INTRODUCTION:- Vaccination is one of the most effective, inexpensive, and cost-effective intervention

strategies to reduce maternal and child morbidity and mortality from several infectious
diseases.1 Globally, over two million deaths are delayed through vaccination each year.2 However,
vaccine preventable diseases (poliomyelitis, measles, tetanus and yellow fever) remain the most
common cause of childhood mortality with an estimated three million deaths each year.3 The World
Health Organization (WHO) initiated the expanded program on immunization (EPI) in May 1974 with the
objective to vaccinate children throughout the world.4 Six vaccine-preventable diseases were initially
included in the EPI namely: tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis and measles. As
time went by, increased knowledge of the immunologic factors of diseases led to the development and
addition of new vaccines to the EPI’s list of recommended vaccines such as hepatitis B and yellow fever
in countries endemic for the disease and Haemophilus influenzae meningitis (Hib) conjugate vaccine in
countries with high burden of disease.3 In 2018, Global efforts had immunized about 86% of infants
worldwide with three doses of diphtheria-tetanus-pertussis (DPT) about 86% of infants worldwide
(116.3 million infants) received 3 doses of diphtheria-tetanus-pertussis (DTP3) vaccine, 89% had
received BCG and 86% had received the first dose of the measles vaccine.5 Despite the safe, effective
and inexpensive nature of vaccines, national childhood immunization program coverage for vaccine
preventable diseases remain insufficient in many African countries and the reoccurrence of epidemics
still occur.

In cases where two or more 9-23 months old children lived in the same household, the youngest child
was selected. Informed consent was obtained from caregivers through a signature of the informed
consent form after adequately explaining the objectives and protocol of the study

. Objectives of the Study

The objective of this study was to assess the vaccination coverage levels of vaccines under the EPI in
diredawa health center and identify factors that affect vaccination coverage

In cases where two or more 9-23 months old children lived in the same household, the youngest child
was selected. Informed consent was obtained from caregivers through a signature of the informed
consent form after adequately explaining the objectives and protocol of the study
1.1. Significance of the study

Methods

2.1. Study Design, Population and Setting

The study was a cross sectional community-based survey involving members of households
selected by clustered and purposive sampling technique

Data collection
Children aged 9-23 months were selected from the households through door to door visits. In
cases where two or more 9-23 months old children lived in the same household, the youngest
child was selected. Informed consent was obtained from caregivers verbally.
This is a community-based cross-sectional study which was conducted in East Gojam Zone
Northwestern Ethiopia in January 2016 to February 2016. The study population was children
aged 12 to 23 in completed months.

Sample size and sampling

A total of 846 children aged 12–23 months were involved in the study. The sample size was
determined using a single population proportion formula with a 95% confidence level, 5%
margin of error and 49.3% full vaccination coverage rate in Mecha district 2013.12 Furthermore, a
10% non-response rate and a design effect of 2 were considered.
The 2005 WHO EPI cluster sampling method was used for sample distribution. The numbers of
clusters were 10 Kebeles (5 from urban and 5 from rural Kebeles of 5 districts of East Gojam
Zone).16 The determined sample was proportionally distributed to each cluster based on a number
of eligible children in each cluster which was known after an enumeration of selected clusters.
Using household identification number, eligible children were selected randomly.

Data collection
Data collection was undertaken by high school completed data collectors and supervised by
diploma-level nurses from January 2016 to February 2016. Data was collected using
questionnaire adopted from WHO and EDHS9 and Amharic translated version. Mothers or
caretakers were interviewed with pretested Amharic version questionnaire and asked to show
vaccination cards for an indexed (selected) child and the data about vaccination were copied into
the study tool (questionnaire). If vaccination card was lost, the mother’s/caretaker’s report was
recorded. Presence of BCG scar was also observed and recorded. Each mother/care taker was
asked questions specifically designed to be answered regarding children vaccination if she
reported there was no vaccination card. To enable mothers/care takers to remember vaccine
taken by the children & to minimize recall bias different strategies were informed by the data
collectors, i.e.,; the site of vaccination given (oral, injection and scar) and at what age the child
received specific vaccine and to differentiate routine vaccination schedules from campaign
vaccination.

Data analysis procedures

Data entry, data cleaning, and coding was performed using SPSS version 20 and analyzed with
the same software. To explain the study population in relation to relevant variables, frequencies
and summary statistics were used. Predictors for the vaccinations of the children have been
assessed by dichotomizing outcome variable (child vaccination status) into fully vaccinated and
not fully vaccinated (partially vaccinated and not vaccinated children). Predictor variables having
a p-value < 0.20 were taken into a multivariable logistic regression analysis to see associations
between dependent and independent variables. All independent variables identified to
significantly associate with the vaccination statuses of the children at bivariate analysis
(p < 0.20) were taken into a multivariable analysis. Backward LR stepwise regression method
was selected to assess the association between children’s full vaccination status and factors
associated with their vaccination status. P-values less than 0.05 were considered statistically
significant in all cases.

Operational definitions
Fully vaccinated: A child aged between 12–23 months who received a total of thirteen doses
vaccines namely; one dose of BCG, at least three doses of pentavalent vaccine (diphtheria/D/,
pertussis/P/, tetanus/T/, Haemophilus influenzae type b/HepB/and Hepatitis B (DPT, HepB,
Hib), three doses of OPV (excluding polio zero given at birth), three doses of pneumococcal
conjugate vaccine 10 (PCV 10), two doses of Rota vaccine and a measles vaccine.14,17
Partially vaccinated: a child who missed at least one dose of the above mentioned (EPI)
vaccines.18
Not vaccinated: a child who does not receive any dose of the EPI vaccines19.
Coverage by card only: Coverage calculated with numerator based only on documented dose,
excluding from the numerator those vaccinated by history.20
Coverage by history: The vaccination coverage calculated with numerator based only on
mother’s/caregiver’s report.22
Dropout rate (DOR): The rate difference between the initial vaccine (BCG or Pentavalent I)
and the final vaccines (Pentavalent III or Measles).22
References
1. Mackroth MS, Irwin K, Vandelaer J, Hombach J, Eckert L. Immunizing school-age children and
adolescents:experience from low-and middle-income countries. Vaccine. 2010 Feb 3;28(5):1138–
47. [PubMed] [Google Scholar]

2. Kennedy J. Vaccine Hesitancy:A Growing Concern. Paediatr Drugs. 2020;22(2):105–

111. doi:10.1007/s40272-020-00385-4. [PubMed] [Google Scholar]

3. Levine R, Kremer M, Albright A. Report of the Center for Global Development. Washington DC: 2005.
Making markets for vaccines. [Google Scholar]

4. Keja K, Chan C, Hayden G, Henderson RH. Expanded program on immunization. World Health Stat
Q. 1988;41(2):59–63. [PubMed] [Google Scholar]

5. Rehm J, Chisholm D, Room R, Lopez AD, et al. Disease Control Priorities in Developing Countries. 2nd
edition. Washington, DC: The International Bank for Reconstruction and Development, The World Bank;
2006. [Google Scholar]

 Central Statistical Agency (CSA) [Ethiopia], ICF. Ethiopia Demographic and Health Survey
2016. Addis Ababa, Ethiop. Rockville, Maryland, USA CSA ICF [Internet]. 2016; Available
from: https://dhsprogram.com/pubs/pdf/FR328/FR328.pdf.
8. Ethiopia National Expanded Program on Immunization, Comprehensive Multi - Year Plan
2016–2020. Federal ministry of health, Addis Ababa, Ethiopia. Addis Ababa, Ethiopia: Federal
Ministry Of Health, Addis Ababa; 2015 p. 1-115. [Google Scholar]
9. Central Statistical Agency and ICF International. Ethiopia Demographic and Health Survey
2011. [Internet]. Heal. San Fr. 2012. Available
from: https://www.unicef.org/ethiopia/ET_2011_EDHS.pdf%0A%0A.
10. Animaw W, Taye W Merdekios B, et al. Expanded program of immunization coverage and
associated factors among children age 12-23 months in Arba Minch town and District Zuria,
Ethiopia Southern, 2013. BMC Public Health [Internet]. 2014;14:464.Available
from: http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-464. [PMC free
article] [PubMed]
11. Mohammed H, Atomsa A.. Assessment of child immunization coverage and associated
factors assessment of child immunization coverage and associated factors in oromia regional
state, eastern ethiopia. Sci Technol Arts Res J. 2013;2:36-41 2:36-41 2: 36. [Google Scholar]
12. Debie A, Taye B.. 2014. Assessment of fully vaccination coverage and associated factors
among children aged 12-23 months in mecha district, north west ethiopia: a cross-sectional
study. Science Journal Of Public Health. 2014;2:342-8 2:342-8 2: 342. [Google Scholar]
13. The Millennium UNDESA. Development Goals Report. United Nations 2005:48.
doi:10.1177/1757975909358250. [CrossRef]
14. EFMOH. Federal Democratic Republic of Ethiopia Ministry of Health: Health Sector
Development Programme IV 2010/11-2014/15 2010; IV: 114. doi: 10.1093/jmp/jht077.
[CrossRef]
15. Ethiopia Federal Ministry of Health. Ethiopia National Expanded Programme on
Immunization: Comprehensive Multi-Year Plan 2011-2015. Addis ababa, Ethiopia; 2010 p. 1-
76. [Google Scholar]
16. WHO Immunization coverage cluster survey- Reference manual [Internet]. World Heal.
Organ. Geneva, Switzerland; 2005. p. 115. Available
from: www.who.int/immunization/.../Vaccination_coverage_cluster_survey_with_annexes.p.
17. Tsega A, Daniel F Steinglass R. Monitoring coverage of fully immunized children. Vaccine.
2014;32:7047–9. [PubMed] [Google Scholar]
18. Fatiregun AA, Okoro AO. 2012. Maternal determinants of complete child immunization
among children aged 12-23 months in a southern district of nigeria. Vaccine. 30:730-6:.
[PubMed] [Google Scholar]
19. Mohamud AN, Feleke A, Worku W, Kifle M Sharma HR Immunization coverage of 12-23
months old children and associated factors in jigjiga district, somali national regional state,
ethiopia. Bmc Public Health.  2014;14:865. [PMC free article] [PubMed] [Google Scholar]
20. Etana B, Deressa W. Factors associated with complete immunization coverage in children
aged 12-23 months in ambo woreda, central ethiopia. Bmc Public Health. 2012;12:566. [PMC
free article] [PubMed] [Google Scholar]
21. Adedire EB, Ajayi I, Fawole OI, Ajumobi O, Kasasa S Wasswa P, et al. Immunisation
coverage and its determinants among children aged 12-23 months in atakumosa-west district,
osun state nigeria: a cross-sectional study. Bmc Public Health. 2016;16:905. [PMC free
article] [PubMed] [Google Scholar]
22. World Health Organization Vaccination Coverage Cluster Surveys [Internet]. 2015.
Available
from: http://www.who.int/immunization/monitoring_surveillance/Vaccination_coverage_cluster
_survey_with_annexes.pdf.
23. Miles M, Ryman TK, Dietz V, Zell E Luman ET. Validity of vaccination cards and parental
recall to estimate vaccination coverage: a systematic review of the literature. Vaccine.
2013;31:1560-8. [PubMed] [Google Scholar]
24. Tadesse H, Deribew A, Woldie M. Predictors of defaulting from completion of child
immunization in south ethiopia, may 2008 - a case control study. Bmc Public Health. 2009;9:4-
9:. [PMC free article] [PubMed] [Google Scholar]
25. Shemwell SA, Peratikos MB, González-Calvo L, Renom-Llonch M, Boon A Martinho S, et
al. Determinants of full vaccination status in children aged 12-23 months in gurùé and milange
districts, mozambique: results of a population-based cross-sectional survey. Int Health.
2017;9:234–42:. [PMC free article] [PubMed] [Google Scholar]
26. Lim KK, Chan YY, Noor Ani A, Rohani J, Siti Norfadhilah ZA Santhi MR. Complete
immunization coverage and its determinants among children in malaysia: findings from the
national health and morbidity survey (nhms) 2016. Public Health. 2017;153:52–7.
[PubMed] [Google Scholar]
27. Bilal NK, Herbst CH Zhao F, et al. Health Extension Workers in Ethiopia: Improved Access
and Coverage for the Rural Poor. 2012. p. 433–444. Available
from: http://documents.worldbank.org/curated/en/304221468001788072/930107812_201408251
045629/additional/634310PUB0Yes0061512B09780821387450.pdf.