Vaccine Trends in Pakistan: A Review of Immunization Challenges and Setbacks Prompted by Inadequate Disaster Management.

Pakistan bears an incredible burden of vaccine-preventable diseases, and efforts to improve widespread immunization have been hindered by inadequate public health management following disasters and other health emergencies. Through a brief review of Pakistan's health system, an understanding of routine immunization challenges is sought based on the organizational changes made to the planning and delivery of immunization activities. Further, recent immunization trends of measles, polio, and tuberculosis are examined in correspondence to health emergencies prompted by climate change and the COVID-19 pandemic. The national public health response to each disease is discussed, and insight is given to how the devolution of Pakistan's health system may have influenced the severity of each emergency. Focus is given to the potential immunization challenges and how they may impact future initiatives for the control of vaccine-preventable diseases. Although incidence rates suggest increased cases of certain vaccine-preventable diseases and disruptions of immunization activities following recent disasters, further studies may need to be conducted to establish a stronger understanding of the immunization trends noted within this review.

Impact of COVID-19 Pandemic on Routine Childhood Immunization Programs in Indonesia: Taking Rural and Urban Area into Account.

Background: To date, the primary global concern has revolved around addressing the COVID-19 pandemic. However, there is a growing awareness of the pandemic's secondary impacts on critical aspects of healthcare, such as childhood immunization programs. Objective: This study aims to assess the impact of the COVID-19 pandemic on childhood immunization programs in Indonesia, with a specific focus on performance disparities between rural and urban areas. It considers factors like access, utilization, and program workload. Methods: Data were collected from primary health cares (PHCs) in two regions in West Java Province, Indonesia, representing rural and urban areas. A descriptive analysis was conducted to compare vaccination coverage, drop-out rates, and the ratio of vaccinators per dose from 2019 to 2021 in 40 and 22 PHCs for rural and urban areas, respectively. A general linear model was employed to evaluate the differences in these parameters over the three consecutive years. Results: The results indicate fluctuations in vaccine coverage over the three years, with the most significant impact observed in 2020, particularly in rural areas. Statistical analysis revealed a significant difference in routine immunization coverage, drop-out rates, and vaccinator ratios between rural and urban areas from 2019 to 2021 (p<0.05). In 2021, both rural and urban areas displayed significant differences in performance parameters for routine immunization and COVID-19 vaccination (p<0.05), except in terms of coverage for IPV and COVID-19 vaccination. Conclusion: The study highlights a reduction in routine immunization coverage during the pandemic, a concerning issue that increases the risk of vaccine-preventable diseases, particularly in rural areas.

Analyzing Subnational Immunization Coverage to Catch up and Reach the Unreached in Seven High-Priority Countries in the Eastern Mediterranean Region, 2019-2021.

Yearly national immunization coverage reporting does not measure performance at the subnational level throughout the year and conceals inequalities within countries. We analyzed subnational immunization coverage from seven high-priority countries in our region. We analyzed subnational, monthly immunization data from seven high-priority countries. Five were Gavi eligible (i.e., Afghanistan, Pakistan, Somalia, Syria, and Yemen); these are countries that according to their low income are eligible for support from the Global Alliance on Vaccine and Immunization, while Iraq and Jordan were included because of a recent decrease in immunization coverage and contribution to the regional number of under and unimmunized children. DTP3 coverage, which is considered as the main indicator for the routine immunization coverage as the essential component of the immunization program performance, varied monthly in 2019-2021 before reaching pre-pandemic coverage in the last two months of 2021. Somalia and Yemen had a net gain in DTP3 coverage at the end of 2021, as improvement in 2021 exceeded the regression in 2020. In Pakistan and Iraq, DTP3 improvement in 2021 equaled the 2020 regression. In Afghanistan, Syria and Jordan, the regression in DTP3 coverage continued in 2020 and 2021. The number of districts with at least 6000 zero-dose children improved moderately in Afghanistan and substantially in Somalia throughout the follow-up period. In Pakistan, the geographical distribution differed between 2020 and 2021.Of the three countries with the highest number of zero-dose children, DTP1 coverage reached 109% in Q4 of 2020 after a sharp drop to 69% in Q2 of 2020. However, in Pakistan, the number of zero-dose children decreased to 1/10 of its burden in Q4 of 2021. In Afghanistan, the number of zero-dose children more than a doubled. Among the even countries, adaptation of immunization service to the pandemic varied, depending on the agility of the health system and the performance of the components of the expanded program on immunization. We recommended monitoring administrative monthly immunization coverage data at the subnational level to detect low-performing districts, plan catchup, identify bottlenecks towards reaching unvaccinated children and customize strategies to improve the coverage in districts with zero-dose children throughout the year and monitor progress.

Factors associated with full childhood vaccination coverage among young mothers in Northern Nigeria.

Introduction: wide regional variation in immunization coverage still persists in Nigeria. Full Immunization Coverage (FIC) for more than 80% of all states in the northern region is lower than 40% relative to their southern counterpart. Studies focusing on young women in the north remain sparse, despite the high prevalence of early marriage and poor health-seeking behavior. This study examines FIC among young women in northern Nigeria. Methods: we performed a secondary analysis of the 2013 and 2018 Nigeria Demographic and Health Survey on 1,198 women of children aged 12-23 months in 2013 and 405 in the 2018 dataset. Analysis was limited to young women 15-24 years, residing in Northern Nigeria. We used logistics regression to predict factors associated with FIC. Results: the proportion of fully immunized children was low, at 11% in 2013 and 18% in 2018. The coverage for most vaccines was low, except for the oral polio vaccine. The children of mothers who had health card [(aOR=18.1,95% C.I (8.1-40.7)], in 2013 and 2018 [(aOR=12.7, 95% C.I (5.9-27.1)], attended ANC [(aOR=8.6, 95% C.I (2.4-30.9)] in 2013 and had facility delivery [(aOR=2.0, 95% C.I (1.0-4.1)] in 2018 were more likely to be fully immunized. Conclusion: the study found FIC among children of young women in Northern Nigeria was abysmally low. Ownership of health care, antenatal attendance, and facility delivery significantly predicted the odds of FIC. These findings suggest the need for approaches that remove barriers to good health-seeking behavior, especially among young mothers in Northern Nigeria.

Determinants of immunization in polio super high-risk union councils of Pakistan.

BACKGROUND: The current polio epidemiology in Pakistan poses a unique challenge for global eradication as the country is affected by ongoing endemic poliovirus transmission. Across the country, 40 union councils (UCs) which serve as core reservoirs for poliovirus with continuous incidences of polio cases are categorized as super-high-risk union councils (SHRUCs). METHODOLOGY: A cross-sectional survey was conducted in 39 SHRUCs using a two-stage stratified cluster sampling technique. 6,976 children aged 12-23 months were covered. A structured questionnaire was used for data collection. Data were analyzed using STATA version 17. RESULTS: Based on both vaccination records and recall, 48.3% of children were fully-, 35.4 % were partially-, and 16.3% were non-vaccinated in the SHRUC districts. A child is considered fully vaccinated when h/she completed vaccination for BCG, OPV0, OPV 1-3, Penta 1-3, PCV 1-3, IPV, and MCV1. Vaccination cards were seen for over half of the children in the SHRUC districts of Khyber Pakhtunkhwa (KP) and the majority of the SHRUC districts in Sindh, except for the SHRUC district of Malir the districts of Balochistan. Results for polio vacancies show that 60.9% of children from the SHRUC districts were vaccinated with at least three doses of OPV and one dose of IPV, while 20.4% were vaccinated with any OPV doses or IPV and 18.7% of children did not receive any polio vaccines. The dropout rate between vaccine visits was higher than the WHO-recommended cutoff point of 10% for all vaccine doses in the SHRUC districts. The likelihood of being fully vaccinated was higher among the children of educated parents. Full vaccination was found significant among the children of any SHRUC districts compared to district Killa Abdullah. CONCLUSION: Context-specific strategies with more focus on community engagement and targeted mobilization, along with robust monitoring mechanisms, would help address the underlying challenges of under-immunization in the SHRUCs.

Innovative approach in assessing the children's immunization status when it cannot be documented.

During surveys, it is recommended that children immunization status should be based on immunization documents. It has been noted that in some communities, a number of children are claimed to be vaccinated but have no evidence of vaccination. This work is proposed to estimate routine immunization coverage in children based on both documented vaccination and the tracking of undocumented immunization. It was a community-based survey targeting children aged 0-59 months in which the immunization status of children was assessed based on vaccination documents and based on a questionnaire tracking immunization sites and period for children with undocumented vaccination. The vaccination coverage and completeness were estimated from data collected in immunization cards and re-estimated after tracking the immunization status of children with no immunization cards. Of 1435 children reached in households, 1430 (99.7%) were included. Of 1072 children aged 12-59 months, 194 (18.1%) received DPT-Hi+Hb 3 with evidence and 399 (37.2%) with evidence and tracking. In the same age group, the dropout rate from DPT-Hi+Hb 1 (157 doses administered) to DPT-Hi+Hb 3 (127 doses administered) with evidence was 19.1% and 42.4% with evidence and tracking. The tracking of immunization status in children with no evidence of vaccination allows to determine their immunization status and to improve the reliability of the estimated vaccination coverage. This strategy could be adopted to be part of the planning and implementation of vaccination coverage surveys of EPI vaccines.

Prevalence and factors associated with immunization coverage among children under five years in Mohamed Mooge health center, Hargeisa, Somaliland: a cross-sectional study.

BACKGROUND: Routine immunization contributes greatly to reduction in mortality from vaccine preventable diseases among children. The Somaliland Demographic and Health survey, 2020 revealed that only 13.7% of children in Marodijeh (Hargeisa) region had received all recommended vaccines, which is far below the World Health Organization (WHO) target of 80%. We therefore, assessed factors associated with immunization coverage among children under five years at Mohamed Mooge Health Center in Hargeisa, Somaliland. METHODS: Institutional based cross-sectional study was conducted on 174 systematically sampled, consented mothers that visited Mohamed Mooge Health Center for antenatal care during December 2022 to May 2023. Data was collected using a structured questionnaire. Data was analysed using SPSS and the relationship between dependent and independent variables was checked chi-square test at p ≤ 0.05. Finally, candidate variables were tested by using multivariate logistic regression in order to control potential confounders and the result was presented using AOR and 95% confidence interval. Model fitness was checked using Hosmer-Lemeshaw goodness of fit test with P > 0.05 for fitness. Multicollinearity between variables was checked using correlation coefficients at 0.80 or higher.  RESULT: Among 174 study participants, the prevalence of overall vaccine completion in this study was 55.3%. Women who had being aware about childhood immunization on BCG vaccination (AOR = 3.887; 95% CI: 1.275, 6.844), pentavalent (AOR = 11.385; 95% CI: 5.424-14.464), and measles (AOR = 3.074; 95% CI: 1.822-6.130) had higher odds of having immunized their children. Mothers who had employment had higher odds of having their children immunized against measles (AOR = 4.069; 95% CI: 1.822-6.130) compared to those who had not. CONCLUSIONS: Full immunization coverage was lower than the target set by the World Health Organization in this study area. The current study revealed that, the mother's awareness of childhood vaccinations on BCG, pentavalent, measles and employment status of mothers were positively associated with immunization coverage. To promote vaccination coverage, the government should implement a national awareness campaign on childhood immunization and increase the number of outreach services.

Knowledge, attitudes, and practices of caregivers on childhood immunization in Okaikoi sub-metro of Accra, Ghana.

Background: Immunization remains one of the most cost-effective health interventions. However, there are still issues of vaccine hesitancy especially in caregivers who are required to protect their children from vaccine-preventable diseases. This thwarts the overall vaccine coverage in disease-endemic areas such as sub-Saharan Africa. Therefore, to determine the factors that promote vaccine hesitancy in caregivers, this study sought to assess the knowledge, attitude, and practices of caregivers on childhood immunization in Okaikoi, a sub-metro of Accra in Ghana. Methods: A cross-sectional study on childhood immunization was conducted to determine the knowledge, attitudes, and practices of caregivers. A total of 120 caregivers with infants aged 12 months to 23 months were interviewed with a structured questionnaire containing open-ended and closed-ended queries. Results: From the community, infants whose caregivers had adhered completely to immunization constituted 53.3% while the rest were partially immunized. The two main deterrents to complete immunization were time constraints (25.8%) and forgetfulness (17.5%). It was observed that vaccination uptake and maternal level of education, as well as vaccination adverse reaction, did not impact the completion of the EPI program by these caregivers. Unfortunately, it was noted that caregivers with higher education levels were unable to complete their vaccination schedules due to their busy work schedules. Nonetheless, the main deterrent to adhering to complete childhood immunization was poor maternal knowledge (58%). Conclusion: The study revealed that, the caregivers in the community had poor knowledge on vaccination and its benefits, and therefore, with no strict adherence to vaccination schedules. This promoted the incomplete immunization of children in the community by their caregivers. Also, since the main source of information with regard to immunization in the sub-metro was through the antenatal and postnatal child welfare clinics and the media, we recommend that the health workers collaborate with media personnel to ensure that standardized information is disseminated.

Tetanus, Diphtheria, and Acellular Pertussis Vaccination Coverage Among Publicly Insured Pregnant Women, U.S., 2016-2019.

Introduction: Vaccination with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine during pregnancy is highly effective against Bordetella pertussis in young infants. We aimed to evaluate the uptake of maternal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination during the recommended gestation period of 27 through 36 weeks among women enrolled in a public medical insurance plan in the U.S. Methods: In this analysis using Centers for Medicare and Medicaid Services insurance claims data, we identified women aged 15 through 49 years who delivered a live-born infant from 2016 through 2019. We identified claims for tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination to calculate the proportion of women who were vaccinated during Weeks 27 through 36 of gestation in each calendar year. We also assessed the average annual maternal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis coverage by age group, race and ethnicity, U.S. Census region of residence, and plan type. Data were analyzed in 2021. Results: Among 4,318,823 deliveries, the 4-year national average for tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination was 26%, improving from 22% in 2016 to 31% in 2019 (p<0.001). Within subgroups, the lowest 4-year average coverage was among women aged 15 through 18 years (22%); Black, non-Hispanic (23%) and Hispanic women (24%); those residing in the South (18%); those enrolled in a Children's Health Insurance Program plan (22%); and those covered by a fee-for-service plan (19%). Coverage increased across all subgroups from 2016 through 2019. Conclusions: Although maternal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis coverage among publicly insured women in the U.S. increased from 2016 through 2019, it remained considerably lower than estimated national coverage, with notable differences by race and ethnicity.

Immunization coverage, knowledge, satisfaction, and associated factors of non-National Immunization Program vaccines among migrant and left-behind families in China: evidence from Zhejiang and Henan provinces.

BACKGROUND: Migrant and left-behind families are vulnerable in health services utilization, but little is known about their disparities in immunization of non-National Immunization Program (NIP) vaccines. This study aims to evaluate the immunization coverage, knowledge, satisfaction, and associated factors of non-NIP vaccines among local and migrant families in the urban areas and non-left-behind and left-behind families in the rural areas of China. METHODS: A cross-sectional survey was conducted in urban areas of Zhejiang and rural areas of Henan in China. A total of 1648 caregivers of children aged 1-6 years were interviewed face-to-face by a pre-designed online questionnaire, and their families were grouped into four types: local urban, migrant, non-left-behind, and left-behind. Non-NIP vaccines included Hemophilus influenza b (Hib) vaccine, varicella vaccine, rotavirus vaccine, enterovirus 71 vaccine (EV71) and 13-valent pneumonia vaccine (PCV13). Log-binomial regression models were used to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs) for the difference on immunization coverage of children, and knowledge and satisfaction of caregivers among families. The network models were conducted to explore the interplay of immunization coverage, knowledge, and satisfaction. Logistic regression models with odds ratios (ORs) and 95% CIs were used to estimate the associated factors of non-NIP vaccination. RESULTS: The immunization coverage of all non-NIP vaccines and knowledge of all items of local urban families was the highest, followed by migrant, non-left-behind and left-behind families. Compared with local urban children, the PRs (95% CIs) for getting all vaccinated were 0.65 (0.52-0.81), 0.29 (0.22-0.37) and 0.14 (0.09-0.21) among migrant children, non-left-behind children and left-behind children, respectively. The coverage-knowledge-satisfaction network model showed the core node was the satisfaction of vaccination schedule. Non-NIP vaccination was associated with characteristics of both children and caregivers, including age of children (> 2 years-OR: 1.69, 95% CI: 1.07-2.68 for local urban children; 2.67, 1.39-5.13 for migrant children; 3.09, 1.23-7.76 for non-left-behind children); and below caregivers' characteristics: family role (parents: 0.37, 0.14-0.99 for non-left-behind children), age (≤ 35 years: 7.27, 1.39-37.94 for non-left-behind children), sex (female: 0.49, 0.30-0.81 for local urban children; 0.31, 0.15-0.62 for non-left-behind children), physical health (more than average: 1.58, 1.07-2.35 for local urban children) and non-NIP vaccines knowledge (good: 0.45, 0.30-0.68 for local urban children; 7.54, 2.64-21.50 for left-behind children). CONCLUSIONS: There were immunization disparities in non-NIP vaccines among migrant and left-behind families compared with their local counterparts. Non-NIP vaccination promotion strategies, including education on caregivers, and optimization of the immunization information system, should be delivered particularly among left-behind and migrant families.

Drivers of early childhood vaccination success in Nepal, Senegal, and Zambia: a multiple case study analysis using the Consolidated Framework for Implementation Research.

INTRODUCTION: The fundamental components of a vaccine delivery system are well-documented, but robust evidence is needed on how the related processes and implementation strategies - including the facilitators and barriers - contribute to improvements in childhood vaccination coverage. The purpose of this study was to identify critical facilitators and barriers to the implementation of common interventions across three countries that have dramatically increased coverage of early childhood vaccination over the past 20 years, and to qualify common or divergent themes in their success. METHODS: We conducted 278 key informant interviews and focus group discussions with public health leaders at the regional, district, and local levels and community members in Nepal, Senegal, and Zambia to identify intervention activities and the facilitators and barriers to implementation. We used thematic analysis grounded in the Consolidated Framework for Implementation Research (CFIR) constructs of inner and outer settings to identify immunization program key facilitators and barriers. RESULTS: We found that the common facilitators to program implementation across the countries were the CFIR inner setting constructs of (1) networks and communications, (2) goals and feedback, (3) relative priority, and (4) readiness for implementation and outer setting constructs of (5) cosmopolitanism and (6) external policies and mandates. The common barriers were incentives and rewards, available resources, access to knowledge and information, and patients' needs and resources. Critical to the success of these national immunization programs were prioritization and codification of health as a human right, clear chain of command and shared ownership of immunization, communication of program goals and feedback, offering of incentives at multiple levels, training of staff central to vaccination education, the provision of resources to support the program, key partnerships and guidance on implementation and adoption of vaccination policies. CONCLUSION: Adequate organizational commitment, resources, communication, training, and partnerships were the most critical facilitators for these countries to improve childhood vaccination.

Philippine immunization coverage and dengvaxia: An infodemiological study.

BACKGROUND: A dengue vaccine, dengvaxia, was licensed for the first time in 2015. It was approved for use in 11 countries where dengue infection is endemic, including the Philippines. In November 2017, controversy arose in the Philippines regarding the dengvaxia vaccine. We hypothesized that the dengvaxia controversy might be correlated with immunization coverage in the Philippines. METHODS: We performed an analytical and infodemiological study on web-based interest in dengvaxia, both globally and in 18 dengue endemic countries, from 2015 to 2020 using Google Trends™. Comparisons were made with search trends for the components of the National Immunization Program (NIP) and vaccine coverage by computing the Pearson product-moment correlation coefficient (r) between each variable. RESULTS: Among the 18 countries included, the Philippines had the highest search volume index for dengvaxia, with peaks in searches coinciding with that of worldwide search trends. There was no correlation between the relative search volume for dengvaxia with that of vaccines included in the NIP in the Philippines from 2015 to 2020. There was no significant correlation between web-based interest in dengvaxia and the estimated immunization coverage from 2015 to 2019. CONCLUSION: There was no significant correlation between web-based interest in dengvaxia, the vaccines in the NIP, and national immunization coverage.

Digitalized to reach and track: a retrospective comparison between traditional and conditional estimate of vaccination coverage and dropout rates using e-Tracker data below one-year children in Bangladesh during-COVID and pre-COVID period.

Background: With an impressive track record in expanding childhood immunization and an inclination to adopt digitalization in healthcare service delivery, Expanded Program on Immunization (EPI) Bangladesh piloted the e-Tracker intervention in Moulvibazar district and Dhaka South City Corporation (Zone-5) from 2019 till the end of 2021. Methods: We retrieved and analyzed the digitalized e-Tracker data of 114,194 infants born between January 1, 2019 and December 31, 2020, with help from Health Management Information System (HMIS) and UNICEF Bangladesh. Childhood vaccination coverage and dropout rates were determined using a 'Traditional approach' traditionally used by WHO and a 'Conditional technique' with a modified denominator. Using a multiple logistic regression model, we examined the effects of COVID-19, birth-cohorts, mother education, and location on vaccination rates (coverages & dropouts) to aid with informed decision-making by the policymakers. Findings: The conditional estimation method yielded a lower full vaccination coverage during pre-COVID period than the national and global reported coverage derived using the 'traditional method' (73.4% vs. 89.0% & 81.0%). As expected, while the coverage has decreased, the dropout rate increased "during-COVID" compared to the "pre-COVID" period. However, dropouts were estimated lower in the 'conditional method.' The average age (in months) for getting BCG was higher in Moulvibazar (∼2.5 months) than that in Dhaka (∼1.4 months). All birth-cohorts from 'the during-COVID period had about 30% lower odds of getting fully vaccinated than those from the 'pre-COVID' period. Interpretations: Age-cohort-specific analysis showed a decline in coverage rates before and during COVID, but e-Tracker didn't have enough data to draw additional conclusions. The server only stored the child's gender, the caregiver's monthly salary, and the mother's education. It didn't track any other factors related to dropout rates. The e-Tracker is an excellent tool for measuring real coverage and should be scaled nationwide. Funding: UNICEF, Bangladesh.

Gaps in childhood immunizations and preventive care visits during the COVID-19 pandemic: a population-based cohort study of children in Ontario and Manitoba, Canada, 2016-2021.

OBJECTIVE: We aimed to estimate the changes to the delivery of routine immunizations and well-child visits through the pandemic. METHODS: Using linked administrative health data in Ontario and Manitoba, Canada (1 September 2016 to 30 September 2021), infants <12 months old (N=291,917 Ontario, N=33,994 Manitoba) and children between 12 and 24 months old (N=293,523 Ontario, N=33,001 Manitoba) exposed and unexposed to the COVID-19 pandemic were compared on rates of receipt of recommended a) vaccinations and b) well-child visits after adjusting for sociodemographic measures. In Ontario, vaccinations were captured using physician billings database, and in Manitoba they were captured in a centralized vaccination registry. RESULTS: Exposed Ontario infants were slightly more likely to receive all vaccinations according to billing data (62.5% exposed vs. 61.6% unexposed; adjusted Relative Rate (aRR) 1.01 [95% confidence interval (CI) 1.00-1.02]) whereas exposed Manitoba infants were less likely to receive all vaccines (73.5% exposed vs. 79.2% unexposed; aRR 0.93 [95% CI 0.92-0.94]). Among children exposed to the pandemic, total vaccination receipt was modestly decreased compared to unexposed (Ontario aRR 0.98 [95% CI 0.97-0.99]; Manitoba aRR 0.93 [95% CI 0.91-0.94]). Pandemic-exposed infants were less likely to complete all recommended well-child visits in Ontario (33.0% exposed, 48.8% unexposed; aRR 0.67 [95% CI 0.68-0.69]) and Manitoba (55.0% exposed, 70.7% unexposed; aRR 0.78 [95% CI 0.77-0.79]). A similar relationship was observed for rates of completed well-child visits among children in Ontario (aRR 0.78 [95% CI 0.77-0.79]) and Manitoba (aRR 0.79 [95% CI 0.77-0.80]). CONCLUSION: Through the first 18 months of the pandemic, routine vaccines were delivered to children < 2 years old at close to pre-pandemic rates. There was a high proportion of incomplete well-child visits, indicating that developmental surveillance catch-up is crucial.

RéSUMé: OBJECTIF: Nous avons voulu estimer les changements dans l'administration des vaccins de routine et dans les consultations pédiatriques pendant la pandémie. MéTHODE: À l'aide des données administratives sur la santé couplées de l'Ontario et du Manitoba, au Canada (1er septembre 2016 au 30 septembre 2021), nous avons comparé les taux de réception : a) des vaccins recommandés et b) des consultations pédiatriques recommandées pour les nourrissons de < 12 mois (N = 291 917 en Ontario, N = 33 994 au Manitoba) et pour les enfants de 12 à 24 mois (N = 293 523 en Ontario, N = 33 001 au Manitoba) exposés et non exposés à la pandémie de COVID-19, après ajustement en fonction de mesures sociodémographiques. En Ontario, les vaccins ont été saisis à l'aide de la base de données des factures des médecins; au Manitoba, ils ont été saisis dans un registre de vaccination centralisé. RéSULTATS: Les nourrissons exposés en Ontario étaient légèrement plus susceptibles de recevoir tous les vaccins selon les données de facturation (62,5 % pour les nourrissons exposés c. 61,6 % pour les nourrissons non exposés; risque relatif ajusté [RRa] 1,01 [intervalle de confiance (IC) de 95 % 1,00-1,02]), tandis que les nourrissons exposés au Manitoba étaient moins susceptibles de recevoir tous les vaccins (73,5 % pour les nourrissons exposés c. 79,2 % pour les nourrissons non exposés; RRa 0,93 [IC de 95 % 0,92-0,94]). Chez les enfants exposés à la pandémie, le total des vaccins reçus était un peu plus faible que chez les enfants non exposés (RRa en Ontario 0,98 [IC de 95 % 0,97-0,99]; RRa au Manitoba 0,93 [IC de 95 % 0,91-0,94]). Les nourrissons exposés à la pandémie étaient moins susceptibles d'avoir eu toutes les consultations pédiatriques recommandées en Ontario (33 % pour les nourrissons exposés, 48,8 % pour les nourrissons non exposés; RRa 0,67 [IC de 95 % 0,68-0,69]) comme au Manitoba (55 % pour les nourrissons exposés, 70,7 % pour les nourrissons non exposés; RRa 0,78 [IC de 95 % 0,77-0,79]). Une relation semblable a été observée pour les taux de consultations pédiatriques complètes chez les enfants en Ontario (RRa 0,78 [IC de 95 % 0,77-0,79]) et au Manitoba (RRa 0,79 [(IC de 95 % 0,77-0,80]). CONCLUSION: Au cours des 18 premiers mois de la pandémie, les vaccins de routine ont été administrés aux enfants de < 2 ans à des taux proches de ceux d'avant la pandémie. Il y a eu une forte proportion de consultations pédiatriques incomplètes, ce qui indique qu'il est essentiel de rattraper la surveillance du développement.

Childhood Immunization and Competing Mortality Risks in Kenya: A Longitudinal Analysis for Multiparous Mothers.

OBJECTIVE: To assess the relationship between childhood immunization and mortality risks for nonvaccine-preventable diseases (competing mortality risks, or CMR) in Kenya. STUDY DESIGN: A combination of the Global Burden of Disease and Demographic Health Survey data was used to measure basic vaccination status, CMR, and control variables for each child in the Demographic Health Survey data. A longitudinal analysis was performed. This uses within-mother variation between children to compare the vaccine decisions for different children, who are exposed to different mortality risks. The analysis also distinguishes between overall and disease-specific risks. RESULTS: The study included 15 881 children born between 2009 and 2013, who were at least 12 months old at the time of interview and not part of a twin birth. Mean basic vaccination rates ranged from 27.1% to 90.2% and mean CMR from 13.00 to 738.32 deaths per 100 000 across different counties. A one-unit increase in mortality risk from diarrhea, the most prevalent disease among children in Kenya, is associated with a 1.1 percentage point decline in basic vaccination status. In contrast, mortality risks for other diseases and HIV increase the likelihood of vaccination. The effect of CMR was found to be stronger for children with higher birth orders. CONCLUSIONS: A significant negative correlation between severe CMR and vaccination status was found, which has important implications for immunization policies, particularly in Kenya. Interventions aimed at reducing the most severe CMR, such as diarrhea, and targeted toward multiparous mothers may improve childhood immunization coverage.

From Authoring to Evaluating an Electronic Health Quality Measure - Applying Logic to FHIR® with CQL for Calculating Immunization Coverage.

BACKGROUND: Current monitoring and evaluation methods challenge the healthcare system. Specifically for the use case of immunization coverage calculation, person-level data retrieval is required instead of inaccurate aggregation methods. The Clinical Quality Language (CQL) by HL7®, has the potential to overcome current challenges by offering an automated generation of quality reports on top of an HL7® FHIR® repository. OBJECTIVES: This paper provides a method to author and evaluate an electronic health quality measure as demonstrated by a proof-of-concept on immunization coverage calculation. METHODS: Five artifact types were identified to transform unstructured input into CQL, to define the terminology, to create test data, and to evaluate the new quality measures. RESULTS: CQL logic and FHIR® test data were created and evaluated by using the different approaches of manual evaluation, unit testing in the HAPI FHIR project, as well as showcasing the functionality with a developed user interface for immunization coverage analysis. CONCLUSION: Simple, powerful, and transparent evaluations on a small population can be achieved with existing open-source tools, by applying CQL logic to FHIR®.

Using geographic information system to track children and optimize immunization coverage and equity in Karachi, Pakistan.

BACKGROUND: Despite the potential of geospatial technologies to track and monitor coverage, they are underutilized for guiding immunization program strategy and implementation, especially in low-and-middle-income countries. We conducted geospatial analysis to explore the geographic and temporal trends of immunization coverage, and examined the pattern of immunization service access (outreach and facility based) by children. METHODOLOGY: We extracted data to analyze coverage rates across different dimensions (by enrolment year, birth year and vaccination year) from 2018 till 2020 in Karachi, Pakistan using the Sindh Electronic Immunization Registry (SEIR). We conducted geospatial analysis to assess variation in coverage rates of BCG, Pentavalent (Penta)-1, Penta-3, and Measles-1 vaccines using Government targets. We also analyzed the proportion of children receiving their routine vaccinations at fixed centers and outreach and examined whether children received vaccinations at the same or multiple immunization centers. RESULTS: A total of 1,298,555 children were born, enrolled or vaccinated from 2018 till 2020. At the district level, analysis by enrollment and birth year showed coverage increased between 2018 and 2019 and declined in 2020, while analysis by vaccination year showed consistent increase in coverage. However, micro-geographic analysis revealed pockets where coverage persistently declined. Notably 27/168, 39/168 and 3/156 Union councils showed consistently declining coverage when analyzing by enrollment, birth and vaccination year respectively. More than half (52.2%, 678,280/1,298,555) of the children received all their vaccinations exclusively through fixed centers and, 71.7% (499,391/696,701) received all vaccinations from the same centers. CONCLUSION: Despite overall improving vaccination coverage between 2018 and 2020, certain geographic areas have consistently declining coverage rates, which is detrimental for equity. Making immunization inequities visible through geospatial analysis is the first step to ensure resources are allocated optimally. Our study provides impetus for immunization programs to develop and invest in geospatial technologies, harnessing its potential for improved coverage and equity.

Prevalence and predictors of vaccine hesitancy among mothers of under-five children: A hospital-based cross-sectional study.

BACKGROUND: The World Health Organization (WHO) states that vaccine hesitancy is one of the top 10 threats to global public health. Evidence shows that vaccine hesitancy studies in India are limited and targeted toward individual vaccines. The study aimed to fill this gap by exploring the relationship between demographics and SAGE factors toward vaccine hesitancy. MATERIALS AND METHODS: A hospital-based, cross-sectional, analytical study was conducted in a non-governmental organization (NGO) hospital with 330 beds, located in Bathalapalli, Andhra Pradesh, India. Mothers of under-five children who attended outpatient departments of pediatrics or obstetrics and gynecology were included. A total of 574 mothers were enrolled and vaccine hesitancy was determined by reviewing the mother-child protection card for the presence of delay or refusal of the recommended vaccine. A face-to-face interview was conducted to obtain demographics and WHO-SAGE variables from the participants. Binary logistic regression analysis was performed to associate independent variables (demographics and SAGE variables) with the dependent variable (vaccine hesitancy). RESULTS: Out of 574 respondents, 161 mother's children were noted as vaccine-hesitant (refusal = 7; delay = 154); and the prevalence of vaccine hesitancy was 28.05%. The delay was observed in all recommended vaccines, but the refusal or reluctance was seen in only four vaccines (hepatitis B birth dose = 1; IPV 1 and 2 = 2; Measles 1 and 2 = 3; and Rota 1, 2, and 3 = 1). The respondents' demographics like no or lower parent education (OR = 3.17; 95%CI = 1.50-6.72) and fewer antenatal visits (OR = 2.30; 95%CI = 1.45-3.36) showed higher odds, whereas the upper socioeconomic status showed lower odds (OR = 0.09; 95%CI = 0.02-0.36) toward vaccine hesitancy. The WHO-SAGE dimensions like awareness (OR = 0.14; 95%CI = 0.03-0.53), poor access (OR = 7.76; 95%CI = 3.65-16.51), and low acceptability of the individual (OR = 07.15; 95%CI = 1.87-27.29), community (OR = 6.21; 95%CI = 1.58-24.33) were significantly associated with vaccine hesitancy. CONCLUSION: The study concludes that the prevalence of vaccine hesitancy was high. Vaccine safety and children's health are primary concerns for parents' refusal/reluctance. To achieve 100% immunization coverage, policymakers need to reduce vaccine hesitancy by developing strategies based on demographic and WHO-SAGE working group predictors.

What Determines the District-Level Disparities in Immunization Coverage in India: Findings from Five Rounds of the National Family Health Survey.

India's Universal Immunization Programme has been performing at a sub-optimal level over the past decade, with there being a wide disparity in terms of immunization coverage between states. This study investigates the covariates that affect immunization rates and inequality in India at the individual and district levels. We used data from the five rounds of the National Family Health Survey (NFHS), conducted from 1992-1993 to 2019-2021. We used multilevel binary logistic regression analysis to examine the association between demographic, socio-economic and healthcare factors and a child's full immunization status. Further, we used the Fairlie decomposition technique to understand the relative contribution of explanatory variables to a child's full immunization status between districts with different immunization coverage levels. We found that 76% of children received full immunization in 2019-2021. Children from less wealthy families, urban backgrounds, Muslims, and those with illiterate mothers were found to have lower chances of receiving full immunization. There is no evidence that gender and caste disparities have an impact on immunization coverage in India. We found that having a child's health card is the most significant contributor to reducing the disparities that exist regarding children's full immunization between mid- and low-performing districts. Our study suggests that healthcare-related variables are more crucial than demographic and socio-economic variables when determining ways in which to improve immunization coverage in Indian districts.

Trends in Urban Immunization Coverage in India: A Meta-Analysis and Meta-Regression.

OBJECTIVES: To assess the gaps and trends in child immunization coverage among urban and rural areas in India, and compare the success of immunisation program in each. METHODS: PubMed, Scopus, and Crossref, and Google Scholar electronic databases were searched on October 9, 2019, and March 21, 2020, for studies that measured and reported immunization coverage indicators in India. Random-effects meta-analyses and meta-regressions were conducted. RESULTS: The authors' search identified 545 studies, and 2 were obtained by expert suggestion. Among these 68 studies and 6 surveys were included. They found that full immunization coverage has grown yearly at 2.65% and 0.82% in rural and urban areas, respectively whereas partial immunization coverage declined by -2.44% and -0.69%, respectively. Percentage of nonimmunized children did not show a statistically significant trend in either. CONCLUSION: While rural immunization coverage has seen a large increase over the past two decades, the progress in urban areas is weak and negligible. This was largely attributable to a focus on minimizing dropouts in rural areas. However, a lack of significant reduction in unimmunized children may indicate left-out children or pockets in both rural and urban areas. The poor performance of immunization programs in urban areas, coupled with a larger impact of COVID-19, warrants that India urgently adopts urban-sensitive and urban-focused policies and programs.