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Nimpa MM, Cikomola Mwana-Wabene A, Otomba J, Mukendi JC, Danovaro-Holliday MC, Mboussou FF, Mwamba D, Kambala L, Ngwanga D, Mwanga C, Etapelong SG, Compaoré I, Yapi MD, Ishoso DK. Characterizing zero-dose and under-vaccinated children among refugees and internally displaced persons in the Democratic Republic of Congo. Trop Dis Travel Med Vaccines 2024; 10:17. [PMID: 39004758 PMCID: PMC11247746 DOI: 10.1186/s40794-024-00225-0] [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: 02/13/2024] [Accepted: 05/24/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND The Democratic Republic of Congo (DRC) has one of the highest numbers of un and under-vaccinated children as well as number of refugees and internally displaced persons (IDPs) in the world. This study aims to determine and compare the proportion and characteristics of zero-dose (ZD) and under-vaccinated (UV) children among refugees and IDPs in the DRC, as well as the reasons for incomplete vaccination schedules. METHODS Data from a rolling vaccination coverage survey conducted from September 10, 2022, to July 03, 2023, among refugees and IDPs in 12 provinces of the DRC. ZD was defined as a child aged 12-23 months who had not received any dose of pentavalent vaccine DTP-Hib-Hep B (by card or recall) and UV as a child who had not received the third dose of pentavalent vaccine. The proportions of non and under-vaccination and the associated factors using a logistic regression model are presented for ZD and UV children. The reasons for non-vaccination of these children are described using the WHO-Immunization behavioral and social-drivers-conceptual framework and compared using Pearson's Chi2 test. RESULTS Of 692 children aged 12 to 23 months included in the analysis, 9.3% (95% CI: 7.2-11.7%) were ZD and 40.9% (95% CI: 95%: 37.2-44.6%) UV. The Penta1/Penta3 drop-out rate was 34.9%. After adjustment, ZD children had a significant history of home or road birth. And UV children were significantly associated with mothers/caregivers being under 40, uneducated, farmers, ranchers, employed, rural residents, as well as with home or road births. Reasons linked to people's perceptions and feelings were cited much more often for ZD (50.0%) than for UV (38.3%). Those related to social reasons were cited much more often by ZD (40.6%) than by UV (35.7%). Reasons related to "programmatic and practical issues" were cited less for ZD (90.5%) than for UV (97.1%). CONCLUSIONS ZD and UV children represent significant proportions in refugee and IDPs sites in the DRC. However, the proportion of ZD is less than for the entire country, while the proportion of UV is comparable, reflected in a very high drop-out rate. Similarly to studies in the general population in DRC, the reasons for ZD children were mainly linked to challenges in caregiver motivation to vaccinate, while for UV children, they were more often linked to pro-grammatic and practical problems of the health system.
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Affiliation(s)
| | | | - John Otomba
- World Health Organization (WHO) Country Office, Kinshasa, Democratic Republic of Congo
| | | | - M Carolina Danovaro-Holliday
- Immunization, Analytics and Insights (IAI), Department of Immunization, Vaccines and Biologicals (IVB), World Health Organization (WHO), Geneva, Switzerland
| | | | - Dieudonné Mwamba
- National Institute of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Leandre Kambala
- World Health Organization (WHO) Country Office, Kinshasa, Democratic Republic of Congo
| | - Dolla Ngwanga
- World Health Organization (WHO) Country Office, Kinshasa, Democratic Republic of Congo
| | - Cedric Mwanga
- World Health Organization (WHO) Country Office, Kinshasa, Democratic Republic of Congo
| | - Sume Gerald Etapelong
- Immunization, Vaccine-Preventable Diseases and Polio Transition (IVP) Unit, Department of Communicable Diseases (DCD), WHO Regional Office for the Eastern Mediterranean (EMRO), Cairo, Egypt
| | - Issaka Compaoré
- Associés en Management public et Développement (AMD) International, Ouagadougou, Burkina Faso
| | - Moise Désiré Yapi
- World Health Organization (WHO) Country Office, Kinshasa, Democratic Republic of Congo
| | - Daniel Katuashi Ishoso
- World Health Organization (WHO) Country Office, Kinshasa, Democratic Republic of Congo.
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo.
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2
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Rachlin A, Adegoke OJ, Bohara R, Rwagasore E, Sibomana H, Kabeja A, Itanga I, Rwunganira S, Mafende Mario B, Rosette NM, Usman Obansa R, Abah AU, Adeoye OB, Sikare E, Lam E, Murrill CS, Montesanti Porter A. Building Data Triangulation Capacity for Routine Immunization and Vaccine Preventable Disease Surveillance Programs to Identify Immunization Coverage Inequities. Vaccines (Basel) 2024; 12:646. [PMID: 38932375 PMCID: PMC11209447 DOI: 10.3390/vaccines12060646] [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: 04/24/2024] [Revised: 05/30/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
The Expanded Programme on Immunization (EPI) and Vaccine Preventable Disease (VPD) Surveillance (VPDS) programs generate multiple data sources (e.g., routine administrative data, VPD case data, and coverage surveys). However, there are challenges with the use of these siloed data for programmatic decision-making, including poor data accessibility and lack of timely analysis, contributing to missed vaccinations, immunity gaps, and, consequently, VPD outbreaks in populations with limited access to immunization and basic healthcare services. Data triangulation, or the integration of multiple data sources, can be used to improve the availability of key indicators for identifying immunization coverage gaps, under-immunized (UI) and un-immunized (zero-dose (ZD)) children, and for assessing program performance at all levels of the healthcare system. Here, we describe the data triangulation processes, prioritization of indicators, and capacity building efforts in Bangladesh, Nigeria, and Rwanda. We also describe the analyses used to generate meaningful data, key indicators used to identify immunization coverage inequities and performance gaps, and key lessons learned. Triangulation processes and lessons learned may be leveraged by other countries, potentially leading to programmatic changes that promote improved access and utilization of vaccination services through the identification of UI and ZD children.
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Affiliation(s)
- Audrey Rachlin
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Oluwasegun Joel Adegoke
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | | | - Edson Rwagasore
- Rwanda Biomedical Centre, Ministry of Health, Kigali P.O. Box 7162, Rwanda
| | - Hassan Sibomana
- Rwanda Biomedical Centre, Ministry of Health, Kigali P.O. Box 7162, Rwanda
| | - Adeline Kabeja
- Rwanda Biomedical Centre, Ministry of Health, Kigali P.O. Box 7162, Rwanda
| | - Ines Itanga
- Rwanda Biomedical Centre, Ministry of Health, Kigali P.O. Box 7162, Rwanda
| | | | | | | | - Ramatu Usman Obansa
- National Stop Transmission of Polio (NSTOP) Program, African Field Epidemiology Network (AFENET), Abuja 900103, Nigeria
| | - Angela Ukpojo Abah
- National Stop Transmission of Polio (NSTOP) Program, African Field Epidemiology Network (AFENET), Abuja 900103, Nigeria
| | - Olorunsogo Bidemi Adeoye
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA
| | - Ester Sikare
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Eugene Lam
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Christopher S. Murrill
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Angela Montesanti Porter
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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3
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Santos TM, Cata-Preta BO, Wendt A, Arroyave L, Blumenberg C, Mengistu T, Hogan DR, Victora CG, Barros AJD. Exploring the "Urban Advantage" in Access to Immunization Services: A Comparison of Zero-Dose Prevalence Between Rural, and Poor and Non-poor Urban Households Across 97 Low- and Middle-Income Countries. J Urban Health 2024; 101:638-647. [PMID: 38767765 PMCID: PMC11189869 DOI: 10.1007/s11524-024-00859-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 05/22/2024]
Abstract
Urban children are more likely to be vaccinated than rural children, but that advantage is not evenly distributed. Children living in poor urban areas face unique challenges, living far from health facilities and with lower-quality health services, which can impact their access to life-saving vaccines. Our goal was to compare the prevalence of zero-dose children in poor and non-poor urban and rural areas of low- and middle-income countries (LMICs). Zero-dose children were those who failed to receive any dose of a diphtheria-pertussis-tetanus (DPT) containing vaccine. We used data from nationally representative household surveys of 97 LMICs to investigate 201,283 children aged 12-23 months. The pooled prevalence of zero-dose children was 6.5% among the urban non-poor, 12.6% for the urban poor, and 14.7% for the rural areas. There were significant differences between these areas in 43 countries. In most of these countries, the non-poor urban children were at an advantage compared to the urban poor, who were still better off or similar to rural children. Our results emphasize the inequalities between urban and rural areas, but also within urban areas, highlighting the challenges faced by poor urban and rural children. Outreach programs and community interventions that can reach poor urban and rural communities-along with strengthening of current vaccination programs and services-are important steps to reduce inequalities and ensure that no child is left unvaccinated.
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Affiliation(s)
- Thiago M Santos
- International Center for Equity in Health, Federal University of Pelotas, Rua Deodoro 1160, Pelotas, RS, 96020-220, Brazil.
| | - Bianca O Cata-Preta
- International Center for Equity in Health, Federal University of Pelotas, Rua Deodoro 1160, Pelotas, RS, 96020-220, Brazil
- Universidade Federal Do Paraná, Rua Padre Camargo, 280, Curitiba, PR, 80060-240, Brazil
| | - Andrea Wendt
- International Center for Equity in Health, Federal University of Pelotas, Rua Deodoro 1160, Pelotas, RS, 96020-220, Brazil
- Programa de Pós-Graduação Em Tecnologia Em Saúde, Pontifícia Universidade Católica Do Paraná, Rua Imaculada Conceição 1155, Curitiba, PR, 80215-901, Brazil
| | - Luisa Arroyave
- International Center for Equity in Health, Federal University of Pelotas, Rua Deodoro 1160, Pelotas, RS, 96020-220, Brazil
| | - Cauane Blumenberg
- International Center for Equity in Health, Federal University of Pelotas, Rua Deodoro 1160, Pelotas, RS, 96020-220, Brazil
| | - Tewodaj Mengistu
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, 1218, Geneva, Switzerland
| | - Daniel R Hogan
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, 1218, Geneva, Switzerland
| | - Cesar G Victora
- International Center for Equity in Health, Federal University of Pelotas, Rua Deodoro 1160, Pelotas, RS, 96020-220, Brazil
| | - Aluisio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Rua Deodoro 1160, Pelotas, RS, 96020-220, Brazil
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Gichuki J, Ngoye B, Wafula F. "I'll take them another day": A qualitative study exploring the socio-behavioral complexities of childhood vaccination in urban poor settlements. PLoS One 2024; 19:e0303215. [PMID: 38739597 PMCID: PMC11090334 DOI: 10.1371/journal.pone.0303215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 04/21/2024] [Indexed: 05/16/2024] Open
Abstract
Despite improvement over recent decades, childhood vaccination uptake remains a concern across countries. The World Health Organization observed that over 25 million children missed out on one or more vaccines in 2021, with urban poor and other marginalized groups being the most affected. Given the higher risk of disease transmission and vaccine-preventable diseases (VPD) outbreaks across densely populated urban slums, identifying effective interventions to improve childhood vaccination in this vulnerable population is crucial. This study explored the behavioral and social factors influencing childhood vaccination uptake in urban informal settlements in Nairobi, Kenya. A grounded theory approach was employed to develop a theoretical account of the socio-behavioral determinants of childhood vaccination. Five focus group discussions (FGDs) were conducted with purposively sampled caregivers of children under five years of age residing in informal settlements. The Theory of Planned Behavior guided the structuring of the FGD questions. An iterative process was used to analyze and identify emerging themes. Thirty-nine caregivers (median age 29 years) participated in the FGDs. From the analysis, four main thematic categories were derived. These included attitude factors such as perceived vaccine benefits, cultural beliefs, and emotional factors including parental love. Additionally, subjective norms, like fear of social judgment, and perceived behavioral control factors, such as self-control and gender-based influences, were identified. Furthermore, a number of practical factors, including the cost of vaccines and healthcare providers attitude, also affected the uptake of vaccination. Various social, behavioral, cultural, and contextual factors influence caregiver vaccination decisions in urban poor settings. Community-derived and context-specific approaches that address the complex interaction between socio-behavioral and other contextual factors need to be tested and applied to improve the timely uptake of childhood vaccinations among marginalized populations.
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Affiliation(s)
- Judy Gichuki
- Institute of Healthcare Management, Strathmore University Business School, Nairobi, Kenya
| | - Ben Ngoye
- Institute of Healthcare Management, Strathmore University Business School, Nairobi, Kenya
| | - Francis Wafula
- Institute of Healthcare Management, Strathmore University Business School, Nairobi, Kenya
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Das H, Jannat Z, Fatema K, Momo JET, Ali MW, Alam N, Chowdhury MEEK, Morgan C, Oliveras E, Correa GC, Reynolds HW, Uddin MJ, Wahed T. Prevalence of and factors associated with zero-dose and under-immunized children in selected areas of Bangladesh: Findings from Lot Quality Assurance Sampling Survey. Vaccine 2024; 42:3247-3256. [PMID: 38627143 DOI: 10.1016/j.vaccine.2024.04.018] [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: 09/16/2023] [Revised: 02/17/2024] [Accepted: 04/04/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND In the era of Gavi's 5.0 vision of "leaving no one behind with immunization", childhood routine vaccination in missed communities is considered as a priority concern. Despite having a success story at the national level, low uptake of immunization is still persistent in selected pocket areas of Bangladesh. However, prevalence and the associated factors of zero-dose (ZD) and under-immunization (UI) are still unknown at those geo-pockets of Bangladesh. Thus, the study aims to report and identify the factors associated with ZD and UI in selected geographical locations. METHODS This study used data from a Lot Quality Assurance Sampling (LQAS) survey where 504 households from 18 clusters of four hard to reach (HTR) and one urban slum were included. Caregivers of children aged 4.5 to 23 months were interviewed. Three outcome variables- ZD, UI and ZD/UI were considered and several related attributes were considered as independent variables. Data were analyzed through bivariate analysis, binary logistic regression and dominance analysis. RESULTS Overall, 32% of the children were either ZD (8%) or UI (26%) in the selected areas. The adjusted odds of ZD/UI for urban slum and haor (wetlands) areas were 5.62 and 3.61 respectively considering coastal areas as reference. However, distance of nearest EPI center, availability of EPI card, age of caregivers, education and occupation of mother and number of earning members in household were influential factors for ZD/UI. According to dominance analysis, availability of EPI card can explain the most of the variation of ZD/UI in this study. CONCLUSION The study findings highlight the high prevalence ZD/UI in certain geo-pockets of the country. It provided a powerful insight of current situation and associated factors in regards to ZD/UI in the country which will help policy-makers and programme managers in designing programmes to reduce missed communities in Bangladesh.
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Affiliation(s)
- Hemel Das
- Health Systems and Population Studies Division, icddr,b, Mohakhali, Dhaka-1212, Bangladesh
| | - Zerin Jannat
- Health Systems and Population Studies Division, icddr,b, Mohakhali, Dhaka-1212, Bangladesh
| | - Kaniz Fatema
- Health Systems and Population Studies Division, icddr,b, Mohakhali, Dhaka-1212, Bangladesh
| | - Jannat-E-Tajreen Momo
- Health Systems and Population Studies Division, icddr,b, Mohakhali, Dhaka-1212, Bangladesh
| | - Md Wazed Ali
- Health Systems and Population Studies Division, icddr,b, Mohakhali, Dhaka-1212, Bangladesh
| | - Nurul Alam
- Health Systems and Population Studies Division, icddr,b, Mohakhali, Dhaka-1212, Bangladesh
| | | | - Christopher Morgan
- Jhpiego, the Johns Hopkins University affiliate, 1615 Thames Street, Baltimore, MD 2231, USA
| | - Elizabeth Oliveras
- Jhpiego, the Johns Hopkins University affiliate, 1615 Thames Street, Baltimore, MD 2231, USA
| | - Gustavo Caetano Correa
- Evaluation and Learning Measurement, Evaluation & Learning (MEL), Gavi The Vaccine Alliance, Geneva, Switzerland
| | - Heidi W Reynolds
- Evaluation and Learning Measurement, Evaluation & Learning (MEL), Gavi The Vaccine Alliance, Geneva, Switzerland
| | - Md Jasim Uddin
- Health Systems and Population Studies Division, icddr,b, Mohakhali, Dhaka-1212, Bangladesh
| | - Tasnuva Wahed
- Health Systems and Population Studies Division, icddr,b, Mohakhali, Dhaka-1212, Bangladesh.
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6
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Costa FS, Silva LA, Cata-Preta BO, Santos TM, Ferreira LZ, Mengistu T, Hogan DR, Barros AJ, Victora CG. Child immunization status according to number of siblings and birth order in 85 low- and middle-income countries: a cross-sectional study. EClinicalMedicine 2024; 71:102547. [PMID: 38524919 PMCID: PMC10958219 DOI: 10.1016/j.eclinm.2024.102547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/22/2024] [Accepted: 02/29/2024] [Indexed: 03/26/2024] Open
Abstract
Background Identification of unvaccinated children is important for preventing deaths due to infections. Number of siblings and birth order have been postulated as risk factors for zero-dose prevalence. Methods We analysed nationally representative cross-sectional surveys from 85 low and middle-income countries (2010-2020) with information on immunisation status of children aged 12-35 months. Zero-dose prevalence was defined as the failure to receive any doses of DPT (diphtheria-pertussis-tetanus) vaccine. We examined associations with birth order and the number of siblings, adjusting for child's sex, maternal age and education, household wealth quintiles and place of residence. Poisson regression was used to calculate zero-dose prevalence ratios. Findings We studied 375,548 children, of whom 13.7% (n = 51,450) were classified as zero-dose. Prevalence increased monotonically with birth order and with the number of siblings, with prevalence increasing from 11.0% for firstborn children to 17.1% for birth order 5 or higher, and from 10.5% for children with no siblings to 17.2% for those with four or more siblings. Adjustment for confounders attenuated but did not eliminate these associations. The number of siblings remained as a strong risk factor when adjusted for confounders and birth order, but the reverse was not observed. Among children with the same number of siblings, there was no clear pattern in zero-dose prevalence by birth order; for instance, among children with two siblings, the prevalence was 13.0%, 14.7%, and 13.3% for firstborn, second, and third-born, respectively. Similar results were observed for girls and boys. 9513 families had two children aged 12-35 months. When the younger sibling was unvaccinated, 61.9% of the older siblings were also unvaccinated. On the other hand, when the younger sibling was vaccinated, only 5.9% of the older siblings were unvaccinated. Interpretation The number of siblings is a better predictor than birth order in identifying children to be targeted by immunization campaigns. Zero-dose children tend to be clustered within families. Funding Gavi, the Vaccine Alliance.
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Affiliation(s)
- Francine S. Costa
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Larissa A.N. Silva
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Bianca O. Cata-Preta
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Public Health Department, Federal University of Parana, Curitiba, Brazil
| | - Thiago M. Santos
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Leonardo Z. Ferreira
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | | | | | - Aluisio J.D. Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Cesar G. Victora
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
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7
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Castro-Aguirre IE, Alvarez D, Contreras M, Trumbo SP, Mujica OJ, Salas Peraza D, Velandia-González M. The Impact of the Coronavirus Pandemic on Vaccination Coverage in Latin America and the Caribbean. Vaccines (Basel) 2024; 12:458. [PMID: 38793709 PMCID: PMC11125655 DOI: 10.3390/vaccines12050458] [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: 01/29/2024] [Revised: 03/14/2024] [Accepted: 03/27/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Routine vaccination coverage in Latin America and the Caribbean declined prior to and during the coronavirus pandemic. We assessed the pandemic's impact on national coverage levels and analyzed whether financial and inequality indicators, immunization policies, and pandemic policies were associated with changes in national and regional coverage levels. METHODOLOGY We compared first- and third-dose coverage of diphtheria-pertussis-tetanus-containing vaccine (DTPcv) with predicted coverages using time series forecast modeling for 39 LAC countries and territories. Data were from the PAHO/WHO/UNICEF Joint Reporting Form. A secondary analysis of factors hypothesized to affect coverages during the pandemic was also performed. RESULTS In total, 31 of 39 countries and territories (79%) had greater-than-predicted declines in DTPcv1 and DTPcv3 coverage during the pandemic, with 9 and 12 of these, respectively, falling outside the 95% confidence interval. Within-country income inequality (i.e., Gini coefficient) was associated with significant declines in DTPcv1 coverage, and cross-country income inequality was associated with declines in DTPcv1 and DTPcv3 coverages. Observed absolute and relative inequality gaps in DTPcv1 and DTPcv3 coverage between extreme country quintiles of income inequality (i.e., Q1 vs. Q5) were accentuated in 2021, as compared with the 2019 observed and 2021 predicted values. We also observed a trend between school closures and greater-than-predicted declines in DTPcv3 coverage that approached statistical significance (p = 0.06). CONCLUSION The pandemic exposed vaccination inequities in LAC and significantly impacted coverage levels in many countries. New strategies are needed to reattain high coverage levels.
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Affiliation(s)
- Ignacio E. Castro-Aguirre
- Comprehensive Family Immunization Unit, Pan American Health Organization, Washington, DC 20037, USA; (I.E.C.-A.); (D.A.)
| | - Dan Alvarez
- Comprehensive Family Immunization Unit, Pan American Health Organization, Washington, DC 20037, USA; (I.E.C.-A.); (D.A.)
| | - Marcela Contreras
- Comprehensive Family Immunization Unit, Pan American Health Organization, Washington, DC 20037, USA; (I.E.C.-A.); (D.A.)
| | - Silas P. Trumbo
- Department of Medicine, University of Central Florida College of Medicine, Orlando, FL 32827, USA
| | - Oscar J. Mujica
- Department of Evidence and Intelligence for Action in Health, Pan American Health Organization, Washington, DC 20037, USA;
| | - Daniel Salas Peraza
- Comprehensive Family Immunization Unit, Pan American Health Organization, Washington, DC 20037, USA; (I.E.C.-A.); (D.A.)
| | - Martha Velandia-González
- Comprehensive Family Immunization Unit, Pan American Health Organization, Washington, DC 20037, USA; (I.E.C.-A.); (D.A.)
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8
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Hartner AM, Li X, Echeverria-Londono S, Roth J, Abbas K, Auzenbergs M, de Villiers MJ, Ferrari MJ, Fraser K, Fu H, Hallett T, Hinsley W, Jit M, Karachaliou A, Moore SM, Nayagam S, Papadopoulos T, Perkins TA, Portnoy A, Minh QT, Vynnycky E, Winter AK, Burrows H, Chen C, Clapham HE, Deshpande A, Hauryski S, Huber J, Jean K, Kim C, Kim JH, Koh J, Lopman BA, Pitzer VE, Tam Y, Lambach P, Sim SY, Woodruff K, Ferguson NM, Trotter CL, Gaythorpe KAM. Estimating the health effects of COVID-19-related immunisation disruptions in 112 countries during 2020-30: a modelling study. Lancet Glob Health 2024; 12:e563-e571. [PMID: 38485425 PMCID: PMC10951961 DOI: 10.1016/s2214-109x(23)00603-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/14/2023] [Accepted: 12/16/2023] [Indexed: 03/19/2024]
Abstract
BACKGROUND There have been declines in global immunisation coverage due to the COVID-19 pandemic. Recovery has begun but is geographically variable. This disruption has led to under-immunised cohorts and interrupted progress in reducing vaccine-preventable disease burden. There have, so far, been few studies of the effects of coverage disruption on vaccine effects. We aimed to quantify the effects of vaccine-coverage disruption on routine and campaign immunisation services, identify cohorts and regions that could particularly benefit from catch-up activities, and establish if losses in effect could be recovered. METHODS For this modelling study, we used modelling groups from the Vaccine Impact Modelling Consortium from 112 low-income and middle-income countries to estimate vaccine effect for 14 pathogens. One set of modelling estimates used vaccine-coverage data from 1937 to 2021 for a subset of vaccine-preventable, outbreak-prone or priority diseases (ie, measles, rubella, hepatitis B, human papillomavirus [HPV], meningitis A, and yellow fever) to examine mitigation measures, hereafter referred to as recovery runs. The second set of estimates were conducted with vaccine-coverage data from 1937 to 2020, used to calculate effect ratios (ie, the burden averted per dose) for all 14 included vaccines and diseases, hereafter referred to as full runs. Both runs were modelled from Jan 1, 2000, to Dec 31, 2100. Countries were included if they were in the Gavi, the Vaccine Alliance portfolio; had notable burden; or had notable strategic vaccination activities. These countries represented the majority of global vaccine-preventable disease burden. Vaccine coverage was informed by historical estimates from WHO-UNICEF Estimates of National Immunization Coverage and the immunisation repository of WHO for data up to and including 2021. From 2022 onwards, we estimated coverage on the basis of guidance about campaign frequency, non-linear assumptions about the recovery of routine immunisation to pre-disruption magnitude, and 2030 endpoints informed by the WHO Immunization Agenda 2030 aims and expert consultation. We examined three main scenarios: no disruption, baseline recovery, and baseline recovery and catch-up. FINDINGS We estimated that disruption to measles, rubella, HPV, hepatitis B, meningitis A, and yellow fever vaccination could lead to 49 119 additional deaths (95% credible interval [CrI] 17 248-134 941) during calendar years 2020-30, largely due to measles. For years of vaccination 2020-30 for all 14 pathogens, disruption could lead to a 2·66% (95% CrI 2·52-2·81) reduction in long-term effect from 37 378 194 deaths averted (34 450 249-40 241 202) to 36 410 559 deaths averted (33 515 397-39 241 799). We estimated that catch-up activities could avert 78·9% (40·4-151·4) of excess deaths between calendar years 2023 and 2030 (ie, 18 900 [7037-60 223] of 25 356 [9859-75 073]). INTERPRETATION Our results highlight the importance of the timing of catch-up activities, considering estimated burden to improve vaccine coverage in affected cohorts. We estimated that mitigation measures for measles and yellow fever were particularly effective at reducing excess burden in the short term. Additionally, the high long-term effect of HPV vaccine as an important cervical-cancer prevention tool warrants continued immunisation efforts after disruption. FUNDING The Vaccine Impact Modelling Consortium, funded by Gavi, the Vaccine Alliance and the Bill & Melinda Gates Foundation. TRANSLATIONS For the Arabic, Chinese, French, Portguese and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Anna-Maria Hartner
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK; Centre for Artificial Intelligence in Public Health Research, Robert Koch Institute, Wildau, Germany
| | - Xiang Li
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK
| | - Susy Echeverria-Londono
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK
| | - Jeremy Roth
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK
| | - Kaja Abbas
- London School of Hygiene & Tropical Medicine, London, UK; School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | | | - Margaret J de Villiers
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK
| | - Matthew J Ferrari
- Center for Infectious Disease Dynamics, Pennsylvania State University, Pennsylvania, PA, USA
| | - Keith Fraser
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK
| | - Han Fu
- London School of Hygiene & Tropical Medicine, London, UK
| | - Timothy Hallett
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK
| | - Wes Hinsley
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK
| | - Mark Jit
- London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of Hong Kong, Hong Kong Special Administrative Region, China
| | | | - Sean M Moore
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN, USA
| | - Shevanthi Nayagam
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK; Section of Hepatology and Gastroenterology, Department of Metabolism, Digestion, and Reproduction, Imperial College London, London, UK
| | | | - T Alex Perkins
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN, USA
| | - Allison Portnoy
- Center for Health Decision Science, T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Quan Tran Minh
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN, USA
| | | | - Amy K Winter
- Department of Epidemiology and Biostatistics and Center for the Ecology of Infectious Diseases, University of Georgia, Athens, GA, USA
| | - Holly Burrows
- School of Public Health, Yale University, New Haven, CT, USA
| | - Cynthia Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Hannah E Clapham
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore; Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam; Nuffield Department of Medicine, Oxford University, Oxford, UK
| | | | - Sarah Hauryski
- Center for Infectious Disease Dynamics, Pennsylvania State University, Pennsylvania, PA, USA
| | - John Huber
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN, USA; School of Medicine, Washington University, St Louis, MO, USA
| | - Kevin Jean
- Laboratoire Modélisation, épidémiologie, et surveillance des risques sanitaires and Unit Cnam risques infectieux et émergents, Institut Pasteur, Conservatoire National des Arts et Metiers, Paris, France
| | - Chaelin Kim
- International Vaccine Institute, Seoul, South Korea
| | | | - Jemima Koh
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | | | - Yvonne Tam
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Philipp Lambach
- Department of Immunization, Vaccines, and Biologicals, WHO, Geneva, Switzerland
| | - So Yoon Sim
- Department of Immunization, Vaccines, and Biologicals, WHO, Geneva, Switzerland
| | - Kim Woodruff
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK
| | - Neil M Ferguson
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK
| | - Caroline L Trotter
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK; Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Katy A M Gaythorpe
- Medical Research Council Centre for Global Infectious Disease Analysis, Jameel Institute School of Public Health, Imperial College London, London, UK.
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9
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Adamu AA, Jalo RI, Ndwandwe D, Wiysonge CS. Informal health sector and routine immunization: making the case for harnessing the potentials of patent medicine vendors for the big catch-up to reduce zero-dose children in sub-Saharan Africa. Front Public Health 2024; 12:1353902. [PMID: 38515595 PMCID: PMC10956693 DOI: 10.3389/fpubh.2024.1353902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/22/2024] [Indexed: 03/23/2024] Open
Abstract
The COVID-19 pandemic caused a surge in the number of unimmunized and under-immunized children in Africa. The majority of unimmunized (or zero-dose) children live in hard-to-reach rural areas, urban slums, and communities affected by conflict where health facilities are usually unavailable or difficult to access. In these settings, people mostly rely on the informal health sector for essential health services. Therefore, to reduce zero-dose children, it is critical to expand immunization services beyond health facilities to the informal health sector to meet the immunization needs of children in underserved places. In this perspective article, we propose a framework for the expansion of immunization services through the informal health sector as one of the pillars for the big catch-up plan to improve coverage and equity. In African countries like Nigeria, Ethiopia, Tanzania, and the Democratic Republic of Congo, patent medicine vendors serve as an important informal health sector provider group, and thus, they can be engaged to provide immunization services. A hub-and-spoke model can be used to integrate patent medicine vendors into the immunization system. A hub-and-spoke model is a framework for organization design where services that are provided by a central facility (hub) are complimented by secondary sites (spokes) to optimize access to care. Systems thinking approach should guide the design, implementation, and evaluation of this model.
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Affiliation(s)
- Abdu A. Adamu
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rabiu I. Jalo
- Department of Community Medicine, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Duduzile Ndwandwe
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Charles S. Wiysonge
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Vaccine-Preventable Diseases Programme, World Health Organization Regional Office for Africa, Djoué, Brazzaville, Republic of Congo
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10
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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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11
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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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12
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Bile AS, Ali-Salad MA, Mahmoud AJ, Singh NS, Abdelmagid N, Sabahelzain MM, Checchi F, Mounier-Jack S, Nor B. Assessing Vaccination Delivery Strategies for Zero-Dose and Under-Immunized Children in the Fragile Context of Somalia. Vaccines (Basel) 2024; 12:154. [PMID: 38400137 PMCID: PMC10892412 DOI: 10.3390/vaccines12020154] [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: 12/20/2023] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 02/25/2024] Open
Abstract
Somalia is one of 20 countries in the world with the highest numbers of zero-dose children. This study aims to identify who and where zero-dose and under-vaccinated children are and what the existing vaccine delivery strategies to reach zero-dose children in Somalia are. This qualitative study was conducted in three geographically diverse regions of Somalia (rural/remote, nomadic/pastoralists, IDPs, and urban poor population), with government officials and NGO staff (n = 17), and with vaccinators and community members (n = 52). The data were analyzed using the GAVI Vaccine Alliance IRMMA framework. Nomadic populations, internally displaced persons, and populations living in remote and Al-shabaab-controlled areas are three vulnerable and neglected populations with a high proportion of zero-dose children. Despite the contextual heterogeneity of these population groups, the lack of targeted, population-specific strategies and meaningful engagement of local communities in the planning and implementation of immunization services is problematic in effectively reaching zero-dose children. This is, to our knowledge, the first study that examines vaccination strategies for zero-dose and under-vaccinated populations in the fragile context of Somalia. Evidence on populations at risk of vaccine-preventable diseases and barriers to vital vaccination services remain critical and urgent, especially in a country like Somalia with complex health system challenges.
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Affiliation(s)
- Ahmed Said Bile
- Somali Institute for Development Research and Analysis (SIDRA), Garowe, Puntland State, Somalia; (M.A.A.-S.); (A.J.M.)
| | - Mohamed A. Ali-Salad
- Somali Institute for Development Research and Analysis (SIDRA), Garowe, Puntland State, Somalia; (M.A.A.-S.); (A.J.M.)
| | - Amina J. Mahmoud
- Somali Institute for Development Research and Analysis (SIDRA), Garowe, Puntland State, Somalia; (M.A.A.-S.); (A.J.M.)
- Department of Women’s and Children’s Health, Uppsala University, 753 10 Uppsala, Sweden;
| | - Neha S. Singh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (N.S.S.); (N.A.); (F.C.)
- Health in Humanitarian Crises Centre, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Nada Abdelmagid
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (N.S.S.); (N.A.); (F.C.)
- Health in Humanitarian Crises Centre, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Majdi M. Sabahelzain
- School of Health Sciences, Ahfad University for Women (AUW), Omdurman P.O. Box 167, Sudan;
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2050, Australia
| | - Francesco Checchi
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (N.S.S.); (N.A.); (F.C.)
- Department of Infectious Disease Epidemiology and International Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK;
| | - Sandra Mounier-Jack
- Department of Infectious Disease Epidemiology and International Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK;
| | - Barni Nor
- Department of Women’s and Children’s Health, Uppsala University, 753 10 Uppsala, Sweden;
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Abdelmagid N, Southgate RJ, Alhaffar M, Ahmed M, Bani H, Mounier-Jack S, Dahab M, Checchi F, Sabahelzain MM, Nor B, Rao B, Singh NS. The Governance of Childhood Vaccination Services in Crisis Settings: A Scoping Review. Vaccines (Basel) 2023; 11:1853. [PMID: 38140257 PMCID: PMC10747651 DOI: 10.3390/vaccines11121853] [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: 11/16/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
The persistence of inadequate vaccination in crisis-affected settings raises concerns about decision making regarding vaccine selection, timing, location, and recipients. This review aims to describe the key features of childhood vaccination intervention design and planning in crisis-affected settings and investigate how the governance of childhood vaccination is defined, understood, and practised. We performed a scoping review of 193 peer-reviewed articles and grey literature on vaccination governance and service design and planning. We focused on 41 crises between 2010 and 2021. Following screening and data extraction, our analysis involved descriptive statistics and applying the governance analysis framework to code text excerpts, employing deductive and inductive approaches. Most documents related to active outbreaks in conflict-affected settings and to the mass delivery of polio, cholera, and measles vaccines. Information on vaccination modalities, target populations, vaccine sources, and funding was limited. We found various interpretations of governance, often implying hierarchical authority and regulation. Analysis of governance arrangements suggests a multi-actor yet fragmented governance structure, with inequitable actor participation, ineffective actor collaboration, and a lack of a shared strategic vision due to competing priorities and accountabilities. Better documentation of vaccination efforts during emergencies, including vaccination decision making, governance, and planning, is needed. We recommend empirical research within decision-making spaces.
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Affiliation(s)
- Nada Abdelmagid
- Department of Infectious Disease Epidemiology and International Health, Faculty of Epidemiology and Population Health, The London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Health in Humanitarian Crises Centre, The London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | | | - Mervat Alhaffar
- Department of Infectious Disease Epidemiology and International Health, Faculty of Epidemiology and Population Health, The London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Syria Research Group (SYRG), Co-Hosted by the London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Saw Swee Hock School of Public Health, National University of Singapore, Singapore 117549, Singapore
| | - Matab Ahmed
- School of Health Sciences, Ahfad University for Women (AUW), Omdurman P.O. Box 167, Sudan
| | - Hind Bani
- School of Health Sciences, Ahfad University for Women (AUW), Omdurman P.O. Box 167, Sudan
| | - Sandra Mounier-Jack
- Department of Global Health and Development, Faculty of Public Health and Policy, The London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
| | - Maysoon Dahab
- Department of Infectious Disease Epidemiology and International Health, Faculty of Epidemiology and Population Health, The London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Health in Humanitarian Crises Centre, The London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Francesco Checchi
- Department of Infectious Disease Epidemiology and International Health, Faculty of Epidemiology and Population Health, The London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Health in Humanitarian Crises Centre, The London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Majdi M. Sabahelzain
- School of Health Sciences, Ahfad University for Women (AUW), Omdurman P.O. Box 167, Sudan
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2050, Australia
| | - Barni Nor
- Department of Women’s and Children’s Health, Uppsala University, 751 23 Uppsala, Sweden
| | - Bhargavi Rao
- Department of Global Health and Development, Faculty of Public Health and Policy, The London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
| | - Neha S. Singh
- Health in Humanitarian Crises Centre, The London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Department of Global Health and Development, Faculty of Public Health and Policy, The London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
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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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Ouattara M, Sié A, Bountogo M, Boudo V, Dah C, Lebas E, Hu H, Porco TC, Arnold BF, Lietman TM, Oldenburg CE. Anthropometric Differences in Community- Versus Clinic-Recruited Infants Participating in a Trial of Azithromycin for Prevention of Childhood Mortality in Burkina Faso. Am J Trop Med Hyg 2023; 109:1187-1191. [PMID: 37783457 PMCID: PMC10622465 DOI: 10.4269/ajtmh.23-0298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/06/2023] [Indexed: 10/04/2023] Open
Abstract
Clinic-based recruitment for preventative interventions for child health may select for healthier populations compared with community-based outreach. Nutritional status during infancy as measured by anthropometry is predictive of mortality, growth faltering later in life, and poor cognitive development outcomes. We evaluated baseline differences in infant nutritional status among children recruited directly in their community versus clinic recruitment among infants participating in a trial of azithromycin compared with placebo for prevention of mortality in three districts of Burkina Faso. Infants between 5 and 12 weeks of age were recruited in their community of residence via vaccine outreach teams or in primary health-care clinics during vaccine clinics. Weight, height, and mid upper arm circumference were measured. We used linear and logistic regression models to compare anthropometric outcomes among community and clinic recruited infants, adjusting for age at enrollment, gender, and season. Among 32,877 infants enrolled in the trial, 21,273 (64.7%) were recruited via community outreach. Mean weight-for-age z-score (WAZ) was -0.60 ± 1.2 (SD), weight-for-length z-score (WLZ) was -0.16 ± 1.5, and length-for-age z-score was-0.53 ± 1.3. Infants enrolled in the community had lower WAZ (mean difference, -0.12; 95% CI, -0.20 to -0.04) and WLZ (mean difference, -0.21; 95% CI, -0.32 to -0.09). Community-recruited infants were more often underweight (WAZ < -2; odds ratio [OR], 1.25; 95% CI, 1.09-1.43) and wasted (WLZ < -2; OR, 1.54; 95% CI, 1.31-1.79). There was no evidence of a difference in height-based measures. Community and clinic recruitment likely reach different populations of children.
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Affiliation(s)
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Burkina Faso, Nouna
| | | | - Valentin Boudo
- Centre de Recherche en Santé de Nouna, Burkina Faso, Nouna
| | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Burkina Faso, Nouna
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Huiyu Hu
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Travis C. Porco
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Benjamin F. Arnold
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Thomas M. Lietman
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Catherine E. Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
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16
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Dadari I, Sharkey A, Hoare I, Izurieta R. Analysis of the impact of COVID-19 pandemic and response on routine childhood vaccination coverage and equity in Northern Nigeria: a mixed methods study. BMJ Open 2023; 13:e076154. [PMID: 37852768 PMCID: PMC10603460 DOI: 10.1136/bmjopen-2023-076154] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/28/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Based on 2021 data, Nigeria had the second largest number of zero-dose children globally estimated at over 2.25 million, concentrated in the northern part of the country due to factors some of which are sociocultural. This study analysed the impact of the COVID-19 pandemic and response on childhood vaccination in Northern Nigeria. METHODS Using a mixed methods sequential study design in the most populous northern states of Kaduna and Kano, quantitative routine immunisation data for the period 2018-2021 and qualitative data collected through 16 focus group discussions and 40 key informant interviews were used. An adaptation of the socioecological model was used as a conceptual framework. Mean vaccination coverages and test of statistical difference in childhood vaccination data were computed. Qualitative data were coded and analysed thematically. RESULTS Mean Penta 1 coverage declined in Kaduna from 69.88% (SD=21.02) in 2018 to 59.54% (SD=19.14%) by 2021, contrasting with Kano where mean Penta 1 coverage increased from 51.87% (SD=12.61) to 56.32% (SD=17.62%) over the same period. Outreaches and vaccination in urban areas declined for Kaduna state by 10% over the pandemic period in contrast to Kano state where it showed a marginal increase. The two states combined had an estimated 25% of the country's zero-dose burden in 2021. Lockdowns, lack of transport and no outreaches which varied across the states were some of the factors mentioned by participants to have negatively impacted childhood vaccination. Special vaccination outreaches were among the recommendations for ensuring continued vaccination through a future pandemic. CONCLUSION While further interrogating the accuracy of denominator estimates for the urban population, incorporating findings into pandemic preparedness and response will ensure uninterrupted childhood vaccination during emergencies. Addressing the identified issues will be critical to achieving and sustaining universal childhood vaccination in Nigeria.
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Affiliation(s)
- Ibrahim Dadari
- College of Public Health, University of South Florida, Tampa, Florida, USA
- PG-Health-Immunization, United Nations Children's Fund, New York, New York, USA
| | - Alyssa Sharkey
- School of Public and International Affairs, Princeton University, Princeton, New Jersey, USA
| | - Ismael Hoare
- College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Ricardo Izurieta
- College of Public Health, University of South Florida, Tampa, Florida, USA
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17
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Wonodi C, Farrenkopf BA. Defining the Zero Dose Child: A Comparative Analysis of Two Approaches and Their Impact on Assessing the Zero Dose Burden and Vulnerability Profiles across 82 Low- and Middle-Income Countries. Vaccines (Basel) 2023; 11:1543. [PMID: 37896946 PMCID: PMC10611163 DOI: 10.3390/vaccines11101543] [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: 06/13/2023] [Revised: 08/15/2023] [Accepted: 09/18/2023] [Indexed: 10/29/2023] Open
Abstract
While there is a coordinated effort around reaching zero dose children and closing existing equity gaps in immunization delivery, it is important that there is agreement and clarity around how 'zero dose status' is defined and what is gained and lost by using different indicators for zero dose status. There are two popular approaches used in research, program design, and advocacy to define zero dose status: one uses a single vaccine to serve as a proxy for zero dose status, while another uses a subset of vaccines to identify children who have missed all routine vaccines. We provide a global analysis utilizing the most recent publicly available DHS and MICS data from 2010 to 2020 to compare the number, proportion, and profile of children aged 12 to 23 months who are 'penta-zero dose' (have not received the pentavalent vaccine), 'truly' zero dose (have not received any dose of BCG, polio, pentavalent, or measles vaccines), and 'misclassified' zero dose children (those who are penta-zero dose but have received at least one other vaccine). Our analysis includes 194,829 observations from 82 low- and middle-income countries. Globally, 14.2% of children are penta-zero dose and 7.5% are truly zero dose, suggesting that 46.5% of penta-zero dose children have had at least one contact with the immunization system. While there are similarities in the profile of children that are penta-zero dose and truly zero dose, there are key differences between the proportion of key characteristics among truly zero dose and misclassified zero dose children, including access to maternal and child health services. By understanding the extent of the connection zero dose children may have with the health and immunization system and contrasting it with how much the use of a more feasible definition of zero dose may underestimate the level of vulnerability in the zero dose population, we provide insights that can help immunization programs design strategies that better target the most disadvantaged populations. If the vulnerability profiles of the truly zero dose children are qualitatively different from that of the penta-zero dose children, then failing to distinguish the truly zero dose populations, and how to optimally reach them, may lead to the development of misguided or inefficient strategies for vaccinating the most disadvantaged population of children.
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18
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Ishoso DK, Mafuta E, Danovaro-Holliday MC, Ngandu C, Menning L, Cikomola AMW, Lungayo CL, Mukendi JC, Mwamba D, Mboussou FF, Manirakiza D, Yapi MD, Ngabo GF, Riziki RB, Aluma ADL, Tsobeng BN, Mwanga C, Otomba J, Lulebo A, Lusamba P, Nimpa MM. Reasons for Being "Zero-Dose and Under-Vaccinated" among Children Aged 12-23 Months in the Democratic Republic of the Congo. Vaccines (Basel) 2023; 11:1370. [PMID: 37631938 PMCID: PMC10459103 DOI: 10.3390/vaccines11081370] [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: 06/12/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
(1) Introduction: The Democratic Republic of the Congo (DRC) has one of the largest cohorts of un- and under-vaccinated children worldwide. This study aimed to identify and compare the main reasons for there being zero-dose (ZD) or under-vaccinated children in the DRC. (2) Methods: This is a secondary analysis derived from a province-level vaccination coverage survey conducted between November 2021 and February 2022; this survey included questions about the reasons for not receiving one or more vaccines. A zero-dose child (ZD) was a person aged 12-23 months not having received any pentavalent vaccine (diphtheria-tetanus-pertussis-Hemophilus influenzae type b (Hib)-Hepatitis B) as per card or caregiver recall and an under-vaccinated child was one who had not received the third dose of the pentavalent vaccine. The proportions of the reasons for non-vaccination were first presented using the WHO-endorsed behavioral and social drivers for vaccination (BeSD) conceptual framework and then compared across the groups of ZD and under-vaccinated children using the Rao-Scott chi-square test; analyses were conducted at province and national level, and accounting for the sample approach. (3) Results: Of the 51,054 children aged 12-23 m in the survey sample, 19,676 ZD and under-vaccinated children were included in the study. For the ZD children, reasons related to people's thinking and feelings were cited as 64.03% and those related to social reasons as 31.13%; both proportions were higher than for under-vaccinated children (44.7% and 26.2%, respectively, p < 0.001). Regarding intentions to vaccinate their children, 82.15% of the parents/guardians of the ZD children said they wanted their children to receive "none" of the recommended vaccines, which was significantly higher than for the under-vaccinated children. In contrast, "practical issues" were cited for 35.60% of the ZD children, compared to 55.60% for the under-vaccinated children (p < 0.001). The distribution of reasons varied between provinces, e.g., 12 of the 26 provinces had a proportion of reasons for the ZD children relating to practical issues that was higher than the national level. (4) Conclusions: reasons provided for non-vaccination among the ZD children in the DRC were largely related to lack of parental/guardian motivation to have their children vaccinated, while reasons among under-vaccinated children were mostly related to practical issues. These results can help inform decision-makers to direct vaccination interventions.
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Affiliation(s)
- Daniel Katuashi Ishoso
- Immunization and Vaccines Development (IVD) Program, World Health Organization (WHO), Country Office, Kinshasa 01205, Democratic Republic of the Congo; (M.D.Y.); (G.F.N.); (R.B.R.); (B.N.T.); (C.M.); (J.O.); (M.M.N.)
- Kinshasa School of Public Health (KSPH), University of Kinshasa, Kinshasa 01302, Democratic Republic of the Congo; (E.M.); (A.L.); (P.L.)
| | - Eric Mafuta
- Kinshasa School of Public Health (KSPH), University of Kinshasa, Kinshasa 01302, Democratic Republic of the Congo; (E.M.); (A.L.); (P.L.)
| | - M. Carolina Danovaro-Holliday
- Immunization, Analytics and Insights (IAI), Department of Immunization, Vaccines and Biologicals (IVB), World Health Organization (WHO), 1211 Geneva, Switzerland; (M.C.D.-H.); (L.M.)
| | - Christian Ngandu
- National Institute of Public Health, Kinshasa 01209, Democratic Republic of the Congo; (C.N.); (D.M.)
| | - Lisa Menning
- Immunization, Analytics and Insights (IAI), Department of Immunization, Vaccines and Biologicals (IVB), World Health Organization (WHO), 1211 Geneva, Switzerland; (M.C.D.-H.); (L.M.)
| | - Aimé Mwana-Wabene Cikomola
- Expanded Program of Immunization, Kinshasa 01208, Democratic Republic of the Congo; (A.M.-W.C.); (C.L.L.); (J.-C.M.)
| | - Christophe Luhata Lungayo
- Expanded Program of Immunization, Kinshasa 01208, Democratic Republic of the Congo; (A.M.-W.C.); (C.L.L.); (J.-C.M.)
| | - Jean-Crispin Mukendi
- Expanded Program of Immunization, Kinshasa 01208, Democratic Republic of the Congo; (A.M.-W.C.); (C.L.L.); (J.-C.M.)
| | - Dieudonné Mwamba
- National Institute of Public Health, Kinshasa 01209, Democratic Republic of the Congo; (C.N.); (D.M.)
| | - Franck-Fortune Mboussou
- Communicable and Noncommunicable Diseases Cluster, World Health Organization Inter-Country Support Teams Central Africa, Libreville BP 820, Gabon;
| | - Deo Manirakiza
- United Nations Children’s Fund (UNICEF) Country Office, Kinshasa 01204, Democratic Republic of the Congo;
| | - Moise Désiré Yapi
- Immunization and Vaccines Development (IVD) Program, World Health Organization (WHO), Country Office, Kinshasa 01205, Democratic Republic of the Congo; (M.D.Y.); (G.F.N.); (R.B.R.); (B.N.T.); (C.M.); (J.O.); (M.M.N.)
| | - Gaga Fidele Ngabo
- Immunization and Vaccines Development (IVD) Program, World Health Organization (WHO), Country Office, Kinshasa 01205, Democratic Republic of the Congo; (M.D.Y.); (G.F.N.); (R.B.R.); (B.N.T.); (C.M.); (J.O.); (M.M.N.)
| | - Richard Bahizire Riziki
- Immunization and Vaccines Development (IVD) Program, World Health Organization (WHO), Country Office, Kinshasa 01205, Democratic Republic of the Congo; (M.D.Y.); (G.F.N.); (R.B.R.); (B.N.T.); (C.M.); (J.O.); (M.M.N.)
- Public Health Section, Higher Institute of Medical Techniques of Nyangezi, Sud-Kivu 11213, Democratic Republic of the Congo
| | | | - Bienvenu Nguejio Tsobeng
- Immunization and Vaccines Development (IVD) Program, World Health Organization (WHO), Country Office, Kinshasa 01205, Democratic Republic of the Congo; (M.D.Y.); (G.F.N.); (R.B.R.); (B.N.T.); (C.M.); (J.O.); (M.M.N.)
| | - Cedric Mwanga
- Immunization and Vaccines Development (IVD) Program, World Health Organization (WHO), Country Office, Kinshasa 01205, Democratic Republic of the Congo; (M.D.Y.); (G.F.N.); (R.B.R.); (B.N.T.); (C.M.); (J.O.); (M.M.N.)
| | - John Otomba
- Immunization and Vaccines Development (IVD) Program, World Health Organization (WHO), Country Office, Kinshasa 01205, Democratic Republic of the Congo; (M.D.Y.); (G.F.N.); (R.B.R.); (B.N.T.); (C.M.); (J.O.); (M.M.N.)
| | - Aimée Lulebo
- Kinshasa School of Public Health (KSPH), University of Kinshasa, Kinshasa 01302, Democratic Republic of the Congo; (E.M.); (A.L.); (P.L.)
| | - Paul Lusamba
- Kinshasa School of Public Health (KSPH), University of Kinshasa, Kinshasa 01302, Democratic Republic of the Congo; (E.M.); (A.L.); (P.L.)
| | - Marcellin Mengouo Nimpa
- Immunization and Vaccines Development (IVD) Program, World Health Organization (WHO), Country Office, Kinshasa 01205, Democratic Republic of the Congo; (M.D.Y.); (G.F.N.); (R.B.R.); (B.N.T.); (C.M.); (J.O.); (M.M.N.)
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Belt RV, Abdullah S, Mounier-Jack S, Sodha SV, Danielson N, Dadari I, Olayinka F, Ray A, Crocker-Buque T. Improving Equity in Urban Immunization in Low- and Middle-Income Countries: A Qualitative Document Review. Vaccines (Basel) 2023; 11:1200. [PMID: 37515016 PMCID: PMC10386579 DOI: 10.3390/vaccines11071200] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION As the world continues to urbanize, particularly in low- and middle-income countries, understanding the barriers and effective interventions to improve urban immunization equity is critical to achieving both Immunization Agenda 2030 targets and the Sustainable Development Goals. Approximately 25 million children missed one or more doses of the diphtheria, tetanus and pertussis (DTP3) vaccine in 2021 and it is estimated that close to 30% of the world's children missing the first dose of DTP, known as zero-dose, live in urban and peri-urban settings. METHODS The aim of this research is to improve understanding of urban immunization equity through a qualitative review of mixed method studies, urban immunization strategies and funding proposals across more than 70 urban areas developed between 2016 and 2020, supported by Gavi, the Vaccine Alliance. These research studies and strategies created a body of evidence regarding the barriers to vaccination in urban settings and potential interventions relevant to low- and middle-income countries (LMICs) with a focus on the vaccination of urban poor, populations of concern and residents of informal settlements. Through the document review we identified common challenges to achieving equitable coverage in urban areas and mapped proposed interventions. RESULTS We identified 70 documents as part of the review and categorized results across (1) social determinants of health, (2) immunization service-delivery barriers and (3) quality of services. Barriers and solutions identified in the documents were categorized in these thematic areas, drawing information from results in more than 21 countries. CONCLUSION Populations of concern such as migrants, refugees, residents of informal settlements and the urban poor face barriers to accessing care which include poor availability and quality of service. Example solutions proposed to these challenges include tailored delivery strategies, improved use of digital data collection and child-friendly services. More research is required on the efficacy of the proposed interventions identified and on gender-specific dynamics in urban poor areas affecting equitable immunization coverage.
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Affiliation(s)
- Rachel Victoria Belt
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, 75 George Street, Oxford OX1 2RL, UK
| | - Shakil Abdullah
- Department of Anthropology, University of Connecticut, Storrs, CT 06269, USA
| | - Sandra Mounier-Jack
- Department of Global Health Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Samir V. Sodha
- Department of Immunization Vaccines and Biologicals, WHO Headquarters, Avenue Appia 20, 1202 Geneva, Switzerland
| | - Niklas Danielson
- Coverage & Equity Unit, Immunization Section, PG-Health, UNICEF Headquarters, 3 UN Plaza, New York, NY 10017, USA
| | - Ibrahim Dadari
- Coverage & Equity Unit, Immunization Section, PG-Health, UNICEF Headquarters, 3 UN Plaza, New York, NY 10017, USA
| | - Folake Olayinka
- Public Health Institute, STAR Fellow Department, 901 D St, SW, Suite 1040, Washington, DC 20024, USA
| | - Arindam Ray
- Bill & Melinda Gates Foundation, New Delhi 110075, India
| | - Tim Crocker-Buque
- Department of Global Health Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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20
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Ishoso DK, Danovaro-Holliday MC, Cikomola AMW, Lungayo CL, Mukendi JC, Mwamba D, Ngandu C, Mafuta E, Lusamba Dikassa PS, Lulebo A, Manirakiza D, Mboussou FF, Yapi MD, Ngabo GF, Riziki RB, Mwanga C, Otomba J, Nimpa MM. "Zero Dose" Children in the Democratic Republic of the Congo: How Many and Who Are They? Vaccines (Basel) 2023; 11:900. [PMID: 37243004 PMCID: PMC10224070 DOI: 10.3390/vaccines11050900] [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: 03/01/2023] [Revised: 03/24/2023] [Accepted: 03/31/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: The Democratic Republic of the Congo (DRC) is one of the countries with the highest number of never vaccinated or "zero-dose" (ZD) children in the world. This study was conducted to examine the proportion of ZD children and associated factors in the DRC. (2) Methods: Child and household data from a provincial-level vaccination coverage survey conducted between November 2021-February 2021 and 2022 were used. ZD was defined as a child aged 12 to 23 months who had not received any dose of pentavalent (diphtheria-tetanus-pertussis-Haemophilus influenzae type b (Hib)-Hepatitis B) vaccine (by card or recall). The proportion of ZD children was calculated and associated factors were explored using logistic regression, taking into account the complex sampling approach. (3) Results: The study included 51,054 children. The proportion of ZD children was 19.1% (95%CI: 19.0-19.2%); ZD ranged from 62.4% in Tshopo to 2.4% in Haut Lomami. After adjustment, being ZD was associated with low level of maternal education and having a young mother/guardian (aged ≤ 19 years); religious affiliation (willful failure to disclose religious affiliation as the highest associated factor compared to being Catholic, followed by Muslims, revival/independent church, Kimbanguist, Protestant); proxies for wealth such as not having a telephone or a radio; having to pay for a vaccination card or for another immunization-related service; not being able to name any vaccine-preventable disease. A child's lack of civil registration was also associated with being ZD. (4) Conclusions: In 2021, one in five children aged 12-23 months in DRC had never been vaccinated. The factors associated with being a ZD child suggest inequalities in vaccination that must be further explored to better target appropriate interventions.
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Affiliation(s)
- Daniel Katuashi Ishoso
- World Health Organization (WHO) Country Office, Kinshasa, Democratic Republic of the Congo
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - M. Carolina Danovaro-Holliday
- Immunization, Analytics and Insights (IAI), Department of Immunization, Vaccines and Biologicals (IVB), World Health Organization (WHO), 1202 Geneva, Switzerland
| | | | | | | | - Dieudonné Mwamba
- National Institute of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Christian Ngandu
- National Institute of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Eric Mafuta
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | - Aimée Lulebo
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Deo Manirakiza
- United Nations Children’s Fund (UNICEF) Country Office, Kinshasa, Democratic Republic of the Congo
| | - Franck-Fortune Mboussou
- World Health Organization African Regional Office, Brazzaville, Democratic Republic of the Congo
| | - Moise Désiré Yapi
- World Health Organization (WHO) Country Office, Kinshasa, Democratic Republic of the Congo
| | - Gaga Fidele Ngabo
- World Health Organization (WHO) Country Office, Kinshasa, Democratic Republic of the Congo
| | - Richard Bahizire Riziki
- World Health Organization (WHO) Country Office, Kinshasa, Democratic Republic of the Congo
- Higher Institute of Medical Techniques of Nyangezi, Public Health Section, Sud-Kivu, Democratic Republic of the Congo
| | - Cedric Mwanga
- World Health Organization (WHO) Country Office, Kinshasa, Democratic Republic of the Congo
| | - John Otomba
- World Health Organization (WHO) Country Office, Kinshasa, Democratic Republic of the Congo
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21
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Dadari I, Belt RV, Iyengar A, Ray A, Hossain I, Ali D, Danielsson N, Sodha SV. Achieving the IA2030 Coverage and Equity Goals through a Renewed Focus on Urban Immunization. Vaccines (Basel) 2023; 11:809. [PMID: 37112721 PMCID: PMC10147013 DOI: 10.3390/vaccines11040809] [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: 02/25/2023] [Revised: 03/24/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
The 2021 WHO and UNICEF Estimates of National Immunization Coverage (WUENIC) reported approximately 25 million under-vaccinated children in 2021, out of which 18 million were zero-dose children who did not receive even the first dose of a diphtheria-tetanus-pertussis-(DPT) containing vaccine. The number of zero-dose children increased by six million between 2019, the pre-pandemic year, and 2021. A total of 20 countries with the highest number of zero-dose children and home to over 75% of these children in 2021 were prioritized for this review. Several of these countries have substantial urbanization with accompanying challenges. This review paper summarizes routine immunization backsliding following the COVID-19 pandemic and predictors of coverage and identifies pro-equity strategies in urban and peri-urban settings through a systematic search of the published literature. Two databases, PubMed and Web of Science, were exhaustively searched using search terms and synonyms, resulting in 608 identified peer-reviewed papers. Based on the inclusion criteria, 15 papers were included in the final review. The inclusion criteria included papers published between March 2020 and January 2023 and references to urban settings and COVID-19 in the papers. Several studies clearly documented a backsliding of coverage in urban and peri-urban settings, with some predictors or challenges to optimum coverage as well as some pro-equity strategies deployed or recommended in these studies. This emphasizes the need to focus on context-specific routine immunization catch-up and recovery strategies to suit the peculiarities of urban areas to get countries back on track toward achieving the targets of the IA2030. While more evidence is needed around the impact of the pandemic in urban areas, utilizing tools and platforms created to support advancing the equity agenda is pivotal. We posit that a renewed focus on urban immunization is critical if we are to achieve the IA2030 targets.
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Affiliation(s)
- Ibrahim Dadari
- Coverage & Equity Unit, Immunization Section, PG-Health, UNICEF Headquarters, 3 UN Plaza, New York, NY 10017, USA
- College of Public Health, University of South Florida, Tampa, FL 33612, USA
| | - Rachel V. Belt
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, 75 George Street, Oxford OX1 2JD, UK
| | - Ananya Iyengar
- Coverage & Equity Unit, Immunization Section, PG-Health, UNICEF Headquarters, 3 UN Plaza, New York, NY 10017, USA
- Johns Hopkins Bloomberg School of Public Health, International Vaccine Access Center (IVAC), Baltimore, MD 21231, USA
| | - Arindam Ray
- New Vaccines and Immunization Systems, Bill and Melinda Gates Foundation, New Delhi 110067, India
| | - Iqbal Hossain
- John Snow, Inc., 2733 Crystal Drive, Arlington, VA 22202, USA
| | - Daniel Ali
- Johns Hopkins Bloomberg School of Public Health, International Vaccine Access Center (IVAC), Baltimore, MD 21231, USA
| | - Niklas Danielsson
- Coverage & Equity Unit, Immunization Section, PG-Health, UNICEF Headquarters, 3 UN Plaza, New York, NY 10017, USA
| | - Samir V. Sodha
- Department of Immunization Vaccines and Biologicals, WHO Headquarters, Avenue Appia 20, 1211 Geneva, Switzerland
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22
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Haeuser E, Nguyen JQ, Rolfe S, Nesbit O, Fullman N, Mosser JF. Assessing Geographic Overlap between Zero-Dose Diphtheria–Tetanus–Pertussis Vaccination Prevalence and Other Health Indicators. Vaccines (Basel) 2023; 11:vaccines11040802. [PMID: 37112714 PMCID: PMC10144604 DOI: 10.3390/vaccines11040802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/17/2023] [Accepted: 03/29/2023] [Indexed: 04/08/2023] Open
Abstract
The integration of immunization with other essential health services is among the strategic priorities of the Immunization Agenda 2030 and has the potential to improve the effectiveness, efficiency, and equity of health service delivery. This study aims to evaluate the degree of spatial overlap between the prevalence of children who have never received a dose of the diphtheria–tetanus–pertussis-containing vaccine (no-DTP) and other health-related indicators, to provide insight into the potential for joint geographic targeting of integrated service delivery efforts. Using geospatially modeled estimates of vaccine coverage and comparator indicators, we develop a framework to delineate and compare areas of high overlap across indicators, both within and between countries, and based upon both counts and prevalence. We derive summary metrics of spatial overlap to facilitate comparison between countries and indicators and over time. As an example, we apply this suite of analyses to five countries—Nigeria, Democratic Republic of the Congo (DRC), Indonesia, Ethiopia, and Angola—and five comparator indicators—children with stunting, under-5 mortality, children missing doses of oral rehydration therapy, prevalence of lymphatic filariasis, and insecticide-treated bed net coverage. Our results demonstrate substantial heterogeneity in the geographic overlap both within and between countries. These results provide a framework to assess the potential for joint geographic targeting of interventions, supporting efforts to ensure that all people, regardless of location, can benefit from vaccines and other essential health services.
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Affiliation(s)
- Emily Haeuser
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA 98195, USA
| | - Jason Q. Nguyen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA 98195, USA
| | - Sam Rolfe
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA 98195, USA
| | - Olivia Nesbit
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA 98195, USA
| | - Nancy Fullman
- Department of Global Health, School of Medicine and School of Public Health, University of Washington, Seattle, WA 98195, USA
| | - Jonathan F. Mosser
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA 98195, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA 98195, USA
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23
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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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24
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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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25
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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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