Contextual factors influencing incomplete immunization and investigation of its geospatial heterogeneity in Pakistan: a cross-sectional study based on PDHS (2017-18).

Immunization is one of the most effective public health initiatives, saving millions of lives and lowering the risk of diseases such as diphtheria, tetanus, influenza, and measles. Immunization saves an estimated 2-3 million lives per year. A study of the regional variations in incomplete immunization will be useful in identifying gaps in the performance of immunization programs that are not noticed by standard vaccination programs monitoring. The primary goal of this study was to identify factors influencing child immunization status and to examine regional variations in incomplete immunization among children aged 12 to 23 months in Pakistan. For the current study, the data were taken from the Demographic and Health Survey for Pakistan (PDHS 2017-2018). Ever-married women who had children aged 12-23 months were included in this study. The immunization status of children was used as an outcome variable. In order to determine the effects of different factors on incomplete immunization, multilevel logistic model was used. To study the geographical variation of incomplete immunization, hotspot analysis was done using ArcGIS 10.7 and SaTScan software and to identify significant predictors of incomplete immunization, GWR 4 software was used. Place of delivery, gender of child, mother's educational level and region were identified as significant determinants of incomplete immunization of children in Pakistan. Chances of incomplete immunization of children were found significantly lower for educated mothers (AOR = 0.52, 95% CI 0.34-0.79) and mothers who had delivered children in the health facilities (AOR = 0.51, 95% CI 0.32-0.83). Female children were more likely (AOR = 1.44, 1.95% CI 1.04-1.99) to be incompletely immunized as compared to male children. FATA (AOR = 11.19, 95% CI 4.89-25.6), and Balochistan (AOR = 10.94, 95% CI 5.08-23.58) were found at the highest risk of incomplete immunization of children as compared to Punjab. The significant spatial heterogeneity of incomplete immunization was found across Pakistan. The spatial distribution of incomplete immunization was clustered all over Pakistan. The high prevalence of incomplete immunization was observed in Balochistan, South Sindh, North Sindh, South KPK, South FATA, Gilgit Baltistan, Azad Jammu Kashmir, South and East Punjab. Drang and Harcho were identified as hotspot areas of incomplete immunization in Gilgit Baltistan. Secondary clusters with a high risk of incomplete immunization were found in regions Balochistan, Sindh and FATA. Gender biasedness towards female children, regarding complete immunization of children prevailed in Pakistan. Spatial heterogeneity was also found for incomplete immunization of children. To overcome the problem access to health facilities is the foremost step. Government should target hotspot areas of incomplete immunization of children to provide primary health care facilities by opening health care units in these areas. The government in collaboration with the media should launch awareness campaigns in those areas to convince people that complete immunization is the right of every child regardless of gender.

Kamal A ，Waseem A ，Siddiqa M ，Ijaz M ，Shakeel A ，Iftikhar S ... -  《BMC PUBLIC HEALTH》

Factors associated with incomplete child immunization in Pakistan: findings from Demographic and Health Survey 2017-18.

The objective of this analysis was to explore the determinants of incomplete immunization in children aged 12-23 months. A secondary analysis was conducted on cross-sectional survey data from Pakistan Demographic and Health survey 2017-2018. The present study was confined to children aged 12-23 months at the time of survey giving a sample size of 2048. Complete immunization was described as having received a dose of BCG (Bacille Calmette Guerin), four doses of oral polio vaccine (OPV0, OPV1, OPV2, and OPV3), three doses of pentavalent and pneumococcal vaccine, and one dose of measles vaccine. Multivariable logistic regression was used to explore the association between outcome and predictor variables. The findings showed that the likelihood of being incompletely immunized was higher for the children of Baluchistan (adjusted odds ratio [aOR] = 6.38; 95% confidence interval [CI] = 4.18-9.71), Federally Administered Tribal Areas (aOR = 6.2; 95% CI = 3.97-9.71), Sindh (aOR = 3.24; 95% CI = 2.33-4.49), Khyber Pakhtunkhwa (aOR = 2.13; 95% CI = 1.54-2.97), Islamabad (aOR = 3.656; 95% CI = 2.34-5.69), and Gilgit Baltistan (aOR = 2.320; 95% CI = 1.50-3.57) relative to those of Punjabi children. Lower odds of partial vaccination were seen among the children of educated mothers (primary or higher) and those who were born at a health facility. Improving maternal literacy rate, providing easy access to health facilities, and minimizing regional disparities can improve the immunization status of children in Pakistan.

Ali A ，Zar A ，Wadood A 《-》

Mapping geographical inequalities of incomplete immunization in Ethiopia: a spatial with multilevel analysis.

Immunization is one of the most cost-effective interventions, averting 3.5-5 million deaths every year worldwide. However, incomplete immunization remains a major public health concern, particularly in Ethiopia. The objective of this study is to investigate the geographical inequalities and determinants of incomplete immunization in Ethiopia. A secondary analysis of the mini-Ethiopian Demographic Health Survey (EDHS 2019) was performed, utilizing a weighted sample of 3,865 children aged 12-23 months. A spatial auto-correlation (Global Moran's I) statistic was computed using ArcGIS version 10.7.1 to assess the geographical distribution of incomplete immunization. Hot-spot (areas with a high proportion of incomplete immunization), and cold spot areas were identified through Getis-Ord Gi* hot spot analysis. Additionally, a Bernoulli probability-based spatial scan statistics was conducted in SaTScan version 9.6 software to determine purely statistically significant clusters of incomplete immunization. Finally, a multilevel fixed-effects logistic regression model was employed to identify factors determining the status of incomplete immunization. Overall, in Ethiopia, more than half (54%, 95% CI: 48-58%) of children aged 12-23 months were not fully immunized. The spatial analysis revealed that the distribution of incomplete immunization was highly clustered in certain areas of Ethiopia (Z-score value = 8.379419, p-value < 0.001). Hotspot areas of incomplete immunization were observed in the Afar, Somali, and southwestern parts of Ethiopia. The SaTScan spatial analysis detected a total of 55 statistically significant clusters of incomplete immunization, with the primary SaTScan cluster found in the Afar region (zones 1, 3, and 4), and the most likely secondary clusters detected in Jarar, Doola, Korahe, Shabelle, Nogob, and Afdar administrative zones of the Somali region of Ethiopia. Indeed, in the multilevel mixed-effect logistic regression analysis, the respondent's age (AOR: 0.92; 95% CI: 0.86-0.98), residence (AOR: 3.11, 95% CI: 1.36-7.14), living in a pastoralist region (AOR: 3.41; 95% CI: 1.29-9.00), educational status (AOR: 0.26; 95% CI: 0.08-0.88), place of delivery (AOR: 2.44; 95% CI: 1.15-5.16), and having PNC utilization status (AOR: 2.70; 95% CI: 1.4-5.29) were identified as significant predictors of incomplete immunization. In Ethiopia, incomplete immunization is not randomly distributed. Various factors at both individual and community levels significantly influence childhood immunization status in the country. It is crucial to reduce disparities in socio-demographic status through enhanced collaboration across multiple sectors and by bolstering the utilization of maternal health care services. This requires concerted efforts from stakeholders.

Bantie B ，Atnafu Gebeyehu N ，Adella GA ，Ambaw Kassie G ，Mengstie MA ，Abebe EC ，Abdu Seid M ，Gesese MM ，Tegegne KD ，Zemene MA ，Anley DT ，Dessie AM ，Fenta Feleke S ，Dejenie TA ，Chanie ES ，Kebede SD ，Bayih WA ，Moges N ，Kebede YS ... -  《Frontiers in Public Health》

Routine Immunization Coverage and Immunization Card Retention in Pakistan: Results From a Cross-sectional National Survey.

Immunization is one of the most successful public health interventions available, saving millions of lives from death and disability each year. Therefore, improving immunization coverage is a high priority for the Government of Pakistan and essential to progress toward universal health coverage. This survey reports the national and provincial/regional coverage and determinants of fully, partially, and not-vaccinated children 12-23 months of age, antigen-wise coverage, percentage of home-based vaccination records (HBR) retention, and reasons for nonretention; dropout, timeliness, and prevalence of missed opportunities for simultaneous vaccination (MOSV). The survey was a descriptive cross-sectional national household survey carried out across Pakistan. The survey included 110,790 children 12-23 months old and their caregivers. A World Health Organization (WHO)-Expanded Program on Immunization (EPI) Survey questionnaire was adapted to collect information. Data were analyzed using the WHO Vaccination Coverage Quality Indicators (VCQI) software and Stata version 17. Nationally excluding Azad Jammu and Kashmir (AJK) and Gilgit Baltistan (GB), the coverage of fully vaccinated children was 76.5%. The likelihood of being fully vaccinated was higher among children of educated parents who belonged to higher wealth quintiles and resided in any province/region other than Balochistan. The main reasons for unimmunization were no faith in immunization, rumors about vaccines, and distance to the facility. About two-thirds (66.2%) of the children had their HBR available, and the main reasons for not having a card were never visiting a health facility and having no awareness about the importance of a card. Dropout was discernible for later doses of vaccines compared with earlier ones. Higher proportions of children received the last doses late by more than two months. Of the 218,002 vaccination visits documented on HBR in the provinces, MOSVs occurred in 17.6% of the visits. The immunization coverage rates provide a direction to strategize the progress to improve the vaccination rates in Pakistan. The country needs to outline the immediate and long-term actions to combat vaccine-preventable diseases, such as escalating integrated immunization campaigns and outreach activities, provision of mobility support, and deploying behavioral interventions as a cross-cutting strategy to improve awareness and reduce misconceptions.

Hussain I ，Khan A ，Rhoda DA ，Ahmed I ，Umer M ，Ansari U ，Shah MA ，Yunus S ，Brustrom J ，Oelrichs R ，Soofi SB ，Bhutta ZA ... -  《-》

Factors associated with non-utilization of child immunization in Pakistan: evidence from the Demographic and Health Survey 2006-07.

Bugvi AS ，Rahat R ，Zakar R ，Zakar MZ ，Fischer F ，Nasrullah M ，Manawar R ... -  《BMC PUBLIC HEALTH》