BACKGROUND: Although very low birthweight infants (VLBWI, birthweight < 1500 g) are at increased risk of infectious diseases, they frequently receive primary vaccinations with the hexavalent vaccine (DTaP-IPV-Hib-HepB) later than recommended. Detailed data on the adherence to the hexavalent 3 + 1 immunisation schedule (at 2, 3, 4 and 11 months of age) in German VLBWI are scarce. OBJECTIVE: This study evaluated the timeliness of the primary hexavalent vaccination series among VLBWI from the German Neonatal Network (GNN) and aimed at identifying risk factors and outcomes associated with delayed series completion. STUDY DESIGN AND METHODS: As part of the multicentre, population-based GNN, N = 3,394 VLBWI born between 2009 and 2016 underwent a follow-up examination at 6 years of age, including documentation of vaccination certificates. Uni- and multivariate analyses were performed to evaluate the timely completion of the 3 + 1 schedule for hexavalent immunisation and to examine risk factors and outcomes associated with delays. RESULTS: Despite a high overall hexavalent vaccination coverage of more than 97% by six years of age, only 3.3% (n = 108) of VLBWI received the hexavalent booster at the recommended age of 11 months, and 41.6% (n = 1,373) had completed the primary vaccination series by 15 months of age. Progressive delays were observed across subsequent doses, with the lowest schedule-adherent coverage recorded for the booster dose. A timely first hexavalent vaccination (OR 0.61; 95% CI 0.52–0.72) was protective against delayed series completion, while bronchopulmonary dysplasia (BPD) was associated with a delay of the booster beyond 15 months of age (OR 1.31; 95% CI 1.07–1.61). Timely series completion was associated with decreased risk of incomplete vaccine protection at daycare entry (OR 0.09; 95% CI 0.07–0.14) and a lower rate of parent-reported pertussis within the first 6 years of life (OR 0.47; 95% CI 0.24–0.90). CONCLUSION: Our data demonstrate significant delays in the primary vaccination series which were most pronounced at the booster dose and particularly affects the most susceptible infants, i.e., VLBWI with BPD. However, vulnerable preterm infants would benefit greatly from timely vaccinations to ensure optimal protection by the time they are increasingly exposed to infectious pathogens, as for instance upon entry into childcare settings.
Background Cervical cancer remains a major cause of morbidity and mortality among women in Uganda. Although the Human Papillomavirus (HPV) vaccine is highly effective in preventing cervical cancer, completion of the recommended two-dose schedule remains low, particularly in rural settings. Rukiga District was selected for this study due to persistently low HPV second-dose (HPV2) completion rates compared with national targets. This study assessed health facility-level barriers influencing HPV vaccine completion among adolescent girls aged 9-14 years in rural Uganda. Methods A mixed-methods cross-sectional study was conducted between June and September 2022 in selected Health Centre II (HC II), Health Centre III (HC III), and Health Centre IV (HC IV) facilities in Rukiga District. A household survey involving 292 caregivers of eligible adolescent girls was conducted using systematic random sampling. The primary outcome was completion of the two-dose HPV vaccination schedule (HPV2). Quantitative data were analysed using logistic regression to identify factors associated with vaccine completion. In addition, 21 key informant interviews involving 11 healthcare workers and 10 Village Health Team (VHT) members were conducted and analysed thematically to explore contextual barriers affecting HPV vaccine uptake and completion. Results The HPV vaccine completion rate was 23.49%, indicating low coverage. In multivariable analysis, vaccine stock-outs and cold-chain challenges (adjusted odds ratio [AOR] = 1.75, 95% confidence interval [CI]: 1.04-2.93; p = 0.004) and understaffing of healthcare workers (AOR = 1.97, 95% CI: 1.05-3.68; p = 0.006) were the only statistically significant predictors of HPV vaccine completion. Although limited healthcare worker knowledge (AOR = 0.94, 95% CI: 0.70-1.24) and absence of government programmes targeting out-of-school girls (AOR = 0.97, 95% CI: 0.73-1.29) were not statistically significant in the adjusted model, qualitative findings highlighted them as important contextual barriers. Additional challenges identified included weak outreach systems, transportation constraints, misconceptions about HPV vaccination, and limited community awareness. Conclusion HPV vaccine completion in rural Uganda remains low and is strongly influenced by health system constraints, particularly vaccine supply-chain disruptions and human resource shortages. Strengthening vaccine logistics, improving staffing levels, enhancing healthcare worker capacity, and expanding outreach strategies targeting underserved populations are essential for improving vaccine completion and achieving national immunisation targets.
Objectives To assess uptake of nirsevimab, a long-acting monoclonal antibody for respiratory syncytial virus (RSV) prevention, during the first season of Ireland's Pathfinder pilot universal newborn immunisation programme and to identify socio-demographic and perinatal predictors of uptake. Design Cross-sectional analysis of routinely collected programme data. Setting Ireland's Mid-West region, served by University Maternity Hospital Limerick, the sole maternity and neonatal hospital for the region. Participants Infants born 1 September 2024 to 28 February 2025. Outcome measure Uptake of nirsevimab before hospital discharge. Results Overall uptake was 89.4% (1600/1790) and did not vary by month (p=0.119); it was similar by sex (male 89.5%, female 89.2%; p=0.838). Preterm infants had higher uptake than term (96.9% vs 88.7%; p=0.001), and those admitted to the neonatal unit also had higher uptake (93.0% vs 88.4%; p=0.009). In adjusted analyses, maternal age (adjusted OR (aOR) 1.06 per year, 95% CI 1.03 to 1.09, p<0.001) and preterm birth (aOR 3.08 (95% CI 1.14 to 8.37), p=0.027) were associated with uptake. Uptake varied by maternal ethnicity: 91.5% in white Irish, 53.6% in Irish Traveller (aOR 0.13 (95% CI 0.08 to 0.23)), 79.7% in other white background (aOR 0.39 (95% CI 0.24 to 0.61)), 90.0% in black or black Irish, 98.3% in Asian or Asian Irish and 84.2% in other/mixed or prefer not to say. Although uptake among white Irish was high, they accounted for the largest absolute number of infants who did not receive nirsevimab, reflecting their predominance in the birth cohort. Conclusions During the first season of Ireland's Pathfinder RSV pilot programme in the Mid-West region, nearly 90% of newborns received nirsevimab before discharge. Uptake was consistently high across months, indicating effective implementation but lower among infants of Irish Traveller and other white background mothers, highlighting the need for targeted, culturally adaptable equity strategies within a high-uptake programme. These findings may inform national and international policies and offer practical lessons for universal RSV immunisation.
Objectives Rapid urbanization is reshaping the distribution of unvaccinated children worldwide, with zero-dose children increasingly concentrated in urban poor settings. We quantified the implications of urbanization and intra-urban wealth stratification for vaccination coverage through 2050. Methods We modeled DTP1 (first dose of diphtheria-tetanus-pertussis vaccine) coverage and zero-dose children for Nigeria, India, Pakistan, Ethiopia, Indonesia, Angola, and Afghanistan and derived global estimates under three projection scenarios: continued historical progress (extrapolating 2000-2019 pre-pandemic trends), static percentage (2023 coverage rates held constant), and static absolute (2023 vaccinated counts held constant). Urban populations were stratified into poor and non-poor strata, using Demographic and Health Surveys-derived coverage ratios. Results By 2050, annual DTP1 zero-dose children in urban poor settings worldwide are projected at 1.1 million under continued historical progress (90% prediction interval for overall coverage: 96.9-97.4%), 5.0 million under static percentage, and 5.7 million under static absolute. Continued historical progress would avert 256.9 million cumulative DTP1 zero-dose child-years over 2023-2050 compared with static absolute. Conclusion Maintaining current coverage rates is insufficient to prevent zero-dose numbers from rising in growing populations. Accelerating coverage gains-particularly, among urban poor communities-is necessary to meet Immunisation Agenda 2030 targets. These are illustrative scenarios; relative differences between scenarios are more robust than absolute estimates.
Background Malaria vaccines have been added to immunisation schedules in 25 sub-Saharan African countries, with the expectation that deaths in young children would be prevented. The introduction of the RTS,S/AS01E malaria vaccine (RTS,S) in Ghana, Kenya, and Malawi in 2019 was evaluated over 4 years to show the impact on mortality in young children and to monitor severe malaria admissions, vaccine uptake, and safety. Favourable evidence on safety and impact on severe malaria admissions during the first 2 years contributed to WHO's recommendations on malaria vaccines. Here, we report the primary analysis of the impact on mortality at 46 months. Methods Clusters of administrative units (districts in Ghana, subcounties in Kenya, and groups of immunisation clinics in Malawi), each with an estimated annual birth cohort of about 4000 children, were randomly assigned 1:1 to introduce the RTS,S malaria vaccine in 2019 (implementation areas), or to implement later (comparison areas). RTS,S was delivered in a four-dose schedule, at age 6, 7, 9, and 24 months in Ghana and Kenya, and at age 5, 6, 7, and 22 months in Malawi. Surveillance for post-neonatal mortality in children younger than 5 years was established throughout by a network of 26 000 local reporters who notified deaths in their community. The families were then visited at home by study staff to confirm details and complete a verbal autopsy. Surveillance for severe malaria and other conditions was strengthened in 18 sentinel hospitals serving part of the study area and maintained for 46 months. Uptake of RTS,S and other vaccines was monitored by the Expanded Programme on Immunisation in each country and independently through three household coverage surveys, at baseline, and at about 18 months and 30 months after introduction of RTS,S. The primary outcome of this impact evaluation was mortality due to any cause, except injury, in children eligible to receive three doses of RTS,S. Mortality rate ratios were estimated by comparing the ratio of deaths among vaccine-eligible age groups to deaths in non-eligible age groups between implementation and comparison areas. This evaluation is registered on ClinicalTrials.gov (NCT03806465) and is complete. Findings 158 clusters (66 in Ghana, 46 in Kenya, and 46 in Malawi) were selected and randomly assigned; 79 areas served as implementation areas and 79 as comparison areas. By the end of the 46-month evaluation period, 1 289 504 children had received the first dose of RTS,S, 1 158 850 had received the second dose, 1 068 039 had received a third dose, and 436 527 had received a fourth dose. Coverage assessed in 2022 was 82·8% (95% CI 80·7-84·9) for the first dose, 71·1% (68·8-73·5) for the third dose, and 39·9% (36·9-42·9) for the fourth dose. Excluding deaths due to injury, there were 5576 deaths in implementation areas versus 6152 in comparison areas in children eligible to have received the third dose of RTS,S, and 7534 versus 7044 deaths among non-eligible children. The mortality rate ratio was 0·87 (95% CI 0·77-0·97; p=0·016). Interpretation Introduction of the RTS,S malaria vaccine in routine immunisation programmes was associated with a significant reduction in mortality in young children, averting about one in eight deaths, in areas with moderate coverage of three doses of the vaccine and low uptake of the fourth dose. These results highlight the urgency to accelerate the deployment of malaria vaccines in areas of Africa where malaria continues to be a leading cause of child mortality. Funding WHO; Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and Unitaid. Translations For the French translation of the abstract see Supplementary Materials section.
Inlow- and middle-income countries (LMICs) like India, Human Resources for Health (HRH) constitute the backbone of a health system, providing critical services to ensure equitable, accessible, and high-quality healthcare for all. However, they are often overburdened, which hinders their performance and impact. The digital health interventions can appear as a boon to assist and enhance the performance of HRH, thereby delivering better healthcare services. To evaluate the impact and the effectiveness of digital health interventions on healthcare workforce capacity building in primary health care settings in India. A systematic review of published research was conducted as per the PRISMA guidelines. Online databases (PubMed and Google Scholar) were explored to identify studies written in English from January 2015 to March 2025 that discuss digital health interventions within Primary Healthcare settings or involve human resources in those settings in the Indian context. The review included all forms of messaging, voice calls, and interactive voice responses as interventions. A total of 22 studies were included (cRCTs: 6; RCTs: 5; interventional: 4; Quasi-experimental: 3; pre-post: 3; pseudo-RCT: 1). In terms of health conditions, the most studied area was Maternal and Child Health, addressed in 9 studies. The studies reported positive outcomes resulting from mobile health interventions. The digital health interventions were found to strengthen adherence to clinical protocols, improve maternal education, and enhance treatment outcomes, reinforcing their potential role in shaping future public health strategies.
Vaccines have saved an estimated 154 million lives in the past 50 years and support 15 of the 17 United Nations sustainable development goals. Vaccines are also an important tool in the control of new outbreaks of infectious diseases. The vaccine cold chain, however, is key in enabling and empowering implementation of vaccine policy and societal protection from all vaccine preventable diseases, and is especially relevant in low and middle income countries in sub-Saharan Africa. The vaccine cold chain is a complex, highly specialised, temperature controlled supply chain network that extends from the point of vaccine manufacture to dose administration, and has multiple points of vulnerability. Large quantities of vaccines are lost because of excess heat or accidental freezing, resulting in missed opportunities for vaccination. Disruption to the provision of routine vaccines during the covid-19 pandemic resulted in millions of children not being vaccinated. The vaccine cold chain needs strategic prioritisation for investment and innovation so that the next generation of vaccine cold chains for low and middle income countries can be designed towards providing reliable and sustainable vaccine security in an uncertain world of climate change, managing the advent of new vaccine technologies, and narrowing inequalities in global health for resource poor communities. This review focuses on the vaccine cold chain in African low and middle income countries, and how new and emerging advances in vaccine science and challenges will affect the readiness to control the burden of vaccine preventable disease on the continent.
Zero-dose children, defined as children who have not received any routine vaccination, are an important indicator of inequity in immunisation systems. Although Malawi reports high national vaccination coverage, little is known about the characteristics and spatial distribution of children who remain unvaccinated. We examined the determinants and geographic patterns of zero-dose status in Malawi. We analysed data from the 2015-16 Malawi Demographic and Health Survey, including 681 children aged 1 to 35 months. Zero-dose status was defined as receiving no routine childhood vaccine in this analysis. Descriptive analyses and mixed-effects logistic regression were used to identify factors associated with zero-dose status, while adjusting for clustering at the enumeration area level. A binomial geostatistical model was applied to map fine-scale spatial variation across the country. Overall, 8.1% of children (n = 55) were zero-dose. Younger children were more likely to be unvaccinated, with one third of zero-dose children aged 1 to 11 months. In adjusted analyses, children aged 12 to 23 months and those aged 24 months or older had significantly lower odds of being zero-dose compared with children aged 1 to 11 months. Home delivery strongly increased the likelihood of being zero-dose (AOR = 4.28; 95% CI: 1.31 to 14.01). More than one antenatal care visit was associated with substantially lower odds of zero-dose status (AOR = 0.06; 95% CI: 0.01 to 0.31). Spatial modelling identified high-prevalence hotspots in Karonga, Nkhatabay, Nkhotakota, Mangochi, and parts of Chikwawa. Zero-dose children in Malawi are concentrated among those with limited maternal health system contact and in specific geographic areas with persistent access barriers. Strengthening antenatal and delivery services, improving early postnatal follow-up, and deploying spatially targeted outreach can help address these inequities and accelerate progress toward national and global immunisation goals.
Background: Measles has re-emerged in recent years as a public health concern in the context of insufficient vaccination coverage. Some children experience significant delays in receiving, or refuse to take, the measles, mumps and rubella (MMR) vaccination, often due to concerns related to hen's egg allergy (HEA). Methods: In this study, we retrospectively assessed the safety of MMR vaccination (Priorix®, GlaxoSmithKline, Belgium) in patients with HEA hospitalised at our clinic. Detailed medical histories were collected, along with skin prick tests and measurements of specific IgE against milk and egg proteins or extracts. The study included 39 patients with a mean age of 19 months, of whom 15 had previously experienced an anaphylactic reaction after egg ingestion. Results: None of these patients experienced a systemic reaction to vaccination. One patient developed a generalised maculopapular rash, which resolved after a single dose of an antihistamine. Vaccination was postponed in 63% of patients, with the longest delay extending to 113 months. Conclusions: Severe adverse reactions following MMR vaccination in patients with HEA are generally rare and are outweighed by the risks associated with natural infection and its complications. Effective communication of vaccine safety data and strengthening public trust in healthcare professionals are crucial.
Background In Ethiopia, chronic hepatitis B virus (HBV) prevalence is high (∼6%) and infant vaccination targets are unmet. We assessed HBV vaccination uptake and associations with parental sociodemographic and obstetric factors among children (aged 12-36 months) in Ethiopia. Methods We utilised the 2016 Ethiopian Demographic and Health Survey. We included a weighted sample of 3,855 children (aged 12-36 month) to assess HBV vaccination coverage level (none, incomplete, and complete) and its spatial distribution. Additionally, we identified associated factors of HBV vaccination coverage level using ordinal logistic regression. Results Overall, 51.2% of children received complete HBV vaccination, with wide regional variation. Older maternal age (adjusted odds ratio (AOR)=1.05, 95% confidence interval (CI): 1.02-1.07), better maternal education level (mean AOR=1.66-2.08), higher household wealth quantile (mean AOR=1.51-2.32), distance to a healthcare facility not a big problem (AOR=1.54, 95% CI: 1.25-1.89), and complete maternal continuum care utilisation (AOR=2.59, 95% CI: 1.25-5.30) were positively associated with HBV vaccination coverage, while higher number of children in the household (AOR=0.86, 95% CI: 0.79-0.92) was negatively associated. Conclusions HBV vaccination coverage falls below World Health Organization (WHO) targets in Ethiopia and has substantial regional variation. Targeted vaccination campaigns for mothers in lower socioeconomic groups and larger families may improve vaccination coverage.
