Abstract Background The COVID-19 pandemic disrupted immunisation programs worldwide, reversing gains that had brought vaccine-preventable diseases largely under control. This study explored the impact of COVID-19 on the uptake of routine child immunisation services in South Africa. Methods We conducted qualitative research using in-depth interviews with 51 purposively selected parents/caregivers of children below the age of five who missed or delayed one or more scheduled immunisation doses in 2020-2022 and with 12 healthcare providers who provided public immunisation services during the pandemic. Findings During the pandemic lockdowns, most caregivers perceived the risk of their child being infected with COVID-19 during a clinic visit as more salient than the risk of missing immunisation doses. Caregivers reported minimal exposure to routine immunisation communication, as well as shortages of routine vaccines for children at public health facilities; healthcare workers experienced anxiety and burnout. There was a post-pandemic shift to more active decision-making about immunisation, which had previously been an almost automatic behaviour, leading some caregivers to delay vaccinating their children. There was also evidence of a “bad vaccine” mental model among some caregivers regarding COVID vaccinations, which could lead to doubts about the safety of routine childhood vaccinations. Interpretation The shift from default to active decision-making highlights a risk that routine immunisation will backslide in future pandemics. Governments should build resilient health systems at all levels and communicate clearly about the benefits and availability of RIs and the safety of vaccinations in general, alongside supply-side interventions. Funding Final Mile Consulting funded this study.
Sangiwe Moyo, Anushka Ashok, Saransh Sharma et al.
Abstract Whilst it is now widely recognised that routine immunisation (RI) was disrupted by the COVID-19 pandemic in 2020 compared to previous immunisation performance, the extent of continued interruptions in 2021 and/or rebounds to previous trends remains unclear, with sporadic surveys reporting signs of immunisation system recovery at the end of 2020. We modelled country-specific RI trends using validated estimates of national coverage from the World Health Organisation and United Nation Children’s Fund for over 160 countries, to project expected diphtheria, tetanus, and pertussis-containing vaccine first-dose (DTP1), third-dose (DTP3) and measles-containing vaccine first-dose (MCV1) coverage for 2021 based on pre-pandemic trends (from 2000-2019). We estimated a 3·6% (95%CI: [2·6%; 4·6%]) decline in global DTP3 coverage in 2021 compared to 2000-2019 trends, from an expected 90·1% to a reported 86·5% across 164 reporting countries, and similar results for DTP1 (2·8% decline; 95%CI: [2·0%; 3·6%]), and for MCV1 (3·8% decline; 95%CI: [4·8%; 2·7%]). 86·5% global coverage in 2021 represents a further decrease from that reported in 2020 and 2019, and translates to a 16-year setback in RI coverage, i.e., 2005 levels. Hypothesised and early signals of rebounds to pre-pandemic coverage were not seen in most countries. The Americas, Africa, and Asia were the most impacted regions, with low- and middle-income countries the most affected income groups. The number of Zero Dose children also continued to increase in 2021. DTP1 coverage declined worldwide from an expected 93·7% to a reported 90·9% (2·8% decline; 95%CI: [2·0%; 3·6%]) which translates into an additional 3.4 million Zero Dose children on top of an expected 11.0 million (30.9% increase) at the global level. We hope this work will provide an objective baseline to inform future interventions and prioritisation aiming to facilitate rebounds in coverage to previous levels and catch-up of growing populations of under- and un-immunised children.
Abstract Background Childhood vaccinations are a vital preventive measure to reduce disease incidence and deaths among children. As a result, immunisation coverage against measles was a key indicator for monitoring the fourth Millennium Development Goal (MDG), aimed at reducing child mortality. India was among the list of countries that missed the target of this MDG. Immunisation targets continue to be included in the post-2015 Sustainable Development Goals (SDG), and are a monitoring tool for the Indian health care system. The SDGs also strongly emphasise reducing inequalities; even where immunisation coverage improves, there is a further imperative to safeguard against inequalities in immunisation outcomes. This study aims to document whether socioeconomic inequalities in immunisation coverage exist among children aged 12–59 months in India. Methods Data for this observational study came from the fourth round of the National Family Health Survey (2015–16). We used the concentration index to assess inequalities in whether children were fully, partially or never immunised. Where children were partially immunised, we also examined immunisation intensity. Decomposition analysis was applied to examine the underlying factors associated with inequality across these categories of childhood immunisation. Results We found that in India, only 37% of children are fully immunised, 56% are partially immunised, and 7% have never been immunised. There is a disproportionate concentration of immunised children in higher wealth quintiles, demonstrating a socioeconomic gradient in immunisation. The data also confirm this pattern of socioeconomic inequality across regions. Factors such as mother’s literacy, institutional delivery, place of residence, geographical location, and socioeconomic status explain the disparities in immunisation coverage. Conclusions In India, there are considerable inequalities in immunisation coverage among children. It is essential to ensure an improvement in immunisation coverage and to understand underlying factors that affect poor uptake and disparities in immunisation coverage in India in order to improve child health and survival and meet the SDGs.
Respiratory syncytial virus (RSV) continues to be a significant source of morbidity and mortality in both adults and children. Natural infection confers incomplete protection, permitting recurrent episodes. Treatment remains limited to supportive care. Initial endeavours to develop a vaccine resulted in an unexpected enhancement of RSV disease and increased recipient mortality. Current proposed strategies to prevent RSV infection rely on the principles of active and passive immunisation and utilise the highly conserved RSV F‐protein. Maternal vaccines administered in pregnancy may provide protection; trials are ongoing. Palivizumab, a monoclonal antibody, has a moderate preventative efficacy. A similar newer longer lasting formulation appears promising. A number of other novel options are being developed and are undergoing assessment. Progress has been made, with more vaccine candidates under consideration. We are edging closer to an effective solution to prevent RSV infection. If successful, the impact on paediatric morbidity, mortality, workload and cost will be substantial.
Background Though Ethiopia has achieved remarkable progress in immunisation services, there is limited evidence on comprehensive national immunisation coverage. Therefore, this national study evaluated the performance of life-course immunisation services. Methods This study was conducted in all Ethiopian regions and city administrations from March to July 2023. Two-stage stratified cluster sampling was used. About 13666 children aged 12-35 months, 5338 adolescent girls (15–18) and 13843 adults aged 12 years or more were included in the study. Child vaccination status was assessed through reviewing immunisation cards/health facility registration books/caregivers’ recall. A descriptive analysis was done with an adjusted sampling weight. Results Three-fourths of children aged 12-23 months received the first dose of the pentavalent vaccine, and two-thirds received the third dose of the Pentavalent Vaccine. About two-thirds and half of the children received the first and second doses of the Measles vaccine, respectively. The dropout rates for Pentavalent was 14.1% and for Measles, was 19.9%. Full immunisation coverage was 43.9%, and zero-dose children accounted for 24.7%. About 85% of mothers received the first dose of the Tetanus-Diphtheria vaccine. Half of adolescent girls received their first vaccination, and a quarter of them received a second dose of the HPV vaccine. Conclusions Although Ethiopia has made strides in child immunisation, coverage remains below national and global targets. Tetanus-diphtheria vaccine uptake was initially high but dropped significantly by the fourth and fifth doses. HPV vaccine coverage was suboptimal, with most not receiving the second or booster doses. Strengthening national efforts to address both demand and supply barriers is vital for increasing vaccine uptake.
Berhanu Fikadie Endehabtu, Getasew Amare, Yohannes Ayanaw et al.
Introduction Immunisation is vital in preventing infectious diseases and promoting public health. This study examines the immunisation landscape in India, focusing on absolute zero dose (defined as a child did not receive any single dose of vaccine as per the National Immunisation Schedule), antigen-wise zero dose (defined as children who did not receive any dose of specific vaccine but received some or complete dose of other vaccines), the pattern of undervaccination (defined as children who missed any one or more than one dose of vaccine from total eight doses of vaccine (one dose-BCG, three doses-DPT, three doses-OPV and one dose-measles vaccine) and immunisation cascade. Methods Using data from the National Family Health Survey-5, we analysed the immunisation status of 43 247 children across India. The prevalence of absolute zero-dose children, antigen-wise zero dose, co-coverage rates and cascade levels for vaccine combinations are assessed. The multilevel regression model has been applied to understand the likelihood of left-out and antigen-wise zero doses by socioeconomic determinants. Results Children lacking vaccination cards experience a higher prevalence of absolute zero dose cases (21.2%). Notably, scheduled tribes (4.1%), the Muslim group (5.4%) and the poorest wealth quintile (4.6%) exhibit the highest prevalence. Remarkably, within partially vaccinated (20%) children, 42.8% show zero dose for measles-containing vaccines, while 6.7% of children failed to achieve full immunisation coverage due to just one missed dose of vaccine. Further, 20% of the partially vaccinated subset revealed that 7.29% missed full immunisation coverage due to oral polio vaccine (OPV) dose gaps. Conclusions Targeted efforts are essential to bridge immunisation gaps and achieve universal coverage in India. Focusing on antigen-specific zero dose and partially vaccinated children, particularly those missing OPV doses and measles vaccine offers the potential to improve full immunisation coverage. Therefore, to achieve the IA2030 requires an intensified target for reaching absolute zero and antigen-wise zero dose.
India witnesses more than one million deaths of under-five children annually and two-third of all these deaths occur due to vaccine preventable diseases High share of incomplete immunization in India (WHO, 2022) leaves socioeconomically disadvantage group exposed to high morbidity and mortality risk factors. It demands comprehensive assessment of nature and extent of socioeconomic related inequity in child immunisation. Using the indirect standardisation method and Erreygers (2009); corrected concentration index we first measured the degree of horizontal and vertical inequities, and then linearly decompose them to identify the major factors contributing towards the respective indices. We also adopt several strategies for robustness and sensitivity check on our findings. Our findings show that the incomplete immunisation is significantly concentrated among children belonging to poorer households. After controlling for the confounding effects of need factors, the inequity is still significantly pro-poor (indicating horizontal inequity). Its decomposition reveals that lower education, lower consumption and rural dwelling are the major factors driving the corresponding inequity. Further, the differential effect of needs between all and the target groups (at least based on education), is observed however is not significant enough to realise into inequity (indicating vertical equity). Hence, the direction and magnitude of vertical inequity is ambiguous but not significant. Overall, the inequity is being induced via non-need factors, but public health services (like Anganwadi) found to be the major reducing factor.
Azharuddin Akhtar, Indrani Roy Chowdhury, Pallabi Gogoi et al.
Background: In 2017, Pakistan outsourced to a non-government organisation the management of its vaccination programme in 2 Sindh Province districts. Aim: To determine the impact on coverage of outsourcing vaccination programme in 2 districts of Sindh Province, Pakistan. Methods: Between August and October 2024, we interviewed parents or caregivers of 1600 children aged 12–24 months from 4 (2 outsourced and 2 non-outsourced) districts in Sindh Province, to collect sociodemographic and immunisation data. We analysed the data with STATA version 17, using chi-square test and Man-Whitney U test to compare the participants’ characteristics and immunisation status, and regression model to estimate the difference in immunisation rates between the 2 groups at 9 months. Results: Full immunisation coverage was slightly higher in the outsourced (78.8%) than the non-outsourced (75.8%) districts, but there was no statistically significant difference (P = 0.067). At 9 months, a significant difference (P = 0.036) was observed in immunisation rates: 15.0% decrease in compliance in the outsourced, compared to 19.7% in the nonoutsourced, districts. Conclusion: There was a partial improvement in vaccination coverage due to outsourcing: coverage was better only in one of the outsourced districts. There is a need for further research to understand the reasons for the slight differences in immunisation coverage between the outsourced and non-outsourced districts, and the cost-effectiveness of outsourcing.
Background/Objectives: Routine immunisation (RI) coverage declines during the COVID-19 pandemic, from 2020 to 2022, are well-reported. With the declared end to the Public Health Emergency of International Concern in May 2023, and the end of most non-pharmaceutical interventions that were introduced to prevent or minimise COVID-19 spread, we (I) assess whether routine immunisation coverage has rebounded to pre-pandemic trends, and (II) seek to identify factors that help predict whether country performance has exceeded, maintained, or declined compared to expectations (based on time-series forecasting). Methods: We quantify global and country-level routine immunisation diphtheria-tetanus-pertussis (DTP) coverage trends post-pandemic (2023) compared to pre-pandemic trends using time-series forecasting across 190 countries. We used Discriminant Analysis of Principal Components and Random Forests to identify relevant predictors of country-level coverage performance, including 28 indicators of health system strength, health workforce, country income, pandemic containment, economic, and health policies, and demographic aspects. Results: We show that mean global DTP third-dose coverage levels remained on average 2.7% [95% confidence intervals: 1.1% - 4.3%] lower than expected in 2023. However, once accounting for temporal demographic changes, we find that this translates to the total number of immunised children almost reverting to expected levels, owing to decreasing fertility reducing global-level immunisation target populations. At a country-level, notable disruption remaining in over 30 countries (17.6% of countries below expectations, 81.6 within expected ranges, and 1.7% above expectations). Neither predictive method performed well at identifying factors associated with coverage disruptions. Conclusions: Despite the end of COVID-19 pandemic measures, RI remains below expectations in 20% of countries. No clear drivers of this continued disruption were identified. Further research is required to inform recovery efforts and prevent future epidemic and pandemic disruptions to routine health services.
BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare systems worldwide, leading to concerns about reduced access to routine childhood immunisations. However, comprehensive data on how the pandemic specifically impacted paediatric vaccination coverage in Switzerland remain limited across the country. The present study provides an analysis of the timeliness and coverage of routine childhood immunisations in Switzerland before and during the COVID-19 pandemic, offering insights into potential fluctuations in coverage. AIMS: To assess the impact of the COVID-19 pandemic on routine childhood immunisation in Switzerland by comparing vaccination coverage and timeliness for children under 35 months of age before and during the pandemic. Additionally, the study seeks to identify factors associated with the likelihood of children receiving vaccinations, considering demographic and geographic variables. METHODS: We used 2019–2023 data from the Swiss National Vaccination Coverage Survey (SNVCS), a cross-sectional survey that collected immunisation information of children under 35 months of age from a nationally representative sample of households. Children who were eligible for a vaccine from March 2020 to March 2021 were considered as the COVID-affected group and those eligible for a vaccine before this date were included in the pre-COVID-19 cohort. Coverage of the following vaccine doses was considered: diphtheria at one, two and three doses (Di1, Di2, Di3); pneumococcus at one, two and three doses (PCV1, PCV2, PCV3); and measles first and second dose (MCV1, MCV2). Vaccine timeliness was defined as receiving a dose on time with a tolerance period of 30 days. We used logistic regression models to identify and understand the factors that might influence vaccination rates. RESULTS: For the diphtheria vaccines (Di1, Di2, Di3), while coverage remained high, there was a slight decrease observed in timely vaccination rates for some doses, with reductions of around 1% to 3% compared to pre-COVID-19 levels. The impact on PCV1, PCV2 and PCV3 showed similar trends, with slight reductions in coverage during the pandemic, but these differences were not statistically significant. For measles-containing vaccines (MCV1 and MCV2), coverage during the pandemic was higher compared to pre-COVID-19 rates. Geographic and demographic factors, such as an urban setting, nationality and linguistic region, significantly influence childhood vaccination rates in Switzerland. CONCLUSION: While minor declines in vaccine timeliness were observed (diphtheria vaccine, pneumococcal conjugate vaccine), the overall likelihood of vaccination was not significantly affected by the COVID-19 pandemic. However, changes in vaccination recommendations introduced in 2019 may have influenced these trends.
Vasiliki Baroutsou, Monica N. Wymann, Jan S. Fehr et al.
