Impact of COVID-19 pandemic response on uptake of routine immunizations in Sindh, Pakistan: An analysis of provincial electronic immunization registry data.
Identifieur interne : 001676 ( Main/Corpus ); précédent : 001675; suivant : 001677Impact of COVID-19 pandemic response on uptake of routine immunizations in Sindh, Pakistan: An analysis of provincial electronic immunization registry data.
Auteurs : Subhash Chandir ; Danya Arif Siddiqi ; Mariam Mehmood ; Hamidreza Setayesh ; Muhammad Siddique ; Amna Mirza ; Riswana Soundardjee ; Vijay Kumar Dharma ; Mubarak Taighoon Shah ; Sara Abdullah ; Mohammed Adil Akhter ; Anokhi Ali Khan ; Aamir Javed KhanSource :
- Vaccine [ 1873-2518 ] ; 2020.
English descriptors
- KwdEn :
- BCG Vaccine (administration & dosage), Betacoronavirus (pathogenicity), COVID-19 (MeSH), Coronavirus Infections (epidemiology), Coronavirus Infections (immunology), Coronavirus Infections (psychology), Electronic Data Processing (MeSH), Female (MeSH), Humans (MeSH), Immunization Programs (statistics & numerical data), Infant (MeSH), Infant, Newborn (MeSH), Male (MeSH), Measles (epidemiology), Measles (immunology), Measles (prevention & control), Measles Vaccine (administration & dosage), Pakistan (epidemiology), Pandemics (MeSH), Pneumonia, Viral (epidemiology), Pneumonia, Viral (immunology), Pneumonia, Viral (psychology), Quarantine (MeSH), Registries (MeSH), Rotavirus Infections (epidemiology), Rotavirus Infections (immunology), Rotavirus Infections (prevention & control), Rotavirus Vaccines (administration & dosage), Rural Population (MeSH), SARS-CoV-2 (MeSH), Tuberculosis, Pulmonary (epidemiology), Tuberculosis, Pulmonary (immunology), Tuberculosis, Pulmonary (prevention & control), Urban Population (MeSH), Vaccination (psychology), Vaccination (statistics & numerical data), Vaccination Coverage (statistics & numerical data), Vaccines, Attenuated (administration & dosage).
- MESH :
- chemical , administration & dosage : BCG Vaccine, Measles Vaccine, Rotavirus Vaccines, Vaccines, Attenuated.
- geographic , epidemiology : Pakistan.
- epidemiology : Coronavirus Infections, Measles, Pneumonia, Viral, Rotavirus Infections, Tuberculosis, Pulmonary.
- immunology : Coronavirus Infections, Measles, Pneumonia, Viral, Rotavirus Infections, Tuberculosis, Pulmonary.
- pathogenicity : Betacoronavirus.
- prevention & control : Measles, Rotavirus Infections, Tuberculosis, Pulmonary.
- psychology : Coronavirus Infections, Pneumonia, Viral, Vaccination.
- statistics & numerical data : Immunization Programs, Vaccination, Vaccination Coverage.
- COVID-19, Electronic Data Processing, Female, Humans, Infant, Infant, Newborn, Male, Pandemics, Quarantine, Registries, Rural Population, SARS-CoV-2, Urban Population.
Abstract
BACKGROUND
COVID-19 pandemic has affected routine immunization globally. Impact will likely be higher in low and middle-income countries with limited healthcare resources and fragile health systems. We quantified the impact, spatial heterogeneity, and determinants for childhood immunizations of 48 million population affected in the Sindh province of Pakistan.
METHODS
We extracted individual immunization records from real-time provincial Electronic Immunization Registry from September 23, 2019, to July 11, 2020. Comparing baseline (6 months preceding the lockdown) and the COVID-19 lockdown period, we analyzed the impact on daily immunization coverage rate for each antigen by geographical area. We used multivariable logistic regression to explore the predictors associated with immunizations during the lockdown.
RESULTS
There was a 52.5% decline in the daily average total number of vaccinations administered during lockdown compared to baseline. The highest decline was seen for Bacille Cal-mette Guérin (BCG) (40.6% (958/2360) immunization at fixed sites. Around 8438 children/day were missing immunization during the lockdown. Enrollments declined furthest in rural districts, urban sub-districts with large slums, and polio-endemic super high-risk sub-districts. Pentavalent-3 (penta-3) immunization rates were higher in infants born in hospitals (RR: 1.09; 95% CI: 1.04-1.15) and those with mothers having higher education (RR: 1.19-1.50; 95% CI: 1.13-1.65). Likelihood of penta-3 immunization was reduced by 5% for each week of delayed enrollment into the immunization program.
CONCLUSION
One out of every two children in Sindh province has missed their routine vaccinations during the provincial COVID-19 lockdown. The pool of un-immunized children is expanding during lockdown, leaving them susceptible to vaccine-preventable diseases. There is a need for tailored interventions to promote immunization visits and safe service delivery. Higher maternal education, facility-based births, and early enrollment into the immunization program continue to show a positive association with immunization uptake, even during a challenging lockdown.
DOI: 10.1016/j.vaccine.2020.08.019
PubMed: 32943265
PubMed Central: PMC7428732
Links to Exploration step
pubmed:32943265Le document en format XML
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Electronic address: subhash.chandir@ird.global.</nlm:affiliation></affiliation></author><author><name sortKey="Siddiqi, Danya Arif" sort="Siddiqi, Danya Arif" uniqKey="Siddiqi D" first="Danya Arif" last="Siddiqi">Danya Arif Siddiqi</name><affiliation><nlm:affiliation>IRD Global, 15 Beach Road #02-01, Singapore 189677, Singapore.</nlm:affiliation></affiliation></author><author><name sortKey="Mehmood, Mariam" sort="Mehmood, Mariam" uniqKey="Mehmood M" first="Mariam" last="Mehmood">Mariam Mehmood</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Setayesh, Hamidreza" sort="Setayesh, Hamidreza" uniqKey="Setayesh H" first="Hamidreza" last="Setayesh">Hamidreza Setayesh</name><affiliation><nlm:affiliation>Gavi, the Vaccine Alliance, Chemin du Pommier 40, 1218 Le Grand-Saconnex, Switzerland.</nlm:affiliation></affiliation></author><author><name sortKey="Siddique, Muhammad" sort="Siddique, Muhammad" uniqKey="Siddique M" first="Muhammad" last="Siddique">Muhammad Siddique</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Mirza, Amna" sort="Mirza, Amna" uniqKey="Mirza A" first="Amna" last="Mirza">Amna Mirza</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Soundardjee, Riswana" sort="Soundardjee, Riswana" uniqKey="Soundardjee R" first="Riswana" last="Soundardjee">Riswana Soundardjee</name><affiliation><nlm:affiliation>Gavi, the Vaccine Alliance, Chemin du Pommier 40, 1218 Le Grand-Saconnex, Switzerland.</nlm:affiliation></affiliation></author><author><name sortKey="Dharma, Vijay Kumar" sort="Dharma, Vijay Kumar" uniqKey="Dharma V" first="Vijay Kumar" last="Dharma">Vijay Kumar Dharma</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan; Global Health Directorate, Indus Health Network, 5th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Shah, Mubarak Taighoon" sort="Shah, Mubarak Taighoon" uniqKey="Shah M" first="Mubarak Taighoon" last="Shah">Mubarak Taighoon Shah</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Abdullah, Sara" sort="Abdullah, Sara" uniqKey="Abdullah S" first="Sara" last="Abdullah">Sara Abdullah</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Akhter, Mohammed Adil" sort="Akhter, Mohammed Adil" uniqKey="Akhter M" first="Mohammed Adil" last="Akhter">Mohammed Adil Akhter</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan; Global Health Directorate, Indus Health Network, 5th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Ali Khan, Anokhi" sort="Ali Khan, Anokhi" uniqKey="Ali Khan A" first="Anokhi" last="Ali Khan">Anokhi Ali Khan</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Khan, Aamir Javed" sort="Khan, Aamir Javed" uniqKey="Khan A" first="Aamir Javed" last="Khan">Aamir Javed Khan</name><affiliation><nlm:affiliation>IRD Global, 15 Beach Road #02-01, Singapore 189677, Singapore; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA.</nlm:affiliation></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PubMed</idno><date when="2020">2020</date><idno type="RBID">pubmed:32943265</idno><idno type="pmid">32943265</idno><idno type="doi">10.1016/j.vaccine.2020.08.019</idno><idno type="pmc">PMC7428732</idno><idno type="wicri:Area/Main/Corpus">001676</idno><idno type="wicri:explorRef" wicri:stream="Main" wicri:step="Corpus" wicri:corpus="PubMed">001676</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en">Impact of COVID-19 pandemic response on uptake of routine immunizations in Sindh, Pakistan: An analysis of provincial electronic immunization registry data.</title><author><name sortKey="Chandir, Subhash" sort="Chandir, Subhash" uniqKey="Chandir S" first="Subhash" last="Chandir">Subhash Chandir</name><affiliation><nlm:affiliation>IRD Global, 15 Beach Road #02-01, Singapore 189677, Singapore; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA. Electronic address: subhash.chandir@ird.global.</nlm:affiliation></affiliation></author><author><name sortKey="Siddiqi, Danya Arif" sort="Siddiqi, Danya Arif" uniqKey="Siddiqi D" first="Danya Arif" last="Siddiqi">Danya Arif Siddiqi</name><affiliation><nlm:affiliation>IRD Global, 15 Beach Road #02-01, Singapore 189677, Singapore.</nlm:affiliation></affiliation></author><author><name sortKey="Mehmood, Mariam" sort="Mehmood, Mariam" uniqKey="Mehmood M" first="Mariam" last="Mehmood">Mariam Mehmood</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Setayesh, Hamidreza" sort="Setayesh, Hamidreza" uniqKey="Setayesh H" first="Hamidreza" last="Setayesh">Hamidreza Setayesh</name><affiliation><nlm:affiliation>Gavi, the Vaccine Alliance, Chemin du Pommier 40, 1218 Le Grand-Saconnex, Switzerland.</nlm:affiliation></affiliation></author><author><name sortKey="Siddique, Muhammad" sort="Siddique, Muhammad" uniqKey="Siddique M" first="Muhammad" last="Siddique">Muhammad Siddique</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Mirza, Amna" sort="Mirza, Amna" uniqKey="Mirza A" first="Amna" last="Mirza">Amna Mirza</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Soundardjee, Riswana" sort="Soundardjee, Riswana" uniqKey="Soundardjee R" first="Riswana" last="Soundardjee">Riswana Soundardjee</name><affiliation><nlm:affiliation>Gavi, the Vaccine Alliance, Chemin du Pommier 40, 1218 Le Grand-Saconnex, Switzerland.</nlm:affiliation></affiliation></author><author><name sortKey="Dharma, Vijay Kumar" sort="Dharma, Vijay Kumar" uniqKey="Dharma V" first="Vijay Kumar" last="Dharma">Vijay Kumar Dharma</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan; Global Health Directorate, Indus Health Network, 5th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Shah, Mubarak Taighoon" sort="Shah, Mubarak Taighoon" uniqKey="Shah M" first="Mubarak Taighoon" last="Shah">Mubarak Taighoon Shah</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Abdullah, Sara" sort="Abdullah, Sara" uniqKey="Abdullah S" first="Sara" last="Abdullah">Sara Abdullah</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Akhter, Mohammed Adil" sort="Akhter, Mohammed Adil" uniqKey="Akhter M" first="Mohammed Adil" last="Akhter">Mohammed Adil Akhter</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan; Global Health Directorate, Indus Health Network, 5th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Ali Khan, Anokhi" sort="Ali Khan, Anokhi" uniqKey="Ali Khan A" first="Anokhi" last="Ali Khan">Anokhi Ali Khan</name><affiliation><nlm:affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</nlm:affiliation></affiliation></author><author><name sortKey="Khan, Aamir Javed" sort="Khan, Aamir Javed" uniqKey="Khan A" first="Aamir Javed" last="Khan">Aamir Javed Khan</name><affiliation><nlm:affiliation>IRD Global, 15 Beach Road #02-01, Singapore 189677, Singapore; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA.</nlm:affiliation></affiliation></author></analytic><series><title level="j">Vaccine</title><idno type="eISSN">1873-2518</idno><imprint><date when="2020" type="published">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>BCG Vaccine (administration & dosage)</term><term>Betacoronavirus (pathogenicity)</term><term>COVID-19 (MeSH)</term><term>Coronavirus Infections (epidemiology)</term><term>Coronavirus Infections (immunology)</term><term>Coronavirus Infections (psychology)</term><term>Electronic Data Processing (MeSH)</term><term>Female (MeSH)</term><term>Humans (MeSH)</term><term>Immunization Programs (statistics & numerical data)</term><term>Infant (MeSH)</term><term>Infant, Newborn (MeSH)</term><term>Male (MeSH)</term><term>Measles (epidemiology)</term><term>Measles (immunology)</term><term>Measles (prevention & control)</term><term>Measles Vaccine (administration & dosage)</term><term>Pakistan (epidemiology)</term><term>Pandemics (MeSH)</term><term>Pneumonia, Viral (epidemiology)</term><term>Pneumonia, Viral (immunology)</term><term>Pneumonia, Viral (psychology)</term><term>Quarantine (MeSH)</term><term>Registries (MeSH)</term><term>Rotavirus Infections (epidemiology)</term><term>Rotavirus Infections (immunology)</term><term>Rotavirus Infections (prevention & control)</term><term>Rotavirus Vaccines (administration & dosage)</term><term>Rural Population (MeSH)</term><term>SARS-CoV-2 (MeSH)</term><term>Tuberculosis, Pulmonary (epidemiology)</term><term>Tuberculosis, Pulmonary (immunology)</term><term>Tuberculosis, Pulmonary (prevention & control)</term><term>Urban Population (MeSH)</term><term>Vaccination (psychology)</term><term>Vaccination (statistics & numerical data)</term><term>Vaccination Coverage (statistics & numerical data)</term><term>Vaccines, Attenuated (administration & dosage)</term></keywords><keywords scheme="MESH" type="chemical" qualifier="administration & dosage" xml:lang="en"><term>BCG Vaccine</term><term>Measles Vaccine</term><term>Rotavirus Vaccines</term><term>Vaccines, Attenuated</term></keywords><keywords scheme="MESH" type="geographic" qualifier="epidemiology" xml:lang="en"><term>Pakistan</term></keywords><keywords scheme="MESH" qualifier="epidemiology" xml:lang="en"><term>Coronavirus Infections</term><term>Measles</term><term>Pneumonia, Viral</term><term>Rotavirus Infections</term><term>Tuberculosis, Pulmonary</term></keywords><keywords scheme="MESH" qualifier="immunology" xml:lang="en"><term>Coronavirus Infections</term><term>Measles</term><term>Pneumonia, Viral</term><term>Rotavirus Infections</term><term>Tuberculosis, Pulmonary</term></keywords><keywords scheme="MESH" qualifier="pathogenicity" xml:lang="en"><term>Betacoronavirus</term></keywords><keywords scheme="MESH" qualifier="prevention & control" xml:lang="en"><term>Measles</term><term>Rotavirus Infections</term><term>Tuberculosis, Pulmonary</term></keywords><keywords scheme="MESH" qualifier="psychology" xml:lang="en"><term>Coronavirus Infections</term><term>Pneumonia, Viral</term><term>Vaccination</term></keywords><keywords scheme="MESH" qualifier="statistics & numerical data" xml:lang="en"><term>Immunization Programs</term><term>Vaccination</term><term>Vaccination Coverage</term></keywords><keywords scheme="MESH" xml:lang="en"><term>COVID-19</term><term>Electronic Data Processing</term><term>Female</term><term>Humans</term><term>Infant</term><term>Infant, Newborn</term><term>Male</term><term>Pandemics</term><term>Quarantine</term><term>Registries</term><term>Rural Population</term><term>SARS-CoV-2</term><term>Urban Population</term></keywords></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p><b>BACKGROUND</b></p><p>COVID-19 pandemic has affected routine immunization globally. Impact will likely be higher in low and middle-income countries with limited healthcare resources and fragile health systems. We quantified the impact, spatial heterogeneity, and determinants for childhood immunizations of 48 million population affected in the Sindh province of Pakistan.</p></div><div type="abstract" xml:lang="en"><p><b>METHODS</b></p><p>We extracted individual immunization records from real-time provincial Electronic Immunization Registry from September 23, 2019, to July 11, 2020. Comparing baseline (6 months preceding the lockdown) and the COVID-19 lockdown period, we analyzed the impact on daily immunization coverage rate for each antigen by geographical area. We used multivariable logistic regression to explore the predictors associated with immunizations during the lockdown.</p></div><div type="abstract" xml:lang="en"><p><b>RESULTS</b></p><p>There was a 52.5% decline in the daily average total number of vaccinations administered during lockdown compared to baseline. The highest decline was seen for Bacille Cal-mette Guérin (BCG) (40.6% (958/2360) immunization at fixed sites. Around 8438 children/day were missing immunization during the lockdown. Enrollments declined furthest in rural districts, urban sub-districts with large slums, and polio-endemic super high-risk sub-districts. Pentavalent-3 (penta-3) immunization rates were higher in infants born in hospitals (RR: 1.09; 95% CI: 1.04-1.15) and those with mothers having higher education (RR: 1.19-1.50; 95% CI: 1.13-1.65). Likelihood of penta-3 immunization was reduced by 5% for each week of delayed enrollment into the immunization program.</p></div><div type="abstract" xml:lang="en"><p><b>CONCLUSION</b></p><p>One out of every two children in Sindh province has missed their routine vaccinations during the provincial COVID-19 lockdown. The pool of un-immunized children is expanding during lockdown, leaving them susceptible to vaccine-preventable diseases. There is a need for tailored interventions to promote immunization visits and safe service delivery. Higher maternal education, facility-based births, and early enrollment into the immunization program continue to show a positive association with immunization uptake, even during a challenging lockdown.</p></div></front></TEI><pubmed><MedlineCitation Status="MEDLINE" Owner="NLM"><PMID Version="1">32943265</PMID><DateCompleted><Year>2020</Year><Month>10</Month><Day>22</Day></DateCompleted><DateRevised><Year>2021</Year><Month>01</Month><Day>10</Day></DateRevised><Article PubModel="Print-Electronic"><Journal><ISSN IssnType="Electronic">1873-2518</ISSN><JournalIssue CitedMedium="Internet"><Volume>38</Volume><Issue>45</Issue><PubDate><Year>2020</Year><Month>10</Month><Day>21</Day></PubDate></JournalIssue><Title>Vaccine</Title><ISOAbbreviation>Vaccine</ISOAbbreviation></Journal><ArticleTitle>Impact of COVID-19 pandemic response on uptake of routine immunizations in Sindh, Pakistan: An analysis of provincial electronic immunization registry data.</ArticleTitle><Pagination><MedlinePgn>7146-7155</MedlinePgn></Pagination><ELocationID EIdType="pii" ValidYN="Y">S0264-410X(20)31050-1</ELocationID><ELocationID EIdType="doi" ValidYN="Y">10.1016/j.vaccine.2020.08.019</ELocationID><Abstract><AbstractText Label="BACKGROUND">COVID-19 pandemic has affected routine immunization globally. Impact will likely be higher in low and middle-income countries with limited healthcare resources and fragile health systems. We quantified the impact, spatial heterogeneity, and determinants for childhood immunizations of 48 million population affected in the Sindh province of Pakistan.</AbstractText><AbstractText Label="METHODS">We extracted individual immunization records from real-time provincial Electronic Immunization Registry from September 23, 2019, to July 11, 2020. Comparing baseline (6 months preceding the lockdown) and the COVID-19 lockdown period, we analyzed the impact on daily immunization coverage rate for each antigen by geographical area. We used multivariable logistic regression to explore the predictors associated with immunizations during the lockdown.</AbstractText><AbstractText Label="RESULTS">There was a 52.5% decline in the daily average total number of vaccinations administered during lockdown compared to baseline. The highest decline was seen for Bacille Cal-mette Guérin (BCG) (40.6% (958/2360) immunization at fixed sites. Around 8438 children/day were missing immunization during the lockdown. Enrollments declined furthest in rural districts, urban sub-districts with large slums, and polio-endemic super high-risk sub-districts. Pentavalent-3 (penta-3) immunization rates were higher in infants born in hospitals (RR: 1.09; 95% CI: 1.04-1.15) and those with mothers having higher education (RR: 1.19-1.50; 95% CI: 1.13-1.65). Likelihood of penta-3 immunization was reduced by 5% for each week of delayed enrollment into the immunization program.</AbstractText><AbstractText Label="CONCLUSION">One out of every two children in Sindh province has missed their routine vaccinations during the provincial COVID-19 lockdown. The pool of un-immunized children is expanding during lockdown, leaving them susceptible to vaccine-preventable diseases. There is a need for tailored interventions to promote immunization visits and safe service delivery. Higher maternal education, facility-based births, and early enrollment into the immunization program continue to show a positive association with immunization uptake, even during a challenging lockdown.</AbstractText><CopyrightInformation>Copyright © 2020 Elsevier Ltd. All rights reserved.</CopyrightInformation></Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Chandir</LastName><ForeName>Subhash</ForeName><Initials>S</Initials><AffiliationInfo><Affiliation>IRD Global, 15 Beach Road #02-01, Singapore 189677, Singapore; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA. Electronic address: subhash.chandir@ird.global.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Siddiqi</LastName><ForeName>Danya Arif</ForeName><Initials>DA</Initials><AffiliationInfo><Affiliation>IRD Global, 15 Beach Road #02-01, Singapore 189677, Singapore.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Mehmood</LastName><ForeName>Mariam</ForeName><Initials>M</Initials><AffiliationInfo><Affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Setayesh</LastName><ForeName>Hamidreza</ForeName><Initials>H</Initials><AffiliationInfo><Affiliation>Gavi, the Vaccine Alliance, Chemin du Pommier 40, 1218 Le Grand-Saconnex, Switzerland.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Siddique</LastName><ForeName>Muhammad</ForeName><Initials>M</Initials><AffiliationInfo><Affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Mirza</LastName><ForeName>Amna</ForeName><Initials>A</Initials><AffiliationInfo><Affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Soundardjee</LastName><ForeName>Riswana</ForeName><Initials>R</Initials><AffiliationInfo><Affiliation>Gavi, the Vaccine Alliance, Chemin du Pommier 40, 1218 Le Grand-Saconnex, Switzerland.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Dharma</LastName><ForeName>Vijay Kumar</ForeName><Initials>VK</Initials><AffiliationInfo><Affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan; Global Health Directorate, Indus Health Network, 5th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Shah</LastName><ForeName>Mubarak Taighoon</ForeName><Initials>MT</Initials><AffiliationInfo><Affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Abdullah</LastName><ForeName>Sara</ForeName><Initials>S</Initials><AffiliationInfo><Affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Akhter</LastName><ForeName>Mohammed Adil</ForeName><Initials>MA</Initials><AffiliationInfo><Affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan; Global Health Directorate, Indus Health Network, 5th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Ali Khan</LastName><ForeName>Anokhi</ForeName><Initials>A</Initials><AffiliationInfo><Affiliation>IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi 75190, Pakistan.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Khan</LastName><ForeName>Aamir Javed</ForeName><Initials>AJ</Initials><AffiliationInfo><Affiliation>IRD Global, 15 Beach Road #02-01, Singapore 189677, Singapore; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA.</Affiliation></AffiliationInfo></Author></AuthorList><Language>eng</Language><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList><ArticleDate DateType="Electronic"><Year>2020</Year><Month>08</Month><Day>15</Day></ArticleDate></Article><MedlineJournalInfo><Country>Netherlands</Country><MedlineTA>Vaccine</MedlineTA><NlmUniqueID>8406899</NlmUniqueID><ISSNLinking>0264-410X</ISSNLinking></MedlineJournalInfo><ChemicalList><Chemical><RegistryNumber>0</RegistryNumber><NameOfSubstance UI="D001500">BCG Vaccine</NameOfSubstance></Chemical><Chemical><RegistryNumber>0</RegistryNumber><NameOfSubstance UI="D008458">Measles Vaccine</NameOfSubstance></Chemical><Chemical><RegistryNumber>0</RegistryNumber><NameOfSubstance UI="C492535">RotaTeq</NameOfSubstance></Chemical><Chemical><RegistryNumber>0</RegistryNumber><NameOfSubstance UI="D022243">Rotavirus Vaccines</NameOfSubstance></Chemical><Chemical><RegistryNumber>0</RegistryNumber><NameOfSubstance UI="D014613">Vaccines, Attenuated</NameOfSubstance></Chemical></ChemicalList><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D001500" MajorTopicYN="N">BCG Vaccine</DescriptorName><QualifierName UI="Q000008" MajorTopicYN="N">administration & dosage</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D000073640" MajorTopicYN="N">Betacoronavirus</DescriptorName><QualifierName UI="Q000472" MajorTopicYN="N">pathogenicity</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D000086382" MajorTopicYN="N">COVID-19</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D018352" MajorTopicYN="N">Coronavirus Infections</DescriptorName><QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName><QualifierName UI="Q000276" MajorTopicYN="N">immunology</QualifierName><QualifierName UI="Q000523" MajorTopicYN="Y">psychology</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D001330" MajorTopicYN="N">Electronic Data Processing</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D005260" MajorTopicYN="N">Female</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D017589" MajorTopicYN="N">Immunization Programs</DescriptorName><QualifierName UI="Q000706" MajorTopicYN="N">statistics & numerical data</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D007223" MajorTopicYN="N">Infant</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D007231" MajorTopicYN="N">Infant, Newborn</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008297" MajorTopicYN="N">Male</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008457" MajorTopicYN="N">Measles</DescriptorName><QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName><QualifierName UI="Q000276" MajorTopicYN="N">immunology</QualifierName><QualifierName UI="Q000517" MajorTopicYN="Y">prevention & control</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D008458" MajorTopicYN="N">Measles Vaccine</DescriptorName><QualifierName UI="Q000008" MajorTopicYN="N">administration & dosage</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D010154" MajorTopicYN="N" Type="Geographic">Pakistan</DescriptorName><QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D058873" MajorTopicYN="Y">Pandemics</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D011024" MajorTopicYN="N">Pneumonia, Viral</DescriptorName><QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName><QualifierName UI="Q000276" MajorTopicYN="N">immunology</QualifierName><QualifierName UI="Q000523" MajorTopicYN="Y">psychology</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D011790" MajorTopicYN="Y">Quarantine</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D012042" MajorTopicYN="N">Registries</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D012400" MajorTopicYN="N">Rotavirus Infections</DescriptorName><QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName><QualifierName UI="Q000276" MajorTopicYN="N">immunology</QualifierName><QualifierName UI="Q000517" MajorTopicYN="Y">prevention & control</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D022243" MajorTopicYN="N">Rotavirus Vaccines</DescriptorName><QualifierName UI="Q000008" MajorTopicYN="N">administration & dosage</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D012424" MajorTopicYN="N">Rural Population</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D000086402" MajorTopicYN="N">SARS-CoV-2</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D014397" MajorTopicYN="N">Tuberculosis, Pulmonary</DescriptorName><QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName><QualifierName UI="Q000276" MajorTopicYN="N">immunology</QualifierName><QualifierName UI="Q000517" MajorTopicYN="Y">prevention & control</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D014505" MajorTopicYN="N">Urban Population</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D014611" MajorTopicYN="N">Vaccination</DescriptorName><QualifierName UI="Q000523" MajorTopicYN="N">psychology</QualifierName><QualifierName UI="Q000706" MajorTopicYN="Y">statistics & numerical data</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D000073887" MajorTopicYN="N">Vaccination Coverage</DescriptorName><QualifierName UI="Q000706" MajorTopicYN="N">statistics & numerical data</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D014613" MajorTopicYN="N">Vaccines, Attenuated</DescriptorName><QualifierName UI="Q000008" MajorTopicYN="N">administration & dosage</QualifierName></MeshHeading></MeshHeadingList><KeywordList Owner="NOTNLM"><Keyword MajorTopicYN="Y">COVID-19</Keyword><Keyword MajorTopicYN="Y">Electronic Immunization Registry</Keyword><Keyword MajorTopicYN="Y">Immunization coverage</Keyword><Keyword MajorTopicYN="Y">Predictors of immunization</Keyword><Keyword MajorTopicYN="Y">mHealth</Keyword></KeywordList><CoiStatement>Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.</CoiStatement></MedlineCitation><PubmedData><History><PubMedPubDate PubStatus="received"><Year>2020</Year><Month>05</Month><Day>13</Day></PubMedPubDate><PubMedPubDate PubStatus="revised"><Year>2020</Year><Month>08</Month><Day>07</Day></PubMedPubDate><PubMedPubDate PubStatus="accepted"><Year>2020</Year><Month>08</Month><Day>09</Day></PubMedPubDate><PubMedPubDate PubStatus="pubmed"><Year>2020</Year><Month>9</Month><Day>19</Day><Hour>6</Hour><Minute>0</Minute></PubMedPubDate><PubMedPubDate PubStatus="medline"><Year>2020</Year><Month>10</Month><Day>23</Day><Hour>6</Hour><Minute>0</Minute></PubMedPubDate><PubMedPubDate PubStatus="entrez"><Year>2020</Year><Month>9</Month><Day>18</Day><Hour>5</Hour><Minute>37</Minute></PubMedPubDate></History><PublicationStatus>ppublish</PublicationStatus><ArticleIdList><ArticleId IdType="pubmed">32943265</ArticleId><ArticleId IdType="pii">S0264-410X(20)31050-1</ArticleId><ArticleId IdType="doi">10.1016/j.vaccine.2020.08.019</ArticleId><ArticleId IdType="pmc">PMC7428732</ArticleId></ArticleIdList><ReferenceList><Reference><Citation>Emerg Infect Dis. 2016 Mar;22(3):433-41</Citation><ArticleIdList><ArticleId IdType="pubmed">26886846</ArticleId></ArticleIdList></Reference><Reference><Citation>Soc Sci Med. 2005 Sep;61(5):989-1000</Citation><ArticleIdList><ArticleId IdType="pubmed">15955401</ArticleId></ArticleIdList></Reference><Reference><Citation>Vaccine. 2015 Nov 27;33(48):6778-85</Citation><ArticleIdList><ArticleId IdType="pubmed">26482146</ArticleId></ArticleIdList></Reference><Reference><Citation>Pan Afr Med J. 2017 Jun 21;27(Suppl 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