Inequalities in Childhood Immunisation in South Asia

Immunisation status of children under 2 years of age visiting Khyber Teaching Hospital, Peshawar, Pakistan: a cross-sectional analysis

OBJECTIVE

The study was conducted to determine the immunisation status of children under 2 years of age, assess the determinants of non-immunisation and evaluate the association between immunisation status and various sociodemographic factors.

METHODS

A cross-sectional questionnaire-based study was conducted at the outpatient department of Khyber Teaching Hospital, Peshawar, over a period of 4 months. A convenience sampling technique was used and the sample size was calculated using the WHO sample size formula, resulting in n=363. A semistructured questionnaire was used to measure the primary outcome, which was the immunisation status of children under 2 years of age. Immunisation data were verified through vaccination cards to ensure accuracy and minimise recall bias. The questionnaire also collected information on sociodemographic factors, including maternal education, place of residence and household income. Statistical analysis was done at the end of the study using SPSS (V.25).

RESULTS

According to the vaccination card, it was found that 43.3% of the children were fully immunised, 32.5% of the children were partially immunised and the percentage of unimmunised children was 24.2.

CONCLUSION

We found that the immunisation status of children was not satisfactory. Sustained efforts are required to achieve universal coverage of immunisation. Significant interventions are required, especially in areas that are more rural and less educated.

Factors influencing vaccine hesitancy toward non-covid vaccines in South Asia: a systematic review

Declared as one of the ten most pressing threats to global health in 2019, the complexity around vaccine acceptance and hesitancy has once again gained great momentum following the COVID-19 pandemic. Lack of vaccine acceptance may endanger the mission of improving vaccine uptake globally to tackle pandemics, reduce morbidity and mortality of preventable diseases and to prevent antibiotic resistance worldwide. Countries of the global south, including South Asian Association for Regional Cooperation (SAARC) countries are especially affected by the dangers of low vaccination uptake and continue to show decreases in coverage in recent years. This paper examines factors contributing to vaccine hesitancy in south Asia and the extent to which they are context and disease specific, guided by a modified version of the WHO SAGE 5 C model by Razai et al. Three databases were searched for peer-reviewed articles by using a comprehensive search strategy. Results from 44 quantitative, qualitative and mixed-method studies were included in the systematic review and appraised for quality, thematically analyzed and mapped onto the 5 C model. findings from India, Pakistan, Bangladesh, Nepal and Afghanistan showed vaccine hesitancy to be context and vaccine-specific within different settings of the countries. The main factors contributing to vaccine hesitancy can be identified as narrow confidence in vaccines, miscommunication, and lack of knowledge embedded into overarching constraints and contexts. To tackle vaccine hesitancy in SAARC countries, interventions need to be co-created by communities and mutual trust needs to be ensured, for instance through increased equity in knowledge distribution.

Mapping changes in the utilization of childhood immunization over 5 years in a south Indian tertiary care hospital

Background

Altered vaccine demands and uneven utilization patterns in childhood immunization are evident nationwide. These variabilities may stem from a range of internal and external factors influencing parental preferences. Regular checks and balances are necessary to ensure equal accessibility for all sections of society.

Aim

To assess the usage trends of childhood vaccines for 5 years (2018-2022) and to monitor instances of delayed/incomplete immunization status within the community.

Methodology

This study recorded the utilization trends of all recommended childhood vaccines over a 5-year period using an ambispective design. The immunization details from 3 years (2018, 2019 and 2020) were retrieved retrospectively, while those from 2 years (2021-2022) were collected prospectively through the immunization registry. Trends in childhood vaccine utilization were recorded across different years, and delays and incomplete vaccine utilization among children, along with factors resulting in deviated immunization timelines, were analysed and compared. The association of factors with deviated immunization utilization was determined using the chi-square test, and a two-way ANOVA analysed utilization variabilities over 5 years.

Result

Overall, the study profiled 32,085 children's (who utilized 87,782 vaccine doses) vaccine utilization pattern for 5 years. Optional vaccines were less utilized (18.12% doses by 25.14% children) compared to mandatory vaccines (81.88% doses utilized by 74.86%). The most utilized mandatory vaccine was oral polio (17.48%) and for optional vaccines, it was measles mumps rubella (MMR; 28.31%). Boys had the highest utilization (55.97%) with a significant male preponderance in optional vaccine utilization (p value <0.05). Overall, there was a 26.12% decline (percent change) in vaccine utilization in 2022 compared to 2018. Among children with delayed immunization timelines (6.02%), 3.38% were on catch-up, and 2.45% were not. The most commonly delayed vaccines were diphtheria + tetanus + pertussis boosters (30.90%), Tdap (26.19%) and MMR vaccines (20.65%). Influenza vaccines (28.08%) were the most partially utilized optional vaccine, followed by varicella vaccines (20.92%). Factors such as gender (female), age over 1 year, rural residence and low- to middle-income families were significant predictors of deviated immunization status in children.

Conclusion

The study mapped the utilization trends of immunizations at a tertiary care hospital in south India over the past 5 years, including the COVID-19 years. Gender inequality in the utilization of optional vaccines is a concern that warrants further research and redressal. Timely administration of childhood vaccinations is crucial for reducing susceptibility to vaccine-preventable diseases and promoting overall well-being.

Socio-demographic factors affecting the first and second dose of measles vaccination status among under-five children: Perspectives from South Asian countries

Background

The measles vaccine is crucial in preventing fatalities and reducing widespread childhood infections worldwide, yet achieving the desired immunization rates remains a challenge in developing countries. Our study aims to identify the impact of socio-demographic factors on measles vaccination among children in South Asian countries.

Methods

Participants (89513) were taken from the most recent Demographic and Health Survey (DHS) datasets of South Asian countries between 2015 and 2021. Descriptive statistics and multivariable analyses were employed to find out the factors associated with measles vaccination among South Asian countries.

Results

Our study found that the first dose of vaccinated children was 51.7 % in Afghanistan which is the lowest among South Asian countries. The key determinants related to two doses of measles vaccination include parental characteristics, media access, and antenatal care (ANC). Mothers who had done baby postnatal checkups (AOR = 1.22, CI = 1.17-1.26) and made more than four ANC (AOR = 1.77, CI: 1.65-1.89) were more likely to fully immunize their child than mothers with no postnatal and antenatal checkups.

Conclusion

The complete dose of measles vaccination rate in South Asia is still low compared to the first dose of measles vaccination among children. The government and stakeholders should organize frequent awareness programs through media and health personnel to inform people about routine vaccinations to eliminate measles.

Inequality in Childhood Immunization Coverage: A Scoping Review of Data Sources, Analyses, and Reporting Methods

Immunization through vaccines among children has contributed to improved childhood survival and health outcomes globally. However, vaccine coverage among children is unevenly distributed across settings and populations. The measurement of inequalities is essential for understanding gaps in vaccine coverage affecting certain sub-populations and monitoring progress towards achieving equity. Our study aimed to characterize the methods of reporting inequalities in childhood vaccine coverage, inclusive of the settings, data source types, analytical methods, and reporting modalities used to quantify and communicate inequality. We conducted a scoping review of publications in academic journals which included analyses of inequalities in vaccination among children. Literature searches were conducted in PubMed and Web of Science and included relevant articles published between 8 December 2013 and 7 December 2023. Overall, 242 publications were identified, including 204 assessing inequalities in a single country and 38 assessing inequalities across more than one country. We observed that analyses on inequalities in childhood vaccine coverage rely heavily on Demographic Health Survey (DHS) or Multiple Indicator Cluster Surveys (MICS) data (39.3%), and papers leveraging these data had increased in the last decade. Additionally, about half of the single-country studies were conducted in low- and middle-income countries. We found that few studies analyzed and reported inequalities using summary measures of health inequality and largely used the odds ratio resulting from logistic regression models for analyses. The most analyzed dimensions of inequality were economic status and maternal education, and the most common vaccine outcome indicator was full vaccination with the recommended vaccine schedule. However, the definition and construction of both dimensions of inequality and vaccine coverage measures varied across studies, and a variety of approaches were used to study inequalities in vaccine coverage across contexts. Overall, harmonizing methods for selecting and categorizing dimensions of inequalities as well as methods for analyzing and reporting inequalities can improve our ability to assess the magnitude and patterns of inequality in vaccine coverage and compare those inequalities across settings and time.

A Holistic Strategy of Mother and Child Health Care to Improve the Coverage of Routine and Polio Immunization in Pakistan: Results from a Demonstration Project

BACKGROUND

The eradication of poliovirus and improving routine immunization (RI) coverage rates present significant challenges in Pakistan. There is a need for interventions that focus on strengthening community engagement to improve routine immunization coverage. Our primary objective is to assess the impact of an integrated strategy designed to enhance community engagement and maternal and child health immunization campaigns on immunization coverage in Pakistan's high-risk union councils of polio-endemic districts.

METHOD

We implemented an integrated approach for routine immunization and maternal and child health in the polio-endemic district of Pakistan. This approach involved setting up health camps and actively engaging and mobilizing the local community. An independent team conducted surveys at three key points: baseline, midline, and endline, to evaluate immunization coverage among children under the age of five. The primary outcome measures for the study were coverage of OPV, IPV, and changes in the proportion of unvaccinated and fully vaccinated children. To select clusters and eligible households in each cluster, we utilized a 30 × 15 cluster sampling technique. Multivariable associations between socio-demographic factors and changes in the proportion of fully vaccinated children at the UC level were assessed using hierarchical linear regression models.

RESULTS

A total of 256,946 children under the age of five (122,950 at baseline and 133,996 at endline) were enrolled in the study. By the endline, full immunization coverage had increased to 60% or more in all three study areas compared to the baseline. Additionally, there was a significant increase in the coverage of both OPV and IPV across all three provinces at the endline. The full immunization rates were assessed on three levels of the framework: the distal, intermediate (access and environment), and proximal level (camp attendance and effectiveness). At the distal level, on multivariate analysis, family size was found to be a significant predictor of change in immunity within the families (β = 0.68; p ≤ 0.0001). At the intermediate level, the likelihood of full immunization decreased with the decrease in knowledge about vaccination (β = -0.38; p = 0.002), knowledge about polio vaccine (β = -0.25; p = 0.011), and knowledge about IPV (β = -0.06; p = 0.546). Perceived obstacles to vaccination were fear of adverse events (β = -0.4; p ≤ 0.0001) and lack of education (β = 0.23; p = 0.031), which were found to be significant in bivariate and multivariate analyses. At the proximal level, community mobilization (β = 0.26; p = 0.008) and attendance at health camp (β = 0.21; p ≤ 0.0001) were found to enhance full immunization coverage. On the other hand, the most prominent reason for not attending health camp included no need to attend the health camp as the child was not ill (β = -0.13; p = 0.008).

CONCLUSIONS

This study found that community mobilization and attendance at health camps significantly enhanced full immunization coverage. The findings highlight the importance of community engagement and targeted interventions in improving immunization coverage and addressing barriers to healthcare seeking.