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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.

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 Improving healthcare providers’ communication about HPV vaccination is critical to increasing uptake. We previously demonstrated that training providers to use presumptive announcements to introduce HPV vaccination improved uptake, whereas training them to use participatory conversations had no effect. To understand how communication training changed provider perceptions and communication practices, we evaluated intermediate outcomes and process measures from our randomized clinical trial, with a particular focus on identifying mechanisms that might explain the announcement training’s impact. Methods In 2015, a physician educator delivered 1-h in-clinic HPV vaccination recommendation trainings at 20 primary care clinics in North Carolina serving 11,578 patients age 11 or 12. Clinics were randomized to receive training to use “announcements” that presume parents are ready to vaccinate or “conversations” that invite dialog about vaccination. Training participants were 83 HPV vaccine providers. Pre- and post-training surveys assessed constructs from the theory of planned behavior (TPB), including providers’ attitudes and subjective norms about HPV vaccination and their perceived behavioral control to recommend HPV vaccination. Surveys also assessed providers’ perceptions of the announcement and conversation communication strategies. Results Both trainings improved TPB-related constructs, including providers’ positive attitudes toward HPV vaccination, subjective norms, and perceived behavioral control to recommend the vaccine (all p  < .001, Cohen’s d  = .62–.90). Furthermore, in both trainings, the amount of time providers reported needing to discuss HPV vaccination with parents decreased from pre-training to 1-month follow-up (mean = 3.8 vs. 3.2 min, p  = .01, d  = .28). However, announcement trainings outperformed conversation trainings on other measures. For example, providers who received announcement training more often reported that the communication strategy saved them time, was easy to use, helped them promote HPV vaccination as routine care, and increased HPV vaccination coverage in their clinics (all p  < .05; d  = .44–.60). Conclusions Both announcement and conversation trainings improved providers’ HPV vaccine-related perceptions. However, providers viewed announcements as easier to use and more effective, which may help to explain the success of this training approach. Future provider communication interventions should consider implementation outcomes, including acceptability, alongside more traditional TPB constructs. Trial registration clinicaltrials.gov, NCT02377843 . Registered on February 27, 2015.

Background Although good progress has been achieved in expanding immunization of children in China, disparities exist across different provinces. Information gaps both from the service supply and demand sides hinder timely vaccination of children in rural areas. The rapid development of mobile health technology (mHealth) provides unprecedented opportunities for improving health services and reaching underserved populations. However, there is a lack of literature that rigorously evaluates the impact of mHealth interventions on immunization coverage as well as the usability and feasibility of smart phone applications (apps). This study aims to assess the effectiveness of a smart phone-based app (Expanded Program on Immunization app, or EPI app) on improving the coverage of children’s immunization. Methods/Design This cluster randomized trial will take place in Xuanhan County, Sichuan Province, China. Functionalities of the app include the following: to make appointments automatically, record and update children’s immunization information, generate a list of children who missed their vaccination appointments, and send health education information to village doctors. After pairing, 36 villages will be randomly allocated to the intervention arm (n = 18) and control arm (n = 18). The village doctors in the intervention arm will use the app while the village doctors in the control arm will record and manage immunization in the usual way in their catchment areas. A household survey will be used at baseline and at endline (8 months of implementation). The primary outcome is full-dose coverage and the secondary outcome is immunization coverage of the five vaccines that are included in the national Expanded Program on Immunization program as well as Hib vaccine, Rotavirus vaccine and Pneumococcal conjugate vaccine. Multidimensional evaluation of the app will also be conducted to assess usability and feasibility. Discussion This study is the first to evaluate the effectiveness of a smart phone app for child immunization in rural China. This study will contribute to the knowledge about the usability and feasibility of a smart phone app for managing immunization in rural China and to similar populations in different settings. Trial registration Chinese Clinical Trials Registry (ChiCTR): ChiCTR-TRC-13003960

Administration of 1/5th dose of Inactivated poliovirus vaccine intradermally (fIPV) provides similar immune response as full-dose intramuscular IPV, however, fIPV administration with BCG needle and syringe (BCG NS) is technically difficult. We compared immune response after one fIPV dose administered with BCG NS to administration with intradermal devices, referred to as Device A and B; and assessed feasibility of conducting a door-to-door vaccination campaign with fIPV. In Phase I, 452 children 6–12months old from Karachi were randomized to receive one fIPV dose either with BCG NS, Device A or Device B in a health facility. Immune response was defined as seroconversion or fourfold rise in polio neutralizing antibody titer 28days after fIPV among children whose baseline titer ≤362. In Phase II, fIPV was administered during one-day door-to-door campaign to assess programmatic feasibility by evaluating vaccinators’ experience. For all three poliovirus (PV) serotypes, the immune response after BCG NS and Device A was similar, however it was lower with Device B (34/44 (77%), 31/45 (69%), 16/30 (53%) respectively for PV1; 53/78 (68%), 61/83 (74%), 42/80 (53%) for PV2; and; 58/76 (76%), 56/80 (70%), 43/77 (56%) for PV3; p<0.05 for all three serotypes). Vaccinators reported problems filling Device B in both Phases; no other operational challenges were reported during Phase II. Use of fIPV offers a dose-saving alternative to full-dose IPV.

Despite the recommendation of the Dutch association of nursing home physicians (NVVA) to be immunized against influenza, vaccine uptake among HCWs in nursing homes remains unacceptably low. Therefore we conducted a cluster randomised controlled trial among 33 Dutch nursing homes to assess the effects of a systematically developed multi-faceted intervention program on influenza vaccine uptake among HCWs. The intervention program resulted in a significantly higher, though moderate, influenza vaccine uptake among HCWs in nursing homes. To take full advantage of this measure, either the program should be adjusted and implemented over a longer time period or mandatory influenza vaccination should be considered.

Objectives. In a population of seniors served by urban primary care centers, we evaluated the effect of the practice-based intervention on influenza immunization rates and disparities in vaccination rates by race/ethnicity and insurance status. Methods. A randomized controlled trial during 2003-2004 tested patient tracking/recall/outreach and provider prompts on improving influenza immunization rates. Patients aged >65 years in six large inner-city primary care practices were randomly allocated to study or control group. Influenza immunization coverage was measured prior to enrollment and on the end date. Results. At study end, immunization rates were greater for the intervention group than for the control group (64% vs. 22%, p<0.0001). When controlling for other factors, the intervention group was more than six times as likely to receive influenza vaccine. The intervention was effective across gender, race/ethnicity, age, and insurance subgroups. Among the intervention group, 3.5% of African Americans and 3.2% of white people refused influenza immunization. Conclusions. Patient tracking/recall/outreach and provider prompts were intensive but successful approaches to increasing seasonal influenza immunization rates among this group of inner-city seniors.

The most extensive use of varicella vaccine has been in the United States and Canada, where it is universally recommended. However, a number of other countries now have recommendations for use of the vaccine, which has been expanding in Europe and Latin America. In this article, we review information concerning varicella vaccination in Japan, where the vaccine was first developed, and in South Korea and parts of Europe. Despite the worldwide availability of an efficient vaccine, varicella vaccination policy is highly variable from country to country. The recent development of a tetravalent vaccine against measles, mumps, rubella, and varicella could modify this variability in the future. It is evident that efforts to control varicella will spread gradually to all continents.

To prevent perinatal transmission of hepatitis B virus (HBV), WHO recommends that the first dose of hepatitis B (HepB) vaccine be given within 24 hours after birth. This presents a challenge in remote areas with limited cold-chain infrastructure and where many children are born at home. Rural townships in three counties in China's Hunan Province were randomized into three groups with different strategies for delivery of the first dose of HepB vaccine. In group 1, vaccine was stored within the cold chain and administered in township hospitals. In group 2, vaccine was stored out of the cold chain in villages and administered by village-based health workers to infants at home. Group 3 used the same strategy as group 2, but vaccine was packaged in a prefilled injection device. Training of immunization providers and public communication conveying the importance of the birth dose was performed for all groups. Among children born at home, timely administration (within 24 hours after birth) of the first dose of HepB vaccine increased in all groups after the study: group 1, from 2.4% to 25.2%; group 2, from 2.6% to 51.8%; and group 3, from 0.6% to 66.7%; P < 0.001 in each case. No significant difference in antibody response to vaccine was observed between the groups. Timely administration of the first dose of HepB vaccine was improved by communication and training activities, and by out-of-cold-chain storage of vaccine and administration at the village level, especially among children born at home.

•One out of two children missed routine immunizations during COVID-19 lockdown in Sindh.•COVID-19 lockdown disproportionately affected coverage rates across the districts.•Drop in the number of immunizations was higher in rural areas followed by urban slums.•Expanding pool of un-immunized children is bringing down herd immunity and raising the risk of vaccine-preventable disease outbreaks. COVID-19 pandemic has affected routine immunization globally. Impact will likely be higher in low and middle-income countries with limited healthcare resources and fragile health systems. We quantified the impact, spatial heterogeneity, and determinants for childhood immunizations of 48 million population affected in the Sindh province of Pakistan. We extracted individual immunization records from real-time provincial Electronic Immunization Registry from September 23, 2019, to July 11, 2020. Comparing baseline (6 months preceding the lockdown) and the COVID-19 lockdown period, we analyzed the impact on daily immunization coverage rate for each antigen by geographical area. We used multivariable logistic regression to explore the predictors associated with immunizations during the lockdown. There was a 52.5% decline in the daily average total number of vaccinations administered during lockdown compared to baseline. The highest decline was seen for Bacille Cal­mette Guérin (BCG) (40.6% (958/2360) immunization at fixed sites. Around 8438 children/day were missing immunization during the lockdown. Enrollments declined furthest in rural districts, urban sub-districts with large slums, and polio-endemic super high-risk sub-districts. Pentavalent-3 (penta-3) immunization rates were higher in infants born in hospitals (RR: 1.09; 95% CI: 1.04–1.15) and those with mothers having higher education (RR: 1.19–1.50; 95% CI: 1.13–1.65). Likelihood of penta-3 immunization was reduced by 5% for each week of delayed enrollment into the immunization program. One out of every two children in Sindh province has missed their routine vaccinations during the provincial COVID-19 lockdown. The pool of un-immunized children is expanding during lockdown, leaving them susceptible to vaccine-preventable diseases. There is a need for tailored interventions to promote immunization visits and safe service delivery. Higher maternal education, facility-based births, and early enrollment into the immunization program continue to show a positive association with immunization uptake, even during a challenging lockdown.