Differential coverage for vaccines in the expanded program on immunization (EPI) among children in rural Pakistan

BackgroundPakistan has a well-established Expanded Program on Immunization (EPI) however vaccine-preventable diseases still account for high infant and child mortality rates. This study describes the differential vaccine coverage and determinants of vaccine uptake in rural Pakistan.MethodsFrom October 2014 to September 2018, we enrolled children younger than 2 years of age from the Matiari Demographic Surveillance System in Sindh, Pakistan. Socio-demographic and vaccination history were collected from all participants. Vaccine coverage rates and timeliness were reported. Socio-demographic variables for missed and untimely vaccination were studied in multivariable logistic regression.ResultsOf the 3140 enrolled children, 48.4 % received all EPI recommended vaccines. Only 21.2 % of these were age appropriate. Around 45.4 % of the children were partially vaccinated, and 6.2 % were unvaccinated. Highest coverage was seen for the first dose of pentavalent (72.8 %), 10-valent Pneumococcal Conjugate Vaccine (PCV10) (70.4 %) and Oral Polio Vaccine (OPV) (69.2 %) and the lowest coverage was for measles (29.3 %) and rotavirus (1.8 %) vaccines. Primary caretakers and wage earners with a higher level of education were protective against missed and untimely vaccination. Enrollment in the 2nd, 3rd and 4th study year was negatively associated with being unvaccinated whereas distance from a major road was positively associated with non-adherence to schedule.ConclusionVaccine coverage was low among children in Matiari, Pakistan, and majority received delayed doses. Parents’ education status and year of study enrollment was protective against vaccine dropout and delayed vaccination whereas geographical distance from a major road was a predictor. Vaccine promotion and outreach efforts may have had a beneficial impact on vaccine coverage and timeliness.     

The impact of the COVID-19 pandemic on vaccine coverage in Kilifi,Kenya: A retrospective cohort study

The COVID-19 pandemic caused unprecedented disruption in health service delivery, globally. This study sought to provide evidence on the impact of the pandemic on vaccine coverage in Kilifi County, Kenya. We conducted a vaccine coverage survey between April and June 2021 within the Kilifi Health and Demographic Surveillance System (KHDSS). Simple random sampling was used to identify 1500 children aged 6 weeks–59 months. Participants were grouped into three retrospective cohorts based on when they became age-eligible for vaccination: before the pandemic, during the first year, or during the second year of the pandemic. Survival analysis with Cox regression was used to evaluate the association between the time-period at which participants became age-eligible for vaccination and the rate of vaccination within a month of age-eligibility for the third dose of pentavalent vaccine (Pentavalent-3) and within three months of age-eligibility for the first dose of Measles vaccine (MCV-1). A total of 1,341 participants were included in the survey. Compared to the pre-COVID-19 baseline period, the rate of vaccination within a month of age-eligibility for Pentavalent-3 was not significantly different in the first year of the pandemic (adjusted hazard ratio [aHR] 1.03, 95 % confidence interval [CI] 0.90–1.18) and was significantly higher during the second year of the pandemic (aHR 1.33, 95 % CI 1.07–1.65). The rate of vaccination with MCV-1 within three months of age-eligibility was not significantly different among those age-eligible for vaccination during the first year of the pandemic (aHR 1.04, 95 % CI 0.88–1.21) and was 35 % higher during the second year of the pandemic (95 % CI 1.11–1.64), compared to those age-eligible pre-COVID-19. After adjusting for known determinants of vaccination, the COVID-19 pandemic did not adversely affect the rate of vaccination within the KHDSS.     

2010年玉溪市儿童麻疹强化免疫接种率快速评估

目的评估玉溪市2010年麻疹减毒活疫苗(MV)后续强化免疫效果,总结经验,为控制并加快消除麻疹工作进程制定针对性的免疫策略提供依据。方法每县抽取城区和2个乡镇各30名目标儿童进行现场接种率快速评估。结果全市麻疹疫苗强化免疫接种率为99.66%,不同年龄段麻疹疫苗强化免疫接种率均在99.36%以上;不同居住形式麻疹疫苗强化免疫接种率均在97.78%以上,0剂次免疫史该县及外地的儿童均集中分布于8月龄～2岁年龄组。结论玉溪市2010年麻疹疫苗强化免疫达到了预期的目标。加强流动儿童管理,发现并适时消除免疫空白人群是实现2012年消除麻疹目标的工作重点。     

Applying a governance barometer to vaccine delivery systems: Lessons from a rural district of Pakistan

IntroductionWeak vaccine delivery systems in countries off-track for routine immunization targets, need in-depth evidence on system level barriers to be critically resourced and monitored. We applied a Balanced Score Card (BSC) approach in a rural underserved district of Pakistan to (i) identify critical areas needing support in the government vaccine delivery system; and (ii) for benchmarking improvements in the vaccine delivery system.MethodologyBSC was developed drawing on desk review, government consultations and field testing. 45 immunization indicators were finalized across 8 domains: human resource; vaccine supply; safe vaccination practice; cold chain maintenance; outreach preparedness; records & supervision; verifiable vaccination volume; and client communication. Data were collected through health facility assessments, client exit interviews and household vaccination assessment. A composite score was calculated for each domain and banded into unsatisfactory, borderline and satisfactory categories. 5 lowest ranking domains were targeted for 2 years of health systems strengthening (HSS) interventions. Post-intervention assessment tracked progress.ResultsThe district obtained a cumulative score of 51% (unsatisfactory) at pre-intervention and improved to 82% (satisfactory) at post-intervention. At pre-intervention, 4 domains scored satisfactory and 4 scored unsatisfactory. Unsatisfactory scores were received for: outreach preparedness; records & supervision; verifiable vaccination volume; and client communication. Post intervention 6 of 8 domains scored satisfactory and 2 moved from unsatisfactory to borderline. Highest percentage point (pp) improvements were seen in outreach preparedness (53 pp, p = 0.01), EPI supervision (52 pp, p = 0.01) and verified vaccination volume (46 pp, p = 0.02). 3 domains that were not intervened through HSS interventions had minimal change in scoring - cold chain maintenance (6 pp), safe vaccination practice (12 pp) and vaccine supply (11 pp).ConclusionBSC served to prioritize interventions towards critical unmet needs for vaccine delivery in the district health system and particularly helped to improve outreach preparedness, EPI supervision and verified vaccination volume.     

Redefining vaccination coverage and timeliness measures using electronic immunization registry data in low- and middle-income countries

Vaccine coverage is routinely used as a performance indicator for immunization programs both at local and global levels. For many national immunization programs, there are challenges with accurately estimating vaccination coverage based on available data sources, however an increasing number of low- and middle-income countries (LMICs) have begun implementing electronic immunization registries to replace health facilities’ paper-based tools and aggregate reporting systems. These systems allow for more efficient capture and use of routinely reported individual-level data that can be used to calculate dose-specific and cohort vaccination coverage, replacing the commonly used aggregate routine health information system data. With these individual-level data immunization programs have the opportunity to redefine performance measures to enhance programmatic decision-making at all levels of the health system. In this commentary, we discuss how measures for assessing vaccination status and program performance can be redefined and recalculated using these data when generated at the health facility level and the implications of the use and availability of electronic individual-level data.     

Contribution of polio eradication initiative to strengthening routine immunization: Lessons learnt in the WHO African region

BackgroundImportant investments were made in countries for the polio eradication initiative. On 25 September 2015, a major milestone was achieved when Nigeria was removed from the list of polio-endemic countries. Routine Immunization, being a key pillar of polio eradication initiative needs to be strengthened to sustain the gains made in countries. For this, there is a huge potential on building on the use of polio infrastructure to contribute to RI strengthening.MethodsWe reviewed estimates of immunization coverage as reported by the countries to WHO and UNICEF for three vaccines: BCG, DTP3 (third dose of diphtheria-tetanus toxoid- pertussis), and the first dose of measles-containing vaccine (MCV1).We conducted a systematic review of best practices documents from eight countries which had significant polio eradication activities.ResultsImmunization programmes have improved significantly in the African Region. Regional coverage for DTP3 vaccine increased from 51% in 1996 to 77% in 2014. DTP3 coverage increased >3 folds in DRC (18–80%) and Nigeria from 21% to 66%; and >2 folds in Angola (41–87%), Chad (24–46%), and Togo (42–87%). Coverage for BCG and MCV1 increased in all countries. Of the 47 countries in the region, 18 (38%) achieved a national coverage for DTP3 ⩾90% for 2 years meeting the Global Vaccine Action (GVAP) target. A decrease was noted in the Ebola-affected countries i.e., Guinea, Liberia and Sierra Leone.ConclusionsPEI has been associated with increased spending on immunization and the related improvements, especially in the areas of micro planning, service delivery, program management and capacity building. Continued efforts are needed to mobilize international and domestic support to strengthen and sustain high-quality immunization services in African countries. Strengthening RI will in turn sustain the gains made to eradicate poliovirus in the region.     

Routine childhood vaccination programme coverage,El Salvador, 2011—In search of timeliness

While assessing immunization programmes, not only vaccination coverage is important, but also timely receipt of vaccines. We estimated both vaccination coverage and timeliness, as well as reasons for non-vaccination, and identified predictors of delayed or missed vaccination, for vaccines of the first two years of age, in El Salvador.     

湖北省2004年常规免疫监测结果评价

目的评价湖北省2004年常规免疫接种率监测结果。方法对湖北省2004年常规免疫监测报表进行估计接种率、差值评价、比值评价和报表及时性、完整性分析。结果湖北省2004年常规免疫监测报表及时性、完整性较以往明显提高;四苗基础和加强免疫报告接种率为92．34％（麻疹疫苗,MV2）～98．98％（口服脊髓灰质炎疫苗,OPV）,（乙型肝炎疫苗,HBV）报告接种率为98．67％;四苗基础免疫估计接种率为78．73％（卡介苗,BCG）～83．65％（MV）,HBV为74．57％;加强免疫估计接种率分别为7．35％（MV2）～73．05％（白喉、百日咳、破伤风混合疫苗,DPT）。结论差值评价说明湖北省报告接种率可信性较低,比值评价说明数据可疑;今后需加强常规免疫规范化管理。     

内蒙古自治区2011年常规免疫接种率监测结果评价

目的了解内蒙古自治区2011年常规免疫接种情况,对常规免疫接种率监测结果进行评价。方法通过差值法和比值法对监测结果进行比较分析。结果内蒙古全区卡介苗(BCG)、百白破疫苗(DPT)、乙肝疫苗(HepB)、脊髓灰质炎疫苗(PV)、麻类疫苗(MCV)和乙脑疫苗(JE)六苗常规免疫报告接种率均高于99%,估算接种率均小于95%。全区D值评价为不可信,R值评价为可信。结论内蒙古常规免疫接种率报告真实性、准确性有待提高。     

Redesigned immunization card and center-based education to reduce childhood immunization dropouts in urban Pakistan: a randomized controlled trial

In Pakistan during 2000-2004, about 11-13% of children who received the first dose of diphtheria-pertussis-tetanus (DPT1) failed to complete its third dose (DPT3). We assessed the effect of a redesigned immunization card and center-based education to mothers on DPT3 completion. We enrolled 1500 mother-child units at DPT1, randomized them to three intervention and one standard care groups, and recorded their DPT3 visits during a 90-day follow-up. In multivariable analysis, a significant increase of 31% (adjusted RR=1.31, 95% CI=1.18-1.46) in DPT3 completion was estimated in the group that received both redesigned card and center-based education compared with the standard care group.     

2011年北京市东城区常规免疫接种率可靠性评价

目的为了解北京市东城区常规免疫接种率监测现状,对2011年常规免疫接种率监测结果进行分析。方法通过中国免疫规划监测信息管理系统和北京市免疫规划信息管理系统客户端,收集2011年北京市东城区常规免疫报告接种率数据,利用比较法进行评价。结果东城区2011年常规免疫报告接种率均为100%,估算接种率为82.35%~90.87%,北京市免疫规划信息管理系统客户端计算导出接种率为94.60%~98.53%。结论东城区报告的接种数据真实可靠,能够做到高免疫接种率。北京市免疫规划信息管理系统建设使用后,免疫规划信息管理系统数据作为常规免疫接种数据很好的评价基础,待时机成熟,可以替代常规手工报告数据。     

湖北省2003年常规免疫监测结果评价

目的　评价湖北省2 0 0 3年常规免疫接种率监测结果。方法　对湖北省2 0 0 3年常规免疫监测报表进行估计接种率、差值评价、比值评价和报表及时性、完整性分析。结果　湖北省2 0 0 3年常规免疫监测报表及时性和完整性较以往明显下降;四苗基础和加强免疫报告接种率为97.4 6 %～99.0 9% ,HBV报告接种率为96 .6 8% ;四苗基础免疫估计接种率为5 5 .89% (BCG)～6 6 .4 7% (MV ) ,HBV为4 9.73% ;加强免疫估计接种率分别为17.15 % (DT)～5 7.72 % (MV)。结论　差值评价说明湖北省报告接种率可信性较低,比值评价说明数据可疑;今后需加强常规免疫规范化管理。     

The effect of mass vaccination campaigns against polio on the utilization of routine immunization services: A regression discontinuity design

BackgroundIn most low and middle-income countries (LMIC), vaccines are primarily distributed by routine immunization services (RI) at health facilities. Additional opportunities for vaccination are also provided through mass vaccination campaigns, conducted periodically as part of disease-specific initiatives. It is unclear whether these campaigns are detrimental to RI services, or wether they may stimulate the utilization of RI.MethodsUnobserved confounders and reverse causality have limited existing evaluations of the effects of mass vaccination campaigns on RI services. We explored the use of a regression discontinuity design (RDD) to measure these effects more precisely. This is a quasi-experimental method, which exploits random variations in birth dates to identify the causal effects of vaccination campaigns. We applied RDD to survey data on a nationwide vaccination campaign against Polio conducted in Bangladesh.ResultsWe compared systematically the children born immediately before vs. after the vaccination campaign. These two groups had similar background characteristics, but differed by their exposure to the vaccination campaign. Contrary to previous studies, exposure to the campaign had positive effects on RI utilization. Children exposed to the campaign received between 0.296 and 0.469 additional doses of DPT vaccine by age 4 months than unexposed children.ConclusionsRDD constitutes a promising tool to assess the effects of mass vaccination campaigns on RI services. It could be tested in additional settings, using larger and more precise datasets. It could also be extended to measure the effects of other disease-specific interventions on the functioning of health systems, in particular those that occur at a discrete point in time and/or include age-related eligibility criteria.     

Pakistan's expanded programme on immunization: An overview in the context of polio eradication and strategies for improving coverage

Since its inception in 1978, Pakistan's Expanded Programme on Immunization (EPI) has contributed significantly towards child health and survival in Pakistan. However, the WHO-estimated immunization coverage of 88% for 3 doses of Diptheria-Tetanus-Pertussis vaccine in Pakistan is likely an over-estimate. Many goals, such as polio, measles and neonatal tetanus elimination have not been met. Pakistan reported more cases of poliomyelits in 2011 than any other country globally, threatening the Global Polio Eradication Initiative. Although the number of polio cases decreased to 58 in 2012 through better organized supplementary immunization campaigns, country-wide measles outbreaks with over 15,000 cases and several hundred deaths in 2012–13 underscore sub-optimal EPI performance in delivering routine immunizations. There are striking inequities in immunization coverage between different parts of the country. Barriers to universal immunization coverage include programmatic dysfunction at lower tiers of the program, socioeconomic inequities in access to services, low population demand, poor security, and social resistance to vaccines among population sub-groups. Recent conflicts and large-scale natural disasters have severely stressed the already constrained resources of the national EPI. Immunization programs remain low priority for provincial and many district governments in the country. The recent decision to devolve the national health ministry to the provinces has had immediate adverse consequences. Mitigation strategies aimed at rapidly improving routine immunization coverage should include improving the infrastructure and management capacity for vaccine delivery at district levels and increasing the demand for vaccines at the population level. Accurate vaccine coverage estimates at district/sub-district level and local accountability of district government officials are critical to improving performance and eradicating polio in Pakistan.     

湖北省2001年常规免疫监测结果与评价

目的 评价湖北省2001年常规免疫接种率监测结果。方法 对湖北省2001年常规免疫监测报表进行估计接种率、差值评价、比值评价和报表及时性、完整性分析。结果 湖北省2001年常规免疫监测报表及时性、完整性较以往明显提高；四苗基础和加强免疫报告接种率为96．76％～98．92％，HBV报告接种率为86．55％；四苗基础免疫估计接种率为58．61％(BCG)～74．25％(MV)，HBV为42．10％；加强免疫估计接种率分别为20．81％(DT)～56．71％(MV)。结论 差值评价说明湖北省报告接种率可信性较低，比值评价说明数据可疑；今后需加强常规免疫规范化管理。     

Refusal of oral polio vaccine in northwestern Pakistan: A qualitative and quantitative study

Background

Refusal of the oral polio vaccine (OPV) is a difficulty faced by the Polio Eradication Initiative (PEI) in multiple endemic areas, including the Khyber Pakhtunkhwa Province (KPP), Pakistan. In 2007, we investigated community perceptions of the OPV and estimated the prevalence of OPV refusal in three districts in Swat Valley, KPP, a polio-endemic area.

Methods

Qualitative data concerning community perceptions were collected by focus group discussions among lady health workers (LHWs) and mothers with children <1 year old and by key informant interviews with local health managers and officials. Quantitative data collection followed using a questionnaire survey of 200 LHWs and a cluster sampling survey of 210 mothers (per district) with children <1 year old.

Results

The qualitative assessments identified the grounded theory of OPV refusal involving facts known by the residents that are related to the OPV (too frequent OPV campaigns, an OPV boycott in northern Nigeria in 2003 and that birth control is viewed as is against Islam), the local interpretations of these facts (perceptions that OPV contained birth control or pork, that OPV was a foreign/central plot against Muslims, and that the vaccination was against the Hadith and the fate determined by God) and different manifestations of OPV refusal. Among the three districts studied, the proportion of LHWs who encountered OPV refusal ranged from 0 to 33%, whereas among the districts, the proportions of mothers unwilling to give OPV to their children ranged from 0.5 to 5.7%. Refusal of other injectable vaccines was almost equally prevalent for reasons that were very similar.

Conclusions

The PEI needs to reflect local value system in the path to polio eradication in the studied districts in the Swat Valley. The religious and cultural values as well as the interpretation of the international political situation are of particular importance.