Demand- and supply-side determinants of diphtheria-pertussis-tetanus nonvaccination and dropout in rural India

Determinants and prevalence of zero-dose children in Somalia: Analysis of the 2020 Health Demographic Survey data

Despite global progress in childhood vaccination coverage, fragile and humanitarian countries, with high burden of infectious diseases, continue to report a significant number of zero-dose and under-vaccinated children. Efforts to equitably reach zero-dose children remain thus critical. This study assesses the prevalence and determinants of zero-dose children in fragile context of Somalia. We used secondary data from 2020 Somali Health and Demographic Survey (SHDS) to determine status of unvaccinated children aged between 12 to 23 months. Variables related to socio-demographic, household, health seeking, and community level factors were extracted from the SHDS data. Variables that were shown to be significantly associated with zero-dose children at p< 0.05 in the single logistic regression analysis were identified and included in a final multiple logistic regression analysis. A total of 2,304 women and their children aged between 12-23 months were used to determine the prevalence and determinants of zero dose children in Somalia. Approximately 60.2% of the children were zero dose children and did not receive any dose of the four basic routine vaccines. Children living in rural and nomadic areas were more likely to be zero dose (aOR 1.515, 95% CI: 1.189-1.93). Mother with primary education and above (aOR 0.519, 95% CI: 0.371-0.725), those who attended antenatal care (aOR 0.161, 95% CI: 0.124-0.209) and postnatal care (aOR 0.145, 95% CI: 0.085-0.245) and listen frequently to radio (aOR 2.212, 95% CI: 1.106-4.424) were less likely to have children with zero dose than with their counterparts. Majority of children under two years of age in Somalia are reported to be zero dose children. Context and population specific interventions that target vulnerable mothers and their children, in rural and nomadic areas, and from lower wealth quintile index families with no education and adequate access to antenatal and postnatal care remain critical.

Determinants of Full Vaccination Coverage among Children Aged 12-23 Months in Bangladesh: A Comparison between High- and Low-Performing Divisions

Introduction

A better understanding of the significant factors behind childhood vaccination is important for designing strategies to increase vaccination coverage and reduce child mortality and morbidity. The study is aimed at identifying the determinants of full vaccination coverage among children aged 12-23 months in Bangladesh and at comparing the determinants between high- and low-performing areas.

Methods

This study used the latest available Bangladesh Demographic and Health Survey 2017-18 data. A weighted sample of 1678 children was included in this study. The association between full vaccination coverage and explanatory variables was identified using chi-square test. Multivariable logistic regression analysis was employed to identify associated factors of full vaccination coverage.

Results

Findings showed that about 88% of the children had full vaccination coverage. The odds of full vaccination coverage was significantly higher among children of mothers with secondary education compared to children of mothers with no formal education (AOR = 2.07, 95%CI = 1.16 to 3.70). Mother's working status was another significant factor behind full vaccination coverage (AOR = 1.53, 95%CI = 1.002 to 2.34). In addition, we identified that higher age of mother (AOR = 2.76, 95%CI = 1.28 to 5.96 for 20-34 years group and AOR = 12.14, 95%CI = 1.21 to 122.41 for 35 and above age group) and being in middle-income household (AOR = 4.66, 95%CI = 1.33 to 16.34) were significantly associated with full vaccination coverage in high-performing areas. On the other hand, children of mothers with secondary education level (AOR = 2.31, 95%CI = 1.86 to 4.49) and exposure to media (AOR = 1.58, 95%CI = 1.001 to 2.50) had higher odds of having full vaccination coverage in low-performing areas.

Conclusions

This study identified the associated factors of full vaccination coverage among children. The findings indicate the importance of maternal education and mothers' employment for children's vaccination uptake. In low-performing areas, investment in education and awareness raising initiatives may play instrumental role in achieving full vaccination coverage.

Comparison of Wealth-Related Inequality in Tetanus Vaccination Coverage before and during Pregnancy: A Cross-Sectional Analysis of 72 Low- and Middle-Income Countries

Immunization of pregnant women against tetanus is a key strategy for reducing tetanus morbidity and mortality while also achieving the goal of maternal and neonatal tetanus elimination. Despite substantial progress in improving newborn protection from tetanus at birth through maternal immunization, umbilical cord practices and sterilized and safe deliveries, inequitable gaps in protection remain. Notably, an infant's tetanus protection at birth is comprised of immunization received by the mother during and before the pregnancy (e.g., through childhood vaccination, booster doses, mass vaccination campaigns, or during prior pregnancies). In this work, we examine wealth-related inequalities in maternal tetanus toxoid containing vaccination coverage before pregnancy, during pregnancy, and at birth for 72 low- and middle-income countries with a recent Demographic and Health Survey or Multiple Indicator Cluster Survey (between 2013 and 2022). We summarize coverage levels and absolute and relative inequalities at each time point; compare the relative contributions of inequalities before and during pregnancy to inequalities at birth; and examine associations between inequalities and coverage levels. We present the findings for countries individually and on aggregate, by World Bank country income grouping, as well as by maternal and neonatal tetanus elimination status, finding that most of the inequality in tetanus immunization coverage at birth is introduced during pregnancy. Inequalities in coverage during pregnancy are most pronounced in low- and lower-middle-income countries, and even more so in countries which have not achieved maternal and neonatal tetanus elimination. These findings suggest that pregnancy is a key time of opportunity for equity-oriented interventions to improve maternal tetanus immunization coverage.

Vaccination dropout and wealth related inequality among children aged 12-35 months in remote and underserved settings of Ethiopia: a cross-sectional evaluation survey

Background

Vaccination is one of the most cost-effective public health interventions that prevents millions of deaths. Although immunization coverage is increasing globally, many children in low- and middle-income countries drop out of the vaccination continuum. This study aimed at determining vaccination dropout rates and predictors in children aged 12-35 months in remote and underserved areas of Ethiopia.

Methods

This study was part of a cross-sectional evaluation survey that was conducted in 2022 in Ethiopia. The study settings include pastoralist, developing & newly established regions, conflict affected areas, urban slums, internally displaced populations and refugees. A sample of 3,646 children aged 12-35 months were selected using a cluster sampling approach. Vaccination dropout was estimated as the proportion of children who did not get the subsequent vaccine among those who received the first vaccine. A generalized estimating equation was used to assess determinants of the dropout rate and findings were presented using an adjusted odds ratio with 95% confidence interval. Concentration curve and index were used to estimate wealth related inequality of vaccination dropout.

Results

A total of 3,646 caregivers of children participated in the study with a response rate of 97.7%. The BCG to Penta-3 (52.5%), BCG to MCV-2 (57.4%), and Penta-1 to Penta-3 (43.9%) dropouts were all high. The highest Penta-1 to Penta-3 dropout rate was found in developing regions (60.1%) and the lowest was in urban slums (11.2%). Caregivers who were working outside their homes [AOR (95% CI) = 3.67 (1.24-10.86)], who had no postnatal care follow-up visits [AOR (95%CI) = 1.66 (1.15-2.39)], who did not receive a service from a skilled birth attendant [AOR (95%CI) = 1.64 (1.21-2.27)], who were older than 45 years [AOR (95% CI) = 12.49 (3.87-40.33)], and who were less gender empowered [AOR (95%CI) = 1.63 (1.24-2.15)] had increased odds of Penta-1 to Penta-3 dropout. The odds of dropout for children from poor caregivers was nearly two times higher compared to their wealthy counterparts [AOR (95%CI) = 1.87 (1.38-2.52)].

Conclusion

Vaccination dropout estimates were high among children residing in remote and underserved settings. Poor wealth quintile, advanced maternal age, low women empowerment, and limited utilization of maternity care services contributed to vaccination dropout.

Vaccination coverage survey of children aged 1-3 years in Beijing, China, 2005-2021

BACKGROUND

The routine immunization program for children is a primary strategy and a core part of vaccination. Achieving and maintaining high level of vaccination coverage are important to reduce morbidity and mortality caused by vaccine-preventable diseases. In Beijing, annual coverage surveys have been conducted since 2005. It is necessary and possible to assess the level and trend of routine vaccination coverage of children in Beijing as well as the disruption of coronavirus disease 2019 (COVID-19) pandemic and provide the reference for the further improve the vaccination coverage.

METHODS

The data of 61,521 children aged 1-3 years in the vaccination coverage surveys during 2005-2021 were analyzed by Beijing Center for Disease Control and Prevention. Descriptive epidemiological method was used to analyze the data and the difference of vaccination coverage within the time period.

RESULTS

More than 99 % of participants had immunization cards and electronic immunization records. The concordance rate of both records were also over 99 %. During 2011-2019, the rates of on-time and in-time vaccination of each routine vaccine reached 96 % or more and increased significantly (all P values <0.05), compared with that of 2005-2010. All rates of the investigated vaccine, except for Bacillus Calmette-Guérin vaccine (BCG) and the first dose of hepatitis B vaccine (HepB), decreased in 2020-2021 significantly (all P values <0.05). For the causes of failing to vaccinate on time, delayed vaccination accounted for 47.82 %. The top two vaccines to be missed were the first dose of hepatitis A vaccine and the 4th dose of diphtheria-tetanus-acellular pertussis vaccine, accounting for 21.41 % and 20.79 %, respectively. The main reason for zero-dose/drop-out vaccination was "Guardians regarded the immunization service time as inappropriate", accounting for 72.27 %.

CONCLUSION

The coverage level and service quality of routine immunization in Beijing were relatively high. However, as influenced by COVID-19 epidemics, both on-time and in-time vaccination rates decreased significantly, except for BCG and HepB. Under the background of COVID-19 pandemic, the keys to maintain high level of vaccination coverage include flexible immunization service time to ensure the guardians bringing their children for vaccination timely, and more attention from providers to the doses after children's first birthday.

Exploring the Pattern of Immunization Dropout among Children in India: A District-Level Comparative Analysis

The dropout rate is one of the determinants of immunization coverage and program performance, program continuity, and follow-up. The dropout rate refers to the proportion of vaccine recipients who did not finish their vaccination schedules, and it is determined by comparing the number of infants who started the schedule to the number who completed it. It is the rate difference between the first and final dosage or the rate difference between the first vaccination and the last vaccine dropout; thus, it denotes that the first recommended dose of vaccine was received, but that the subsequently recommended dose was missed. In India, immunization coverage has shown significant improvements over the last two decades, but full immunization coverage has remained stagnant at 76.5%, of which 19.9% are partially immunized, and 3.6% are children who have been left out. In India, the Universal Immunization Programme (UIP) is challenged with cases related to dropout in immunization. Although immunization coverage in India is improving, the program is challenged by vaccination dropouts. This study provides an analysis of the determinants of vaccination dropout in India using data from two rounds of the National Family Health Survey. The finding shows that the mother's age, education, family wealth, antenatal care visit, and place of delivery were some of the variables that significantly contributed to reducing the dropout rate of immunization among children. The findings of this paper show that the dropout rate has reduced over a certain period of time. The overall improvement in the rates of dropout and increase in full immunization coverage could be attributed to various policy measures taken in the last decade in India, which brought structural changes with a positive impact on full immunization coverage and its components.

Patterns in the Prevalence of Unvaccinated Children Across 36 States and Union Territories in India, 1993-2021

IMPORTANCE

Children who do not receive any routine vaccinations (ie, who have 0-dose status) are at elevated risk of death, morbidity, and socioeconomic vulnerabilities that limit their development over the life course. India has the world's highest number of children with 0-dose status; analysis of national and subnational patterns is the first important step to addressing this problem.

OBJECTIVES

To examine the patterns among children with 0-dose immunization status across all 36 states and union territories (UTs) in India over 29 years, from 1993 to 2021, and to elucidate the relative share of multiple geographic regions in the total geographic variation in 0-dose immunization.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study analyzed all 5 rounds of India's National Family Health Survey (1992-1993, 1998-1999, 2005-2006, 2015-2016, and 2019-2021) to compare the prevalence of children with 0-dose status across time-space and geographic regions. The Integrated Public Use of Microdata Series was used to construct comparable geographic boundaries for states and UTs across surveys. The study included a total of 125 619 live children aged 12 to 23 months who were born to participating women.

MAIN OUTCOMES AND MEASURES

The outcome was a binary indicator of children's 0-dose vaccination status, coded as children aged 12 to 23 months at the time of the survey who had not received the first dose of the diphtheria-tetanus-pertussis-containing vaccine. The significance of each geographic unit was computed using the variance partition coefficient (VPC).

RESULTS

Among 125 619 children, the national prevalence of those with 0-dose status in India decreased from 33.4% (95% CI, 32.5%-34.2%) in 1993 to 6.6% (95% CI, 6.4%-6.8%) in 2021. A substantial reduction in the IQR of 0-dose prevalence across states from 30.1% in 1993 to 3.1% in 2021 suggested a convergence in state disparities. The prevalence in the northeastern states of Meghalaya (17.0%), Nagaland (16.1%), Mizoram (14.3%), and Arunachal Pradesh (12.6%) remained relatively high in 2021. Prevalence increased between 2016 and 2021 in 10 states, including several traditionally high-performing states and UTs, such as Telangana (1.16 percentage points) and Sikkim (0.92 percentage points). In 2021, 53.0% of children with 0-dose status resided in the populous states of Uttar Pradesh, Bihar, and Maharashtra. A multilevel analysis comparing the share of variation at the state, district, and cluster (primary sampling unit) levels revealed that clusters accounted for the highest share of the total variation in 2016 (44.7%; VPC [SE], 1.04 [0.32]) and 2021 (64.3%; VPC [SE], 0.38 [0.12]).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, findings from approximately 3 decades of analysis suggest the need for sustained efforts to target populous states like Uttar Pradesh and Bihar and northeastern parts of India. The resurgence of 0-dose prevalence in 10 states highlights the importance of programs like Intensified Mission Indradhanush 4.0, a major national initiative to improve immunization coverage. Prioritizing small administrative units will be important to strengthening India's efforts to bring every child into the immunization regime.

Capacity and quality of maternal and child health services delivery at the subnational primary healthcare level in relation to intermediate health outputs: a cross-sectional study of 12 low-income and middle-income countries

OBJECTIVES

To examine the capacity and quality of maternal and child health (MCH) services at the subnational primary healthcare (PHC) level in 12 low-income and middle-income countries (LMICs) and its association with intermediate health outputs such as coverage and access to care.

DESIGN

Observational cross-sectional study using matched subnational data from service provision assessment surveys and demographic health surveys from 2007 to 2019.

SETTINGS

138 subnational areas with available survey data in 12 LMICs (Afghanistan, Bangladesh, Democratic Republic of Congo, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania and Uganda).

OUTCOMES

Eight intermediate MCH outcomes/outputs were explored: (1) met need for family planning by modern methods; (2) attendance of four or more antenatal care visits; (3) perceived financial barriers to care; (4) perceived geographical barriers to care; (5) diphtheria-pertussis-tetanus (DPT) third dose coverage; (6) DPT dropout-rate; (7) care-seeking for pneumonia; and (8) oral rehydration solutions coverage.

RESULTS

Overall, moderate-to-poor PHC performance was observed across the 12 countries, with substantial heterogeneity between the different subnational areas in the same country as well as within the same subnational area across both capacity and quality subdomains. The analysis of the relationship between PHC service delivery and child health outcomes revealed that recent supervision (b=0.34, p<0.01) and supervisors' feedback (b=0.28, p<0.05) were each associated with increased care-seeking for pneumonia. We also observed the associations of several measures of capacity and quality with DPT immunisation. The analysis of maternal health outcomes yielded only a few statistically significant results at p<0.05 level, however, none remained significant after adjusting for other covariates.

CONCLUSION

The results of this analysis illustrate the heterogeneity in the capacity and quality of PHC service delivery within LMICs. Countries seeking to strengthen their PHC systems could improve PHC monitoring at the subnational level to better understand subnational bottlenecks in service delivery.

Improving routine childhood immunisation outcomes in low-income and middle-income countries: an evidence gap map

OBJECTIVE

To support evidence-informed decision-making, we created an evidence gap map to characterise the evidence base on the effectiveness of interventions in improving routine childhood immunisation outcomes in low-income and middle-income countries (LMICs).

METHODS

We developed an intervention-outcome matrix with 38 interventions and 43 outcomes. We searched academic databases and grey literature sources for relevant impact evaluations (IEs) and systematic reviews (SRs). Search results were screened on title/abstract. Those included on title/abstract were retrieved for full review. Studies meeting the eligibility criteria were included and data were extracted for each included study. All screening and data extraction was done by two independent reviewers. We analysed these data to identify trends in the geographic distribution of evidence, the concentration of evidence across intervention and outcome categories, and attention to vulnerable populations in the literature.

RESULTS

We identified 309 studies, comprising 226 completed IEs, 58 completed SRs, 24 ongoing IEs and 1 ongoing SR. Evidence from IEs is heavily concentrated in a handful of countries in sub-Saharan Africa and South Asia. Among interventions, the most frequently evaluated are those related to education and material incentives for caregivers or health workers. There are gaps in the study of non-material incentives and outreach to vulnerable populations. Among outcomes, those related to vaccine coverage and health are well covered. However, evidence on intermediate outcomes related to health system capacity or barriers faced by caregivers is much more limited.

CONCLUSIONS

There is valuable evidence available to decision-makers for use in identifying and deploying effective strategies to increase routine immunisation in LMICs. However, additional research is needed to address gaps in the evidence base.

Resource mobilization for tetanus vaccination in Vietnam: Uptake, demand and willingness to pay among women of reproductive age

Introduction

Tetanus vaccine coverage in Vietnam has been declining in recent years due to a rapid population growth rate, shrinking budget, and inefficient resource mobilization strategy. This study examined the uptake, demand, and willingness to pay (WTP) for tetanus vaccines in Vietnamese women of reproductive age as well as determined associated factors and assessed the feasibility of the long-term tetanus vaccine resource mobilization scheme.

Methods

Cross-sectional data were obtained on 807 women of childbearing age in Hanoi, Vietnam in 2016. Tetanus vaccine uptake, demand, and willingness to pay were collected by using a structured questionnaire. Multivariable logistic and interval regression models were used to examine associated factors with vaccine uptake, demand, and WTP.

Results

Of 807 participants, 42.4 and 64.8% had sufficient tetanus vaccination (i.e., received at least three doses of vaccine) and were willing to pay for tetanus vaccination. The mean amount of WTP for one dose of tetanus was US$ 7.3 (95% CI = 6.7-7.9). Having children or being aware that the tetanus vaccine was free-of-charge were negatively associated with WTP for tetanus vaccine. Having a high school education, living in a rural area, and not being aware of vaccine prices or being aware that vaccines were provided freely reduced the amount of WTP. WTP increased among women receiving information from friends and relatives.

Conclusion

Despite of exemption from the tetanus vaccination programs, this study indicated a low tetanus vaccination coverage and a moderate degree of WTP for tetanus vaccine among Vietnamese women of childbearing age. Target-specific educational and financial support interventions, along with efforts to reduce vaccination costs are critical to improving the vaccine uptake, demand, and WTP for tetanus immunization among women.

Case Report: Pharyngeal Diphtheria in a Pregnant Woman from South India

Diphtheria is a vaccine-preventable disease and is caused by toxigenic strains of Corynebacterium diphtheriae. Several case reports have been published in the recent years, and this resurgence of cases has occurred mainly in adolescent and adult populations. Also, several research articles have reported waning immunity against diphtheria in adults who have completed childhood immunization. Thus, it is an important need to conduct larger sero-surveillance studies to understand the cause of rising diphtheria cases. Here, we report a case of a 23-year-old pregnant women of 8 weeks' gestation who presented to the outpatient department with fever, severe throat pain, odynophagia, dysphagia, neck pain, and neck swelling of 3 days' duration. On clinical examination, a gray, leathery membrane was noted on the soft palate. An Albert's stain from the membrane revealed organisms resembling Corynebacterium diphtheriae. Appropriate treatment was initiated immediately, and follow-up examination at 2 weeks from date of discharge was uneventful. The gray membrane had completely resolved. Contact tracing was done and the appropriate antimicrobial agent was administered. This case study indicates the importance of timely clinical and microbiological diagnosis and reinforces the previously reported resurgence of diphtheria infection.

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.

Determinants of immunisation dropout among children under the age of 2 in Zambézia province, Mozambique: a community-based participatory research study using Photovoice

OBJECTIVE

Immunisations are highly impactful, cost-effective public health interventions. However, substantial gaps in complete vaccination coverage persist. We aimed to describe caregivers' immunisation experiences and identify determinants of vaccine dropout.

DESIGN

We used a community-based participatory research approach employing Photovoice, SMS (short messaging service) exchanges and in-depth interviews. A team-based approach was used for thematic analysis. The Increasing Vaccination Model guided the analysis and identification of vaccination facilitators and barriers.

SETTING

This study was conducted in Zambézia province, Mozambique, in Namarroi and Gilé districts, where roughly 19% of children under 2 start but do not complete the recommended vaccination schedule.

PARTICIPANTS

Participants were identified through health facility vaccination records and included caregivers of children aged 25-34 months who were fully vaccinated (n=10) and partially vaccinated (n=22). We also collected data from 12 health workers responsible for delivering immunisations at the selected health facilities.

RESULTS

Four main patterns of barriers leading to dropout emerged: (1) social norms and limited family support place the immunisation burden on mothers; (2) perceived poor quality of health services reduces caregivers' trust in vaccination services; (3) concern about side effects causes vaccine hesitancy; and (4) caregivers hesitate to seek and advocate for vaccination due to power imbalances with health workers. COVID-19 created additional barriers related to social distancing, mask requirements, supply chain challenges and disrupted outreach services. For most caregivers, dropout becomes increasingly likely with compounding barriers. Caregivers of fully-vaccinated children noted facilitators, including accompaniment to health facilities or assistance caring for other children, which enabled them to complete vaccination.

CONCLUSIONS

Overcoming immunisation barriers requires strengthening health systems, including improving logistics to avert vaccine stockouts and building health worker capacity, including empathic communication with caregivers. Consistent and reliable immunisation outreach services could address access challenges and improve immunisation uptake, particularly in distant communities.

Public health facility quality and child immunization outcomes in rural India: A decomposition analysis

Universal coverage of routine childhood vaccines remains a challenge in many low- and middle-income countries (LMICs). In India, vaccination campaigns have increased full immunization coverage among 12–23 month old children from an estimated 62% in 2015–2016 to 76% in 2019–2020. Long-term improvements in coverage will likely require systemic changes to both the supply and demand sides of immunization programs. However, the effect of health system inputs on child vaccination outcomes remains poorly quantified in India. We examined the association between the quality of public health facilities and child vaccination outcomes in rural India using data from the nationally representative Integrated Child Health and Immunization Survey (2015–2016) which covered 1,346 public primary health sub-centers and 44,571 households. We constructed two indices of sub-center quality using multiple correspondence analysis: one related to the general health infrastructure quality and the other measuring vaccine service delivery. Using probit regression, we analyzed the relationship between vaccination outcomes in children under 2 years of age and sub-center quality, controlling for household socioeconomic characteristics. Additionally, we conducted Fairlie decomposition analysis by wealth group — bottom wealth quintile relative to the top four wealth quintiles— to examine factors contributing to gaps in immunization between rich and poor households. Infrastructure quality index was positively associated with completion of seven vaccination outcomes: full immunization, DPT-1 (first dose of diphtheria, pertussis, and tetanus), DPT-2, DPT-3, Bacillus Calmette–Guérin (BCG), hepatitis B (birth dose), and on-time vaccination (OTV). Vaccine service delivery index was positively associated with completion of measles vaccination. The distribution of infrastructure quality contributed to increased gaps in full immunization and OTV between rich and poor households, while greater proximity to vaccination site for poorer households reduced these gaps. Improved quality of health facilities, particularly facilities used by low-income households, may improve vaccination outcomes.

Factors affecting recommended childhood vaccine demand

Reaching a high vaccination coverage level is of vital essence when preventing epidemic diseases. For mandatory vaccines, the demand can be forecasted using some demographics such as birth rates or populations between certain ages. However, it has been difficult to forecast non-mandatory vaccine demands because of vaccine hesitation, alongside other factors such as social norms, literacy rate, or healthcare infrastructure. Consequently, the purpose of this study is to explore the predominant factors that affect the non-mandatory vaccine demand, focusing on the recommended childhood vaccines, which are usually excluded from national immunization programs. For this study, fifty-nine factors were determined and categorized as system-oriented and human-oriented factors. After a focus group study conducted with ten experts, seven system-oriented and eight human-oriented factors were determined. To reveal the cause and effect relationship between factors, one of the multi-criteria decision-making methods called Fuzzy-DEMATEL was implemented. The results of the analysis showed that “Immunization-related beliefs”, “Media/social media contents/messaging”, and “Social, cultural, religious norms” have a strong influence on non-mandatory childhood vaccine demand. Furthermore, whereas “Availability and access to health care facilities” and “Political/ financial support to health systems” are identified as cause group factors, “Quality of vaccine and service delivery management” is considered an effect group factor. Lastly, a guide was generated for decision-makers to help their forecasting process of non-mandatory vaccine demands to avoid vaccine waste or shortage.

Prevalence, Trends and Conditions for the DTP3 Vaccine: A 25-Year Historical Perspective

Background

The aim was to verify the prevalence of vaccination coverage, tendency and factors of the third dose of the vaccine against diphtheria, tetanus and pertussis-DTP3 in surveys over the period of 25 years in a state of the Northeast of Brazil.

Methods

Cross-sectional and temporal series, utilizing ad hoc database, were extracted from the Health and Nutrition State Research 1991, 1997, 2006 and 2015/2016. Children from 12 to 23 months of age with proof in the vaccination card were included. The vaccination coverage (outcome) of each year was calculated, the tendency throughout the period was analyzed and the associations through Pearson chi-squared were tested. The results of the first and last survey were compared with a significance level of 5%. The reasons of the crude prevalence and confidence intervals of 95% were estimated.

Results

The vaccination coverage in 1991, 1997, 2006 and 2015/2016 was 77.6%, 82.7%, 89.7% and 72.9%, respectively, with an increasing tendency from 1991 to 2006 (p<0.001) and decreasing between 2006 and 2015/2016 (p<0.001). Factors in 1991: low socioeconomic conditions; lack of access to health service and pre-natal care, nutritional deficit and diarrhea in children (p<0.005). In 2015/2016, low socioeconomic conditions and diarrhea persisted and a larger family size, black, negative self-perception of happiness, both from the mother (p<0.05), were identified.

Conclusion

The factors of the recent decrease of vaccination coverage are complex, multifactorial, dependent of context and even on subjective aspects of the maternal perception. Its identification contributed to the understanding of inadequate vaccination at the state level.

Does exposure to health information through mobile phones increase immunisation knowledge, completeness and timeliness in rural India?

Introduction

Immunisation plays a vital role in reducing child mortality and morbidity against preventable diseases. As part of a randomised controlled trial in rural Madhya Pradesh, India to assess the impact of Kilkari, a maternal messaging programme, we explored determinants of parental immunisation knowledge and immunisation practice (completeness and timeliness) for children 0–12 months of age from four districts in Madhya Pradesh.

Methods

Data were drawn from a cross-sectional survey of women (n=4423) with access to a mobile phone and their spouses (n=3781). Parental knowledge about immunisation and their child’s receipt of vaccines, including timeliness and completeness, was assessed using self-reports and vaccination cards. Ordered logistic regressions were used to analyse the factors associated with parental immunisation knowledge. A Heckman two-stage probit model was used to analyse completeness and timeliness of immunisation after correcting for selection bias from being able to produce the immunisation card.

Results

One-third (33%) of women and men knew the timing for the start of vaccinations, diseases linked to immunisations and the benefits of Vitamin-A. Less than half of children had received the basic package of 8 vaccines (47%) and the comprehensive package of 19 vaccines (44%). Wealth was the most significant determinant of men’s knowledge and of the child receiving complete and timely immunisation for both basic and comprehensive packages. Exposure to Kilkari content on immunisation was significantly associated with an increase in men’s knowledge (but not women’s) about child immunisation (OR: 1.23, 95% CI 1.02 to1.48) and an increase in the timeliness of the child receiving vaccination at birth (Probit coefficient: 0.08, 95% CI 0.08 to 0.24).

Conclusion

Gaps in complete and timely immunisation for infants persist in rural India. Mobile messaging programmes, supported by mass media messages, may provide one important source for bolstering awareness, uptake and timeliness of immunisation services.

Trial registration number

NCT03576157.

Effects of engaging communities in decision-making and action through traditional and religious leaders on vaccination coverage in Cross River State, Nigeria: A cluster-randomised control trial

Background

Vaccination coverage levels fall short of the Global Vaccine and Action Plan 90% target in low- and middle- income countries (LMICs). Having identified traditional and religious leaders (TRLs) as potential public health change agents, this study aimed at assessing the effect of training them to support routine immunisation for the purpose of improving uptake of childhood vaccines in Cross River State, Nigeria.

Methods

A cluster-randomised controlled study was conducted between 2016 and 2019. Of the 18 Local Government Areas (LGA) in Cross River State, eight (four urban and four rural LGAs) were randomized into the intervention and control study arms. A multi-component intervention involving the training of traditional and religious leaders was implemented in the four intervention LGAs. Baseline, midline and endline surveys collected information on children aged 0–23 months. The effect of the intervention on outcomes including the proportion fully up-to-date with vaccination, timely vaccination for pentavalent and measles vaccines, and pentavalent 1–3 dropout rates were estimated using logistic regression models using random effects to account for the clustered data.

Results

A total of 2598 children at baseline, 2570 at midline, and 2550 at endline were included. The intervention was effective in increasing the proportion with at least one vaccine (OR 12.13 95% CI 6.03–24.41p<0.001). However, there was no evidence of an impact on the proportion of children up-to-date with vaccination (p = 0.69). It was effective in improving timeliness of Pentavalent 3 (OR 1.55; 95% CI: 1.14, 2.12; p = 0.005) and Measles (OR 2.81; 96% CI: 1.93–4.1; p<0.001) vaccination. The odds of completing Pentavalent vaccination increased (OR = 1.66 95% CI: 1.08,2.55).

Conclusion

Informal training to enhance the traditional and religious leaders’ knowledge of vaccination and their leadership role can empower them to be good influencers for childhood vaccination. They constitute untapped resources in the community to boost routine immunisation.

Pan African Clinical Trial Registry (PACTR) PACTR202008784222254.

Determinants of childhood vaccination in Nagaland, India: a cross-sectional study with multilevel modelling

OBJECTIVES

Childhood vaccination coverage in Nagaland has lagged almost all states in India for more than two decades. This study aims to find drivers and barriers of childhood vaccination in Nagaland from the perspective of demand, supply and local health governance.

DESIGN

A cross-sectional study was designed using a survey conducted by the Directorate of Health and Family in 2015.

SETTING

Households, community-based health centres and health committees were surveyed.

PARTICIPANTS

285 children aged under 2 years with vaccination cards and data on households, health centres and health committees were included.

OUTCOMES

Variables indicating whether a child received each of bacillus calmette-guérin (BCG), diphtheria-tetanus-pertussis (DTP3), oral polio (OPV3) and measles vaccination and all of them were outcome variables. Associated factors were identified using multilevel logistic regressions.

RESULTS

Antenatal care at least three times was significantly associated with BCG, DTP3, OPV3 and full vaccination with adjusted ORs ranging from 2.4 (95% CI 1.1 to 5.1) to 3.3 (1.1 to 9.9). The availability of bus to health centre was slightly significant for BCG and OPV3 with the adjusted ORs of 2.0 (0.9 to 4.5) and 2.1 (0.9 to 4.8), respectively. Health committees' budget provision to health centres was significant for OPV3 and full vaccination with the respective adjusted ORs of 15.7 (1.0 to 234.1) and 15.9 (1.2 to 214.7), the wide 95% CIs of which were driven by a small sample size. Health committees' review of expenditure of health centres was significant for measles and full vaccination with the adjusted ORs of 4.0 (1.4 to 11.4) and 5.2 (1.4 to 19.4), respectively.

CONCLUSION

This study suggests that enhancing the utilisation of antenatal care and providing reliable transportation between villages and health centres are required to improve childhood vaccination coverage. Also, the significant association of budget administration of health committees suggests that supporting local health committees for effective financial management is important.

Determining Significant Factors Affecting Vaccine Demand and Factor Relationships Using Fuzzy DEMATEL Method

Even though deadly effects of outbreaks such as SARS, H1N1, EBOLA and COVID-19 took the attention of the community, generating 100% vaccination uptake from people who are expected to be affected by such outbreaks is almost impossible. Hence, determining the actual vaccine demand for typical viruses and reaching this population are becoming important issues to prevent from spreading such viruses like wildfire. Many countries have been forecasting vaccine demand according to birth rates. However, factors such as district-level per capita income, literacy rate, urbanization, and some other factors should also be considered for more accurate forecasts. There is another factor affecting countries’ vaccine demand; some of the vaccines that WHO recommends are included in the national immunization programs, while others are only recommended. Thus, this study first aims to explore the most significant factors that affect the demand of vaccines that are not included in national immunization campaigns then to present the cause and effect relationships among the factors using the fuzzy DEMATEL method to provide insights to managers for better vaccine demand forecast and to increase vaccine uptake. According to the analysis results, immunization related beliefs is the most important factor among others included in this research.

Impact of Multiple Risk Factors on Vaccination Inequities: Analysis in Indian Infants Over 2 Decades

INTRODUCTION

Several authors have explored the effect of individual risk factors on vaccination inequity in Indian infants. This study explores the combined impact of >1 risk factor on the probability of full vaccination.

METHODS

The proportion of fully vaccinated infants (aged 1-2 years) was calculated from the National Family Health Survey conducted during 1997-1998 (National Family Health Survey-2, n=10,211), 2005-2006 (National Family Health Survey-3, n=9,582), and 2015-2016 (National Family Health Survey-4, n=48,715). Full vaccination was defined as receiving Bacille Calmette‒Guerin (1 dose); diphtheria, pertussis, tetanus (3 doses); oral polio (3 doses); and measles (1 dose) vaccines. The association between full vaccination status and 6 factors (infant sex, birth order, family wealth status, maternal education level, residence type, and religion) was analyzed individually, followed by the combined impact of ≥1 of the first 4, using logistic regression models.

RESULTS

The AORs for full vaccination in the 3 surveys, respectively, were 1.09, 1.13, and 1.00 for male versus female infants; 0.68, 0.71, and 0.88 for birth order >1 versus birth order 1; 1.54, 1.96, and 1.20 for greater wealth versus lowest wealth stratum; 2.21, 2.27, and 1.27 for any maternal education versus none; 1.08, 1.10, and 1.08 for Hindu versus other religion; and 1.51, 1.10, and 0.88 for urban versus rural residence. The respective ORs of full vaccination in the 3 surveys by the number of risk factors were as follows: 1.26, 1.54, and 1.27 for 3 risk factors; 2.41, 3.23, and 1.68 for 2 risk factors; 4.42, 6.45, and 2.18 for 1 risk factor; and 7.32, 9.84, and 2.61 for no risk factor.

CONCLUSIONS

The presence of multiple risk factors had a cumulative negative impact on infant vaccination in India. Despite an improvement over 2 decades, significant inequities persist.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Social and behavioral determinants of attitudes towards and practices of hepatitis B vaccine birth dose in Vietnam

BACKGROUND

Hepatitis B virus (HBV) infection is a significant public health issue in Vietnam. Our goal was to understand the determinants of attitudes towards and practices of hepatitis B vaccine birth dose (HepB-BD) in certain regions of Vietnam.

METHOD

A rapid qualitative assessment was conducted in three geographically diverse provinces that reported low coverage (<50%) of HepB-BD. Using purposive sampling of participants, 29 focus group discussions and 20 in-depth interviews were held with caregivers (n = 96), healthcare providers (n = 75), and healthcare administrators (n = 16). Summary notes from these were translated, and inductive coding was used to derive themes. The SAGE Vaccine Hesitancy Determinants Matrix was used as a theoretical framework to organize barriers and facilitators associated with the themes into three levels of influence.

RESULTS

At the individual and group level, caregivers who had higher levels of knowledge about HepB-BD sought the vaccine proactively, while others with lower knowledge faced barriers to the vaccine. Some caregivers reported a negative attitude toward health services because of a language barrier or had generalized concerns about HepB-BD due to media reporting of the past adverse events. Distress arising from potential adverse events was equally common among healthcare providers. At the contextual level, the physical environment made it difficult for caregivers to access healthcare facilities and for providers to conduct outreach. Home births posed a challenge for timely administration of HepB-BD, while health facility births facilitated it. Vaccination-specific barriers included misinterpretation of pre-vaccination screening criteria and asking for the consent of caregivers. Inadequate resources for service delivery negatively influenced HepB-BD attitudes and practices.

CONCLUSION

Given the diversity of barriers associated with attitudes towards and practices of HepB-BD in the three provinces, tailored interventions will be necessary for both demand- and supply-side factors. Rural areas, often with more home births and geographic barriers, may require focused attention.

Structural equation modeling to detect correlates of childhood vaccination: A moderated mediation analysis

Objectives

This study used a health belief theory derived framework and structural equation model to examine moderators, mediators, and direct and indirect predictors of childhood vaccination.

Methods

A secondary analysis was conducted using data collected from a cross-sectional survey of a random sample of 1599 parents living in urban and rural areas of Mysore district, India. Applying two-stage probability proportionate-to-size sampling, adolescent girls attending 7^th through 10^th grades in 23 schools were selected to take home a questionnaire to be answered by their parents to primarily assess HPV vaccine intentions. Parents were also asked whether their children had received one dose of Bacillus Calmette–Guérin; three doses of Diphtheria, Pertussis, Tetanus; three doses of oral Polio vaccine; and one dose of Measles vaccine. In addition, parents were asked about their attitudes towards childhood vaccination.

Results

Out of the 1599 parents, 52.2% reported that their children had received all the routine vaccines (fully vaccinated); 42.7% reported their children had missed at least one routine vaccine, and 5.2% reported that their children had missed all routine vaccinations. Perceptions about the benefits/facilitators to childhood vaccination significantly predicted the full vaccination rate (standardized regression coefficient (β) = 0.29) directly and mediated the effect of parental education (β = 0.11) and employment (β = -0.06) on the rate of full vaccination. Parental education was significantly associated indirectly with higher rates of full vaccination (β = 0.11). Parental employment was significantly associated indirectly with decreasing rates of full vaccination (β = -0.05). Area of residence moderated the role of religion (β = 0.24) and the ‘number of children’ in a family (β = 0.33) on parental perceptions about barriers to childhood vaccination. The model to data fit was acceptable (Root Mean Square Error of Approximation = 0.02, 95% CI 0.018 to 0.023; Comparative Fit Index = 0.92; Tucker–Lewis Index = 0.91).

Conclusions

Full vaccination rate was relatively low among children in Mysore, especially among parents who were unsure about the benefits of routine vaccination and those with low educational levels. Interventions increasing awareness of the benefits of childhood vaccination that target rural parents with lower levels of education may help increase the rate of full childhood vaccination in India.

Perplexing condition of child full immunisation in economically better off Gujarat in India: An assessment of associated factors

BACKGROUND

Despite decent progress in Children Full Immunisation (CFI) in India during the last decade, surprisingly, Gujarat, an economically more developed state, had the second-lowest coverage of CFI (50%) in the country, lower than economically less developed states such as Bihar (62%). Further, the proportion of children with no immunisation in Gujarat has risen from 5% in 2005 to 9% in 2016. This paper investigated factors associated with the low level of CFI coverage in Gujarat.

METHODS

The study used two types of datasets: (1) the information on immunisation from 7730 children aged 12-23 months and their mothers from the fourth round of the Gujarat chapter of National Family Health Survey (NFHS 2015-16). (2) A macro (district) level data on both supply and demand-side factors of CFI are compiled from multiple sources. Bivariate and multivariate linear and logistic regression techniques were employed to identify the factors associated with CFI coverage.

RESULTS

In Gujarat, during 2015-2016, 50% of children aged 12-23 months did not receive full immunisation. The odds of receiving CFI was higher among children whose mothers had a Maternal and Child Protection (MCP) card (OR: 1.97, 95% CI 1.48-2.60) and those who received "high" maternal health services utilisation (OR: 1.59, 95% CI 1.10-2.26) compared to their counterparts. The odds of receiving CFI was about three times higher among the richest households (OR: 6.50, 95% CI 3.75-11.55) compared to their counterparts in the poorer households. Macro-level analyses suggest that poverty, maternal health care, and higher-order births are defining factors of CFI coverage in Gujarat.

CONCLUSIONS

In order of importance, focusing on poverty, economic inequalities, pregnancy registration, and maternal health care services utilisation are likely to improve receiving CFI uptake in Gujarat. The disadvantageous position of urban areas and non-scheduled tribes in CFI coverage needs further investigation.

Inequalities in Rotavirus Vaccine Uptake in Ethiopia: A Decomposition Analysis

A previous study in Ethiopia reported significant variation in rotavirus vaccine uptake across socioeconomic strata. This study aims to quantify socioeconomic inequality of rotavirus vaccine uptake in Ethiopia and to identify the contributing factors for the inequality. The concentration curve (CC) and the Erreygers Normalized Concentration Index (ECI) were used to assess the socioeconomic related inequality in rotavirus vaccine uptake using data from the 2016 Ethiopian Demographic and Health Survey. Decomposition analysis was conducted to identify the drivers of inequalities. The CC for rotavirus vaccine uptake lay below the line of equality and the ECI was 0.270 (p < 0.001) indicating that uptake of rotavirus vaccine in Ethiopia was significantly concentrated among children from families with better socioeconomic status. The decomposition analysis showed that underlining inequalities in maternal health care services utilization, including antenatal care use (18.4%) and institutional delivery (8.1%), exposure to media (12.8%), and maternal educational level (9.7%) were responsible for the majority of observed inequalities in the uptake of rotavirus vaccine. The findings suggested that there is significant socioeconomic inequality in rotavirus vaccine uptake in Ethiopia. Multi-sectoral actions are required to reduce the inequalities, inclusive increasing maternal health care services, and educational attainments among economically disadvantaged mothers.

Diphtheria resurgence in India: A case study from south Karnataka

Corynebacterium diphtheriae is a gram-positive bacillus with characteristic polar metachromatic granules. It was a significant public health problem, infecting the throat and upper airways and producing a highly potent exotoxin but with the advent of diphtheria vaccine, cases have rapidly decreased. Now over the last decade, the reemergence of this infection has been noted and case reports from India have been documented. India represents 78% of globally reported cases with significant mortality despite national immunization programs in place. This case study indicates the severity of an improperly managed case, the importance of microbiological diagnosis with a special interest in molecular detection, and reinforces a resurgence of diphtheria infection.

Diphtheria

Diphtheria is a potentially fatal infection mostly caused by toxigenic Corynebacterium diphtheriae strains and occasionally by toxigenic C. ulcerans and C. pseudotuberculosis strains. Diphtheria is generally an acute respiratory infection, characterized by the formation of a pseudomembrane in the throat, but cutaneous infections are possible. Systemic effects, such as myocarditis and neuropathy, which are associated with increased fatality risk, are due to diphtheria toxin, an exotoxin produced by the pathogen that inhibits protein synthesis and causes cell death. Clinical diagnosis is confirmed by the isolation and identification of the causative Corynebacterium spp., usually by bacterial culture followed by enzymatic and toxin detection tests. Diphtheria can be treated with the timely administration of diphtheria antitoxin and antimicrobial therapy. Although effective vaccines are available, this disease has the potential to re-emerge in countries where the recommended vaccination programmes are not sustained, and increasing proportions of adults are becoming susceptible to diphtheria. Thousands of diphtheria cases are still reported annually from several countries in Asia and Africa, along with many outbreaks. Changes in the epidemiology of diphtheria have been reported worldwide. The prevalence of toxigenic Corynebacterium spp. highlights the need for proper clinical and epidemiological investigations to quickly identify and treat affected individuals, along with public health measures to prevent and contain the spread of this disease.

Are providers' recommendation and knowledge associated with uptake of optional vaccinations among children? A multilevel analysis in three provinces of China

BACKGROUND

Immunization services providers play a crucial role in the successful implementation of immunization, particularly for new vaccines. Several childhood vaccinations that are important for public health are not included in the National Immunization Programme in China, although they are available as optional and self-paid vaccines. Their coverage remains low.

OBJECTIVE

To examine the association between providers' knowledge and recommendations of optional vaccines, as well as other supply- and demand-side factors, and their uptake among children.

METHODS

A cross-sectional study, that included an in-person questionnaire survey for parents of children under-3 years and a self-administrative questionnaire survey for their vaccination services providers, was conducted in 36 townships or sub-districts in three provinces of China in 2013. Using a sample of 1791 household from 30 townships or sub-districts, we applied multilevel logistic analyses to examine the factors associated with the uptake of optional vaccines based on a hierarchal framework that combined demand-side and supply-side factors.

RESULTS

Coverage of optional childhood vaccinations varied across small areas. Supply- and demand-side factors were both associated with the uptake of these vaccines. Immunization services providers' recommendations and their knowledge about optional vaccination were positively and significantly associated with uptake. Children were more likely to receive the vaccines if they lived in communities with higher immunization worker density or larger immunization clinics. Several demand-side psychological factors about childhood vaccination were also associated with optional vaccinations.

CONCLUSIONS

Promoting immunization services providers to conduct evidence-based recommendations about some important childhood optional vaccinations and enhancing their knowledge regarding optional vaccinations and communication skills are useful strategies to increase the coverage of these vaccinations.

Mapping vaccination coverage to explore the effects of delivery mechanisms and inform vaccination strategies

The success of vaccination programs depends largely on the mechanisms used in vaccine delivery. National immunization programs offer childhood vaccines through fixed and outreach services within the health system and often, additional supplementary immunization activities (SIAs) are undertaken to fill gaps and boost coverage. Here, we map predicted coverage at 1 × 1 km spatial resolution in five low- and middle-income countries to identify areas that are under-vaccinated via each delivery method using Demographic and Health Surveys data. We compare estimates of the coverage of the third dose of diphtheria-tetanus-pertussis-containing vaccine (DTP3), which is typically delivered through routine immunization (RI), with those of measles-containing vaccine (MCV) for which SIAs are also undertaken. We find that SIAs have boosted MCV coverage in some places, but not in others, particularly where RI had been deficient, as depicted by DTP coverage. The modelling approaches outlined here can help to guide geographical prioritization and strategy design.

What is causing high polio vaccine dropout among Pakistani children?

OBJECTIVES

Although the antipolio drive is undertaken across Pakistan, there are still children who have not received any oral polio vaccine or are unable to complete recommended doses of polio vaccine. This study aims at empirically analyzing the associated factors with the no oral polio vaccination (OPV) and OPV dropout groups of children in Pakistan.

STUDY DESIGN

This is a cross-sectional study.

METHODS

Data were obtained from the three waves of Pakistan Demographic and Health Survey of children aged between 12 and 23 months (1990-1991: n = 1214; 2006-2007: n = 1522; 2012-2013: n = 2074). Children who received no OPV and those who drop out of polio vaccination (OPV1-OPV3) were considered as outcome variables. The bivariate relationship of outcome variable with each socio-economic, demographic, and spatial variable is estimated with a P-value of <0.01. For both no OPV and OPV dropout children, we used logistic regression analysis separately.

RESULTS

The percentage of children aged 12-23 months who dropped out of OPV1-OPV3 vaccination was about 76% in the year 1990-1991; 21% in 2006-2007, and 17.5% in 2012-2013 at the national level. Among all indicators, provinces, rural versus urban residence, the mother's age at marriage, the child's birth place (home versus hospital), parental education, and household wealth status are significant predictors of no OPV and/or OPV dropout in Pakistan. Among provinces, Balochistan, Khyber Pakhtunkhwa (KPK), and Sindh are the lagging provinces.

CONCLUSION

Improving the socio-economic status of women helps decrease the chance of polio dropout and thus improves service delivery and program implementation.

Demand-side determinants of timely vaccination of oral polio vaccine in social mobilization network areas of CORE Group polio project in Uttar Pradesh, India

Background

Children who receive all doses of scheduled vaccines reduce their susceptibility to vaccine-preventable diseases. In India, full immunization coverage has increased significantly. However, only a small proportion of children are immunized on time. Globally, studies on factors affecting coverage of childhood immunization have found a significant impact by demand and supply-side determinants. This paper explores the demand-side determinants of timely immunization of the third dose of oral polio vaccine (OPV3) among children aged 6–11 months in the catchment areas of CORE Group Polio Project India.

Methods

We analyzed secondary de-identified data from a household level ‘Doers and Non-doers survey’ conducted in 2015. Determinants of timely OPV3 immunization were identified by modeling the characteristics of index children and survey respondents, surveyed households, respondents’ media habits, their exposure to immunization services and perceptions towards child immunization, through a multinomial regression analysis.

Results

The eight demand-side predictors based on the background characteristics and perceptions of caregivers determined timely vaccination of OPV3. The strongest predictor of timely OPV3 immunization was found to be the fathers’ educational level. Children of uneducated or lesser educated fathers had increased odds of not receiving the OPV1 vaccination, as compared to children of more educated fathers (OR > 10). Respondents who strongly perceived other (non-health) benefits of child immunization were three times more likely to timely vaccinate their children than those who do not. Furthermore, mothers who disagreed with the positive attributes of child immunization were 25 times more likely to delay or not to take their children for OPV immunization on time.

Conclusions

This study found eight essential factors that are responsible for timely OPV3. Despite limitations in data collection and analysis, immunization programs in India could use the eight identified demand-side determinants of timeliness and tailor communication strategies accordingly. We suggest that program communication efforts be directed at male community members; such messaging should address parents’ perceptions of non-health benefits and stress the positive attributes of child immunization. Further investigation would be helpful to assess the various risk factors of under-vaccination as well as vaccinators’ understating about timely immunization.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3129-2) contains supplementary material, which is available to authorized users.

Impact evaluation of a community engagement intervention in improving childhood immunization coverage: a cluster randomized controlled trial in Assam, India

BACKGROUND

To improve immunization coverage, most interventions that are part of the national immunization program in India address supply-side challenges. But, there is growing evidence that addressing demand-side factors can potentially contribute to improvement in childhood vaccination coverage in low- and middle-income countries. Participatory engagement of communities can address demand-side barriers while also mobilizing the community to advocate for better service delivery. The objective of this study is to evaluate the impact of a novel community engagement approach in improving immunization coverage. In our proposed intervention, we go a step beyond merely engaging the community and strive towards increasing 'ownership' by the communities.

METHODS/DESIGN

We adopt a cluster randomized design with two groups to evaluate the intervention in Assam, a state in the northeast region of India. To recruit villages and participants at baseline, we used a two-stage stratified random sampling method. We stratified villages; our unit of randomization, based on census data and randomly selected villages from each of the four strata. At the second-stage, we selected random sub-sample of eligible households (having children in the age group of 6-23 months) from each selected village. The study uses a repeated cross sectional design where we track the same sampled villages but draw independent random samples of households at baseline and endline. Total number of villages required for the study is 180 with 15 eligible HHs from each village. Post-baseline survey, we adopt a stratified randomization strategy to achieve better balance in intervention and control groups, leveraging information from the extensive baseline survey.

DISCUSSION

The proposed intervention can help identify barriers to vaccination at the local level and potentially lead to more sustainable solutions over the long term. Our sampling design, sample size calculation, and randomization strategy address internal validity of our evaluation design. We believe that it would allow us to causally relate any observed changes in immunization coverage to the intervention.

TRIAL REGISTRATION

The trial has been registered on 7th February, 2017 under the Clinical Trials Registry- India (CTRI), hosted at the ICMR's National Institute of Medical Statistics, having registration number CTRI/2017/02/007792 . This is the original study protocol.

Factors associated with routine childhood vaccine uptake and reasons for non-vaccination in India: 1998-2008

BACKGROUND

Despite almost three decades of the Universal Immunization Program in India, a little more than half the children aged 12-23months receive the full schedule of routine vaccinations. We examined socio-demographic factors associated with partial-vaccination and non-vaccination and the reasons for non-vaccination among Indian children during 1998 and 2008.

METHODS

Data from three consecutive, nationally-representative, District Level Household and Facility Surveys (1998-99, 2002-04 and 2007-08) were pooled. Multinomial logistic regression was used to identify individual and household level socio-demographic variables associated with the child's vaccination status. The mother's reported reasons for non-vaccination were analyzed qualitatively, adapting from a previously published framework.

RESULTS

The pooled dataset contained information on 178,473 children 12-23months of age; 53%, 32% and 15% were fully vaccinated, partially vaccinated and unvaccinated respectively. Compared with the 1998-1999 survey, children in the 2007-2008 survey were less likely to be unvaccinated (Adjusted Prevalence Odds Ratio (aPOR): 0.92, 95%CI=0.86-0.98) but more likely to be partially vaccinated (aPOR: 1.58, 95%CI=1.52-1.65). Vaccination status was inversely associated with female gender, Muslim religion, lower caste, urban residence and maternal characteristics such as lower educational attainment, non-institutional delivery, fewer antenatal care visits and non-receipt of maternal tetanus vaccination. The mother's reported reasons for non-vaccination indicated gaps in awareness, acceptance and affordability (financial and non-financial costs) related to routine vaccinations.

CONCLUSIONS

Persisting socio-demographic disparities related to partial-vaccination and non-vaccination were associated with important childhood, maternal and household characteristics. Further research investigating the causal pathways through which maternal and social characteristics influence decision-making for childhood vaccinations is needed to improve uptake of routine vaccination in India. Also, efforts to increase uptake should address parental fears related to vaccination to improve trust in government health services as part of ongoing social mobilization and communication strategies.