Factors Associated with Vaccination Status of Children Aged 12-48 Months in India, 2012-2013

Parents's knowledge and awareness about hepatitis B can influence the vaccination of their children

BACKGROUND

Birth-dose (Hep-BD) followed by three additional doses (Hep-B3) of hepatitis B virus (HBV) vaccine are key to eliminating HBV by 2030. Unfortunately, Hep-BD and Hep-B3 coverage in our country is poor.

AIM

To studied the parent's knowledge and awareness about HBV infection, its prevention, consequences and vaccination.

METHODS

Parents of 6 months to 8 years old children were interviewed to assess their knowledge & awareness about hepatitis B, its transmission, prevention, illness caused by this, and vaccination. Eighteen close-ended questions were administered, and responses were recorded as 'yes', 'no', or 'not sure'. HBV knowledge score was calculated based on the sum of correct answers. Each correct response scored one point and incorrect, missing or 'not sure' responses received no points. Categorical data are presented as number (%) and numerical data are expressed as median. Data were compared using Chi2 tests and level of significance was kept as P < 0.05.

RESULTS

Parents (58.3% mothers) of 384 children (89.9% age < 5 years; 82% age-appropriately vaccinated) were included. Three hundred and twenty-two (83.9%) children were Hep-B3 vaccinated. 94.3%, 87.5%, and 29.2% parents knew about polio, tetanus, and hepatitis B vaccine. Overall, 41.2%, 15.8%, and 23% parents knew about hepatitis B transmission, consequences of infection, and prevention respectively. Only 7.6% parents knew about three-dose schedule of hepatitis B vaccination. Only 23% parents believed that vaccine could prevent HBV, 15.7% knew that HBV affects liver. Parents of Hep-B3 vaccinated children were significantly more aware about HBV than the parents of unvaccinated children (P < 0.05 for 17/18 questions).

CONCLUSION

The knowledge and awareness among the parents about hepatitis B is poor. The Increasing knowledge/awareness about HBV among parents may improve Hep-B3 vaccination coverage.

Understanding household-level risk factors for zero dose immunization in 82 low- and middle-income countries

INTRODUCTION

In 2021, an estimated 18 million children did not receive a single dose of routine vaccinations and constitute the population known as zero dose children. There is growing momentum and investment in reaching zero dose children and addressing the gross inequity in the reach of immunization services. To effectively do so, there is an urgent need to characterize more deeply the population of zero dose children and the barriers they face in accessing routine immunization services.

METHODS

We utilized the most recent DHS and MICS data spanning 2011 to 2020 from low, lower-middle, and upper-middle income countries. Zero dose status was defined as children aged 12-23 months who had not received any doses of BCG, DTP-containing, polio, and measles-containing vaccines. We estimated the prevalence of zero-dose children in the entire study sample, by country income level, and by region, and characterized the zero dose population by household-level factors. Multivariate logistic regressions were used to determine the household-level sociodemographic and health care access factors associated with zero dose immunization status. To pool multicountry data, we adjusted the original survey weights according to the country's population of children 12-23 months of age. To contextualize our findings, we utilized United Nations Population Division birth cohort data to estimate the study population as a proportion of the global and country income group populations.

RESULTS

We included a total of 82 countries in our univariate analyses and 68 countries in our multivariate model. Overall, 7.5% of the study population were zero dose children. More than half (51.9%) of this population was concentrated in African countries. Zero dose children were predominantly situated in rural areas (75.8%) and in households in the lowest two wealth quintiles (62.7%) and were born to mothers who completed fewer than four antenatal care (ANC) visits (66.5%) and had home births (58.5%). Yet, surprisingly, a considerable proportion of zero dose children's mothers did receive appropriate care during pregnancy (33.5% of zero dose children have mothers who received at least 4 ANC visits). When controlled for other factors, children had three times the odds (OR = 3.00, 95% CI: 2.72, 3.30) of being zero dose if their mother had not received any tetanus injections, 2.46 times the odds (95% CI: 2.21, 2.74) of being zero dose if their mother had not received any ANC visits, and had nearly twice the odds (OR = 1.87, 95% CI: 1.70, 2.05) of being zero dose if their mother had a home delivery, compared to children of mothers who received at least 2 tetanus injections, received at least 4 ANC visits, and had a facility delivery, respectively.

DISCUSSION

A lack of access to maternal health care was a strong risk factor of zero dose status and highlights important opportunities to improve the quality and integration of maternal and child health programs. Additionally, because a substantial proportion of zero dose children and their mothers do receive appropriate care, approaches to reach zero dose children should incorporate mitigating missed opportunities for vaccination.

Vaccination inequities among children 12-23 months in India: An analysis of inter-state differences

Background

Previous research has shown that socioeconomic and demographic risk factors in children are additive and lead to increasingly negative impacts on vaccination coverage. The goal of this study is to examine if different combinations of four risk factors (infant sex, birth order, maternal education level, and family wealth status) vary by state among children 12-23 months in India and to determine the impact of ≥ 1 risk factor on differences in state vaccination rates.

Methods

Using data from the National Family Health Survey (NFHS) conducted in India between 2005 and 2006 (NFHS-3) and 2015-2016 (NFHS-4), full vaccination of children 12-23 months was examined. Full vaccination was defined as receipt of one dose of bacillus Calmette-Guérin (BCG), three doses of diphtheria-pertussis-tetanus vaccine (DPT) vaccine, three doses of oral polio vaccine (OPV), and one dose of measles-containing vaccine (MCV). Associations between full vaccination and the four risk factors were assessed using logistic regression. Data were analyzed by the state of residence.

Results

A total of 60.9% of children 12-23 months were fully vaccinated, in NFHS-4, ranging from 33.9% in Arunachal Pradesh to 91.3% in Punjab. In NFHS-4, the odds of full vaccination across all states were 15% lower among infants with 2 risk factors versus 0 or 1 risk factors (OR: 0.85, 95% CI: 0.80-0.91), and 28% lower among infants with 3 or 4 risk factors versus 0 or 1 risk factor (OR: 0.72, 95% CI: 0.67-0.78). Overall, the absolute difference in the full vaccination coverage in those with > 2 vs < 2 risk factors decreased from -13% in NFHS-3 to -5.6% in NFHS-4, with substantial variation across states.

Conclusions

Disparities in full vaccination exist among children 12-23 months experiencing > 1 risk factor. Indian states that are more populous or located in the north were more likely to have greater disparities.

Religious affiliation as a driver of immunization coverage: Analyses of zero-dose vaccine prevalence in 66 low- and middle-income countries

Background

The literature on the association between religion and immunization coverage is scant, mostly consisting of single-country studies. Analyses in low and middle-income countries (LMICs) to assess whether the proportions of zero-dose children vary according to religion remains necessary to better understand non-socioeconomic immunization barriers and to inform interventions that target zero-dose children.

Methods

We included 66 LMICs with standardized national surveys carried out since 2010, with information on religion and vaccination. The proportion of children who failed to receive any doses of a diphtheria-pertussis-tetanus (DPT) containing vaccine - a proxy for no access to routine vaccination or "zero-dose" status - was the outcome. Differences among religious groups were assessed using a test for heterogeneity. Additional analyses were performed controlling for the fixed effect of country, household wealth, maternal education, and urban-rural residence to assess associations between religion and immunization.

Findings

In 27 countries there was significant heterogeneity in no-DPT prevalence according to religion. Pooled analyses adjusted for wealth, maternal education, and area of residence showed that Muslim children had 76% higher no-DPT prevalence than Christian children. Children from the majority religion in each country tended to have lower no-DPT prevalence than the rest of the population except in Muslim-majority countries.

Interpretation

Analyses of gaps in coverage according to religion are relevant to renewing efforts to reach groups that are being left behind, with an important role in the reduction of zero-dose children.

How to ensure full vaccination? The association of institutional delivery and timely postnatal care with childhood vaccination in a cross-sectional study in rural Bihar, India

Incomplete and absent doses in routine childhood vaccinations are of major concern. Health systems in low- and middle-income countries (LMIC), in particular, often struggle to enable full vaccination of children, which affects their immunity against communicable diseases. Data on child vaccination cards from a cross-sectional primary survey with 1,967 households were used to assess the vaccination status. The association of timely postnatal care (PNC) and the place of delivery with any-dose (at least one dose of each vaccine) and full vaccination of children between 10-20 months in Bihar, India, was investigated. Bivariate and multivariable logistic regression models were used. The vaccines included targeted tuberculosis, hepatitis B, polio, diphtheria/pertussis/tetanus (DPT) and measles. Moreover predictors for perinatal health care uptake were analysed by multivariable logistic regression. Of the 1,011 children with card verification, 47.9% were fully vaccinated. Timely PNC was positively associated with full vaccination (adjusted odds ratio (aOR) 1.48, 95% confidence interval (CI) 1.06-2.08) and with the administration of at least one dose (any-dose) of polio vaccine (aOR 3.37 95% CI 1.79-6.36), hepatitis B/pentavalent vaccine (aOR 2.11 95% CI 1.24-3.59), and DPT/pentavalent vaccine (aOR 2.29 95% CI 1.35-3.88). Additionally, delivery in a public health care facility was positively associated with at least one dose of hepatitis B/pentavalent vaccine administration (aOR 4.86 95% CI 2.97-7.95). Predictors for timely PNC were institutional delivery (public and private) (aOR 2.7 95% CI 1.96-3.72, aOR 2.38 95% CI 1.56-3.64), at least one ANC visit (aOR 1.59 95% CI 1.18-2.15), wealth quintile (Middle aOR 1.57 95% CI 1.02-2.41, Richer aOR 1.51 95% CI 1.01-2.25, Richest aOR 2.06 95% CI 1.28-3.31) and household size (aOR 0.95 95% CI 0.92-0.99). The findings indicate a correlation between childhood vaccination and timely postnatal care. Further, delivery in a public facility correlates with the administration of at least one dose of hepatitis B vaccine and thus impedes zero-dose vaccination. Increasing uptake of timely PNC, encouraging institutional delivery, and improving vaccination services before discharge of health facilities may lead to improved vaccination rates among children.

Economic-Related Inequalities in Zero-Dose Children: A Study of Non-Receipt of Diphtheria-Tetanus-Pertussis Immunization Using Household Health Survey Data from 89 Low- and Middle-Income Countries

Despite advances in scaling up new vaccines in low- and middle-income countries, the global number of unvaccinated children has remained high over the past decade. We used 2000–2019 household survey data from 154 surveys representing 89 low- and middle-income countries to assess within-country, economic-related inequality in the prevalence of one-year-old children with zero doses of diphtheria–tetanus–pertussis (DTP) vaccine. Zero-dose DTP prevalence data were disaggregated by household wealth quintile. Difference, ratio, slope index of inequality, concentration index, and excess change measures were calculated to assess the latest situation and change over time, by country income grouping for 17 countries with high zero-dose DTP numbers and prevalence. Across 89 countries, the median prevalence of zero-dose DTP was 7.6%. Within-country inequalities mostly favored the richest quintile, with 19 of 89 countries reporting a rich–poor gap of ≥20.0 percentage points. Low-income countries had higher inequality than lower–middle-income countries and upper–middle-income countries (difference between the median prevalence in the poorest and richest quintiles: 14.4, 8.9, and 2.7 percentage points, respectively). Zero-dose DTP prevalence among the poorest households of low-income countries declined between 2000 and 2009 and between 2010 and 2019, yet economic-related inequality remained high in many countries. Widespread economic-related inequalities in zero-dose DTP prevalence are particularly pronounced in low-income countries and have remained high over the previous decade.

Socioeconomic inequalities in non- coverage of full vaccination among children in Bangladesh: a comparative study of Demographic and Health Surveys, 2007 and 2017-18

BACKGROUND

Vaccination is considered as a powerful and cost-effective weapon against many communicable diseases. An increase in full vaccination among the most vulnerable populations in Bangladesh was observed in the last decade. This study aimed to capture the socioeconomic inequalities in non-coverage of full vaccination among children aged 12-23 months using the nationally representative data from the Bangladesh Demographic and Health Surveys (BDHS).

METHODS

Data for this study have been drawn from the 2007 and 2017-18 BDHS, which covered 10,996 and 20,127 ever-married women aged 15-49 years in 2007 and 2017-18, respectively. Binary logistic regression analysis was performed to find the factors associated with children who did not receive full vaccination. Further, the concentration index was used to observe the socioeconomic inequality for the outcome variable.

RESULTS

The proportion of children who did not get fully vaccinated decreased by more than 6 points (18.2 percent to 11.8 percent) between the years 2007 and 2017-18. In 2017-18, the odds of children who were not fully vaccinated were 58 percent and 53 percent less among mothers who had primary education in 2007 [adjusted odds ratio (AOR): 0.42; confidence interval (CI): 0.24-0.73] and 2017-18 [AOR: 0.47; CI: 0.23-0.94] respectively, compared to mothers with no education. The inequality for children who were not fully vaccinated had declined between two survey periods [concentration index (CCI) value of - 0.13 in 2007 and -0.08 in 2017-18]. The concentration of inequality in children with higher parity who did not receive full vaccination had increased from 5 percent in 2007 to 16.9 percent in 2017-18. There was a drastic increase in the socioeconomic inequality contributed by place of delivery from 2.9 percent (2007) to 60.5 percent (2017-18) among children who did not receive full vaccination.

CONCLUSIONS

The present study provide eminent evidence that non-coverage of full vaccination is more prevalent among children from poor households in Bangladesh, which is mainly associated with factors like mother's education, father's education and working status and household wealth index across the two rounds. These factors suggest multifaceted pro-poor interventions that will protect them from hardship and reduce their socioeconomic inequalities in coverage of full vaccination.

Vaccine coverage, timeliness and delay estimated from regional and national cross-sectional surveys in Ethiopia, 2016

Introduction

measures of vaccine timing require data on vaccination dates, which may be unavailable. This study compares estimates of vaccine coverage and timing; and compares regression techniques that model these measures in the presence of incomplete data.

Methods

this cross-sectional study used the 2016 Ethiopian Demographic and Health Survey (DHS), and a 2016 survey from Worabe, Ethiopia. Three measures of vaccine uptake were calculated: coverage (regardless of timing), timeliness (within 1 week of recommended administration), and delay (the number of days between the recommended and actual date of vaccination). Vaccine coverage and timeliness were modeled with logistic regressions. After excluding those without dates, vaccine delay was estimated using linear regression or survival analysis. Vaccine delay was also estimated using accelerated failure time (AFT) models.

Results

the DHS survey included 3819 children aged 12-60 months and the Worabe survey included 484 children aged 12-23 months. In the Worabe survey, vaccine coverage for pentavalent vaccine dose 3 was 87.4%, with 8.6% receiving it within 1 week, and 71.7% within 4 weeks; the median delay was 19 days. Predictors of outcomes were similar in both the Worabe survey and Ethiopian DHS, with the largest numbers of significant associations seen in models with vaccine coverage or delays (with AFT models) as the outcomes.

Conclusion

estimates of coverage may miss a substantial proportion of infants who have delayed vaccination. Accelerated failure time (AFT) models are useful to estimate vaccine delay because they include information from all respondents (those with full and partial data on vaccination dates) and are agnostic about an age limit for timely vaccination.

Finding Children with High Risk of Non-Vaccination in 92 Low- and Middle-Income Countries: A Decision Tree Approach

Reducing vaccination inequalities is a key goal of the Immunization Agenda 2030. Our main objective was to identify high-risk groups of children who received no vaccines (zero-dose children). A decision tree approach was used for 92 low- and middle-income countries using data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys, allowing the identification of groups of children aged 12-23 months at high risk of being zero dose (no doses of the four basic vaccines-BCG, polio, DPT and measles). Three high-risk groups were identified in the analysis combining all countries. The group with the highest zero-dose prevalence (42%) included 4% of all children, but almost one in every four zero-dose children in the sample. It included children whose mothers did not receive the tetanus vaccine during and before the pregnancy, who had no antenatal care visits and who did not deliver in a health facility. Separate analyses by country presented similar results. Children who have been missed by vaccination services were also left out by other primary health care interventions, especially those related to antenatal and delivery care. There is an opportunity for better integration among services in order to achieve high and equitable immunization coverage.

Demographics of Vaccine Hesitancy in Chandigarh, India

The impact of vaccine hesitancy on childhood immunization in low- and middle-income countries remains largely uncharacterized. This study describes the sociodemographic patterns of vaccine hesitancy in Chandigarh, India. Mothers of children <5 years old were sampled from a two-stage cluster, systematic sample based on Anganwadi child care centers in Chandigarh. Vaccine hesitancy was measured using a 10-item Vaccine Hesitancy Scale, which was dichotomized. A multivariable logistic regression assessed the association between socioeconomic factors and vaccine hesitancy score. Among 305 mothers, >97% of mothers thought childhood vaccines were important, effective, and were a good way to protect against disease. However, many preferred their child to receive fewer co-administered vaccines (69%), and were concerned about side effects (39%). Compared to the “other caste” group, scheduled castes or scheduled tribes had 3.48 times greater odds of vaccine hesitancy (95% CI: 1.52, 7.99). Those with a high school education had 0.10 times the odds of vaccine hesitancy compared to those with less education (95% CI: 0.02, 0.61). Finally, those having more antenatal care visits were less vaccine hesitant (≥4 vs. <4 visits OR: 0.028, 95% CI: 0.1, 0.76). As India adds more vaccines to its Universal Immunization Program, consideration should be given to addressing maternal concerns about vaccination, in particular about adverse events and co-administration of multiple vaccines.

Vaccination assessments using the Demographic and Health Survey, 2005-2018: a scoping review

OBJECTIVE

To characterise studies which have used Demographic and Health Survey (DHS) datasets to evaluate vaccination status.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases including PubMed, EBSCOhost and POPLINE, from 2005 to 2018.

STUDY SELECTION

All English studies with vaccination status as the outcome and the use of DHS data.

DATA EXTRACTION

Studies were selected using a predetermined list of eligibility criteria and data were extracted independently by two authors. Data related to the study population, the outcome of interest (vaccination) and commonly seen predictors were extracted.

RESULTS

A total of 125 articles were identified for inclusion in the review. The number of countries covered by individual studies varied widely (1-86), with the most published papers using data from India, Nigeria, Pakistan and Ethiopia. Many different definitions of full vaccination were used although the majority used a traditional schedule recommended in the WHO's Expanded Programme on Immunisation. We found studies analysed a wide variety of predictors, but the most common were maternal education, wealth, urbanicity and child's sex. Most commonly reported predictors had consistent relationships with the vaccination outcome, outside of sibling composition.

CONCLUSIONS

Researchers make frequent use of the DHS dataset to describe vaccination patterns within one or more countries. A clearer idea of past use of DHS can inform the development of more rigorous studies in the future. Researchers should carefully consider whether a variable needs to be included in the multivariable model, or if there are mediating relationships across predictor variables.

Vaccine Hesitancy as a Challenge or Vaccine Confidence as an Opportunity for Childhood Immunisation in India

Vaccines have contributed substantially to decreasing the morbidity and mortality rates of many infectious diseases worldwide. Despite this achievement, an increasing number of parents have adopted hesitant behaviours towards vaccines, delaying or even refusing their administration to children. This has implications not only on individuals but also society in the form of outbreaks for e.g. measles, chicken pox, hepatitis A, etc. A review of the literature was conducted to identify the determinants of vaccine hesitancy (VH) as well as vaccine confidence and link them to challenges and opportunities associated with vaccination in India, safety concerns, doubts about the need for vaccines against uncommon diseases and suspicions towards new vaccines were identified as major vaccine-specific factors of VH. Lack of awareness and limited access to vaccination sites were often reported by hesitant parents. Lastly, socio-economic level, educational level and cultural specificities were contextual factors of VH in India. Controversies and rumours around some vaccines (e.g., human papillomavirus) have profoundly impacted the perception of the risks and benefits of vaccination. Challenges posed by traditions and cultural behaviours, geographical specificities, socio-demographic disparities, the healthcare system and vaccine-specific features are highlighted, and opportunities to improve confidence are identified. To overcome VH and promote vaccination, emphasis should be on improving communication, educating the new generation and creating awareness among the society. Tailoring immunisation programmes as per the needs of specific geographical areas or communities is also important to improve vaccine confidence. Fig. 1 Plain language summary.

Explaining socioeconomic inequalities in immunisation coverage in India: new insights from the fourth National Family Health Survey (2015-16)

BACKGROUND

Childhood vaccinations are a vital preventive measure to reduce disease incidence and deaths among children. As a result, immunisation coverage against measles was a key indicator for monitoring the fourth Millennium Development Goal (MDG), aimed at reducing child mortality. India was among the list of countries that missed the target of this MDG. Immunisation targets continue to be included in the post-2015 Sustainable Development Goals (SDG), and are a monitoring tool for the Indian health care system. The SDGs also strongly emphasise reducing inequalities; even where immunisation coverage improves, there is a further imperative to safeguard against inequalities in immunisation outcomes. This study aims to document whether socioeconomic inequalities in immunisation coverage exist among children aged 12-59 months in India.

METHODS

Data for this observational study came from the fourth round of the National Family Health Survey (2015-16). We used the concentration index to assess inequalities in whether children were fully, partially or never immunised. Where children were partially immunised, we also examined immunisation intensity. Decomposition analysis was applied to examine the underlying factors associated with inequality across these categories of childhood immunisation.

RESULTS

We found that in India, only 37% of children are fully immunised, 56% are partially immunised, and 7% have never been immunised. There is a disproportionate concentration of immunised children in higher wealth quintiles, demonstrating a socioeconomic gradient in immunisation. The data also confirm this pattern of socioeconomic inequality across regions. Factors such as mother's literacy, institutional delivery, place of residence, geographical location, and socioeconomic status explain the disparities in immunisation coverage.

CONCLUSIONS

In India, there are considerable inequalities in immunisation coverage among children. It is essential to ensure an improvement in immunisation coverage and to understand underlying factors that affect poor uptake and disparities in immunisation coverage in India in order to improve child health and survival and meet the SDGs.