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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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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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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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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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Shearer JC, Nava O, Prosser W, Nawaz S, Mulongo S, Mambu T, Mafuta E, Munguambe K, Sigauque B, Cherima YJ, Durosinmi-Etti O, Okojie O, Hadejia IS, Oyewole F, Mekonnen DA, Kanagat N, Hooks C, Fields R, Richart V, Chee G. Uncovering the Drivers of Childhood Immunization Inequality with Caregivers, Community Members and Health System Stakeholders: Results from a Human-Centered Design Study in DRC, Mozambique and Nigeria. Vaccines (Basel) 2023; 11:vaccines11030689. [PMID: 36992273 DOI: 10.3390/vaccines11030689] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/17/2023] [Accepted: 02/27/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND The importance of immunization for child survival underscores the need to eliminate immunization inequalities. Few existing studies of inequalities use approaches that view the challenges and potential solutions from the perspective of caregivers. This study aimed to identify barriers and context-appropriate solutions by engaging deeply with caregivers, community members, health workers, and other health system actors through participatory action research, intersectionality, and human-centered design lenses. METHODS This study was conducted in the Demographic Republic of Congo, Mozambique and Nigeria. Rapid qualitative research was followed by co-creation workshops with study participants to identify solutions. We analyzed the data using the UNICEF Journey to Health and Immunization Framework. RESULTS Caregivers of zero-dose and under-immunized children faced multiple intersecting and interacting barriers related to gender, poverty, geographic access, and service experience. Immunization programs were not aligned with needs of the most vulnerable due to the sub-optimal implementation of pro-equity strategies, such as outreach vaccination. Caregivers and communities identified feasible solutions through co-creation workshops and this approach should be used whenever possible to inform local planning. CONCLUSIONS Policymakers and managers can integrate HCD and intersectionality mindsets into existing planning and assessment processes, and focus on overcoming root causes of sub-optimal implementation.
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Affiliation(s)
| | - Olivia Nava
- Independent Consultant, Oakland, CA 94608, USA
| | - Wendy Prosser
- JSI Research and Training Institute USA, Arlington, VA 22202, USA
| | | | - Salva Mulongo
- PATH DRC, Kinshasa 7525, Democratic Republic of the Congo
| | - Thérèse Mambu
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa 11, Democratic Republic of the Congo
| | - Eric Mafuta
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa 11, Democratic Republic of the Congo
| | - Khatia Munguambe
- Community Health Department, Eduardo Mondlane University, Maputo 1102, Mozambique
| | - Betuel Sigauque
- JSI Research and Training Institute Mozambique, Maputo, Mozambique
| | | | | | - Obehi Okojie
- Department of Community Health, University of Benin, Benin City 300271, Nigeria
| | | | - Femi Oyewole
- Consultant Public Health Physician, Lagos, Nigeria
| | | | - Natasha Kanagat
- JSI Research and Training Institute USA, Arlington, VA 22202, USA
| | | | - Rebecca Fields
- JSI Research and Training Institute USA, Arlington, VA 22202, USA
| | - Vanessa Richart
- JSI Research and Training Institute USA, Arlington, VA 22202, USA
| | - Grace Chee
- JSI Research and Training Institute USA, Arlington, VA 22202, USA
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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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Geospatial and Time Trend of Prevalence and Characteristics of Zero-Dose Children in Nigeria from 2003 to 2018. Vaccines (Basel) 2022; 10:vaccines10091556. [PMID: 36146634 PMCID: PMC9501512 DOI: 10.3390/vaccines10091556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction: While recent years have observed a substantial improvement in vaccination coverage among children in developing countries, many children are still left out and remain unvaccinated. This study analyzes the trend of the prevalence and characteristics of zero-dose children in Nigeria over time. Methods: Using data from the Demographic and Health Survey in Nigeria from 2003 to 2018, I analyzed the prevalence and determinants of zero-dose children who had not received any DTP vaccine by geographical zone and over time. In addition, I conducted Blinder–Oaxaca decomposition analysis to evaluate the reasons for the change in the prevalence of zero-dose children over time. Results: The overall prevalence of zero-dose children reduced from over 60% in 2003 to 40% in 2018 in Nigeria. Rural areas had a higher prevalence of zero-dose children than urban areas and the gap was consistent over time. Southern zones consistently had a lower prevalence of zero-dose children, but northern zones observed more reductions in the prevalence of zero-dose children. The mother’s education and wealth level in a household are strongly associated with a lower likelihood of having zero-dose children. In both urban and rural areas, an improvement in the mother’s education level strongly explained the reduction in zero-dose children over time, while an increase in the wealth level also explained the reduction in zero-dose children in rural areas. Conclusions: While Nigeria has observed a substantial reduction in the prevalence of zero-dose children in the 15 years since 2003, the pattern of and explanatory factors for the reduction differ by geographical region. This analysis can be useful for identifying a targeting strategy to further reduce the prevalence of zero-dose children in Nigeria in the future.
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