical Research, University of Southern received this vaccine. Since the effect differed for the The BHP rural HDSS in its present form Denmark, Odense, Denmark different vaccines, no bias explained the contrasting findings. was set up in 1989–1990 with support from 2Bandim Health Project, Future plans New health interventions are introduced Unicef to assess the prevalence of neonatal INDEPTH Network, Bissau, with little assessment of real-life effects. Through the tetanus and to collect data on child mortality Guinea-Bissau HDSS, we can describe both the implementation of to monitor the impact of a Danish Inter- 3Research Center for Vitamins interventions (eg, the vaccination programme) and their national Development Agency (DANI- and Vaccines, Bandim Health effects. Furthermore, the intensive follow-up allows the DA)-sponsored project to strengthen primary Project, Statens Serum Institut, implementation of randomised trials testing potential Copenhagen, Denmark better vaccination programmes. healthcare. 4Center for Global Health, Aarhus The surveillance initially comprised University, Aarhus, Denmark randomly selected village clusters in the five INTRODUCTION most populous rural regions of Guinea-Bissau Correspondence to Bandim Health Project (BHP) implements a (Oio, Biombo, Gabu, Cacheu and Bafata), Dr. Ane Bærent Fisker; health and demographic surveillance system a. fisker@ bandim. org where 83% of the rural Guinean population Thysen SM, et al. BMJ Open 2019;9:e028775. doi:10.1136/bmjopen-2018-028775 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-028775 on 11 June 2019. Downloaded from lived. The focus was on ensuring accurate data on child women when they reach 13–15 years of age. New women mortality and therefore the emphasis was on pregnancy are registered at the first village visit after they are stated registration, antenatal care and childhood vaccinations. to have moved into the village and remain under surveil- Before the present setup, in 1979–1990, a convenience lance until death or out-migration. Women are followed sample of 20 villages in Biombo, Cacheu, Oio and Tombali from date of registration and are considered part of the was followed; some of the original villages continued as cohort as long as they state that they live in the village (we part of the present HDSS. do not operate with quarantine periods during which an in-migrant has to remain in the area before being regis- Cohort description tered, as has been done in other HDSS sites). Children The BHP rural HDSS covers women of reproductive age are registered already as fetuses. In-migrating children and children below the age of 5 years residing in the under 5 years of age are registered when they move into clusters. Between 1990 and 2006, the HDSS covered 20 the village. All children are followed from birth or date of clusters in Oio, Biombo, Gabu, Cacheu and Bafata. The registration, whichever comes last. Thus, children regis- clusters were selected using the method recommended tered after birth only enter the cohort from date of regis- by the Expanded Programme on Immunizations for tration. All children are followed to death, out-migration surveys of immunisation coverage. In all, 20 clusters of or 5 years of age. 100 women per region were selected based on a listing While key information on pregnancies, births and of the population size. The chance of being selected was deaths has been registered throughout, additional infor- proportional to the population size. If the village selected mation has been collected for shorter periods as displayed had fewer than 100 women, the closest neighbouring in figure 3. When a woman is registered, basic information village was included. A third village was added if the sample was still below 100 women. on ethnicity, age, schooling, obstetric history and vaccina- In 2006, with support from World Bank, two additional tion scar status is obtained. Since 2011, we have also regis- rural regions (Tombali and Quinara) with 20 clusters and tered the name of her mother and whether the woman two regions on the islands (Bubaque and Bolama) with was born in the village, but linkage to child records has 10 and 12 clusters, respectively, were added. The Cacheu not been performed. At registration and subsequent visits, health region was split in two health regions (Cacheu and the woman is asked if she is pregnant, whether she has São Domingos) and therefore 20 clusters were added to had any births or miscarriages since last visit and use of the already included clusters in Cacheu. Thus, from 2006 bed net (figure 3). On registration of a pregnancy, infor- and onwards, the rural HDSS consisted of 182 clusters in mation on antenatal care and gestational age is obtained, the nine rural health regions (figure 1). Details of annual and maternal mid-upper-arm circumference (MUAC) is population followed are provided in table 1. measured. Information on socioeconomic background The clusters are followed through biannual household factors is collected at the first registration of a pregnancy/ http://bmjopen.bmj.com/ visits. The surveillance in the rural HDSS has been unin- child. When registering the pregnancy outcome and at terrupted, except for slightly longer intervals between registration of infants, information on antenatal care, visits in 1998–1999, due to a civil war. Since September tetanus vaccines during pregnancy and place of birth is 2007, a nurse who administers vaccines has accompanied collected. At all subsequent household visits, information the BHP teams. Since 2012, monthly and bimonthly visits about vaccination status, nutritional status (assessed by have been conducted in the three health regions closest MUAC) and hospital admissions is obtained (figure 3). to Bissau (Oio, Biombo and Cacheu). At these more Furthermore, for children under 1 year of age and newly frequent visits, only pregnancies and children below 12 registered children, BCG scar status is assessed. In the on September 29, 2021 by guest. Protected copyright. months of age were registered and followed up (figure 2). regions with shorter intervals between follow-up visits, we The BHP rural HDSS is an open cohort: Girls who have also register whether the child has been ill since the last grown up in the village are registered in the cohort of visit, and if the child was taken for outpatient consultation.
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