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Alghofaili MA, Aljuaid SO, Alqahtani N, Alghufaili M, Abd-Ellatif EE. Factors Contributing to the Delayed Vaccination Among Children in Riyadh City, Saudi Arabia: A Cross-Sectional Study. Cureus 2023; 15:e43188. [PMID: 37692740 PMCID: PMC10485872 DOI: 10.7759/cureus.43188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/02/2023] Open
Abstract
Background Immunizations protect children from deadly infectious diseases. The timeliness of vaccinating children is crucial to ensure effective immunization and to decrease the burden of many infectious diseases. Therefore, this study assessed the prevalence and determinants of vaccination delay among children in Riyadh City, Saudi Arabia. Methods This cross-sectional study was conducted at the primary healthcare centers in Riyadh City, Saudi Arabia, on 593 parents with children of two years of age or below. It used a self-administered questionnaire inquiring about socio-demographic characteristics and assessing the vaccination statuses of their children and the causes of delayed vaccinations. Results The results showed that 7.1% of children had a delay in the previous vaccination. Of those delays, collectively, 77.5% were delays in inactivated poliovirus vaccine (IPV), oral poliovirus vaccine (OPV), and meningococcal vaccine (MCV) vaccines. The delay was mostly caused by an illness of the child on vaccination day, carelessness of parents, or long postponement. After adjusting for confounders, the father's high school or bachelor's education level (OR = 1.18, 95% CI: 1.03, 1.36) (p<0.05), child's mix-type nutrition (OR = 1.06, 95% CI: 1.02, 1.10) (p=0.001), and the belief that multiple vaccines are harmful to the child (POR = 1.03, 95% CI: 1.01, 1.06) (p=0.005) were positively associated with vaccination delay, while prematurity was negatively associated with vaccination delay (OR = 0.96, 95% CI: 0.93, 0.99) (p=0.031). Conclusion The study found the prevalence of vaccination delay was lower than in previous COVID-19-era studies. The child's illness was the main reason for the delay. Factors like parental education, nutrition type, and vaccine beliefs contributed to delays, while prematurity reduced delays. Measures should be strengthened to increase vaccination coverage for children.
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Affiliation(s)
| | - Sultan O Aljuaid
- Preventive Medicine, Prince Sultan Military Medical City, Riyadh, SAU
| | - Najd Alqahtani
- College of Medicine, Princess Nourah Bint Abdul Rahman University, Riyadh, SAU
| | | | - Eman E Abd-Ellatif
- Public Health and Preventive Medicine, Mansoura University, Mansoura, EGY
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Nayar R, Pattath B, Mantha N, Debnath S, Deo S. Routine childhood vaccination in India from 2005-2006 to 2015-2016: Temporal trends and geographic variation. Vaccine 2022; 40:6924-6930. [PMID: 36280561 DOI: 10.1016/j.vaccine.2022.10.024] [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: 02/09/2022] [Revised: 09/22/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | | | - Nivedita Mantha
- Department of International Economics, The Graduate Institute, Geneva, Switzerland
| | - Sisir Debnath
- Department of Humanities and Social Sciences, Indian Institute of Technology Delhi, New Delhi, India
| | - Sarang Deo
- Indian School of Business, Hyderabad, India
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Wariri O, Okomo U, Kwarshak YK, Utazi CE, Murray K, Grundy C, Kampmann B. Timeliness of routine childhood vaccination in 103 low-and middle-income countries, 1978-2021: A scoping review to map measurement and methodological gaps. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000325. [PMID: 36962319 PMCID: PMC10021799 DOI: 10.1371/journal.pgph.0000325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 06/14/2022] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Oghenebrume Wariri
- Vaccines and Immunity Theme, MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Vaccine Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Uduak Okomo
- Vaccines and Immunity Theme, MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | | | - Chigozie Edson Utazi
- WorldPop, School of geography and Environmental Science, University of Southampton, Southampton, United Kingdom
- Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, United Kingdom
| | - Kris Murray
- MRC Unit The Gambia at The London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- MRC Centre for Global Infectious Disease Analysis, Imperial College School of Public Health, Imperial College London, London, United Kingdom
| | - Chris Grundy
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Beate Kampmann
- Vaccines and Immunity Theme, MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Vaccine Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Lee DID, Vanderhout S, Aglipay M, Birken CS, Morris SK, Piché-Renaud PP, Keown-Stoneman CDG, Maguire JL. Delay in childhood vaccinations during the COVID-19 pandemic. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2022; 113:126-134. [PMID: 35060107 PMCID: PMC8773389 DOI: 10.17269/s41997-021-00601-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 12/07/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES In many jurisdictions, routine medical care was reduced in response to the COVID-19 pandemic. The objective of this study was to determine whether the frequency of on-time routine childhood vaccinations among children age 0-2 years was lower following the COVID-19 declaration of emergency in Ontario, Canada, on March 17, 2020, compared to prior to the pandemic. METHODS We conducted a longitudinal cohort study of healthy children aged 0-2 years participating in the TARGet Kids! primary care research network in Toronto, Canada. A logistic mixed effects regression model was used to determine odds ratios (ORs) for delayed vaccination (> 30 days vs. ≤ 30 days from the recommended date) before and after the COVID-19 declaration of emergency, adjusted for confounding variables. A Cox proportional hazards model was used to explore the relationship between the declaration of emergency and time to vaccination. RESULTS Among 1277 children, the proportion of on-time vaccinations was 81.8% prior to the COVID-19 declaration of emergency and 62.1% after (p < 0.001). The odds of delayed vaccination increased (odds ratio = 3.77, 95% CI: 2.86-4.96), and the hazard of administration of recommended vaccinations decreased after the declaration of emergency (hazard ratio = 0.75, 95% CI: 0.60-0.92). The median vaccination delay time was 5 days (95% CI: 4-5 days) prior to the declaration of emergency and 17 days (95% CI: 12-22 days) after. CONCLUSION The frequency of on-time routine childhood vaccinations was lower during the first wave of the COVID-19 pandemic. Sustained delays in routine vaccinations may lead to an increase in rates of vaccine-preventable diseases.
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Affiliation(s)
- Da In Diane Lee
- Department of Paediatrics, St. Michael's Hospital, 61 Queen Street East, 2nd Floor, Toronto, ON, M5C 2T2, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Shelley Vanderhout
- Department of Paediatrics, St. Michael's Hospital, 61 Queen Street East, 2nd Floor, Toronto, ON, M5C 2T2, Canada.,Department of Nutritional Sciences, Medical Sciences Building, University of Toronto, 1 King's College Circle, Room 5253, Toronto, ON, M5S 1A8, Canada
| | - Mary Aglipay
- Department of Paediatrics, St. Michael's Hospital, 61 Queen Street East, 2nd Floor, Toronto, ON, M5C 2T2, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Catherine S Birken
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Nutritional Sciences, Medical Sciences Building, University of Toronto, 1 King's College Circle, Room 5253, Toronto, ON, M5S 1A8, Canada.,Division of Paediatric Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, ON, Toronto, Canada
| | - Shaun K Morris
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, ON, Toronto, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
| | - Pierre-Philippe Piché-Renaud
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, ON, Toronto, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
| | - Charles D G Keown-Stoneman
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Applied Health Research Centre, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Jonathon L Maguire
- Department of Paediatrics, St. Michael's Hospital, 61 Queen Street East, 2nd Floor, Toronto, ON, M5C 2T2, Canada. .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. .,Department of Nutritional Sciences, Medical Sciences Building, University of Toronto, 1 King's College Circle, Room 5253, Toronto, ON, M5S 1A8, Canada. .,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, ON, Toronto, Canada. .,Applied Health Research Centre, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada.
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Bani Salameh AK, Malak MZ, Abu Adas MH. Factors Associating Vaccination Delay among Jordanian Children under Two Years of Age. J Pediatr Nurs 2021; 59:e1-e6. [PMID: 33500152 DOI: 10.1016/j.pedn.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 01/07/2021] [Accepted: 01/09/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE This study examines the association between selected socio-demographic factors (gender, birth order, parents' educational levels, and parents' employment status) and reasons for vaccination delay among Jordanian children under two years of age. DESIGN & METHODS A cross-sectional, prospective study was conducted in the three comprehensive public health centres in Amman Governorate in Jordan from January-June, 2019. The electronic vaccination record was designed to collect socio- demographic information and reasons for vaccination delay in children. This data was collected from the medical records of those children. RESULTS The findings revealed that 150 (8.3%) children under two years of age were registered as vaccination-delayed cases. The factors associated with vaccination delay were age (Chi-square test [χ2] [6150] = 15.02, p-value [p] < 0.01), birth order (χ2 [6150] = 15.02, p < 0.01), mother's educational level (χ2 [2150] = 9.27, p < 0.05), and father's and mother's employment (χ2 [2150] = 7.89, p < 0.05; χ2 [2150] = 10.54, p < 0.01, respectively). CONCLUSION Timeliness of vaccination should be promoted to prevent illness outbreaks and provide specific protection for children, taking into consideration the significance of age and birth order. PRACTICE IMPLICATIONS Interventions and strategies need to implementation to reduce vaccination delay and improve timeliness.
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Affiliation(s)
- Ayman K Bani Salameh
- Pediatric Health Nursing, Faculty of Nursing, Al-Zaytoonah University of Jordan, Amman, Jordan
| | - Malakeh Z Malak
- Community Health Nursing, Al-Zaytoonah University of Jordan, Amman, Jordan.
| | - Mohammed H Abu Adas
- Community Health Nursing, College of Nursing-Khamis Mushait, King Khalid University, Ahba, Saudi Arabia
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Woldu Anbesu E, Abubeker SA, Berhe BM. Age-appropriate vaccination practice and associated factors among mothers of children aged less than one year in the pastoral community of Afar region, Ethiopia. Hum Vaccin Immunother 2021; 17:3178-3185. [PMID: 34062099 DOI: 10.1080/21645515.2021.1919480] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Achieving and maintaining high-level immunization coverage is the priority of the health-care delivery system. However, any delay in receiving the vaccine leaves youngsters inadequately protected. Timely vaccination has scarcely been reported and given little attention in developing nations like Ethiopia, which hinders effective interventions. Therefore, this study aimed to assess age-appropriate vaccination practice and associated factors among mothers of children aged less than one year in the pastoral community. A community-based cross-sectional study has conducted among 340 mothers/caregivers of children aged less than one year in Samara-logia city administration. A systematic random sampling technique was employed to identify and enroll mothers-child paired. The logistic regression analysis had done to identify the factors associated with age-appropriate vaccination practice. The statistical association had measured, and a p-value < 0.05 was considered statistically significant. In this study, a total of 331 mothers/caregivers-child pairs participated with a response rate of 97.3%. The age-appropriate vaccination practice was 43.7% (95% CI, 38%, 49.5%). Mothers who had higher educational level (Adjusted odds ratio (AOR)) = AOR = 2.89, 95% CI (1.14, 7.3), antenatal care follow-up (AOR = 2.1, 95% CI (1.04, 4.1)), and had good knowledge on vaccination (AOR = 3.1, 95% CI (1.4, 6.78)) were associated with increased odds of age-appropriate vaccination practice.
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Affiliation(s)
- Etsay Woldu Anbesu
- Department of Public Health, College of Medical and Health Sciences, Samara University, Samara, Ethiopia
| | - Seada Ali Abubeker
- Department of Neglected Tropical Disease, Afar Regional Health Bureau, Samara, Ethiopia
| | - Brhanu Medhin Berhe
- Department of Public Health, College of Medical and Health Sciences, Samara University, Samara, Ethiopia
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Baghdadi LR, Younis A, Al Suwaidan HI, Hassounah MM, Al Khalifah R. Impact of the COVID-19 Pandemic Lockdown on Routine Childhood Immunization: A Saudi Nationwide Cross-Sectional Study. Front Pediatr 2021; 9:692877. [PMID: 34222155 PMCID: PMC8249725 DOI: 10.3389/fped.2021.692877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/27/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Routine childhood immunization is the most cost-effective method to prevent infection and decrease childhood morbidity and mortality. The COVID-19 pandemic has affected access to health care in Saudi Arabia, including mandatory vaccinations for young children. We aimed to assess the prevalence of intentionally delayed vaccinations in children aged ≤ 2 years during the COVID-19 pandemic curfew in Saudi Arabia, its relation to the caregivers' fear of infection, and identifying factors affecting the caregivers' decision. Methods: We conducted a cross-sectional study using a self-administered survey that targeted primary caregivers of children aged ≤ 2 years residing in Saudi Arabia during the COVID-19 pandemic curfew (March 4-July 6, 2020). Results: We received responses from 577 caregivers, of whom 90.8% were mothers. The prevalence of intentional vaccination delay was 37%. Upon adjusting the potential confounders, the odds of delaying scheduled childhood vaccination because of COVID-19 pandemic fears were greater among caregivers with higher levels of fear (OR 1.10, 95% CI 1.02-1.11). Common reasons for delaying vaccinations were COVID-19 infection and prevention of exposure to COVID-19 cases. Conclusion: Intentional vaccination delay leaves young children vulnerable to preventable infectious diseases. Identifying these children and offering catch-up vaccinations reduces this risk. Campaigns to increase awareness about the dangers of delaying vaccine-preventable diseases must be promoted to caregivers in addition to the promotion of home vaccination services. In preparation for future pandemics, we recommend countries consider interventions to control the level of fear and anxiety provoked by the pandemics and media, and interventions for improved access to vaccinations.
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Affiliation(s)
- Leena R Baghdadi
- Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Afnan Younis
- Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hessah I Al Suwaidan
- Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Marwah M Hassounah
- Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Reem Al Khalifah
- Paediatric Endocrinology Division, Paediatrics Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Marefiaw TA, Yenesew MA, Mihirete KM. Age-appropriate vaccination coverage and its associated factors for pentavalent 1-3 and measles vaccine doses, in northeast Ethiopia: A community-based cross-sectional study. PLoS One 2019; 14:e0218470. [PMID: 31419230 PMCID: PMC6697368 DOI: 10.1371/journal.pone.0218470] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/03/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In Ethiopia, there are limited studies on age-appropriate vaccinations that children received at the recommended specific ages. Therefore, we assessed age-appropriate vaccinations coverage and its associated factors among children 12 to 23 months of age in Menz Lalo district, northeast Ethiopia. METHODS A community-based cross-sectional study was conducted in Menz Lalo district from March to April/2018 among 417 mothers/caregivers with children 12 to 23 months of age using simple random sampling technique. Data were collected using a pretested structured questionnaire. Information about children's vaccination status was collected from vaccination cards. Age-appropriate vaccination coverage was measured using World Health Organization vaccination schedule recommendation. Data was entered into Epi-Info7 software and exported to SPSS-20 for analysis. Four consecutive logistic regression models were performed to identify factors associated with age-inappropriate vaccinations. A P-value of ≤ 0.05 was considered to state statistically significant associations. RESULTS Age-appropriate vaccination coverage was 39.1% (95% CI: 34.3 to 44) for pentavalent 1, 36.3% (95% CI: 31.6 to 41.5) for pentavalent 2, 30.3% (95% CI: 25.6 to 35) for pentavalent 3 and 26.4% (95% CI: 21.7 to 31) for measles vaccine doses. Age-inappropriate pentavalent 1-3 vaccinations was associated with being male sex (AOR: 0.47, 95% CI: 0.29-0.74), lack of telephone (AOR: 2.2, 95% CI: 1.4-3.6), lack of usual caretaker (AOR: 2.6, 95% CI: 1.3-5.2), unplanned pregnancy (AOR: 1.9, 95% CI: 1.1-3.5), missing pregnant women's conference (AOR: 2.7, 95% CI: 1.3-5.7), decreasing birth order (AOR: 0.34, 95% CI: 0.17-0.68) and insufficient knowledge (AOR: 2.7, 95% CI: 1.6-4.4). CONCLUSION The proportions of age-appropriate vaccination coverage were low in the study area. Modifiable factors were associated with age-inappropriate vaccinations. Vaccination interventions should consider identified modifiable factors to improve age-appropriate vaccinations coverage.
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Affiliation(s)
- Tefera Alemu Marefiaw
- Amhara Public Health Institute, Public Health Emergency Management Directorate, Dessie, Ethiopia
- * E-mail:
| | - Muluken Azage Yenesew
- Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Kebadnew Mulatu Mihirete
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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