The coronavirus disease 2019 (COVID-19) pandemic has resulted in a substantial decline in routine immunisation coverage in children globally, especially in low- and middle-income countries (LMICs). This study summarises the reasons for disruptions to routine child immunisations in LMICs. A systematic review (PROSPERO CRD42021286386) was conducted following PRISMA 2020 guidelines. Six databases were searched: MEDLINE, Embase, Global Health, CINAHL, Scopus and MedRxiv, on 11/02/2022. Observational and qualitative studies published from January 2020 onwards were included if exploring reasons for missed immunisations during the COVID-19 pandemic in LMICs. Study appraisal used National Heart, Lung, and Blood Institute and Critical Appraisal Skills Programme tools. Reasons for disruption were defined with descriptive codes; cross-sectional (quantitative) data were summarised as mean percentages of responses weighted by study population, and qualitative data were summarised narratively. A total of thirteen studies were included describing reasons behind disruptions; 7 cross-sectional (quantitative), 5 qualitative and 1 mixed methods. Seventeen reasons for disruptions were identified. In quantitative studies (total respondents = 2,853), the most common reasons identified were fear of COVID-19 and consequential avoidance of health centres (41.2%, SD ±13.3%), followed by transport challenges preventing both families and healthcare professionals from reaching vaccination services (11.1% SD ±16.6%). Most reasons stemmed from reduced healthcare-seeking (83.4%), as opposed to healthcare-delivery issues (15.2%). Qualitative studies showed a more even balance of healthcare-seeking (49.5%) and healthcare-delivery issues (50.5%), with fear of COVID-19 remaining a major identified issue (total respondents = 92). The most common reasons for disruption were parental fear of COVID-19 and avoidance of health services. Health systems must therefore prioritise public health messaging to encourage vaccine uptake and recovery of missed immunisations.
Alexandra Cardoso Pinto, Sameed Shariq, Lasith Ranasinghe et al.
A comprehensive understanding of the costs of routine vaccine delivery is essential for planning, budgeting and sustaining India's Universal Immunisation Programme. India currently allocates approximately US$25 per child for vaccines and operational costs. This budget is prepared based on historical expenditure data as information on cost is not available. This study estimated the cost of routine immunisation services based on a stratified, random sample of 255 public health facilities from 24 districts across seven states-Bihar, Gujarat, Kerala, Meghalaya, Punjab, Uttar Pradesh and West Bengal. The economic cost for the fiscal year 2013-2014 was measured by adapting an internationally accepted approach for the Indian context. Programme costs included the value of personnel, vaccines, transport, maintenance, training, cold chain equipment, building and other recurrent costs. The weighted average national level cost per dose delivered was US$2.29 including vaccine costs, and the cost per child vaccinated with the third dose of diphtheria-pertussis-tetanus (DPT) vaccine (a proxy for full immunisation) was US$31.67 (at 2017 prices). There was wide variation in the weighted average state-level cost per dose delivered inclusive of vaccine costs (US$1.38 to US$2.93) and, for the cost per DTP3 vaccinated child (US$20.08 to US$34.81). Lower costs were incurred by facilities and districts that provided the largest number of doses of vaccine. Out of the total cost, the highest amount (57%) was spent on personnel. This costing study, the most comprehensive conducted to date in India, provides evidence, which should help improve planning and budgeting for the national programme. The budget generally considers financial costs, while this study focused on economic costs. For using this study's results for planning and budgeting, the collected data can be used to extract the relevant financial costs. Variation in cost per dose and doses administered across facilities, districts and states need to be further investigated to understand the drivers of cost and measure the efficiency of service delivery.
Susmita Chatterjee, Palash Das, Aditi Nigam et al.
Background Low-income and Middle-income Countries (LMIC) are continually working to ensure everyone can access life-saving vaccines. Recognising the considerable impact of Information and Communication Technology (ICT) in healthcare, we performed a systematic review and meta-analysis to summarise ICT effectiveness in improving vaccine delivery in LMICs. Methods A systematic search from January 2010 to August 2023 in MEDLINE, EMBASE, Cochrane Library, BMJ Health & Care Informatics, and grey literature was performed. This search focused on randomised controlled trials (RCTs), non-RCTs, observational, and mixed-methods studies in English, examining ICT's effects on childhood immunisation in LMICs. Risk of bias in RCTs and non-RCTs was assessed using the Joanna Briggs Institute tool, and mixed-methods studies were evaluated with the Mixed Methods Appraisal Tool. A meta-analysis summarised ICT's impact on third pentavalent dose coverage and full immunisation by age one. The study is registered with PROSPERO (CRD42023446062). Findings Of 6535 screened studies, 27 involving 354,979 children were included. All apart from one study demonstrated a positive impact on immunisation coverage and timeliness, completeness and accuracy of records, number of adverse events reporting, vaccine stockouts, and cold chain expansion. The meta-analysis demonstrated that reminders effectively improved coverage rate of the third dose of the pentavalent vaccine (OR 2.32, 95% CI 1.34–4.03) and the full immunisation at one year of age (OR 2.61, 95% CI 1.2–5.67) with significant degrees of heterogeneity, respectively I 2 82% and I 2 89%. Main concerns for bias in RCTs included unblinded outcome assessors and intervention providers. Interpreting quasi-experimental studies was more challenging due to the higher risk of baseline differences between study arms, statistical methods, and dropouts. Mixed-methods studies often lacked clarity in integrating qualitative and quantitative data. Interpretation This systematic review confirms the benefits of ICT in immunisation programmes by enhancing various stages of vaccine delivery. Specifically, reminders have been shown to enhance childhood immunisation coverage rates. Funding Deutsche Gesellschaft für Internationale Zusammenarbeit (German Corporation for International Cooperation, GIZ) as part of the Digital Innovation in Pandemic Control (DIPC) Initiative, financed by the Bundesministerium für Wirtschaftliche Zusammenarbeit (Federal Ministry for Economic Cooperation and Development, BMZ).
Mohini Zarekar, Hussein Al-Shehabi, Rita Dörner et al.
Since its establishment in 1978, China's National Immunization Program has made remarkable achievements in the control of vaccine-preventable diseases. The National Immunization Program is a vertically integrated programme in the health system, which delivers immunisation services to children. However, achieving the ambitious goals of the Immunization Agenda 2030 and Healthy China 2030 will require overcoming challenges to the National Immunization Program's future expansion and development. Key challenges include inclusion of all WHO-recommended vaccines into the routine programme, improving the function and support of the National Immunization Advisory Committee, increasing and sustaining reliable vaccination financing, ensuring uninterrupted vaccine supplies, overcoming regional disparities in immunisation practices and cold chain processes, strengthening the workforce, and integrating immunisation information systems into all aspects of the programme. It is crucially important to strengthen the National Immunization Program to attain universal coverage of life-saving vaccines in China and meet the 2030 goals.
Empowering women is presented as a key strategy to achieve several goals of the sustainable development (SDG) agenda, including child health. However, the literature on the subject shows mixed results and is limited regarding political empowerment. Responding to this gap, we explore whether women's political empowerment is associated with positive health outcomes for children under 5 years of age. We use the V-Dem project's 'Women's Political Empowerment Index' (WPEI) in combination with selected SDG indicators of child health from the Institute for Health Metrics and Evaluation's 2017 Global Burden of Disease, for 161 countries, between 1990 and 2016. We estimate fixed-effects regressions for the WPEI against child mortality, stunting and immunisation coverage, controlling for structural and socio-economic indicators from the SDGs and potential lagged effects. The WPEI is associated with improved nutrition and immunisation but its substantive effect is small. High-, low-income and least developed countries benefit more from the effect of women's political empowerment on child mortality. The effect of women's political empowerment on stunting is stronger in middle-income countries while its effect on immunisation is more relevant to low-income and least developed countries. Our study demonstrates the complexity of the relations between women's political empowerment and child health.
Globally, migrants experience a higher burden of vaccine-preventable disease and lower immunisation rates than non-migrants.1, 2 Frequently, migrant families require catch-up vaccinations to comply with Australian immunisation requirements. For migrant parents, access barriers are more prominent than lack of acceptance3 and anomalies with immunisation records may reflect under-vaccination or inadequate reporting to the Australian Immunisation Register (AIR).4 Recent immunisation coverage data for migrant children is limited, including information about how these families can access vaccinations. Australian coverage data focuses on refugee children, or reports on Australian-born children with mothers born overseas.5-8 This two-phase study aimed to explore under-immunisation among children of migrant parents in Melbourne, Victoria by identifying gaps in service delivery and awareness of immunisation services. Phase I was an audit of catch-up immunisation encounters with the City of Melbourne immunisation service. Children were eligible if they were migrants, aged <18 years, resided in the City of Melbourne and attended at least one appointment during the study period (2016–2020). Phase II was a survey (available in English, Hindi or Mandarin) with migrant parents who had attended the service between January 2019 and August 2021. Participants reported demographics, patterns of health-care service use, access, motivation to get vaccinations and sources of information. Surveys were completed between 31 May and 18 August 2021. Data for both phases were analysed descriptively. Approval was obtained from the Royal Children's Hospital Human Research Ethics Committee (72165). For phase I, 1403 records were eligible for analysis (Table 1). Most (85.3%) presentations were for children <5 years. Presentations decreased throughout each calendar year. Overall, 1,062 children (75.7%) had vaccines due, 328 (23.4%) did not require any vaccines but still required their vaccination history to be evaluated and uploaded to the AIR, a further 13 (1%) had AIR issues that required resolving (e.g. incorrect vaccine or date). Nine percent of children who presented for catch-up did not receive all required vaccines or were lost to follow-up. Some 59% of families were referred to the City of Melbourne immunisation service through informal sources (i.e. word of mouth, Google, social media and Melbourne magazine). In phase II, 92 of 147 eligible parents completed the survey: response rate 63%. The median age of parents was 36 years (Table 1). Almost half obtained information on the need for catch-up vaccines from informal (43/91; 47% family, friends, work or online) rather than formal sources (48/91; 53%, General Practitioner, Maternal and Child Health nurse, hospital, educational facility (school, day-care, kindergarten)); only 35% (32/91) were informed by a health-care provider. Many parents (46/92; 50%) were primarily motivated by wanting their child to attend an educational facility or receive benefits, with the majority reporting either 'no' (76/92; 83%) or 'minor' concerns (15/92; 16%) towards vaccination. Just 55% (50/90) reported being explained the process to access vaccinations in Australia, with many 36% (18/50) acquiring this knowledge informally. Our study identified intensive resource requirements for catch-up vaccination and challenges for migrant parents to access immunisation services. While not all children in phase I required vaccines, the high proportion requiring a review and associated reporting to the AIR, has resource implications. As the AIR is principally used to determine up-to-date status for the purpose of such policies, not having an accurate AIR record can have implications for the child and their family. We found most catch-up presentations were initiated in the first two quarters of the year suggesting that the No Jab immunisation policies impact migrant families, despite the majority (99%; 91/92) reporting low vaccine hesitancy, confirming previous research.9-11 Consistent with international studies,9, 10, 12 our findings indicate that parents' sources of health information are highly variable and informal. Concerningly, numerous parents initiated catch-up vaccination but were lost to follow-up. This study found many migrant parents established contact and engaged with immunisation services through informal channels. Our findings support work to establish the best ways of placing information about immunisation services for migrant parents. The Migrant Immunisation Access (MIA) Project was a recipient of a Public Health Association of Australia 2020 GlaxoSmithKline Immunisation Grant. Open access publishing facilitated by The University of Melbourne, as part of the Wiley - The University of Melbourne agreement via the Council of Australian University Librarians.
Jane Tuckerman, Philippa Holland, Jessica Kaufman et al.
Background The COVID-19 pandemic response has impacted the delivery of healthcare, including routine childhood immunisation. This manuscript studies the extent of this impact. To assess the decline in daily average routine childhood immunisation uptake compared toObjectives the baseline level and to assess the problems faced by the beneciaries in accessing the immunisation services during the pandemic period at a tertiary care centre in Mumbai. Data of daily routine childhood immunisations in the year 2019 and 2020 was collected from theMethods immunisation records register of Child Welfare Centre (CWC) of the tertiary care centre. The baseline (2019) and the COVID-19 lockdown period data were compared to analyse the impact on daily routine childhood immunisation uptake. Guardians of beneciaries visiting the CWC from 24 December 2020 to 23 January 2021 were interviewed using a questionnaire to study the causes of delayed/missed immunisations. ThereResults was 24.62% decline (p<0.05) in the number of immunisations administered in 2020 compared to 2019. Fear of COVID-19 infection (45.9%), migration to hometown due to lockdown (13.11%), travelling restrictions during lockdown (9.84%) and miscellaneous reasons (31.15%) were the reasons given by the 93 guardians interviewed for delayed/missed immunisations (63.16%). COVID-19 pandemic response has led toConclusion a disruption in immunisation services, leading to a drop in uptake. Childhood immunisation and implementation of strategies to achieve signicant immunisation coverage should be prioritised during pandemics.
Background: Immunisation is a protective measure against infectious diseases and is one of the most crucial public health interventions (WHO, 2019). Mothers face challenges which are facility-related factors such as long waiting times, stock-outs and negative staff attitudes, as well as cultural and religious beliefs held by mothers and families, which further shape whether children receive vaccinations (Wiysonge et al, 2020; South Africa qualitative study, 2023). Purpose: The aim of the study was to assess the experiences of mothers in accessing childhood immunisation services from the perspective of mothers in the paediatric outpatient department at a tertiary hospital in South Africa. Methodology: A quantitative cross-sectional design approach was used to investigate the challenges faced by mothers when accessing childhood vaccination. A probability sampling method was used to sample 221 respondents by means of systemic sampling. Data was collected by means of self-administered questionnaire. Validity was ensured through face and content validity. The reliability was ensured through clear and detailed instructions as well as pilot testing. Data was collected and analyzed using Statistical Package for Social Science (SPSS) version 27. The results analyzed were then carefully interpreted to identify key trends and patterns. The data analyzed was presented visually through tables and charts to make the findings easier to understand and interpret. Results: The study comprised of 222 participants. The study results showed that majority of mothers knew and understood enough about immunization and their advantages. However, long waiting times, high transport expenses and vaccine shortages made it difficult for many of the mothers and impacted schedule adherence. According to the study’s findings, expanding vaccine coverage requires improving service accessibility, effectiveness and ongoing health education. Conclusion: The study revealed that mothers face several challenges when accessing childhood immunisation services, including long waiting times, lack of information regarding vaccines and limited accessibility. These barriers negatively impact immunisation uptake and threaten child health outcomes. Recommendations: Addressing the challenges that mothers face when accessing immunisation through improved health education, resource allocation, and community engagement is essential to strengthen immunisation coverage.
Vhulenda Maranda, Tinyiko Chawane, Hakhakhi Mphaphuli et al.
The Advisory Committee on Vaccines of the Spanish Association of Paediatrics annually publishes the immunisation schedule considered optimal for children resident in Spain, according to available evidence on current vaccines. As regards funded immunisations, the 2 + 1 strategy (2, 4, 11 months) with hexavalent (DTPa-IPV-Hib-HB) and 13-valent pneumococcal vaccines are recommended. Administration of the 6-year booster dose with DTPa is recommended, with a poliomyelitis dose for children who had received the 2 + 1 scheme, as well as Tdap vaccine for adolescents and pregnant women in every pregnancy between 27 and 32 weeks gestation. The 2-dose scheme should be used for MMR (12 months and 3–4 years) and varicella (15 months and 3–4 years). MMRV vaccine could be applied as the second dose. Vaccination against HPV is recommended in both genders, preferably at 12 years of age. A stronger effort should be made to improve vaccination coverage. The new 9-valent vaccine is now available, expanding the coverage for both genders. Tetravalent meningococcal vaccine (MenACWY) is recommended at 12 months and 12-14 years, with a catch-up up at 19 years of age. It is also recommended in infants older than 6 weeks of age with risk factors, or travellers to countries with high incidence of ACWY meningococcal serogroups. As regards non-funded immunisations, meningococcal B vaccination is recommended, with a 2 + 1 schedule, and requests that it be included in the National Immunisation Programme. Vaccination against rotavirus is recommended in all infants.
David Moreno‐Pérez, Francisco José Álvarez García, Javier Álvarez Aldeán et al.
The World Health Organization's Tailoring Immunization Programmes approach was used to develop a new strategy to increase child vaccination coverage in a disadvantaged community in New South Wales, Australia, including reminders, outreach and home visiting. After 18 months, the strategy hasn't been fully implemented. A process evaluation was conducted to identify barriers and facilitators for research translation. Participants included child health nurses, Population Health staff, managers and general practitioners. The Capability-Opportunity-Motivation model of behaviour change (COM-B) was used to develop questions. Twenty-four participants took part in three focus groups and four interviews. Five themes emerged: (i) designing and adopting new ways of working is time-consuming and requires new skills, new ways of thinking and changes in service delivery; (ii) genuine engagement and interaction across fields and institutions helps build capacity and strengthen motivation; (iii) implementation of a new strategy requires clarity; who's doing what, when and how?; (iv) it is important not to lose sight of research findings related to the needs of disadvantaged families; and (v) trust in the process and perseverance are fundamental. There was strong motivation and opportunity for change, but a need to enhance service capability. Areas requiring support and resources were identified.
