Infant vaccination timing: Beyond traditional coverage metrics for maximizing impact of vaccine programs, an example from southern Nepal

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Highlights

•

We prospectively examined, via weekly recall, the timing of EPI immunizations in infants less than 6 months in rural Nepal.
•

The majority of infants less than 6 months received immunizations on a delayed schedule.
•

National immunization coverage estimates do not capture delay in the first 6 months of life.

Abstract

Background

Immunization programs currently measure coverage by assessing the proportion of children 12–24 months who have been immunized but this does not address the important question of when the scheduled vaccines were administered. Data capturing the timing of vaccination in first 6 months, when severe disease is most likely to occur, are limited.

Objective

To estimate the time to Bacillus Calmette–Guérin (BCG) (recommended at birth), diphtheria-tetanus-pertussis-H, influenza b-hepatitis B (DTP-Hib-HepB), and oral polio vaccine (OPV) (recommended at 6, 10, and 14 weeks) vaccinations and risk factors for vaccination delay in infants <6 months of age in a district in southern Nepal where traditional coverage metrics are high.

Design/methods

Infants enrolled in a randomized controlled trial of maternal influenza vaccination were visited weekly at home from birth through age 6 months to ascertain if any vaccinations had been given in the prior week. Infant, maternal, and household characteristics were recorded. BCG, DTP-Hib-HepB, and OPV vaccination coverage at 4 and 6 months was estimated. Time to vaccination was estimated through Kaplan–Meier curves; Cox-proportional hazards models were used to examine risk factors for delay for the first vaccine.

Results

The median age of BCG, first OPV and DTP-Hib-HepB receipt was 22, 21, and 18 weeks, respectively. Almost half of infants received no BCG by age 6 months. Only 8% and 7% of infants had received three doses of OPV and DTP-Hib-HepB, respectively, by age 6 months.

Conclusion

A significant delay in receipt of infant vaccines was found in a prospective, population-based, cohort in southern Nepal despite traditional coverage metrics being high. Immunization programs should consider measuring time to receipt relative to the official schedule in order to maximize benefits for disease control and child health.

Related collections

Most cited references 21

Record: found
Abstract: found
Article: not found

The likeness of fetal growth and newborn size across non-isolated populations in the INTERGROWTH-21st Project: the Fetal Growth Longitudinal Study and Newborn Cross-Sectional Study.

Ann Lambert, Michael G. Gravett, Jose Villar … (2014)

Large differences exist in size at birth and in rates of impaired fetal growth worldwide. The relative effects of nutrition, disease, the environment, and genetics on these differences are often debated. In clinical practice, various references are often used to assess fetal growth and newborn size across populations and ethnic origins, whereas international standards for assessing growth in infants and children have been established. In the INTERGROWTH-21(st) Project, our aim was to assess fetal growth and newborn size in eight geographically defined urban populations in which the health and nutrition needs of mothers were met and adequate antenatal care was provided. For this study, fetal growth and newborn size were measured in two INTERGROWTH-21(st) component studies using prespecified markers and the same methods, equipment, and selection criteria. In the Fetal Growth Longitudinal Study (FGLS), we studied educated, affluent, healthy women, with adequate nutritional status who were at low risk of intrauterine growth restriction. The primary markers of fetal growth were ultrasound measurements of fetal crown-rump length at less than 14 weeks and 0 days of gestation and fetal head circumference from 14 weeks and 0 days to 40 weeks and 0 days of gestation, and birthlength for newborn size. In the concomitant, population-based Newborn Cross-Sectional Study (NCSS), we measured birthlength in all newborn babies from the eight geographically defined urban populations with the same methods, instruments, and staff as in FGLS. From this large NCSS cohort, we selected an FGLS-like subpopulation to match FGLS with the same eligibility criteria. Between May 14, 2009, and Aug 2, 2013, we enrolled 4607 women in FGLS and 59 137 women in NCSS. From NCSS, 20 486 (34·6%) women met the FGLS eligibility criteria, and constituted the FGLS-like subpopulation. With variance component analysis, only between 1·9% and 3·5% of the total variability in crown-rump length, fetal head circumference, and newborn birthlength could be attributed to between-site differences. With standardised site effect analysis in 16 gestational age windows from 9 weeks and 0 days of gestation to birth for the three measures (128 comparisons), only one was marginally higher than 0·5 SD of the standardised site difference range. Sensitivity analyses, excluding individual populations in turn from the pooling of all-site centiles across gestational ages, showed no noticeable effect on the 3rd, 50th, and 97th centiles derived from the remaining populations. Our populations were consistent at birth with those in the WHO Multicentre Growth Reference Study (MGRS). The mean birthlength for term newborn babies in that study was 49·5 cm (SD 1·9), which was very similar to that in the FGLS cohort (49·4 cm [1·9]) and the NCSS derived FGLS-like subpopulation (49·3 cm [1·8]). Fetal growth and newborn length are similar across diverse geographical settings when mothers' nutritional and health needs are met, and environmental constraints on growth are low. The findings for birthlength are in strong agreement with those of the WHO MGRS. These results provide the conceptual frame to create international standards for growth from conception to newborn baby, which will extend the present infant to childhood WHO MGRS standards. Bill & Melinda Gates Foundation. Copyright © 2014 Elsevier Ltd. All rights reserved.

0 comments Cited 110 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Timeliness of childhood vaccinations in the United States: days undervaccinated and number of vaccines delayed.

K. Shaw, Mary M McCauley, Elizabeth Luman … (2005)

Only 18% of children in the United States receive all vaccinations at the recommended times or acceptably early. To determine the extent of delay of vaccination during the first 24 months of life. The 2003 National Immunization Survey was conducted by random-digit dialing of households and mailings to vaccination providers to estimate vaccination coverage rates for US children aged 19 to 35 months. Data for this study were limited to 14,810 children aged 24 to 35 months. Cumulative days undervaccinated during the first 24 months of life for each of 6 vaccines (diphtheria and tetanus toxoids and acellular pertussis; poliovirus; measles, mumps, and rubella; Haemophilus influenzae type b; hepatitis B; and varicella) and all vaccines combined, number of late vaccines, and risk factors for severe delay of vaccination. Children were undervaccinated a mean of 172 days (median, 126 days) for all vaccines combined during their first 24 months of life. Approximately 34% were undervaccinated for less than 1 month and 29% for 1 to 6 months, while 37% were undervaccinated for more than 6 months. Vaccine-specific undervaccination of more than 6 months ranged from 9% for poliovirus vaccine to 21% for Haemophilus influenzae type b vaccine. An estimated 25% of children had delays in receipt of 4 or more of the 6 vaccines. Approximately 21% of children were severely delayed (undervaccinated for more than 6 months and for > or vaccines). Factors associated with severe delay included having a mother who was unmarried or who did not have a college degree, living in a household with 2 or more children, being non-Hispanic black, having 2 or more vaccination providers, and using public vaccination provider(s). More than 1 in 3 children were undervaccinated for more than 6 months during their first 24 months of life and 1 in 4 children were delayed for at least 4 vaccines. Standard measures of vaccination coverage mask substantial shortfalls in ensuring that recommendations are followed regarding age at vaccination throughout the first 24 months of life.

0 comments Cited 81 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Timeliness of childhood vaccinations in 31 low and middle-income countries.

Manas Akmatov, Rafael T Mikolajczyk (2012)

This study assessed the extent of delays in childhood vaccinations and examined sociodemographic correlates of delayed and missing vaccinations. Datasets from the 2005-7 Multiple Indicator Cluster Surveys from 31 countries were used. Information on vaccinations was based on vaccination cards. Survival analysis was applied to assess age-specific vaccination rates, and multilevel logistic regression analysis was used to assess factors associated with delayed and missing vaccinations. The median vaccination coverage across all countries varied from 91% measles-containing vaccine (MCV) to 98% bacille Calmette-Guérin vaccine (BCG). The median fraction of timely administered vaccinations was 65% (range 14.5-97.2%) for BCG, 67% (11.6-89.3%) for the first dose of vaccine against diphtheria, tetanus and pertussis (DTP1), 41% (10.8-82.1%) for DTP3, 68% (29.7-90.3%) for the first dose of polio vaccine (polio1), 38% (10.5-81.0%) for polio3 and 51% (22.3-91.1%) for MCV. The median of the median delays across all countries was 2.1 weeks (IQR 0.9-3.0) for BCG, 2.4 weeks (1.5-3.1) for DTP1; 6.3 weeks (3.3-9.0) for DTP3; 2.0 weeks (1.3-3.1) for polio1, 6.6 weeks (4.3-9.3) for polio3 and 4.1 weeks (2.5-5.8) for MCV. A higher number of children in households and lower socioeconomic status were associated with delayed and missing vaccinations; however, the effects of socioeconomic gradient varied by country. Most countries achieved high up-to-date vaccination coverage. However, there were substantial vaccination delays. Collecting information on the timeliness of vaccination in national surveillance systems will provide a more complete view of vaccination coverage. Missing and delayed vaccinations can be addressed jointly in prevention programmes.

0 comments Cited 60 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Contributors

Michelle M. Hughes

Joanne Katz

Janet A. Englund

Subarna K. Khatry

Laxman Shrestha

Steven C. LeClerq

Mark Steinhoff

James M. Tielsch

Journal

Journal ID (nlm-ta): Vaccine

Journal ID (iso-abbrev): Vaccine

Title: Vaccine

Publisher: Elsevier Science

ISSN (Print): 0264-410X

ISSN (Electronic): 1873-2518

Publication date PMC-release: 10 February 2016

Publication date (Print): 10 February 2016

Volume: 34

Issue: 7

Pages: 933-941

Affiliations

[a ]Johns Hopkins Bloomberg School of Public Health, Department of International Health, Global Disease Epidemiology and Control, 615 North Wolfe Street, Baltimore, MD 21205, USA

[b ]University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, MA 7.234, Seattle, WA 98105, USA

[c ]Nepal Nutrition Intervention Project – Sarlahi, Kathmandu, Nepal

[d ]Tribhuvan University Teaching Hospital, Department of Paediatrics, Institute of Medicine, Maharajgunj, Kathmandu, Nepal

[e ]Cincinnati Children's Hospital and Medical Center, Global Health Center, R8508, 3333 Burnet Avenue, Cincinnati, OH 45229, USA

[f ]George Washington University Milken Institute School of Public Health, Department of Global Health, 950 New Hampshire Avenue, Washington, DC 20052, USA

Author notes

[* ]Corresponding author. Tel.: +1 3145402499. michelle.hughes@ 123456jhu.edu

Article

Publisher ID: S0264-410X(15)01872-1

DOI: 10.1016/j.vaccine.2015.12.061

PMC ID: 4744084

PubMed ID: 26788880

SO-VID: deaa35c7-e664-4fdd-9d63-f7a8f7b7397f

License:

This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

History

Date received : 18 September 2015

Date revision received : 11 December 2015

Date accepted : 23 December 2015

Comments

Comment on this article

scite_

Cited by 20

See all cited by

Most referenced authors 547

See all reference authors

- Version 1

Infant vaccination timing: Beyond traditional coverage metrics for maximizing impact of vaccine programs, an example from southern Nepal

Read this article at

Highlights

Abstract

Background

Objective

Design/methods

Results

Conclusion

Related collections

Malaria vaccine development

Most cited references 21

The likeness of fetal growth and newborn size across non-isolated populations in the INTERGROWTH-21st Project: the Fetal Growth Longitudinal Study and Newborn Cross-Sectional Study.

Timeliness of childhood vaccinations in the United States: days undervaccinated and number of vaccines delayed.

Timeliness of childhood vaccinations in 31 low and middle-income countries.

Author and article information

Contributors

Journal

Affiliations

Author notes

Article

History

Categories

Comments

Comment on this article

Similar content 71

Cited by 20

Most referenced authors 547