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India's Vaccine Deficit: Why More Than Half Of Indian Children Are Not Fully Immunized, And What Can-And Should-Be Done
Abstract
Although India is a leading producer and exporter of vaccines, the country is home to one-third of the world's unimmunized children. Fewer than 44 percent of India's young children receive the full schedule of immunizations. India's vaccine deficit has several causes: little investment by the government; a focus on polio eradication at the expense of other immunizations; and low demand as a consequence of a poorly educated population and the presence of anti-vaccine advocates. In this article we describe India's vaccine deficit and recommend that the government move quickly to increase spending on, and otherwise strengthen, national immunization programs.
... As of 2016, only about 62.0% of children aged 12-23 months were fully vaccinated in India [7]. India has a large and heterogeneous population with varied cultures, sociodemographics, religion, and education status, leading to variations in vaccination levels among regions [8][9][10][11]. The presence of under-vaccinated groups in some regions may be a source of infectious disease outbreaks in the country. ...
... In addition, as sociodemographics vary between urban and rural residents in India, [8,9], we hypothesize that the effect of sociodemographic factors may vary by place of residence (urban and rural). Despite the availability of health frameworks that can help us examine factors affecting childhood vaccinations in a comprehensive manner, most studies on childhood vaccination in India did not use a theoretical framework [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. ...
... Analysis of the National Family Health Survey data collected during 1992-93, 1998-99, 2005-06 and 2015-2016 also showed a lower vaccination rate among rural Indian children compared to those living in urban areas [9,44,45]. Low education and lack of awareness about the importance of childhood vaccines, poor access to healthcare and vaccines, may at least partially explain the lower rural vaccination rates [8,9]. Indeed, when compared to urban parents (14.9%), a significantly greater portion of parents living in rural areas were illiterate (63.4%). ...
Objectives
This study used a health belief theory derived framework and structural equation model to examine moderators, mediators, and direct and indirect predictors of childhood vaccination.
Methods
A secondary analysis was conducted using data collected from a cross-sectional survey of a random sample of 1599 parents living in urban and rural areas of Mysore district, India. Applying two-stage probability proportionate-to-size sampling, adolescent girls attending 7th through 10th grades in 23 schools were selected to take home a questionnaire to be answered by their parents to primarily assess HPV vaccine intentions. Parents were also asked whether their children had received one dose of Bacillus Calmette–Guérin; three doses of Diphtheria, Pertussis, Tetanus; three doses of oral Polio vaccine; and one dose of Measles vaccine. In addition, parents were asked about their attitudes towards childhood vaccination.
Results
Out of the 1599 parents, 52.2% reported that their children had received all the routine vaccines (fully vaccinated); 42.7% reported their children had missed at least one routine vaccine, and 5.2% reported that their children had missed all routine vaccinations. Perceptions about the benefits/facilitators to childhood vaccination significantly predicted the full vaccination rate (standardized regression coefficient (β) = 0.29) directly and mediated the effect of parental education (β = 0.11) and employment (β = -0.06) on the rate of full vaccination. Parental education was significantly associated indirectly with higher rates of full vaccination (β = 0.11). Parental employment was significantly associated indirectly with decreasing rates of full vaccination (β = -0.05). Area of residence moderated the role of religion (β = 0.24) and the ‘number of children’ in a family (β = 0.33) on parental perceptions about barriers to childhood vaccination. The model to data fit was acceptable (Root Mean Square Error of Approximation = 0.02, 95% CI 0.018 to 0.023; Comparative Fit Index = 0.92; Tucker–Lewis Index = 0.91).
Conclusions
Full vaccination rate was relatively low among children in Mysore, especially among parents who were unsure about the benefits of routine vaccination and those with low educational levels. Interventions increasing awareness of the benefits of childhood vaccination that target rural parents with lower levels of education may help increase the rate of full childhood vaccination in India.
... There is a substantial lack of coordination between those people and organisation who procure vaccines for shipments to developing countries and storekeepers to supply chain managers who are in charge for receiving and distribution. This lack of coordination often results in an increase in procurement lead-time (Kaufmann et al., 2011;Milstien and Lambert, 2002;Laxminarayan and Ganguly, 2011). ...
... The shortage of health workers in the immunisation programs is identified as one of the most critical issues in the improvement of vaccination rates (Kaufmann et al., 2011;Gupta et al., 2013;Laxminarayan and Ganguly, 2011;O'Leary et al., 2016). ...
... India has experienced remarkable enhancements in its economic repute and populace health all through the past two decades. However, it lags behind other countries of similar per capita gross domestic product in child survival (Laxminarayan and Ganguly, 2011). Although India is a main producer and exporter of vaccines, the country has the highest number of unvaccinated children in the world, with 8.9 million children not receiving all vaccines and 1.7 million not being vaccinated at all. ...
In the present study, an effort has been made to identify issues in the supply of basic vaccines required to immunise each child based upon the field survey of Uttarakhand State, India. The Delphi method that uses expert’s opinion in decision-making has been employed for selection of 25 key issues as factors of vaccine supply chain. Using interpretive structural modelling (ISM) approach, a hierarchical structure has been developed to show interrelationships among various factors. Then, MICMAC analysis has been performed to classify the factors based on their driving and dependence power. From the ISM model and the MICMAC analysis and from further discussions with the experts, it has been found that the factors ‘demand forecast’, ‘communication between the supply chain members’ and ‘proper planning and scheduling’ are three most critical factors of vaccine supply chain. The study will provide a direction to the policymakers for implementing the state immunisation plan.
... India's slow progress to achieving universal immunization for all children has generally been attributed to its sheer population size, high growth rate, geographic and cultural diversity and limited healthcare spending [6,7]. However, large inter-state and inter-district disparities in immunization coverage have helped uncover important supply and demand-side factors associated with uptake of routine vaccinations [7][8][9]. ...
... However, large inter-state and inter-district disparities in immunization coverage have helped uncover important supply and demand-side factors associated with uptake of routine vaccinations [7][8][9]. Supply-side factors generally include a lack of trained personnel to manage and deliver immunization services, poor relationship between health care workers and mothers, inconvenient timing or location of immunization services and even vaccine stock outs [6,8,10]. Demandside factors associated with routine vaccination uptake however are complex and often multi-faceted. ...
... Demandside factors associated with routine vaccination uptake however are complex and often multi-faceted. Previous research from India tends to highlight socio-demographic characteristics associated with uptake such as child's gender, order of birth, place of delivery, maternal age at childbirth, parental education, caste and religious preference, household wealth and location (urban or rural), [6][7][8]11,12]. Of late, non-socio-demographic demand-side issues such as awareness regarding the need for and timing of routine childhood vaccinations, fears regarding some or all routine vaccines and parental beliefs regarding false contraindications to routine vaccinations have been reported as reasons linked to partialvaccination and non-vaccination of Indian children [4, 12,13]. ...
Background:
Despite almost three decades of the Universal Immunization Program in India, a little more than half the children aged 12-23 months receive the full schedule of routine vaccinations. We examined socio-demographic factors associated with partial-vaccination and non-vaccination and the reasons for non-vaccination among Indian children during 1998 and 2008.
Methods:
Data from three consecutive, nationally-representative, District Level Household and Facility Surveys (1998-99, 2002-04 and 2007-08) were pooled. Multinomial logistic regression was used to identify individual and household level socio-demographic variables associated with the child's vaccination status. The mother's reported reasons for non-vaccination were analyzed qualitatively, adapting from a previously published framework.
Results:
The pooled dataset contained information on 178,473 children 12-23 months of age; 53%, 32% and 15% were fully vaccinated, partially vaccinated and unvaccinated respectively. Compared with the 1998-1999 survey, children in the 2007-2008 survey were less likely to be unvaccinated (Adjusted Prevalence Odds Ratio (aPOR): 0.92, 95%CI=0.86-0.98) but more likely to be partially vaccinated (aPOR: 1.58, 95%CI=1.52-1.65). Vaccination status was inversely associated with female gender, Muslim religion, lower caste, urban residence and maternal characteristics such as lower educational attainment, non-institutional delivery, fewer antenatal care visits and non-receipt of maternal tetanus vaccination. The mother's reported reasons for non-vaccination indicated gaps in awareness, acceptance and affordability (financial and non-financial costs) related to routine vaccinations.
Conclusions:
Persisting socio-demographic disparities related to partial-vaccination and non-vaccination were associated with important childhood, maternal and household characteristics. Further research investigating the causal pathways through which maternal and social characteristics influence decision-making for childhood vaccinations is needed to improve uptake of routine vaccination in India. Also, efforts to increase uptake should address parental fears related to vaccination to improve trust in government health services as part of ongoing social mobilization and communication strategies.
... About 44% of the 27 million children born in India annually receive a full schedule of immunisation, consisting of the diphtheria, tetanus, pertussis, poliomyelitis, measles, hepatitis B, rotavirus and pneumonia vaccines (1). Despite the Universal Immunisation Programme (UIP) re-launched in India in 1985, with the aim of extending the coverage of the basic vaccines to all infants and pregnant women, 9.6 million children remain unimmunised (1). ...
... About 44% of the 27 million children born in India annually receive a full schedule of immunisation, consisting of the diphtheria, tetanus, pertussis, poliomyelitis, measles, hepatitis B, rotavirus and pneumonia vaccines (1). Despite the Universal Immunisation Programme (UIP) re-launched in India in 1985, with the aim of extending the coverage of the basic vaccines to all infants and pregnant women, 9.6 million children remain unimmunised (1). ...
... The national Technical Advisory group on Immunisation (nTAgI), established in 2002 by the ministry of health, recommends that vaccination be considered in the UIP and its reach be expanded to cover all children (1). The introduction of the rotavirus vaccine by the nTAgI in 2013 was clouded by controversy due to the low efficacy (only 56%) of the vaccine and because the safety data of the clinical trials were not revealed for expert analysis (8). ...
Vaccines are a widely accepted public health intervention. They are also a profitable tool for pharmaceutical companies manufacturing vaccines. There are many vaccines in the pipeline, for various diseases, or as combination vaccines for several diseases. However, there is also a growing concern about vaccines and the manner in which they are developed and approved by the authorities. Approvals are fast tracked and adverse events and serious adverse events following vaccination are seldom reported once the vaccine gets its marketing approval. Thus, vaccines have been clouded with many controversies and their use as a public health tool to prevent diseases is constantly under challenge.
... Furthermore, the programmatic interventions and outreach programs related to BCG vaccination have percolated to grassroot levels due to the early and strict initiatives undertaken by the Government of India. Since 1948, BCG has gathered incessant attention as it was the only preventive vaccination available to control Tuberculosis in India [36]. DPT and Measles acquired attention much later with the implementation of the National Immunisation Programme called Expanded Programme of Immunisation in 1978 which aimed at expanding the coverage of both the diseases to 80 percent. ...
... Despite these efforts, the coverage of DPT3 and Measles had remained sub-optimal and inequitable. This could be due to dearth of trained personnel managing the programme at the national and state levels [36,37] ...
Background
Diligent monitoring of inequalities in the coverage of essential reproductive, maternal, new-born and child health related (RMNCH) services becomes imperative to smoothen the journey towards Sustainable Development Goals (SDGs). In this study, we aim to measure the magnitude of inequalities in the coverage of RMNCH services. We also made an attempt to divulge the relationship between the various themes of governance and RMNCH indices.
Methods
We used National Family Health Survey dataset (2015–16) and Public Affairs Index (PAI), 2016 for the analysis. Two summative indices, namely Composite Coverage Index (CCI) and Co-Coverage (Co-Cov) indicator were constructed to measure the RMNCH coverage. Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were employed to measure inequality in the distribution of coverage of RMNCH. In addition, we have used Spearman’s rank correlation matrix to glean the association between governance indicator and coverage indices.
Results & conclusions
Our study indicates an erratic distribution in the coverage of CCI and Co-Cov across wealth quintiles and state groups. We found that the distribution of RII values for Punjab, Tamil Nadu, and West Bengal hovered around 1. Whereas, RII values for Haryana was 2.01 indicating maximum inequality across wealth quintiles. Furthermore, the essential interventions like adequate antenatal care services (ANC4) and skilled birth attendants (SBA) were the most inequitable interventions, while tetanus toxoid and Bacilli Calmette- Guerin (BCG) were least inequitable. The Spearman’s rank correlation matrix demonstrated a strong and positive correlation between governance indicators and coverage indices.
... India has exported complex vaccines such as the penta-valent rotavirus vaccine in the past [10]. What's unique about India is that it has the expertise for low-cost per-unit vaccine production of vaccines. ...
... https://doi.org/10.1016/j.vaccine.2020.10.056 0264-410X/Ó 2020 Elsevier Ltd. ...
... However, disparities in rates of new vaccine adoption and sustained vaccination rates across different regions persist. In addition, an increase in the number of communities in both developed and developing countries with low or decreasing vaccination rates has resulted in disease outbreaks [2,3]. While access to health care services can lead to disparities in vaccination rates, vaccine acceptance is another critical component of sustainable immunization programs. ...
... The coding schema on completion was reorganized from three domains into four domains: (1) knowledge and communication, (2) interactions with the health care system; (3) attitudes and beliefs; and (4) logistics of vaccine delivery. Within each theme, comments were categorized into nodes within NVivo that were neutral toward, supported, or presented a barrier to vaccine acceptance. ...
Introduction
Vaccine acceptance is a critical component of sustainable immunization programs, yet rates of vaccine hesitancy are rising. Increased access to misinformation through media and anti-vaccine advocacy is an important contributor to hesitancy in the United States and other high-income nations with robust immunization programs. Little is known about the content and effect of information sources on attitudes toward vaccination in settings with rapidly changing or unstable immunization programs.
Objective
The objective of this study was to explore knowledge and attitudes regarding vaccines and vaccine-preventable diseases among caregivers and immunization providers in Botswana, the Dominican Republic, and Greece and examine how access to information impacts reported vaccine acceptance.
Methods
We conducted 37 focus groups and 14 semi-structured interviews with 96 providers and 153 caregivers in Botswana, the Dominican Republic, and Greece. Focus groups were conducted in Setswana, English, Spanish, or Greek; digitally recorded; and transcribed. Transcripts were translated into English, coded in qualitative data analysis software (NVivo 10, QSR International, Melbourne, Australia), and analyzed for common themes.
Results
Dominant themes in all three countries included identification of health care providers or medical literature as the primary source of vaccine information, yet participants reported insufficient communication about vaccines was available. Comments about level of trust in the health care system and government contrasted between sites, with the highest level of trust reported in Botswana but lower levels of trust in Greece.
Conclusions
In Botswana, the Dominican Republic, and Greece, participants expressed reliance on health care providers for information and demonstrated a need for more communication about vaccines. Trust in the government and health care system influenced vaccine acceptance differently in each country, demonstrating the need for country-specific data that focus on vaccine acceptance to fully understand which drivers can be leveraged to improve implementation of immunization programs.
... The UIP provides free vaccines and immunisation services to the eligible population through a large network of public health facilities and outreach sessions across the country. However, several factors hindered universal coverage of basic vaccines in the recent past such as hard-to-reach and mobile populations, poor demand from uninformed and uneducated populations, and fear of side effects [26,27]. To target underserved, and inaccessible populations and improve coverage rates in hard-to-reach areas, the Mission Indradhanush (MI) programme was implemented. ...
Background
Despite free immunisation services through the Universal Immunisation Programme (UIP), around 14% of Indian households seek immunisation in the private sector. We examined the potential impact of rotavirus vaccine (RVV) introduction in the Universal Immunisation Programme (UIP) on private-sector rotavirus vaccine utilisation.
Methods
We analysed nationally representative private-sector vaccine sales data. The intervention under consideration is RVV introduction in the UIP in selected Indian states. The outcome is the ‘monthly RVV sales volume’—a proxy for vaccine utilisation. We performed a Poisson regression interrupted time series analysis to detect the pre-intervention trend, post-intervention level change and trend change relative to the pre-intervention for monthly rotavirus vaccine utilisation.
Results
Poisson segmented regression analysis showed that immediately after RVV introduction in the UIP private-sector RVV sales showed a decline in Rajasthan by 37.4% (Incidence Risk Ratio (IRR): 0.626; 95% CI: 0.504–0.779), in Tamil Nadu by 26% (IRR: 0.740; 95% CI: 0.513–1.068), in Uttar Pradesh-East by 72.2% (IRR: 0.278; 95% CI: 0.178–0.436) and in Kerala by 3% (IRR: 0.970; 95% CI: 0.651–1.447). Rajasthan, Tamil Nadu and Kerala had sustained reduction in the postintervention trend relative to the preintervention trend by 20.1% (IRR: 0.799; 95% CI: 0.763–0.836), 6.4% (IRR: 0.936; 95% CI: 0.906–0.967) and 3.3% (IRR: 0.967; 95% CI: 0.926–0.960) per month, respectively. However, in Haryana and UP-west, in the first-month post-UIP introduction, the private-sector RVV sales increased by 101% and 3.8%, respectively which was followed by a sustained decrease of 14.2% (IRR: 0.858; 95% CI: 0.688–1.070) and 5.8% (IRR: 0.942; 95% CI: 0.926–0.960) per month, respectively. In terms of long-term impact, the private sector RVV sales post-UIP introduction decreased at a monthly rate of 4.4% (IRR: 0.956, 95% CI: 0.939–0.974) in Rajasthan but increased by 5.5% (IRR: 1.055; 95% CI: 1.040–1.070) in UP-east, 0.3% (IRR: 1.003, 95% CI: 0.976–1.031)) in Kerala and 0.2% (IRR: 1.002, 95% CI: 0.993–1.011) in Tamil Nadu whereas Haryana and UP-west had a reduction in RVV utilisation by 2.8% (IRR: 0.972; 95% CI: 0.955–0.990) and 1% (IRR: 0.990; 95% CI: 0.982–0.998), respectively.
Conclusions
The study provides evidence that access to RVV through UIP leads to a reduction in private-sector RVV utilisation. We recommend strengthening UIP to expand the basket of new vaccines.
... The gains of the four phases of 'Mission Indradhanush' both in urban and rural areas, and the goal of 90 percent vaccination is not being achieved [14] . Few of the possible reasons for the hesitancy towards a vaccine and the factors limiting vaccination coverage include a) parents often thinking about the vaccines that are unnecessary because their children appear healthy; b) parents feel children may fall sick but may recover by normal treatment; c)parents lack awareness about immunization (45%); d) the service gap of the health workers who may not have visited some families or vaccines may not have been delivered (4%); e) the large mobile and isolated populations that are difficult to reach in the immunization sites (8%); f) ill-informed population who fear side effects (24%) and are biased by false information and anti-vaccination messages [18,19,20] . Hence, this study aimed to assess the hesitancy towards vaccination and to identify the predictors associated with VH among the Indian Population. ...
Objectives: This study aimed to assess the hesitancy towards vaccination and to identify the factors and predictor variables within the study population. Methodology: This was a cross-sectional study conducted via a web-based platform where a validated questionnaire was circulated among the public to understand their hesitancy towards vaccination. WHO SAGE Working Group Questionnaire was used to collect the data. The predictors for hesitancy were determined by using bivariate logistic regression analysis and the prevalence of vaccine hesitancy was identified. Results: A total of 353 subjects enrolled in the study during the 6 months of the study. Among them, 133 (37.67%) subjects showed vaccine hesitancy. On performing the bi-variate analysis, it was found that among the subsets studies those who were more hesitant to receive vaccines were females (OR: 1.476); individuals who are widowed/separated/divorced (OR: 3.109), age 40–49 yrs (OR: 3.710); from a rural (OR: 1.277) and not graduated (OR: 1.077). These subsets were predictors identified for vaccine hesitancy. Among the vaccines, maximum hesitancy was observed for the chicken pox vaccine [47 (13.31%)], followed by TCV [25 (7.08%)] and Rota [24 (6.79%), whereas the minimum hesitancy was observed for BCG [2 (0.56%)], OPV [4 (1.13%)] and IPV [8 (2.26%)]. Reasons provided for the hesitancy observed were mainly (i) Did not think it was needed [163 (46.17%)], (ii) Did not think the vaccine was safe [41 (11.61%)] and (iii) Did not know where to get vaccinated [24 (6.79%)]. Conclusion: The study observed less vaccine hesitancy among vaccines included in the EPI program. A major contributing factor for VH among the study population was their wrong perception about vaccines as that is not needed and not safe. Hence, there is a real need for education to the population to improve vaccine confidence among the general population.
... DNA vaccines DNA vaccines involve administering weakened infectious components of a virus to elicit an immune response without causing the actual infection. [47] These vaccines consist of antigen-coded plasmid vectors containing the gene of interest. DNA vaccines are more thermostable than viral or bacterial vaccines, easier to produce at a large scale, cost-effective, and safe, as they cannot revert to virulent forms. ...
... Nations around the globe have started providing vaccines to limit the transmission of the pandemic. Availability and proper distribution of vaccines is a big challenge for developing countries like India (Laxminarayan and Ganguly, 2011). The government is planning strategies so that the production of the vaccine and the delivery of the vaccine is increased. ...
Purpose
Immunization is one of the most cost-effective ways to save lives while promoting good health and happiness. The coronavirus disease 2019 (COVID-19) pandemic has served as a stark reminder of vaccines' ability to prevent transmission, save lives, and have a healthier, safer and more prosperous future. This research investigates the sustainable development (SD) of the COVID-19 vaccine supply chain (VSC).
Design/methodology/approach
This study investigates the relationship between internal process, organizational growth, and its three pillars of SD environmental sustainability, economic sustainability and social sustainability. Survey-based research is carried out in the hospitals providing COVID-19 vaccines. Nine hypotheses are proposed for the study, and all the hypotheses got accepted. The survey was sent to 428 respondents and received 291 responses from health professionals with a response rate of 68%. For the study, the healthcare professionals working in both private and public hospitals across India were selected.
Findings
The structural equation modelling (SEM) approach is used to test the hypothesis. All nine hypotheses are supported. This study examines a link between internal processes and organizational learning and the three sustainability pillars (environmental sustainability, economic sustainability and social sustainability).
Practical implications
This study will help the management and the policymakers to think and adopt SD in the COVID-19 VSC. This paper also implies that robust immunization systems will be required in the future to ensure that people worldwide are protected from COVID-19 and other diseases.
Originality/value
This paper shows the relationship between organizational learning and internal process with environmental sustainability, economic sustainability and social sustainability for the COVID-19. Studies on VSC of COVID-19 are not evident in any previous literature.
... Like most LMICs, India has been struggling to meet its immunization coverage goals. India has the largest birth cohort in the world and contributes significantly to child mortality and morbidity resulting from VPDs [6]. India has shown approximately a 19-percentage point increase in the national average of full immunization (BCG, Measles, and three doses each of Polio and DPT) since the NFHS-4 (2005-06). ...
COVID-19 has impacted children’s immunization rates, putting the lives of children at risk. The present study assesses the impact of phone-call counseling, on immunization uptake during the pandemic. Families of babies discharged from the SNCUs in six government centers in three South Indian states were recruited. Calls were made 10 days after the immunization due date. Missed vaccinees were counseled and followed up on 7 and 15 days. Of 2313 contacted, 2097 completed the survey. Respondents were mostly mothers (88.2%), poor (67.5%), and had secondary level education (37.4%). Vaccinations were missed due to the baby’s poor health (64.1%), COVID-19 related concerns (32.6%), and lack of awareness (16.8%). At the end of the intervention, the immunization uptake increased from 65.2% to 88.2%. Phone-call intervention can safely support immunization and lower the burden on health workers.
... Currently, the massive online dissemination of unconfirmed information on vaccination poses a serious risk to public health [2]. Rates of vaccine-preventable diseases have increased in many developed and developing countries [3,4]. Vaccination prevents two to three million deaths per year worldwide; however, 1.5 million deaths could be prevented if due vaccinations were applied. ...
(1) Background: Health professionals play an important role in addressing parents who are hesitant or reluctant to immunise their children. Despite the importance of this topic, gaps remain in the literature about these experiences. This meta-ethnography aimed to synthesise the available body of qualitative work about the care experiences of community and hospital health professionals in encounters with parents hesitant or reluctant to vaccinate their children. The aim is to provide key information for the creation of strategies that address vaccine hesitancy or refusal and ensure public trust in vaccination programs, which are required in a pandemic context such as the current one. (2) Methods: Noblit and Hare’s interpretive meta-ethnography of 12 studies was followed. A line of argument synthesis based on a metaphor was developed. (3) Results: The metaphor “The stone that refuses to be sculpted”, accompanied by three themes, symbolises the care experiences of health professionals in their encounters with parents that hesitate or refuse to vaccinate their children. (4) Conclusions: The creation of clearer communication strategies, the establishment of a therapeutic alliance, health literacy and the empowerment of parents are recommended. The incorporation of health professionals in decision making and the strengthening of multidisciplinary teams interacting with such parents are also included.
... India, despite being one of the leading producers of vaccines, has the highest number of under-five deaths, 20% of which are related to VPDs [2,3]. Of 27 million unvaccinated children globally, more than one-third i.e. almost 9.6 million are from India [3,4]. Between 2005 and 2016, full vaccination coverage increased from 44% to 62% with wide variation across states, regions, districts and blocks [5]. ...
Purpose
A qualitative study can help in understanding the unpolluted perspectives of key stakeholders involved in the vaccination practices and can explore vital factors that could influence vaccination-related behaviors and their utilization. This study aims to document the perceptions of caretakers, community members and healthcare service providers related to childhood vaccination practices in slums under the national immunization program (NIP) of India.
Design/methodology/approach
This was a qualitative community-based cross-sectional study. Focus group discussions with caretakers, community members and healthcare service providers were used to build a holistic, detailed description and analysis of the factors associated with childhood vaccination practices within its real-world context.
Findings
Lack of awareness, fear of adverse events following immunization, inappropriate timing of vaccination sessions, loss of daily earnings, migration, lack of good behavior of health staffs, shortage of logistics and vaccines, limited resources and infrastructures and high expectations of beneficiaries were some of the vital barriers impacting vaccination practices in slums.
Research limitations/implications
Though this study provides significant good information on the indicators that can be considered to improve the vaccination practices in any slum settings, it has is also a limitations too due to its setting. Therefore, one needs to be cautious while generalizing these results to other settings like rural. In addition, Though we believe that these strategies could be useful in any setting, it is also important to tailor these observations them as per the need of the society and the population. Also, this is a self-reported qualitative study and therefore the perspectives reported in this study need to be taken with caution. Further, low vaccination, poor awareness, compromised healthcare services, high expectations could be considered as a stigma/fear among the responders and therefore there is always a chance of underreporting. Thus, it would be important in future to conduct a study involving a broader group of people in society and to establish factors associated with the vaccination coverage. that can help in improvement of vaccination.
Originality/value
Initiatives such as regular interactions at different levels, effective communication including reminders, behavior interventions, the continued supply of vaccines and logistics, additional resources for the vaccination program, incentives and recognition, extended sessions and people-friendly healthcare delivery system could be helpful to strengthen the routine vaccination practices in slums.
... Immunization coverage is lower among children in lower-income households, in households with lower rates of parental education, and in households where the mother did not receive the recommended number of antenatal or postnatal care visits (Sissoko et al., 2014). Reasons for under-immunization include supply-side issues such as inaccessibility of vaccination services (Francis et al., 2018) and under-staffing of health facilities (Vashishtha, 2012) and demand-side issues such as low awareness (Francis et al., 2018) and anti-vaccine sentiment (Laxminarayan and Ganguly, 2011). In a 2008 household survey, the most common reason for under-vaccination (reported by caregivers) was unawareness of the need for vaccination (45%) (Francis et al., 2018). ...
The world is not on track to achieve the goals for immunization coverage and equity described by the World Health Organization’s Global Vaccine Action Plan. Many countries struggle to increase coverage of routine vaccination, and there is little evidence about how to do so effectively. In India in 2016, only 62% of children had received a full course of basic vaccines. In response, in 2017–18 the government implemented Intensified Mission Indradhanush (IMI), a nationwide effort to improve coverage and equity using a campaign-style strategy. Campaign-style approaches to routine vaccine delivery like IMI, sometimes called ‘periodic intensification of routine immunization’ (PIRI), are widely used, but there is little robust evidence on their effectiveness. We conducted a quasi-experimental evaluation of IMI using routine data on vaccine doses delivered, comparing districts participating and not participating in IMI. Our sample included all districts that could be merged with India’s 2016 Demographic and Health Surveys data and had available data for the full study period. We used controlled interrupted time-series analysis to estimate the impact of IMI during the 4-month implementation period and in subsequent months. This method assumes that, if IMI had not occurred, vaccination trends would have changed in the same way in the participating and not participating districts. We found that, during implementation, IMI increased delivery of 13 infant vaccines, with a median effect of 10.6% (95% confidence interval 5.1% to 16.5%). We did not find evidence of a sustained effect during the 8 months after implementation ended. Over the 12 months from the beginning of implementation, we estimated reductions in the number of under-immunized children that were large but not statistically significant, ranging from 3.9% (−6.9% to 13.7%) to 35.7% (−7.5% to 77.4%) for different vaccines. The largest effects were for the first doses of vaccines against diphtheria-tetanus-pertussis and polio: IMI reached approximately one-third of children who would otherwise not have received these vaccines. This suggests that PIRI can be successful in increasing routine immunization coverage, particularly for early infant vaccines, but other approaches may be needed for sustained coverage improvements.
... Vaccine studies also indicate the need to embed CE within India's immunization programs [19,21,22]. This growing sensitization about CE among Indian vaccine decisionmakers has been bolstered by the Supreme Court advisory which recommends meaningful dialogue with communities to accelerate vaccination uptake [21]. ...
Background: Globally, and in India, research has highlighted the importance of community engagement in achieving national vaccination goals and in promoting health equity. However, community engagement is not well-defined and remains an underutilized approach. There is also paucity of literature on community engagement’s effectiveness in achieving vaccination outcomes. To address that gap, this study interviewed Indian vaccination decisionmakers to derive a shared understanding of the evolving conceptualization of community engagement, and how it has been fostered during India’s Decade of Vaccines (2010-2020).
Methods: Semi-structured interviews were conducted with 25 purposefully sampled national-level vaccine decisionmakers in India, including policymakers, immunization program heads, and vaccine technical committee leads. Participants were identified by their ‘elite’ status among decisionmakers in the Indian vaccination space. Schutz’ Social Phenomenological Theory guided development of an a priori framework derived from the Social Ecological Model. The framework helped organize participants’ conceptualizations of communities, community engagement, and related themes. Inter-rater reliability was computed for a subsample of coded interviews, and findings were validated in a one-day member check-in meeting with study participants and teams.
Results: The interviews successfully elucidated participants’ understanding of key terminology (“community”) and approaches to community engagement propagated by the vaccine decisionmakers. Participants conceptualized ‘communities’ as vaccine-eligible children, their parents, frontline healthcare workers, and vaccination influencers. Engagement with those communities was understood to mean vaccine outreach, capacity-building of healthcare workers, and information dissemination. However, participants indicated that there were neither explicit policy guidelines defining community engagement nor pertinent evaluation metrics, despite awareness that community engagement is complex and under-researched. Examples of different approaches to community engagement ranged from vaccine imposition to empowered community vaccination decision-making. Finally, participants proposed an operational definition of community engagement and discussed concerns related to implementing it.
Conclusions: Although decisionmakers had different perceptions about what constitutes a community, and how community engagement should optimally function, the combined group articulated its importance to ensure vaccination equity and reiterated the need for concerted political will to build trust with communities. At the same time, work remains to be done both in terms of research on community engagement as well as development of appropriate implementation and outcome metrics.
... India has the greatest number of children aged <5 years globally and has experienced gradual improvements in childhood vaccination in the last 2 decades. 6 According to India's National Family Health Survey (NFHS), the proportion of fully vaccinated children aged 1−2 years increased from 35% in 1992−1993 to 44% in 2005−2006 to 62% in 2015−2016. 7 However, the degree of that improvement varied widely among the individual states and territories, suggesting substantial disparities in access to vaccination persist across India. ...
Introduction:
India's childhood vaccination coverage has increased amid the implementation of national health policies intended to improve immunization levels. However, there is a dearth of contemporary studies comparing state-level childhood vaccination rates across India's highly diverse states and territories. This study assesses SES-based inequalities in childhood vaccination by state for 2002-2013.
Methods:
National surveys from 2002 to 2004, 2007 to 2008, and 2012 to 2013 were used for analyses. Household SES was assessed using an asset index created through principal component analysis. Full vaccination comprised 1 dose bacille Calmette-Guerin, 3 doses diphtheria-pertussis-tetanus vaccine, 3 doses oral polio vaccine, and 1 dose measles-containing vaccine at age 12-60 months. Inequality analyses were stratified by 3 time periods and by government-designated high focus group versus nonhigh focus group states.
Results:
Childhood vaccination steadily increased between 2002 and 2013 in high focus group states but fell in some nonhigh focus group states, whereas SES-based vaccination inequalities generally decreased in both. In 2012-2013, rural areas had lower vaccination rates than urban areas in high focus group states but similar vaccination rates as urban areas in non-high focus group states. Increases in vaccination rates were not consistently accompanied by improvements in SES-based inequalities in vaccination.
Conclusions:
Childhood vaccination in India has improved overall, although increases are more pronounced in high focus group states than in nonhigh focus group states over the study period. The gap in coverage between these states decreased over time owing in part to the latter experiencing reductions in full vaccination rates during 2007-2013. SES-based vaccination disparities persist in India, highlighting the need to improve vaccination rates for all children, especially those from disadvantaged and underserved groups.
Supplement information:
This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.
... Vaccine studies also indicate the need to embed CE within India's immunization programs [19,21,22]. This growing sensitization about CE among Indian vaccine decision makers has been bolstered by the Supreme Court advisory which recommends meaningful dialogue with communities to accelerate vaccination uptake [21]. ...
Background
Globally, and in India, research has highlighted the importance of community engagement in achieving national vaccination goals and in promoting health equity. However, community engagement is not well-defined and remains an underutilized approach. There is also paucity of literature on community engagement’s effectiveness in achieving vaccination outcomes. To address that gap, this study interviewed Indian vaccination decision makers to derive a shared understanding of the evolving conceptualization of community engagement, and how it has been fostered during India’s Decade of Vaccines (2010-2020).
Methods
Semi-structured interviews were conducted with 25 purposefully sampled national-level vaccine decision makers in India, including policymakers, immunization program heads, and vaccine technical committee leads. Participants were identified by their ‘elite’ status among decisionmakers in the Indian vaccination space. Schutz’ Social Phenomenological Theory guided development of an a priori framework derived from the Social Ecological Model. The framework helped organize participants’ conceptualizations of communities, community engagement, and related themes. Inter-rater reliability was computed for a subsample of coded interviews, and findings were validated in a one-day member check-in meeting with study participants and teams.
Results
The interviews successfully elucidated participants’ understanding of key terminology (“community”) and approaches to community engagement propagated by the vaccine decision makers. Participants conceptualized ‘communities’ as vaccine-eligible children, their parents, frontline healthcare workers, and vaccination influencers. Engagement with those communities was understood to mean vaccine outreach, capacity-building of healthcare workers, and information dissemination. However, participants indicated that there were neither explicit policy guidelines defining community engagement nor pertinent evaluation metrics, despite awareness that community engagement is complex and under-researched. Examples of different approaches to community engagement ranged from vaccine imposition to empowered community vaccination decision-making. Finally, participants proposed an operational definition of community engagement and discussed concerns related to implementing it.
Conclusions
Although decision makers had different perceptions about what constitutes a community, and how community engagement should optimally function, the combined group articulated its importance to ensure vaccination equity and reiterated the need for concerted political will to build trust with communities. At the same time, work remains to be done both in terms of research on community engagement as well as development of appropriate implementation and outcome metrics.
... Vaccine studies also indicate the need to embed CE within India's immunization programs [21,22,23]. This growing sensitization about CE among Indian vaccine decisionmakers has been bolstered by the Supreme Court advisory which recommends meaningful dialogue with communities to accelerate vaccination uptake [24]. ...
Background: Globally, and in India, research has highlighted the importance of community engagement in achieving national vaccination goals. However, community engagement is not well-defined and remains an underutilized approach to realizing health equity in this context. There is also paucity of literature on community engagement’s effectiveness in achieving vaccination outcomes. To address that gap, this study interviewed Indian vaccination decisionmakers to derive a shared understanding of the evolving conceptualization of community engagement, and how it has been fostered during India’s Decade of Vaccines (2010-2020).
Methods: Semi-structured interviews were conducted with 25 purposefully sampled national-level vaccine decisionmakers in India, including policymakers, immunization program heads, and vaccine technical committee leads. Participants were identified by their ‘elite’ status among decisionmakers in the Indian vaccination space. Using Schutz’ Social Phenomenological theory, an a priori framework derived from the Social Ecological Model was used to guide coders’ conceptualizations of communities, community engagement, and related themes. Inter-rater reliability was computed for a subsample of coded interviews, and findings were validated in a one-day member check-in meeting with study participants and teams.
Results: The interviews successfully elucidated participants’ understanding of key terminology (“community”) and approaches to community engagement propagated by the vaccine decisionmakers. Participants conceptualized ‘communities’ as vaccine-eligible children, their parents, frontline healthcare workers, and vaccination influencers. Engagement with those communities was understood to mean vaccine outreach, capacity-building of healthcare workers, and information dissemination. However, participants indicated that there were neither explicit policy guidelines defining community engagement nor pertinent evaluation metrics, despite awareness that community engagement is complex and under-researched. Examples of different approaches to community engagement ranged from vaccine imposition to empowered community vaccination decision-making. Finally, participants proposed an operational definition of community engagement and discussed concerns related to implementing it.
Conclusions: Although decisionmakers had different perceptions about what constitutes a community, and how community engagement should optimally function, the combined group articulated its importance and reiterated the need for concerted political will to build trust with communities. At the same time, work remains to be done both in terms of research on community engagement as well as development of appropriate implementation and outcome metrics.
... Vaccine studies in the country also indicate the need for embedding CE within India's immunization programs [21,22,23]. This growing sensitization about CE among Indian vaccine decisionmakers has been bolstered by the Supreme Court advisory which recommends meaningful dialogue with communities to accelerate vaccination uptake [24]. is also perceived to be an important step in addressing community's vaccine resistance leading to delays inhibiting vaccines' timely uptake. ...
Background: Globally, and in India, the research literature on vaccination highlights importance of community engagement in achieving national vaccination goals. However, community engagement, and “community” itself, are not well-defined and remains underutilized approach to realize health equity in this context. There is also paucity of literature on community engagement’s effectiveness in achieving vaccination outcomes. To address that gap, this study interviewed influential Indian vaccination decisionmakers to derive a shared understanding of the evolving conceptualization of community engagement, and how it has been fostered during India’s Decade of Vaccines (2010-2020).
Methods: Semi-structured interviews were conducted with 25 purposefully sampled national-level vaccine decisionmakers in India, including policymakers, immunization program heads, and vaccine technical committee leads. Participants were identified by their ‘elite’ status among decisionmakers in the Indian vaccination space. Using Schutz’ Social Phenomenological theory, an a priori framework derived from the Social Ecological Model was used to guide coders’ conceptualizations of communities, community engagement, and related themes. Inter-rater reliability was computed for a subsample of coded interviews, and findings were validated in a one-day member check-in meeting with study participants and teams.
Results: Interpretation of the data elucidated commonly-held understanding of terminology and engagement interventions by elite vaccine decisionmakers. Participants conceptualized ‘communities’ as vaccine-eligible children, their parents, frontline healthcare workers, and vaccination influencers. Engagement with those communities was understood to mean vaccine outreach, capacity-building of healthcare workers, and information dissemination. However, participants indicated that there were neither explicit policy guidelines defining community engagement nor pertinent evaluation metrics, despite awareness that community engagement is complex and under-researched. Examples of different approaches to community engagement ranged from vaccine imposition to empowered community vaccination decision-making. Finally, participants proposed an operational definition of community engagement and discussed concerns related to implementing it.
Conclusions: Although decisionmakers had different perceptions about what constitutes a community, and how community engagement optimally should function, the combined group articulated its importance and reiterated the need for concerted political-will to build trust with communities. At the same time, work remains to be done both in terms of research on community engagement as well as development of appropriate implementation and outcome metrics.
... Regional disparities in non-immunisation and partial immunisation can be attributed not only to demand, but also to supply-side factors. India's vaccine deficit system may therefore also be a reason for non-vaccination or partial vaccination of children [44]. Supply-side factors include failure of health workers to arrive on time and/ or reliably and inadequate supplies of vaccines [45]. ...
Background: Childhood vaccinations are a vital preventive measure to reduce disease incidence and deaths among children. As a result, immunisation coverage against measles was a key indicator for monitoring the fourth Millennium Development Goal (MDG), aimed at reducing child mortality. India was among the list of countries that missed the target of this MDG. Immunisation targets continue to be included in the post-2015 Sustainable Development Goals (SDG), and are a monitoring tool for the Indian health care system. The SDGs also strongly emphasise reducing inequalities; even where immunisation coverage improves, there is a further imperative to safeguard against inequalities in immunisation outcomes. This study aims to document whether socioeconomic inequalities in immunisation coverage exist among children aged 12-59 months in India. Methods: Data for this observational study came from the fourth round of the National Family Health Survey (2015-16). We used the concentration index to assess inequalities in whether children were fully, partially or never immunised. Where children were partially immunised, we also examined immunisation intensity. Decomposition analysis was applied to examine the underlying factors associated with inequality across these categories of childhood immunisation.
... Regional disparities in non-immunisation and partial immunisation can be attributed not only to demand, but also to supply-side factors. India's vaccine deficit system may therefore also be a reason for non-vaccination or partial vaccination of children [44]. Supply-side factors include failure of health workers to arrive on time and/ or reliably and inadequate supplies of vaccines [45]. ...
Background: Childhood vaccinations are a vital preventive measure to reduce disease incidence and deaths among children. As a result, immunisation coverage against measles was a key indicator for monitoring the fourth Millennium Development Goal (MDG), aimed at reducing child mortality. India was among the list of countries that
missed the target of this MDG. Immunisation targets continue to be included in the post-2015 Sustainable Development Goals (SDG), and are a monitoring tool for the Indian health care system. The SDGs also strongly emphasise reducing inequalities; even where immunisation coverage improves, there is a further imperative to safeguard against inequalities in immunisation outcomes. This study aims to document whether ocioeconomic inequalities in immunisation coverage
exist among children aged 12–59 months in India.
Methods: Data for this observational study came from the fourth round of the National Family Health Survey (2015–16). We used the concentration index to assess inequalities in whether children were fully, partially or never immunised. Where children were partially immunised, we also examined immunisation intensity. Decomposition analysis was applied to examine the underlying factors associated with inequality across these categories of childhood immunisation.
Results: We found that in India, only 37% of children are fully immunised, 56% are partially immunised, and 7% have never been immunised. There is a disproportionate concentration of immunised children in higher wealth quintiles, demonstrating a socioeconomic gradient in immunisation. The data also confirm this pattern of socioeconomic inequality across regions. Factors such as mother’s literacy, institutional delivery, place of residence, geographical location, and socioeconomic status explain the disparities in immunisation coverage.
Conclusions: In India, there are considerable inequalities in immunisation coverage among children. It is essential to ensure an improvement in immunisation coverage and to understand underlying factors that affect poor uptake and disparities in immunisation coverage in India in order to improve child health and survival and meet the SDGs.
... Many children and pregnant women do not receive the full schedule of vaccines. Reasons for under-immunization include low awareness (13), inaccessibility of vaccination services (13), anti-vaccine sentiment (14), and under-staffing of health facilities (15). In recent years, in an effort to increase coverage, the Government of India implemented a series of campaign-like interventions called Mission Indradhanush (MI). ...
Introduction: The world is not on track to achieve the goals for immunization coverage and equity described by the World Health Organization in the Global Vaccine Action Plan. In India, only 62 percent of children had received a full course of basic vaccines in 2016. We evaluated the Intensified Mission Indradhanush (IMI), a campaign-style intervention to increase routine immunization coverage and equity in India, implemented in 2017-2018.
Methods: We conducted a comparative interrupted time-series analysis using monthly district-level data on vaccine doses delivered, comparing districts participating and not participating in IMI. We estimated the impact of IMI on coverage and under-coverage (defined as the proportion of children who were unvaccinated) during the four-month implementation period and in subsequent months.
Findings: During implementation, IMI increased delivery of thirteen infant vaccines by between 1.6 percent (95 percent CI: -6.4, 10.2) and 13.8 percent (3.0, 25.7). We did not find evidence of a sustained effect during the 8 months after implementation ended. Over the 12 months from the beginning of implementation, IMI reduced under-coverage of childhood vaccination by between 3.9 percent (-6.9, 13.7) and 35.7 percent (-7.5, 77.4). The largest estimated effects were for the first doses of vaccines against diptheria-tetanus-pertussis and polio.
Interpretation: IMI had a substantial impact on infant immunization delivery during implementation, but this effect waned after implementation ended. Our findings suggest that campaign-style interventions can increase routine infant immunization coverage and reach formerly unreached children in the shorter term, but other approaches may be needed for sustained coverage improvements.
... An estimated 38% of children failed to receive all basic vaccines in the first year of life in 2016. (4)(5)(6) The factors limiting vaccination coverage include large mobile and isolated populations that are difficult to reach, and low demand from underinformed and misinformed populations who fear side effects and are influenced by anti-vaccination messages.(5-7) With this background a retrospective study was conducted at Department of Pediatrics , Integral Institute of Medical Sciences & Hospital, Lucknow to assess the extent of immunization coverage of children. ...
Introduction: Vaccination is proven to be one of the most cost-effective child survival interventions. This retrospective
study was conducted to assess the extent of immunization coverage among children in a tertiary care hospital in District
Lucknow.
Material and Methods: A cross-sectional retrospective study was conducted at Department of Pediatrics at Integral Institute of Medical
Sciences & Hospital, Lucknow to assess the extent of immunization coverage of children aged 12-23 months registered between 1st Jan 2019-
15th January 2020. The statistical analysis has been done using the Microsoft excel. Data were presented in number and percentages.
Results: Among the children registered, 1255 infants received BCG, 1077 infants received OPV 0 dose and 623 infants were administered
Hepatitis B at birth. Overall 582 infants had received three doses of OPV and 600 infants were given two doses of IPV. A total of 964 infants were
registered for having measles vaccination. The administration of DPT booster first and second dose was reported among 427 and 38 infants
respectively. A total of 227 infants were given only one PCV dose while 192 infants had received three doses of PCV. Overall 514 infants were
administered two doses of JE vaccine and 214 infants were administrated all doses of rotavirus vaccine. Overall 582 infants were found to be fully
immunized.
Conclusion: IEC is the key to ensure 100% vaccination coverage. Ignorance and false beliefs, such as rumours about adverse events or vaccines
causing sterilization should be removed from the community by the community workers and health care providers.
... Childhood vaccination rates vary widely across regions and socioeconomic groups in India. [32][33][34] Standard of living, access to postnatal care and subsidized vaccines, maternal schooling, and health insurance coverage have all been linked positively to vaccination rates. 35 make Hib-vaccinated and -unvaccinated children systematically different, potentially biasing least squares regression-based estimates of the associations of the vaccine with our outcomes of interest because such differences may also be linked to these outcomes. ...
Haemophilus influenzae type b (Hib) affects 337,000 Indian children every year. A vaccine against Hib was introduced in 2011 as part of the pentavalent vaccine and scaled up nationwide. This study investigated the associations between Hib vaccination and child anthropometry, cognition, and schooling outcomes in India. We used longitudinal survey data and employed propensity score matching to control for observed systematic differences between children who reported receipt or nonreceipt of Hib vaccine before age 6 years (n = 1824). Z‐scores of height‐for‐age (HAZ) and BMI‐for‐age (BMIZ), percentage scores of English, mathematics, reading, and Peabody Picture Vocabulary tests, and attained schooling grade of children were examined. Hib‐vaccinated children had 0.25 higher HAZ, scored 4.09 percentage points (pp) higher on the English test and 4.78 pp higher on the mathematics test, and attained 0.16 more schooling grades than Hib‐unvaccinated children at age 11–12 years. At age 14–15 years, they had 0.18 higher HAZ, scored 3.63 pp higher on the reading test and 3.22 pp higher on the mathematics test, and attained 0.15 more schooling grades than Hib‐unvaccinated children. The findings indicate potential long‐term health, cognitive, and schooling benefits of the Hib vaccine, subject to the effect of unobserved confounding factors.
... The challenge of decreasing dropouts and enrolling the ones with no immunization at all becomes ever more daunting as the country adds a pool of 12.5 million partially immunized children each year. [12] Therefore, it is important to assess the determinants of partial and no immunization so that attention can be paid to overcome the factors or barriers impeding the compliance for full immunization. Moreover, it is well documented that the epidemiology of nonimmunization may differ substantially from the epidemiology of partial immunization. ...
Background: The immunization coverage in India is far away from satisfactory with full immunization coverage being only 62% at national level. Targeting the intensive efforts to poor performing areas and addressing the determinants of nonimmunization and dropouts offers a quick solution. In this paper, we assess the inter‑district variations in Haryana state, and the association of social determinants with partial and no immunization.
Methodology: This analysis is based on data collected as part of a large household survey undertaken in the state of Haryana to measure the extent of Universal Health Coverage. A multistage stratified random sampling design was used to select primary sampling units (i.e., subcenters), villages, and households. A total of 11,594 mothers with a child between 12 and 23 months were interviewed on receipt
of immunization services. Determinants of nonimmunization and partial immunization were assessed using multiple logistic regression.
Results: About 21% of children aged 12–23 months were partially immunized, while 4.3% children aged 12–23 months had received “no immunization.” While the coverage of full immunization was 74.7% at the state level, it varied from 95% in best performing district to 38% in poorest performing district. Odds of a partially immunized child were significantly higher in urban area (odds ratio [OR] = 1.23; 95% confidence interval [CI] = 1.1–1.38), among Muslim household (OR = 3.52; 95% CI = 3.03–4.11), children of illiterate parents (OR = 1.58; 95% CI = 1.22–2.05), and poorest quintile (OR = 1.61; 95% CI = 1.36–1.89).
Conclusions: Wide interdistrict variations call for a need to consider changes in resource allocation and strengthening of the government initiatives to improve routine immunization in these districts.
... Total vaccination programme cost for the Government of India in introduction of PCV program nationwide would be approxi- mately around $4791 million for a period of 10 years (2018)(2019)(2020)(2021)(2022)(2023)(2024)(2025)(2026)(2027). However, current spending on vaccines by the government is far less accounting for only 2% of national health budget [32]. After the end of partnership with GAVI and subsidization of rate by Pfizer, the amount need to be spent on vaccines will be manifold compared to the current expenditure. ...
... [2][3][4] The factors limiting vaccination coverage include large mobile and isolated populations that are difficult to reach, and low demand from underinformed and misinformed populations who fear side effects and are influenced by anti-vaccination messages. [5][6][7] Owing to low childhood vaccination coverage, India's Ministry of Health and Family Welfare launched Mission Indradhanush (MI) in 2014, to target underserved, vulnerable, resistant, and inaccessible populations. 8 The programme ran between April 2015 and July 2017, vaccinating around 25.5 million children and 6.9 million pregnant women. ...
The Intensified Mission Indradhanush strategy showed that cross-sectoral participation can increase vaccination rates in children at high risk.
Strengthening of the system and practice changes could make it more effective.
Sustained high level political support, advocacy, and supervision across sectors, together with flexibility to reallocate financial resources and staff were essential for success.
Districts must strengthen staff capacity to list household beneficiaries, add additional vaccination sites, and invest in the transportation required for both.
Better communication and counselling skills tailored to local beliefs are needed to deal with barriers to seeking vaccinations.
Districts and primary care facilities work must more effectively with non-health stakeholders by involving them early in logistics planning, communication, and messaging strategies.
... The challenge of decreasing dropouts and enrolling the ones with no immunization at all becomes ever more daunting as the country adds a pool of 12.5 million partially immunized children each year. [12] Therefore, it is important to assess the determinants of partial and no immunization so that attention can be paid to overcome the factors or barriers impeding the compliance for full immunization. Moreover, it is well documented that the epidemiology of nonimmunization may differ substantially from the epidemiology of partial immunization. ...
Background
The immunization coverage in India is far away from satisfactory with full immunization coverage being only 62% at national level. Targeting the intensive efforts to poor performing areas and addressing the determinants of nonimmunization and dropouts offers a quick solution. In this paper, we assess the inter-district variations in Haryana state, and the association of social determinants with partial and no immunization.
Methodology
This analysis is based on data collected as part of a large household survey undertaken in the state of Haryana to measure the extent of Universal Health Coverage. A multistage stratified random sampling design was used to select primary sampling units (i.e., subcenters), villages, and households. A total of 11,594 mothers with a child between 12 and 23 months were interviewed on receipt of immunization services. Determinants of nonimmunization and partial immunization were assessed using multiple logistic regression.
Results
About 21% of children aged 12–23 months were partially immunized, while 4.3% children aged 12–23 months had received “no immunization.” While the coverage of full immunization was 74.7% at the state level, it varied from 95% in best performing district to 38% in poorest performing district. Odds of a partially immunized child were significantly higher in urban area (odds ratio [OR] = 1.23; 95% confidence interval [CI] = 1.1–1.38), among Muslim household (OR = 3.52; 95% CI = 3.03–4.11), children of illiterate parents (OR = 1.58; 95% CI = 1.22–2.05), and poorest quintile (OR = 1.61; 95% CI = 1.36–1.89).
Conclusions
Wide interdistrict variations call for a need to consider changes in resource allocation and strengthening of the government initiatives to improve routine immunization in these districts.
... Considering the problems in the sustained vaccine supply and funding, several options have been offered for consideration. Vaccines are being developed by Shanta Biotechnic Pvt. Ltd., Hyderabad, Biological E Ltd., Hyderabad and Indian Immunologicals Ltd., Hyderabad as well as Bharat Biotech Hyderabad [52]. ...
Introduction
Japanese encephalitis (JE) is recently declared as a notifiable disease in India due to its expanding geographical distribution. The disease notification facilitates effective implementation of preventive measures and case management.
Expalantion
JE is a vector-borne disease that can be prevented by vaccine administration. It is caused by Japanese encephalitis virus (JEV), belonging to family Flaviviridae. Amongst the known etiological viral encephalitis agents, it is one of the leading viral agents of acute encephalitis syndrome in many Asian countries where it is identified to cause substantial morbidity and mortality as well as disability. Globally, it is responsible for approximately 68,000 clinical cases every year.
Conclusion
In the absence of antivirals, patients are given supportive treatment to relieve and stabilize. Amongst available control strategies; vector control is resource intensive while animal and human vaccination are the most effective tool against the disease. This review highlights recent progress focusing challenges with diagnosis and prophylactic interventions.
... It has been found out that parental refusal of vaccination for children resulted in an increase of prevalence of vaccine-preventable diseases nationally (9,10). It has been shown that the number of measles cases has increased nationally due to parental vaccine refusal. ...
Vaccines are one of the most successful methods used for preventing infectious diseases. However, there has been an increased public concern regarding the adverse effects of vaccines, especially among parents who are concerned about the false link between autism and vaccine. Evidence shows there is an increasing incidence of parental vaccine refusal resulting in outbreaks. This recent emergence puts a limitation on the role of parents in autonomous determination for their children, under the age of consent. In this review, we aim to identify vaccine safety concerns among parents and to evaluate the role of parents in giving informed consent on behalf of their children. Autonomy, although an ethical principle afforded to the parents of under-age children must be reviewed in the context of the results of the studies reviewed as parental refusal seems prevalent with the false belief that vaccines cause more harm to children than good.
... India has almost 9.6 million unimmunized children which contribute to more than one-third of the unimmunized children around the world. 8 In India only 43.5 % of children receive a full schedule of vaccination according to NFHS-3. 9 Nine million immunization sessions are organized each year to target these infants and 30 million pregnant women for routine immunization (RI) in India. ...
... For example, in Bangladesh, 82% of children are fully immunized by two years of age. In Nepal as well, 80% of children are fully immunized by one year of age (Laxminarayan and Ganguly, 2011). ...
Aims:
Almost, one third of the world's urban population resides in slums and the number would double by 2030. Slums denotes collection of people from various communities having a meagre income and living in unhygienic conditions thus making themselves most vulnerable for outbreaks of communicable diseases. India contributes substantially to the global disease burden and under-five mortality rates i.e. 20% attributable to vaccine preventable diseases. Immunization plays a crucial role in combating high childhood mortality rates attributable to vaccine preventable diseases across the globe. This systematic review, provides insights on immunization status in slums, identifies various factors influencing it thus, exploring opportunities that may be available to improve vaccination coverage under the National Immunization Program.
Methods:
Taking into account the above aspects, a review of literature was undertaken in various databases that included studies published between 2006 and 2017.
Results:
In India, ~33% of the urban population lives in slums with suboptimal vaccination coverage ranging from 14% to upto 90%. Few of the important causes for low coverage included socioeconomic factors such as poor community participation, lack of awareness, frequent migration, and loss of daily income. Hence, mere presence of vaccines in the National Immunization Program doesn't do the job, there is a definite unmet need to emphasize upon the importance of immunization among slums dwellers and take necessary steps. For instance, delivering immunization services at the doorstep (e.g. pulse polio program), community-based education, text messaging as reminders and incentivized immunization services are some of the opportunities that can be explored and implemented to improve immunization status in the slums.
Conclusion:
Thus, in addition to inclusion of more and more vaccines in the National Immunization Program, there is a definite need to focus on people living in high risk areas in order to improve coverage and healthcare indicators.
... Several authors have studied the reasons behind the low immunization coverage in India, and though the main reason appears to be low government spending in this sector, another important identified gap is the poor demand for the vaccines. 8,9 The reasons for that could range from poor awareness, limited access to health care services or also a distrust in the childhood vaccination programme or anxiety due to the apparent side effects of the vaccines. With the introduction of newer antigens in the childhood immunization programme in several states, there is a need to assess the awareness among parents regarding the revised schedule and acceptability of the newer vaccines. ...
Background: With the introduction of newer antigens in the childhood immunization programme in several states, the nationwide UIP is eventually going to be further expanded to increase the number of diseases against which children will be protected through the vaccination programme. However, despite the best intentions of the government, a poor awareness of the new vaccines among the caregivers may defeat this purpose and only result in poor coverage and poor uptake. This study was carried out to assess the awareness of mothers regarding the new vaccines introduced in the childhood vaccination programme in Delhi State. Methods: The study was conducted in the immunization clinic of a tertiary care hospital of Delhi. A total sample of 388 mothers was interviewed. The data was analyzed using SPSS ver 20. Results: Only 18.3% (95% CI, 14.76-22.46) of the participants were aware that newer vaccines have been introduced into the programme. 48.2% (95% CI 43.27- 53.16) of the respondents were unaware about the same, while 33.5% (95% CI, 28.99-38.35) claimed to have heard about it but were not sure whether newer vaccines had been introduced. It was observed that as the education status of mothers improved, their awareness regarding newer vaccines in the programme also increased. The knowledge regarding age of administration, number of doses etc. was very poor. However multiple pricks during a single vaccination visit was not a disincentive for the mother to get the child vaccinated. The willingness to buy a vaccine that was not available free of cost from the hospital, increased with increasing education level of the mother. Conclusions: There is a requirement of focused publicity campaigns to increase the awareness and thereby uptake of the new vaccines among caregivers.
... Further, the coverage of existing vaccines under the UIP has been variable with nearly half of India's children not being fully vaccinated. 5,6 The Indian health system comprises of a mix of public and private services providers. India's private sector is sought out for care and treatment by a huge segment of its population. ...
Key debates on improving vaccination coverage tend to focus on factors that affect uptake in the public health system while ignoring the private sector that plays an important role in providing health services in any low or middle-income country setting. Using in-depth interviews, we explored factors that influenced the decision of parents as well as pediatricians working in the private sector across 8 Indian cities on whether their children should be vaccinated with a particular vaccine Pediatricians and their relationship with parents was an important factor that influenced the decision on whether parents vaccinated their children with a particular vaccine or not. The decision to recommend a vaccine is taken on the principle that it is better to be safe than sorry than on any objective assessment of whether a child requires a particular vaccine or not. Family members and social factors also played a major role in the decision-making. According to some parents, vaccinating their child added an aspirational value to their growth. This is especially true of the newer vaccines that are considered optional in India. The cost of a vaccine did not come up as an inhibiting factor in the decision to vaccinate a child. Access to appropriate evidence was limited for both pediatricians and parents and evidence per se played a minimal role in the final decision to vaccinate a child or not. Far more important were the influences of factors such as relationship with the pediatrician, the role of decisions related to vaccination taken by people in the immediate social network.
... 17 It is possible that predictors such as religion, caste, gender and residency could partially explain vaccination delays as well. The interaction of these variables in combination with the contextual challenges of vaccine service delivery such as supply logistics, storage of sufficient vaccine stock, cold chain maintenance, inadequate staffing at health centers and discontinuity of clinic services, 13,29 all call for further study to assess potential associations with vaccination delays. ...
Background:
India has the highest number of deaths among children younger than 5 years of age globally; the majority are from vaccine preventable diseases. Untimely vaccination unnecessarily prolongs susceptibility to disease and contributes to the burden of childhood morbidity and mortality yet there is scarce literature on vaccination delays. The aim of this study is to characterize the timeliness of childhood vaccinations administered under India's routine immunization program using a novel application of an existing statistical methodology.
Methods:
This study utilized the District Level Household and Facility Survey Data, 2008 from India using vaccination data from children with and without immunization cards. Turnbull estimator of the cumulative distribution function was used to estimate the probability of vaccination at each age. Timeliness of Bacille Calmette-Guerin (BCG), all three doses of diphtheria, pertussis, and tetanus vaccine (DPT), and measles-containing vaccine (MCV) were considered for this analysis.
Findings:
Vaccination data on 268,553 children who were 0 to 60 months of age were analyzed; timely administration of BCG, DPT3 and MCV occurred in 31%, 19%, and 34% of children, respectively. The estimated vaccination probability plateaued for DPT and BCG around the age of 24 months, whereas MCV uptake increased another 5% after 24 months of age. The five year coverage of BCG, DPT3, and MCV in Indian children was 87%, 63%, and 76%, respectively.
Interpretation:
Lack of timely administration of key childhood vaccines, especially DPT3 and MCV, remains a major challenge in India and likely contributes to the significant burden of VPD-related morbidity and mortality in children.
Background:Internet access penetration in Indonesia is growing, all information can be obtained very easily, including how the child's immune system can be obtained against diseases that can be prevented by immunization. However, the internet can also have a bad impact, because it is very easy to use to spread false news or hoaxes. Objective: An analysis will be conducted to find the relationship between internet access in the family and the status of completeness of basic immunization for children under two years Method: The study will use data from the Indonesian Health Demographic Survey (IDHS) conducted in 2017. The unit of analysis is children under two years. The analysis of the relationship between internet access in the family and the completeness status of basic immunization for children under two years used logistic regression analysis with a complex sample mode. Result: The analysis shows that families in Indonesia who have internet access based on the 2017 IDHS data are 46.0 percent, and children under two years with complete basic immunization status is 65.3 percent. It can be seen that there is a relationship between internet access and the completeness status of basic immunization for children with OR 1.37 (1.14-1.66). Conclusion: The internet is like a double-edged sword, one side can be used to find various information that is beneficial to health, but can also be used to spread false information. Therefore it is important to educate all Indonesians to use internet access positively. Keywords: immunization, vaccine, IDHS, Indonesia. Abstrak Latar belakang: Penetrasi akses internet di Indonesia semakin berkembang, semua informasi dapat diperoleh dengan sangat mudah, termasuk bagaimana diperolehnya kekebalan tubuh anak terhadap penyakit-penyakit yang dapat dicegah dengan imunisasi. Akan tetapi, internet juga bisa memberikan dampak yang tidak baik karena sangat mudah dimanfaatkan untuk menyebarkan berita yang tidak benar atau hoax. Tujuan: Akan dilakukan analisis untuk mencari hubungan antara akses internet dalam keluarga terhadap status kelengkapan imunisasi dasar anak bawah dua tahun. Metode: Penelitian akan menggunakan data Survei Demografi Kesehatan Indonesia (SDKI) yang dilakukan tahun 2017. Unit analisis adalah anak bawah dua tahun (baduta). Analisis hubungan antara akses internet dalam keluarga dengan status kelengkapan imunisasi dasar anak bawah dua tahun menggunakan analisis regresi logistik dengan mode kompleks sampel. Hasil: Analisis memperlihatkan bahwa keluarga di Indonesia yang memiliki akses internet berdasarkan data SDKI 2017 adalah sebesar 46,0 persen, dan baduta dengan status imunisasi dasar lengkap adalah sebesar 65,3 persen. Terlihat adanya hubungan antara akses internet dengan status kelengkapan imunisasi dasar anak dengan OR 1,37 (1,14-1,66). Kesimpulan: Internet bagai pedang bermata dua, satu sisi dapat digunakan untuk mencari berbagai informasi yang bermanfaat bagi kesehatan, akan tetapi bisa juga dapat digunakan untuk menyebarkan informasi yang tidak benar. Oleh sebab itu, edukasi penting bagi seluruh penduduk Indonesia untuk menggunakan akses internet dengan positif. Kata kunci: imunisasi, vaksin, internet, SDKI, Indonesia
Background: In developing countries various childhood diseases lead the morbidity, mortality and irreversible losses which can be prevented by proper vaccination. This study was conducted to analyse the changing trends of childhood vaccination in India and its impact on childhood diseases and mortality, the trends in coverage of each vaccine along with identification of geographical areas of concern. Materials and methods: NFHS data published by Government of India was analyzed to see the trends in vaccination coverage, female literacy, childhood diseases and under-five mortality, along with online database search for relevant literature. Results: Total vaccination coverage in India has reached to 76.4% as per NFHS- 5 data. Orissa stands at the top with 90.5% coverage while Nagaland at the bottom with 57.9% coverage. Prevalence of childhood diseases and under-five mortality has reduced overtime accountable to increase in vaccination coverage as one of the major factors for same. Conclusion: Despite improvement in total vaccination coverage, the goal of Intensified Mission Indra Dhanush of 90% coverage still remains unachieved. There is reduction in childhood disease and mortality rate, but the pandemic has adversely affected these advances. Therefore, immediate steps should be taken to gain the lost ground.
Background: Child health inequality between genders is a persisting problem throughout low and middle-income countries like India. With the limited sources of child health care facilities, parental and other senior members' values and expertise may have played a vital role in shaping the upbringing of child health and minimizing the inequalities to sustain the equity. This study sought to explore the parent and other guardians' roles in a child's health inequalities with this backdrop. The present study investigates child health differences based on birth information, child immunization, feeding patterns, the morbid and nutritional condition between boys and girls and explores parental roles on curative measures and general perception of children. Methods: The study used quantitative and qualitative approaches, including Focused Group Discussion (FGD) and specific case studies from 208 households (413 children aged up to 8 years) from different settlements in North 24 Parganas district of West Bengal, India. Results: We found that not much significant difference existed between boys and girls for health inequalities markers. But altogether, girls had a disadvantageous position in getting delayed health care facilities after illness, inappropriate breastfeeding patter, stunting and being underweight. The Muslim children suffered more from health inequalities compared to Hindu children. However, the qualitative approach revealed that parents and guardians did not discriminate between boys and girls for their upbringing in health care facilities. Still, specific case studies, the parental statements and participant observation exposed the crude facts of preferring nature towards boys than girls in the thought process of the parents and guardians in the present study. Conclusion: Therefore, in the current scenario, gender and community-specific public health intervention must get more sustainable child health equity
Purpose
Due to the introduction of new vaccines in the child immunization program and inefficient vaccine supply chain (VSC), the universal immunization program (UIP), India is struggling to provide a full schedule of vaccination to the targeted children. In this paper, the authors investigate the critical factors for improving the performance of the existing VSC system by implementing the next-generation vaccine supply chain (NGVSC) in India.
Design/methodology/approach
The authors design a fuzzy multi-criteria framework using a fuzzy analytical hierarchical process (FAHP) and fuzzy multi-objective optimization on the basis of ratio analysis (FMOORA) to identify and analyze the critical barriers and enablers for the implementation of NGVSC. Further, the authors carry out a numerical simulation to validate the model.
Findings
The outcome of the analysis contends that demand forecasting is the topmost supply chain barrier and sustainable financing is the most important/critical enabler to facilitate the implementation of the NGVSC. In addition, the simulation reveals that the results of the study are reliable.
Social implications
The findings of the study can be useful for the child immunization policymakers of India and other developing countries to design appropriate strategies for improving existing VSC performance by implementing the NGVSC.
Originality/value
To the best of the authors’ knowledge, the study is the first empirical study to propose the improvement of VSC performance by designing the NGVSC.
Background:Internet access penetration in Indonesia is growing, all information can be obtained very easily, including how the child's immune system can be obtained against diseases that can be prevented by immunization. However, the internet can also have a bad impact, because it is very easy to use to spread false news or hoaxes. Objective: An analysis will be conducted to find the relationship between internet access in the family and the status of completeness of basic immunization for children under two years Method: The study will use data from the Indonesian Health Demographic Survey (IDHS) conducted in 2017. The unit of analysis is children under two years. The analysis of the relationship between internet access in the family and the completeness status of basic immunization for children under two years used logistic regression analysis with a complex sample mode. Result: The analysis shows that families in Indonesia who have internet access based on the 2017 IDHS data are 46.0 percent, and children under two years with complete basic immunization status is 65.3 percent. It can be seen that there is a relationship between internet access and the completeness status of basic immunization for children with OR 1.37 (1.14-1.66). Conclusion: The internet is like a double-edged sword, one side can be used to find various information that is beneficial to health, but can also be used to spread false information. Therefore it is important to educate all Indonesians to use internet access positively. Keywords: immunization, vaccine, IDHS, Indonesia. Abstrak Latar belakang: Penetrasi akses internet di Indonesia semakin berkembang, semua informasi dapat diperoleh dengan sangat mudah, termasuk bagaimana diperolehnya kekebalan tubuh anak terhadap penyakit-penyakit yang dapat dicegah dengan imunisasi. Akan tetapi, internet juga bisa memberikan dampak yang tidak baik karena sangat mudah dimanfaatkan untuk menyebarkan berita yang tidak benar atau hoax. Tujuan: Akan dilakukan analisis untuk mencari hubungan antara akses internet dalam keluarga terhadap status kelengkapan imunisasi dasar anak bawah dua tahun. Metode: Penelitian akan menggunakan data Survei Demografi Kesehatan Indonesia (SDKI) yang dilakukan tahun 2017. Unit analisis adalah anak bawah dua tahun (baduta). Analisis hubungan antara akses internet dalam keluarga dengan status kelengkapan imunisasi dasar anak bawah dua tahun menggunakan analisis regresi logistik dengan mode kompleks sampel. Hasil: Analisis memperlihatkan bahwa keluarga di Indonesia yang memiliki akses internet berdasarkan data SDKI 2017 adalah sebesar 46,0 persen, dan baduta dengan status imunisasi dasar lengkap adalah sebesar 65,3 persen. Terlihat adanya hubungan antara akses internet dengan status kelengkapan imunisasi dasar anak dengan OR 1,37 (1,14-1,66). Kesimpulan: Internet bagai pedang bermata dua, satu sisi dapat digunakan untuk mencari berbagai informasi yang bermanfaat bagi kesehatan, akan tetapi bisa juga dapat digunakan untuk menyebarkan informasi yang tidak benar. Oleh sebab itu, edukasi penting bagi seluruh penduduk Indonesia untuk menggunakan akses internet dengan positif. Kata kunci: imunisasi, vaksin, internet, SDKI, Indonesia
In recent years, vaccine incidents occurred around the world. This paper presents a blockchain based solution to protect the whole process of vaccine circulation. We first propose a model to supervise the vaccine circulation process by incorporating existing regulatory practices. Then, we propose a blockchain based tracing system to implement this model. The proposed system takes the blockchain as a global, unique, and verifiable database to store all the circulation data. Through data insertions and queries on the global, unique database, the proposed system achieves the protection of vaccine circulation. We also implement a proof-of-concept prototype of the proposed system.
Background:
In spite of being a principal producer and exporter of vaccines and billions spent over decades, India is home to one-third of the world's under-five children (U5C) with no immunization.
Objectives:
The objective of this study was to find the outcome of child-to-child and child-to-parent Information, Education and Communication (IEC) strategy on the current percentage of immunization coverage (IC).
Methods:
A mixed design research with multilevel concurrent sampling was conducted in Pune. Based on school students' households, 44 clusters having U5C were divided randomly into 11 experimental/control groups each. IEC strategy to students was independent variable and IC among U5C was dependent variable. Data were collected from 1092 students and 2352 U5C parents over 6 years. Vaccination card and Bacillus Calmette-Guérin mark were considered as evidence to conclude on full, partial and no IC. Change in knowledge quotient (KQ) among students/parents and U5C IC before and after IEC strategy assessed.
Results:
Rural/urban age-appropriate full IC of U5C was 51% and 67% before and 88% and 85% in post-IEC, respectively. The mean KQ change score of 8-12/20 in students is likely to increase full IC by 37% and 18%, decrease partial coverage at 14% and 12%, and improve none coverage at 23% and 16%, from its existing level positively in experimental groups. Numerous factors discouraged parents to pursue their U5C immunization.
Conclusions:
Advocacy through school students can be an economically viable alternative marketing strategy for inadequate U5C IC than billions spent on treating vaccine-preventable diseases and impractical options.
Purpose
Delivering vaccines to the children who need them requires a supply chain that is efficient and effective. In most of the developing countries, however, the unknown and unresolved supply chain issues are causing inefficiencies in distributing vaccines. There is, therefore, a great need in such countries to recognize the issues that cause delays in vaccine delivery. With this purpose, the present study aims to identify and analyze the key issues in the supply chain of basic vaccines required to immunize children in developing countries.
Design/methodology/approach
Based on a field survey of three states of India, in-depth review of relevant literature and experts’ opinions, 25 key issues were recognized as factors of the vaccine supply chain (VSC) and categorized into five main domains. Using integrated interpretive structural modeling and fuzzy analytic network process approaches, the issues have been prioritized to determine their relative importance in the VSC. In addition, a sensitivity analysis has been performed to investigate the priority stability of the issues.
Findings
The results of the analysis show that among the five domains of VSC issues, the economic domain with a weight of 0.4262 is the most important domain, followed by the management (0.2672), operational (0.2222), environmental (0.0532) and social (0.0312).
Research limitations/implications
This study focuses on the prioritization of VSC issues; therefore, the results of the present study can provide direction to the decision-makers of immunization programs of developing countries in driving their efforts and resources on eliminating the most important obstacles to design successful vaccination programs.
Originality/value
To the authors’ knowledge, this paper is first to provide a direction to the decision-makers in identifying and managing important issues through the use of an analytical approach.
Introduction:
In recent years, demand to improve child immunization coverage globally, and the development of the latest vaccines and technology has made the vaccine market very complex. The rise in such complexities often gives birth to numerous issues in the vaccine supply chain, which are the primary cause of its poor performance. Figuring out the cause of the performance problem can help you decide how to address it. The goal of the present study is to identify and analyze important issues in the supply chain of basic vaccines required for child immunization in the developing countries.
Research design & methods:
Twenty-five key issues as various factors of the vaccine supply chain have been presented in this paper. Fuzzy MICMAC analysis has been carried out to classify the factors based on their driving and dependence power and to develop a hierarchy based model. Further, the findings have been discussed with the field experts to identify the critical factors.
Results & conclusion:
Three factors: better demand forecast, communication between the supply chain members, and proper planning and scheduling have been identified as the critical factors of vaccine supply chain. These factors should be given special care to improve vaccine supply chain performance.
Objective
Studies have highlighted that children of adolescent (aged 15–19 years) mothers are likely to receive relatively poor healthcare. With an unacceptably high adolescent birth rate, India houses the highest number of adolescent mothers globally, putting children at risk of inadequate vaccination. This paper assesses trends and extent of socioeconomic disparities in the coverage of full immunisation among children of adolescent mothers in India.
Design
Repeated cross-sectional analytical study.
Data sources
3 consecutive rounds of the National Family Health Survey (NFHS) conducted during 1992–1993, 1998–1999 and 2005–2006 were used. Besides, the required information is also extracted from the 2011 Indian Census.
Participants
Children (aged 12–23 months) of adolescent (aged 15–19 years) mothers. Sample inclusion criteria involved the last child of the adolescent eligible to avail full immunisation.
Setting
Nationally representative sample.
Data analysis
The Cochran-Armitage test, χ2 test and binary logistic regression methods were applied to attain the study objective.
Results
Between 1990 and 2006, a non-significant increase of 4 percentage points in full immunisation of children of adolescent mothers was estimated. During the same period, a large difference between the probability of children of adolescent mothers receiving full immunisation belonging to the least (predicted probability (PP): 0.196 in 1990–1993, and PP: 0.213 in 2003–2006) and the most (PP: 0.589 in 1990–1993, and PP: 0.645 in 2003–2006) socioeconomically privileged group was estimated, and this disparity persisted over the survey period.
Conclusions
During 1990–2006, an insufficient improvement in provision of full immunisation to children born to adolescent mothers was recorded. The study underscored the suboptimum immunisation of rural, illiterate and poor children of adolescent women. The programme and policymakers could focus on district-wise concentration of adolescent women, especially those belonging to the underprivileged groups, to design a targeted intervention to elevate the level of immunisation of children of adolescent mothers.
Background:
India's Universal Immunization Programme (UIP) provides basic vaccines free-of-cost in the public sector, yet national vaccination coverage is poor. The Government of India has urged an expanded role for the private sector to help achieve universal immunization coverage. We conducted a state-by-state analysis of the role of the private sector in vaccinating Indian children against each of the six primary childhood diseases covered under India's UIP.
Methods:
We analyzed IMS Health data on Indian private-sector vaccine sales, 2011 Indian Census data and national household surveys (DHS/NFHS 2005-06 and UNICEF CES 2009) to estimate the percentage of vaccinated children among the 2009-12 birth cohort who received a given vaccine in the private sector in 16 Indian states. We also analyzed the estimated private-sector vaccine shares as function of state-specific socio-economic status.
Results:
Overall in 16 states, the private sector contributed 4.7% towards tuberculosis (Bacillus Calmette-Guérin (BCG)), 3.5% towards measles, 2.3% towards diphtheria-pertussis-tetanus (DPT3) and 7.6% towards polio (OPV3) overall (both public and private sectors) vaccination coverage. Certain low income states (Uttar Pradesh, Rajasthan, Madhya Pradesh, Orissa, Assam and Bihar) have low private as well as public sector vaccination coverage. The private sector's role has been limited primarily to the high income states as opposed to these low income states where the majority of Indian children live. Urban areas with good access to the private sector and the ability to pay increases the Indian population's willingness to access private-sector vaccination services.
Conclusion:
In India, the public sector offers vaccination services to the majority of the population but the private sector should not be neglected as it could potentially improve overall vaccination coverage. The government could train and incentivize a wider range of private-sector health professionals to help deliver the vaccines, especially in the low income states with the largest birth cohorts. We recommend future studies to identify strengths and limitations of the public and private health sectors in each Indian state.
India has one of the lowest immunization rates of any country in the world, and accounts for more than 20 percent of the child deaths under 5 years of age worldwide. Poor vaccination coverage has been identified as one of the leading causes of high child mortality rates in India, despite the government???s longstanding free Universal Immunization Program. The overarching aim of this dissertation research was to identify barriers to receiving the recommended vaccinations among Indian children, using the District Level Household and Facility Survey Data, 2007-08.
The first study investigated the association between socio-cultural characteristics and risk of under-vaccination and non-vaccination. The results suggested that the reasons for under- and non-vaccination in India were similar. Inequities in vaccination coverage among social and religious groups were clearly evident after controlling for all the traditional risk factors of vaccination.
The second study examined vaccination timeliness utilizing data from children both with and without a vaccination card in a novel application of an existing statistical methodology. Vaccine administration at the recommended time or by the maximum recommended age is considered timely. The results indicated that relatively small percentages (approximately 35%) of Indian children received vaccinations at the ages recommended by India???s national immunization schedule. Furthermore, the state-specific analysis found that considerable variation in vaccination probabilities existed across Indian states.
The third paper examined state-level factors that influence childhood vaccination, controlling for individual-level confounders. Average population served by a primary health center and the state-level poverty were variables which explained some of the between state variability in full-vaccination coverage. Additionally, the association of religion with vaccination was found to depend on the percent Muslim population in a state.
The findings of this dissertation research further the current knowledge regarding the drivers of childhood vaccinations in India, and demonstrate a novel application of a known methodology for studying vaccination timeliness to assess vaccination program performance; these results may help to shape interventions that reduce disparities in full vaccination among children of different demographic/cultural groups.
We used published and unpublished studies and national statistics to estimate the number of deaths, hospitalizations, and outpatient visits due to rotavirus diarrhoea and the associated national economic burden of disease in India. Annually in India, rotavirus diarrhoea causes an estimated 122,000-153,000 deaths, 457,000-884,000 hospitalizations, and 2 million outpatient visits in children <5 years of age. India spends Rs 2.0-3.4 billion (US$ 41-72 million) annually in medical costs to treat rotavirus diarrhoea. The use of specific interventions against rotavirus, such as newly available vaccines, would help prevent much of this large disease and economic burden.
To assess the value of rotavirus vaccination in India, we determined the potential impact and cost-effectiveness of a national rotavirus vaccination program.
We compared the national rotavirus disease and cost burden with and without a vaccination program and assessed the cost-effectiveness of vaccination. Model inputs included measures of disease and cost burden, vaccine performance, and vaccination coverage and cost. We measured the annual number of health-related events and treatment costs averted, as well as the cost-effectiveness in US dollars per disability-adjusted life-year (DALY) and cost per death averted. One-way sensitivity analyses were performed by individually varying each model input.
With use of a vaccine that has an estimated effectiveness of 50%, a rotavirus vaccination program in India would prevent ~44,000 deaths, ~293,000 hospitalizations, and ~328,000 outpatient visits annually, which would avert 0.15 per dose. At 49.8 million, which would result in an expenditure of 662.94 per life saved. Even at $7.00 per dose, vaccination would be highly cost-effective. In sensitivity analyses, varying efficacy against severe rotavirus disease and vaccine price had the greatest impact on cost-effectiveness.
A national rotavirus vaccination program in India would prevent substantial rotavirus morbidity and mortality and would be highly cost-effective at a range of vaccine prices. Public health officials can use this locally derived data to evaluate how this highly cost-effective intervention might fit into India's long-term health care goals.
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.
Clustered randomised controlled study.
Rural Rajasthan, India.
1640 children aged 1-3 at end point.
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).
Proportion of children aged 1-3 at the end point who were partially or fully immunised.
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 56 (2202 rupees) in intervention B.
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.
IRSCTN87759937.
The National Technical Advisory Group on Immunisation in India (NTAGI) fulfils a need for informing decision-making concerning the introduction of new vaccines and strengthening the Universal Immunisation Programme (UIP). The role and membership of NTAGI have expanded over the years in tune with the emerging needs and priorities of the Government of India. Current challenges include institutionalizing mechanisms to follow-up and monitor recommendations, to support research needs to fill information gaps, and to provide technical assistance for monitoring and periodically reviewing the UIP.
Few studies have investigated the impact of immunization campaigns conducted under the global polio eradication program on sustainability of polio vaccination coverage, on coverage of non-polio vaccines (administered under Expanded Program on Immunization (EPI)), and on changes in social inequities in immunization coverage. This study proposes to fill the gaps in the evidence by investigating the impact of a polio immunization campaign launched in India in 1995. The study uses a before-and-after study design using representative samples from rural areas of four North Indian states. The National Family Health Survey I (NFHS I) and NFHS II, conducted in 1992-93 and 1998-99 respectively, were used as pre- and post-intervention data. Using pooled data from both the surveys, multivariate logistic regression models with interaction terms were used to investigate the changes in social inequities. During the study period, a greater increase was observed in the coverage of first dose of polio compared to three doses of polio. Moderate improvements in at least one dose of non-polio EPI vaccinations, and no improvements in complete immunization against non-polio EPI diseases were observed. The polio campaign was successful, to some extent, in reducing gender-, caste- and wealth-based inequities, but had no impact on religion- or residence-based inequities. Social inequities in non-polio EPI vaccinations did not reduce during the study period. Significant dropouts between first and third dose of polio raise concerns of sustainability of immunization coverage under a campaign approach. Similarly, little evidence to support synergy between polio campaign and non-polio EPI vaccinations raises questions about the effects of polio campaign on routine health system's functions. However, moderate success of the polio campaign in reducing social inequities in polio coverage may offer valuable insights into the routine health systems for addressing persistent social inequities in access to health care.
Vaccine development in India, though slow to start, has progressed by leaps and bounds in the past 60 years transforming it from a nation completely dependent on imported vaccines to one not only self-sufficient in the production of vaccines conforming to international standards, but also a major supplier of the same to UNICEF. Vaccine development is tightly regulated by a hierarchy of regulatory bodies. Guidelines provided by the Indian Council of Medical Research (ICMR) set the rules of conduct for clinical trials from Phase I to IV studies as well as studies on combination vaccines. These guidelines address ethical issues that arise during a vaccine study. A network of Adverse Drug Reaction (ADR) monitoring centers along with the Adverse Events Following Immunization (AEFI) monitoring program provide the machinery for vaccine pharmacovigilance.
Up-to-date information on the causes of child deaths is crucial to guide global efforts to improve child survival. We report new estimates for 2008 of the major causes of death in children younger than 5 years.
We used multicause proportionate mortality models to estimate deaths in neonates aged 0-27 days and children aged 1-59 months, and selected single-cause disease models and analysis of vital registration data when available to estimate causes of child deaths. New data from China and India permitted national data to be used for these countries instead of predictions based on global statistical models, as was done previously. We estimated proportional causes of death for 193 countries, and by application of these proportions to the country-specific mortality rates in children younger than 5 years and birth rates, the numbers of deaths by cause were calculated for countries, regions, and the world.
Of the estimated 8.795 million deaths in children younger than 5 years worldwide in 2008, infectious diseases caused 68% (5.970 million), with the largest percentages due to pneumonia (18%, 1.575 million, uncertainty range [UR] 1.046 million-1.874 million), diarrhoea (15%, 1.336 million, 0.822 million-2.004 million), and malaria (8%, 0.732 million, 0.601 million-0.851 million). 41% (3.575 million) of deaths occurred in neonates, and the most important single causes were preterm birth complications (12%, 1.033 million, UR 0.717 million-1.216 million), birth asphyxia (9%, 0.814 million, 0.563 million-0.997 million), sepsis (6%, 0.521 million, 0.356 million-0.735 million), and pneumonia (4%, 0.386 million, 0.264 million-0.545 million). 49% (4.294 million) of child deaths occurred in five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan, and China.
These country-specific estimates of the major causes of child deaths should help to focus national programmes and donor assistance. Achievement of Millennium Development Goal 4, to reduce child mortality by two-thirds, is only possible if the high numbers of deaths are addressed by maternal, newborn, and child health interventions.
WHO, UNICEF, and Bill & Melinda Gates Foundation.
Poor routine immunization coverage in India has led to a large burden of vaccine-preventable diseases borne by children under 5 years of age. Despite efforts to strengthen infrastructure and service delivery in the past decade, immunization coverage rates have reached a plateau. To meet the formidable needs of India's growing population and address the shortcomings of health services for rural populations, the country is now turning toward a new national community health worker (CHW) plan. This article reviews the effectiveness of CHWs in expanding immunization coverage in developing countries and examines the potential contribution of CHWs toward strengthening immunization services in rural India. While the limited number and quality of available studies make it difficult to directly compare CHW interventions to other strategies for improving immunization coverage, it is clear that CHWs make diverse contributions toward strengthening immunization programs. Incorporation of evidence-based strategies for CHW selection, retention, and training is critical for success of India's immunization program. In addition, there is growing need to develop efficient mechanisms for monitoring children's vaccination status to generate actionable feedback and identify cost-effective strategies.
Haemophilus influenzae type b (Hib) is a leading cause of childhood bacterial meningitis, pneumonia, and other serious infections. Hib disease can be almost completely eliminated through routine vaccination. We assessed the global burden of disease to help national policy makers and international donors set priorities.
We did a comprehensive literature search of studies of Hib disease incidence, case-fatality ratios, age distribution, syndrome distribution, and effect of Hib vaccine. We used vaccine trial data to estimate the proportion of pneumonia cases and pneumonia deaths caused by Hib. We applied these proportions to WHO country-specific estimates of pneumonia cases and deaths to estimate Hib pneumonia burden. We used data from surveillance studies to develop estimates of incidence and mortality of Hib meningitis and serious non-pneumonia, non-meningitis disease. If available, high-quality data were used for national estimates of Hib meningitis and non-pneumonia, non-meningitis disease burden. Otherwise, estimates were based on data from other countries matched as closely as possible for geographic region and child mortality. Estimates were adjusted for HIV prevalence and access to care. Disease burden was estimated for the year 2000 in children younger than 5 years.
We calculated that Hib caused about 8.13 million serious illnesses worldwide in 2000 (uncertainty range 7.33-13.2 million). We estimated that Hib caused 371,000 deaths (247,000-527,000) in children aged 1-59 months, of which 8100 (5600-10,000) were in HIV-positive and 363,000 (242,000-517,000) in HIV-negative children.
Global burden of Hib disease is substantial and almost entirely vaccine preventable. Expanded use of Hib vaccine could reduce childhood pneumonia and meningitis, and decrease child mortality.
GAVI Alliance and the Vaccine Fund.
Streptococcus pneumoniae is a leading cause of bacterial pneumonia, meningitis, and sepsis in children worldwide. However, many countries lack national estimates of disease burden. Effective interventions are available, including pneumococcal conjugate vaccine and case management. To support local and global policy decisions on pneumococcal disease prevention and treatment, we estimated country-specific incidence of serious cases and deaths in children younger than 5 years.
We measured the burden of pneumococcal pneumonia by applying the proportion of pneumonia cases caused by S pneumoniae derived from efficacy estimates from vaccine trials to WHO country-specific estimates of all-cause pneumonia cases and deaths. We also estimated burden of meningitis and non-pneumonia, non-meningitis invasive disease using disease incidence and case-fatality data from a systematic literature review. When high-quality data were available from a country, these were used for national estimates. Otherwise, estimates were based on data from neighbouring countries with similar child mortality. Estimates were adjusted for HIV prevalence and access to care and, when applicable, use of vaccine against Haemophilus influenzae type b.
In 2000, about 14.5 million episodes of serious pneumococcal disease (uncertainty range 11.1-18.0 million) were estimated to occur. Pneumococcal disease caused about 826,000 deaths (582,000-926,000) in children aged 1-59 months, of which 91,000 (63,000-102,000) were in HIV-positive and 735,000 (519,000-825,000) in HIV-negative children. Of the deaths in HIV-negative children, over 61% (449,000 [316,000-501,000]) occurred in ten African and Asian countries.
S pneumoniae causes around 11% (8-12%) of all deaths in children aged 1-59 months (excluding pneumococcal deaths in HIV-positive children). Achievement of the UN Millennium Development Goal 4 for child mortality reduction can be accelerated by prevention and treatment of pneumococcal disease, especially in regions of the world with the greatest burden.
GAVI Alliance and the Vaccine Fund.
Since the launch of the Global Polio Eradication Initiative (GPEI) in 1988, knowledge as to the nature of circulating polioviruses and the challenges to their interruption has increased tremendously, particularly during the period 2000-2005. By January 2006, however, the systematic application of the standard polio eradication strategies, combined with recent refinements, had reduced the number of countries with ongoing transmission of indigenous wild polioviruses to just four (Nigeria, India, Pakistan, and Afghanistan), the lowest ever in history. In addition, only 8 of the 22 areas that had been re-infected by wild poliovirus in 2003-2005 still required large-scale 'mop-up' activities and circulating vaccine-derived poliovirus (cVDPV) outbreaks were being readily addressed. This progress, despite new challenges late in the GPEI, was greatly facilitated by a range of solutions that included two new monovalent oral polio vaccines (mOPVs), new and robust international standards for polio outbreak response, and renewed political commitment across the remaining infected countries.
Immunization has played a major part in reducing childhood morbidity and mortality worldwide. Knowledge of vaccine coverage and reasons for poor uptake are essential for the achievement of herd immunity.
An observational study was carried out in September 2003, in 10 villages in the Vikas Nagar area around Herbertpur Christian Hospital in Uttaranchal, North India. We aimed to assess vaccination rates and potential socio-cultural, economic and religious influences on vaccine uptake. A total of 470 families were visited and details of immunization status of the oldest child under 7 years in each household were taken. Age range of children included was 9 months to 6 years.
The overall primary immunization rate was 77.2%, children receiving the first booster was 73.1% and children receiving the second booster was 58.4%. The most common vaccinations to be missed were the diphtheria, pertussis, tetanus at 18 months and diphtheria, tetanus at 5 years. Measles was the most frequently omitted vaccination in the primary course (19.4%). Poor education was the most frequent reason given by parents for failure to vaccinate. Immunization rates did not differ according to gender of the child. A lower immunization rate was found in Muslim families (65.4% primary) compared with Hindu (85.2%). Parental literacy had a beneficial effect such that up to 20% more children were immunized.
These results highlight the potential importance of literacy, and religious or cultural influences on the success of the Expanded Programme of Immunization, and will have important implications for areas with similar cultural demographics.
India faces major challenges in sustaining the health gains achieved in the better-performing states and ensuring that the lagging states catch up with the rest of the country. In this paper we examine the current status of health financing in India, as well as alternatives for realizing maximal health gains for the incremental spending. A principal conclusion is that public expenditures of an additional US7 per person per year (about 1 percent of gross domestic product) would, if focused on about sixteen key interventions, provide universal access to those interventions and have a favorable affect on population health.
Parental recall and the effect of basic immunisation on overall child mortality: a population-based study in Chandigarh
- R Kumar
- P Jha
- D Bassani
- N Dhingra
- D Corsi
- N Kaur
Kumar R, Jha P, Bassani D, Dhingra
N, Corsi D, Kaur N. Parental recall
and the effect of basic immunisation
on overall child mortality: a population-based study in Chandigarh,
India. Toronto: University of
Toronto; 2009.
Executive director/ CEO report to the GAVI Alliance and fund board meeting [Internet
- Alliance
Alliance. Executive director/
CEO report to the GAVI Alliance and
fund board meeting [Internet].
Choosing health: an entitlement for all Indians
- P Jha
- R Laxminarayan
Jha P, Laxminarayan R. Choosing
health: an entitlement for all Indians. Toronto: Center for Global
Health Research, University of
Toronto; 2009.
Global, regional, and national causes of child mortality in 2008: a systematic analysis
- Re Black
- S Cousens
- Hl Johnson
- Je Lawn
- I Rudan
- Dg Bassani
7 Black RE, Cousens S, Johnson HL,
Lawn JE, Rudan I, Bassani DG, et al.
Global, regional, and national causes
of child mortality in 2008: a systematic analysis. Lancet. 2010;
375(9730):1969-87.
Gates offers govt $110 mn for 5-in-one shot rollout. Times of India
- S Kounteya
Kounteya S. Gates offers govt
$110 mn for 5-in-one shot rollout.
Times of India. 2011 Mar 23.
Geneva: GAVI Available from: http://www .gavialliance.org/resources/1_CEO_ report_June_2008.pdf 19 GAVI Alliance [Internet]. Geneva: GAVI. Press release, 18 million Indian children to receive life-saving five-in-one vaccine Available from: http://www.gavialliance.org/ media_centre/press_releases
18 GAVI Alliance. Executive director/
CEO report to the GAVI Alliance and
fund board meeting [Internet].
Geneva: GAVI; 2008 [cited 2011 May
6]. Available from: http://www
.gavialliance.org/resources/1_CEO_
report_June_2008.pdf
19 GAVI Alliance [Internet]. Geneva:
GAVI. Press release, 18 million Indian children to receive life-saving
five-in-one vaccine; 2009 Aug 11
[cited 2011 Apr 18]. Available from:
http://www.gavialliance.org/
media_centre/press_releases/
2009_08_11_india_pentavalent.php
20 Vashishta VM. Introduction of Hib
containing pentavalent vaccine in
national immunization program of
India: the concerns and the reality.
Indian Pediatr. 2009;46(9):781-2.
The global burden of disease and risk factors 2 National Family Health Survey. Child health. Chap. 9 in: Results of the National Family Health Survey Mumbai: NFHS
- A Lopez
- Annex
Lopez A. Annex 2a. In: The global
burden of disease and risk factors.
Washington (DC), New York (NY):
World Bank and Oxford University
Press; 2006.
2 National Family Health Survey.
Child health. Chap. 9 in: Results of
the National Family Health Survey
2005-2006. Mumbai: NFHS; 2006
[cited 2011 May 26]. Available from:
http://hetv.org/india/nfhs/nfhs3/
NFHS-3-Chapter-09-Child-Health
.pdf
3
Routine immunization: releases to state H&FW society routine immunization for the financial year 2010-11
- Family Ministry Of Health
- Welfare
Ministry of Health and Family
Welfare. Routine immunization: releases to state H&FW society routine
immunization for the financial year
2010-11 [Internet]. New Delhi: The
Ministry; 2011 [cited 2011 May 17].
Executive director/ CEO report to the GAVI Alliance and fund board meeting
- Gavi Alliance
GAVI Alliance. Executive director/
CEO report to the GAVI Alliance and
fund board meeting [Internet].
18 million Indian children to receive life-saving five-in-one vaccine
- Gavi Alliance
GAVI Alliance [Internet]. Geneva:
GAVI. Press release, 18 million Indian children to receive life-saving
five-in-one vaccine; 2009 Aug 11
[cited 2011 Apr 18]. Available from:
http://www.gavialliance.org/
media_centre/press_releases/
2009_08_11_india_pentavalent.php
Introduction of Hib containing pentavalent vaccine in national immunization program of India: the concerns and the reality
- V M Vashishta
Vashishta VM. Introduction of Hib
containing pentavalent vaccine in
national immunization program of
India: the concerns and the reality.
Indian Pediatr. 2009;46(9):781-2.