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Zegeye AF, Tamir TT, Mekonen EG, Ali MS, Gonete AT, Techane MA, Wassie M, Kassie AT, Ahmed MA, Tsega SS, Wassie YA, Tekeba B, Workneh BS. Number of tetanus toxoid injections before birth and associated factors among pregnant women in low and middle income countries: Negative binomial poisson regression. Hum Vaccin Immunother 2024; 20:2352905. [PMID: 38772729 PMCID: PMC11110706 DOI: 10.1080/21645515.2024.2352905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/04/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND In low- and middle-income countries where vaccination rates are low, tetanus is still an important threat to public health. Although maternal and neonatal tetanus remains a major global health concern, its magnitude and determinates are not well studied. Therefore, this study aimed to assess the number of tetanus toxoid injections and associated factors among pregnant women in low- and middle-income countries. METHODS Data from the most recent Demographic and Health Surveys, which covered 60 low- and middle-income countries from 2010 to 2022, was used for secondary data analysis. The study included a total of 118,704 pregnant women. A statistical software package, STATA 14, was used to analyze the data. A negative binomial regression of a cross-sectional study was carried out. Factors associated with the number of tetanus vaccinations were declared significant at a p-value of < 0.05. The incidence rate ratio and confidence interval were used to interpret the results. A model with the smallest Akaike Information Criterion and Bayesian Information Criterion values and the highest log likelihood was considered the best-fit model for this study. RESULTS In low- and middle-income countries, 26.0% of pregnant women took at least two doses of the tetanus toxoid vaccine. Factors such as maternal education, primary (IRR = 1.22, 95% CI: 1.17, 1.26), secondary (IRR = 1.19, 95% CI: 1.15, 1.23), higher (IRR = 1.16, 95% CI: 1.12, 1.20), employment (IRR = 1.11, 95% CI: 1.09, 1.13), 1-3 ANC visits (IRR = 2.49, 95% CI: 2.41, 2.57), ≥4 visits (IRR = 2.94, 95% CI: 2.84, 3.03), wealth index (IRR = 1.06; 95% CI: 11.04, 1.08), ≥birth order (IRR = 1.04, 95% CI: 1.02, 1.27), distance to health facility (IRR = 1.02, 95% CI: 1.00, 1.03), and health insurance coverage (IRR = 1.08; 95% CI: 1.06, 1.10) had a significant association with the number of tetanus vaccinations among pregnant women. CONCLUSIONS AND RECOMMENDATIONS This study concludes that the number of tetanus toxoid vaccinations among pregnant women in low- and middle-income countries is low. In the negative binomial model, the frequency of tetanus vaccinations has a significant association with maternal employment, educational status, wealth index, antenatal care visits, birth order, distance from a health facility, and health insurance. Therefore, the ministries of health in low and middle-income countries should give attention to those women who had no antenatal care visits and women from poor wealth quantiles while designing policies and strategies.
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Affiliation(s)
- Alebachew Ferede Zegeye
- Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tadesse Tarik Tamir
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Enyew Getaneh Mekonen
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mohammed Seid Ali
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Almaz Tefera Gonete
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Masresha Asmare Techane
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mulugeta Wassie
- School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Alemneh Tadesse Kassie
- Department of Clinical Midwifery, School of Midwifery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Medina Abdela Ahmed
- Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Sintayehu Simie Tsega
- Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yilkal Abebaw Wassie
- Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Berhan Tekeba
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Belayneh Shetie Workneh
- Department of Emergency and Critical Care Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Aguinaga-Ontoso I, Guillen-Aguinaga S, Guillen-Aguinaga L, Alas-Brun R, Onambele L, Aguinaga-Ontoso E, Guillen-Grima F. COVID-19 Impact on DTP Vaccination Trends in Africa: A Joinpoint Regression Analysis. Vaccines (Basel) 2023; 11:1103. [PMID: 37376492 DOI: 10.3390/vaccines11061103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/24/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Deaths due to vaccine-preventable diseases are one of the leading causes of death among African children. Vaccine coverage is an essential measure to decrease infant mortality. The COVID-19 pandemic has affected the healthcare system and may have disrupted vaccine coverage. METHODS DTP third doses (DTP3) Vaccine Coverage was extracted from UNICEF databases from 2012 to 2021 (the last available date). Joinpoint regression was performed to detect the point where the trend changed. The annual percentage change (APC) with 95% confidence intervals (95% CI) was calculated for Africa and the regions. We compared DTP3 vaccination coverage in 2019-2021 in each country using the Chi-square test. RESULT During the whole period, the vaccine coverage in Africa increased with an Annual Percent change of 1.2% (IC 95% 0.9-1.5): We detected one joinpoint in 2019. In 2019-2021, there was a decrease in DTP3 coverage with an APC of -3.5 (95% -6.0; -0,9). (p < 0.001). Vaccination rates decreased in many regions of Sub-Saharan Africa, especially in Eastern and Southern Africa. There were 26 countries (Angola, Cabo Verde, Comoros, Congo, Côte d'Ivoire, Democratic Republic of the Congo, Djibouti, Ethiopia, Eswatini, The Gambia, Guinea-Bissau, Liberia, Madagascar, Malawi, Mauritania, Mauritius, Mozambique, Rwanda, Senegal, Seychelles, Sierra Leone, Sudan, Tanzania, Togo, Tunisia, Uganda, and Zimbabwe) where the vaccine coverage during the two years decreased. There were 10 countries (Angola, Cabo Verde, Comoros, Democratic Republic of the Congo, Eswatini, The Gambia, Mozambique, Rwanda, Senegal, and Sudan) where the joinpoint regression detected a change in the trend. CONCLUSIONS COVID-19 has disrupted vaccine coverage, decreasing it all over Africa.
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Affiliation(s)
- Ines Aguinaga-Ontoso
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain
- Healthcare Research Institute of Navarra (IdiSNA), 31008 Pamplona, Spain
| | | | - Laura Guillen-Aguinaga
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain
- Sykepleieavdelingen, Suldal Sykehjem, 4230 Sand, Norway
| | - Rosa Alas-Brun
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain
| | - Luc Onambele
- School of Health Sciences, Catholic University of Central Africa, Yaounde 1110, Cameroon
| | | | - Francisco Guillen-Grima
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain
- Healthcare Research Institute of Navarra (IdiSNA), 31008 Pamplona, Spain
- Department of Preventive Medicine, Clínica Universidad de Navarra, 31008 Pamplona, Spain
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Mekuria DK, Hailu G, Bedimo M, Tefera AA. Determinants of default from full completion of vaccination among children between 12 and 23 months old in Yilmana Densa district, west Gojam zone, Ethiopia, 2019. Front Public Health 2022; 10:974858. [PMID: 36311590 PMCID: PMC9615568 DOI: 10.3389/fpubh.2022.974858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/31/2022] [Indexed: 01/21/2023] Open
Abstract
Background Vaccination is one of the best cost-effective public health interventions to safeguard children from vaccine-preventable diseases. In Ethiopia, the prevalence of default to the full completion of child immunization is high. However, the determinants of default to full completion have not been thoroughly investigated in this study area. Therefore, this study assessed the determinants of default to the full compilation of vaccination among children between 12 and 23 months old in Yilmana Densa District, west Gojam, northwest Ethiopia. Methods A community-based unmatched case-control study design was employed in the Yilmana Densa district among 343 (111 cases and 232 controls) randomly selected 12-23 months old children. Face-to-face interviews were used to collect data using a multistage sampling method. For analysis, data were entered into epidata version 3.1 and exported to SPSS 23 software. Descriptive analysis followed by binary and multivariable logistic regression analysis was conducted. The statistical significance was declared at a p-value of 0.05. Result This study identified that mothers who had not attended ANC follow-up [AOR = 5.55, 95% CI: (1.789-17.217)], mothers who had not gotten information about vaccinations [AOR = 8.589, 95% CI: (4.414-16.714)], and mothers whose time taken to reach vaccination site is more than 39 min were at higher risk to default from completion of vaccination [AOR = 3.252, 95% CI: (1.952-5.417)]. Furthermore, maternal waiting time (>45 min) for child vaccination [AOR = 2.674, 95% CI: (1.517-4.714)] and home delivery [AOR 3.19, 95% CI: (1.751-5.814)] were risk factors to default child from full completion of vaccination. Conclusion Mothers delivered at home, mothers not attending ANC follow-up, mothers who did not get health information about the vaccine, mothers taking longer time to reach the vaccination site, and staying longer time for child vaccination are causes of default. Motivated institutional delivery services utilization is recommended. The district office should consider the distribution of vaccination sites by the opening of new outreach site to reduce the waiting time of mothers.
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Affiliation(s)
| | - Getachew Hailu
- Health Science College, Bahir Dar University, Bahir Dar, Ethiopia
| | - Melkamu Bedimo
- Health Science College, Bahir Dar University, Bahir Dar, Ethiopia
| | - Alemu Adela Tefera
- Department of Biomedical Science, Health Science College, Debre Berhan University, Debre Berhan, Ethiopia,*Correspondence: Alemu Adela Tefera
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Srivastava S, Kumar P, Chauhan S, Banerjee A. Household expenditure for immunization among children in India: a two-part model approach. BMC Health Serv Res 2021; 21:1001. [PMID: 34551769 PMCID: PMC8459463 DOI: 10.1186/s12913-021-07011-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 09/10/2021] [Indexed: 01/12/2023] Open
Abstract
Background Despite the Indian government’s Universal Immunization Program (UIP), the progress of full immunization coverage is plodding. The cost of delivering routine immunization varies widely across facilities within country and across country. However, the cost an individual bears on child immunization has not been focussed. In this context, this study tries to estimate the expenditure on immunization which an individual bears and the factors affecting immunization coverage at the regional level. Methods Using the 75th round of National Sample Survey Organization data, the present paper attempts to check the individual expenditure on immunization and the factors affecting immunization coverage at the regional level. Descriptive statistics and multivariate regression analysis were used to fulfil the study objectives. The two-part model has been employed to inspect the determinants of expenditure on immunization. Results The overall prevalence of full immunization was 59.3 % in India. Full immunization was highest in Manipur (75.2 %) and lowest in Nagaland (12.8 %). The mean expenditure incurred on immunization varies from as low as Rs. 32.7 in Tripura to as high as Rs. 1008 in Delhi. Children belonging to the urban area [OR: 1.04; CI: 1.035, 1.037] and richer wealth quintile [OR: 1.14; CI: 1.134–1.137] had higher odds of getting immunization. Moreover, expenditure on immunization was high among children from the urban area [Rs. 273], rich wealth quintile [Rs. 297] and who got immunized in a private facility [Rs. 1656]. Conclusions There exists regional inequality in immunization coverage as well as in expenditure incurred on immunization. Based on the findings, we suggest looking for the supply through follow-up and demand through spreading awareness through mass media for immunization. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07011-0.
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Affiliation(s)
- Shobhit Srivastava
- Department of Mathematical Demography & Statistics, International Institute for Population Sciences, Mumbai, India
| | - Pradeep Kumar
- Department of Mathematical Demography & Statistics, International Institute for Population Sciences, Mumbai, India.
| | - Shekhar Chauhan
- Department of Population Policies and Programmes, International Institute for Population Sciences, Mumbai, India
| | - Adrita Banerjee
- Department of Public Health and Mortality Studies, International Institute for Population Sciences, Mumbai, India
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Sahito A, Ahmed S, Fatmi Z. Covering the last mile for vaccination: Feasibility and acceptability of traditional birth attendant-based referral system in hard-to-reach areas in rural Pakistan. J Glob Health 2020; 10:021303. [PMID: 33437466 PMCID: PMC7774025 DOI: 10.7189/jogh.10.021303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Pakistan has a decent network of community-based workers including lady health workers (LHWs) and vaccinators. However, a major section of the population is not covered by LHWs/vaccinators, labeled here as hard-to-reach (HTR) areas, where immunization coverage is also considerably low. This study explored the feasibility of engagement of traditional birth attendants (TBAs) to improve EPI vaccination coverage in HTR areas in rural Sindh, Pakistan. Methods This implementation research was conducted in two sub-districts of Sukkur (a district in Sindh Province). In an HTR selected intervention arm, TBAs were trained for vaccination and monetary incentives were provided to counsel and refer mothers for vaccination. While LHWs covered areas in the adjacent sub-district were provided with refresher training for vaccination only without any monetary incentive, and were considered as control arm. Considering the inherent differences in intervention and comparison group (HTR intervention area being worse regarding infrastructure and access), between groups and within group change in knowledge of TBA/LHWs and vaccination coverage was assessed before and after the intervention. Furthermore, focus group discussions were conducted with vaccinators, TBAs and LHWs and in-depth interviews with supervisors of vaccinators. Results TBAs and LHWs' vaccine related knowledge increased significantly after training (pretest vs post test score: 10.5 to 15.4). The BCG coverage improved 74.1% (percentage change) in TBA arm. While completion of vaccination (ie, Penta-3 coverage) increased by 147% from baseline following the intervention. The TBAs, LHWs, vaccinators and their supervisors all welcomed the initiative and considered it as a feasible option. Conclusions Involvement of TBAs' to form a referral system has potential to improve vaccine coverage and completion in HTR areas in Pakistan. The system is acceptable to the population and implementation is feasible due to availability of TBAs. However, in order to sustain the initiative minimal incentive need to be provided to TBAs to improve the vaccination coverage. Compared to establishing the infrastructure in HTR the intervention seems less costly however, it requires formal cost-effective or cost-benefit analysis.
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Affiliation(s)
- Ambreen Sahito
- Department of Community Medicine, Isra University Hyderabad, Pakistan
| | - Siraj Ahmed
- Department of Health, Government of Sindh, Pakistan
| | - Zafar Fatmi
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
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Trends, Spatial Disparities, and Social Determinants of DTP3 Immunization Status in Indonesia 2004-2016. Vaccines (Basel) 2020; 8:vaccines8030518. [PMID: 32927862 PMCID: PMC7563731 DOI: 10.3390/vaccines8030518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 11/17/2022] Open
Abstract
Although 91% of 12-23-month-old children in Indonesia received at least one immunization in 2013, only 76% completed DTP3 immunization. This percentage is below the UNICEF and WHO recommended standards. Thus, this study aims to investigate trends, spatial disparities, and social determinants related to low coverage of DTP3 immunization in Indonesia. Using a multilevel approach, we analyzed data from 305,090 12-23-month-old children living across approximately 500 districts in Indonesia to study demand and supply factors determining DTP3 immunization status. We examined unique, nationally representative data from the National Socioeconomic Survey (Survei Sosial Ekonomi Nasional or Susenas) and Village Potential Census (Potensi Desa or Podes) from 2004 to 2016. The percentage of children receiving complete DTP3 immunization increased from 37.8% in 2004 to 75.9% in 2016. Primarily income, parity status, and education, showed influence on DTP3 coverage. Among individual-level factors, the presence of a professional birth attendant was the most influential factor. At the district level, the factors varied. Low progress in DTP3 immunization status in Indonesia is due to huge disparities across the country's islands, in the density of health services, and in household socioeconomic status.
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Imran W, Abbas F, Javed SA. What is causing high polio vaccine dropout among Pakistani children? Public Health 2018; 164:16-25. [PMID: 30153528 DOI: 10.1016/j.puhe.2018.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 05/24/2018] [Accepted: 07/10/2018] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- W Imran
- Idara-e-Talim-o-Aghai (ITA), Center for Education and Consciousness, Islamabad, Pakistan.
| | - F Abbas
- Courant Research Center, "Poverty, Equity and Growth in Developing and Transition Countries", Department of Economics, George August University, Goettingen, Germany.
| | - S A Javed
- Head Policy Solution Lab, Sustainable Development Policy Institute (SDPI), Islamabad, Pakistan.
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Anatea MD, Mekonnen TH, Dachew BA. Determinants and perceptions of the utilization of tetanus toxoid immunization among reproductive-age women in Dukem Town, Eastern Ethiopia: a community-based cross-sectional study. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2018; 18:27. [PMID: 29950171 PMCID: PMC6022706 DOI: 10.1186/s12914-018-0168-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 06/20/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Maternal and neonatal tetanus (MNT) is still the major public health problem in about 25 countries, mainly in Africa and Asia. However, the utilization of intervention strategies, like tetanus toxoid (TT) immunization remains low in these countries. In Ethiopia, only 49% of the pregnant mothers received TT2+ in 2016. This study was designed to evaluate perceptions and factors affecting the utilization of TT immunization among reproductive-age women in Dukem town, Eastern Ethiopia, 2016. METHODS We conducted a community-based cross-sectional study from May to October 2016. A simple random sampling method was employed to select samples of 422 women. Data were collected using a, pretested semi-structured and a face-to-face interviewer-administered questionnaire. We entered data in to Epi Info version 7 and analyzed them by SPSS version 20 software. Odds ratios and a 95% CI at 0 < 0.05 p-value were calculated to ascertain the significance of associations. RESULTS Response rate was 98.6% (N = 416). Mean age with standard deviation was 29.25± 5.11 years, and average family size was 4.19. Our study showed the utilization of TT immunization was 39.2% (N = 163). Of the participants, 33.9% (N = 141) had never been vaccinated. ANC follow up service [AOR: 2.56, 95% CI: (1.18, 5.49)], distance from health facilities [AOR: 2.27, 95% CI: (1.27, 4.09)], knowing vaccination date [AOR: 1.98, 95% CI: (1.23, 3.18)], having a TV set in the house [AOR: 1.80, 95% CI: (1.11, 2.917)], maternal education [AOR: 1.41, 95% CI: (1.84, 2.30), and place of delivery [AOR: 1.19, 95% CI: (1.00, 1.43)] were factors significantly associated with the utilization of TT immunization. CONCLUSIONS This study indicated the utilization of TT immunization was low. ANC service follow up, distance from health facilities, knowing vaccination date, having a TV in the house, mothers' educational status, and place of delivery were significant predictors. Our study suggests that policymakers and other stakeholders should consider the need for increasing access to maternal education, like basic adult education, ANC follow up services, providing accessible health facilities, improving varieties of communication media, promoting female occupational status, and providing appropriate vaccination cards.
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Affiliation(s)
| | - Tesfaye Hambisa Mekonnen
- Department of Environmental and Occupational Health and Safety, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia.
| | - Berihun Assefa Dachew
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Aregawi HG, Gebrehiwot TG, Abebe YG, Meles KG, Wuneh AD. Determinants of defaulting from completion of child immunization in Laelay Adiabo District, Tigray Region, Northern Ethiopia: A case-control study. PLoS One 2017; 12:e0185533. [PMID: 28953970 PMCID: PMC5617221 DOI: 10.1371/journal.pone.0185533] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 09/14/2017] [Indexed: 11/30/2022] Open
Abstract
Background Globally 2.5 million children under five years of age die every year due to vaccine preventable diseases. In Tigray Region in Northern Ethiopia, full vaccination coverage in children is low. However, the determinants of defaulting from completion of immunization have not been studied in depth. This study aimed to identify the determinants of defaulting from child immunization completion among children aged 9–23 months in the Laelay Adiabo District, North Ethiopia. Methods An unmatched community based case-control study design was conducted among children aged 9–23 months in the Laelay Adiabo District from February—March 2015. A survey was conducted to identify the existence of cases and controls. Two hundred and seventy children aged 9–23 months (90 cases and 180 controls) were recruited from 11 kebeles (the smallest administrative units) by a simple random sampling technique using computer based Open Epi software. Cases were children aged 9–23 months who missed at least one dose of the recommended vaccine. Controls were children aged 9–23 months who had received all recommended vaccines. Data were collected from mothers/care givers using structured pretested questionnaire. The data were entered into Epi Info version 3.5.1 and analyzed using Statistical Package for Social Sciences (SPSS) version 21. Bivariate and Multiple logistic regression analysis were used to identify the predictors of the outcome variable. The degree of association was assessed by using odds ratio with 95% Confidence Interval (CI). Result This study shows that mothers who take >30 minutes to reach the vaccination site (Adjusted Odds Ratio (AOR) = 3.56,95%CI:1.58–8.01); households not visited by health extension workers at least monthly (AOR = 2.68,95%CI:1.30–5.51); poor participation in women's developmental groups (AOR = 3.3,95%CI 1.54–7.08); no postnatal care follow-up (AOR = 5.2,95%CI:2.36–11.46); and poor knowledge of child immunization (AOR = 3.3,95%CI:1.87–7.43) were predictors of defaulting from completion of child immunization. Conclusion Postnatal care follow-up, household visits by health extension workers and maternal participation in women’s development groups are important mediums for disseminating information and increasing knowledge to mothers about child immunization. To reduce the rate of defaulters, health providers should motivate and counsel mothers to attend postnatal care. Health extension workers should visit households at least once per month and strengthen mothers’ participation in the women’s development groups.
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Affiliation(s)
| | | | | | | | - Alem Desta Wuneh
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
- * E-mail:
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Guarecuco R, Lu J, McHugh KJ, Norman JJ, Thapa LS, Lydon E, Langer R, Jaklenec A. Immunogenicity of pulsatile-release PLGA microspheres for single-injection vaccination. Vaccine 2017. [PMID: 28625520 PMCID: PMC5960071 DOI: 10.1016/j.vaccine.2017.05.094] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The World Health Organization's Expanded Programme on Immunization has led to a dramatic rise in worldwide vaccination rates over the past 40 years, yet 19.4 million infants remain underimmunized each year. Many of these infants have received at least one vaccine dose but may remain unprotected because they did not receive subsequent booster doses due to logistical challenges. This study aimed to develop injectable controlled release microparticles with kinetics that mimic common vaccine dosing regimens consisting of large antigen doses administered periodically over the course of months in order to eliminate the need for boosters. Sixteen poly(lactic-co-glycolic acid) (PLGA) microsphere formulations containing bovine serum albumin (BSA) as a model vaccine antigen were screened in vitro to determine their respective release kinetics. Three formulations that exhibited desirable pulsatile release profiles were then selected for studying immunogenicity in mice. Two low-dose microsphere formulations induced peak anti-BSA IgG antibody titers of 13.9 ± 1.3 and 13.7 ± 2.2 log2 compared to 15.5 ± 1.5 log2 for a series of three bolus injections delivered at 0, 4, and 8 weeks with an equivalent cumulative dose. Similarly, high-dose formulations induced peak antibody titers that were 16.1 ± 2.1 log2 compared to 17.7 ± 2.2 log2 for controls. All three microparticle formulations studied in vivo induced peak antibody titers that were statistically similar to bolus controls. These results suggest that pulsatile antigen release from polymeric microparticles is a promising approach for single-injection vaccination, which could potentially reduce the logistical burden associated with immunization in the developing world.
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Affiliation(s)
- Rohiverth Guarecuco
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, 500 Main Street, Cambridge, MA 02142, USA
| | - Jennifer Lu
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, 500 Main Street, Cambridge, MA 02142, USA
| | - Kevin J McHugh
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, 500 Main Street, Cambridge, MA 02142, USA
| | - James J Norman
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, 500 Main Street, Cambridge, MA 02142, USA
| | - Lavanya S Thapa
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, 500 Main Street, Cambridge, MA 02142, USA
| | - Emily Lydon
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, 500 Main Street, Cambridge, MA 02142, USA
| | - Robert Langer
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, 500 Main Street, Cambridge, MA 02142, USA.
| | - Ana Jaklenec
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, 500 Main Street, Cambridge, MA 02142, USA.
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Ghosh A, Laxminarayan R. Demand- and supply-side determinants of diphtheria-pertussis-tetanus nonvaccination and dropout in rural India. Vaccine 2017; 35:1087-1093. [PMID: 28081971 PMCID: PMC5297340 DOI: 10.1016/j.vaccine.2016.12.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 12/08/2016] [Accepted: 12/09/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although 93% of 12- to 23-month-old children in India receive at least one vaccine, typically Bacillus Calmette-Guérin, only 75% complete the recommended three doses of diphtheria-pertussis-tetanus (DPT, also referred to as DTP) vaccine. Determinants can be different for nonvaccination and dropout but have not been examined in earlier studies. We use the three-dose DPT series as a proxy for the full sequence of recommended childhood vaccines and examine the determinants of DPT nonvaccination and dropout between doses 1 and 3. METHODS We analyzed data on 75,728 6- to 23-month-old children in villages across India to study demand- and supply-side factors determining nonvaccination with DPT and dropout between DPT doses 1 and 3, using a multilevel approach. Data come from the District Level Household and Facility Survey 3 (2007-08). RESULTS Individual- and household-level factors were associated with both DPT nonvaccination and dropout between doses 1 and 3. Children whose mothers had no schooling were 2.3 times more likely not to receive any DPT vaccination and 1.5 times more likely to drop out between DPT doses 1 and 3, compared with children whose mothers had 10 or more years of schooling. Although supply-side factors related to availability of public health facilities and immunization-related health workers in villages were not correlated with dropout between DPT doses 1 and 3, children in districts where 46% or more villages had a healthcare subcentre were 1.5 times more likely to receive at least one dose of DPT vaccine compared with children in districts where 30% or fewer villages had subcentres. CONCLUSIONS Nonvaccination with DPT in India is influenced by village- and district-level contextual factors over and above individuals' background characteristics. Dropout between DPT doses 1 and 3 is associated more strongly with demand-side factors than with village- and district-level supply-side factors.
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Affiliation(s)
- Arpita Ghosh
- Public Health Foundation of India, Gurgaon, Haryana, India.
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA; Princeton University, Princeton, NJ, USA.
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Tan T, Dalby T, Forsyth K, Halperin SA, Heininger U, Hozbor D, Plotkin S, Ulloa-Gutierrez R, Wirsing von König CH. Pertussis Across the Globe: Recent Epidemiologic Trends From 2000 to 2013. Pediatr Infect Dis J 2015; 34:e222-32. [PMID: 26376316 DOI: 10.1097/inf.0000000000000795] [Citation(s) in RCA: 165] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pertussis has reemerged as a problem across the world. To better understand the nature of the resurgence, we reviewed recent epidemiologic data and we report disease trends from across the world. Published epidemiologic data from January 2000 to July 2013 were obtained via PubMed searches and open-access websites. Data on vaccine coverage and reported pertussis cases from 2000 through 2012 from the 6 World Health Organization regions were also reviewed. Findings are confounded not only by the lack of systematic and comparable observations in many areas of the world but also by the cyclic nature of pertussis with peaks occurring every 3-5 years. It appears that pertussis incidence has increased in school-age children in North America and western Europe, where acellular pertussis vaccines are used, but an increase has also occurred in some countries that use whole-cell vaccines. Worldwide, pertussis remains a serious health concern, especially for infants, who bear the greatest disease burden. Factors that may contribute to the resurgence include lack of booster immunizations, low vaccine coverage, improved diagnostic methods, and genetic changes in the organism. To better understand the epidemiology of pertussis and optimize disease control, it is important to improve surveillance worldwide, irrespective of pertussis vaccine types and schedules used in each country.
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Affiliation(s)
- Tina Tan
- *Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL; †Department of Immunology, Microbiology, and Molecular Biology, Statens Serum Institut, Copenhagen, Denmark; ‡Department of Pediatrics, Flinders University, Adelaide, Australia; §Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada; ¶Department of Pediatrics, University Children's Hospital (UKBB), University of Basel, Basel, Switzerland; ‖Department of Pediatrics, Laboratorio VacSal, Instituto de Biotecnología y Biología Molecular (IBBM), Facultad de Ciencias Exactas, Universidad Nacional de La Plata, CCT-CONICET La Plata, Argentina; **Department of Pediatrics, University of Pennsylvania, Philadelphia, PA; ††Department of Pediatrics, Hospital Nacional de Niños de Costa Rica "Dr. Carlos Sáenz Herrera," San José, Costa Rica; and ‡‡Labor:Medizin Krefeld MVZ, Krefeld, Germany
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Carnell MA, Dougherty L, Pomeroy AM, Karim AM, Mekonnen YM, Mulligan BE. Effectiveness of scaling up the 'three pillars' approach to accelerating MDG 4 progress in Ethiopia. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2014; 32:549-563. [PMID: 25895187 PMCID: PMC4438684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This paper describes the integrated approach taken by the Government of Ethiopia with support from the Essential Services for Health in Ethiopia (ESHE) Project and assesses its effect on the coverage of six child health practices associated with reducing child mortality. The ESHE Project was designed to contribute to reducing high child mortality rates at scale among 14.5 million people through the 'three pillars' approach. This approach aimed to (i) strengthen health systems, (ii) improve health workers' performance, and (iii) engage the community. The intervention was designed with national and subnational stakeholders' input. To measure the Project's effect on the coverage of child health practices, we used a quasi-experimental design, with representative household survey data from the three most populous regions of Ethiopia, collected at the 2003-2004 baseline and 2008 endline surveys of the Project. Adifference-in-differences analysis model detected an absolute effect of the ESHE intervention of 8.4% points for DTP3 coverage (p=0.007), 12.9% points for measles vaccination coverage (p<0.001), 12.6% points for latrines (p=0.002), and 9.8% points for vitamin A supplementation (p<0.001) across the ESHE-intervention districts (woredas) compared to all non-ESHE districts of the same three regions. Improvements in the use of modern family planning methods and exclusive breastfeeding were not significant. Important regional variations are discussed. ESHE was one of several partners of the Ministry of Health whose combined efforts led to accelerated progress in the coverage of child health practices.
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Fatiregun AA, Etukiren EE. Determinants of uptake of third doses of oral polio and DTP vaccines in the Ibadan North Local Government Area of Nigeria. Int Health 2014; 6:213-24. [PMID: 24844557 DOI: 10.1093/inthealth/ihu027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND High dropout rates in the uptake of oral polio vaccine (OPV) and DTP vaccine persist despite efforts to improve immunisation coverage. This study identified determinants of uptake of third doses of OPV3 and DTP3 among infants who received first doses of either or both vaccines at immunisation centres in the Ibadan North Local Government Area of Nigeria. METHODS Using a cohort study design, 400 mother-child pairs were assessed. A semi-structured, interviewer-administered questionnaire was used to collect data from each participant who were followed up for 90 days. Dates of subsequent doses of the vaccines were recorded. Multivariate analysis was performed using the log-rank test and Cox's regression analysis to identify predictive factors. RESULTS Only 43.5% (174/400) and 24.8% (89/359) of children completed the OPV3 and DTP3 vaccines, respectively. Factors predictive of uptake of OPV3 were first birth (HR=1.66, 95% CI 1.11-2.48) and attending a tertiary health facility (HR=2.27, 95% CI 1.41-3.65), while attending a secondary health facility was significant for DTP3 uptake (HR=2.43, 95% CI 1.30-4.61). CONCLUSIONS Uptake of third doses of vaccines was influenced by the type of health facility attended and the child birth order. Efforts to reduce vaccination dropouts should include creation of awareness of the importance of completing immunisation schedules for children of higher birth orders as well as improved service delivery at health facilities.
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Affiliation(s)
- Akinola Ayoola Fatiregun
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Emem Emmanuel Etukiren
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
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Zaidi SMA, Khowaja S, Kumar Dharma V, Khan AJ, Chandir S. Coverage, timeliness, and determinants of immunization completion in Pakistan: evidence from the Demographic and Health Survey (2006-07). Hum Vaccin Immunother 2014; 10:1712-20. [PMID: 24784118 DOI: 10.4161/hv.28621] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Immunization coverage data and determinants for completion are not well described for Pakistan. This study determines immunization coverage rates and timeliness based on the 2006-07 Pakistan Demographic and Health Survey (DHS) and identifies determinants for completion of immunizations. METHODS DHS data from 9177 randomly selected households from across Pakistan were analyzed to assess immunization coverage and timeliness for children aged 0-5 years, and to investigate determinants of immunization completion through logistic regressions. RESULTS The proportion of children immunized for a third dose of the oral poliovirus vaccine (OPV3) was 80.3%, and combination diphtheria, tetanus, and pertussis vaccines (DTP3) was 55.9%. Measles coverage was 62.5%. Late immunizations were most likely to occur for third doses of the OPV (65.5%) and DTP series (65.5%). Early doses were most likely to be administered for measles (21.9%). The proportion of children not immunized for any vaccine was 6.2%. Receiving a dose of maternal tetanus was a major determinant for immunization completion for OPV3 (OR 1.35, 95% CI: 1.14-1.60), DTP3 (OR 2.54, 95% CI: 2.13-3.02), and measles (OR 2.78, 95% CI: 2.27-3.40). Other independent variables associated with improved immunization completion included higher household wealth and maternal education. CONCLUSION Poor routine immunization coverage and timeliness were identified through the DHS in Pakistan. Encouraging maternal tetanus uptake among women of child-bearing age and greater integration of immunization services with antenatal care may help improve childhood immunization completion.
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Affiliation(s)
| | - Saira Khowaja
- Interactive Research & Development; Karachi, Pakistan
| | | | - Aamir J Khan
- Interactive Research & Development; Karachi, Pakistan
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Bugvi AS, Rahat R, Zakar R, Zakar MZ, Fischer F, Nasrullah M, Manawar R. Factors associated with non-utilization of child immunization in Pakistan: evidence from the Demographic and Health Survey 2006-07. BMC Public Health 2014; 14:232. [PMID: 24602264 PMCID: PMC3973983 DOI: 10.1186/1471-2458-14-232] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 02/25/2014] [Indexed: 11/10/2022] Open
Abstract
Background The proportion of incompletely immunized children in Pakistan varies from 37-58%, and this has recently resulted in outbreaks of measles and polio. The aim of this paper is to determine the factors associated with incomplete immunization among children aged 12-23 months in Pakistan. Methods Secondary analysis was conducted on nationally representative cross-sectional survey data from the Pakistan Demographic and Health Survey, 2006-07. The analysis was limited to ever-married mothers who had delivered their last child during the 23 months immediately preceding the survey (n = 2,435). ‘Complete immunization’ was defined as the child having received twelve doses of five vaccines, and ‘incomplete immunization’ was defined if he/she had missed at least one of these twelve doses. The association between child immunization status and determinants of non-utilization of vaccines was assessed by calculating unadjusted and adjusted odds ratios (AOR) with 95% confidence intervals using a multivariable binary logistic regression. Results The findings of this research showed that nearly 66% of children were incompletely immunized against seven preventable childhood diseases. The likelihood of incomplete immunization was significantly associated with the father’s occupation as a manual worker (AOR = 1.47; 95% CI: 1.10-1.97), lack of access to information (AOR = 1.35; 95% CI: 1.09-1.66), non-use of antenatal care (AOR = 1.33; 95% CI: 1.07-1.66), children born in Baluchistan region (AOR = 1.74; 95% CI: 1.12-2.70) and delivery at home (AOR = 1.39; 95% CI: 1.14-1.69). Conclusions Despite governmental efforts to increase rates of immunization against childhood diseases, the proportion of incompletely immunized children in Pakistan is still high. Targeted interventions are needed to increase the immunization rates in Pakistan. These interventions need to concentrate on people with low socioeconomic and educational status in order to improve their knowledge of this topic.
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Affiliation(s)
| | | | | | | | - Florian Fischer
- Department of Public Health Medicine, School of Public Health, Bielefeld University, Bielefeld, Germany.
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Shah M, Shams S, Rahman Z. Molecular relationship between field and vaccine strain of measles virus and its persistence in Pakistan. GENETIC VACCINES AND THERAPY 2012; 10:1. [PMID: 22284834 PMCID: PMC3298470 DOI: 10.1186/1479-0556-10-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 01/30/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Countrywide 5.9 million, 0-11 Month old children are immunized annually by EPI (Expended Program on Immunization) against 8 vaccine preventable diseases including measles and so on. Unfortunately the basic immunity centers are not uniform throughout the country. Each center provides services to about 27000 people which is inadequate. The purpose of this study was to explore the development of EPI Pakistan in terms of immunization of measles. METHODS Nucleotide sequences were analyzed by neighbor joining method (bootstrap test) using Bio- edit and MEGA-5 software to find evolutionary relationship between wild type measles strain and vaccine strain (Edmonston strain) used in Pakistan. For statistical analysis of data SPSS 16 was used. RESULTS Currently 1.3 vaccinators are working at each U C (union council) which according to national EPI policy should be at least 2. About 56% and 44% children of age 0-11 months did not received second dose of measles in the last two years respectively. Out of these 4231 cases which were reported last year, 1370 have received their first dose of measles vaccine. CONCLUSION Seroconversion and seroprevalence study of the vaccine and field strain of measles virus is needed to confirm whether its failure is due to service unavailability or vaccine in-affectivity.
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Affiliation(s)
- Masaud Shah
- Center of Excellence in Molecular Biology (CEMB), University of the Punjab, Lahore, Pakistan
| | - Sulaiman Shams
- Center of Excellence in Molecular Biology (CEMB), University of the Punjab, Lahore, Pakistan
| | - Ziaur Rahman
- Center of Excellence in Molecular Biology (CEMB), University of the Punjab, Lahore, Pakistan
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Fatiregun AA, Okoro AO. Maternal determinants of complete child immunization among children aged 12–23 months in a southern district of Nigeria. Vaccine 2012; 30:730-6. [DOI: 10.1016/j.vaccine.2011.11.082] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Revised: 11/12/2011] [Accepted: 11/19/2011] [Indexed: 10/14/2022]
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Shah M, Khan MK, Shakeel S, Mahmood F, Sher Z, Sarwar MB, Sumrin A. Resistance of polio to its eradication in Pakistan. Virol J 2011; 8:457. [PMID: 21962145 PMCID: PMC3192783 DOI: 10.1186/1743-422x-8-457] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 10/02/2011] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND This study is based on EPI (Expanded Program on Immunization) immunization surveys and surveillance of polio, its challenges in immunization and the way forward to overcome these challenges. METHODS Several Government documents, survey reports and unpublished program documents were studied and online search was made to find information on EPI Pakistan. SPSS 16 and Microsoft Excel 2007 were used for the statistical analysis. RESULTS Immunization against polio is higher in urban areas as compared to rural areas. Marked variation in vaccination has been observed in different provinces of Pakistan in the last decade. Secondly 10-20% of the children who have received their first dose of trivalent polio vaccine were deprived of their 2nd and 3rd dose because of poor performance of EPI and Lack of information about immunization. CONCLUSION In spite of numerous successes, such as the addition of new vaccines and raising immunization to over 100% in some areas, EPI is still struggling to reach its polio eradication goals. Inadequate service delivery, lack of information about immunization and limited number of vaccinators were found to be the key reason for poor performance of immunization and for large number of cases reported each year due to the deficiency of second and third booster dose.
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Affiliation(s)
- Masaud Shah
- National Center of Excellence in Molecular Biology, University of the Punjab, Lahore, Pakistan
| | - Muhammad Kazim Khan
- National Center of Excellence in Molecular Biology, University of the Punjab, Lahore, Pakistan
| | - Saleha Shakeel
- National Center of Excellence in Molecular Biology, University of the Punjab, Lahore, Pakistan
| | - Faiza Mahmood
- National Center of Excellence in Molecular Biology, University of the Punjab, Lahore, Pakistan
| | - Zunaira Sher
- National Center of Excellence in Molecular Biology, University of the Punjab, Lahore, Pakistan
| | - Muhammad Bilal Sarwar
- National Center of Excellence in Molecular Biology, University of the Punjab, Lahore, Pakistan
| | - Aleena Sumrin
- National Center of Excellence in Molecular Biology, University of the Punjab, Lahore, Pakistan
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Murakami H, Phuong NM, Thang HV, Chau NV, Giao PN, Tho ND. Endemic diphtheria in Ho Chi Minh City; Viet Nam: A matched case–control study to identify risk factors of incidence. Vaccine 2010; 28:8141-6. [DOI: 10.1016/j.vaccine.2010.09.088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 09/18/2010] [Accepted: 09/26/2010] [Indexed: 10/19/2022]
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