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Finding Children with High Risk of Non-Vaccination in 92 Low- and Middle-Income Countries: A Decision Tree Approach
Authors: Thiago M. Santos, Bianca O. Cata-Preta, Cesar G. Victora, and Aluisio J. D. Barros
Source: Vaccines, Volume 9(6), 646; DOI:
Topic(s): Antenatal care
Child health
Country: More than one region
  Multiple Regions
Published: JUN 2021
Abstract: Reducing vaccination inequalities is a key goal of the Immunization Agenda 2030. Our main objective was to identify high-risk groups of children who received no vaccines (zero-dose children). A decision tree approach was used for 92 low- and middle-income countries using data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys, allowing the identification of groups of children aged 12–23 months at high risk of being zero dose (no doses of the four basic vaccines—BCG, polio, DPT and measles). Three high-risk groups were identified in the analysis combining all countries. The group with the highest zero-dose prevalence (42%) included 4% of all children, but almost one in every four zero-dose children in the sample. It included children whose mothers did not receive the tetanus vaccine during and before the pregnancy, who had no antenatal care visits and who did not deliver in a health facility. Separate analyses by country presented similar results. Children who have been missed by vaccination services were also left out by other primary health care interventions, especially those related to antenatal and delivery care. There is an opportunity for better integration among services in order to achieve high and equitable immunization coverage.