OBJECTIVE: To determine the costs to develop, roll out and maintain electronic immunisation registries (EIRs) and a related suite of data use interventions. METHODS: The Better Immunisation Data (BID) Initiative conducted the activities from 2013 to 2018 in three regions in Tanzania and one province in Zambia. The Initiative's financial records were used to account for the financial costs of designing and developing the EIRs, BID staff time, expenditures for rolling out the EIR systems and the related suite of interventions to health facilities, and recurrent costs. Total financial costs, cost per facility and cost per child were calculated in 2018 US$. FINDINGS: Total expenditures were ~US$4.2 million in Tanzania and US$3.6 million in Zambia. System design and development costs accounted for ~33% and 26% of the expenditures in each country, respectively, while BID staff costs accounted for 39% and 52%, respectively. Average expenditures per health facility for rolling out the EIR system were between US$709 and US$1320 for the Tanzania regions and US$2591 for Zambia. The annualised average expenditure per child was estimated to be between US$3.30 and US$3.81 for the regions in Tanzania and US$8.46 in Zambia. Expenditures per child were higher in Zambia partly because of a much smaller birth cohort compared with Tanzania. CONCLUSION: Other countries may benefit from the investments made and lessons learnt in Tanzania and Zambia by leveraging these now existing EIR platforms and rollout strategies, and hence may be able to implement EIRs at lower costs than reported here.
Mercy Mvundura, Laura Di Giorgio, Dafrossa C. Lymo et al.
Background: The expanded programme of immunisation (EPI) has been a major success in Sri Lanka. However, despite its success, vaccine hesitancy remains a concern. Timely vaccination is crucial, as delays and missed doses reduce herd immunity and increase susceptibility to vaccine-preventable diseases.Objectives: To evaluate vaccine compliance, parental attitudes toward childhood immunization, and the factors influencing vaccination compliance among parents in the Doluwa Medical Officer of Health (MOH) area.Method: A community-based cross-sectional descriptive study was conducted with 176 participants attending vaccination and well-baby clinics in conveniently selected Public Health Midwife (PHM) areas within the Doluwa MOH area in Kandy district. Data were collected using a structured interviewer-administered questionnaire and Child Health Development Records.Results: Study involved 176 parents, with mean participant age of 31 years. All participants had appropriately vaccinated their children for their age, except for 47 (26.7%) who reported vaccination delays, primarily due to child illness (23.4%). There were no non-vaccinated participants. A significant association was found between child’s age and vaccination delay (OR= 1.045, 95% CI=1.02–1.07). All participants obtained vaccines from government sector. A majority (96.6%) had positive attitudes towards EPI, citing the high responsibility of the government sector (76.7%).Conclusions: Despite excellent vaccination coverage, vaccination delays persist, indicating areas for improvement in the implementation of EPI.
R. A. S. M. B. Ramanayake, N. J. Gajanayake, M. Nishanthini et al.
Dear Editor, Childhood immunisation in Pakistan has advanced substantially over the past two decades. Sustained programmatic investment, most notably through the National Immunization Support Project has expanded routine coverage, and national full immunisation rates among children aged 12–23 months have risen accordingly [1]. Yet this progress remains uneven. The Pakistan Demographic and Health Survey 2017–18 found that only 66% of children aged 12–23 months were fully immunised [2], and coverage falls further in rural, low-income, and conflict-affected districts. In the Matiari district of Sindh, for example, Shahid et al. reported that just 48.4% of children under two had received all vaccines recommended under the Expanded Programme on Immunization (EPI), with rural coverage lagging well behind urban areas (62.9%) and geographical distance to services emerging as a significant predictor of delayed vaccination [3]. Such figures are illustrative rather than nationally representative, but they capture a consistent pattern: the burden of under-immunisation falls disproportionately on the most marginalised. Under-immunisation in these settings is not attributable to vaccine hesitancy alone. Insecurity and targeted violence against vaccination teams, fragile health infrastructure, workforce shortages, and limited physical access all constrain coverage [3,4]. The COVID-19 pandemic compounded these barriers, disrupting routine immunisation and diverting frontline health workers, while heightened distress and altered risk perception independently shaped vaccine attitudes; in one national survey, 66.9% of respondents expressed some degree of hesitancy [5]. Against this backdrop, hesitancy is best understood as one determinant among several but a distinctly modifiable one, rooted in confidence, complacency, and convenience [6], and therefore squarely within the influence of the medical profession. At its core, hesitancy in Pakistan reflects an erosion of trust. Misinformation amplified on social media magnifies fears about side effects, infertility, and religiously framed objections; in one recent study, 83.2% of parents had encountered negative messaging about the polio vaccine, even as television and clinicians remained their most trusted sources of information [7]. This mistrust has been deepened by the politicisation of immunisation. The 2011 disclosure that the Central Intelligence Agency had used a sham vaccination campaign to help locate Osama bin Laden lent credibility to circulating conspiracy theories and was followed by measurable declines in immunisation, with vaccination rates falling by an estimated 23–39% in districts most exposed to the ensuing anti-vaccine propaganda [8]. Reports of negative experiences and perceived coercion have arisen largely in the context of repeated, high-intensity polio eradication campaigns, particularly in communities already wary of state institutions [4]. Vaccine hesitancy in Pakistan is thus not merely an information deficit, but a symptom of strained relationships between citizens and the institutions meant to serve them. This reframing carries a specific ethical charge for medical leadership, by which we mean not only individual clinicians but the councils, hospital administrations, and professional bodies that set the standards of the profession. Four obligations follow. Justice requires that health systems act to close, rather than tolerate, the coverage gap borne by marginalised children. Respect for persons demands honest, culturally attuned communication and genuine engagement with communities, rather than outreach experienced as coercive. Non-maleficence extends beyond the clinical encounter: because clinicians are among the most trusted sources of health information [9], misinformation originating from within the profession is uniquely harmful, lending false legitimacy to unfounded fears [10]. And fidelity to the public trust obliges leadership to safeguard the credibility of immunisation as a shared good. The distinctive contribution of this letter is to locate the response to hesitancy not solely in patient education, but in the professional accountability of medical leadership itself, including a duty to correct and, where necessary, sanction the propagation of falsehoods by clinicians. Several measures follow directly. Training should equip health workers to communicate the benefits and risks of vaccination effectively and empathetically. Accurate materials in regional languages are needed wherever literacy is low. In insecure and rural areas, where distrust of government services runs deepest, partnership with community and religious leaders can help rebuild confidence and disseminate credible information. Vaccine-related misinformation should be monitored within routine public-health surveillance so that damaging narratives can be identified before they take hold [7]. Finally, medical councils and hospital administrations should uphold professional accountability, prioritising education and support, but ensuring that the repeated dissemination of misinformation by clinicians carries consequences [10]. Vaccine hesitancy in Pakistan is ultimately a test of institutional trust as much as a logistical challenge, and the profession’s response is a measure of its ethical commitments. Restoring confidence will require transparency, cultural humility, and leadership willing to hold its own members to account, so that every child’s right to protection from preventable harm is upheld not through campaigns alone, but by a profession that earns, and keeps, the public’s trust.
In Australia, we used the World Health Organization’s Tailoring Immunization Programmes to identify areas of low immunisation coverage in First Nations children. The qualitative study was led by First Nations researchers using a strength-based approach. In 2019, Tamworth had 179 (23%) children who were overdue for immunisations. Yarning sessions were conducted with 50 parents and health providers. Themes that emerged from this research included: (a) Cultural safety in immunisation services provides a supportive place for families, (b) Service access could be improved by removing physical and cost barriers, (c) Positive stories promote immunisation confidence among parents, (d) Immunisation data can be used to increase coverage rates for First Nations children. Knowledge of these factors and their impact on families helps ensure services are flexible and culturally safe.
Susan L Thomas, Natalie Allan, Paula Taylor et al.
BACKGROUND: Immunization is one of the most cost-effective health intervention to halt the spread of childhood diseases, and improve child health. Yet, there is a substantial disparity in childhood immunization coverage. The overall objective of the study is to investigate the trends of within-country inequalities in childhood immunization coverage among children aged 12-23 months in Kenya, Ghana, and Côte d'Ivoire. The three countries included in this study are countries that are on the verge of entering the accelerated phase of the Gavi, the Vaccine Alliance's co-sharing of costs of vaccine and eventually assuming full costs of vaccines. Côte d'Ivoire is in the Gavi preparatory transition phase, entering the accelerated transition phase in 2020, with an expected transition to full self-financing in 2025. Ghana is expected to enter the accelerated transition phase in 2021 and to full self-financing in 2026 while Kenya will enter in 2022 and fully self-finance in 2027. We examine the pattern of inequality in childhood immunization coverage over time through an equity lens by mainly exploring the direction of inequality in coverage. METHODS: We use data from the Demographic Health Surveys and Multiple Indicator Cluster Surveys. The rate difference, rate ratio, and relative concentration index are used as measures of inequality. RESULTS: Results of the study suggest that in most years inequality in immunization coverage in the three countries persist over time, and it favors the most-advantaged households. However, there is a sharp decrease pattern in inequalities in childhood immunization coverage in Ghana over time. CONCLUSION: Policymakers could be more strategic in addressing pro-rich inequality in immunization coverage by designing health interventions through an equity lens. Using inequality data and putting disadvantaged households at the center of health intervention designs could increase the efficiency of the primary health care system and reduce the incidence of mortality and morbidity as a result of vaccine-preventable disease.
Hermann Pythagore Pierre Donfouet, Gaye Agesa, Martin Kavao Mutua
BACKGROUND: Routine maternal immunisation against influenza and pertussis are recommended by the WHO to protect mother and child, and new vaccines are under development. Introducing maternal vaccines into national programmes requires an understanding of vaccine delivery costs - particularly in low resource settings. METHODS: We searched Medline, Embase, Econlit, and Global Health for studies reporting costs of delivering vaccination during pregnancy but excluded studies that did not separate the vaccine purchase price. Extracted costs were inflated and converted to 2018 US dollars. RESULTS: Sixteen studies were included, of which two used primary data to estimate vaccine delivery costs. Costs per dose ranged from $0.55 to $0.64 in low-income countries, from $1.25 to $6.55 for middle-income countries, and from $5.76 to $39.87 in high-income countries. CONCLUSIONS: More research is needed on the costs of delivering maternal immunisation during pregnancy, and of integrating vaccine delivery into existing programmes of antenatal care especially in low and middle-income countries.
Simon R. Procter, Omar Mukhtar Salman, Clint J Pecenka et al.
After the 2016 Balkan route border closures, vaccination of refugee children in Greece was mainly performed by non-governmental organisations. Activities varied between camps, resulting in heterogeneity of vaccination coverage (VC). In April 2017, the European programme ‘PHILOS - Emergency health response to refugee crisis’ took over vaccination coordination. Interventions were planned for the first time for refugee children in the community and unaccompanied minors at safe zones. From April 2017–April 2018, 57,615 vaccinations were performed against measles-mumps-rubella (MMR) (21,031), diphtheria-tetanus-pertussis (7,341), poliomyelitis (7,652), pneumococcal disease (5,938), Haemophilus influenzae type b (7,179) and hepatitis B (8,474). In April 2018, the vaccination status of children at camps (reception and identification centres and community facilities such as hostels/hotels were excluded) was recorded and VC for each disease, stratified by dose, nationality and camp size, was calculated. More than 80% of the children received the first MMR dose, with VC dropping to 45% for the second dose. For all other vaccines, VC was < 50% for the first dose in children aged 0–4 years and < 25% for the second dose. Despite challenges, PHILOS improved planning and monitoring of vaccination activities; however, further efforts towards improving VC in refugee children are needed.
Kassiani Μellou, Chrysovalantis Silvestros, Eirini Saranti Papasaranti et al.
Routine childhood immunisation is a critical public health intervention for preventing vaccine-preventable diseases and reducing under-five mortality, yet adherence and completion remain sub-optimal in many low-resource settings, including Northern Uganda. This study examined immunisation adherence and compliance among mothers and caregivers of children aged 0–18 months in Pager Cell, Kitgum Municipality, using a P-factors analytical framework that considers provider and parental factors, procedures and practices, policy and programme influences, and political–contextual determinants. A cross-sectional analytical mixed-methods design was used, collecting data from 323 caregivers through structured questionnaires, child health card reviews, and key informant inputs. Quantitative data were analysed using descriptive statistics, while qualitative findings were thematically analysed within the P-factors framework. Results showed that full immunisation coverage was below national targets, with significant drop-out between early and later vaccine doses, influenced by caregiver knowledge and trust, health facility operational practices, programme implementation gaps, and broader political and infrastructural constraints. Overall, the findings demonstrate that immunisation adherence in Northern Uganda is shaped by interconnected individual providers and parental factors, health system procedure and practices, programme policy, and politico-contextual factors, highlighting the usefulness of the P-factors framework for understanding and improving routine immunisation performance in low-resource and post-conflict settings.
Globally, there has been little growth in vaccination coverage, with countries in the Horn of Africa having the lowest vaccination rates. This study investigated factors associated with vaccination status among children under five years old in Somaliland. The 2020 Somaliland Demographic and Health Survey surveyed women aged 15-49 years from randomly selected households. This multilevel analysis included 2673 primary caregivers of children under five. Only 34% of children were ever vaccinated. Childhood vaccination coverage was positively associated with high-budget regions, high healthcare facility density, and children older than 23 months. Vaccination coverage was greater for urban and rural residents than for nomadic people. Children whose mothers could read part of one sentence or one complete sentence were more likely to be vaccinated than illiterate mothers. Children whose mothers received antenatal care (ANC) once, two to three times, or four times or more were more likely to be vaccinated than those whose mothers received no ANC. Childhood vaccination coverage in Somaliland is low. Promoting maternal ANC visits and increasing women's literacy may enhance vaccination coverage. Funds should be allocated to areas with low resources, particularly for nomadic people, to boost vaccination uptake.
Mohamed Abdalle Osman, Alexander Waits, Li‐Yin Chien
Since 2008, the Philippines has been facing a continuous decline in its immunization rate for vaccine-preventable diseases leading to the re-emergence of polio cases and a nationwide measles outbreak. In 2017, more than half of the entire child population did not receive the complete set of vaccines. This study addressed this issue by discussing selected non-price factors that may affect immunization coverage of children, specifically, parental/caregiver vaccine literacy, the distance of the household's residence to a health facility, and the household size. This research used data from the survey questionnaires that were answered by parents or caregivers with children aged above one to five residing in Barangay 845, Pandacan, Manila. Multiple logistic regression was applied to analyze the data, and it was determined that parental/caregiver vaccine literacy and household size are significant factors that affect immunization coverage of children. However, the distance of the household's residence to a health facility was found to be insignificant to a child's immunization coverage.
Maria Ranja Victoria Porras, Mariel Anne Agsalud, Raziela Thea Evangelista et al.
