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Mohamoud SA, Ali-Salad MA, Bile AS, Singh NS, Mahmud AJ, Nor B. Determinants and prevalence of zero-dose children in Somalia: Analysis of the 2020 Health Demographic Survey data. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002612. [PMID: 38954718 PMCID: PMC11218971 DOI: 10.1371/journal.pgph.0002612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 04/07/2024] [Indexed: 07/04/2024]
Abstract
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.
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Affiliation(s)
| | - Mohamed Abdullahi Ali-Salad
- Somali Institute for Development and Research Analysis (SIDRA), Garowe, Puntland, Somalia
- College of Arts, Humanities and Social Sciences, School of Social and Political Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Ahmed Said Bile
- Somali Institute for Development and Research Analysis (SIDRA), Garowe, Puntland, Somalia
| | - Neha S. Singh
- Global Health and Development Department, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amina J. Mahmud
- Somali Institute for Development and Research Analysis (SIDRA), Garowe, Puntland, Somalia
- Uppsala University, Department of International Maternal and Child Health, Uppsala, Sweden
| | - Barni Nor
- Uppsala University, Department of International Maternal and Child Health, Uppsala, Sweden
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Habib SS, Zaidi S, Riaz A, Tahir HN, Mazhar LA, Memon Z. Social determinants of low uptake of childhood vaccination in high-risk squatter settlements in Karachi, Pakistan - A step towards addressing vaccine inequity in urban slums. Vaccine X 2024; 17:100427. [PMID: 38299204 PMCID: PMC10827488 DOI: 10.1016/j.jvacx.2023.100427] [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: 07/06/2023] [Revised: 12/22/2023] [Accepted: 12/29/2023] [Indexed: 02/02/2024] Open
Abstract
Background Routine vaccination has remained historically low in major urban pockets of Pakistan, and now lags behind rural vaccination rates. Grossly insufficient publicly funded primary healthcare infrastructure, heterogeneous mix of providers and multi-ethnicity of populations pose challenges in the delivery of essential health services. This paper ascertains factors associated with uptake of routine childhood vaccination, using Pentavalent-3 vaccine, as a proxy indicator for completion of age-appropriate vaccines in urban slums of Karachi, at high risk of Polio and vaccine preventable disease outbreaks. Methods Data was drawn from baseline assessment of an urban immunization delivery pilot project in urban slums of Karachi, Pakistan. The study sample comprised of 2,097 households with children aged 4-12 months, sampled through a cross-sectional cluster survey, applying a structured questionnaire. Multivariable logistic regression was used to determine the association between Penta-3 vaccination, as the outcome variable, and predictor variables including socio-demographic characteristics and healthcare access factors. Results The findings showed that the likelihood of being immunized with Penta-3 was higher for non-Pashtun ethnicity [adjusted odds ratio (aOR) 1.69; 95% CI 1.33-2.14], children of educated mothers, secondary or higher [aOR 2.95, 95% CI 2.34-3.71], and those whose fathers were formally employed (aOR 1.53; 95% CI 1.19-1.97). No association was seen by gender of child [aOR 0.89; 95% CI 0.73-1.08], and place of new born delivery [aOR 1.01; 95% CI 0.83-1.24]. Conclusion Pockets of critically low under-vaccinations within the urban slums of Karachi are associated with Pashtun ethnicity, distance to the vaccination centre, lack of mothers' education and lack of stable family income as in the case of unemployed and daily wage-earning fathers. Recognition of these factors is required in designing contextually appropriate strategies to address vaccine inequity in urban settings.
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Affiliation(s)
- Shifa Salman Habib
- Department of Community Health Sciences, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi 74800, Pakistan
| | - Shehla Zaidi
- Department of Community Health Sciences, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi 74800, Pakistan
- Aga Khan University (International), AKU-UK, Aga Khan Centre, 10 Handyside Street, London N1C 4DN, UK
| | - Atif Riaz
- Department of Community Health Sciences, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi 74800, Pakistan
| | - Hasan Nawaz Tahir
- Department of Community Health Sciences, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi 74800, Pakistan
| | - Lala Aftab Mazhar
- Department of Community Health Sciences, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi 74800, Pakistan
| | - Zahid Memon
- Department of Community Health Sciences, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi 74800, Pakistan
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Biks GA, Shiferie F, Tsegaye DA, Asefa W, Alemayehu L, Wondie T, Zelalem M, Lakew Y, Belete K, Gebremedhin S. High prevalence of zero-dose children in underserved and special setting populations in Ethiopia using a generalize estimating equation and concentration index analysis. BMC Public Health 2024; 24:592. [PMID: 38395877 PMCID: PMC10893596 DOI: 10.1186/s12889-024-18077-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Globally, according to the World Health Organization (WHO) 2023 report, more than 14.3 million children in low- and middle-income countries, primarily in Africa and South-East Asia, are not receiving any vaccinations. Ethiopia is one of the top ten countries contributing to the global number of zero-dose children. OBJECTIVE To estimate the prevalence of zero-dose children and associated factors in underserved populations of Ethiopia. METHODS A cross-sectional vaccine coverage survey was conducted in June 2022. The study participants were mothers of children aged 12-35 months. Data were collected using the CommCare application system and later analysed using Stata version 17. Vaccination coverage was estimated using a weighted analysis approach. A generalized estimating equation model was fitted to determine the predictors of zero-dose children. An adjusted odds ratio (AOR) with 95% confidence interval (CI) and a p-value of 0.05 or less was considered statistically significant. RESULTS The overall prevalence of zero-dose children in the study settings was 33.7% (95% CI: 34.9%, 75.7%). Developing and pastoralist regions, internally displaced peoples, newly formed regions, and conflict-affected areas had the highest prevalence of zero-dose children. Wealth index (poorest [AOR = 2.78; 95% CI: 1.70, 4.53], poorer [AOR = 1.96; 95% CI: 1.02, 3.77]), single marital status [AOR = 2.4; 95% CI: 1.7, 3.3], and maternal age (15-24 years) [AOR = 1.2; 95% CI: 1.1, 1.3] were identified as key determinant factors of zero-dose children in the study settings. Additional factors included fewer than four Antenatal care visits (ANC) [AOR = 1.3; 95% CI: 1.2, 1.4], not receiving Postnatal Care (PNC) services [AOR = 2.1; 95% CI: 1.5, 3.0], unavailability of health facilities within the village [AOR = 3.7; 95% CI: 2.6, 5.4], women-headed household [AOR = 1.3; 95% CI:1.02, 1.7], low gender empowerment [AOR = 1.6; 95% CI: 1.3, 2.1], and medium gender empowerment [AOR = 1.7; 95% CI: 1.2, 2.5]. CONCLUSION In the study settings, the prevalence of zero-dose children is very high. Poor economic status, disempowerment of women, being unmarried, young maternal age, and underutilizing antenatal or post-natal services are the important predictors. Therefore, it is recommended to target tailored integrated and context-specific service delivery approach. Moreover, extend immunization sessions opening hours during the evening/weekend in the city administrations to meet parents' needs.
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Affiliation(s)
| | | | | | | | | | - Tamiru Wondie
- Project HOPE, Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Meseret Zelalem
- Maternal and Child Health, Minister of Health, Addis Ababa, Ethiopia
| | - Yohannes Lakew
- Maternal and Child Health, Minister of Health, Addis Ababa, Ethiopia
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Corrêa GC, Uddin MJ, Wahed T, Oliveras E, Morgan C, Kamya MR, Kabatangare P, Namugaya F, Leab D, Adjakidje D, Nguku P, Attahiru A, Sequeira J, Vollmer N, Reynolds HW. Measuring Zero-Dose Children: Reflections on Age Cohort Flexibilities for Targeted Immunization Surveys at the Local Level. Vaccines (Basel) 2024; 12:195. [PMID: 38400178 PMCID: PMC10892624 DOI: 10.3390/vaccines12020195] [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: 01/10/2024] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Zero-dose (ZD) children is a critical objective in global health, and it is at the heart of the Immunization Agenda 2030 (IA2030) strategy. Coverage for the first dose of diphtheria-tetanus-pertussis (DTP1)-containing vaccine is the global operational indicator used to estimate ZD children. When surveys are used, DTP1 coverage estimates usually rely on information reported from caregivers of children aged 12-23 months. It is important to have a global definition of ZD children, but learning and operational needs at a country level may require different ZD measurement approaches. This article summarizes a recent workshop discussion on ZD measurement for targeted surveys at local levels related to flexibilities in age cohorts of inclusion from the ZD learning Hub (ZDLH) initiative-a learning initiative involving 5 consortia of 14 different organizations across 4 countries-Bangladesh, Mali, Nigeria, and Uganda-and a global learning partner. Those considerations may include the need to generate insights on immunization timeliness and on catch-up activities, made particularly relevant in the post-pandemic context; the need to compare results across different age cohort years to better identify systematically missed communities and validate programmatic priorities, and also generate insights on changes under dynamic contexts such as the introduction of a new ZD intervention or for recovering from the impact of health system shocks. Some practical considerations such as the potential need for a larger sample size when including comparisons across multiple cohort years but a potential reduction in the need for household visits to find eligible children, an increase in recall bias when older age groups are included and a reduction in recall bias for the first year of life, and a potential reduction in sample size needs and time needed to detect impact when the first year of life is included. Finally, the inclusion of the first year of life cohort in the survey may be particularly relevant and improve the utility of evidence for decision-making and enable its use in rapid learning cycles, as insights will be generated for the population being currently targeted by the program. For some of those reasons, the ZDLH initiative decided to align on a recommendation to include the age cohort from 18 weeks to 23 months, with enough power to enable disaggregation of key results across the two different cohort years. We argue that flexibilities with the age cohort for inclusion in targeted surveys at the local level may be an important principle to be considered. More research is needed to better understand in which contexts improvements in timeliness of DTP1 in the first year of life will translate to improvements in ZD results in the age cohort of 12-23 months as defined by the global DTP1 indicator.
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Affiliation(s)
- Gustavo C. Corrêa
- Gavi, The Vaccine Alliance, Chemin du Pommier 40, Le Grand Saconnex, 1218 Geneva, Switzerland
| | - Md. Jasim Uddin
- International Centre for Diarrhoeal Disease Research, Bangladesh, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh (T.W.)
| | - Tasnuva Wahed
- International Centre for Diarrhoeal Disease Research, Bangladesh, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh (T.W.)
| | - Elizabeth Oliveras
- Jhpiego, The Johns Hopkins University Affiliate, 1615 Thames Street, Baltimore, MD 21231, USA (C.M.)
| | - Christopher Morgan
- Jhpiego, The Johns Hopkins University Affiliate, 1615 Thames Street, Baltimore, MD 21231, USA (C.M.)
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration (IDRC), Kampala P.O. Box 7475, Uganda; (M.R.K.); (F.N.)
- Department of Medicine, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Patience Kabatangare
- Infectious Diseases Research Collaboration (IDRC), Kampala P.O. Box 7475, Uganda; (M.R.K.); (F.N.)
| | - Faith Namugaya
- Infectious Diseases Research Collaboration (IDRC), Kampala P.O. Box 7475, Uganda; (M.R.K.); (F.N.)
| | - Dorothy Leab
- GaneshAID, 143 Doc Ngu, Lieu Giai, Ba Dinh, Hanoi 152960, Vietnam
| | - Didier Adjakidje
- GaneshAID, 143 Doc Ngu, Lieu Giai, Ba Dinh, Hanoi 152960, Vietnam
| | - Patrick Nguku
- African Field Epidemiology Network (AFENET), 50 Haile Selassie St, Asokoro, Abuja 900103, Nigeria
| | - Adam Attahiru
- African Field Epidemiology Network (AFENET), 50 Haile Selassie St, Asokoro, Abuja 900103, Nigeria
| | - Jenny Sequeira
- The Geneva Learning Foundation (TGLF), Av. Louis-Casaï 18, 1209 Geneva, Switzerland
| | - Nancy Vollmer
- JSI Research & Training Institute, Inc. (JSI), 2733 Crystal Dr 4th Floor, Arlington, VA 22202, USA;
| | - Heidi W. Reynolds
- Gavi, The Vaccine Alliance, Chemin du Pommier 40, Le Grand Saconnex, 1218 Geneva, Switzerland
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Aheto JMK, Olowe ID, Chan HMT, Ekeh A, Dieng B, Fafunmi B, Setayesh H, Atuhaire B, Crawford J, Tatem AJ, Utazi CE. Geospatial Analyses of Recent Household Surveys to Assess Changes in the Distribution of Zero-Dose Children and Their Associated Factors before and during the COVID-19 Pandemic in Nigeria. Vaccines (Basel) 2023; 11:1830. [PMID: 38140234 PMCID: PMC10747017 DOI: 10.3390/vaccines11121830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/25/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
The persistence of geographic inequities in vaccination coverage often evidences the presence of zero-dose and missed communities and their vulnerabilities to vaccine-preventable diseases. These inequities were exacerbated in many places during the coronavirus disease 2019 (COVID-19) pandemic, due to severe disruptions to vaccination services. Understanding changes in zero-dose prevalence and its associated risk factors in the context of the COVID-19 pandemic is, therefore, critical to designing effective strategies to reach vulnerable populations. Using data from nationally representative household surveys conducted before the COVID-19 pandemic, in 2018, and during the pandemic, in 2021, in Nigeria, we fitted Bayesian geostatistical models to map the distribution of three vaccination coverage indicators: receipt of the first dose of diphtheria-tetanus-pertussis-containing vaccine (DTP1), the first dose of measles-containing vaccine (MCV1), and any of the four basic vaccines (bacilli Calmette-Guerin (BCG), oral polio vaccine (OPV0), DTP1, and MCV1), and the corresponding zero-dose estimates independently at a 1 × 1 km resolution and the district level during both time periods. We also explored changes in the factors associated with non-vaccination at the national and regional levels using multilevel logistic regression models. Our results revealed no increases in zero-dose prevalence due to the pandemic at the national level, although considerable increases were observed in a few districts. We found substantial subnational heterogeneities in vaccination coverage and zero-dose prevalence both before and during the pandemic, showing broadly similar patterns in both time periods. Areas with relatively higher zero-dose prevalence occurred mostly in the north and a few places in the south in both time periods. We also found consistent areas of low coverage and high zero-dose prevalence using all three zero-dose indicators, revealing the areas in greatest need. At the national level, risk factors related to socioeconomic/demographic status (e.g., maternal education), maternal access to and utilization of health services, and remoteness were strongly associated with the odds of being zero dose in both time periods, while those related to communication were mostly relevant before the pandemic. These associations were also supported at the regional level, but we additionally identified risk factors specific to zero-dose children in each region; for example, communication and cross-border migration in the northwest. Our findings can help guide tailored strategies to reduce zero-dose prevalence and boost coverage levels in Nigeria.
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Affiliation(s)
- Justice Moses K. Aheto
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton SO17 1BJ, UK; (I.D.O.); (H.M.T.C.); (A.J.T.); (C.E.U.)
- Department of Biostatistics, School of Public Health, College of Health Sciences, University of Ghana, Accra P.O. Box LG13, Ghana
| | - Iyanuloluwa Deborah Olowe
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton SO17 1BJ, UK; (I.D.O.); (H.M.T.C.); (A.J.T.); (C.E.U.)
| | - Ho Man Theophilus Chan
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton SO17 1BJ, UK; (I.D.O.); (H.M.T.C.); (A.J.T.); (C.E.U.)
- School of Mathematical Sciences, University of Southampton, Southampton SO17 1BJ, UK
| | | | | | | | | | - Brian Atuhaire
- Gavi, The Vaccine Alliance, Geneva, Switzerland; (H.S.); (B.A.); (J.C.)
| | - Jessica Crawford
- Gavi, The Vaccine Alliance, Geneva, Switzerland; (H.S.); (B.A.); (J.C.)
| | - Andrew J. Tatem
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton SO17 1BJ, UK; (I.D.O.); (H.M.T.C.); (A.J.T.); (C.E.U.)
| | - Chigozie Edson Utazi
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton SO17 1BJ, UK; (I.D.O.); (H.M.T.C.); (A.J.T.); (C.E.U.)
- School of Mathematical Sciences, University of Southampton, Southampton SO17 1BJ, UK
- Department of Statistics, Nnamdi Azikiwe University, Awka PMB 5025, Nigeria
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Farrenkopf BA, Zhou X, Shet A, Olayinka F, Carr K, Patenaude B, Chido-Amajuoyi OG, Wonodi C. Understanding household-level risk factors for zero dose immunization in 82 low- and middle-income countries. PLoS One 2023; 18:e0287459. [PMID: 38060516 PMCID: PMC10703331 DOI: 10.1371/journal.pone.0287459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 06/06/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION In 2021, an estimated 18 million children did not receive a single dose of routine vaccinations and constitute the population known as zero dose children. There is growing momentum and investment in reaching zero dose children and addressing the gross inequity in the reach of immunization services. To effectively do so, there is an urgent need to characterize more deeply the population of zero dose children and the barriers they face in accessing routine immunization services. METHODS We utilized the most recent DHS and MICS data spanning 2011 to 2020 from low, lower-middle, and upper-middle income countries. Zero dose status was defined as children aged 12-23 months who had not received any doses of BCG, DTP-containing, polio, and measles-containing vaccines. We estimated the prevalence of zero-dose children in the entire study sample, by country income level, and by region, and characterized the zero dose population by household-level factors. Multivariate logistic regressions were used to determine the household-level sociodemographic and health care access factors associated with zero dose immunization status. To pool multicountry data, we adjusted the original survey weights according to the country's population of children 12-23 months of age. To contextualize our findings, we utilized United Nations Population Division birth cohort data to estimate the study population as a proportion of the global and country income group populations. RESULTS We included a total of 82 countries in our univariate analyses and 68 countries in our multivariate model. Overall, 7.5% of the study population were zero dose children. More than half (51.9%) of this population was concentrated in African countries. Zero dose children were predominantly situated in rural areas (75.8%) and in households in the lowest two wealth quintiles (62.7%) and were born to mothers who completed fewer than four antenatal care (ANC) visits (66.5%) and had home births (58.5%). Yet, surprisingly, a considerable proportion of zero dose children's mothers did receive appropriate care during pregnancy (33.5% of zero dose children have mothers who received at least 4 ANC visits). When controlled for other factors, children had three times the odds (OR = 3.00, 95% CI: 2.72, 3.30) of being zero dose if their mother had not received any tetanus injections, 2.46 times the odds (95% CI: 2.21, 2.74) of being zero dose if their mother had not received any ANC visits, and had nearly twice the odds (OR = 1.87, 95% CI: 1.70, 2.05) of being zero dose if their mother had a home delivery, compared to children of mothers who received at least 2 tetanus injections, received at least 4 ANC visits, and had a facility delivery, respectively. DISCUSSION A lack of access to maternal health care was a strong risk factor of zero dose status and highlights important opportunities to improve the quality and integration of maternal and child health programs. Additionally, because a substantial proportion of zero dose children and their mothers do receive appropriate care, approaches to reach zero dose children should incorporate mitigating missed opportunities for vaccination.
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Affiliation(s)
- Brooke Amara Farrenkopf
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Xiaobin Zhou
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Anita Shet
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Folake Olayinka
- United States Department of International Development, Immunization Team, District of Columbia, Washington, DC, United States of America
| | - Kelly Carr
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Bryan Patenaude
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Onyema Greg Chido-Amajuoyi
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Chizoba Wonodi
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Dhalaria P, Kapur S, Singh AK, Priyadarshini P, Dutta M, Arora H, Taneja G. Exploring the Pattern of Immunization Dropout among Children in India: A District-Level Comparative Analysis. Vaccines (Basel) 2023; 11:vaccines11040836. [PMID: 37112748 PMCID: PMC10143302 DOI: 10.3390/vaccines11040836] [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: 02/28/2023] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
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.
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Affiliation(s)
- Pritu Dhalaria
- Immunization Technical Support Unit, Ministry of Health & Family Welfare, New Delhi 110070, India
| | | | - Ajeet Kumar Singh
- Immunization Technical Support Unit, Ministry of Health & Family Welfare, New Delhi 110070, India
| | - Pretty Priyadarshini
- Immunization Technical Support Unit, Ministry of Health & Family Welfare, New Delhi 110070, India
| | - Mili Dutta
- Immunization Technical Support Unit, Ministry of Health & Family Welfare, New Delhi 110070, India
| | | | - Gunjan Taneja
- Bill & Melinda Gates Foundation, New Delhi 110067, India
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Hogan D, Gupta A. Why Reaching Zero-Dose Children Holds the Key to Achieving the Sustainable Development Goals. Vaccines (Basel) 2023; 11:vaccines11040781. [PMID: 37112693 PMCID: PMC10142906 DOI: 10.3390/vaccines11040781] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Immunization has one of the highest coverage levels of any health intervention, yet there remain zero-dose children, defined as those who do not receive any routine immunizations. There were 18.2 million zero-dose children in 2021, and as they accounted for over 70% of all underimmunized children, reaching zero-dose children will be essential to meeting ambitious immunization coverage targets by 2030. While certain geographic locations, such as urban slum, remote rural, and conflict-affected settings, may place a child at higher risk of being zero-dose, zero-dose children are found in many places, and understanding the social, political, and economic barriers they face will be key to designing sustainable programs to reach them. This includes gender-related barriers to immunization and, in some countries, barriers related to ethnicity and religion, as well as the unique challenges associated with reaching nomadic, displaced, or migrant populations. Zero-dose children and their families face multiple deprivations related to wealth, education, water and sanitation, nutrition, and access to other health services, and they account for one-third of all child deaths in low- and middle-income countries. Reaching zero-dose children and missed communities is therefore critical to achieving the Sustainable Development Goals commitment to “leave no one behind”.
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Affiliation(s)
- Dan Hogan
- Gavi, The Vaccine Alliance, 1218 Le Grand-Saconnex, Switzerland
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Fullman N, Correa GC, Ikilezi G, Phillips DE, Reynolds HW. Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children. Vaccines (Basel) 2023; 11:vaccines11030647. [PMID: 36992231 DOI: 10.3390/vaccines11030647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/15/2023] Open
Abstract
Background: Understanding past successes in reaching unvaccinated or “zero-dose” children can help inform strategies for improving childhood immunization in other settings. Drawing from positive outlier methods, we developed a novel approach for identifying potential exemplars in reducing zero-dose children. Methods: Focusing on 2000–2019, we assessed changes in the percentage of under-one children with no doses of the diphtheria–tetanus–pertussis vaccine (no-DTP) across two geographic dimensions in 56 low- or lower-middle-income countries: (1) national levels; (2) subnational gaps, as defined as the difference between the 5th and 95th percentiles of no-DTP prevalence across second administrative units. Countries with the largest reductions for both metrics were considered positive outliers or potential ‘exemplars’, demonstrating exception progress in reducing national no-DTP prevalence and subnational inequalities. Last, so-called “neighborhood analyses” were conducted for the Gavi Learning Hub countries (Nigeria, Mali, Uganda, and Bangladesh), comparing them with countries that had similar no-DTP measures in 2000 but different trajectories through 2019. Results: From 2000 to 2019, the Democratic Republic of the Congo, Ethiopia, and India had the largest absolute decreases for the two no-DTP dimensions—national prevalence and subnational gaps—while Bangladesh and Burundi registered the largest relative reductions for each no-DTP metric. Neighborhood analyses highlighted possible opportunities for cross-country learning among Gavi Learning Hub countries and potential exemplars in reducing zero-dose children. Conclusions: Identifying where exceptional progress has occurred is the first step toward better understanding how such gains could be achieved elsewhere. Further examination of how countries have successfully reduced levels of zero-dose children—especially across variable contexts and different drivers of inequality—could support faster, sustainable advances toward greater vaccination equity worldwide.
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Affiliation(s)
- Nancy Fullman
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - Gustavo C Correa
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, Le Grand-Saconnex, 1218 Geneva, Switzerland
| | - Gloria Ikilezi
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - David E Phillips
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - Heidi W Reynolds
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, Le Grand-Saconnex, 1218 Geneva, Switzerland
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10
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Ducharme J, Correa GC, Reynolds HW, Sharkey AB, Fonner VA, Johri M. Mapping of Pro-Equity Interventions Proposed by Immunisation Programs in Gavi Health Systems Strengthening Grants. Vaccines (Basel) 2023; 11:vaccines11020341. [PMID: 36851218 PMCID: PMC9961887 DOI: 10.3390/vaccines11020341] [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: 12/23/2022] [Revised: 01/17/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
Reaching zero-dose (ZD) children, operationally defined as children who have not received a first dose of the diphtheria, tetanus, and pertussis (DTP1) vaccine, is crucial to increase equitable immunisation coverage and access to primary health care. However, little is known about the approaches already taken by countries to improve immunisation equity. We reviewed all Health System Strengthening (HSS) proposals submitted by Gavi-supported countries from 2014 to 2021 inclusively and extracted information on interventions favouring equity. Pro-equity interventions were mapped to an analytical framework representing Gavi 5.0 programmatic guidance on reaching ZD children and missed communities. Data from keyword searches and manual screening were extracted into an Excel database. Open format responses were analysed using inductive and deductive thematic coding. Data analysis was conducted using Excel and R. Of the 56 proposals included, 51 (91%) included at least one pro-equity intervention. The most common interventions were conducting outreach sessions, tailoring the location of service delivery, and partnerships. Many proposals had "bundles" of interventions, most often involving outreach, microplanning and community-level education activities. Nearly half prioritised remote-rural areas and only 30% addressed gender-related barriers to immunisation. The findings can help identify specific interventions on which to focus future evidence syntheses, case studies and implementation research and inform discussions on what may or may not need to change to better reach ZD children and missed communities moving forward.
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Affiliation(s)
- Joelle Ducharme
- Measurement, Evaluation and Learning Department, Gavi, The Vaccine Alliance, 1218 Le Grand-Saconnex, Switzerland
- Correspondence:
| | - Gustavo Caetano Correa
- Measurement, Evaluation and Learning Department, Gavi, The Vaccine Alliance, 1218 Le Grand-Saconnex, Switzerland
| | - Heidi W. Reynolds
- Measurement, Evaluation and Learning Department, Gavi, The Vaccine Alliance, 1218 Le Grand-Saconnex, Switzerland
| | - Alyssa B. Sharkey
- School of Public and International Affairs, Princeton University, Princeton, NJ 08544, USA
| | | | - Mira Johri
- Carrefour de l’Innovation, Centre de Recherche de l’Université de Montréal (CRCHUM), Montréal, QC H2X 0A9, Canada
- Département de Gestion, D’évaluation, et de Politique de Santé, École de Santé Publique de l’Université de Montréal (ESPUM), Montréal, QC H3N 1X9, Canada
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11
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Taneja G, Datta E, Sapru M, Johri M, Singh K, Jandu HS, Das S, Ray A, Laserson K, Dhawan V. An Equity Analysis of Zero-Dose Children in India Using the National Family Health Survey Data: Status, Challenges, and Next Steps. Cureus 2023; 15:e35404. [PMID: 36851944 PMCID: PMC9963392 DOI: 10.7759/cureus.35404] [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] [Accepted: 02/23/2023] [Indexed: 02/26/2023] Open
Abstract
Background While immunization programs across the world have made considerable progress, children and communities continue to be beyond the reach of healthcare services. Globally, they are now referred to as zero-dose (ZD) children (those who have not received a single dose of diphtheria, pertussis, and tetanus-containing vaccine). Pre-COVID-19 pandemic analyses suggest that nearly 50% of vaccine-preventable deaths occur among ZD children. Two-thirds of these children live in extremely poor households suffering from multiple deprivations including lack of access to reproductive health services, water, and sanitation. Hence, ZD children have now been prioritized as a key cohort for identification and integration with the health systems as we build back from the pandemic. Methodology Extracting data from the last two National Family Health Survey (NFHS) rounds (NFHS 4, 2015-2016 and NFHS 5, 2019-2021), this study aims to ascertain the status of ZD children aged 12-23 months in India, the challenges, and the necessary action agenda going forward. Data were analyzed for equity determinants such as gender, place of residence, religion, birth order, caste, and mother's schooling. Key determinants included the change in ZD prevalence at the national, state, and district levels; variations across equity parameters and states with maximum improvements; and disparity across these indicators. A correlation analysis was also conducted to understand the nature of the association between ZD prevalence and critical maternal and child health indicators. Results The overall ZD prevalence between the two rounds was reduced by 4.1% (10.5-6.4%). A total of 26 states in the country reported a ZD prevalence of <10% in NFHS 5 compared to 18 in NFHS 4. In total, 324 districts reported a ZD prevalence of <5%, and 145 districts reported a prevalence of >10%. The equity parameters reflected a slow-footed reduction among ZD for girl children, across urban geographies, firstborn children, mothers with 12 or more years of schooling, and children in families with the highest wealth quintiles. A negative correlation accentuated between the two NFHS rounds was established between first-trimester registration, four or more antenatal visits, institutional deliveries, and ZD prevalence. Conclusions The findings point toward sustained improvement across key equity parameters, however, challenges do exist. Moreover, the impact of the pandemic on immunization programs across the globe and in India is bound to halt and reverse the progress and potentiate further inequities. It is thus imperative that continued and augmented efforts are continued to identify, integrate, and immunize ZD children, families, and communities.
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Affiliation(s)
- Gunjan Taneja
- Infectious Disease Cluster, India Country Office, Bill & Melinda Gates Foundation, New Delhi, IND
| | - Eshita Datta
- Social Impact Practice, Evalueserve, New Delhi, IND
| | - Mahima Sapru
- Social Impact Practice, Evalueserve, New Delhi, IND
| | - Mira Johri
- School of Public Health, University of Montreal, Montreal, CAN
| | - Kapil Singh
- Immunization Division, Ministry of Health and Family Welfare, Government of India, New Delhi, IND
| | | | - Shyamashree Das
- Infectious Disease Cluster, India Country Office, Bill & Melinda Gates Foundation, New Delhi, IND
| | - Arindam Ray
- Infectious Disease Cluster, India Country Office, Bill & Melinda Gates Foundation, New Delhi, IND
| | - Kayla Laserson
- Infectious Disease Cluster, India Country Office, Bill & Melinda Gates Foundation, New Delhi, IND
| | - Veena Dhawan
- Immunization Division, Ministry of Health and Family Welfare, Government of India, New Delhi, IND
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12
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Utazi CE, Aheto JMK, Wigley A, Tejedor-Garavito N, Bonnie A, Nnanatu CC, Wagai J, Williams C, Setayesh H, Tatem AJ, Cutts FT. Mapping the distribution of zero-dose children to assess the performance of vaccine delivery strategies and their relationships with measles incidence in Nigeria. Vaccine 2023; 41:170-181. [PMID: 36414476 DOI: 10.1016/j.vaccine.2022.11.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 10/19/2022] [Accepted: 11/14/2022] [Indexed: 11/21/2022]
Abstract
Geographically precise identification and targeting of populations at risk of vaccine-preventable diseases has gained renewed attention within the global health community over the last few years. District level estimates of vaccination coverage and corresponding zero-dose prevalence constitute a potentially useful evidence base to evaluate the performance of vaccination strategies. These estimates are also valuable for identifying missed communities, hence enabling targeted interventions and better resource allocation. Here, we fit Bayesian geostatistical models to map the routine coverage of the first doses of diphtheria-tetanus-pertussis vaccine (DTP1) and measles-containing vaccine (MCV1) and corresponding zero-dose estimates in Nigeria at 1x1 km resolution and the district level using geospatial data sets. We also map MCV1 coverage before and after the 2019 measles vaccination campaign in the northern states to further explore variations in routine vaccine coverage and to evaluate the effectiveness of both routine immunization (RI) and campaigns in reaching zero-dose children. Additionally, we map the spatial distributions of reported measles cases during 2018 to 2020 and explore their relationships with MCV zero-dose prevalence to highlight the public health implications of varying performance of vaccination strategies across the country. Our analysis revealed strong similarities between the spatial distributions of DTP and MCV zero dose prevalence, with districts with the highest prevalence concentrated mostly in the northwest and the northeast, but also in other areas such as Lagos state and the Federal Capital Territory. Although the 2019 campaign reduced MCV zero-dose prevalence substantially in the north, pockets of vulnerabilities remained in areas that had among the highest prevalence prior to the campaign. Importantly, we found strong correlations between measles case counts and MCV RI zero-dose estimates, which provides a strong indication that measles incidence in the country is mostly affected by RI coverage. Our analyses reveal an urgent and highly significant need to strengthen the country's RI program as a longer-term measure for disease control, whilst ensuring effective campaigns in the short term.
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Affiliation(s)
- C Edson Utazi
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton SO17 1BJ, UK; Southampton Statistical Sciences Research Institute, University of Southampton, Southampton SO17 1BJ, UK; Department of Statistics, Nnamdi Azikiwe University, Awka PMB 5025, Nigeria.
| | - Justice M K Aheto
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton SO17 1BJ, UK; Department of Biostatistics, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Adelle Wigley
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton SO17 1BJ, UK
| | - Natalia Tejedor-Garavito
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton SO17 1BJ, UK
| | - Amy Bonnie
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton SO17 1BJ, UK
| | - Christopher C Nnanatu
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton SO17 1BJ, UK; Department of Statistics, Nnamdi Azikiwe University, Awka PMB 5025, Nigeria
| | - John Wagai
- World Health Organization Consultant, Abuja, Nigeria
| | - Cheryl Williams
- U.S. Centers for Disease Control and Prevention, Nigeria Country Office, Abuja, Nigeria
| | | | - Andrew J Tatem
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton SO17 1BJ, UK
| | - Felicity T Cutts
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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13
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Wigley A, Lorin J, Hogan D, Utazi CE, Hagedorn B, Dansereau E, Tatem AJ, Tejedor-Garavito N. Estimates of the number and distribution of zero-dose and under-immunised children across remote-rural, urban, and conflict-affected settings in low and middle-income countries. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001126. [PMID: 36962682 PMCID: PMC10021885 DOI: 10.1371/journal.pgph.0001126] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/05/2022] [Indexed: 02/11/2023]
Abstract
While there has been great success in increasing the coverage of new childhood vaccines globally, expanding routine immunization to reliably reach all children and communities has proven more challenging in many low- and middle-income countries. Achieving this requires vaccination strategies and interventions that identify and target those unvaccinated, guided by the most current and detailed data regarding their size and spatial distribution. Through the integration and harmonisation of a range of geospatial data sets, including population, vaccination coverage, travel-time, settlement type, and conflict locations. We estimated the numbers of children un- or under-vaccinated for measles and diphtheria-tetanus-pertussis, within remote-rural, urban, and conflict-affected locations. We explored how these numbers vary both nationally and sub-nationally, and assessed what proportions of children these categories captured, for 99 lower- and middle-income countries, for which data was available. We found that substantial heterogeneities exist both between and within countries. Of the total 14,030,486 children unvaccinated for DTP1, over 11% (1,656,757) of un- or under-vaccinated children were in remote-rural areas, more than 28% (2,849,671 and 1,129,915) in urban and peri-urban areas, and up to 60% in other settings, with nearly 40% found to be within 1-hour of the nearest town or city (though outside of urban/peri-urban areas). Of the total number of those unvaccinated, we estimated between 6% and 15% (826,976 to 2,068,785) to be in conflict-affected locations, based on either broad or narrow definitions of conflict. Our estimates provide insights into the inequalities in vaccination coverage, with the distributions of those unvaccinated varying significantly by country, region, and district. We demonstrate the need for further inquiry and characterisation of those unvaccinated, the thresholds used to define these, and for more country-specific and targeted approaches to defining such populations in the strategies and interventions used to reach them.
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Affiliation(s)
- Adelle Wigley
- WorldPop, Geography and Environmental Science, University of Southampton, Highfield Campus, Southampton, United Kingdom
| | - Josh Lorin
- Gavi, The Vaccine Alliance, Geneva, Switzerland
| | - Dan Hogan
- Gavi, The Vaccine Alliance, Geneva, Switzerland
| | - C. Edson Utazi
- WorldPop, Geography and Environmental Science, University of Southampton, Highfield Campus, Southampton, United Kingdom
| | - Brittany Hagedorn
- Institute for Disease Modelling, Bill & Melinda Gates Foundation, Seattle, Washington, WA, United States of America
| | - Emily Dansereau
- Institute for Disease Modelling, Bill & Melinda Gates Foundation, Seattle, Washington, WA, United States of America
| | - Andrew J. Tatem
- WorldPop, Geography and Environmental Science, University of Southampton, Highfield Campus, Southampton, United Kingdom
| | - Natalia Tejedor-Garavito
- WorldPop, Geography and Environmental Science, University of Southampton, Highfield Campus, Southampton, United Kingdom
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