Vaccination data and

research opportunities in
low- & middle-income
countries

Dr. Ibrahim Dadari

Pharmacy Scholars Initiative (PSI) Webinar

23 July 2022
OUTLINE

➢ Basics of Vaccination
➢ Sources of Vaccination Data & Description
➢ 2021 WUENIC
➢ 2021 PAPA LQAS
➢ 2021 MICS_NICS
➢ Research Opportunities
BASICS OF VACCINATION

Vaccination is the act of introducing a vaccine into the body to produce protection from a specific disease or the
administration of a vaccine to help the immune system develop immunity from a disease.

Vaccines contain a part or whole microorganism or virus in a weakened, live or killed state, or proteins or toxins
from the organism.

Herd immunity is achieved when a sufficiently large percentage of a population are vaccinated and depends on
factors such as the virulence and infectivity of the pathogen.

Herd immunity provides protection to those who may be immunocompromised and cannot get a vaccine
because even a weakened version would harm them

Target population for childhood vaccination is the estimated newborn population and, or surviving infant for that
locality

Source: Immunization: The Basics. https://www.cdc.gov/vaccines/vac-gen/imz-basics.htm

DEFINITIONS

 Zero-dose children are those that have not received any routine vaccine. For operational purposes, Gavi defines zero-
dose children based on lack of the first dose of diphtheria-tetanus-pertussis containing vaccine (DTPcv1).
 Under-immunised are those who have not received a full course of routine vaccines. For operational purposes, Gavi
defines under-immunised children as those missing a third dose of diphtheria-tetanus-pertussis containing vaccine.
 Missed communities are home to clusters of zero-dose and underimmunised children, even before the COVID-19
pandemic. These communities often face multiple deprivations and vulnerabilities, including lack of services, socio-
economic inequities and often gender related barriers.
 Equity: The organising principle of the Alliance’s 2021-2025 strategy, whose vision is Leaving no-one behind with
Immunisation. This entails a laser focus on using all Gavi levers to reach missed communities and zero-dose children with
immunisation.
NIGERIA EPI SCHEDULE
Child Age Vaccination Schedule
Birth BCG HepB_Pediatric OPV
6 weeks Pneumo_conj DTwPHibHepB OPV Rotavirus

10 weeks Pneumo_conj DTwPHibHepB OPV Rotavirus

14 weeks Pneumo_conj DTwPHibHepB OPV IPV Rotavirus

6 months VitaminA
9 months Yellow Fever Measles MenA_conj

12 months VitaminA
15 months Measles
PRINCIPAL SOURCES OF VACCINATION DATA FOR MONITORING AND
DECISION MAKING

Routine Data Collection Systems

District Health Information System 2 (DHIS2)
Other health management information systems (HMIS) e.g., DVD-MT

Surveys
Demographic and Health Surveys (DHS)
Multiple Indicator Cluster Surveys (MICS)
National (Subnational) Immunization Coverage Surveys (NICS)

WUENIC

WHO-UNICEF Estimates of National Immunization Coverage

 2021 WUENIC DATA
Officially released on the 15th of July 2022
WUENIC
METHODOLOGY
Estimates
produced
for 195+
states
VACCINE-
DOSES
ESTIMATE
D
 25 million children were un-or under-vaccinated in 2021,
Coverage of the third dose of
2 million more than in 2020, and 6 million more than in 2019 diphtheria, tetanus, and
pertussis vaccine (DTP-3)
dropped a further 2% compared
2020, to 81% in 2021, leaving 25
million children vulnerable to
vaccine-preventable diseases

The Immunization Agenda 2030 is to

make vaccination available to
everyone, everywhere, by 2030. The
Covid-19 pandemic, associated
disruptions, and Covid-19 vaccination
efforts have strained health systems
in 2020 and 2021, resulting in 25
million children missing out on
vaccination, 6 million more than in
2019 and the highest number since
2008. The number of children missing
out on any vaccination - “zero-dose
children” – increased by 5 million,
from 13 to 18 million.

In this analysis, zero-dose children are those

who lack any dose of DTP. Under-vaccinated
are those who received one dose, but not a
third protective dose.

WUENIC 2022
The number of zero-dose children increased sharply during the
2020-2021 pandemic years
An additional 5m zero-dose children from 2019
The number of zero-dose
children – those never
vaccinated with a first dose of
DTP-containing vaccine,
increased by 37%, from 13 to
18 million between 2019-2021.
18 million children were left out by
immunization services in 2021, a
number not seen since 2005.
Almost all zero-dose children live in
low- and middle-income countries,
with global share of zero-dose
children distributed as such:
WCAR 24% (4.4m)
ROSA 21% (3.8m)
ESAR 20% (3.6m )
EAPR 19% (3.4m)
LACR 10% (1.8m)
MENA 4% (0.8m)
ECAR 1% (0.2m)
In this analysis, zero-dose children are those
who lack any dose of DTP. Under-vaccinated
are those who received one dose, but not a
third protective dose.
WUENIC 2022
 Just 10 countries account for
Countries with the most unprotected children in 2021 62% of zero-dose children.
Roughly the same countries
also account for 59% of the
children missing out on a
measles vaccine.

​”Zero-dose children” lack DTP, which

indicates that they are not served
through routine services, although
they may be reached through
disease-specific Supplemental
Immunization Activities (SIA). They
are likely to miss out on other
essential health services as well.

Measles estimates do not include

doses delivered through campaigns.

Source: https://data.unicef.org/resources/immunization-country-profiles/ WUENIC 2022

 Countries with most
Zero-dose children in 2021: Top 10 countries unprotected children
10 countries account for 11 of the 18
million zero-dose children in the world
(62%). This list includes some
Millions of “zero-dose” children, defined as lacking a single dose of DTP-containing vaccine. countries with moderate coverage
- 0.5 1.0 1.5 2.0 2.5 3.0 and very large birth cohorts, and
other countries with substantially
India, 12% 2.7 lower coverage.

Nigeria, 30% 2.2 This list is dominated by Lower-

Middle-Income countries (LMC). Only
1.1 the Democratic Republic of the
Indonesia, 26% Congo and Ethiopia are classified as
1.1 low-income countries (LIC) by the
Ethiopia, 30% World Bank.

Philippines, 43% 1.0

India, Indonesia, the Philippines and
Myanmar show large increases in the
DR Congo, 19% 0.7
numbers of children without access to
vaccination over the last few years.
Brazil, 26% 0.7

Pakistan, 10% 0.6

Zero-dose children are defined as those
Angola, 43% 0.6 lacking DTP 1 in this analysis.

Myanmar, 55% 0.5

% of ZD 2021 2020 2019

children
WUENIC 2022
First dose measles coverage dropped to 81% in 2021, leaving
Coverage of a first dose of a
5 million more unvaccinated children compared to 2019 vaccine protecting against
measles (MCV-1) dropped to
81% in 2021, the lowest level
since 2008.

This leaves 25 million children

vulnerable. ​A further nearly 15 million
children received only a first dose,
but not a needed second dose
through regular public health
services.

Supplemental Immunization Activities

(campaigns) continue to be required
to ensure that all receive the 2 doses
that will protect these children from
Measles.

WUENIC 2022
 Countries with most
Just 10 countries account for 59% of children who missed the first unprotected children
dose of a measles vaccine 10 countries account for 14.6 of the
24.7 million children who missed a
Millions of children lacking a single dose of measles containing vaccine. first dose of measles vaccine in the
- 0.5 1.0 1.5 2.0 2.5 3.0 3.5 world (59%). This list includes some
countries with moderate coverage
Nigeria, 41% 3.1 and very large birth cohorts, and
other countries with substantially
India, 11% 2.5 lower coverage.

1.7 This list is dominated by Lower-

DR Congo, 45% Middle-Income countries (LMIC).
Only the Democratic Republic of the
Ethiopia, 46% 1.7
Congo and Ethiopia are classified as
low-income countries (LIC) by the
Indonesia, 28% 1.2 World Bank.

Pakistan, 19% 1.2

Philippines, 43% 1.0

Angola, 64% 0.8

Un-or under vaccination and lack of
Brazil, 27% 0.7 protection is measured through the lack
of DTP 1 and 3 in this analysis
UR Tanzania, 24% 0.5

2021 2020 2019

% of surviving infants
who did not receive a WUENIC 2022
first dose of measles
Nigeria: WHO and
UNICEF estimates
of immunization
coverage: 2021
 2021 PAPA LQAS (Q4, 2021)
The RI Programme Assessment for Performance management & Action — PAPA LQAS
 RI LQAS METHODS

 RI LQAS was conducted in all the 36 states plus FCT.

 All the LGAs in the 36 states plus FCT except 3 LGAs in Borno, 1 LGA in Kaduna and 1 LGA in Niger states were surveyed.
 In each LGA, 6 HFs were selected using Probability Proportional to Size (PPS)
 In each HF, 6 settlements were selected using PPS.
 In each settlement, 10 households were randomly selected.
 In each household, a child 0-11 months with the mother were randomly selected.
 Assessment of the RI activities in 18 NERICC priority States in Nigeria

State 1 State 2 State 3 State 4 State n

LGA 1 LGA 2 LGA 3 LGA n = LOTS

HF1 HF2 HF3 HF4 HF5 HF6

Settlement

House 1 House 2 House 3 House 4 House 5 House 6 House 7 House 8 House 9 House 10
Child 1 Child 2 Child 3 Child 4 Child 5 Child 6 Child 7 Child 8 Child 9 Child 10

= ONE CLUSTER 20
 RI LQAS Methods (2)
LQAS data analysis & Interpretation

Results interpretations of LGAs in categories as:

• ≤ 8 unvaccinated: lot is accepted for target coverage >80%

• 9 to 32 unvaccinated: lot is rejected as with coverage between 50%- 79.9%

• 33 to 56 unvaccinated: lot is rejected as with coverage between 25%- 49.9%

• > 56 - unvaccinated: lot is rejected as with coverage below 25%

PAPA LQAS, Expected vs Actual sampled, Q4, 2021

Total Lots (LGAs) expected = 774

Total Lots (LGAs) sampled = 769

Proportion of Lots (LGAs) sampled = 99%

Settlements surveyed for PAPA LQAS, Q4, 2021

States = 37
LGAs = 769
HFs = 4,513
Settlements = 4,614

NPHCDA – National Primary Health Care Development Agency

 PAPA RI-LQAS Results, Quarter 4, 2021

99% (769/774) of the Lots were surveyed; out of which 308 (40%) Lots passed
NPHCDA – National Primary Health Care Development Agency
 100%

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
68%
Abia 75%
90%
Adamawa 89%
72%
Akwa Ibom 71%
82%
Anambra 85%
77%
Bauchi 85%
66%
Bayelsa 70%
53%
Benue 60%
78%
Borno 85%
72%
Cross River 49%
68%
Delta 79%
75%
Ebonyi 71%
87%
Edo 83%
86%
Ekiti 84%
75%
Enugu 72%
76%
FCT, Abuja 77%
81%
Gombe 85%
83%
Imo 82%
88%
Q4-2020

Jigawa 86%
72%
Kaduna 70%
88%
Kano 86%
68%
Katsina 76%
Card+ History

75%
Kebbi 83%
73%
Kogi 68%
71%
Kwara 68%
Q4-2021

91%
Lagos 92%
79%
Nasarawa 83%
73%
Niger 75%
68%
Ogun 65%
States, PAPA RI LQAS, Q4-2020 vs Q4, 2021

84%
Ondo 83%
NPHCDA – National Primary Health Care Development Agency

83%
Osun 78%
61%
Oyo 66%
69%
Plateau 76%
Proportion of children appropriately immunized for age by

81%
Rivers 81%
70%
Sokoto 56%
70%
Taraba 57%
81%
Yobe 89%
52%
Zamfara 62%
76%
Average 76%
 Reason for Partially/Not appropriately immunized for age, Q4, 2021

Caregiver unable to take child 16%

Others 12%
Vaccine not available 9%
No reason 8%
Unaware of EPI schedule 8%
Unaware of need for immunization 7%
Mother/ caregiver forgot 6%
Fear of side reactions 6%
Child ill 5%
No felt need 5%
Security challenges 3%
No faith in immunization 3%
Vaccinator absent 3%
Place of immunization too far 2%
Financial constraints 2%
Place/time of immunization unknown 2%
No immunization services in Settlement 1%
Misplaced card 1%
Religious concern 1%
Dissatisfied with Health Worker 0%
0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

NPHCDA – National Primary Health Care Development Agency

 MICS-NICS 2021
Multiple Indicator Cluster Survey - National Immunization Coverage Survey 2021 (Embargoed Prelim Data)
COVID-19 VACCINATION UPDATES
10.7 billion doses of COVID-19 vaccine have been administered globally
as of Feb. 28, 2022
DATA AS OF FEB 28, 11:00 AM CET

Persons vaccinated with at least one dose per 100 population

10.7bn vaccine doses have
been administered
26M doses are administered
every day as of Feb. 28,
2022
Immunization programmes
have not yet started in 2
countries, economies &
territories

Note: The designations employed, and the presentation of these materials do not imply the expression of any opinion whatsoever on the part of WHO
concerning the legal status of any country, territory or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed
lines on maps represent approximate border lines for which there may not yet be full agreement.

31 Source: WHO COVID-19 Dashboard (map), UNICEF Procurement Portal (COVAX shipments), Bloomberg (total # of doses administered),
82% of the population of the African Union has not received any Covid-19
vaccine dose as of Feb. 28, 2022
Share of population vaccinated with complete initial protocol Share of population partially vaccinated1

DATA AS OF FEB 28, 11:00 AM CET Vaccinated with

complete initial Partially vaccinated, Not vaccinated, #M
WHO region COVID-19 vaccination status, % of population protocol, #M people #M people1 people
WHO MS
56% 7% 37% 4,320 576 2,884
7,780M pop.

EUR
61% 5% 34% 572 44 315
931M pop

WPR
81% 3% 16% 1,594 57 312
1,964M pop

AMR
65% 11% 24% 662 109 247
1,018M pop

EMR
37% 9% 55% 267 62 396
726M pop

SEAR
55% 13% 32% 1,103 267 651
2,021M pop

AFR 3%
86% 120 37 963
1,120M pop 11%
AU
14% 4% 82% 184 57 1,098
1,339M pop

1. Excl. people that completed the initial protocol

32 Source: WHO COVID-19 Dashboard

RESEARCH OPPORTUNITIES
NIGERIA AND SSA HAVE VERY LOW RESEARCH OUTPUT
IMMUNIZATION AGENDA 2030

IA2030 Vision
• A world where everyone, everywhere, at
every age fully benefits from vaccines for
good health and well-being

Source: Immunization Agenda 2030: A Global Strategy to Leave No One Behind.

https://www.who.int/teams/immunization-vaccines-and-biologicals/strategies/ia2030
Infographic of IA2030 Impact Goals (baseline data)

PHASE 1 SCORECARD

36
 Equity Reference Group (ERG)

ERG
The ERG has identified
four priorities of work --
urban poor areas,
remote/rural areas,
children affected by
conflict, and gender-
related inequities and
barriers to
immunization.

https://sites.google.com/view/erg4immunisation/home
GAVI ALLIANCE FRAMEWORK: IDENTIFY, REACH, MONITOR,
MEASURE, AND ADVOCATE (IRMMA)

38
GAVI COUNTRY LEARNING HUBS

Learning hub theory of change (TOC) Illustrative country-level learning hub model
 EQUITY LEARNING PRIORITIES
IDENTIFY
• Where, who and how many are
zero-dose children, and missed
communities? Why are they
being missed and what are the
root causes?
• What are the most effective
approaches and methods
used for identifying zero-dose
communities? What works well,
what does not work well and
why?
• What are the key barriers and
enabling factors at each level
(policy to community) to identify
zero-dose communities?
40
REACH
• What specific approaches are designed
to reach zero-dose children and
missed communities and to bring them
in to the health system towards full
immunization? What works well, what
does not work well and why?
• What are the key barriers and enabling
factors at community level to reach
zero-dose children and to bring them in
to the health system through full
immunization?
MONITOR & MEASURE
• What are the most effective
approaches and methods to
ADVOCATE monitor and measure reaching
• What strategies are effective in zero-dose, under-immunised
securing and sustaining political will children and missed
across different levels to identify and communities? What works well,
reach zero dose populations? what does not work well and why?

IMPLEMENTATIO
N RESEARCH
“The integration of research within
existing health programme
implementation and policymaking
cycles to improve programme
outcomes (i.e., coverage,
sustainability, efficiency, cost,
scale) and overcome
implementation bottlenecks”
• IR approach: work in partnership with
decision-makers and implementers in
countries to identify priority implementation
challenges (and related research
questions) for immunization
• Support in evidence-generation: identify
and test strategies to overcome
implementation bottlenecks and improve
systems, explore what works best and what
not, suggests optimal pro-equity
immunization strategies for scaling up
• Support in disseminate of IR findings and
recommendations and integrate those into
policies and programmes designed to
improve outcomes in zero-dose
communities
Integrating COVID 19 vaccination into Primary Healthcare and
Routine Immunization
Sustainability
01 Current efforts in delivering C19 vaccination are primary through resource-intensive campaigns, with
some level of integration. A shift towards sustainability in vaccination is required.

Life-course approach
02 Current immunization systems are not optimized for adult vaccination, most services are organized
around mother and child vaccination. What needs to be done to include adults and high-risk groups?

Epidemiological challenge
03 Regular boosters will likely be needed for high-risk groups.

Leveraging resources
04 Resource levels now available for C19 response can be utilized to strengthen systems. How can we
leverage existing opportunities and financing?
A NETWORK OF ORGANIZATIONS ALIGNING, COORDINATING AND
CATALYSING ZERO DOSE LEARNING & RESEARCH
Catalytic functions

• Alliance roles
(guidance, technical,
capacity)
• Generate/synthesize
additional learning
• Global learning
networks
• Other technical and
capacity support
• Southern/regional
technical, learning, and
capacity networks
SOME RESOURCES
 Equity Reference Group for Immunization. https://sites.google.com/view/erg4immunisation/home
 Immunization Agenda 2030: A Global Strategy to Leave No One Behind. https://www.who.int/teams/immunization-vaccines-and-
biologicals/strategies/ia2030
 Immunization country profiles. https://data.unicef.org/resources/immunization-country-profiles/
 Immunization: The Basics. https://www.cdc.gov/vaccines/vac-gen/imz-basics.htm
 The Zero-Dose Child: Explained. https://www.gavi.org/vaccineswork/zero-dose-child-explained
 Multiple Indicator Cluster Survey (MICS). https://mics.unicef.org/
 Demographic and Health Survey (DHS). https://dhsprogram.com/Methodology/Survey-
Types/DHS.cfm#:~:text=Demographic%20and%20Health%20Surveys%20(DHS,population%2C%20health%2C%20and%20nutrition.
 District Health Information Software (DHIS). https://dhis2.org/
 Country/territory research output table. (n.d.). Nature Index. https://www.natureindex.com/country-outputs/generate/All/global
THANK YOU!