Missed Opportunities For Immunization Research Articles

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.

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. 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. 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. 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.

Effect of Electronic Health Record Reminders for Routine Immunizations and Immunizations Needed for Chronic Medical Conditions.

Immunization reminders in electronic health records (EHR) provide clinical decision support (CDS) that can reduce missed immunization opportunities. Little is known about using CDS rules from a regional immunization information system (IIS) to power local EHR immunization reminders. This study aimed to assess the impact of EHR reminders using regional IIS CDS-provided rules on receipt of immunizations in a low-income, urban population for both routine immunizations and those recommended for patients with chronic medical conditions (CMCs). We built an EHR-based immunization reminder using the open-source resource used by the New York City IIS in which we overlaid logic regarding immunizations needed for CMCs. Using a randomized cluster-cross-over pragmatic clinical trial in four academic-affiliated clinics, we compared captured immunization opportunities during patient visits when the reminder was "on" versus "off" for the primary immunization series, school-age boosters, and adolescents. We also assessed coverage of CMC-specific immunizations. Up-to-date immunization was measured by end of quarter. Rates were compared using chi square tests. Overall, 15,343 unique patients were seen for 26,647 visits. The alert significantly impacted captured opportunities to complete the primary series in both well-child and acute care visits (57.6% on vs. 54.3% off, p = 0.001, and 15.3% on vs. 10.1% off, p = 0.02, respectively), among most age groups, and several immunization types. Captured opportunities for CMC-specific immunizations remained low regardless of alert status. The alert did not have an effect on up-to-date immunization overall (89.1 vs. 88.3%). CDS in this population improved captured immunization opportunities. Baseline high rates may have blunted an up-to-date population effect. Converting Centers for Disease Control and Prevention (CDC) rules to generate sufficiently sensitive and specific alerts for CMC-specific immunizations proved challenging, and the alert did not have an impact on CMC-specific immunizations, potentially highlighting need for more work in this area.

Determinants of Poor Utilization and Accessibility of Immunization Services: A Qualitative Study in Selected Counties in South Sudan

BACKGROUND: Reducing vaccine-preventable diseases mortality and morbidity in non-industrialized countries requires the enforcement of robust immunization strategies aimed at increasing coverage and reducing dropouts and missed immunization opportunities. Attaining high (>80%) immunization coverage with a low drop-out rate in South Sudan has been challenging because of the program’s high defaulting rates. This study aimed to determine the reasons for poor accessibility and utilization of immunization services in counties earmarked for Fragility, Emergency and Refugees (FER) in South Sudan.
 
 METHODS: A descriptive phenomenological study design was conducted across four counties of Northern Bahr El Ghazal, South Sudan, between May 2019 and December 2020 in which 42 focused group discussions and key-informant interviews involving the community and primary healthcare centers and units were conducted. Relevant EPI (Expanded program on immunization) tools were reviewed and data were analyzed using thematic analysis. 
 
 RESULTS: The main reasons identified were negative attitudes towards healthcare workers and immunization services, competing priorities of the caregivers, delayed opening of the immunization sessions, insufficient cold chain facilities, inadequate knowledge and information about immunization services, and non-availability of vaccines at the health facility.
 
 CONCLUSIONS: A plan to supply adequate vaccines and related supplies to the counties by identifying stock levels in time must be a priority. Health facility micro-plan development and implementation should be supported by increased funding for the implementation of outreach and mobile sessions to reach missed children, intensified door-to-door health awareness, and regular community meetings to increase vaccine uptake.

Validation of mobile Decision Support System for scheduling age-appropriate immunizations

Abstract Background The prevalence of missed opportunities for immunization among children is estimated to be 32.2%. The introduction of new vaccines in EPI schedule and lack of training of frontline health workers (FHWs) on the guidelines for number and spacing of doses and manual construction of vaccine schedules based on a child's age deteriorates efficiencies of FHWs, especially in forecasting catch-up schedules. We have designed and tested the validity of an innovative Decision Support System Application Programming Interface (DSS-API) which will automatically generate an age-appropriate immunization schedule for a child. Methods Using a multi-country setting approach, DSS was deployed in six immunization facilities of Pakistan and Bangladesh between July 2019 to April 2020. Details of all visiting children were recorded in database. Information on date of birth and past immunization history was used by the DSS-API to determine an individualized age-appropriate immunization schedule. These schedules were compared to the gold standard's outputs calculated by an immunization expert. Results A total of 6,241 vaccination events were recorded from all the sites. Using area under the curve, the calculated sensitivity of DSS to determine age-appropriate immunization schedule was found between 99-100% for the individual EPI vaccines, while the specificity of the DSS algorithm was found between 98-100%. Conclusions DSS is a feasible feature that can be incorporated in Digital Immunization Registries to accurately schedule routine and catch-up immunizations and can effectively reduce Missed Opportunities for Immunizations by assisting FHWs through automatic construction of immunization schedules. Key messages DSS-API is a unique application that can improve process efficiencies of frontline health workers by automatic generation of accurate age-appropriate catch-up vaccine schedules. DSS has the potential to reduce missed opportunities for immunization (MOI) and improve immunization coverage and timeliness among children aged under 2 years.

Primary Health-Care Staff Barriers to Immunization.

Background:Missed opportunities for immunization (MOI) is considered as the most important preventable reason for underimmunization. Health-care workers stand beyond more than half the children's missed opportunities due to gaps in their knowledge, attitudes, and practices (KAP) regarding immunization.Objectives:This study assessed immunization staff at primary health-care centers in Baghdad/Al-Karkh for KAP that may lead to MOI.Materials and Methods:KAP survey was conducted on field immunization service providers at primary health-care centers in Baghdad/Al-Karkh. Barriers are considered to present whenever scores found <80 in any of KAP. Data were collected using a self-administered structured questionnaire analyzed by SPSS 24.Results:Among 217 respondent health professionals, 69 (31.8%) were physicians and 148 (68.2%) were nurses. The studied sample got mean scores for KAP of 84.7 ± 11.4, 71.1 ± 22.7, and 74.8 ± 20.3, respectively. Physicians had higher mean knowledge score compared to nurses (P < 0.05). Both physicians and nurses got mean scores below 80 for both attitudes and practices.Conclusion:Attitudes and practices in both physicians and nurses need to be improved to avoid MOI.

Missed opportunities for immunization among children attending a Paediatric Outpatient Clinic at Juba Teaching Hospital

Background: Immunization prevents child morbidity and mortality through the universal access to routinely recommended childhood vaccines. Objectives: To determine the prevalence and factors associated with missed opportunities for immunization (MOI). Method: An out-patient paediatric clinic-based study conducted in May - June 2012 using the standard World Health Organization (WHO), Expanded Programme on Immunization (EPI) protocol for assessing MOI. The study involved client exit interviews with caregivers of children aged less than 2 years, reviews of immunization cards and parental recall of immunization history, and interviews with health workers. Results: Data were collected on 448 children aged 0-23 months and from 18 health workers. The prevalence of MOI was most common among children older than 12 months. As the age of administration of the vaccine increased so did the number of MOI. MOI were more common for DPT3 (22.1%) OPV3 (24.4%), and measles (31.2%) compared to other vaccines. Factors associated with MOI included home births, inadequate antenatal care, lack of information, and, among health workers, poor knowledge of immunization schedules and contraindications. Conclusion: The high prevalence of MOI could be reduced by defaulter tracing, encouraging antenatal visits and hospital deliveries, and education of caregivers and health workers. Keywords: Immunization, missed opportunities, young children, South Sudan

Strengthening routine immunization systems to improve global vaccination coverage.

Global coverage with the third dose of diphtheria-tetanus-pertussis vaccine among children under 1 year of age stagnated at ∼ 83-84% during 2008-13. Annual World Health Organization and UNICEF-derived national vaccination coverage estimates. Incomplete vaccination is associated with poor socioeconomic status, lower education, non-use of maternal-child health services, living in conflict-affected areas, missed immunization opportunities and cancelled vaccination sessions. Vaccination platforms must expand to include older ages including the second year of life. Immunization programmes, including eradication and elimination initiatives such as those for polio and measles, must integrate within the broader health system. The Global Vaccine Action Plan (GVAP) 2011-20 is a framework for strengthening immunization systems, emphasizing country ownership, shared responsibility, equity, integration, sustainability and innovation. Immunization programmes should identify, monitor and evaluate gaps and interventions within the GVAP framework.

Tetanus and diphtheria immunity among term and preterm infant-mother pairs in Turkey, a country where maternal and neonatal tetanus have recently been eliminated.

The aim of our study was to investigate the anti-tetanus and anti-diphtheria antibody titres and the placental transfer of these antibodies in a group of vaccinated and unvaccinated mothers and their term or preterm offsprings. Anti-tetanus and anti-diphtheria toxoid IgG antibodies were measured quantitatively by ELISA in 91 infant-mother pairs. Protective concentrations of anti-tetanus and anti-diphtheria were found in 58.3 and 50% of mothers in the unvaccinated group and 94.5 and 85.5% of the mothers in the vaccinated group. Protective concentrations were found in 63.9 and 50% of cord samples, respectively, in the unvaccinated group and in 96.4 and 85.5% of cord samples, respectively, in the vaccinated group (p = 0.0001). There were no differences in the maternal and cord geometric mean concentrations (GMCs) of anti-toxoid antibodies between those who received two doses or one dose of Td. The GMCs of maternal and cord anti-tetanus and anti-diphtheria were statistically similar between preterm and term groups. Placental transfer ratios (TR) for anti-tetanus and anti-diphtheria were 175 and 150%, respectively, in the preterm group and 213 and 178%, respectively, in the term group. There was a strong correlation between maternal and cord anti-toxoid antibody levels. Maternal vaccination was the only predictor of having protective concentrations of anti-toxoid antibodies in cord blood. Vaccinating pregnant women with at least one dose of Td would confer protection for both the term and preterm infant-mother pairs. Therefore, health personnel caring for pregnant women have the responsibility to emphasize the importance of Td vaccination to avoid missed immunization opportunities.

An observational, health service based survey for missed opportunities for immunization

Studies cite missed opportunities for immunization (MOI) as a contributor to under-vaccination. The present prospective survey aimed at determining the magnitude of MOI, its contribution to under-vaccination, and identifying risk factors for MOI. Mothers of 1384 indoor patients £6 years were interviewed. There were 266 (19.2%) children with MOI, accounting for 79.6% of under-vaccination and 93% of under-vaccination time. MOI occurred significantly more often with home delivery (P <0.001, Odds ratio 5.1), incomplete or incorrect maternal knowledge of immunization (P=0.001, Odds ratio 4.8) and, general practice and non-Pediatric/non-Medical college based practice (P=0.001, Odds ratio 4.0). The impact of sociodemographic factors on likelihood of MOI was not significant.

Health Care Workers Contribution to Missed Immunization Opportunities in Children

This study was aimed at identifying the health workers' knowledge and inappropriate practices that potentially contribute to missed immunization opportunities in children. A cross-sectional survey was conducted in August 2007 among Primary Health Care workers in Khana Local Government Area of Rivers State, Nigeria on the knowledge and practices of childhood immunization. It focused on their knowledge and practices of the national immunization schedule and false contraindications to childhood immunization. All data generated was analyzed using Epi Info version 6.04d statistical package. Most of the primary health care workers, 285 (76.0%) had adequate knowledge of the National Immunization Schedule for children with accurate knowledge of vaccine dosages, routes of administration and intervals between doses. However, their knowledge of false contraindications to immunization was low. Two-thirds of the health care workers, 65.9% [95%CI=60.0-70.8] had poor knowledge of the importance of routine screening of children for immunization when they presented to the health facilities for other curative services. Similarly, less than a quarter of the health care workers, 50 (13.3%) knew that HIVpositive status of women was not a contraindication for the immunization of their children. In the same vein only about a quarter of the health care workers 85 (22.7%) immunized severely malnourished children (p=0.0000). Also, less than half of the health care workers, 145 (35.7%) immunized children with mild feverish conditions (t0

Seize the moments: missed opportunities to immunize at the family practice level

Missed immunization opportunities (MOs) are a significant barrier to achieving high immunization coverage. To describe the nature of MOs to immunize within primary care in New Zealand and their effect on immunization completeness. Audit of medical records of approximately 10 randomly selected children <2 years old from each of 62 primary care practices in Auckland, New Zealand. The 616 audited children made 10 094 visits to primary care practices. MOs occurred at 97% (60) of practices, in 556 (5.5%) of visits, and 31% of the children had one or more visits that were an MO. Overall, children who had any recorded MO visit were 3.1 times more likely to be incompletely immunized than children who had no recorded MO (95% CI 1.87-5.14). Children with the greater percentage of overall visits that were MOs had up to a 9 times increased likelihood of incomplete immunization compared to those who had no MO visits. Nurse visits have less MOs than doctor (1.5% versus 6%) but are more likely to occur within well-child visits. MOs are common in primary care practices, occurring in nearly one-third of visiting children. The risk of under-immunization increases with the increasing percentage of visits that are MOs. Overall strategies directed at reducing MOs need to focus on a range of aspects for the practitioner and the practice system.

Assessing immunization programs

Assessing immunization programs

Assessing Immunization Programs

Assessing Immunization Programs

Susceptibility to tetanus and missed vaccination opportunities in Portuguese women

Maternal and cord sera (96 pairs) were tested to measure antitetanus toxin IgG (ATT IgG) levels, using a commercial enzyme immunoassay. One mother had no detectable antitetanus antibody and four more had levels below those considered to be reliably protective (<160 mIU/ml). All five had been eligible for vaccination during pregnancy according to Portuguese guidelines, although one had received seven lifetime doses of TT. In maternal and cord sera, ATT IgG levels among those not vaccinated during the current pregnancy were significantly lower than among vaccinees ( p<0.0001), but there was no difference between those vaccinated once or twice during pregnancy. Among those not vaccinated during pregnancy, levels of ATT IgG decreased with time since last dose of vaccine ( P=0.0001). The total number of doses of vaccine was not significantly associated after controlling for time since last dose. Missed immunization opportunities occurred among half the women studied. Efforts to sustain protection against tetanus must be intensified.

Challenges to Private Provider Participation in Immunization Registries

Background For immunization registries to be effective, all providers (both private and public) of childhood vaccines must be willing to participate. The purpose of this study was to identify and fully understand the (1) benefits of the North Carolina Immunization Registry (NCIR), (2) barriers to participation by private practice physicians, and (3) potential incentives to address the barriers identified. Methods We conducted a statewide series of 13 focus groups (6 with pediatricians, 5 with family physicians, and 2 with office managers). Participants represented the full range of nonpublic practice settings (e.g., solo, small, and large group practices, HMOs, and university clinics). Many participants questioned the need for an immunization registry and wanted evidence that it is a cost-effective intervention. We compared our findings with those found in other All Kids Count (AKC) sites. Results The benefits of the NCIR commonly identified included having access to a complete and accurate history of a child’s immunizations, thus eliminating the need for phone calls to other practices for immunization records and eliminating the need to document immunization information in multiple sites, thus automatically producing immunization forms for daycare, school, etc., and decreasing missed immunization opportunities. Barriers to participation included the following: the staff time needed to submit and obtain data, direct and indirect costs to practices (e.g., computer software, hardware, upgrades, data entry time), accuracy of data, liability for errors, and access to and security of data. Conclusions Physicians must be convinced that the NCIR will be simple and inexpensive to use, flexible, and easy to integrate into their existing office systems. Public health officials should not underestimate the effort that will be required to achieve full participation by private-practice providers.

Missed opportunities for immunization in a pediatric hospital in Fortaleza, State of Ceará - Brazil

To define missed opportunities for immunization (MOI) at Albert Sabin Children's Hospital, in the city of Fortaleza, Brazil, the author studied 119 outpatients aged under 24 months that were attended at the hospital. Thirty-seven children (31%) were missing vaccines. Ninety percent of the children had immunization cards but only 40% had their cards verified by health workers.Fifty-eight percent out of 43 inpatients were missing vaccines without contraindication and 54% of the mothers were missing doses of tetanus toxoid vaccine.Eighty-six percent of 22 health workers had good knowledge about the vaccination schedule, but only 23% did know 3 true contraindications to vaccines. The most important causes of MOI were health workers' neglect to ask for the vaccination card and false contraindications.

Missed Opportunities for Immunization at The Out-Patient Clinic: Prevalence and Related Factors

From November 1992 through January 1993 a cross sectional study was conducted to determine the prevalence and related factors of missed opportunities for immunization (MOI). The study involved 280 babies aged less than 12 months. Interview was performed by using a questionnaire as the babies left the clinic after seeing the clinic personnel (exit interview). The primary source of information was the accompanying person and their immunization card. There were 149 (53 percent) male and 131 (47 percent) female babies. A total of 208 babies (74.3 percent) stated to have immunization card, although only 19 (9.1 percent) took it at the time of the study. Out of 234 babies (83.5 percent) with partial immunization status, 9 had contraindication to immunization. Among 225 babies without contraindication, only 88 babies were suggested to have immunization. MOI was found in 137 (48.8 percent) babies (95 percent confidence interval: 43 percent; 55 percent). Concerning the kind of vaccine, OPV was the most often missed. Of 88 babies (31.4 percent) suggested for immunization, 43 agrreed and had been given various vaccines including simultaneus immunization at the Well-child Clinic. Screening for immunization not consistently practiced, missed interpretation to contraindication was detected. Among babies suggested for immunization, significant relationships were found between the number of children in the family (p less than 0.05), father's (p less than 0.05) and mother's education (p less than 0.001) and acceptance to immunization.

Missed Immunization Opportunities

We read with great interest the recent studies in Pediatrics on missed opportunities for childhood immunization. Given the current national debate on ways to control health care costs and the recent proposals for federal procurement of all vaccine supplies, it is encouraging and illuminating to know that significant increases in immunization rates might be achieved without tremendous additional expense. One of the major limitations of these studies, clearly acknowledged by the authors of the first but not the second study, was the inability to assess the role of immunization record availability in missed opportunities. Our experience leads us to agree that lack of immunization records contribute to missed opportunities for immunization far more often than the 2% of visits suggested by the first study.

In Reply: Missed Immunization Opportunities

Drs Derauf and Derauf make an important point. The reduction of missed immunization opportunities is a very cost-effective way to deal with low vaccination rates in our cities, and the portable record might overcome one of the major obstacles to using immunization opportunities, namely, lack of immunization status information at the medical encounter. As suggested, the effectiveness of the portable record might be vastly improved by making it more attractive through use of baby pictures. Complimentary ideas include the use of reminder stickers on these cards for the next appointment and expanding the cards into "baby passports" that include developmental data and other screening information.

Obstacles to Achieving Immunization for all 2000: Missed Immunization Opportunities and Inappropriately Timed Immunization

Missed opportunities and inappropriately time immunization substantially reduced the coverage achieved in Mozambique and Guinea Conakry. During coverage surveys in Mozambique, we noted dates of attendance at a health facility for growth monitoring or vaccination, and in Conakry we also abstracted dates of curative care visits from home-based documents. In Mozambique, an average of 84 per cent of children aged 12-23 months had documents, and an average of 53 per cent of children were fully and correctly vaccinated. Among children with cards, 11 per cent had received all vaccines, but at least one dose was applied before the recommended age or with too short an interval between doses (inappropriately timed vaccinations). A further 8 per cent of children had sufficient documented contacts with preventive services to be fully vaccinated, but immunization opportunities had been missed. In Conakry, 54 per cent of 12-23 month-old children had immunization cards, and only 19 per cent were fully and correctly vaccinated. Among children with cards, 9 per cent had received all vaccines, but some were inappropriately timed, and 19 per cent had enough contacts with curative or preventative services to be fully vaccinated, but opportunities had been missed. We recommend that home-based records document all health centre visits, including those for curative care, and that missed opportunities and vaccination timing be routinely evaluated during vaccine coverage surveys.