Opportunities to improve vaccination coverage in a country with a fledgling health system: Findings from an assessment of missed opportunities for vaccination among health center attendees-Timor Leste, 2016

An Application of an Initial Full Value of Vaccine Assessment Methodology to Measles-Rubella MAPs for Use in Low- and Middle-Income Countries

Measles and rubella micro-array patches (MR-MAPs) are a promising innovation to address limitations of the current needle and syringe (N&S) presentation due to their single-dose presentation, ease of use, and improved thermostability. To direct and accelerate further research and interventions, an initial full value vaccine assessment (iFVVA) was initiated prior to MR-MAPs entering phase I trials to quantify their value and identify key data gaps and challenges. The iFVVA utilized a mixed-methods approach with rapid assessment of literature, stakeholder interviews and surveys, and quantitative data analyses to (i) assess global need for improved MR vaccines and how MR-MAPs could address MR problem statements; (ii) estimate costs and benefits of MR-MAPs; (iii) identify the best pathway from development to delivery; and (iv) identify outstanding areas of need where stakeholder intervention can be helpful. These analyses found that if MR-MAPs are broadly deployed, they can potentially reach an additional 80 million children compared to the N&S presentation between 2030-2040. MR-MAPs can avert up to 37 million measles cases, 400,000 measles deaths, and 26 million disability-adjusted life years (DALYs). MR-MAPs with the most optimal product characteristics of low price, controlled temperature chain (CTC) properties, and small cold chain volumes were shown to be cost saving for routine immunization (RI) in low- and middle-income countries (LMICs) compared to N&S. Uncertainties about price and future vaccine coverage impact the potential cost-effectiveness of introducing MR-MAPs in LMICs, indicating that it could be cost-effective in 16-81% of LMICs. Furthermore, this iFVVA highlighted the importance of upfront donor investment in manufacturing set-up and clinical studies and the critical influence of an appropriate price to ensure country and manufacturer financial sustainability. To ensure that MR-MAPs achieve the greatest public health benefit, MAP developers, vaccine manufacturers, donors, financiers, and policy- and decision-makers will need close collaboration and open communications.

Leaving no one behind: Defining and implementing an integrated life course approach to vaccination across the next decade as part of the immunization Agenda 2030

Strategic Priority 4 (SP4) of the Immunization Agenda 2030 aims to ensure that all people benefit from recommended immunizations throughout the life-course, integrated with essential health services. Therefore, it is necessary for immunization programs to have coordination and collaboration across all health programs. Although there has been progress, immunization platforms in the second year of life and beyond need continued strengthening, including booster doses and catch-up vaccination, for all ages, and recommended vaccines for older age groups. We note gaps in current vaccination programs policies and achieved coverage, in the second year of life and beyond. In 2021, the second dose of measles-containing vaccine (MCV2), given in the second year of life, achieved 71% global coverage vs 81% for MCV1. For adolescents, 60% of all countries have adopted human papillomavirus vaccines in their vaccination schedule with a global coverage rate of only 12 percent in 2021. Approximately 65% of the countries recommend influenza vaccines for older adults, high-risk adults and pregnant women, and only 25% recommended pneumococcal vaccines for older adults. To achieve an integrated life course approach to vaccination, we reviewed the evidence, gaps, and strategies in four focus areas: generating evidence for disease burden and potential vaccine impact in older age groups; building awareness and shifting policy beyond early childhood; building integrated delivery approaches throughout the life course; and identifying missed opportunities for vaccination, implementing catch-up strategies, and monitoring vaccination throughout the life course. We identified needs, such as tailoring strategies to the local context, conducting research and advocacy to mobilize resources and build political will. Mustering sufficient financial support and demand for an integrated life course approach to vaccination, particularly in times of COVID-19, is both a challenge and an opportunity.

Contextualising missed opportunities for children's vaccination: A theory-informed qualitative study in primary care settings in Cape Town, South Africa

This study aimed to explore the contextual factors that may be associated with missed opportunities for vaccination (MOV) from the perspectives of healthcare providers and caregivers attending primary healthcare facilities in the Cape Town Metro Health District, South Africa. The ultimate goal of the assessment was to help inform the design and implementation of a contextually appropriate quality improvement programme targeted at reducing MOV in primary healthcare settings. We used a theory-informed exploratory qualitative research design involving focus group discussions with caregivers of children aged 0-23 months; and in-depth interviews of facility staff. A thematic template analysis approach, integrating the theoretical domains framework (TDF) and the capability, opportunity and motivation model of behavior (COM-B) was used to code and analyze the data. Three focus group sessions were conducted, each consisting of 5-8 caregivers and five in-depth interviews involving facility staff. Capability factors comprised caregivers' knowledge, attitude and behavior toward children's immunization. Opportunity factors included the organization of immunization services, long waiting time, vaccine stock out, staff shortage and health workers' attitude, knowledge and capability to assess children's immunization status and needs. Motivation factors included optimism and beliefs about immunization, fear of vaccine-preventable diseases and immunization safety concerns. This study identified important caregiver-, provider- and health system-related factors, which influence immunization outcomes; offering useful contextual insights for informing quality improvement strategies for reducing MOV at primary healthcare level.

Missed opportunities for immunization among children 0 to 11 months of age that were attended to at debre tabor comprehensive specialized hospital, south gondar zone, Ethiopia

Background

The World Health Organization's Expanded Immunization Program was established in 1974 and aimed to provide vaccines to children all over the world. Since the inception of this program, numerous initiatives and campaigns have been launched, and millions of children around the world have been saved from death. Many vaccine-preventable diseases, however, remain prevalent in developing countries. This is because most of those countries have low immunization coverage for an unknown number of reasons. As a result, the goal of this study was to examine missed opportunities for immunization among children aged 0 to 11 months.

Methods

A cross-sectional survey was carried out from May to August 2022. A structured questionnaire was used to collect data, and the sample was chosen using a simple random sampling technique. Before being entered into the Epidata and exported to the Statistical Package for Social Science for analysis, the data were checked for consistency and completeness. The statistical significance was determined using binary and multiple logistic regression analyses. The statistical level of significance was established at p ≤ 0.05.

Result

In this study, 49.1% of immunization opportunities were missed. Education status [AOR = 2.45, 95% CI = 2.14, 4.22], rural residence [AOR = 4.32, 95% CI = 3.11, 6.38], and perception of caretakers [AOR = 2.13, 95% CI = 1.89, 4.07] were associated with the missed opportunity of immunization.

Conclusion

When compared to previous studies, the proportion of missed immunization opportunities was high in this study. The healthcare staff should be applying the multi-dose vial policy, which is recommended by the World Health Organization to increase the services. The doses for BCG and measles should be minimized to lower doses per vial in order to conduct immunization without having to wait for enough children and without worrying about vaccine waste. All infants who visit the hospital should be linked to immunization services.

Missed opportunities for vaccination (MOV) in children up to 5 years old in 19 Médecins Sans Frontières-supported health facilities: a cross-sectional survey in six low-resource countries

OBJECTIVE

To describe missed opportunities for vaccination (MOV) among children visiting Médecins Sans Frontières (MSF)-supported facilities, their related factors, and to identify reasons for non-vaccination.

DESIGN

Cross-sectional surveys conducted between 2011 and 2015.

SETTING AND PARTICIPANTS

Children up to 59 months of age visiting 19 MSF-supported facilities (15 primary healthcare centres and four hospitals) in Afghanistan, Democratic Republic of the Congo, Mauritania, Niger, Pakistan and South Sudan. Only children whose caregivers presented their vaccination card were included.

OUTCOME MEASURES

We describe MOV prevalence and reasons for no vaccination. We also assess the association of MOV with age, type of facility and reason for visit.

RESULTS

Among 5055 children's caregivers interviewed, 2738 presented a vaccination card of whom 62.8% were eligible for vaccination, and of those, 64.6% had an MOV. Presence of MOV was more likely in children visiting a hospital or a health facility for a reason other than vaccination. MOV occurrence was significantly higher among children aged 12-23 months (84.4%) and 24-59 months (88.3%) compared with children below 12 months (56.2%, p≤0.001). Main reasons reported by caregivers for MOV were lack of vaccines (40.3%), reason unknown (31.2%) and not being informed (17.6%).

CONCLUSIONS

Avoiding MOV should remain a priority in low-resource settings, in line with the new 'Immunization Agenda 2030'. Children beyond their second year of life are particularly vulnerable for MOV. We strongly recommend assessment of eligibility for vaccination as routine healthcare practice regardless of the reason for the visit by screening vaccination card. Strengthening implementation of 'Second year of life' visits and catch-up activities are proposed strategies to reduce MOV.

Missed Opportunities for Vaccination and Associated Factors among Children Attending Primary Health Care Facilities in Cape Town, South Africa: A Pre-Intervention Multilevel Analysis

Despite the substantial efforts at ensuring universal access to routine immunisation services among children in South Africa, major gaps in immunisation coverage remain. This study assessed the magnitude of missed opportunities for vaccination (MOV) and associated factors among children aged 0–23 months attending primary health care (PHC) facilities in Cape Town. We used multilevel binomial logistic regression models to explore individual and contextual factors associated with MOV, with children aged 0–23 months at Level 1, nested within PHC facilities (Level 2). A total of 674 children and their caregivers were enrolled. MOV prevalence was 14.1%, ranging from 9.1% to 18.9% across sub-districts. Dose-specific MOV prevalence was highest for the second dose of measles vaccine (9.5%) and lowest for the first dose of rotavirus vaccine (0.6%). The likelihood of a child experiencing MOV was significantly associated with caregivers’ low level of education (Odds ratio (OR) = 3.53, 95% credible interval (CrI): 1.13–11.03), recent receipt of immunisation messages (OR = 0.46, 95%CrI: 0.25–0.87), shared immunisation decision making by both parents (OR = 0.21, 95%CrI: 0.07–0.62) and health facility staff number (OR = 0.18, 95%CrI: 0.06–0.61). The burden of MOV among children in Cape Town is influenced by individual and contextual factors, which provide important opportunities for quality improvement and broader strategies to improve routine immunisation service delivery.

Missed opportunities for vaccination among children aged 0-23 months visiting health facilities in a southwest State of Nigeria, December 2019

Background

Despite efforts to improve childhood immunization coverage in Nigeria, coverage has remained below the national acceptable level. In December 2019, we conducted an assessment of Missed Opportunities for Vaccination (MOV) in Ondo State, in Southwest Nigeria. The objectives were to determine the magnitude of, explore the reasons for, as well as possible solutions for reducing MOV in the State.

Methods

This was a cross-sectional study using a mixed-methods approach. We purposively selected 66 health facilities in three local government authorities, with a non-probabilistic sampling of caregivers of children 0–23 months for exit interviews, and health workers for knowledge, attitudes, and practices (KAP) surveys. Data collection was complemented with focus group discussions and in-depth interviews with caregivers and health workers. The proportion of MOV among children with documented vaccination histories were determined and thematic analysis of the qualitative data was carried out.

Results

984 caregivers with children aged 0–23 months were interviewed, of which 869 were eligible for inclusion in our analysis. The prevalence of MOV was 32.8%. MOV occurred among 90.8% of children during non-vaccination visits, and 7.3% during vaccination visits. Vaccine doses recommended later in the immunization series were given in a less timely manner. Among 41.0% of health workers, they reported their vaccination knowledge was insufficient. Additionally, 57.5% were concerned about and feared adverse events following immunization. Caregivers were found to have a low awareness about vaccination, and issues related to the organization of the health system were found to contribute towards MOV.

Conclusions

One in three children experienced a MOV during a health service encounter. Potential interventions to reduce MOV include training of health workers about immunization policies and practices, improving caregivers’ engagement and screening of vaccination documentation by health workers during every health service encounter.

Using Household Surveys to Assess Missed Opportunities for Simultaneous Vaccination: Longitudinal Examples from Colombia and Nigeria

One important strategy to increase vaccination coverage is to minimize missed opportunities for vaccination. Missed opportunities for simultaneous vaccination (MOSV) occur when a child receives one or more vaccines but not all those for which they are eligible at a given visit. Household surveys that record children’s vaccination dates can be used to quantify occurrence of MOSVs and their impact on achievable vaccination coverage. We recently automated some MOSV analyses in the World Health Organization’s freely available software: Vaccination Coverage Quality Indicators (VCQI) making it straightforward to study MOSVs for any Demographic & Health Survey (DHS), Multi-Indicator Cluster Survey (MICS), or Expanded Programme on Immunization (EPI) survey. This paper uses VCQI to analyze MOSVs for basic vaccine doses among children aged 12–23 months in four rounds of DHS in Colombia (1995, 2000, 2005, and 2010) and five rounds of DHS in Nigeria (1999, 2003, 2008, 2013, and 2018). Outcomes include percent of vaccination visits MOSVs occurred, percent of children who experienced MOSVs, percent of MOSVs that remained uncorrected (that is, the missed vaccine had still not been received at the time of the survey), and the distribution of time-to-correction for children who received the MOSV dose at a later visit.

COVID-19 and the Gaping Wounds of South Africa's Suboptimal Immunisation Coverage: An Implementation Research Imperative for Assessing and Addressing Missed Opportunities for Vaccination

Despite South Africa's substantial investments in and efforts at ensuring universal access to immunisation services, progress has stalled and remains suboptimal across provinces and districts. An additional challenge is posed by the ongoing coronavirus disease 2019 (COVID-19) pandemic, which has disrupted immunisation services globally, including in South Africa. While there is growing evidence that missed opportunities for vaccination (MOV) are a major contributor to suboptimal immunisation progress globally, not much is known about the burden and determinants of MOV in the South African context. Herein, we make a case for assessing MOV as a strategy to address current immunisation coverage gaps while mitigating the adverse impacts of the COVID-19 pandemic on immunisation services. We illustrate a practical implementation research approach to assessing the burden of MOV among children in primary care settings; for understanding the factors associated with MOV; and for designing, implementing, and evaluating context-appropriate quality improvement interventions for addressing missed opportunities. Such efforts are vital for building health system resilience and maintaining immunisation programme capacity to optimally deliver essential health services such as routine childhood immunisation, even during pandemics.

Determining the burden of missed opportunities for vaccination among children admitted in healthcare facilities in India: a cross-sectional study

OBJECTIVES

Children accessing healthcare systems represent a vulnerable population with risk factors for poor health outcomes, including vaccine-preventable diseases. We aimed to quantify missed vaccination opportunities among hospitalised children in India, and identify vaccination barriers perceived by caregivers and healthcare providers.

DESIGN

Cross-sectional study.

SETTING

Two public-sector tertiary-care hospitals in northern India, during November 2018 and March 2019.

PARTICIPANTS

We tracked 263 hospitalised children aged 1-59 months through hospital discharge, to assess vaccination status, and document catch-up vaccinations given during the hospital stay. We interviewed caregivers and healthcare providers to assess their perceptions on vaccination.

OUTCOMES

Proportion of hospitalised children considered under-vaccinated for their age; proportion of missed opportunities for vaccination among under-vaccinated children who were eligible for vaccination; and vaccine coverage by antigen.

RESULTS

We found that 65.4% (172/263) of hospitalised children were under-vaccinated for their age when they presented to the hospital. Among under-vaccinated children, 61.0% were less than 4 months old, and 55.6% reported prior contact with a health facility for a sick visit. The proportion of under-vaccinated children in hospitals were higher compared with the general population as indicated by regional vaccination coverage data. Among under-vaccinated children who were tracked till discharge, 98.1% (158/161) remained incompletely vaccinated at discharge and were considered 'missed opportunities for vaccination'. Perceived vaccination contraindications that are not part of established contraindications included in national and international guidelines was the most common reason for healthcare providers not to vaccinate children during hospital stay. Among caregivers of under-vaccinated children, 90.1% reported being comfortable having their children vaccinated while they were sick, if recommended by the healthcare provider.

CONCLUSION

This pilot study confirmed that hospitalised sick children had substantial missed vaccination opportunities. Addressing these opportunities through concerted actions involving caregivers, healthcare providers and healthcare systems can improve overall vaccination coverage.

Assessment of missed opportunities for vaccination (MOV) in Burkina Faso using the World Health Organization's revised MOV strategy: Findings and strategic considerations to improve routine childhood immunization coverage

•

We assessed reasons for missed opportunities for vaccination (MOV) in Burkina Faso.

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We found the prevalence of MOV was 76% among all eligible children.

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The prevalence of MOV was 97% among children attending for a non-vaccination visit.

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Health workers’ knowledge, attitude and practices were insufficient to minimize MOV.

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Reducing MOV can result in increases to both vaccine coverage and equity.

Background

Despite the remarkable achievements of the Expanded Programme on Immunization (EPI) in Burkina Faso, numerous challenges remain, including missed opportunities for vaccination (MOV) which occur when people visit a health facility with at least one vaccine due according to the national immunization schedule, are free of contraindications, and leave without receiving all due vaccine doses. In 2016, we used the revised World Health Organization’s (WHO) MOV strategy to assess the extent of and reasons for MOV in Burkina Faso.

Methods

We purposively selected 27 primary health facilities (PHFs) from the eight health districts with the highest absolute numbers of children who missed the first dose of measles-rubella (MR1) in 2015. We conducted exit interviews with caregivers of children aged 0–23 months, and requested health workers to complete a self-administered knowledge, attitudes and practices (KAP) questionnaire.

Results

A total of 489 caregivers were interviewed, of which 411 were eligible for inclusion in our analysis. Medical consultation (35%) and vaccination (24.5%) were the most frequent reasons for visiting PHFs. Among the 73% of children eligible for vaccination, 76% of vaccination opportunities were missed. Among eligible children, the percentage with MOV was significantly higher in those aged ≥12 months and also in those attending for a reason other than vaccination. A total of 248 health workers completed the KAP questionnaire. Of these, 70% (n = 168/239) considered their knowledge on immunization to be insufficient or outdated; 83% failed to correctly identify valid contraindications to vaccination.

Conclusion

Addressing MOV offers the potential for substantial increases in vaccine coverage and equity, and ultimately reducing the burden of vaccine-preventable diseases (VPDs). This will require the implementation of a series of interventions aimed at improving community knowledge and practices, raising health workers’ awareness, and fostering the integration of immunization with other health services.

Country-Level Assessment of Missed Opportunities for Vaccination in South Africa: Protocol for Multilevel Analysis

BACKGROUND

Vaccination is one of the greatest public health interventions of all time. Vaccination coverage in South Africa has shown a steady improvement in reaching the national target. However, while there is progress nationally, there are districts within the country that are below the set target for vaccination coverage. One of the main drivers of suboptimal vaccination coverage is thought to be missed opportunities for vaccination.

OBJECTIVE

This study aims to understand the magnitude and determinants of missed opportunities for vaccination in South Africa.

METHODS

The 2016 South African Demographic and Health Survey will be used to conduct multilevel regression analyses to determine individual and contextual factors associated with missed opportunities for vaccination in South Africa. The perspectives of parents attending health care facilities in South Africa will be explored through exit interviews and focus group discussions. Similarly, perspectives of the health care providers will be sought to understand enablers and barriers to vaccination coverage at the facility level. Insights to such factors will aid in designing tailor-made interventions to improve vaccination coverage in South Africa.

RESULTS

Ethical review submission is planned for October 2020. Data collection is expected to be underway in January 2021.

CONCLUSIONS

The extent of missed opportunities in South Africa coupled with the associated factors presents an opportunity for efforts to increase uptake in districts where vaccination coverage is below the national target. Population-level data such as those from the 2016 South African Demographic Health Survey will provide an idea of the magnitude of missed opportunities for vaccination in South Africa at the national and subnational levels. The findings of the study will inform national and subnational policy implementation on vaccinations and help to find context-specific interventions to improve vaccination coverage.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/16672.

Assessment of missed opportunities for vaccination in Kenyan health facilities, 2016

Background

In November 2016, the Kenya National Vaccines and Immunization Programme conducted an assessment of missed opportunities for vaccination (MOV) using the World Health Organization (WHO) MOV methodology. A MOV includes any contact with health services during which an eligible individual does not receive all the vaccine doses for which he or she is eligible.

Methods

The MOV assessment in Kenya was conducted in 10 geographically diverse counties, comprising exit interviews with caregivers and knowledge, attitudes, and practices (KAP) surveys with health workers. On the survey dates, which covered a 4-day period in November 2016, all health workers and caregivers visiting the selected health facilities with children <24 months of age were eligible to participate. Health facilities (n = 4 per county) were purposively selected by size, location, ownership, and performance. We calculated the proportion of MOV among children eligible for vaccination and with documented vaccination histories (i.e., from a home-based record or health facility register), and stratified MOV by age and reason for visit. Timeliness of vaccine doses was also calculated.

Results

We conducted 677 age-eligible children exit interviews and 376 health worker KAP surveys. Of the 558 children with documented vaccination histories, 33% were visiting the health facility for a vaccination visit and 67% were for other reasons. A MOV was seen in 75% (244/324) of children eligible for vaccination with documented vaccination histories, with 57% (186/324) receiving no vaccinations. This included 55% of children visiting for a vaccination visit and 93% visiting for non-vaccination visits. Timeliness for multi-dose vaccine series doses decreased with subsequent doses. Among health workers, 25% (74/291) were unable to correctly identify the national vaccination schedule for vaccines administered during the first year of life. Among health workers who reported administering vaccines as part of their daily work, 39% (55/142) reported that they did not always have the materials they needed for patients seeking immunization services, such as vaccines, syringes, and vaccination recording documents.

Conclusions

The MOV assessment in Kenya highlighted areas of improvement that could reduce MOV. The results suggest several interventions including standardizing health worker practices, implementing an orientation package for all health workers, and developing a stock management module to reduce stock-outs of vaccines and vaccination-related supplies. To improve vaccination coverage and equity in all counties in Kenya, interventions to reduce MOV should be considered as part of an overall immunization service improvement plan.

Childhood vaccination coverage and equity impact in Ethiopia by socioeconomic, geographic, maternal, and child characteristics

BACKGROUND

Ethiopia is a priority country of Gavi, the Vaccine Alliance to improve vaccination coverage and equitable uptake. The Ethiopian National Expanded Programme on Immunisation (EPI) and the Global Vaccine Action Plan set coverage goals of 90% at national level and 80% at district level by 2020. This study analyses full vaccination coverage among children in Ethiopia and estimates the equity impact by socioeconomic, geographic, maternal and child characteristics based on the 2016 Ethiopia Demographic and Health Survey dataset.

METHODS

Full vaccination coverage (1-dose BCG, 3-dose DTP3-HepB-Hib, 3-dose polio, 1-dose measles (MCV1), 3-dose pneumococcal (PCV3), and 2-dose rotavirus vaccines) of 2,004 children aged 12-23 months was analysed. Mean coverage was disaggregated by socioeconomic (household wealth, religion, ethnicity), geographic (area of residence, region), maternal (maternal age at birth, maternal education, maternal marital status, sex of household head), and child (sex of child, birth order) characteristics. Concentration indices estimated wealth and education-related inequities, and multiple logistic regression assessed associations between full vaccination coverage and socioeconomic, geographic, maternal, and child characteristics.

RESULTS

Full vaccination coverage was 33.3% [29.4-37.2] in 2016. Single vaccination coverage ranged from 49.1% [45.1-53.1] for PCV3 to 69.2% [65.5-72.8] for BCG. Wealth and maternal education related inequities were pronounced with concentration indices of 0.30 and 0.23 respectively. Children in Addis Ababa and Dire Dawa were seven times more likely to have full vaccination compared to children living in the Afar region. Children in female-headed households were 49% less likely to have full vaccination.

CONCLUSION

Vaccination coverage in Ethiopia has a pro-advantaged regressive distribution with respect to both household wealth and maternal education. Children from poorer households, rural regions of Afar and Somali, no maternal education, and female-headed households had lower full vaccination coverage. Targeted programmes to reach under-immunised children in these subpopulations will improve vaccination coverage and equity outcomes in Ethiopia.