Explore the vast range of titles available.

Background Lower-level private for-profit health service providers form part of the pluralistic health systems delivering immunization services in urban areas of sub–Saharan Africa. However, their operational context is less documented since the conventional national Expanded Programme on Immunization (EPI) programmes tend to support delivery through public structures. Yet, private providers contribute greatly to immunization service coverage in urban settings. This paper explores the operational level context and stakeholders’ perspectives regarding immunization data among lower-level private for-profit service providers in the city of Kampala, Uganda. The objective of this baseline assessment was to document the current implementation context of immunization data among urban lower-level private for-profit immunization service providers to inform implementation research to improve immunization data in Kampala, Uganda. Methods The study adopted an exploratory qualitative design where key informant interviews and in-depth interviews were conducted. Analysis was guided by the health systems building-block framework, which informed the design of the codebook with coding done in Atlas.ti, a qualitative data management software. Results Overall, private for-profit immunization service providers reflected a context consisting of both barriers and opportunities underlying immunization data management practices. The barriers identified included: high staff turnover; data overload and manipulation tendencies; a transient population that access immunization services from different service providers without data linkage systems; computation of catchment populations, which affects utilization coverage data; financial barriers to the collection of community-level data; and inadequate facilitation leading to lean human resources at EPI departments managing immunization data from private providers. Nonetheless, opportunities to improve immunization data included the ability to widen data coverage through their services, enhanced public–private-partnership through data sharing arrangements, linkage of urban data among providers, improved recording of urban surveillance data, additional human resource to record data, widened scope for capturing adverse events data, improved community data linkages, and transitioning from paper-based to electronic data capture. Conclusions Opportunities to improve urban immunization data management through private for-profit providers exist amidst numerous barriers. This calls for innovative strategies by the programme managers to design interventions with specific emphasis on addressing barriers inherent among urban lower-level private for-profit service providers if immunization data management among these entities is to be improved.

Introduction: As the world continues to urbanize, particularly in low- and middle-income countries, understanding the barriers and effective interventions to improve urban immunization equity is critical to achieving both Immunization Agenda 2030 targets and the Sustainable Development Goals. Approximately 25 million children missed one or more doses of the diphtheria, tetanus and pertussis (DTP3) vaccine in 2021 and it is estimated that close to 30% of the world’s children missing the first dose of DTP, known as zero-dose, live in urban and peri-urban settings. Methods: The aim of this research is to improve understanding of urban immunization equity through a qualitative review of mixed method studies, urban immunization strategies and funding proposals across more than 70 urban areas developed between 2016 and 2020, supported by Gavi, the Vaccine Alliance. These research studies and strategies created a body of evidence regarding the barriers to vaccination in urban settings and potential interventions relevant to low- and middle-income countries (LMICs) with a focus on the vaccination of urban poor, populations of concern and residents of informal settlements. Through the document review we identified common challenges to achieving equitable coverage in urban areas and mapped proposed interventions. Results: We identified 70 documents as part of the review and categorized results across (1) social determinants of health, (2) immunization service-delivery barriers and (3) quality of services. Barriers and solutions identified in the documents were categorized in these thematic areas, drawing information from results in more than 21 countries. Conclusion: Populations of concern such as migrants, refugees, residents of informal settlements and the urban poor face barriers to accessing care which include poor availability and quality of service. Example solutions proposed to these challenges include tailored delivery strategies, improved use of digital data collection and child-friendly services. More research is required on the efficacy of the proposed interventions identified and on gender-specific dynamics in urban poor areas affecting equitable immunization coverage.

The 2021 WHO and UNICEF Estimates of National Immunization Coverage (WUENIC) reported approximately 25 million under-vaccinated children in 2021, out of which 18 million were zero-dose children who did not receive even the first dose of a diphtheria-tetanus-pertussis-(DPT) containing vaccine. The number of zero-dose children increased by six million between 2019, the pre-pandemic year, and 2021. A total of 20 countries with the highest number of zero-dose children and home to over 75% of these children in 2021 were prioritized for this review. Several of these countries have substantial urbanization with accompanying challenges. This review paper summarizes routine immunization backsliding following the COVID-19 pandemic and predictors of coverage and identifies pro-equity strategies in urban and peri-urban settings through a systematic search of the published literature. Two databases, PubMed and Web of Science, were exhaustively searched using search terms and synonyms, resulting in 608 identified peer-reviewed papers. Based on the inclusion criteria, 15 papers were included in the final review. The inclusion criteria included papers published between March 2020 and January 2023 and references to urban settings and COVID-19 in the papers. Several studies clearly documented a backsliding of coverage in urban and peri-urban settings, with some predictors or challenges to optimum coverage as well as some pro-equity strategies deployed or recommended in these studies. This emphasizes the need to focus on context-specific routine immunization catch-up and recovery strategies to suit the peculiarities of urban areas to get countries back on track toward achieving the targets of the IA2030. While more evidence is needed around the impact of the pandemic in urban areas, utilizing tools and platforms created to support advancing the equity agenda is pivotal. We posit that a renewed focus on urban immunization is critical if we are to achieve the IA2030 targets.

Background Asia is a region that is rapidly urbanising. While overall urban health is above rural health standards, there are also pockets of deep health and social disadvantage within urban slum and peri-urban areas that represent increased public health risk. With a focus on vaccine preventable disease and immunisation coverage, this commentary describes and analyses strengths and weaknesses of existing urban health and immunisation strategy, with a view to recommending strategic directions for improving access to immunisation and related maternal and child health services in urban areas across the region. The themes discussed in this commentary are based on the findings of country case studies published by the United Nations Childrens Fund (UNICEF)  on the topic of immunisation and related health services for the urban poor in Cambodia, Indonesia, Mongolia, Myanmar, the Philippines, and Vietnam. Main body Although overall urban coverage is higher than rural coverage in selected countries of Asia, there are also wide disparities in coverage between socio economic groups within urban areas. Consistent with these coverage gaps, there is emerging evidence of outbreaks of vaccine preventable diseases in urban areas. In response to this elevated public health risk, there have been some promising innovations in operational strategy in urban settings, although most of these initiatives are project related and externally funded. Critical issues for attention for urban health services access include reaching consensus on accountability for management and resourcing of the strategy, and inclusion of an urban poor approach within the planning and budgeting procedures of Ministries of Health and local governments. Advancement of local partnership and community engagement strategies to inform operational approaches for socially marginalised populations are also urgently required. Such developments will be reliant on development of municipal models of primary health care that have clear delegations of authority, adequate resources and institutional capabilities to implement. Conclusions The development of urban health systems and immunisation strategy is required regionally and nationally, to respond to rapid demographic change, social transition, and increased epidemiological risk.

•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.

Background Through a combination of strong routine immunization (RI), strategic supplemental immunization activities (SIA) and robust surveillance, numerous countries have been able to approach or achieve measles elimination. The fragility of these achievements has been shown, however, by the resurgence of measles since 2016. We describe trends in routine measles vaccine coverage at national and district level, SIA performance and demographic changes in the three regions with the highest measles burden. Findings WHO-UNICEF estimates of immunization coverage show that global coverage of the first dose of measles vaccine has stabilized at 85% from 2015 to 19. In 2000, 17 countries in the WHO African and Eastern Mediterranean regions had measles vaccine coverage below 50%, and although all increased coverage by 2019, at a median of 60%, it remained far below levels needed for elimination. Geospatial estimates show many low coverage districts across Africa and much of the Eastern Mediterranean and southeast Asian regions. A large proportion of children unvaccinated for MCV live in conflict-affected areas with remote rural areas and some urban areas also at risk. Countries with low RI coverage use SIAs frequently, yet the ideal timing and target age range for SIAs vary within countries, and the impact of SIAs has often been mitigated by delays or disruptions. SIAs have not been sufficient to achieve or sustain measles elimination in the countries with weakest routine systems. Demographic changes also affect measles transmission, and their variation between and within countries should be incorporated into strategic planning. Conclusions Rebuilding services after the COVID-19 pandemic provides a need and an opportunity to increase community engagement in planning and monitoring services. A broader suite of interventions is needed beyond SIAs. Improved methods for tracking coverage at the individual and community level are needed together with enhanced surveillance. Decision-making needs to be decentralized to develop locally-driven, sustainable strategies for measles control and elimination.

Background Migrant and left-behind families are vulnerable in health services utilization, but little is known about their disparities in immunization of non-National Immunization Program (NIP) vaccines. This study aims to evaluate the immunization coverage, knowledge, satisfaction, and associated factors of non-NIP vaccines among local and migrant families in the urban areas and non-left-behind and left-behind families in the rural areas of China. Methods A cross-sectional survey was conducted in urban areas of Zhejiang and rural areas of Henan in China. A total of 1648 caregivers of children aged 1–6 years were interviewed face-to-face by a pre-designed online questionnaire, and their families were grouped into four types: local urban, migrant, non-left-behind, and left-behind. Non-NIP vaccines included Hemophilus influenza b (Hib) vaccine, varicella vaccine, rotavirus vaccine, enterovirus 71 vaccine (EV71) and 13-valent pneumonia vaccine (PCV13). Log-binomial regression models were used to calculate prevalence ratios ( PR s) and 95% confidence intervals ( CI s) for the difference on immunization coverage of children, and knowledge and satisfaction of caregivers among families. The network models were conducted to explore the interplay of immunization coverage, knowledge, and satisfaction. Logistic regression models with odds ratios ( OR s) and 95% CI s were used to estimate the associated factors of non-NIP vaccination. Results The immunization coverage of all non-NIP vaccines and knowledge of all items of local urban families was the highest, followed by migrant, non-left-behind and left-behind families. Compared with local urban children, the PR s (95% CI s) for getting all vaccinated were 0.65 (0.52–0.81), 0.29 (0.22–0.37) and 0.14 (0.09–0.21) among migrant children, non-left-behind children and left-behind children, respectively. The coverage-knowledge-satisfaction network model showed the core node was the satisfaction of vaccination schedule. Non-NIP vaccination was associated with characteristics of both children and caregivers, including age of children (> 2 years- OR : 1.69, 95% CI : 1.07–2.68 for local urban children; 2.67, 1.39–5.13 for migrant children; 3.09, 1.23–7.76 for non-left-behind children); and below caregivers’ characteristics: family role (parents: 0.37, 0.14–0.99 for non-left-behind children), age (≤ 35 years: 7.27, 1.39–37.94 for non-left-behind children), sex (female: 0.49, 0.30–0.81 for local urban children; 0.31, 0.15–0.62 for non-left-behind children), physical health (more than average: 1.58, 1.07–2.35 for local urban children) and non-NIP vaccines knowledge (good: 0.45, 0.30–0.68 for local urban children; 7.54, 2.64–21.50 for left-behind children). Conclusions There were immunization disparities in non-NIP vaccines among migrant and left-behind families compared with their local counterparts. Non-NIP vaccination promotion strategies, including education on caregivers, and optimization of the immunization information system, should be delivered particularly among left-behind and migrant families. Graphical Abstract

Most vaccinations in the immunization schedule need two or more doses to elicit a protective immune response. Therefore, completion of all doses is crucial for achieving the best possible immunity. The objective of this study was to investigate the factors influencing missed opportunities of polio vaccination in children between the ages of 1–3 years in urban Dhaka. In 2018, according to the immunization card records or histories from parents/guardians, we sorted1–3-year-old children from areas of Dhaka South City Corporation who were not fully immunized. Immunization records were obtained from the Expanded Program on Immunization (EPI) card or maternal recall. Reasons for non-vaccination were documented. A total of 501 children were tracked down to determine the causes of their incomplete polio doses. Determinants of incomplete immunization and factors for missed opportunities were assessed by using bivariate and multivariable logistic regression model. The households with a child who had not received all the recommended vaccines had a considerably lower monthly income (18,000 BDT; p < 0.001). In both the complete and partial vaccination groups, the average family size was five people, and the average child age was 28 months. Education level of the household head after adjustment (AOR), the odds of the event occurring decrease by 25% with primary education (95% CI: 0.66, 0.85), p-value: < 0.001). Occupation of the household head for rickshaw/van/cart puller, AOR, the odds increase even more, with the event being 3.15 times more likely for this occupation (95% CI: 1.95, 5.08) and statistical significance (p-value < 0.05). Again, for daily wager AOR, 2.16 times higher for daily wagers (95% CI: 1.35, 3.45) and statistical significance (p-value: 0.001). This study identifies sociodemographic factors that influence incomplete childhood immunization in this urban area of Dhaka. In order to improve the coverage, the identified factors need to be mitigated and policymakers should focus on enhancing community engagement, combating misinformation and increasing the accessibility of vaccination services.

Background In 2014, over half (54%) of the world’s population lived in urban areas and this proportion will increase to 66% by 2050. This urbanizing trend has been accompanied by an increasing number of people living in urban poor communities and slums. Lower immunization coverage is found in poorer urban dwellers in many contexts. This study aims to identify factors associated with immunization coverage in poor urban areas and slums, and to identify interventions to improve coverage. Methods We conducted a systematic review, searching Medline, Embase, Global Health, CINAHL, Web of Science and The Cochrane Database with broad search terms for studies published between 2000 and 2016. Results Of 4872 unique articles, 327 abstracts were screened, leading to 63 included studies: 44 considering factors and 20 evaluating interventions (one in both categories) in 16 low or middle-income countries. A wide range of socio-economic characteristics were associated with coverage in different contexts. Recent rural-urban migration had a universally negative effect. Parents commonly reported lack of awareness of immunization importance and difficulty accessing services as reasons for under-immunization of their children. Physical distance to clinics and aspects of service quality also impacted uptake. We found evidence of effectiveness for interventions involving multiple components, especially if they have been designed with community involvement. Outreach programmes were effective where physical distance was identified as a barrier. Some evidence was found for the effective use of SMS (text) messaging services, community-based education programmes and financial incentives, which warrant further evaluation. No interventions were identified that provided services to migrants from rural areas. Conclusion Different factors affect immunization coverage in different urban poor and slum contexts. Immunization services should be designed in collaboration with slum-dwelling communities, considering the local context. Interventions should be designed and tested to increase immunization in migrants from rural areas.

Background Under-five mortality remains high in sub-Saharan Africa despite global decline. One quarter of these deaths are preventable through interventions such as immunization. The aim of this study was to examine the independent effects of individual-, community- and state-level factors on incomplete childhood immunization in Nigeria, which is one of the 10 countries where most of the incompletely immunised children in the world live. Methods The study was based on secondary analyses of cross-sectional data from the 2013 Nigeria Demographic and Health Survey (DHS). Multilevel multivariable logistic regression models were applied to the data on 5,754 children aged 12–23 months who were fully immunized or not (level 1), nested within 896 communities (level 2) from 37 states (level 3). Results More than three-quarter of the children (76.3%) were not completely immunized. About 83% of children of young mothers (15–24 years) and 94% of those whose mothers are illiterate did not receive full immunization. In the fully adjusted model, the chances of not being fully immunized reduced for children whose mothers attended antenatal clinic (adjusted odds ratio [aOR] = 0.49; 95% credible interval [CrI] = 0.39–0.60), delivered in health facility (aOR = 0.62; 95% CrI = 0.51–0.74) and lived in urban area (aOR = 0.66; 95% CrI = 0.50–0.82). Children whose mothers had difficulty getting to health facility (aOR = 1.28; 95% CrI = 1.02–1.57) and lived in socioeconomically disadvantaged communities (aOR = 2.93; 95% CrI = 1.60–4.71) and states (aOR = 2.69; 955 CrI =1.37–4.73) were more likely to be incompletely immunized. Conclusions This study has revealed that the risk of children being incompletely immunized in Nigeria was influenced by not only individual factors but also community- and state-level factors. Interventions to improve child immunization uptake should take into consideration these contextual characteristics.