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.
Israel Oluwaseyidayo Idris, Janet Tapkigen, Luke Ouma et al.
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.
Samrawit Birhanu Alemu, Aynalem Belay, Redait Awoke Assefa et al.
An analytical cross-sectional study was conducted among a randomly selected sample of 374 households with at least one child aged 6 to 59 months in the Kirundo health district, Burundi. Sociodemographic, socioeconomic, socio-sanitary factors, food insecurity, behavioral, and environmental data were collected using a structured questionnaire. Children's weight was measured using a standard procedure (SECA scale), their height using a standard UNICEF height rod, and their age was obtained from the birth certificate. Anthropometric data were analyzed using Emergency Nutrition Assessment (ENA for Smart) software. Modeling was performed using logistic regression to eliminate confounding factors, and all independent variables with a significance level less than or equal to 20% in the bivariate analysis were included to explore factors associated with stunting in children aged 6 to 59 months. In this study, the prevalence of stunting is estimated at 61.5%. According to multivariate logistic regression, sex (AOR = 2.83; 95% CI:1.40-5.75), age (AOR= 10.40; 95% CI: 1.21-88.30), food insecurity (AOR = 10.47;95% CI: 3.58-30.61), latrine type (AOR = 6.83; 95% CI: 3.12-14.94), diarrhea (AOR = 2.56; 95% CI: 1.19-5.48), water source (AOR = 3.17; 95% CI: 1.54-6.52), media exposure (AOR = 0.24, 95% CI: 0.11-0.51), nutritional knowledge (AOR = 0.11; 95% CI: 0.05-0.25), birth spacing (AOR = 0.39, 95% CI: 0.16-0.93), complete vaccination (AOR = 0.06; 95% CI: 0.02-0.21), father's occupation (AOR = 0.25; 95% CI: 0.09-0.72), and mother's education (AOR = 0.21; 95% CI: 0.07-0.64) were significantly associated with stunting. The predictive model showed an area under the curve (AUC) of 0.95, indicating excellent discrimination ability. The high prevalence of stunting in this study highlights the importance of urgent action to end this problem.
Nzigamasabo Aloys, Ndayikengurukiye Honoré, Nizigama Chris Tresor et al.
ABSTRACT One of the major sources of public health concern in many developing countries is child stunting, which accounts for more than a third of all deaths of children below the age of 5 years worldwide. Although child stunting generally seems to be on a downward trend in the country, the present prevalence is still very high based on international standards. Several studies have established that the extent of early childhood dietary exposure to aflatoxins (AFs) and fumonisins (FBs) in the country occurs through complementary feeding. However, there is a paucity of information on whether this is linked to child stunting. This review discusses child stunting and nutrition and strives to draw a link between early childhood dietary exposure to AFs and FBs and child stunting in Tanzania. The review further outlines the mechanisms of mycotoxin‐induced growth impairment and deliberates on the past, present, and future interventions that can be useful in alleviating the problem of stunting that is linked to these mycotoxins. Such information can be crucial for developing and adopting appropriate interventions that can contribute to the further reduction of child stunting in Tanzania.
Globally, the prevalence of child stunting is almost the same for both sexes. However, in developing countries, boys are more likely to be shorter than the norm for their age and sex. In sub-Saharan Africa, there is a need to understand this widespread phenomenon in order to help reduce the high prevalence and low decreasing level of stunting observed, in comparison to other parts of the world. In this perspective, we used pooled data from the demographic and health surveys conducted in twenty sub-Saharan countries. On the basis of 134,814 children under the age of five years with a valid anthropometric index constituted, the prevalence of child stunting obtained is 33.4%, with 35.4% (CI=[34.7%; 36.1%]) for boys and 31.3% (CI=[30.6%; 32.0%]) for girls; the largest gender gaps are found in the Great Lakes countries (Rwanda (8.1 points) and Burundi (8.9 points)). It appears that the gender gap in stunting in sub-Saharan Africa is more related to the size of the child at birth, the number of siblings, the birth assistance and wasting. Intensified action on these modifiable factors could help to reduce the observed gender differences and ultimately improve the overall nutritional status of children.
AbstractManagement of undernourished children depends only on wasting yet it can coexist with underweight and/or stunting. Among children admitted to hospital with acute illness, we determined the proportion with wasting coexisting with underweight and/or stunting and their risk factors. A retrospective review of hospital records of children 6‒59 months old admitted at Garissa County referral hospital, Kenya, from January 2017 to December 2019 was conducted. Using World Health Organization 2006 growth standards, undernutrition were defined: wasting as Weight‐for‐height Z‐score < −2, stunting Height‐for‐age Z‐score < −2 and underweight Weight‐for‐age Z‐score < −2. We studied wasting coexisting with underweight and/or stunting. Among 624 children recruited, 347 (56%) were males and 511 (82%) <24 months old. Diarrhoea 210 (34%) and pallor/anaemia 310 (50%) were the most frequent admission diagnosis. HIV infection was present among 8 (1.3%) children. Wasting, underweight and stunting were present among 595 (95%), 518 (83%) and 176 (28%) children respectively. 161 (26%), 506 (81%) and 161 (26%) children had wasting coexisting with stunting, underweight and both stunting and underweight respectively. In the multivariable regression, diarrhoea was positively associated with wasting coexisting with stunting (adjusted risk ratio [aRR = 2.96] [95% CI = 2.06‒4.23]) and anaemia with wasting coexisting with underweight (aRR = 1.23) (95% CI = 1.03‒1.47). Overall, 343 (55%) children were discharged alive, 67 (11%) absconded from the wards, 164 (26%) were transferred to another hospital and 50 (8.0%) died before discharge. The risk of inpatient death was 10.3%, 7.9%, 8.4% and 6.8% among children not wasted, wasted only, wasted & underweight, and wasted and underweight and stunted respectively (Chi‐square p = 0.60). The study reports an unacceptably high levels of undernourishment, including coexisting forms of undernutrition among hospitalised children. This highlights a public health priority for current nutrition therapeutic care and need of continuity of care among those children discharged alive in the community‐based management of acute malnutrition programmes.
Mutuvi Wambua, Symon M. Kariuki, Hassan Abdullahi et al.
