Immunization Service Delivery Research Articles

COVID-19 vaccine acceptability among people in Australia who inject drugs: Update from the 2021 Illicit Drug Reporting System interviews.

People who inject drugs may be at higher risk of COVID‐19 transmission and more severe negative health outcomes following COVID‐19 infection. Early research on hypothetical COVID‐19 vaccines suggests this population may be less likely to accept vaccination. This commentary extends this research by presenting vaccine intention data from Illicit Drug Reporting System interviews conducted in June–July 2021, in the early stages of vaccine rollout, with people in Australia who inject drugs (N = 888). Half the sample (48%, n = 419) reported that they were hesitant to receive the COVID‐19 vaccine, with key barriers relating to vaccine safety and side effect concerns. This level of hesitancy is substantially higher than that of the general population at a similar time. While we note that the subsequent Delta variant‐driven third wave of cases in Australia and efforts to increase population vaccination coverage may have altered intent in this group, this level of hesitancy warrants a targeted strategy to mitigate vaccine‐related concerns and maximise uptake. Ideally, this should comprise an inclusive health response that is peer‐led, with peer‐based organisations ideally positioned to direct immunisation service delivery and provide vaccine‐related messaging.

Strengthening pre-service training of healthcare workers on immunisation and effective vaccine management: the experience of Kenya Medical Training College.

Pre-service health training institutions have a key role in training qualified medical and nursing staff deployable in immunisation programmes, making them capable of addressing complex situations, sustaining routine immunisation and introducing new vaccines and technologies. The incorporation of immunisation-related content into nursing and midwifery education is essential to improve and strengthen immunisation service delivery, disease surveillance, logistics, communication and management practices. Clinical and public health training incorporating learning objectives on immunisation that are specific to the Expanded Programme on Immunisation (EPI), will enable students to develop a firm basis of core knowledge and skills in immunisation. To assist health training institutions in the African Region and to facilitate the systematic revision of EPI curricula, two prototype curricula, one for medical and one for nursing/midwifery schools, were developed by WHO/AFRO, NESI/University of Antwerp and other partners in 2006 and revised in 2015. Kenya Medical Training College (KMTC) has been at the forefront in revising and updating their institutional EPI curriculum for the pre-service Kenyan Registered Community Health Nursing programme based on the EPI prototype curriculum. Building on the successful strengthening of the EPI curriculum, KMTC will now embark on improving education and training for effective vaccine and cold chain management for selected training programmes. The different steps taken by KMTC to strengthen EPI teaching and learning can support other health training institutions who are willing to integrate the content of the EPI prototype curriculum in their own institutional curricula by adapting them to the local context.

A rapid qualitative assessment of barriers associated with demand and uptake of health facility-based childhood immunizations and recommendations to improve immunization service delivery in Sokoto State, Northwest Nigeria, 2017.

IntroductionThis rapid qualitative assessment aimed to understand factors associated with persistent low vaccination demand and uptake, and recommendations to improve health facility-based childhood immunization services in Sokoto State, Nigeria.MethodsIn 2017, 20 focus group discussions and 16 in-depth interviews were conducted with administrative personnel, healthcare workers, caregivers, and community influencers across three local government areas in Sokoto state, Northwest Nigeria. Participants were purposefully selected to capture a range of perspectives regarding access to health services, campaign- and facility-based immunizations, confidence in immunizations, and recommendations to improve childhood immunization uptake.ResultsOne hundred and ninety-three individuals participated in the assessment. Commonly reported barriers to receiving childhood immunizations include: inadequacy of health services to meet community needs, preference for campaign vs. facility-based immunizations, the negative influence of rumors and misinformation, and opposition to vaccines among male heads of households. Recommendations to improve uptake of childhood immunizations include: improving immunization service delivery in health facilities, involving community leaders in building demand for immunization, and providing access to free health services and non-cash incentives.ConclusionRapid assessment results highlight community, facility, and administrative barriers associated with low demand for and uptake of health facility-based childhood immunizations and offer recommendations to improve immunization services in Sokoto state, Nigeria. Findings demonstrate the persistence of service and supply side barriers such as infrastructure and personnel issues, but also highlight the influence of behavioral factors such as low prioritization of receiving childhood immunizations, misinformation, and gender dynamics on whether communities accept or seek out immunization services.

Strengthening facility-based immunization service delivery in local government areas at high risk for polio in Northern Nigeria, 2014-2015.

IntroductionThe National Stop Transmission of Polio (NSTOP) program was created in 2012 to support the Polio Eradication Initiative (PEI) in Local Government Areas (LGAs) at high risk for polio in Northern Nigeria. We assessed immunization service delivery prior to the commencement of NSTOP support in 2014 and after one year of implementation in 2015 to measure changes in the implementation of key facility-based Routine Immunization (RI) components.MethodsThe pre- and post-assessment was conducted in selected health facilities (HFs) in 61 LGAs supported by NSTOP in 5 states. A standardized questionnaire was administered to the LGA and HF immunization staff by trained interviewers on key RI service delivery components.ResultsAt the LGA level, an increase was observed in key components including availability of updated Reach Every Ward (REW) micro-plans with identification of hard to reach settlements (65.6% baseline, 96.8% follow-up, PR = 1.5 (95% CI 3.4 - 69.8), vaccine forecasting (77.1% baseline, 93.5% follow-up, PR =1.2 (95% CI 1.8 - 13.8), and timely delivery of monthly immunization reports (73.8% baseline, 90.2% follow-up; PR =1.2 (95% CI 1.2 - 9.0). At the HF level, there was an increase in percentage of HFs with written supervisory feedback (44.5% baseline, 82.5% follow-up, PR = 1.8 (95% CI 4.7 - 7.3), written stock records (66.5% baseline, 87.9% follow-up, PR = 1.3 (95% CI 2.9 - 4.7) and updated immunization monitoring charts (76.3% baseline, 95.6% follow-up, PR = 1.3 (95% CI 4.6 - 9.9).ConclusionWe observed an improvement in key RI service delivery components following implementation of NSTOP program activities in supported LGAs.

Organization of immunization services for public health

Immunization is a key public health intervention that can help nations attain Goal #3 of the UN Sustainable Development Goals as vaccines already prevent about 2–3 million deaths each year. To be effective, immunization services must be designed and delivered in a way to reach populations who need them, irrespective of who they are and where they live. Effective national immunization systems must have clear plans based on a vision of the future and a step-by-step process on how the vision will be translated into reality. Such plans are structured around eight topics that go beyond vaccine licensure and recommendations, including management, financing, logistics, human resources, service delivery, vaccine supply and quality, disease surveillance, advocacy and communication. The cold chain system is the backbone of any immunization program and consists of a network of equipment, material, people, processes, and financial resources that enable safe transportation of vaccines from the factory to the point of administration to the patient. Immunization service delivery includes any strategies and activities for delivering immunization service to a target population. Introduction of a new vaccine in a country program requires coordinated decision-making, considering the burden of disease, the characteristics of the respective vaccine and the capacity of the immunization system to deliver it. Adverse Events Following Immunization is another key component as documentation of vaccine safety is crucial for trust in a vaccination program. Scientifically valid and timely burden-of-disease surveillance as well as vaccine uptake data are core functions of any vaccination program and needed for information of the public and for timely actions.

Linked vaccination coverage surveys plus serosurveys among Ethiopian toddlers undertaken three years apart to compare coverage and serologic evidence of protection in districts implementing the RED-QI approach

In low and middle-income countries, estimating the proportion of vaccinated toddlers in a population is important for controlling vaccine-preventable diseases by identifying districts where immunization services need strengthening. Estimates measured before and several years after specific interventions can assess program performance. However, employing different methods to derive vaccination coverage estimates often yield differing results. MethodsLinked vaccination coverage surveys and seroprotection surveys performed among ~300 toddlers 12–23 months of age in districts (woredas), one per region, of Ethiopia (total, ~900 toddlers) in 2013 to estimate the proportion vaccinated with tetanus toxoid (a proxy for pentavalent vaccine) and measles vaccine. The surveys were followed by implementation of the Reaching Every District using Quality Improvement (RED-QI) approach to strengthen the immunization system.Linked coverage/serosurveys were repeated in 2016 to assess effects of the interventions on vaccination coverage. Indicators included “documented coverage” (vaccination card and/or health facility register records) and “crude coverage” (documented plus parent/caretaker recall for children without cards). Seroprotection thresholds were IgG-ELISA tetanus antitoxin ≥0.05 IU/ml and plaque reduction neutralization (PRN) measles titers ≥120 mIU/ml. FindingsImproved markers in 2016 over 2013 include coverage of pentavalent vaccination, vaccination timeliness, and fewer missed opportunities to vaccinate. In parallel, tetanus seroprotection increased in the 3 woredas from 59.6% to 79.1%, 72.9% to 83.7%, and 94.3 to 99.3%. In 2015, the Ethiopian government conducted supplemental measles mass vaccination campaigns in several regions including one that involved a project woreda and the campaign overlapped with the RED-QI intervention timeframe; protective measles PRN titers there rose from 31.0% to 50.0%. InterpretationThe prevalence of seroprotective titers of tetanus antitoxin (stimulated by tetanus toxoid components within pentavalent vaccine) provides a reliable biomarker to identify children who received pentavalent vaccine. In the three study woredas, the RED-QI intervention appeared to improve immunization service delivery, as documented by enhanced pentavalent vaccine coverage, vaccination timeliness, and fewer missed vaccination opportunities. A measles mass vaccination campaign was followed by a markedly increased prevalence of measles PRN antibodies. Collectively, these observations suggest that wider implementation of RED-QI can strengthen immunization, and periodic linked vaccination surveys/serosurveys can monitor changes.

The coverage of hepatitis B birth dose vaccination in Nigeria: Does the place of delivery matter?

Hepatitis B birth dose (HepB-BD) vaccination coverage remains suboptimal in Nigeria. While evidence suggests that institutional delivery is associated with the uptake of HepB-BD vaccine, little is known about how the uptake differs by facility ownership (public or private). This study examined the HepB-BD vaccination coverage by place of delivery in Nigeria. This study is a secondary analysis of data on 6143 children aged 12-23 mo obtained from the 2018 Nigeria Demographic and Health Survey. We assessed the association between HepB-BD vaccination and the place of delivery using logistic regression models. About 53% of the children received the HepB-BD vaccine. Approximately 77, 83 and 33% of those delivered at a public health facility, private health facility and at home received the HepB-BD vaccine, respectively. After controlling for child- and maternal-level factors, the odds of receiving HepB-BD vaccine were significantly lower in children delivered at a private health facility (adjusted OR [aOR]=0.77, 95% CI 0.59 to 0.99) or at home (aOR=0.48, 95% CI 0.36 to 0.63). Wealth index and region of residence were significantly associated with the receipt of HepB-BD vaccination in all three places of delivery. Children are less likely to receive the HepB-BD vaccine if they are delivered at a private health facility or at home. There is a need for private health sector engagement for immunization service delivery and innovative community-based interventions to reach the children delivered at home.

Using participatory action research to improve immunization utilization in areas with pockets of unimmunized children in Nigeria

BackgroundIn 2005, Nigeria adopted the Reaching Every Ward strategy to improve vaccination coverage for children 0–23 months of age. By 2015, Ogun state had full coverage (100%) in 12 of its 20 local government areas, but eight had pockets of unimmunized children, with the highest burden (37%) in Remo North. A participatory action research (PAR) approach was used to facilitate implementation of local solutions to contextual barriers to immunization in Remo North. This article assesses and seeks to explain the outcomes of the PAR implemented in Remo North to understand whether and possibly how it improved immunization utilization.MethodsThe PAR intervention took place from 2016 to 2017. It involved two (4-month) cycles of dialogue and action between community members, frontline health workers and local government officials in two wards of Remo North, facilitated by the research team. The PAR was assessed using a pre/post-intervention-only design with mixed methods. These included household surveys of caregivers of 215 and 213 children, respectively, 25 semi-structured interviews with stakeholders involved in immunization service delivery and 16 focus group discussions with community members. Data were analysed using the Strategic Advisory Group of Experts (SAGE) vaccine hesitancy framework.ResultsCollaboration among the three stakeholder groups enabled the development and implementation of solutions to identified problems related to access to and use of immunization services. At endline, assessment by card for children older than 9 months revealed a significant increase in those fully immunized, from 60.7% at baseline to 90.9% (p < .05). A significantly greater number of caregivers visited fixed government health facilities for routine immunization at endline (83.2%) than at baseline (54.2%) (p < .05). The reasons reported by caregivers for improved utilization of routine immunization services were increased community mobilization activities and improved responsiveness of the health workers. Spillover effects into maternal health services enhanced the use of immunization services by caregivers. Spontaneous scale-up of actions occurred across Remo North due to the involvement of local government officials.ConclusionThe PAR approach achieved contextual solutions to problems identified by communities. Collection and integration of evidence into discussions/dialogues with stakeholders can lead to change. Leveraging existing structures and resources enhanced effectiveness.

Impact evaluation of immunisation service integration to nutrition programmes and paediatric outpatient departments of primary healthcare centres in Rumbek East and Rumbek Centre counties of South Sudan

ObjectiveTo evaluate the impact of immunisation service integration to nutrition programmes and under 5-year-old paediatric outpatient departments of primary healthcare centres in Rumbek East and Rumbek Centre counties of South...

Leveraging on the 2017/2018 measles vaccination campaign to improve health workers knowledge and practice on injection safety: A case study of north-central states, Nigeria

IntroductionGlobally, knowledge of health workers has been documented to be key in effective immunisation service delivery. The parenteral route of drug administration is a vital healthcare procedure used in the administration of medicines using needle and syringe. Despite the importance of this procedure, improper handling of the device has resulted in an unsafe practice among health workers who attend to patients receiving injectable medications. A phased measles vaccination campaign (MVC) was conducted in 2017/2018 with a key objectives of training health workers on injection safety. This paper examines the association between improvement on knowledge of health workers through improved training curriculum and their practice on injection safety. MethodsWe reviewed information on handling and administration of the measles vaccine from the open data kit (ODK) platform finalised microplans and the training curriculum used during the 2015/2016 and 2017/2018 MVC. We analysed our results using paired t-test analysis, SPSS and Microsoft Excel spreadsheet and reported results in frequencies and proportions using charts and tables. ResultsOur findings revealed more health workers were trained during the 2017/2018 MVC as compared to 2015/2016 MVC. The curriculum adopted during the 2017/2018 MVC showed that multiple techniques were adopted during training compared to only class lectures used during the 2015/2016 MVC. A paired t-test analysis comparing the impact of training on the knowledge of the health workers during 2015/2016 and 2017/2018 MVC revealed significant improvement across five states during the 2017/2018 MVC, with mean ranging from 6.5% in the FCT to 23.7% in Nassarawa state. ConclusionThe review of training curriculum and use of multiple training styles during the 2017/2018 MVC improved the knowledge of health workers. Immunisation programmes will benefit from adopting the training curriculum to meet the specific needs of the health workers.

Tracking government spending on immunization: The joint reporting forms, national health accounts, comprehensive multi-year plans and co-financing data

BackgroundCoverage rates for immunization have dropped in lower income countries during the COVID-19 pandemic, raising concerns regarding potential outbreaks and premature death. In order to re-invigorate immunization service delivery, sufficient financing must be made available from all sources, and particularly from government resources. This study utilizes the most recent data available to provide an updated comparison of available data sources on government spending on immunization. MethodsWe examined data from WHO/UNICEF’s Joint Reporting Form (JRF), country Comprehensive Multi-Year Plan (cMYP), country co-financing data for Gavi, and WHO National Health Accounts (NHA) on government spending on immunization for consistency by comparing routine and vaccine spending where both values were reported. We also examined spending trends across time, quantified underreporting and utilized concordance analyses to assess the magnitude of difference between the data sources. ResultsRoutine immunization spending reported through the cMYP was nearly double that reported through the JRF (rho = 0.64, 95% 0.53 to 0.77) and almost four times higher than that reported through the NHA on average (rho = 3.71, 95% 1.00 to 13.87). Routine immunization spending from the JRF was comparable to spending reported in the NHA (rho = 1.30, 95% 0.97 to 1.75) and vaccine spending from the JRF was comparable to that from the cMYP data (rho = 0.97, 95% 0.84 to 1.12). Vaccine spending from both the JRF and cMYP was higher than Gavi co-financing by a at least two (rho = 2.66, 95% 2.45 to 2.89) and (rho = 2.66, 95% 2.15 to 3.30), respectively. ImplicationsOverall, our comparative analysis provides a degree of confidence in the validity of existing reporting mechanisms for immunization spending while highlighting areas for potential improvements. Users of these data sources should factor these into consideration when utilizing the data. Additionally, partners should work with governments to encourage more reliable, comprehensive, and accurate reporting of vaccine and immunization spending.

Community chain pharmacists’ perceptions of increased technicians’ involvement in the immunization process

BackgroundOver the past 2 decades, pharmacists have positioned immunization services as an important aspect of their expanding role in patient care. ObjectivesTo examine how community chain pharmacists view time spent on immunization, available in-store resources and barriers, and pharmacy technician involvement in the context of their views about the achievement of key National Vaccine Advisory Committee (NVAC) Standards of Adult Immunization Practice in their workplace. MethodsA representative, nationwide survey was administered electronically to chain community pharmacists over a 4-week period. Community pharmacists offering year-round immunization in retail chain, supermarket, and mass-merchant settings, randomly sampled from a database maintained by the American Pharmacists Association. We examined several sets of interrelated relationships regarding pharmacists’ perceived achievement of 3 key NVAC standards (assessment, recommendation and administration), time spent on the overall immunization process, the effectiveness of available in-store resources, immunization impediments, and the endorsement of increased technician involvement in community pharmacy-based immunization service (PBIS) delivery. ResultsA sample of 590 survey responses was obtained from 9717 e-mails delivered, with 489 deemed eligible (5% response rate). Sizeable numbers of pharmacists acknowledged that several activities integral to achieving optimal immunization levels were not being addressed. Although pharmacists accepted that appropriately trained pharmacy technicians should be able to ask (77%) and assess (66%) patients, only 24% agreed that technicians should be able to administer vaccine doses. Pharmacists satisfied with in-store immunization resources and technicians’ involvement were more likely to report achieving the 3 key NVAC standards. Paradoxically, how pharmacists viewed their immunization time expenditures was unrelated to whether they agreed that pharmacy technicians should have an expanded role in asking, assessing, or administering vaccines to their patients. ConclusionOverall, community pharmacies would likely better meet national immunization goals by achieving all 3 key NVAC standards and incorporating expanded roles for appropriately trained and supervised technicians in PBIS.

Using an adaptive, codesign approach to strengthen clinic-level immunisation services in Khayelitsha, Western Cape Province, South Africa

IntroductionOptimal immunisation programme service delivery and childhood vaccine coverage remains an ongoing challenge in South Africa. Previous health systems approaches have made recommendations on how to address identified barriers but...

Assessment of healthcare worker’s implementation of childhood routine immunization in primary healthcare centers in Edo State, Nigeria: A mixed method survey

The role of the health care personnel in the delivery of immunization services is very important in achieving the target of immunization coverage of 90% given by the world Health Organisation (WHO). The objective of the study was to determine the challenges affecting healthcare worker’s implementation of immunization services in Primary Healthcare Care (PHC) centres in Edo State, Nigeria. A descriptive cross-sectional study design, with a mixed method of data collection approach (incorporating quantitative and qualitative methods) using an interviewer administered questionnaire among 295 respondents (comprised of 270 health care providers, 7 key informants and 18 supervisors) of immunization activities in the various health care facilities for the Focus Group Discussion (FGD) guide. Ethical clearance for the study was obtained from the Ethics Committee of the University of Benin Teaching Hospital. Quantitative data collected was analyzed using the International Business Machine statistical package for Social Science (IBM) version 21.0 while themes occurring in the qualitative data were analyzed using ATLAS.ti software. Logistic regression was calculated to determine odds ratio and level of significance was set at &lt;0.05. This study showed that good knowledge of immunization. age, training on the implementation of immunization, and designation affected their knowledge of immunization, and some of the challenges encountered were insufficient workers and transport for outreach activities, funding and impress, lack of motivation. Health worker’s knowledge of immunization was good, majority were trained on implementation on immunization services but there were still numerous challenges such as insufficient workers and transportation which must be addressed to strengthen and improve immunization service delivery.

Application of the Geographic Information System (GIS) in immunisation service delivery; its use in the 2017/2018 measles vaccination campaign in Nigeria

BackgroundAs global effort is made towards measles elimination, the use of innovative technology to enhance planning for the campaign has become critical. GIS technology has been applied to track polio vaccination activities in Nigeria with encouraging outcomes. Despite numerous measles vaccination campaigns after the first catch up campaign in 2005, sub-optimal outcomes of previous measles supplemental immunization activities necessitated the use of innovative ideas to achieve better outcomes especially when planning for the 2017/2018 measles vaccination campaign. This led to the application of the use of the GIS technology for the Northern states in 2017/2018 campaign. This study is a report of what was achieved with the use of the GIS in the 2017/2018 measles vaccination campaign in Nigeria. MethodsGIS generated ward maps were used for the microplanning processes for the 2017/2018 measles vaccination campaign. These ward maps had estimates of the target population by settlements, the number and location of vaccination posts ensuring that a vaccination post is sited within one-kilometer radius of a settlement, and the number of teams needed to support the vaccination campaign as well as the catchment area and daily implementation plans. The ward microplans were verified by checking for accuracy and consistency of the target population, settlements, number of teams, vaccination posts and daily implementation work plans using a standard checklist. The ward maps were deployed into use for the measles vaccination campaign after the state team driven validation and verification by the National team (Government and Partners) ResultsThe Northern states that applied the GIS technology had a closer operational target population to that on the verified microplan than those of the non-GIS technology states. Greater than 90% of the ward maps had all that is expected in the maps - i.e settlements, target populations, and vaccination posts captured, except Kaduna, Katsina and Adamawa states. Of all enumeration areas sampled during the post-campaign survey in states with GIS ward maps, none had a zero-vaccination coverage of the surveyed children, with the exception of one in Borno state that had security issues. In the post campaign coverage survey, the percentage of responses that gave vaccination post being too far as a reason for non-vaccination of children in the Northern zones that used GIS generated ward maps was less than half the rate seen in the southern zones where the GIS microplanning was not used. ConclusionThe use of GIS-generated wards maps improved the quality of ward micro plans and optimized the placement of vaccination posts, resulting in a significant reduction in zero-dose clusters found during the post campaign coverage survey.

Rethinking Strategies to Address Inequity in Immunization Services towards Achieving Universal Immunization Coverage (UIC) in Karachi, Pakistan

Karachi, the largest city in Pakistan, having high population growth and a complex health care environment, has highest density of unimmunized (zero dose) and under-immunized children. The main reasons of low immunization coverage in Karachi were lack of governance and accountability in a duplicative and fragmented health management structure, weak and inequitable immunization services, and lack of demand and trust among people for immunization services. The Expanded Programme on Immunization (EPI), Ministry of Health (MOH) in Sindh Province spearheaded a structured and collaborative process to develop strategies for addressing inequity in immunization services towards achieving Universal Immunization Coverage (UIC) in Karachi. The process included a situation analysis with gathering quantitative and qualitative information on the root causes of zero-dose and inequity of the immunization services. The strategies and interventions were developed with multi-layer input and feedback of the stakeholders and partners, and focusing primarily to address gaps in three program areas: governance, leadership and accountability; immunization service delivery; and building demand and trust among the people. The interventions were further prioritized for high-risk areas; identified based on maximum number zero-dose children, presence of large slum areas, measles outbreak and on-going circulation of wild poliovirus. Finally, costing for the Roadmap activities was done through consultation with partners and aligning domestic and external (donor) resources. In this paper, we have highlighted the unique process the Sindh Government undertook in collaboration with the stakeholders and partners to develop strategies and interventions for addressing inequity in urban immunization services in Karachi towards achieving Universal Immunization Coverage (UIC). Similar processes can be adapted, as a potential model, for developing strategies to achieve universal health coverage in the cities of Pakistan and in other countries.

Assessment of immunization service delivery in Pakistan: A cross-sectional survey of health facilities

Abstract Background Routine childhood immunization coverage in Pakistan remains sub-par, in part, due to the poor quality of service delivery. This study aims to summarize the quality of immunization centers throughout the Sindh province, Pakistan, by assessing all Government vaccination facilities and their associated health workers. Methods A health facility and worker assessment survey adapted from tools developed by BASICS and EPI-Sindh was used to record facility infrastructure, processes, and human resources. Using expert panel ranking, we developed critical criteria to indicate items immunization centers need to be operational (vaccinator, a cold box or refrigerator, and vaccine supplies) as well as high, low, and moderate function requirements and their respective scores. Results Out of 1396 centers assessed, 1236 (88.5%) were operational, while 1209 (86.6%) offered immunization services. Only 793 (66.0%) of the functional immunization facilities met the critical criteria. The average scores for high, moderate, and low function requirements were significantly lower for centers that did not meet the critical criteria. Of 2,153 healthcare workers interviewed, 1874 (87.1%) were vaccinators. 1805 (96.3%), 1655 (88.3%), and 1387 (74.0%) were trained in vaccination, cold chain, and inventory, respectively. Discussion One out of three immunization centers in Sindh lack the critical components essential for quality vaccination services. Health workers have adequate training and experience, suggesting that sub-optimal vaccination center quality is due to inadequate infrastructure and inefficient processes. Our study presents innovative and critical research findings with high-impact policy implications for identifying and addressing gaps to improve vaccination uptake within an LMIC setting. Key messages Every 2 out of 5 facilities in Sindh Province lacked essential equipment for immunizations such as vaccines, vaccinator and cold box for vaccination. In all health facilities, the health workers appear sufficiently trained, indicating that poor quality may be due to missing infrastructure and inefficient processes in resource-constrained settings.

Integrated Family Planning and Immunization Service Delivery at Health Facility and Community Sites in Dowa and Ntchisi Districts of Malawi: A Mixed Methods Process Evaluation.

The Government of Malawi’s Health Sector Strategic Plan II highlights the importance of service integration; however, in practice, this has not been fully realized. We conducted a mixed methods evaluation of efforts to systematically implement integrated family planning and immunization services in all health facilities and associated community sites in Ntchisi and Dowa districts during June 2016–September 2017. Methods included secondary analysis of service statistics (pre- and postintervention), focus group discussions with mothers and fathers of children under age one, and in-depth interviews with service providers, supervisors, and managers. Results indicate statistically significant increases in family planning users and shifts in use of family planning services from health facilities to community sites. The intervention had no effect on immunization doses administered or dropout rates. According to mothers and fathers, benefits of service integration included time savings, convenience, and improved understanding of services. Provision and use of integrated services were affected by availability of human resources and commodities, community linkages, data collection procedures and availability, sociocultural barriers, organization of services, and supervision and commitment of health surveillance assistants. The integration approach was perceived to be feasible and beneficial by clients and providers.

Routine immunization coverage in Pakistan: a survey of children under 1 year of age in community-based vaccination areas

Pakistan is one of two countries in which poliovirus remains endemic. Considering the high number of children born every year, reaching and vaccinating new birth cohorts by improving routine immunization coverage in children <1 year of age is crucial to halting virus transmission. In 2015, a community-based vaccination (CBV) strategy, using local community members to enhance vaccine acceptance and improve routine immunization service delivery, was introduced in areas of Pakistan that have never interrupted poliovirus transmission. In order to assess progress towards improving routine immunization, we performed house-to-house immunization surveys across ten CBV areas in 2017 and 2018. In each household, we determined age-appropriate routine antigen coverage for children <1 year of age based on vaccination card and caregiver recall. We surveyed 5,499 and 5,264 children in 2017 and 2018, respectively. Overall, coverage of inactivated poliovirus vaccine (IPV) at 14 weeks of age was 32% in 2017 and 39% in 2018 based on vaccination card and recall. Across the surveyed areas, coverage ranged from 7% in Killa Abdullah to 61% in Peshawar in 2018. Oral poliovirus vaccination coverage decreased with successive vaccination visits, ranging from 66% for the birth dose to 42% for the 14-week dose in 2018. No area reached the target of 80% coverage for any routine antigen. Our findings highlight the need for concerted efforts to improve routine immunization coverage in these critical areas of wild poliovirus transmission.

Promoting equity in immunization coverage through supply chain design in Pakistan.

To improve equity in immunization coverage, potent immunization products must be available in the communities in which low coverage rates persist. Most supply side investments are focused on replacing or establishing new health facilities to improve access to immunization. However, supply chain design must be improved to ensure that potent vaccines are available at all facilities to promote immunization equity. We used the supply chain design process in Pakistan as an opportunity to conceptualize how supply chains could impact equity outcomes. This paper outlines our approach and key considerations for assessing supply chain design as a contributing factor in achieving equitable delivery of immunization services. We conducted a supply chain analysis based on sub-national supply chain and immunization coverage at district level. Supply chain metrics included cold chain coverage and distances between vaccination sites and storage locations. Immunization coverage metrics included the third-dose diphtheria- tetanus-pertussis (DTP3) vaccination rate and the disparity in DTP3 coverage between urban and rural areas. All metrics were analyzed at the district level. Despite data limitations, triangulation across these metrics provided useful insights into the potential contributions of supply chain to equitable program performance at the district level within each province. Overall, our analysis identified supply chain gaps, highlighted supply chain contributions to program performance and informed future health system investments to prioritize children unreached by immunization services.