Christopher Morgan

Background: Zero-dose (ZD) children—those who receive no routine vaccines—remain highly vulnerable, with global evidence showing that they are concentrated in marginalized and hard-to-reach settings. In Bangladesh, stagnant full-immunization coverage, population mobility, and inconsistencies in administrative data complicate accurate estimation of ZD and underimmunized children. Gaps in the completeness, timeliness, and accuracy of routine Expanded Programme on Immunization (EPI) information systems further limit the ability to identify and target these populations. Objective: This study aimed to assess the completeness, timeliness, and accuracy of Bangladesh’s immunization data systems and to identify challenges and strategies for integrating ZD analysis into routine EPI information systems. Methods: We used a mixed methods exploratory descriptive qualitative approach comprising a desk review and stakeholder interviews conducted from February 2024 to April 2024. The desk review assessed program documents, gray literature, and published studies to map routine immunization data sources and their relevance for ZD analysis. Thirteen purposively selected stakeholders, including EPI and District Health Information Software 2 (DHIS2) managers, were interviewed using semistructured interview guides to gather insights on data availability, reporting practices, and system challenges. Information from both steps was synthesized using a structured checklist to evaluate completeness, timeliness, accuracy, and feasibility of ZD tracking across data sources. Data were analyzed manually using a deductive thematic approach. Results: Ten routine immunization data sources were identified, with DHIS2, the Rapid Convenience Monitoring (RCM) tool, and the EPI Coverage Evaluation Survey (CES) emerging as the primary systems for ZD tracking. Although most sources captured child-level data, the use of unique identifiers and household-level variables was inconsistent. Data quality and timeliness varied: DHIS2 faced denominator inaccuracies, CES and Bangladesh Demographic and Health Survey (BDHS) provided high-quality survey estimates, and RCM delivered real-time data from hard-to-reach areas. Multiple systems supported ZD identification, although each had limitations related to data completeness, sampling, geographic granularity, or operational constraints. Conclusions: Immunization data systems in Bangladesh are fragmented, with limited ZD tracking and predominantly district-level reporting. DHIS2, RCM, and Health and Demographic Surveillance System (HDSS) are the most promising platforms for routine ZD monitoring, offering nationwide integration, real-time field data, and detailed local analysis. Harmonizing these systems and combining data from multiple sources can improve targeted interventions, subnational monitoring, and equitable vaccine coverage.

Background: Over the past decade, the East New Britain Provincial Health Authority in Papua New Guinea has worked with partner research organisations to implement data-driven interventions to improve immunisation coverage. This paper reports on facility assessments conducted as part of a cross-sectional study to understand improvements and identify enablers and barriers to routine childhood immunisation in the province. Methods: Between May and August 2023, nine urban and rural health facilities, providing immunisation services at the time of the study in five areas, were assessed using an adapted World Health Organisation (WHO) Service Availability and Readiness Assessment tool. The tool evaluated facility characteristics, routine childhood immunisation readiness and vaccine supply data. Data were analysed using descriptive statistics and findings were mapped to adapted WHO health system categories to identify service delivery improvement priorities. Findings: Several aspects of immunisation service availability and quality had improved since an assessment in 2016/17. Strengths included fixed-facility and outreach service models tailored to catchment populations, high availability of cold chain and vaccine administration equipment, improved immunisation guidance and job-aids. Priority areas included increasing workforce capacity, improving health record completion to inform outreach, increasing availability of guidelines and reporting tools, reducing stock-outs and enhancing stock tracking. Conclusions: Offering accessible vaccination at every opportunity and using quality data to inform programme implementation and resource allocation are priorities for the Provincial Health Authority. This facility-level assessment identified existing immunisation delivery strengths and highlighted community- and provincial-level priority investment areas to strengthen facility capacity and routine immunisation service delivery.

Measles and rubella remain significant public health challenges, with an estimated 107 500 measles deaths in 2023, and ~ 32 000 infants born with congenital rubella syndrome each year [1,2]. These challenges are particularly acute in low- and middle-income countries (LMICs), where resource-constrained immunisation systems face barriers to reaching underserved populations. To achieve elimination, the World Health Organization […]

Introduction: Gavi, the Vaccine Alliance and the Global Immunisation Agenda 2030 have intensified their emphasis on equity, with the intent of reaching zero-dose (ZD—missing the first dose of pentavalent) and under-immunised (UI—missing the third dose of pentavalent) children and their communities. In Bangladesh, inequities in immunisation coverage continue and a country learning hub is supporting the Expanded Programme on Immunisation (EPI) with implementation research on how to identify and reach these vulnerable and underserved communities. We report on an assessment of the prevalence of ZD and UI children, and of potential reasons. Methods: This cross-sectional household survey was conducted in 12 rural and urban subdistricts, purposefully selected from diverse socio-ecological zones: haor (wetlands), hills, coastal, char (silty lands), plain land and urban slums. We interviewed 12 756 caregivers of children aged 4.5–23 months. Households were selected using cluster sampling methodology. The data were collected from September to December 2023. We used χ ² tests and binary logistic regression models for data analysis. Results: We found that 1.9% of children were ZD and 11.6% were UI. The highest percentage of ZD/UI was in haor areas (21.3%: 2.6% ZD and 18.7% UI). Findings from logistic regression show that children residing in haor (OR 2.0; 95% CI 1.2 to 3.5), coastal (OR 2.1; 95% CI 1.2 to 3.6) and urban slum areas (OR 2.8; 95% CI 1.4 to 5.6) were approximately 2~3 times more likely to be ZD compared with children living in plain areas. Female children were 1.4 times more likely to be ZD than were male children (OR 1.4; 95% CI 1.1 to 1.8). Commonly mentioned reasons for non-vaccination were childhood illness (all areas) and busy schedule of caregivers (char areas). Conclusion: ZD and UI children are spread throughout the country, with higher ZD in haor, urban slum and coastal areas. Children who are female and those residing in households located distant from the EPI centre are more vulnerable to becoming ZD or UI. Our study findings provide insight on children of specific areas and gender who require greater attention from the policymakers and EPI managers to design programmes to reduce the number of ZD and UI children and thus improve equity in immunisation coverage.

BACKGROUND Zero-dose (ZD) children—those who receive no routine vaccines—remain highly vulnerable, with global evidence showing that they are concentrated in marginalized and hard-to-reach settings. In Bangladesh, stagnant full-immunization coverage, population mobility, and inconsistencies in administrative data complicate accurate estimation of ZD and underimmunized children. Gaps in the completeness, timeliness, and accuracy of routine Expanded Programme on Immunization (EPI) information systems further limit the ability to identify and target these populations. OBJECTIVE This study aimed to assess the completeness, timeliness, and accuracy of Bangladesh’s immunization data systems and to identify challenges and strategies for integrating ZD analysis into routine EPI information systems. METHODS We used a mixed methods exploratory descriptive qualitative approach comprising a desk review and stakeholder interviews conducted from February 2024 to April 2024. The desk review assessed program documents, gray literature, and published studies to map routine immunization data sources and their relevance for ZD analysis. Thirteen purposively selected stakeholders, including EPI and District Health Information Software 2 (DHIS2) managers, were interviewed using semistructured interview guides to gather insights on data availability, reporting practices, and system challenges. Information from both steps was synthesized using a structured checklist to evaluate completeness, timeliness, accuracy, and feasibility of ZD tracking across data sources. Data were analyzed manually using a deductive thematic approach. RESULTS Ten routine immunization data sources were identified, with DHIS2, the Rapid Convenience Monitoring (RCM) tool, and the EPI Coverage Evaluation Survey (CES) emerging as the primary systems for ZD tracking. Although most sources captured child-level data, the use of unique identifiers and household-level variables was inconsistent. Data quality and timeliness varied: DHIS2 faced denominator inaccuracies, CES and Bangladesh Demographic and Health Survey (BDHS) provided high-quality survey estimates, and RCM delivered real-time data from hard-to-reach areas. Multiple systems supported ZD identification, although each had limitations related to data completeness, sampling, geographic granularity, or operational constraints. CONCLUSIONS Immunization data systems in Bangladesh are fragmented, with limited ZD tracking and predominantly district-level reporting. DHIS2, RCM, and Health and Demographic Surveillance System (HDSS) are the most promising platforms for routine ZD monitoring, offering nationwide integration, real-time field data, and detailed local analysis. Harmonizing these systems and combining data from multiple sources can improve targeted interventions, subnational monitoring, and equitable vaccine coverage.

Background/Objectives: The Tropis^® ID device (PharmaJet^®), a needle-free injection system, is a World Health Organization prequalified, hand-held device, which delivers intradermal injections without the use of needles and has previously been used for the delivery of fractional doses of inactivated polio vaccine (fIPV) in campaign and house-to-house settings. This implementation research study aimed to comparatively evaluate the vaccine coverage, cost, feasibility, and acceptability of using Tropis for fIPV for routine immunizations in two states in Nigeria (Kano and Oyo). Methods: The study included: (i) a cluster randomized trial (22 intervention facilities using Tropis for fIPV and 30 control facilities using the standard of care [SoC—full-dose IPV]) to assess the effectiveness in terms of improving the coverage of two doses of IPV, using a coverage survey involving 3433 children (aged 3–12 months); (ii) a pre- and post-implementation micro-costing evaluation involving the intervention facilities to estimate the costs; and (iii) mixed methods assessments (post-training assessment, provider survey, key informant interviews, and focus group discussions) to assess the feasibility and acceptability of fIPV delivery using Tropis. Results: The intention-to-treat analysis among the 3433 children surveyed did not show any difference between the intervention and control groups, primarily due to low compliance (approximately 50% of target beneficiaries reported Tropis use). The more relevant per protocol analysis, adjusting for lower compliance, showed that among those vaccinated with Tropis, second dose IPV coverage was 11.2% higher than the SoC. The delivery of fIPV using Tropis compared to the SoC resulted in incremental program cost savings, ranging from USD 0.07 to USD 1.00 per dose, administered across the scenarios evaluated. High acceptability was seen amongst caregivers (94%), and 95% of healthcare workers preferred Tropis over the SoC. Conclusions: Tropis is effective, feasible, acceptable, and saves costs when used as part of routine immunization programs.

The Immunization Agenda 2030 emphasises the need for a motivated, skilled and knowledgeable workforce equipped to plan, manage, implement and monitor immunisation programmes at all levels. The rapid introduction of COVID-19 vaccines during the pandemic highlighted the adaptability of the health workforce but also exposed gaps in professional development and learning.This practice paper describes the implementation of an immunisation training programme in the Kingdom of Cambodia and the Lao People’s Democratic Republic. The programme was developed and delivered by the project team in partnership with local stakeholders and technical experts. A country-centric approach ensured that training programmes met each country’s needs, while input from technical experts ensured an evidence-based programme that aligned with international standards. There were 445 training participants from professional groups across various levels and sectors of the health system. Training curricula included a range of differentiated training modules which aimed to build knowledge and skills to drive increased vaccine demand, improve service delivery and optimise monitoring and evaluation of programmes.The Gavi Learning and Performance Management framework supported a structured reflection of programme strengths, limitations and opportunities. Strengths were the country-centric and learner-centric approach and the high technical quality of the programme. The pandemic context necessitated agility and adaptation to meet changing country needs and priorities, however, this introduced some limitations. Future training programmes should undertake an enhanced assessment of training needs, workforce and digital capabilities and learning and performance management systems, alongside the development of country-driven immunisation workforce training roadmaps to ensure optimal impact and sustainability.

Background: Measles is consistently one of the leading causes of death from vaccine-preventable diseases in children, and cases and deaths have increased globally since 2019. While measles often serves as a ‘canary in the coalmine’ for health system weaknesses, global definitions of zero-dose and under-immunised children continue to centre on those who have missed diphtheria-tetanus-pertussis (DTP) containing vaccine. We propose that lack of receipt of measles vaccine is included in global definitions of ‘under-immunised’ children. Methods: We used publicly available WHO/UNICEF estimates of national immunization coverage (WUENIC) data to determine the number and proportion of children missing out on routine immunisations in each country globally in 2019 and 2022. We stratified countries by income status to further investigate inequalities in vaccine coverage between different countries. Results: In 2022, 50% more children missed out on their first dose measles-containing vaccine compared to DTP1, and 96% of these children resided in low-middle income countries (LMICs), highlighting the compounding inequities in measles immunisations globally. Furthermore, countries with the largest number of children missing out on DTP1 were not reflective of countries with the lowest measles immunisation coverage rates, suggesting targeted programs are needed to reach children who are missing out on measles vaccination. Recommendations: Given the high transmissibility and inequitable burden measles outbreaks pose to both at-risk individuals and communities, especially in LMICs, measles immunisation coverage should be included as a key metric when reporting and estimating the number of under-immunised children globally.

Background: The integration of maternal and child health services (MCH) with routine immunization is an important global health strategy, particularly in low- and middle-income countries (LMICs). However, evidence is lacking regarding the best practices for service integration and the effect of integration on immunization and linked health service outcomes. Methods: We searched publication databases and gray literature for articles published between 2011 and 2020 that include approaches to integrating MCH services with immunizations during the first two years of life in LMICs. Abstracts and full-text articles were screened for eligibility. For the included articles, data extraction and analysis examined the descriptive characteristics of studies, outcomes, and implementation considerations. Results: Among the 16,578 articles screened, 44 met the criteria for inclusion, representing 34 studies, of which 29 were from Africa. The commonly linked MCH services were family planning (24%), human immunodeficiency virus (HIV) diagnosis or care (21%), and malaria prevention or control (21%). Multiple integration strategies were typically used; the co-location of linked services (65%), the provision of extra services by immunization staff (41%), and/or the provision of extra information by immunization staff (41%) were the most common. In general, integration improved MCH service outcomes (76%) and was either beneficial (55%) or neutral for immunization (35%), with some examples in family planning, malaria, and HIV where integrated services were not beneficial. Important implementation considerations included the careful matching of target populations in service re-design, ensuring support from policy, logistics, and information systems, the provision of adequate training and support of staff to avoid overload, clear client communication regarding service integration, and the need to address community concerns. Conclusions: Integrating MCH services with routine immunization can expand linked services and improve immunization coverage. This study has identified key implementation considerations relevant to both childhood and adult vaccination programs. More research is needed regarding costs and client preferences.