Coverage, timeliness, and determinants of immunization completion in Pakistan: evidence from the Demographic and Health Survey (2006-07)

Trends in childhood vaccination in Pakistan and associated factors; 2006-2018

INTRODUCTION

Pakistan still has ongoing transmission of wild type polio virus. This study aims to determine changes in full vaccination with recommended Expanded Program on Immunization vaccines, including polio, by several socio-economic and demographic factors.

METHODS

We used three waves of Pakistan's Demographic and Health Survey, a population-based cross-sectional study from 2006-07 (N = 1471), 2012-13 (N = 1706), and 2017-18 (N = 1549), analyzed by residence, wealth, and sociodemographic factors. Analysis was limited to children aged 12-23 months in Punjab, Sindh, Northwest Frontier Province/Khyber Pakhtunkhwa and Balochistan. Full vaccination was measured as receipt of one Bacillus Calmette-Guérin dose, one measles dose, 3 polio doses, and 3 Diphtheria-Tetanus-Pertussis doses. Odds ratios (ORs) and 95 % confidence intervals (CIs) from logistic regression were used to determine associations between undervaccination and demographic variables.

RESULTS

Full vaccination coverage was 50.6 % in 2006-07, 54.7 % in 2012-13, and 68.3 % in 2017-18. In 2006-07, the odds of undervaccination were significantly higher in Sindh (OR: 1.74, 95 % CI: 1.30, 2.31) than Punjab, and disparities across province changed over time (P < 0.0001); notably, undervaccination was significantly higher in Sindh, KPK, and Balochistan than Punjab in 2017. Compared to the middle wealth quintile, the poorest had significantly higher odds of undervaccination in 2006-07 (OR: 2.58, 95 % CI: 1.76, 3.78), and this did not significantly change over time (P = 0.2168). The proportion of those with a polio birth dose increased across waves from 56.3 % in 2006-07 to 83.7 % in 2017-18; receiving three or more polio vaccine doses remained unchanged.

CONCLUSION

This study showed that the proportion of fully vaccinated children in Pakistan increased across three waves. Full vaccination and administration of polio vaccine birth doses have increased recently in Pakistan. The association between undervaccination with province differed significantly across the waves, with vaccination disparities between provinces increasing. Those in the poorest wealth quintile had the greatest odds of undervaccination.

A Holistic Strategy of Mother and Child Health Care to Improve the Coverage of Routine and Polio Immunization in Pakistan: Results from a Demonstration Project

BACKGROUND

The eradication of poliovirus and improving routine immunization (RI) coverage rates present significant challenges in Pakistan. There is a need for interventions that focus on strengthening community engagement to improve routine immunization coverage. Our primary objective is to assess the impact of an integrated strategy designed to enhance community engagement and maternal and child health immunization campaigns on immunization coverage in Pakistan's high-risk union councils of polio-endemic districts.

METHOD

We implemented an integrated approach for routine immunization and maternal and child health in the polio-endemic district of Pakistan. This approach involved setting up health camps and actively engaging and mobilizing the local community. An independent team conducted surveys at three key points: baseline, midline, and endline, to evaluate immunization coverage among children under the age of five. The primary outcome measures for the study were coverage of OPV, IPV, and changes in the proportion of unvaccinated and fully vaccinated children. To select clusters and eligible households in each cluster, we utilized a 30 × 15 cluster sampling technique. Multivariable associations between socio-demographic factors and changes in the proportion of fully vaccinated children at the UC level were assessed using hierarchical linear regression models.

RESULTS

A total of 256,946 children under the age of five (122,950 at baseline and 133,996 at endline) were enrolled in the study. By the endline, full immunization coverage had increased to 60% or more in all three study areas compared to the baseline. Additionally, there was a significant increase in the coverage of both OPV and IPV across all three provinces at the endline. The full immunization rates were assessed on three levels of the framework: the distal, intermediate (access and environment), and proximal level (camp attendance and effectiveness). At the distal level, on multivariate analysis, family size was found to be a significant predictor of change in immunity within the families (β = 0.68; p ≤ 0.0001). At the intermediate level, the likelihood of full immunization decreased with the decrease in knowledge about vaccination (β = -0.38; p = 0.002), knowledge about polio vaccine (β = -0.25; p = 0.011), and knowledge about IPV (β = -0.06; p = 0.546). Perceived obstacles to vaccination were fear of adverse events (β = -0.4; p ≤ 0.0001) and lack of education (β = 0.23; p = 0.031), which were found to be significant in bivariate and multivariate analyses. At the proximal level, community mobilization (β = 0.26; p = 0.008) and attendance at health camp (β = 0.21; p ≤ 0.0001) were found to enhance full immunization coverage. On the other hand, the most prominent reason for not attending health camp included no need to attend the health camp as the child was not ill (β = -0.13; p = 0.008).

CONCLUSIONS

This study found that community mobilization and attendance at health camps significantly enhanced full immunization coverage. The findings highlight the importance of community engagement and targeted interventions in improving immunization coverage and addressing barriers to healthcare seeking.

Urban-rural disparities in immunization coverage among children aged 12-23 months in Ethiopia: multivariate decomposition analysis

BACKGROUND

Immunization is one of the most cost-effective public health interventions for improving children's health and survival. In Ethiopia, low immunization coverage and disparity across residences are major public health problems. However, the factors that contributed to the urban-rural disparity have not been thoroughly investigated. Therefore, the objective of this study was to examine the change and contributing factors in full immunization coverage across geographic locations (urban-rural) in Ethiopia.

METHODS

We analyzed data on children aged 12 to 23 months obtained from the 2019 mini-Ethiopian demographic and health survey. A total of 996 weighted samples (299 in urban and 697 in rural areas) were included in the analysis. A multivariate decomposition analysis technique was used to determine the disparity and identify factors that contribute to the disparity across geographical locations. Statistical significance was defined at a 95% confidence interval with a p-value of less than 0.05.

RESULTS

The percentage of children aged 12-23 months who received full immunization increased from 36.84% (95% CI:31.59, 42.41) in rural areas to 64.59% (95% CI:47.10, 78.89) in urban areas. The decomposition analysis showed that the observed urban-rural disparity was attributed to a change in the effect of population characteristics (coefficient) across residences. Specifically, receiving 1-3 (β = 0.0895, 95% CI: 0.0241, 0.1550) and 4 or more (β = 0.1212, 95% CI: 0.0224, 0.2199) antenatal care visits, delivering at a health facility (β = 0.1350, 95% CI: 0.0227, 0.2472), and the source of information about immunization status from vaccination cards (β = 0.2666, 95% CI:0.1763, 0.3569) significantly contributed to the widening urban-rural disparity. On the other hand, being of high wealth status (β=-0.141, 95% CI: -0.1945, -0.0876), receiving postnatal care (β=-0.0697, 95% CI: -0.1344, -0.0051), and having four or more living children (β=-0.1774, 95% CI: -0.2971, -0.0577) significantly contributed to narrowing the urban-rural disparity.

CONCLUSIONS

There was a significant urban-rural disparity in immunization coverage in Ethiopia, with urban children more likely to complete immunization. The change in the composition of population characteristics was not significant for the observed disparity. The observed disparity in full immunization coverage was mainly driven by the coefficients related to maternal healthcare utilization, household wealth status, the number of living children, and the source of immunization information. Therefore, strengthening maternal health services utilization, encouraging mothers to maintain their children's immunization records, and addressing economic inequality, particularly in rural areas, may narrow the urban-rural disparity and enhance immunization coverage nationwide.

Routine childhood vaccination in India from 2005-2006 to 2015-2016: Temporal trends and geographic variation

OBJECTIVE

India has experienced a substantial increase in the coverage of routine childhood vaccines in recent years. However, a large fraction of these vaccines is not delivered in a timely manner, i.e., at the recommended age. Further, substantial disparities exist in both coverage and timeliness across states. We aim to quantify the changes in coverage and timeliness of routine childhood vaccination in India over time, their variation across states, and changes in these variations over time.

METHODS

We used data from two rounds of India's National Family Health Surveys, NFHS-3 (2005-06) and NFHS-4 (2015-16) on bacille Calmette-Guerin vaccine (BCG), three doses of diphtheria, pertussis, and tetanus vaccine (DPT1, DPT2, DPT3), and measles-containing vaccine (MCV). We used the Turnbull estimator to estimate the cumulative distribution function (CDF) of administering each vaccine by a certain age while accounting for two-sided censoring in the survey data. We then used these estimated CDFs to calculate coverage and timeliness at the national and state levels.

FINDINGS

At the national level, both vaccination coverage and timeliness estimates increased from NFHS-3 to NFHS-4 for all vaccines. The increase in timeliness ranging from 27.3% for DPT3 to 74.0% for MCV continued to be lower than coverage, ranging from 75.3% (95% CI 57.7-87.2) for DPT3 to 74.0% (95% CI 42.2-33.0) for MCV, for all vaccines. Cross-state variation in timeliness was greater than the variation in coverage. Variation in both timeliness and coverage reduced from NFHS-3 to NFHS-4. However, this reduction was greater for timeliness than for coverage.

CONCLUSIONS

A large fraction of the children in India receive vaccines later than the recommended age thereby keeping them exposed to vaccine-preventable diseases. Interventions that specifically focus on improving the timely delivery of vaccines are needed to improve the overall effectiveness of the routine immunization program.

Timeliness of routine childhood vaccination in 103 low-and middle-income countries, 1978-2021: A scoping review to map measurement and methodological gaps

Empiric studies exploring the timeliness of routine vaccination in low-and middle-income countries (LMICs) have gained momentum in the last decade. Nevertheless, there is emerging evidence suggesting that these studies have key measurement and methodological gaps that limit their comparability and utility. Hence, there is a need to identify, and document these gaps which could inform the design, conduct, and reporting of future research on the timeliness of vaccination. We synthesised the literature to determine the methodological and measurement gaps in the assessment of vaccination timeliness in LMICs. We searched five electronic databases for peer-reviewed articles in English and French that evaluated vaccination timeliness in LMICs, and were published between 01 January 1978, and 01 July 2021. Two reviewers independently screened titles and abstracts and reviewed full texts of relevant articles, following the guidance framework for scoping reviews by the Joanna Briggs Institute. From the 4263 titles identified, we included 224 articles from 103 countries. China (40), India (27), and Kenya (23) had the highest number of publications respectively. Of the three domains of timeliness, the most studied domain was 'delayed vaccination' [99.5% (223/224)], followed by 'early vaccination' [21.9% (49/224)], and 'untimely interval vaccination' [9% (20/224)]. Definitions for early (seven different definitions), untimely interval (four different definitions), and delayed vaccination (19 different definitions) varied across the studies. Most studies [72.3% (166/224)] operationalised vaccination timeliness as a categorical variable, compared to only 9.8% (22/224) of studies that operationalised timeliness as continuous variables. A large proportion of studies [47.8% (107/224)] excluded the data of children with no written vaccination records irrespective of caregivers' recall of their vaccination status. Our findings show that studies on vaccination timeliness in LMICs has measurement and methodological gaps. We recommend the development and implement of guidelines for measuring and reporting vaccination timeliness to bridge these gaps.

Vaccination status and factors associated among children age 12–23 months in Ethiopia, based on 2016 EDHS: Logit based multinomial logistic regression analysis

Background

Childhood immunization is one of the most cost-effective prevention measures for children’s mortality and morbidity, saving 2–3 million lives per year. In Ethiopia, under-five mortality rates, about 190,000 children die each year. Different research conducted in Ethiopia on childhood vaccination have focused on either vaccination coverage of individual vaccine or complete and incomplete vaccination. As far as my literature searching, studies separated the vaccination status into non-vaccinated, partially vaccinated and full vaccinated and assorted factors among children age 12–23 month in Ethiopia were limited. Therefore, the aim of this study was to identify factors associated with vaccination status among children 12–23 months of age in Ethiopia.

Method

A secondary data analysis was done based on the 2016 Ethiopian Demographic and Health Survey (EDHS). A total weighted sample of 1911 children age 12–23 months of age were included in the study. Logit based Multinomial logistic regression analysis was computed to distinguish factors associated with routine vaccination of children aged 12–23 months. P-value less than 0.05 was used to declare statistical significance of each independent variables, and adjusted odd ratio (AOR) with 95% confidence interval were used to present the result and STATA 14 was utilized for data management and analysis.

Result

Overall the prevalence of full vaccinated children was 35%, while 49% of children were partially vaccinated and 16% were non-vaccinated. In multinomial analysis, having focused ANC (at least four visits) contrasted to no ANC visits at all had 9.7 higher odd of being fully vaccinated than not vaccinated [AOR = 9.74, 95% CI = 3.52–26.94], and 5 times higher odd of being partially vaccinated than not vaccinated [AOR = 4.97, 95% CI = 2.00–12.33].

Conclusion

The present study found that childhood full vaccination status was low compared with the World Health Organization targets. Frequency of ANC visit and visited by field worker were significantly associated both partially and full vaccination whereas, visited health facility last 12 months and wealth status were significantly associated with childhood full vaccination.

Determinants of vaccine coverage and timeliness in a northern Pakistani village

The incidence of vaccine preventable disease in Pakistan remains high despite a long-standing Expanded Program on Immunization (EPI). We describe vaccine completeness, timeliness and determinants of coverage from a remote rural cohort (2012–2014). Vaccination histories were taken from EPI records. Vaccination was complete if all doses were received according to the EPI schedule and timely if doses were not ≥3 days early or ≥ 28 days late. Three models are presented: a multivariable logistic regression of household demographic and socioeconomic factors associated with complete vaccination, a multivariable mixed effects logistic regression assessing whether or not the vaccine was administered late (versus on-time), and a mixed effects multivariable Poisson regression model analysing the interval (in days) between vaccine doses. Of 959 enrolled children with full vaccination histories, 88.2 and 65.1% were fully vaccinated following either the pentavalent or DPT/HBV schedules if measles was excluded; coverage dropped to 50.0 and 27.1% when both doses of measles were included. Sixty-four (6.7%) were unvaccinated. Coverage and timeliness declined with subsequent doses. Migrating into the village after 1995 (95%CI 1.88 to 5.17) was associated with late vaccination. Being male, having an older father, and having parents with at least some formal education reduced the likelihood of a late dose. The interval between doses was consistent at 5 weeks (compared with the 4 weeks recommended by EPI). None of the socio-demographic variables were related to the likelihood of receiving full coverage. Vaccine coverage in Oshikhandass was higher than national averages. Measles vaccine coverage and timeliness were low; special consideration should be paid to this vaccine. The local vaccination schedule differed from the EPI, but the consistency suggests good local administration.

Effect of Mobile Phone Text Message Reminders on the Completion and Timely Receipt of Routine Childhood Vaccinations: Superiority Randomized Controlled Trial in Northwest Ethiopia

BACKGROUND

Nonattendance at vaccination appointments is a big challenge for health workers as it is difficult to track routine vaccination schedules. In Ethiopia, 3 out of 10 children have incomplete vaccination and the timely receipt of the recommended vaccines is low. Thus, innovative strategies are required to reach the last mile where mobile technology can be effectively utilized to achieve better compliance. Despite this promising technology, little is known about the role of text message-based mobile health interventions in improving the complete and timely receipt of routine childhood vaccinations in Ethiopia.

OBJECTIVE

This trial aimed to determine the effect of mobile phone text message reminders on the completion and timely receipt of routine childhood vaccinations in northwest Ethiopia.

METHODS

A two-arm, parallel, superiority randomized controlled trial was conducted in 9 health facilities in northwest Ethiopia. A sample size of 434 mother-infant pairs was considered in this trial. Randomization was applied in selected health facilities during enrollment with a 1:1 allocation ratio by using sealed and opaque envelopes. Participants assigned to the intervention group received mobile phone text message reminders one day before the scheduled vaccination visits. Owing to the nature of the intervention, blinding of participants was not possible. Primary outcomes of full and timely completion of vaccinations were measured objectively at 12 months. A two-sample test of proportion and log-binomial regression analyses were used to compare the outcomes between the study groups. A modified intention-to-treat analysis approach was applied and a one-tailed test was reported, considering the superiority design of the trial.

RESULTS

A total of 426 participants were included for the analysis. We found that a higher proportion of infants in the intervention group received Penta-3 (204/213, 95.8% vs 185/213, 86.9%, respectively; P<.001), measles (195/213, 91.5% vs 169/213, 79.3%, respectively; P<.001), and full vaccination (176/213, 82.6% vs 151/213, 70.9%, respectively; P=.002; risk ratio 1.17, 95% lower CI 1.07) compared to infants in the usual care group. Similarly, a higher proportion of infants in the intervention group received Penta-3 (181/204, 88.7% vs 128/185, 69.2%, respectively; P<.001), measles (170/195, 87.1% vs 116/169, 68.6%, respectively; P<.001), and all scheduled vaccinations (135/213, 63.3% vs 85/213, 39.9%, respectively; P<.001; risk ratio 1.59, 95% lower CI 1.35) on time compared to infants in the usual care group. Of the automatically sent 852 mobile phone text messages, 764 (89.7%) were delivered successfully to the participants.

CONCLUSIONS

Mobile phone text message reminders significantly improved complete and timely receipt of all recommended vaccines. Besides, they had a significant effect in improving the timely receipt of specific vaccines. Thus, text message reminders can be used to supplement the routine immunization program in resource-limited settings. Considering different contexts, studies on the implementation challenges of mobile health interventions are recommended.

TRIAL REGISTRATION

Pan African Clinical Trial Registry PACTR201901533237287; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5839.

Timeliness of childhood vaccinations in the Philippines

Timeliness of vaccinations is rarely part of monitoring in a routine immunization program. We reviewed infant immunization and conducted caregiver interviews in three regions in the Philippines from January to October 2016. We randomly selected thirty public health centers, one for each region. We defined timeliness of the receipt of antigen as within 4 weeks after the recommended age at vaccination. We assessed a total of 986 infants for timeliness of vaccination. The median age of receipt of vaccine was at 2.7 weeks (BCG), 10.1 weeks (Penta 1), and 21.7 weeks (Penta 3) compared to the recommended 0, 6, and 14 weeks of age, respectively. We found timely receipt only in 74.4% for BCG, 70.3% for Penta 1, and 39.1% for Penta 3 recipients. Thus, alongside declining immunization coverage, the infants in the Philippines had substantial delays in vaccine receipt.

Characterization of immunization secondary analyses using demographic and health surveys (DHS) and multiple indicator cluster surveys (MICS), 2006-2018

BACKGROUND

Infant immunization coverage worldwide has plateaued at about 85%. Using existing survey data to conduct analyses beyond estimating coverage may help immunization programmes better tailor strategies to reach un- and under-immunized children. The Demographic and Health Survey (DHS) and the Multiple Indicators Cluster Survey (MICS), routinely conducted in low and middle-income countries (LMICs), collect immunization data, yet vaccination coverage is often the only indicator reported and used. We conducted a review of published immunization-related analyses to characterize and quantify immunization secondary analyses done using DHS and MICS databases.

METHODS

We conducted a systematic search of the literature, of immunization-related secondary analyses from DHS or MICS published between 2006 and August 2018. We searched 15 electronic databases without language restrictions. For the articles included, relevant information was extracted and analyzed to summarize the characteristics of immunization-related secondary analyses. Results are presented following the PRISMA guidelines.

RESULTS

Among 1411 papers identified, 115 met our eligibility criteria; additionally, one article was supplemented by the Pan American Health Organization. The majority were published since 2012 (77.6%), and most (68.9%) had a first or corresponding author affiliated with institutions in high-income countries (as opposed to LMICs where these surveys are conducted). The median delay between survey implementation and publication of the secondary analysis was 5.4 years, with papers with authors affiliated to institutions in LMIC having a longer median publication delay (p < 0.001). Over 80% of the published analyses looked at factors associated with a specific vaccine or with full immunization. Quality proxies, such as reporting percent of immunization data from cards vs recall; occurrence and handling of missing data; whether survey analyses were weighted; and listing of potential biases or limitations of the original survey or analyses, were infrequently mentioned.

CONCLUSION

Our review suggests that more needs to be done to increase the increase the utilization of existing DHS and MICS datasets and improve the quality of the analyses to inform immunization programmes. This would include increasing the proportion of analyses done in LMICs, reducing the time lag between survey implementation and publication of additional analyses, and including more qualitative information about the survey in the publications to better interpret the results.

An Artificial Intelligence-Based, Personalized Smartphone App to Improve Childhood Immunization Coverage and Timelines Among Children in Pakistan: Protocol for a Randomized Controlled Trial

BACKGROUND

The immunization uptake rates in Pakistan are much lower than desired. Major reasons include lack of awareness, parental forgetfulness regarding schedules, and misinformation regarding vaccines. In light of the COVID-19 pandemic and distancing measures, routine childhood immunization (RCI) coverage has been adversely affected, as caregivers avoid tertiary care hospitals or primary health centers. Innovative and cost-effective measures must be taken to understand and deal with the issue of low immunization rates. However, only a few smartphone-based interventions have been carried out in low- and middle-income countries (LMICs) to improve RCI.

OBJECTIVE

The primary objectives of this study are to evaluate whether a personalized mobile app can improve children's on-time visits at 10 and 14 weeks of age for RCI as compared with standard care and to determine whether an artificial intelligence model can be incorporated into the app. Secondary objectives are to determine the perceptions and attitudes of caregivers regarding childhood vaccinations and to understand the factors that might influence the effect of a mobile phone-based app on vaccination improvement.

METHODS

A mixed methods randomized controlled trial was designed with intervention and control arms. The study will be conducted at the Aga Khan University Hospital vaccination center. Caregivers of newborns or infants visiting the center for their children's 6-week vaccination will be recruited. The intervention arm will have access to a smartphone app with text, voice, video, and pictorial messages regarding RCI. This app will be developed based on the findings of the pretrial qualitative component of the study, in addition to no-show study findings, which will explore caregivers' perceptions about RCI and a mobile phone-based app in improving RCI coverage.

RESULTS

Pretrial qualitative in-depth interviews were conducted in February 2020. Enrollment of study participants for the randomized controlled trial is in process. Study exit interviews will be conducted at the 14-week immunization visits, provided the caregivers visit the immunization facility at that time, or over the phone when the children are 18 weeks of age.

CONCLUSIONS

This study will generate useful insights into the feasibility, acceptability, and usability of an Android-based smartphone app for improving RCI in Pakistan and in LMICs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04449107; https://clinicaltrials.gov/ct2/show/NCT04449107.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/22996.

Vaccination assessments using the Demographic and Health Survey, 2005-2018: a scoping review

OBJECTIVE

To characterise studies which have used Demographic and Health Survey (DHS) datasets to evaluate vaccination status.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases including PubMed, EBSCOhost and POPLINE, from 2005 to 2018.

STUDY SELECTION

All English studies with vaccination status as the outcome and the use of DHS data.

DATA EXTRACTION

Studies were selected using a predetermined list of eligibility criteria and data were extracted independently by two authors. Data related to the study population, the outcome of interest (vaccination) and commonly seen predictors were extracted.

RESULTS

A total of 125 articles were identified for inclusion in the review. The number of countries covered by individual studies varied widely (1-86), with the most published papers using data from India, Nigeria, Pakistan and Ethiopia. Many different definitions of full vaccination were used although the majority used a traditional schedule recommended in the WHO's Expanded Programme on Immunisation. We found studies analysed a wide variety of predictors, but the most common were maternal education, wealth, urbanicity and child's sex. Most commonly reported predictors had consistent relationships with the vaccination outcome, outside of sibling composition.

CONCLUSIONS

Researchers make frequent use of the DHS dataset to describe vaccination patterns within one or more countries. A clearer idea of past use of DHS can inform the development of more rigorous studies in the future. Researchers should carefully consider whether a variable needs to be included in the multivariable model, or if there are mediating relationships across predictor variables.

Individual- and Community-Level Determinants for Complete Vaccination among Children Aged 12-23 Months in Ethiopia: A Multilevel Analysis

Background

Childhood vaccination continues to increase dramatically. In spite of the success of immunization programs to date, millions of children continued to die each year, and sub-Saharan Africa (SSA) accounted for the world's highest neonatal deaths. Childhood vaccination was designed as one of the most effective ways to reduce child mortalities from fatal vaccine-preventable diseases. Therefore, this study is aimed at investigating the individual- and community-level determinants of childhood complete vaccination in Ethiopia.

Methods

A secondary data analysis was done based on the 2016 Ethiopian Demographic and Health Survey (EDHS). A total weighted sample of 1,984 children aged 12-23 months was included for analysis. Considering the hierarchical nature of EDHS data, a two-level multilevel analysis for assessing individual- and community-level determinants of childhood complete vaccination was done. The intraclass correlation coefficient (ICC), Median Odds Ratio (MOR), Proportional Change in Variance (PCV), and deviance (-2LL) were used for model comparison and for checking model fitness. Variables with p value < 0.2 in the bivariable multilevel analysis were considered for the multivariable multilevel analysis. In the multivariable multilevel logistic regression analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was reported to declare significant determinants of complete childhood vaccination.

Results

Overall complete vaccination status among children aged 12-23 months was 39% (95% CI: 36.8, 41.2). In the multilevel analysis, secondary or above educated mothers (AOR = 2.48; 95% CI: 1.41, 4.36), richest wealth status (AOR = 2.24; 95% CI: 1.16, 4.32), ≥four ANC visits (AOR = 2.77; 95% CI: 1.90-4.02), employed mothers (AOR = 1.66; 95% CI: 1.26, 2.18), urban residence (AOR = 1.84; 95% CI: 1.00, 3.51), and children in city administration (AOR = 2.66; 9% CI: 1.53, 4.62) were positively associated with vaccination status. On the other hand, children with a female household head (AOR = 0.68; 95% CI: 0.48, 0.96) were negatively associated.

Conclusion

Overall, childhood full vaccination status was low compared with the WHO targets. Maternal education, wealth status, ANC visit, maternal occupation, residence, region, and sex of household head were significant predictors of childhood complete vaccination. As a result, it is better to design a compensation mechanism to the costs associated with childhood vaccination for the poor households and strengthen awareness creation for rural residents to improve the access, utilization, and continuum of vaccination service.

Timely completion of vaccination and its determinants among children in northwest, Ethiopia: a multilevel analysis

BACKGROUND

Timely vaccination is key to prevent unnecessary childhood mortality from vaccine-preventable diseases. Despite the substantial efforts to improve vaccination completeness, the effort towards timeliness of vaccination is limited with non-attendance and delays to vaccination appointments remaining a big challenge in developing countries. There is also a limited evidence on timeliness of vaccination. Therefore, this study aimed to determine the magnitude and associated factors for timely completion of vaccination among children in Gondar city administration, north-west, Ethiopia.

METHOD

This study employed a community-based cross sectional study design. A sample size of 821 children aged 12 to 23 months were considered. Two stages random sampling technique was used to select study subjects. To account the effect of clustering, bivariable and multivariable multilevel logistic regression analysis were applied. The measures of association estimates were expressed as adjusted odds ratio (AOR) with their 95% confidence intervals (CIs).

RESULTS

Of the 774 children included for analysis, 498 (64.3%) were fully vaccinated while 247 (31.9%) were fully vaccinated on-time. Caregivers who had secondary education and above (AOR = 2.391; 95% CI: 1.317-4.343), from richest households (AOR = 2.381; 95% CI: 1.502-3.773), children whose mother attended four or more ante natal care visits (AOR = 2.844; 95% CI: 1.310-6.174) and whose mother had two or more post natal care visits (AOR = 2.054; 95%CI:1.377-3.063) were positively associated with on-time full vaccination. In contrary, caregivers aged above 35 years (AOR = 0.469; 95 % CI: 0.253-0.869], being vaccinated at health post (AOR = 0.144; 95%CI: 0.048-0.428) and travelling more than 30 min to the vaccination site (AOR = 0.158; 95%CI: 0.033-0.739) were negatively associated with on-time full vaccination. The random effects indicated that 26% of the variability in on-time full vaccination was attributable to differences between communities.

CONCLUSION

In this study, untimely vaccination was found to be high. Different individual and contextual factors were found to be associated with on-time full vaccination. Therefore, tailored strategies have to be designed and implemented to address people and the communities where they live. Moreover, timeliness of vaccination should be considered as important indicator of the immunization program performance in Ethiopia.

Role of Maternal Education and Vaccination Coverage: Evidence From Pakistan Demographic and Health Survey

The aim of this study was to examine the impact of maternal education on child immunization uptake in Pakistan, both at individual and community levels. Pakistan Demographic and Health Survey data were used for analysis. Multilevel logistic regression was used to access the individual- and community-level factors associated with childhood immunization coverage. Out of 6765 children 2659 (39.3%) were fully immunized. Parents education, access to media, and wealth status have positive while ethnicity and working status of mother have a negative impact on the immunization uptake. In the community with a high percentage of educated mothers, the odds of immunized children were high (odds ratio = 1.43, 95% confidence interval = 1.14-1.80) as compared with communities with lower percentage of educated mothers. Moreover, significant variation was found in the likelihood of full immunization across communities. Both community- and individual-level factors have substantial impact on children immunization status. There is a need of improvement in maternal education, poverty alleviation, and removal of rural-urban disparities.

Determinants of timeliness in early childhood vaccination among mothers with vaccination cards in Sindh province, Pakistan: a secondary analysis of cross-sectional survey data

OBJECTIVE

Untimely vaccination refers to receiving the given dose before (early) or after (delayed) the recommended time window. The purpose of this study was to assess the extent of timeliness of childhood vaccinations and examine the determinants of vaccination timeliness in Sindh province, Pakistan.

DESIGN

Cross-sectional analysis of data from the 2013 and 2014 Maternal and Child Health Program Indicator Surveys.

SETTING

Community-based maternal and child health surveys.

PARTICIPANTS

Among 10 200 respondents of Maternal and Child Health Program Indicator Surveys, 1143 women who had a live birth in the 2 years preceding the survey were included.

OUTCOMES

At the participants' home, an interviewer asked mothers to show their children's vaccination cards, which contained information regarding vaccinations. Children's vaccination status was categorised into timely or early/delayed compared with vaccination schedule. A logistic regression analysis using Firth's penalised likelihood was performed to identify factors associated with timeliness of vaccinations.

RESULTS

238 children (20.8% of children who received a full set of basic vaccinations) received all vaccinations on schedule among children who received a full set of basic vaccinations. The percentages of timely vaccinations ranged from 2.3% for second measles vaccination to 89.3% for bacillus Calmette-Guérin. Child's age and place of delivery were associated with timely vaccinations. Older child age and institutional delivery were associated with decreased timely vaccination rate.

CONCLUSIONS

Home-based vaccination record is a key tool to improve the timeliness of vaccinations. The redesigned vaccination cards, the new electronic registries for vaccination card information and the vaccination tracking system to remind the second/third vaccination visits may be helpful to improve timely vaccinations for children under 2 years old.

Vaccination timeliness and delay in low- and middle-income countries: a systematic review of the literature, 2007-2017

Background: Traditional measurements of vaccine coverage at specific ages can mask poor vaccine timeliness. However, optimal measurement of timing is unclear due to variations in countries’ recommended vaccination schedules and lack of a commonly accepted standard for “timeliness”. We conducted a systematic review of literature on vaccine timeliness and delay in low- and middle-income countries from 2007 to 2017.

Methods: A search of articles published between January 1 2007 and December 31 2017, was performed in PubMed, EBSCOhost, and Embase.

Results: 67 papers were included, of which 83% used a categorical measure of delay and 41% evaluated continuous delay. The most common age at assessment was 1 month, with earlier age benchmarks typically used with birth doses.

Conclusions: Categorical definitions of vaccination timing vary widely, with benchmarks of delay varying from days to weeks to months. Use of a continuous measure of vaccine delay may be more informative and comparable.

Factors affecting age-appropriate timeliness of vaccination coverage among children in Lebanon

Background: The effect of immunization does not only depend on its completeness, but also on its timely administration. Routine childhood vaccinations schedules recommend that children receive the vaccine doses at specific ages. This article attempts to assess timeliness of routine vaccination coverage among a sub-sample of children from a survey conducted in 2016. Methods: This analysis was based on data from a cross-sectional multistage cluster survey conducted between December 2015 and June 2016 among caregivers of children aged 12-59 months in all of Lebanon using a structured survey questionnaire. The analysis used Kaplan-Meier curves and logistic regression to identify the predictors of age-appropriate immunization. Results: Among the 493 randomly selected children, timely administration of the third dose of polio vaccine, diphtheria-tetanus-pertussis (DTP)-containing vaccine and hepatitis B (HepB) vaccine occurred in about one-quarter of children. About two-thirds of children received the second dose of a measles-containing vaccine (MCV) within the age interval recommended by the Expanded Programme on Immunization (EPI). Several factors including socio-demographic, knowledge, beliefs and practices were found to be associated with age-appropriate vaccination; however, this association differed between the types and doses of vaccine. Important factors associated with timely vaccination included being Lebanese as opposed to Syrian and being born in a hospital for hepatitis B birth dose; believing that vaccination status was up-to-date was related to untimely vaccination. Conclusions: The results suggest that there is reason for concern over the timeliness of vaccination in Lebanon. Special efforts need to be directed towards the inclusion of timeliness of vaccination as another indicator of the performance of the EPI in Lebanon.

Factors affecting complete and timely childhood immunization coverage in Sindh, Pakistan; A secondary analysis of cross-sectional survey data

BACKGROUND

Pakistan has a high burden of newborn mortality, which would be significantly preventable through appropriate routine immunization. The purpose of this study was to measure the basic timely childhood immunization coverage and to identify determinants of factors influencing childhood immunization coverage in Sindh, Pakistan.

METHODS

Data from Maternal and Child Health Program Indicator Survey 2013-2014 which was conducted in Sindh province of Pakistan was used. Outcome measure was full coverage of the basic immunization schedule from child's vaccination card. The association of receiving basic immunization with demographic factors, socioeconomic status, mother and child health information sources, and perinatal care factors were tested by binary logistic regression.

RESULTS

Among 2,253 children, 1,156 (51.3%) received age-based full basic immunization. The basic immunization rates were 69.1% for under five weeks old, 38.3% for six to nine weeks, 18.8% for 10-13 weeks, 44.0% for 14 weeks-eight months, 60.4% for nine to 11 months, and 59.1% for over one year. Child's age, number of living children, parents' education level, wealth, the source of mother and child health information, number of antenatal care, and assistance during delivery were associated with completing basic immunization.

CONCLUSIONS

The overall full basic immunization coverage in Pakistan was still low. Policy makers should identify children at risk of low immunization coverage and obstacles of receiving antenatal care, implement educational interventions targeting on less educated parents, and conduct mass immunization campaigns for timely and complete immunization.

Vaccination timeliness and co-administration among Kenyan children

BACKGROUND

Timely administration of recommended vaccines requires children to have multiple vaccines co-administered in the first year of life. The objectives of this study were to estimate the proportion of timely vaccinations and the proportion of co-administered vaccines, and to assess the relationship between vaccine co-administration and vaccine timeliness in Kenyan children.

METHODS

Using the 2014 Kenyan Demographic and Health Survey (DHS), we calculated the proportion of children who received co-administered and timely vaccine doses. Co-administration was defined as doses administered on the same day with dates recorded on vaccination cards. Vaccines were considered timely if given within four days before to four weeks after the recommended interval for administration.

RESULTS

10,385 children aged 1-4 years in the Kenyan 2014 DHS dataset had vaccination cards which comprised the study sample. Analysis revealed wide a range for receipt of timely doses, from 90.2% for OPV0 to 56.0% for Measles. Co-administration of the 6-week dose was associated with 2.81 times higher odds of a timely Penta dose 1 (95% CI: 2.28, 3.46) and birth-dose co-administration was associated with a substantial increase in timely BCG vaccination: AOR 7.43 (95% CI: 6.31, 8.75).

CONCLUSIONS

Though vaccine coverage in Kenya was high, timely vaccination was markedly low, with resultant implications for population immunity and potential spread of communicable diseases in unvaccinated infants. Co-administration of vaccines, place of residence, wealth index, and child age were consistently related to the odds of timely vaccine receipt. These relationships reinforce the importance of dedicating resources to programs that educate low socio-economic groups about the importance of vaccine co-administration.

Individual- and community-level determinants of child immunization in the Democratic Republic of Congo: A multilevel analysis

Understanding modifiable determinants of full immunization of children provide a valuable contribution to immunization programs and help reduce disease, disability, and death. This study is aimed to assess the individual and community-level determinants of full immunization coverage among children in the Democratic Republic of Congo. This study used data from the Demographic and Health Survey 2013–14 from the Democratic Republic of Congo. Data regarding total 3,366 children between 12 and 23 months of age were used in this study. Children who were immunized with one dose of BCG, three doses of polio, three doses of DPT, and a dose of measles vaccine was considered fully immunized. Descriptive statistics were calculated for the prevalence and distribution of full immunization coverage. Two-level multilevel logistic regression analysis, with individual-level (level 1) characteristics nested within community-level (level 2) characteristics, was used to assess the individual- and community-level determinants of full immunization coverage. This study found that about 45.3% [95%CI: 42.02, 48.52] of children aged 12–23 months were fully immunized in the DRC. The results confirmed immunization coverage varied and ranged between 5.8% in Mongala province to 70.6% in Nord-Kivu province. Results from multilevel analysis revealed that, four Antenatal Care (ANC) visits [AOR: 1.64; 95%CI: 1.23, 2.18], institutional delivery [AOR: 2.37; 95%CI: 1.52, 3.72], and Postnatal Care (PNC) service utilization [AOR: 1.43; 95%CI: 1.04, 1.95] were statistically significantly associated with the full immunization coverage. Similarly, children of mothers with secondary or higher education [AOR: 1.32; 95%CI: 1.00, 1.81] and from the richest wealth quintile [AOR: 1.96; 95%CI: 1.18, 3.27] had significantly higher odds of being fully immunized compared to their counterparts whose mothers were relatively poorer and less educated. Among the community-level characteristics, residents of the community with a higher rate of institutional delivery [AOR: 2.36; 95%CI: 1.59, 3.51] were found to be positively associated with the full immunization coverage. Also, the random effect result found about 35% of the variation in immunization coverage among the communities was attributed to community-level factors.The Democratic Republic of Congo has a noteworthy gap in full immunization coverage. Modifiable factors–particularly health service utilization including four ANC visits, institutional delivery, and postnatal visits–had a strong positive effect on full immunization coverage. The study underlines the importance of promoting immunization programs tailored to the poor and women with little education.

Vaccine hesitancy among caregivers and association with childhood vaccination timeliness in Addis Ababa, Ethiopia

INTRODUCTION

Vaccines are vital to reducing childhood mortality, and prevent an estimated 2 to 3 million deaths annually which disproportionately occur in the developing world. Overall vaccine coverage is typically used as a metric to evaluate the adequacy of vaccine program performance, though it does not account for untimely administration, which may unnecessarily prolong children's susceptibility to disease. This study explored a hypothesized positive association between increasing vaccine hesitancy and untimeliness of immunizations administered under the Expanded Program on Immunization (EPI) in Addis Ababa, Ethiopia.

METHODS

This cross-sectional survey employed a multistage sampling design, randomly selecting one health center within five sub-cities of Addis Ababa. Caregivers of 3 to 12-month-old infants completed a questionnaire on vaccine hesitancy, and their infants' vaccination cards were examined to assess timeliness of received vaccinations.

RESULTS

The sample comprised 350 caregivers. Overall, 82.3% of the surveyed children received all recommended vaccines, although only 55.9% of these vaccinations were timely. Few caregivers (3.4%) reported ever hesitating and 3.7% reported ever refusing a vaccine for their child. Vaccine hesitancy significantly increased the odds of untimely vaccination (AOR 1.94, 95% CI: 1.02, 3.71) in the adjusted analysis.

CONCLUSIONS

This study found high vaccine coverage among a sample of 350 young children in Addis Ababa, though only half received all recommended vaccines on time. High vaccine hesitancy was strongly associated with infants' untimely vaccination, indicating that increased efforts to educate community members and providers about vaccines may have a beneficial impact on vaccine timeliness in Addis Ababa.

Coverage, Timelines, and Determinants of Incomplete Immunization in Bangladesh

Immunization has become one of the major contributors to public health globally as it prevents communicable disease, particularly in children. The objective of this study was to estimate the extent of timely immunization coverage and to investigate the determinants of incomplete and untimely vaccination. Methods: The study used data from the latest Bangladesh Demographic Health Survey (BDHS) 2014. A total sample of 1631 children aged 12–23 months who had an Expanded Program on Immunization (EPI) card and immunization history were analyzed. Multivariable logistic regression models were used to determine the significant influencing factors on untimely vaccination (BCG, pentavalent vaccine/OPV, and measles) and incomplete vaccination. The results were presented in terms of adjusted odds ratio (AOR) with a 95% confidence interval and a significance level p < 0.05. Results: The proportions of children who received timely vaccinations were 24% for BCG, 46% for pentavalent 3, and 53% for measles, whereas 76%, 51%, and 36% children failed to receive the BCG, pentavalent 3, and measles vaccines, respectively, in a timely manner. The proportion of early vaccination was 3% for pentavalent 3 and 12% for measles. Several significant influencing factors including age, maternal education and working status, awareness of community clinics, socioeconomic status, and geographic variation significantly contributed to untimely and incomplete vaccination of children in Bangladesh. Conclusions: The study identified some key determinants of untimely and incomplete childhood vaccinations in the context of Bangladesh. The findings will contribute to the improvement of age-specific vaccination and support policy makers in taking the necessary control strategies with respect to delayed and early vaccination in Bangladesh.

A prospective observational description of frequency and timing of antenatal care attendance and coverage of selected interventions from sites in Argentina, Guatemala, India, Kenya, Pakistan and Zambia

Background

The Global Network for Women’s and Children’s Health Research is one of the largest international networks for testing and generating evidence-based recommendations for improvement of maternal-child health in resource-limited settings. Since 2009, Global Network sites in six low and middle-income countries have collected information on antenatal care practices, which are important as indicators of care and have implications for programs to improve maternal and child health. We sought to: (1) describe the quantity of antenatal care attendance over a four-year period; and (2) explore the quality of coverage for selected preventative, screening, and birth preparedness components.

Methods

The Maternal Newborn Health Registry (MNHR) is a prospective, population-based birth and pregnancy outcomes registry in Global Network sites, including: Argentina, Guatemala, India (Belgaum and Nagpur), Kenya, Pakistan, and Zambia. MNHR data from these sites were prospectively collected from January 1, 2010 – December 31, 2013 and analyzed for indicators related to quantity and patterns of ANC and coverage of key elements of recommended focused antenatal care. Descriptive statistics were generated overall by global region (Africa, Asia, and Latin America), and for each individual site.

Results

Overall, 96% of women reported at least one antenatal care visit. Indian sites demonstrated the highest percentage of women who initiated antenatal care during the first trimester. Women from the Latin American and Indian sites reported the highest number of at least 4 visits. Overall, 88% of women received tetanus toxoid. Only about half of all women reported having been screened for syphilis (49%) or anemia (50%). Rates of HIV testing were above 95% in the Argentina, African, and Indian sites. The Pakistan site demonstrated relatively high rates for birth preparation, but for most other preventative and screening interventions, posted lower coverage rates as compared to other Global Network sites.

Conclusions

Results from our large, prospective, population-based observational study contribute important insight into regional and site-specific patterns for antenatal care access and coverage. Our findings indicate a quality and coverage gap in antenatal care services, particularly in regards to syphilis and hemoglobin screening. We have identified site-specific gaps in access to, and delivery of, antenatal care services that can be targeted for improvement in future research and implementation efforts.

Trial registration

Registration at Clinicaltrials.gov (ID# NCT01073475)