Reasons for reductions in routine childhood immunisation uptake during the COVID-19 pandemic in low- and middle-income countries: A systematic review

Vaccination readiness among adults in Norway: A cross-sectional survey using the 7C model

BACKGROUND

Maintaining high vaccination readiness is key to sustaining high vaccination coverage. In this study, we aim to estimate the vaccination readiness of the Norwegian adult population and explore its associations with sociodemographic characteristics and the intention to be vaccinated.

METHODS

A representative sample of the adult Norwegian population were surveyed with the validated 7C questionnaire on general vaccination readiness, which contains items about seven components of vaccination readiness (confidence, complacency, constraints, calculation, collective responsibility, compliance and conspiracy). Participants were also asked about sociodemographic background and their intention to be vaccinated against COVID-19 and influenza. We assessed associations involving vaccination readiness in linear and logistic regression models.

RESULTS

A total of 4137 individuals participated in the survey (overall response rate 50.5 %). Our study sample was comparable to the Norwegian population in terms of sociodemographic characteristics. On a scale from 1 to 7, the mean overall 7C vaccination readiness score was 4.82. Low overall vaccination readiness was associated with sociodemographic characteristics such as male sex, younger age, low education, low income and living alone. Overall vaccination readiness was strongly associated with intention to receive a booster dose of COVID-19 vaccine among those aged 18 years or older (adjusted odds ratio (aOR) 10.23, 95 % confidence interval (95 %CI) 8.38 to 12.49)), and with influenza vaccination among those aged 65 years or older (aOR 7.38, 95 %CI 4.51 to 12.10)), as were each of the seven vaccination readiness components when regressed on vaccination intention.

CONCLUSION

Overall general vaccination readiness was relatively high in the adult population in Norway. However, it differed between sociodemographic groups. Component and overall vaccination readiness scores were associated with intention to be vaccinated, and these associations were stronger for booster vaccination against COVID-19 than against influenza. The observed 7C estimates enable tracking of vaccination readiness over time and help identify themes and populations that can be targeted to improve compliance with vaccination program recommendations.

Routine Immunisation Coverage Shows Signs of Recovery at Global Level Postpandemic, but Important Declines Persist in About 20% of Countries

Background/Objectives: Routine immunisation (RI) coverage declines during the COVID-19 pandemic, from 2020 to 2022, are well-reported. With the declared end to the Public Health Emergency of International Concern in May 2023, and the cessation of most nonpharmaceutical interventions that were introduced to prevent or minimise COVID-19 spread, we (I) assess whether routine immunisation coverage has rebounded to the level of prepandemic trends and (II) seek to identify factors that help predict whether country performance has exceeded, maintained, or declined compared with expectations (based on time-series forecasting). Methods: We quantified global and country-level routine immunisation diphtheria-tetanus-pertussis (DTP) coverage trends postpandemic (2023) compared with prepandemic trends using time-series forecasting across 190 countries. We used discriminant analysis of principal components and random forests to identify relevant predictors of country-level coverage performance, including twenty-eight indicators of health system strength, health workforce, country income, pandemic containment, economic and health policies, and demographic aspects. Results: We show that mean global DTP third-dose coverage levels remained on average 2.7% [95% confidence intervals: 1.1-4.3%] lower than expected in 2023. However, once accounting for temporal demographic changes, we find that this translated to the total number of immunised children almost reverting to expected levels because of decreasing fertility reducing global-level immunisation target populations. At the country level, notable disruption remained in over thirty countries (16.8% of countries below expectations, 81.6% within expected ranges, and 1.6% above expectations). Neither predictive method performed well at identifying factors associated with coverage disruptions. Conclusions: Despite the end of COVID-19 pandemic measures, RI remains below expectations in about 20% of countries. No clear drivers of this continued disruption were identified. Further research is required to inform recovery efforts and prevent future epidemic and pandemic disruptions to routine health services.

Maintaining Immunizations for Vaccine-Preventable Diseases in a Changing World

Immunization has saved an estimated 154 million lives over the past 50 years since the launch of the Essential (formerly Expanded) Program on Immunization in 1974, representing 6 lives saved every minute, every year, for 50 years. But achieving and maintaining high immunization coverage have required sustained political and public commitment, financial resources, strong partnerships, research and innovation, and communication and advocacy. New and evolving challenges to maintaining high immunization coverage have emerged alongside long-standing stubborn obstacles. We review some of these key challenges to immunization in this dynamic, changing world and summarize some promising solutions. Success in some regions of the world in eliminating polio, measles, and rubella, and reducing morbidity and mortality from other vaccine-preventable diseases, should provide hope that progress can be made in achieving and maintaining high immunization coverage. We cannot afford to do otherwise.

How the COVID-19 pandemic affected routine child vaccination: an integrative review

BACKGROUND

Child immunization plays a critical role in preventing numerous diseases. However, the COVID-19) pandemic has profoundly disrupted healthcare systems globally, including routine child vaccination programs.

OBJECTIVE

To provide an overview of the reduction in vaccine coverage among infants and children during the pandemic and analyze the potential impacts of decreased child immunization during this period.

METHODS

A comprehensive search was conducted using the MeSH terms "Child," "Vaccination", and "COVID-19," along with their synonyms. Systematic reviews published between March 11, 2020, and June 1, 2023, in Portuguese or English were included. Databases searched included PubMed, BVS (Biblioteca Virtual em Saúde), Embase, and Scopus. Two blinded independent reviewers performed the selection process, with conflicts resolved by a third reviewer. The AMSTAR-II tool was used to assess the methodological quality of the included studies.

RESULTS

Of the 1,534 eligible articles, only 13 addressed the pandemic's impact on children's vaccination coverage. Most studies involved multiple countries and reported a significant decrease in children's vaccination coverage due to the COVID-19 pandemic.

CONCLUSION

The findings were heterogeneous but consistently highlighted the substantial impact of the COVID-19 pandemic on routine vaccination coverage in most countries. Further research is needed to explore the epidemiological consequences of disruptions to vaccination schedules, potentially guiding public policies and raising awareness about the importance of adhering to health protection programs.

Text message reminders to improve the timeliness of birth dose vaccine administration among newborns in an urban informal settlement in Kenya

BACKGROUND

We evaluated the effectiveness of text message reminders on the timely administration of birth dose vaccines among newborns in Viwandani urban informal settlement in Nairobi County, Kenya.

METHODS

In a pilot stepped-wedge cluster-randomized trial, we sequentially randomized pregnant women to receive text message reminders or routine care. Three standardized text messages were sent notifying pregnant women to take their newborn for vaccination at birth during the intervention period. No text messages were sent during the control period but vaccinations were provided as standard practice in Kenya. The primary outcome was timely administration of birth dose vaccines-oral polio vaccine (OPV 0) and Bacillus Calmette-Guerin (BCG) administered at birth or within 2 weeks of birth.

RESULTS

Among 491 newborns (355 intervention period versus 136 control period), timely administration of birth dose vaccines during the respective intervention and control periods were as follows: OPV 0 only (93.0% vs. 80.9%), BCG only (92.7% vs. 81.6%), and OPV 0 or BCG (92.1% vs. 77.9%). Timeliness of birth dose vaccine administration showed a borderline improvement in the intervention period than the control period: OPV 0 only (adjusted RR [aRR] 1.16, 95% CI: 1.00-1.35), BCG only (aRR 1.14, 95% CI: 0.98-1.33), and both OPV 0 and BCG (aRR 1.19, 95% CI: 1.00-1.43).

CONCLUSION

This trial showed that text message reminders can improve the timely administration of birth dose vaccines among newborns in an urban informal settlement and can be used as an additional tool for improving the timeliness of administering vaccines in such settings.

Childhood vaccination trends during 2019 to 2022 in Tanzania and the impact of the COVID-19 pandemic

The COVID-19 pandemic has significantly disrupted healthcare systems at all levels globally, notably affecting routine healthcare services, such as childhood vaccination. This study examined the impact of these disruptions on routine childhood vaccination programmes in Tanzania. We conducted a longitudinal study over four years in five Tanzanian regions: Mwanza, Dar es Salaam, Mtwara, Arusha, and Dodoma. This study analyzed the trends in the use of six essential vaccines: Bacille Calmette-Guérin (BCG), bivalent Oral Polio Vaccine (bOPV), Diphtheria Tetanus Pertussis, Hepatitis-B and Hib (DTP-HepB-Hib), measles-rubella (MR), Pneumococcal Conjugate Vaccine (PCV), and Rota vaccines. We evaluated annual and monthly vaccination trends using time-series and regression analyses. Predictive modeling was performed using an autoregressive integrated moving average (ARIMA) model. A total of 32,602,734 vaccination events were recorded across the regions from 2019 to 2022. Despite declining vaccination rates in 2020, there was a notable rebound in 2021, indicating the resilience of Tanzania's immunization program. The analysis also highlighted regional differences in vaccination rates when standardized per 1000 people. Seasonal fluctuations were observed in monthly vaccination rates, with BCG showing the most stable trend. Predictive modeling of BCG indicated stable and increasing vaccination coverage by 2023. These findings underscore the robustness of Tanzania's childhood immunization infrastructure in overcoming the challenges posed by the COVID-19 pandemic, as indicated by the strong recovery of vaccination rates post-2020. We provide valuable insights into the dynamics of vaccination during a global health crisis and highlight the importance of sustained immunization efforts to maintain public health.

The impact of COVID-19 on routine child immunisation in South Africa

BACKGROUND

The COVID-19 pandemic disrupted immunisation programs worldwide, reversing gains that had brought vaccine-preventable diseases largely under control. This study explored the impact of COVID-19 on the uptake of routine child immunisation services in South Africa.

METHODS

We conducted qualitative research using in-depth interviews with 51 purposively selected parents/caregivers of children below the age of five who missed or delayed one or more scheduled immunisation doses in 2020-2022 and with 12 healthcare providers who provided public immunisation services during the pandemic.

RESULTS

During the pandemic lockdowns, most caregivers perceived the risk of their child being infected with COVID-19 during a clinic visit as more salient than the risk of missing immunisation doses. Caregivers reported minimal exposure to routine immunisation communication, as well as shortages of routine vaccines for children at public health facilities, healthcare workers experienced anxiety and burnout. There was a post-pandemic shift to more active decision-making about immunisation, which had previously been an almost automatic behaviour, leading some caregivers to delay vaccinating their children. There was also evidence of a "bad vaccine" mental model among some caregivers regarding COVID vaccinations, which could lead to doubts about the safety of routine childhood vaccinations.

DISCUSSION

The shift from default to active decision-making highlights a risk that routine immunisation will backslide in future pandemics. Governments should build resilient health systems at all levels and communicate clearly about the benefits and availability of RIs and the safety of vaccinations in general, alongside supply-side interventions.

CONCLUSION

Routine immunisation is widely accepted in South Africa, driven by generational norms and provider recommendations. During the COVID-19 pandemic, many caregivers faced the dilemma of balancing COVID-19 exposure risk with the risk of their child developing a deadly VPD, leading to missed RI visits. This shift to active decision-making highlights a future pandemic risk. Governments should build resilient health systems and focus on understanding and engaging procrastinating and doubtful caregivers. Clear communication about RI benefits and vaccine safety is crucial, as misinformation can lead to distrust in new vaccines.

Trends of Diphtheria-Tetanus-Pertussis and Measles Vaccine Coverage Preceding and during the COVID-19 Pandemic: An Analysis of the WHO European Region from 2000 to 2022

Available data highlights the significant impact of the COVID-19 pandemic on global vaccination trends. Despite this, comprehensive evaluations of these changes at the European level are still scarce. This study examines coverage for diphtheria, tetanus, and pertussis (DTP) and measles-containing vaccines (MCV) in the WHO European Region from 2000 to 2022. Vaccination coverage data, defined as the percentage of surviving infants who received the first and third doses of DTP (DTP1 and DTP3) and the first and second doses of MCV (MCV1 and MCV2), were extracted from UNICEF databases. Joinpoint regression analysis was employed to identify joinpoints in the time series and to estimate Annual Percent Changes (APCs) and Average Annual Percent Changes (AAPCs) over predefined timeframes. The coverages for DTP1 and MCV1 exhibit a similar trend, overall characterized by four joinpoints, one of which is in 2019. In contrast, the coverage for DTP3 does not show a significant temporal trend and lacks joinpoints, while the vaccination coverage for MCV2 shows a steadily increasing trend, with three identified joinpoints. A comparative analysis with the pre-pandemic period reveals a significant increase in the number of countries characterized by a decreasing trend during the pandemic period for all considered vaccination coverages, as indicated by the negative AAPC values. These results highlight the effect of the pandemic on childhood vaccination coverage. Compared to a mere descriptive analysis, the temporal analysis of trends using joinpoint regression provides significant opportunities to identify variations in vaccination coverages and pinpoint areas for intervention in future vaccination strategies.

Impact of the emergence of severe acute respiratory syndrome coronavirus 2 omicron variants on routine childhood immunization in Japan

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic disrupted routine childhood vaccination worldwide, especially at the beginning of the pandemic. After the emergence of variants of concern, particularly the Omicron variants, the number of COVID-19 cases significantly increased, especially in children. However, the impact of the Omicron variants on routine childhood vaccination is unknown.

METHODS

This retrospective observational study collected data on vaccines included in the Japanese national immunization program (NIP) of children 15 years or younger between 2016 and 2022 in Niigata, Japan. During the study period, hepatitis B virus vaccine and rotavirus vaccines were introduced to the NIP in October 2016 and October 2020, respectively. The monthly number of vaccine doses per eligible child population between 2020 and 2022 (pandemic period) was compared to the average number of vaccine doses in the corresponding month between 2016 and 2019 (pre-pandemic period). The effect of 8 surges of COVID-19 patients on trends in routine childhood vaccination was also analyzed.

RESULTS

The numbers of doses during the pre-Omicron pandemic period were comparable to the values administered before the pandemic. However, after the emergence of the Omicron variants, and especially after the surge of Omicron variant BA.5 in 2022, the number of vaccine doses declined. The decline was notable in second doses of MR vaccine at age 5-6 years by - 9.6 % and diphtheria-tetanus vaccine at ages 11-12 years by - 14.1 %.

CONCLUSIONS

Routine childhood immunization was significantly affected by the emergence of the Omicron variants most likely due to the facts that more candidates and their guardians contracted COVID-19, or were required isolation for close contacts. The findings highlight the importance of continued monitoring to maintain high coverage of routine childhood immunizations for controlling vaccine preventable diseases. A follow-up study should investigate changes in the number of declined vaccine doses during Omicron variant predominance.

Trust in health workers and patient-centeredness of care were strongest factors associated with vaccination for Kenyan children born between 2017-2022

Objective

Although vaccination confidence is declining globally, there is little detailed information from low- and middle-income countries about factors influencing routine vaccination behavior in these contexts.

Methods

In mid-2022, we surveyed people who gave birth in Kenya between 2017-2022, and asked them about their children's vaccination history and about hypothesized correlates of vaccination per the Behavioural and Social Drivers of Vaccination model.

Results

Of 873 children in this sample, 117 (13%) were under-vaccinated (i.e., delayed or missing vaccine dose(s)) - and under-vaccination was more common among births during the COVID-19 pandemic (2020-2022) versus pre-pandemic (2017-2019). In multi-level multivariable models, children of respondents who expressed concerns about serious side effects from vaccines had significantly higher odds of missed vaccine dose(s) (aOR 2.06, 95 % CI 1.14-3.72), and there was a strong association between having more safety concerns now versus before the COVID-19 pandemic (aOR missed dose(s) 4.44, 95 % CI 1.71-11.51; aOR under-vaccination 3.03, 95 % CI 1.28-7.19). People with greater trust in health workers had lower odds of having a child with missed vaccine dose(s) (aOR 0.85, 95 % CI 0.75-0.97). People who reported higher patient-centered quality of vaccination care had much lower odds of having children with delayed or missed vaccine dose(s) (aOR missed dose(s) 0.14, 95 % CI 0.04-0.58; aOR under-vaccination 0.27, 95 % CI 0.10-0.79).

Conclusions

These findings highlight potential strategies to improve vaccine coverage: greater focus on patient-centered quality of care, training healthcare workers on how to address safety concerns about vaccines, and building trust in the health care system and in health workers.

How the COVID-19 pandemic affected infant vaccination trends in rural and urban communities in Ibadan, Nigeria: a cross-sectional study

OBJECTIVES

This study compared the infant vaccination trends a year before and a year after the onset of the COVID-19 pandemic in selected urban and rural communities in Ibadan, Nigeria.

DESIGN

This was a cross-sectional study in which data were extracted from infant vaccination records.

SETTING

Two rural and three urban vaccination centres in primary health clinics at Ibadan Southeast and Olúyòlé local government areas, respectively.

PARTICIPANTS

Infant vaccination records 1 year before and 1 year after the onset of the COVID-19 pandemic (March 2019-February 2020 and March 2020-February 2021, respectively).

OUTCOME MEASURES

Timeliness of vaccination (vaccination taken within 2 weeks of appointment) and vaccination completion according to the Nigerian routine infant vaccination schedule.

RESULTS

2000 vaccination records were included in the study (1013 (50.6%) for male infants). 840 (42.0%) of the records were from the rural immunisation clinics. There were 1194 (59.7%) and 806 (40.3%) records from before and after the onset of the COVID-19 pandemic, respectively. Before the pandemic, birth dose vaccines were timelier among infants from urban communities, while vaccines given at 6 weeks were timelier in the rural areas. Following the onset of the pandemic, the rural communities had a higher proportion of infants with timelier and complete vaccination except for the birth dose vaccines. Overall, there was higher vaccination completion before the pandemic, and this was higher in the rural compared with the urban communities both before (54.8% vs 11.7%) and after (23.6% vs 1.0%) the onset of the pandemic.

CONCLUSIONS

A decline in infant vaccination uptake, timeliness and completion persisted 1 year after the COVID-19 pandemic onset, and urban communities were more affected. More efforts are required to ensure optimal infant vaccination, especially in urban communities, to forestall outbreaks of vaccine-preventable diseases.

Developing and validating a scale to measure the perceptions of safety, usability and acceptability of microarray patches for vaccination: a study protocol

Background

Vaccination is a fundamental tenet of public and population health. Several barriers to vaccine uptake exist, exacerbated post-COVID-19, including misconceptions about vaccine efficacy and safety, vaccine hesitancy, vaccine inequity, costs, religious beliefs, and insufficient education and guidance for healthcare professionals. Vaccine uptake may be aided using microarray patches (MAPs) due to reduced pain, no hypodermic needle, enhanced thermostability, and potential for self and lay administration.

Objectives

This protocol outlines the development of a scale that aims to accurately measure the perceived safety, usability, and acceptability of MAPs for vaccination among laypeople, MAP recipients, clinicians, and parents or guardians of children.

Methods and analysis

This study will follow three phases of scale development and validation, including (1) item development, (2) scale development, and (3) scale evaluation. Inductive (interviews) and deductive methods (literature searches) will be used to develop scale items, which experts from target populations will assess through an online survey. Cognitive interviews will be conducted to observe their processes of answering the draft survey. Thematic analysis will be conducted to analyse qualitative data. Lastly, four surveys will be administered online to our target populations over two time points to determine their repeatability. Exploratory and confirmatory factor analyses, Cronbach's alpha, and construct validity will be performed.

Ethics

This study was approved by Metro South Health (HREC/2021/QMS/81653) and Western Sydney Local Health District (2023/ETH00705) Human Research Ethics Committees.

Discussion

The scale will support a standardised approach to assessing the social and behavioural aspects of MAP vaccines, enabling comparison of outcomes across studies. Once validated, this scale will assist vaccination programmes in developing effective strategies for integrating MAPs and overcoming barriers to vaccination. This includes improving vaccine equity and accessibility, especially in lower- and middle-income countries and rural or remote locations.

Interventions addressing routine childhood immunization and its behavioral and social drivers

Introduction

Despite the advances in vaccination, there are still several challenges in reaching millions of children in low- and middle-income countries (LMICs). In this review, we present an extensive summary of the various strategies used for improving routine immunization in LMICs to aid program implementers in designing vaccination interventions.

Methods

Experimental and quasi-experimental impact evaluations conducted in LMICs evaluating the effectiveness of interventions in improving routine immunization of children aged 0-5 years or the intermediate outcomes were included from 3ie's review of systematic reviews. Some additional impact evaluation studies published in recent years in select LMICs with large number of unvaccinated children were also included. Studies were coded to identify interventions and the barriers in the study context using the intervention framework developed in 3ie's Evidence Gap Map and the WHO's Behavioral and Social Drivers (BeSD) of vaccination framework, respectively. Qualitative analysis of the content was conducted to analyze the intervention strategies and the vaccination barriers that they addressed.

Results and conclusion

One hundred and forty-two impact evaluations were included to summarize the interventions. To address attitudinal and knowledge related barriers to vaccination and to motivate caregivers, sensitization and educational programs, media campaigns, and monetary or non-monetary incentives to caregivers, that may or may not be conditional upon certain health behaviors, have been used across contexts. To improve knowledge of vaccination, its place, time, and schedule, automated voice messages and written or pictorial messages have been used as standalone or multicomponent strategies. Interventions used to improve service quality included training and education of health workers and providing monetary or non-monetary perks to them or sending reminders to them on different aspects of provision of vaccination services. Interventions like effective planning or outreach activities, follow-up of children, tracking of children that have missed vaccinations, pay-for-performance schemes and health system strengthening have also been used to improve service access and quality. Interventions aimed at mobilizing and collaborating with the community to impact social norms, attitudes, and empower communities to make health decisions have also been widely implemented.

COVID-19 epidemiology, health services utilisation and health care seeking behaviour during the first year of the COVID-19 pandemic in Mweso health zone, Democratic Republic of Congo

Background

Although the evidence about coronavirus disease 2019 (COVID-19) has increased exponentially since the beginning of the pandemic, less is known about the direct and indirect effects of the pandemic in humanitarian settings. In the Democratic Republic of the Congo (DRC), most studies occurred in Kinshasa and other cities. Limited research was conducted in remote conflict-affected settings. We investigated the COVID-19 epidemiology, health service utilisation, and health care-seeking behaviour during the first year of the pandemic (March 2020-March 2021) in the Mweso health zone, North Kivu, DRC.

Methods

This mixed-methods study includes a descriptive epidemiological analysis of reported COVID-19 cases data extracted from the provincial line list, interrupted time series analysis of health service utilisation using routine health service data, qualitative perceptions of health care workers about how health services were affected, and community members' health care seeking behaviour from a representative household survey and focus group discussions.

Results

The COVID-19 epidemiology in North Kivu aligns with evidence reported globally, yet case fatality rates were high due to underreporting. Testing capacity was limited and initially mainly available in the province's capital. Health service utilisation showed different patterns - child measles vaccinations experienced a decrease at the beginning of the pandemic, while outpatient consultations, malaria, and pneumonia showed an increase over time. Such increases might have been driven by insecurity and population displacements rather than COVID-19. Community members continued seeking care during the first months of the COVID-19 pandemic and visited the same health facilities as before COVID-19. Financial constraints, not COVID-19, were the main barrier reported to accessing health care.

Conclusions

The first year of the COVID-19 pandemic in the Mweso health zone was characterised by low testing capacity and an underestimation of reported COVID-19 infections. The increase in health care utilisation should be further explored to understand the role of factors unrelated to COVID-19, such as insecurity, population displacement, and poverty, which remain major challenges to successfully providing health services and improving the population's health. Measles vaccination coverage dropped, which exacerbated the ongoing measles outbreak. Improved decentralised testing capacity will be crucial for future epidemics and enhanced efforts to maintain child vaccination coverage.

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.