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Objective To assess the efficacy of modest non-financial incentives on immunisation rates in children aged 1-3 and to compare it with the effect of only improving the reliability of the supply of services.Design Clustered randomised controlled study. Setting Rural Rajasthan, India.Participants 1640 children aged 1-3 at end point.Interventions 134 villages were randomised to one of three groups: a once monthly reliable immunisation camp (intervention A; 379 children from 30 villages); a once monthly reliable immunisation camp with small incentives (raw lentils and metal plates for completed immunisation; intervention B; 382 children from 30 villages), or control (no intervention, 860 children in 74 villages). Surveys were undertaken in randomly selected households at baseline and about 18 months after the interventions started (end point).Main outcome measures Proportion of children aged 1-3 at the end point who were partially or fully immunised.Results Among children aged 1-3 in the end point survey, rates of full immunisation were 39% (148/382, 95% confidence interval 30% to 47%) for intervention B villages (reliable immunisation with incentives), 18% (68/379, 11% to 23%) for intervention A villages (reliable immunisation without incentives), and 6% (50/860, 3% to 9%) for control villages. The relative risk of complete immunisation for intervention B versus control was 6.7 (4.5 to 8.8) and for intervention B versus intervention A was 2.2 (1.5 to 2.8). Children in areas neighbouring intervention B villages were also more likely to be fully immunised than those from areas neighbouring intervention A villages (1.9, 1.1 to 2.8). The average cost per immunisation was $28 (1102 rupees, about £16 or €19) in intervention A and $56 (2202 rupees) in intervention B.Conclusions Improving reliability of services improves immunisation rates, but the effect remains modest. Small incentives have large positive impacts on the uptake of immunisation services in resource poor areas and are more cost effective than purely improving supply.Trial registration IRSCTN87759937.

Enhancing vaccine uptake is a critical public health challenge 1 . Overcoming vaccine hesitancy 2 , 3 and failure to follow through on vaccination intentions 3 requires effective communication strategies 3 , 4 . Here we present two sequential randomized controlled trials to test the effect of behavioural interventions on the uptake of COVID-19 vaccines. We designed text-based reminders that make vaccination salient and easy, and delivered them to participants drawn from a healthcare system one day (first randomized controlled trial) ( n  = 93,354 participants; clinicaltrials number NCT04800965) and eight days (second randomized controlled trial) ( n  = 67,092 individuals; clinicaltrials number NCT04801524) after they received a notification of vaccine eligibility. The first reminder boosted appointment and vaccination rates within the healthcare system by 6.07 (84%) and 3.57 (26%) percentage points, respectively; the second reminder increased those outcomes by 1.65 and 1.06 percentage points, respectively. The first reminder had a greater effect when it was designed to make participants feel ownership of the vaccine dose. However, we found no evidence that combining the first reminder with a video-based information intervention designed to address vaccine hesitancy heightened its effect. We performed online studies ( n  = 3,181 participants) to examine vaccination intentions, which revealed patterns that diverged from those of the first randomized controlled trial; this underscores the importance of pilot-testing interventions in the field. Our findings inform the design of behavioural nudges for promoting health decisions 5 , and highlight the value of making vaccination easy and inducing feelings of ownership over vaccines. Two randomized controlled trials demonstrate the ability of text-based behavioural ‘nudges’ to improve the uptake of COVID-19 vaccines, especially when designed to make participants feel ownership over their vaccine dose.

Vaccination is a cost-effective public health intervention, yet evidence abounds that vaccination uptake is still poor in many low- and middle-income countries. Traditional and Religious Leaders play a substantial role in improving the uptake of health services such as immunization. However, there is paucity of evidence on the cost-effectiveness of using such strategies. This study aimed to assess the cost-effectiveness of using a multi-faceted intervention that included traditional and religious leaders for community engagement to improve uptake of routine immunisation services in communities in Cross River State, Southern Nigeria. The target population for the intervention was traditional and religious leaders in randomly selected communities in Cross River State. The impact of the intervention on the uptake of routine vaccination among children 0 to 23 months was assessed using a cluster randomized trials. Outcome assessments were performed at the end of the project (36 months).The cost of the intervention was obtained from the accounting records for expenditures incurred in the course of implementing the intervention. Costs were assessed from the health provider perspective. The cost-effectiveness analysis showed that the incremental cost of the initial implementation of the intervention was US $19,357and that the incremental effect was 323 measles cases averted, resulting in an incremental cost-effectiveness ratio (ICER) of US$ 60/measles case averted. However, for subsequent scale-up of the interventions to new areas not requiring a repeat expenditure of some of the initial capital expenditure the ICER was estimated to be US$34 per measles case averted. Involving the traditional and religious leaders in vaccination is a cost-effective strategy for improving the uptake of childhood routine vaccinations.

Five hundred thousand children under the age of 5 die from vaccine preventable diseases in India every year. More than just improving coverage, increasing timeliness of immunizations is critical to ensuring infant health in the first year of life. Novel, culturally appropriate community engagement strategies are worth exploring to close the immunization gap. In our study, a digital NFC (Near Field Communication) pendant worn on black thread and voice call reminder system was tested for the effectiveness in improving DTP3 adherence within 2 monthly camps from DTP1 administration. A cluster randomized controlled trial was conducted in which 96 village health camps were randomized to 3 arms: NFC sticker, NFC pendant, and NFC pendant with voice call reminder in local dialect. Randomization was done across 5 blocks in the Udaipur District serviced by Seva Mandir from August 2015 to April 2016. In terms of our three primary outcomes related to DTP3 adherence, point estimates show conflicting results. Two outcomes presented adherence in the control. DTP3 completion within two camps after DTP1 showed higher adherence in the Control (Sticker) (74.2%) arm compared to the Pendant (67.2%) and Pendant and Voice arms (69.3%). Likewise, the estimate for DTP3 completion within 180 days of birth in the Control (Sticker) (69.4%) arm was higher than estimates in the Pendant (57.4%) and Pendant and Voice arms (58.7%). However, one outcome displayed higher adherence in the intervention. DTP3 completion within two months from the time of registration was higher in the Pendant (37.7%) and Pendant and Voice arms (38.7%) compared to the Control (Sticker) arm (27.4%). In all primary outcomes, differences in adherence were statistically insignificant both before and after controlling for confounding factors. In terms of secondary outcomes, our results suggest that providing a necklace generated significant community discussion (H = 8.8796, df = 2, p = .0118), had strong satisfaction among users (χ2=26.039, df = 4, p < .0001), and resulted in increased visibility within families (grandmothers:χ2=34.023, df = 2, p < .0001, fathers: χ2=34.588, df = 2, p < .0001). Neither the NFC necklace nor the necklace with additional voice call reminders in the local dialect directly resulted in an increase in infant immunization timeliness through DTP3, the primary outcome. Still our process outcomes suggest that our culturally symbolic necklace has potential to be an assistive tool in immunization campaigns. Follow-on work will seek to examine whether positive behavior change towards vaccines can be fostered with earlier engagement of this platform beginning in the prenatal stage, under a continuum of care framework.

State health departments commonly use quality improvement coaching as an implementation strategy for improving low human papillomavirus (HPV) vaccination coverage, but such coaching can be resource intensive. To explore opportunities for improving efficiency, we compared in-person and webinar delivery of coaching sessions on implementation outcomes, including reach, acceptability, and delivery cost. In 2015, we randomly assigned 148 high-volume primary care clinics in Illinois, Michigan, and Washington State to receive either in-person or webinar coaching. Coaching sessions lasted about 1 hr and used our Immunization Report Card to facilitate assessment and feedback. Clinics served over 213,000 patients ages 11-17. We used provider surveys and delivery cost assessment to collect implementation data. This report is focused exclusively on the implementation aspects of the intervention. More providers attended in-person than webinar coaching sessions (mean 9 vs. 5 providers per clinic, respectively, p = .004). More providers shared the Immunization Report Card at clinic staff meetings in the in-person than webinar arm (49% vs. 20%; p = .029). In both arms, providers' belief that their clinics' HPV vaccination coverage was too low increased, as did their self-efficacy to help their clinics improve (p < .05). Providers rated coaching sessions in the two arms equally highly on acceptability. Delivery cost per clinic was$733 for in-person coaching versus $ 461 for webinar coaching. In-person and webinar coaching were well received and yielded improvements in provider beliefs and self-efficacy regarding HPV vaccine quality improvement. In summary, in-person coaching cost more than webinar coaching per clinic reached, but reached more providers. Further implementation research is needed to understand how and for whom webinar coaching may be appropriate. Keywords HPV vaccine, Immunization programs, Quality improvement coaching, Primary care, State health departments, Assessment and feedback

This article presented the World Health Organization’s (WHO) recommendations on the use of Rabies vaccines excerpted from the Rabies vaccines: WHO position paper – April 2018 published in the Weekly Epidemiological Record [1] This position paper replaces the 2010 WHO position paper on rabies vaccines [2]. It presents new evidence in the field of rabies and the use of rabies vaccines, focussing on programmatic feasibility, simplification of vaccination schedules and improved cost-effectiveness. The recommendations concern the 2 main immunization strategies, namely vaccination for post-exposure prophylaxis and vaccination for pre-exposure prophylaxis. In the context of post-exposure prophylaxis, recommendations are also provided on the use of rabies immunoglobulins. Footnotes to this paper provide a number of core references including references to grading tables that assess the quality of the scientific evidence, and to the evidence-to-recommendation tables. In accordance with its mandate to provide guidance to Member States on health policy matters, WHO issues a series of regularly updated position papers on vaccines and combinations of vaccines against diseases that have an international public health impact. These papers are concerned primarily with the use of vaccines in large-scale immunization programmes; they summarize essential background information on diseases and vaccines, and conclude with WHO’s current position on the use of vaccines in the global context. Recommendations on the use of cholera vaccines were discussed by the Strategic Advisory Group of Experts (SAGE) in October 2017; evidence presented at these meetings can be accessed at: http://www.who.int/immunization/sage/meetings/2017/october/presentations_background_docs/en/.

The WHO recommends annual influenza vaccination to prevent influenza illness in high-risk groups. Little is known about national influenza immunization policies globally. The 2014 WHO/UNICEF Joint Reporting Form (JRF) on Immunization was adapted to capture data on influenza immunization policies. We combined this dataset with additional JRF information on new vaccine introductions and strength of immunization programmes, as well as publicly available data on country economic status. Data from countries that did not complete the JRF were sought through additional sources. We described data on country influenza immunization policies and used bivariate analyses to identify factors associated with having such policies. Of 194 WHO Member States, 115 (59%) reported having a national influenza immunization policy in 2014. Among countries with a national policy, programmes target specific WHO-defined risk groups, including pregnant women (42%), young children (28%), adults with chronic illnesses (46%), the elderly (45%), and health care workers (47%). The Americas, Europe, and Western Pacific were the WHO regions that had the highest percentages of countries reporting that they had national influenza immunization policies. Compared to countries without policies, countries with policies were significantly more likely to have the following characteristics: to be high or upper middle income (p<0.0001); to have introduced birth dose hepatitis B virus vaccine (p<0.0001), pneumococcal conjugate vaccine (p=0.032), or human papilloma virus vaccine (p=0.002); to have achieved global goals for diphtheria-tetanus-pertussis vaccine coverage (p<0.0001); and to have a functioning National Immunization Technical Advisory Group (p<0.0001). The 2014 revision of the JRF permitted a global assessment of national influenza immunization policies. The 59% of countries reporting that they had policies are wealthier, use more new or under-utilized vaccines, and have stronger immunization systems. Addressing disparities in public health resources and strengthening immunization systems may facilitate influenza vaccine introduction and use.

Background Vaccination is a cost-effective and life-saving intervention. Recently several new, but more expensive vaccines have become part of immunization programmes in low and middle income countries (LMIC). Monitoring vaccine wastage helps to improve vaccine forecasting and minimise wastage. As the costs of vaccination increases better vaccine management is essential. Many LMIC however do not consistently monitor vaccine wastage. Methods We conducted two surveys in health facilities in rural and urban Gambia; 1) a prospective six months survey in two regions to estimate vaccine wastage rates and type of wastage for each of the vaccines administered by the Expanded programme on Immunization (EPI) and 2) a nationwide cross sectional survey of health workers from randomly selected facilities to assess knowledge, attitude and practice on vaccine waste management. We used WHO recommended forms and standard questionnaires. Wastage rates were compared to EPI targets. Results Wastage rates for the lyophilised vaccines BCG, Measles and Yellow Fever ranged from 18.5–79.0%, 0–30.9% and 0–55.0% respectively, mainly through unused doses at the end of an immunization session. Wastage from the liquid vaccines multi-dose/ single dose vials were minimal, with peaks due to expiry or breakage of the vaccine diluent. We interviewed 80 health workers and observed good knowledge. Batching children for BCG was uncommon (19%) whereas most health workers (73.4%) will open a vial as needed. Conclusion National projected wastage targets were met for the multi-dose/single dose vials, but for lyophilised vaccines, the target was only met in the largest major health facility.

Background The National Expanded Program on Immunization in the Democratic Republic of the Congo implemented a program in 9 Provinces to generate georeferenced immunization microplans to strengthen the planning and implementation of vaccination services. The intervention aimed to improve identification and immunization of zero-dose children and overall immunization coverage. Methods This study applies a mixed-methods design including survey tools, in-depth interviews and direct observation to document the uptake, use, and acceptance of the immunization microplans developed with geospatial data in two intervention provinces and one control province from February to June 2023. A total of 113 health facilities in 98 Health Areas in 15 Health Zones in the three provinces were included in the study sample. Select providers received training on gender-intentional approaches for the collection and use of geospatial data which was evaluated through a targeted qualitative study. A secondary analysis of immunization coverage survey data (2020–2022) was conducted to assess the associated effects on immunization coverage, especially changes in rates of zero dose children, defined as those aged 12–23 months who have not received a single dose of Pentavalent vaccine. Results This research study shows that georeferenced microplans are well received, utilized, and led to changes in routine immunization service planning and delivery. In addition, the gender intervention is perceived to have led to changes in the approaches taken to overcome sociocultural gender norms and engage communities to reach as many children as possible, leveraging the ability of women to engage more effectively to support vaccination services. The quantitative analyses showed that georeferenced microplans may have contributed to a dramatic and sustained trend of high immunization coverage in the intervention site of Haut-Lomami, which saw dramatic improvement in coverage for 3 antigens and little change in Pentavalent drop-out rate over three years of implementation. Conclusion The overall study identified positive contributions of the georeferenced data in the planning and delivery of routine immunization services. It is recommended to conduct further analyses in Kasai in 2024 and 2025 to evaluate the longer-term effects of the gender intervention on immunization coverage and equity outcomes. Trial registration The study was registered and given BMC Central International Standard. Randomised Controlled Trial Number ISRCTN65876428 on March 11, 2021.

•This article presents a review of the WHO Tailoring Immunization Programmes approach.•Understanding the perspectives of susceptible populations is crucial to improve programmes.•TIP provides a framework that successfully facilitated this in four countries consulted in the review.•Strengths of TIP are interdisciplinary approach, community engagement and qualitative research. The WHO Regional Office for Europe developed the Guide to tailoring immunization programmes (TIP), offering countries a process through which to diagnose barriers and motivators to vaccination in susceptible low vaccination coverage and design tailored interventions. A review of TIP implementation was conducted in the European Region. The review was conducted during June to December 2016 by an external review committee and was based on visits in Bulgaria, Lithuania, Sweden and the United Kingdom that had conducted a TIP project; review of national and regional TIP documents and an online survey of the Member States in the WHO European Region that had not conducted a TIP project. A review committee workshop was held to formulate conclusions and recommendations. The review found the most commonly cited strengths of the TIP approach to be the social science research as well as the interdisciplinary approach and community engagement, enhancing the ability of programmes to “listen” and learn, to gain an understanding of community and individual perspectives. National immunization managers in the Region are generally aware that TIP exists and that there is strong demand for the type of research it addresses. Further work is needed to assist countries move towards implementable strategies based on the TIP findings, supported by an emphasis on enhanced local ownership; integrated diagnostic and intervention design; and follow-up meetings, advocacy and incentives for decision-makers to implement and invest in strategies. Understanding the perspectives of susceptible and low-coverage populations is crucial to improving immunization programmes. TIP provides a framework that facilitated this in four countries. In the future, the purpose of TIP should go beyond identification of susceptible groups and diagnosis of challenges and ensure a stronger focus on the design of strategies and appropriate and effective interventions to ensure long-term change.