title: Vaccine coverage and adherence to EPI schedules in eight resource poor settings in the MAL-ED cohort study.
abstract: Launched in 1974, the Expanded Program on Immunization (EPI) is estimated to prevent two-three million deaths annually from polio, diphtheria, tuberculosis, pertussis, measles, and tetanus. Additional lives could be saved through better understanding what influences adherence to the EPI schedule in specific settings.
  
  
  
  The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) study followed cohorts in eight sites in South Asia, Africa, and South America and monitored vaccine receipt over the first two years of life for the children enrolled in the study. Vaccination histories were obtained monthly from vaccination cards, local clinic records and/or caregiver reports. Vaccination histories were compared against the prescribed EPI schedules for each country, and coverage rates were examined in relation to the timing of vaccination. The influence of socioeconomic factors on vaccine timing and coverage was also considered.
  
  
  
  Coverage rates for EPI vaccines varied between sites and by type of vaccine; overall, coverage was highest in the Nepal and Bangladesh sites and lowest in the Tanzania and Brazil sites. Bacillus Calmette-Guérin coverage was high across all sites, 87-100%, whereas measles vaccination rates ranged widely, 73-100%. Significant delays between the scheduled administration age and actual vaccination date were present in all sites, especially for measles vaccine where less than 40% were administered on schedule. A range of socioeconomic factors were significantly associated with vaccination status in study children but these results were largely site-specific.
  
  
  
  Our findings highlight the need to improve measles vaccination rates and reduce delayed vaccination to achieve EPI targets related to the establishment of herd immunity and reduction in disease transmission.
authors.affiliation: Division of International Epidemiology and Population Studies of Fogarty International Center, National Institutes of Health, 16 Center Drive, Bethesda, MD 20892, USA. Electronic address: christel.host@nih.gov.
authors.forename: Christel
authors.initials: C
authors.lastname: Hoest
authors.affiliation: Division of International Epidemiology and Population Studies of Fogarty International Center, National Institutes of Health, 16 Center Drive, Bethesda, MD 20892, USA.
authors.forename: Jessica C
authors.initials: JC
authors.lastname: Seidman
authors.affiliation: Department of International Health, Johns Hopkins University, Baltimore, MD, 21205, USA.
authors.forename: Gwenyth
authors.initials: G
authors.lastname: Lee
authors.affiliation: Division of Infectious Diseases and International Health, University of Virginia, P.O. Box 801340, 345 Crispell Drive, Carter Harrison Building, Charlottesville, VA 22908, USA.
authors.forename: James A
authors.initials: JA
authors.lastname: Platts-Mills
authors.affiliation: Aga Khan University, Department of Pediatrics and Child Health, Stadium Road, Karachi, Pakistan.
authors.forename: Asad
authors.initials: A
authors.lastname: Ali
authors.affiliation: Asociaciόn Benéfica Proyectos de Informática, Salud, Medicina, y Agricultura (A.B. PRISMA), Ramirez Hurtado 622, Iquitos, Peru.
authors.forename: Maribel Paredes
authors.initials: MP
authors.lastname: Olortegui
authors.affiliation: HIV/AIDS and Global Health Research Programme, University of Venda, Thohoyandou 0950, South Africa.
authors.forename: Pascal
authors.initials: P
authors.lastname: Bessong
authors.affiliation: Department of Child Health, Institute of Medicine, Tribhuvan University, Katmandu, Nepal; Centre for International Health, University of Bergen, P.O. Box 7800, 5020 Bergen, Norway.
authors.forename: Ram
authors.initials: R
authors.lastname: Chandyo
authors.affiliation: Department of Gastrointestinal Sciences/Department of Community Health, Christian Medical College, Vellore, Tamil Nadu 632004, India.
authors.forename: Sudhir
authors.initials: S
authors.lastname: Babji
authors.affiliation: Department of Gastrointestinal Sciences/Department of Community Health, Christian Medical College, Vellore, Tamil Nadu 632004, India.
authors.forename: Venkata Raghava
authors.initials: VR
authors.lastname: Mohan
authors.affiliation: Nutrition and Clinical Services Division, International Centre For Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh.
authors.forename: Dinesh
authors.initials: D
authors.lastname: Mondal
authors.affiliation: Nutrition and Clinical Services Division, International Centre For Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh.
authors.forename: Mustafa
authors.initials: M
authors.lastname: Mahfuz
authors.affiliation: Haydom Lutheran Hospital, POB 9041, Haydom, Manyara Region, Tanzania.
authors.forename: Estomih R
authors.initials: ER
authors.lastname: Mduma
authors.affiliation: HIV/AIDS and Global Health Research Programme, University of Venda, Thohoyandou 0950, South Africa.
authors.forename: Emanuel
authors.initials: E
authors.lastname: Nyathi
authors.affiliation: Instituto de Biomedicina, Departamento de Fisiologia e Farmacologia, Faculdade de Medicina Federal University of Ceara, Rua Coronel Nunes de Melo, 1315, CEP: 60.430-270 - C.P. 3229 - Porangabussu, Fortaleza Ceará, Brazil.
authors.forename: Claudia
authors.initials: C
authors.lastname: Abreu
authors.affiliation: Division of International Epidemiology and Population Studies of Fogarty International Center, National Institutes of Health, 16 Center Drive, Bethesda, MD 20892, USA.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Miller
authors.affiliation: Department of Environmental Science and Policy and the Duke Global Health Institute, Duke University, Durham, NC, USA.
authors.forename: William
authors.initials: W
authors.lastname: Pan
authors.affiliation: Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand.
authors.forename: Carl J
authors.initials: CJ
authors.lastname: Mason
authors.affiliation: Division of International Epidemiology and Population Studies of Fogarty International Center, National Institutes of Health, 16 Center Drive, Bethesda, MD 20892, USA.
authors.forename: Stacey L
authors.initials: SL
authors.lastname: Knobler
mesh_terms: D000349:Africa; D001210:Asia, Southeastern; D015331:Cohort Studies; D003906:Developing Countries; D005500:Follow-Up Studies; D006801:Humans; D007115:Immunization Schedule; D007223:Infant; D007231:Infant, Newborn; D055118:Medication Adherence; D013020:South America; D000073887:Vaccination Coverage; D014612:Vaccines / Q000008:administration & dosage*
chemical_list: D014612:Vaccines
keywords: EPI; Measles; Public health; Socioeconomic factors; Vaccine coverage; Vaccine timing