Background: Vaccination is the most cost-effective intervention to improve health and reduce morbidity and mortality due to vaccine-preventable diseases in the child population. The South Asian region was home to 1.8 of the 6 million babies who died within twenty-eight days of birth in 2015. Objective: To describe the status and its determinants of immunisation coverage in three South Asian countries, India, Bangladesh and Nepal.Method: The study utilized data from the Demographic Health Surveys of India, Bangladesh and Nepal. We used the principal component analysis (PCA) to compute the wealth index. Descriptive statistics, bivariate analysis and multivariate logistic regression model were utilised to access the status and factors associated with immunisation coverage.Results:The study found increasing trends in immunisation coverage in India, Bangladesh and Nepal. More than 85% of children from Nepal and Bangladesh were fully immunised in contrast to 43.6% from India. There was a wide variation in child immunisation coverage in terms of socioeconomic and demographic factors. Multivariate logistic regression revealed that factors like mother’s age, residence, birth order and religion had minimal impact on complete immunisation coverage. However, mother’s education and wealth index appeared as the significant confounding factors of full immunization coverage. Children belonging to the higher educated and rich families were more likely to be fully immunised. Maximum impact of education (AOR=9.833; p<0.01) and wealth index (AOR=8.105; p<0.01) were observed in 2006 and 2011 respectively in Nepal.Conclusions: More than 85% of children from Nepal and Bangladesh were fully immunised in contrast to 43.6% from India. Mother’s education and wealth index appeared to have a significant impact on full immunization coverage.Sri Lanka Journal of Child Health, 2018; 47(1): 56-63
Abstract In a bid to address the high burden of vaccine-preventable disease and low immunisation coverage in Africa, Ministers of health and finance from several African countries conveyed at the maiden Ministerial Conference on Immunisation at Addis Ababa, Ethiopia on the 25th of February 2016 to pledge political commitments to reduce the prevalence and deaths from vaccine-preventable diseases to the barest minimum. The fulfilment of this pledge across Africa would require the design of contextually tailored sustainable plans to finance the procurement of vaccines and the running of apt immunisation programs. A robust understanding of the trend of immunisation financing in Africa will support the development of suitable national immunization financing plans, guide policy makers to develop immunisation financing strategies focused on domestic resources but factor in donor support; and provide insights for the rejuvenation and expansion of immunisation programs. Our study’s objective is to estimate the minimum fraction of a country’s health budget that should be invested in the national immunisation programme to achieve a national immunisation coverage of 80% or greater depending on the context with and without donors’ support. The study results did not find any evidence to indicate that health expenditure on immunisation (as a proportion of total health expenditure) could be a strong predictor of immunisation coverage. However, we observed an association between total health expenditure (as a % of the GDP) and immunisation coverage, for BCG (p=0.047) and DPT3 (p=0.013) vaccines. Therefore, health expenditure as a percentage of GDP can be considered as an important predictor of immunisation coverage. We demonstrate in selected countries that to achieve the GAVI target of 80% in the countries with low DPT3 coverage, health expenditure as a percentage of GDP would need to be increased by more than 45%. We are optimistic that our study results and recommendations will facilitate the development of strategies that support African countries to increase domestic financing for national immunization programmes towards achieving 2030 targets for immunization coverage. Evidence before this study We conducted a desk review to identify official government records and reports on immunisation financing in African countries in Google scholar, WHO Library, GAVI and World bank databases using keywords such as “immunisation financing”, “health budget”, “health financing policies”, “immunisation financing policies” and “health expenditure”. We identified data for all countries in Africa but were only able to retrieve complete data from 24 countries. We considered the retrieved data for each country to be complete for our study if we found data on immunisation expenditure, health expenditure as a percentage of Gross Domestic Product, Gross Domestic Product, BCG coverage, DPT3 coverage, PCV1 coverage, MCV1 coverage, fertility rates, under-five mortality rates, under-five population and the total population. Added value of this study We sought for any association between immunisation expenditure and health expenditure (as a % of the GDP) and immunisation coverage over a five-year period (2013 to 2017) in twenty-four African countries. To our knowledge, this is the first study that has shown a correlation between immunisation financing, health expenditure and immunisation coverage and how this association varies across countries. Prediction modelling of vaccine coverage time series for countries with less than desired level of coverage (below 80%) enabled us to construct a predictive index that visualised the effect of increasing health expenditure (as a % of the GDP) would have on immunisation coverage with all other variables unchanged. Implications of the available evidence We posit that immunisation expenditure is not a statistically significant predictor for immunisation coverage for DPT3 and BCG vaccines; rather, with strong statistical evidence, health expenditure (as a % of the GDP) can be used to predict immunization coverage. Our prediction model estimated the percentage increase in health expenditure (as a % of the GDP) that would be required for countries with low immunization coverage to attain the target for immunization coverage recommended by the IA2030 Framework for Action.
Sub–Saharan Africa (SSA) alone accounts for 40% of all global deaths, a phenomenon attributed to lack of access to available lifesaving vaccines (Wiysonge, Uthman, Ndumbe, & Hussey, 2012). WHO estimates that in 2019 the African region accounted for approximately 43% of unimmunised and incomplete immunised infants in the world (i.e.: 8.5 million of the global 19.4 million). Relatedly, the region scores the lowest immunisation coverage, at 76% versus the global coverage of 86% (WHO, 2020a). This is despite several documented efforts by different stakeholders to improve coverage in the region (Mihigo, Okeibunor, Anya, Mkanda, & Zawaira, 2017). Many studies have been conducted on coverage and drivers for and bottlenecks against immunisation in SSA. (Wiysonge, Uthman, Ndumbe, & Hussey, 2012), (Wiysonge, Young, Kredo, McCaul, & Volmik, 2015), (Mihigo, Okeibunor, Anya, Mkanda, & Zawaira, 2017), (Madhi & Rees, 2018),(Bangura, et al., 2020), all of which have observed that there is varied performance among the constituent countries, and also within countries over time, denoting some implicitly common underlying correlates threading through areas of higher performance; and the same is seen with the poorer performing areas. This consensus study therefore seeks to categorise and make explicit these “root causes” and based on documented successes, to make recommendations to address the bottlenecks and harness the opportunities for reaching every child with all the recommended vaccines. The theory of change presentation style used in this report, categorising the root causes under four broad interlinked themes, can provide a common basis to rally like-minded partners around a thematic cause and thus develop multi-component, comprehensive strategies to bring about impactful change. This is in line with the call made by the World Health Organisation Strategic Advisory Group of Experts on Immunisation, which recommended that countries, regions and global immunisation partners commit to a comprehensive review of progress, impact, and implementation of the WHO Global Vaccine Action Plan to inform a post-2020 strategy taking into account lessons learned. This strategy will assist with attaining the relevant United Nations Sustainable Development Goals by 2030.
Introduction Child immunisation is a cost-effective strategy to reduce vaccine-preventable diseases. While effective coverage is key to ensuring quality immunisation, little is known about its geographical distribution in Ethiopia. This study aims to assess the spatial distribution of effective coverage of child immunisation and identify areas with low coverage to inform targeted interventions. Methods We used the 2019 Ethiopia Mini Demographic and Health Survey and Ethiopia Service Provision Assessment datasets. After calculating the effective coverage of immunisation, Bayesian model-based geostatistics were employed to assess the spatial distribution of effective immunisation coverage in Ethiopia, using relevant covariates to estimate coverage rates across regions. Results The national effective coverage of immunisation was 34% (95% CI: 31.9% to 36.5%), with significant regional variation. Addis Ababa, western Benishangul-Gumuz, Dire Dawa city administrative, the northern part of South West Ethiopia and the northwest part of Amhara had hotspots for high level of effective coverage of child immunisation. On the other hand, central Amhara, northern Gambela, central Oromia, Sidama, northern Southern Nations, Nationalities and Peoples regions (SNNPR) and Somali had low effective coverage of child immunisation. Travel time to the nearest city (−0.292: 95% CI:−0.533 to −0.052) was found to be negative predictor of spatial distribution. Conclusion There were significant geographical variations in the effective coverage of immunisation services in Ethiopia. Travel time to nearest city was a significant predictor of spatial distribution. Policymakers are advised to prioritise underserved areas and improve spatial predictors to have a safe, effective and life-saving vaccination program in Ethiopia.
Samrawit Birhanu Alemu, Daniel Gashaneh Belay, Aynalem Belay et al.
The COVID-19 pandemic posed significant challenges to healthcare systems globally, including Tanzania, disrupting essential health services, including child basic immunisation programmes. Using an interrupted time series (ITS) analysis, we analysed how the pandemic influenced child fundamental immunisation trends across three key tears: 2020 (partial lockdown), 2021 (introduction of COVID-19 vaccination programmes), and 2022 (post-pandemic recovery phase). The results reveal a slight decline in immunisation coverage in 2020, with no significant impacts when this year is used as an intervention point. However, a sharp decline in 2021 indicates a more substantial disruption in immunisation services, coinciding with the implementation of COVID-19 vaccination campaigns. When 2021 is considered the intervention year, the study finds significant immediate and prolonged impacts, suggesting that the combination of pandemic fatigue, the reallocation of health resources, and public fear may have exacerbated the decline in immunisation rates. By 2022, immunisation coverage showed signs of recovery. These findings highlight the complex and evolving nature of the pandemic’s impact on child immunisation services. This study highlights the need for targeted interventions to restore and maintain essential health services, particularly in global health emergencies. Recommendations include improving healthcare resource allocation during crises, strengthening public health messaging, and expanding community outreach to mitigate long-term service disruptions.
Steven Mwaseba, Emmanuel Mwang’onda, Winnie Donald
Abstract Background The global Immunisation Agenda 2030 highlights coverage and equity as a strategic priority goal to reach high equitable immunisation coverage at national levels and in all districts. We estimated inequities in full immunisation coverage associated with socioeconomic, geographic, maternal, child, and place of birth characteristics among children aged 12–23 months in Kenya. Methods We analysed full immunisation coverage (1-dose BCG, 3-dose DTP-HepB-Hib (diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type B), 3-dose polio, 1-dose measles, and 3-dose pneumococcal vaccines) of 3943 children aged 12–23 months from the 2014 Kenya Demographic and Health Survey. We disaggregated mean coverage by socioeconomic (household wealth, religion, ethnicity), geographic (place of residence, province), maternal (maternal age at birth, maternal education, maternal marital status, maternal household head status), child (sex of child, birth order), and place of birth characteristics, and estimated inequities in full immunisation coverage using bivariate and multivariate logistic regression. Results Immunisation coverage ranged from 82% [81–84] for the third dose of polio to 97.4% [96.7–98.2] for the first dose of DTP-HepB-Hib, while full immunisation coverage was 68% [66–71] in 2014. After controlling for other background characteristics through multivariate logistic regression, children of mothers with primary school education or higher have at least 54% higher odds of being fully immunised compared to children of mothers with no education. Children born in clinical settings had 41% higher odds of being fully immunised compared to children born in home settings. Children in the Coast, Western, Central, and Eastern regions had at least 74% higher odds of being fully immunised compared to children in the North Eastern region, while children in urban areas had 26% lower odds of full immunisation compared to children in rural areas. Children in the middle and richer wealth quintile households were 43–57% more likely to have full immunisation coverage compared to children in the poorest wealth quintile households. Children who were sixth born or higher had 37% lower odds of full immunisation compared to first-born children. Conclusions Children of mothers with no education, born in home settings, in regions with limited health infrastructure, living in poorer households, and of higher birth order are associated with lower rates of full immunisation. Targeted programmes to reach under-immunised children in these subpopulations will lower the inequities in childhood immunisation coverage in Kenya.
Abstract Background: The WHO Immunisation Agenda 2030 highlights coverage and equity as a strategic priority goal to reach high equitable immunisation coverage at national levels and in all districts. We estimated inequities in full immunisation coverage associated with socioeconomic, geographic, maternal, child, and place of birth characteristics among children aged 12-23 months in Kenya. Methods: We analysed full immunisation coverage (1-dose BCG, 3-dose DTP-HepB-Hib, 3-dose polio, 1-dose measles, and 3-dose pneumococcal vaccines) of 3,943 children aged 12–23 months from the 2014 Kenya Demographic and Health Survey. We disaggregated mean coverage by socioeconomic (household wealth, religion, ethnicity), geographic (place of residence, province), maternal (maternal age at birth, maternal education, maternal marital status, maternal household head status), child (sex of child, birth order), and place of birth characteristics, and estimated inequities in full immunisation coverage using bivariate and multivariate logistic regression. Results: Immunisation coverage ranged from 82% [81–84] for the third dose of polio to 97.4% [96.7–98.2] for the first dose of DTP-HepB-Hib, while full immunisation coverage was 68% [66–71] in 2014. After controlling for other background characteristics, children of mothers with primary school education or higher have at least 54% higher odds of being fully immunised compared to children of mothers with no education. Children born in clinical settings have 41% higher odds of being fully immunised compared to children born in home settings. Children in the Coast, Western, Central, and Eastern regions had at least 74% higher odds of being fully immunised compared to children in the North Eastern region, while children in urban areas had 26% lower odds of full immunisation compared to children in rural areas. Children in the middle and richer wealth quintile households were 43–57% more likely to have full immunisation coverage compared to children in the poorest wealth quintile households. Children who were sixth born or higher had 37% lower odds of full immunisation compared to first-born children. Conclusions: The inequities in full immunisation adversely affect children of mothers with no education, born in home settings, in regions with limited health infrastructure, living in poorer households, and of higher birth order.
Abstract Vaccines are one of the safest and most cost-effective interventions to prevent disease and disabilities worldwide. Yet, nearly 19 million children do not receive basic vaccines and most of them are from low and middle-income countries. The Sustainable Development Goal 3 aims at eliminating preventable deaths of newborns and under-five children by 2030. However, Ethiopia has a high child mortality rate, and most of them are from preventable causes. Quality provision of immunisation could reduce vaccine-preventable morbidity and mortality. Despite this, the quality-adjusted coverage of immunisation services in Ethiopia has not been well-documented. We used the Kids’ record from the 2019 Ethiopian Demographic and Survey (EDHS) and the health facility recode from the 2021–2022 Ethiopian Service Provision Assessment (ESPA). The EDHS and ESPA data were linked using administrative boundary linkage using administrative regions and city administrations. The crude coverage was weighted before linking with the ESPA dataset. Health facilities which provide child immunisation services were included. The quality of immunisation service provision was constructed from 14 indicators. The quality of immunisation was calculated as the sum of the availability of items in each domain, divided by the total number of items in the domain, and finally multiplied by 100. The effective coverage was measured as the product of contact coverage and quality of immunisation service provision. We use STATA 17 for analysis. A total of 951 respondents who have a live children aged 12–23 month were included. The national effective coverage of immunisation was 34.3% (95% Confidence interval (CI): 33.0, 35.5) with a large variation in different regions, ranged from 14.8% in Afar to 83.5% in Addis Ababa. The crude coverage of immunisation services was 39.6% (95% CI: 36.5, 42.7), ranged from 19.2% in Afar to 87.39% in Addis Ababa. The overall score for quality of immunisation service was 82% (95% CI: 80.44, 83.51). The quality ranged from 74.6% in SNNPR to 95.5% in Addis Ababa. The quality of immunisation varies with the managing authority of health facilities, private facilities had the highest quality (90% (95% CI: 85.35, 95.36)) and government facilities scored the lowest quality (82% (95% CI: 80.06, 83.22)). There was low effective coverage of immunisation services provision in Ethiopia. The effective coverage was lower in the pastoral regions (Afar and Somali). Government facilities and facilities in rural areas had lower-quality immunisation services. Facilities in SNNPR and Afar region had low-quality of immunisation service. Policymakers should focus on improving the quality of government facilities and the facilities in rural areas and pastoral regions to improve immunisation services.
AbstractIn 2014, the Emergency Nutrition Network published a report on the relationship between wasting and stunting. We aim to review evidence generated since that review to better understand the implications for improving child nutrition, health and survival. We conducted a systematic review following PRISMA guidelines, registered with PROSPERO. We identified search terms that describe wasting and stunting and the relationship between the two. We included studies related to children under five from low‐ and middle‐income countries that assessed both ponderal growth/wasting and linear growth/stunting and the association between the two. We included 45 studies. The review found the peak incidence of both wasting and stunting is between birth and 3 months. There is a strong association between the two conditions whereby episodes of wasting contribute to stunting and, to a lesser extent, stunting leads to wasting. Children with multiple anthropometric deficits, including concurrent stunting and wasting, have the highest risk of near‐term mortality when compared with children with any one deficit alone. Furthermore, evidence suggests that the use of mid‐upper‐arm circumference combined with weight‐for‐ageZscore might effectively identify children at most risk of near‐term mortality. Wasting and stunting, driven by common factors, frequently occur in the same child, either simultaneously or at different moments through their life course. Evidence of a process of accumulation of nutritional deficits and increased risk of mortality over a child's life demonstrates the pressing need for integrated policy, financing and programmatic approaches to the prevention and treatment of child malnutrition.
Susan Thurstans, Natalie Sessions, Carmel Dolan et al.
AbstractEvidence suggests children HIV‐exposed and uninfected (CHEU) experience poor growth. We analysed child anthropometrics and explored factors associated with stunting among Malawian CHEU. Mothers with HIV and their infants HIV‐exposed were enroled in a nationally representative prospective cohort within the National Evaluation of Malawi's Prevention of Mother‐to‐Child HIV Transmission Programme after Option B+ implementation (2014–2018). Anthropometry was measured at enrolment (age 1–6 months), visit 1 (approximately 12 months), and visit 2 (approximately 24 months). Weight‐for‐age (WAZ) and length‐for‐age (LAZ) z‐scores were calculated using World Health Organization Growth Standards; underweight and stunting were defined as WAZ and LAZ more than 2 standard deviations below the reference median. Multivariable logistic regression restricted to CHEU aged 24 months (±3 months) was used to identify factors associated with stunting. Among 1211 CHEU, 562/1211 attended visit 2, of which 529 were aged 24 months (±3 months) and were included. At age 24 months, 40.4% of CHEU were stunted and/or underweight, respectively. In multi‐variable analysis, adjusting for child age and sex, the odds of stunting were higher among CHEU with infectious disease diagnosis compared to those with no diagnosis (adjusted odds ratio = 3.35 [95% confidence interval: 1.82–6.17]), which was modified by co‐trimoxazole prophylaxis (p = 0.028). Infant low birthweight was associated with an increased odds of stunting; optimal feeding and maternal employment were correlated with reduced odds. This is one of the first studies examining CHEU growth since Option B+. Interventions to improve linear growth among CHEU should address their multi‐faceted health risks, alongside maternal ART prescription, and follow‐up of mother‐child pairs.
Gabriela Toledo, Megan Landes, Monique van Lettow et al.
Survival
Israel Oluwaseyidayo Idris, Janet Tapkigen, Luke Ouma et al.
