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. 2023 Jan 4;18(1):e0280083. doi: 10.1371/journal.pone.0280083

Exploring spatial variations and the individual and contextual factors of uptake of measles-containing second dose vaccine among children aged 24 to 35 months in Ethiopia

Achamyeleh Birhanu Teshale 1,*, Tsegaw Amare 2
Editor: Tefera Chane Mekonnen3
PMCID: PMC9812309  PMID: 36598928

Abstract

Background

To eliminate measles, which is a devastating contagious disease, Ethiopia introduced the measles-containing second dose vaccine (MCV2) that will be given in the second year of life. Despite its paramount benefit, the coverage was low worldwide and, in Ethiopia, there is scarce evidence on the geographic variations and factors associated with uptake of MCV2.

Objective

This study aimed to explore the spatial variations and the individual and contextual factors of uptake of measles-containing second dose vaccine among children aged 24 to 35 months in Ethiopia.

Methods

We used the 2019 Ethiopian Mini Demographic and Health Survey data. A total weighted sample of 800 children aged 24 to 35 months was used. Multilevel analysis was employed and an adjusted odds ratio (AOR) with a 95% confidence interval (CI) was reported. Factors with a p-value<0.05 in the multivariable analysis were declared to be significant predictors of MCV2 uptake. To explore the spatial variations of MCV2 uptake, we have conducted spatial analysis using both Arc GIS version 10.7 and SaTScan version 9.6 software.

Results

The proportion of MCV2 uptake was 9.84% (95% CI: 7.96%, 12.11%). Children whose mothers were aged 20–34 years (AOR = 0.19; 95%CI: 0.05, 0.69) and 35–49 years (AOR = 0.21; 95%CI: 0.04, 0.90), being the 4th-5th child (AOR = 4.02; 95%CI: 1.45, 11.14) and 6th and above child (AOR = 4.12; 95%CI: 1.42, 13.05) and children who did not receive full childhood vaccinations (AOR = 0.44; 95%CI: 0.25, 0.77) were significantly associated with MCV2 uptake. Besides, MCV2 uptake was clustered in Ethiopia (Global Moran’s I = 0.074, p-value <0.01). The primary cluster spatial window was detected in the Benishangul-Gumuz region with LLR = 10.05 and p = 0.011.

Conclusion

The uptake of MCV2 in Ethiopia was low. Maternal age, birth order, and uptake of the other basic vaccines were associated with MCV2 uptake. Besides, MCV2 uptake was clustered in Ethiopia and the primary cluster spatial window was located in the Benishangul-Gumuz region. Therefore, special concern should be given to regions with lower MCV2 uptake such as the Benishangul-Gumuz region. Besides, it is better to give attention to basic vaccination programs.

Background

One of the major causes of death among under-five children is measles, which is a very contagious respiratory disease caused by the measles virus. It spreads through respiratory droplets when an infected person coughs or sneezes [1, 2]. Globally, according to estimates from the World Health Organization (WHO) and the United States Centers for Diseases Control and Prevention, more than 140,000 people died from measles in 2018 [3].

In Ethiopia, the incidence of measles is high (greater than 50 cases per 1,000,000 population per year) [4] despite the childhood immunization coverage is improved through the combined effect of reaching every district approach, health extension program, and implementation of enhanced routine immunization activities [3–6]. Measles outbreaks are occurring continuously in most parts of the country as well [5].

The Global Measles and Rubella Strategic Plan 2012–2020 was developed by WHO or United Nations Children’s Fund and other partners [7]. The main goal of this strategic plan was to give each child measles-containing second dose vaccine (MCV2) [8]. To eliminate this devastating contagious disease, Ethiopia also introduced the MCV2 on February 11, 2019 [4]. The uptake of the MCV2 vaccine helps to prevent measles outbreaks, attain the measles elimination goals, and resolve primary vaccination failure or boost the antibody titers after the immunity wanes. Besides, adding MCV2 to the national immunization schedule can be helpful to provide additional health services [4].

In Ethiopia, the national targets for measles accelerated control by 2012 (less than five cases per 1,000,000 population per year), and its elimination by 2020 (less than one case per 100,000 population per year) was not achieved [4]. Different studies revealed different factors for the uptake of MCV2 such as maternal education, age of the mother, wealth status, region, recommended antenatal care visit (ANC), place of delivery, postnatal care (PNC), distance from the health facility, and residence [9–14].

Despite the paramount benefit of MCV2, there is scarce evidence regarding the geographic variations and the factors associated with the uptake of MCV2. Therefore, this study aimed to explore the spatial variations and the individual and contextual factors of uptake of measles-containing second dose vaccine among children aged 24 to 35 months in Ethiopia.

Methods

Data source

The 2019 Ethiopian Mini Demographic and Health Survey (EMDHS), the second EMDHS, that was implemented from March 21 to June 28, 2019, was our data source. It was conducted by the Ethiopian Public Health Institute in collaboration with the Central Statistical Agency (CSA) and the Federal Ministry of Health. The survey is intended to generate data for assessing the progress of maternal and child health.

Study population and sampling procedure

A complete list of the 149,093 census enumeration areas (EAs) created for the 2019 Ethiopian Population and Housing Census that was conducted by the CSA was used as a sampling frame. The survey used a two-stage stratified sampling. At stage one, 93 urban EAs and 212 rural EAs (total EAs = 305) were chosen with a probability proportional to EA size. Then, a household listing operation was carried out in all the selected EAs from January to April 2019 and the resulting lists served as a sampling frame for the selection of households. Then, in the second stage, a fixed number of 30 households per cluster were selected from the newly created household lists.

Among the different datasets in the survey, we used the Kid’s data set (KR data). Our study population was children aged from 24 to 35 months. If there is more than one child in the age range, we took the last child since information such as ANC and other maternal characteristics are for the last child. Finally, for this study, a total weighted sample of 800 (unweighted = 809) children aged 24 to 35 months was used. Further information regarding the survey was found elsewhere [15, 16].

Study variables

Outcome variable

MCV2 uptake was the outcome variable, a binary outcome variable recoded as "1" if the child received the vaccine and "0" if the child did not receive the vaccine. Written vaccination records such as vaccination cards and mothers’ verbal reports were used to identify whether the child receives the vaccine.

Independent variables

Incorporates both individual and community-level variables. The individual-level variables were the age of the mother (recoded as 15–19, 20–34, and 34–49 years), educational status of the mother (categorized as no formal education, primary education, and secondary and above), marital status (currently married or unmarried), religion (categorized as Orthodox Christian, Protestant, Muslim, and others), wealth index (with four categories; poorest, poorer, middle, richer, and richest), sex of household head (male or female), birth order (recoded as only one, 2–3, 4–5, and 6 and above), possession of radio (yes or no), possession of television (yes or no), recommended ANC visit (yes or no), place of delivery (home or health facility), sex of the child (male or female), taking full immunization for other childhood vaccinations (yes or no), and child PNC checked within 2 months (yes or no). While place of residence (urban or rural) and region (large central, small peripheral, or metropolitan) were the community-level variables.

Operational definitions

Region

Ethiopia has nine geographical regions and two administrative cities (a total of 11 regions), for this study, we have categorized these regions into three since there were small samples per some of the regions; the large central regions (Tigray, Amhara, Oromia and Southern Nation Nationalities and Peoples Region (SNNPR)), the small peripheral regions (Afar, Somalia, Gambela, and Benishangul-Gumuz region), and the metropolitans (Dire Dawa, Addis Ababa, and Harari). This categorization is in line with different studies conducted elsewhere [17, 18].

Full immunization for basic vaccines

We considered full vaccination if the child received one dose of BCG, three doses of pentavalent, three doses of PCV, three doses of OPV, and two doses of Rotavirus. Then the immunization status was recoded as “yes” if the child received all vaccines and “no” if at least one vaccine or dose was missed. Taking the measles first dose vaccine at nine months is excluded deliberately because to take the MCV2, it is a must to take the first dose.

Recommended ANC visit

If a woman had at least four ANC visits during her pregnancy for the child incorporated in this study.

Data management and statistical analysis

The data were managed (extracted, recoded, and cleaned) using Stata version 16. Description of study participants and the proportion of uptake of MCV2 with its 95% confidence interval (CI) were reported using text and tables.

Multilevel analysis of the uptake of MCV2

Fixed effects analysis (measures of association). We have employed a multilevel multivariable logistic regression analysis since the survey had hierarchical nature (children were nested within EAs). Four models were fitted initially; a model with no explanatory factors (Null model), a model with only individual-level factors (Model I), a model with community-level factors (Model II), and a model fitted with both individual and community-level factors (Model III). For selecting the best fit model, we have used deviance. Then, an adjusted odds ratio (AOR) with a 95% confidence interval (CI) was reported for all models. Finally, variables with a P-value <0.05 in the best-fitted model were declared to be significant predictors for MCV2 uptake.

Measures of variation (random-effects). we have employed intra-class correlation coefficient (ICC), median odds ratio (MOR), and proportional change in variance (PCV) to assess variations in MCV2 uptake between or across clusters [19–21].

Spatial analysis of the uptake of MCV2

For the spatial analysis (spatial autocorrelation, interpolation, hot spot analysis, and SaTScan analysis), Arc GIS version 10.7 and Kuldorff’s SaTScan version 9.6 software were used. To ascertain whether the spatial distribution of uptake of MCV2 was clustered, dispersed, or random across the study area (Ethiopia), the global spatial autocorrelation using the Global Moran’s I statistic was employed [22]. Spatial interpolation was employed to predict the proportion of uptake of MCV2 on the un-sampled areas based on the sampled measurements [23]. Besides, using Getis-Ord Gi* statistics, hot spot regions (regions with lower rates of MCV2 uptake) and cold spot regions (regions with higher rates of MCV2 uptake) were identified [22, 24]. Furthermore, to detect significant primary and secondary clusters, the Bernoulli-based spatial scan statistical analysis was employed [25]. While conducting the analysis, our cases were children with non-uptake of MCV2 and our controls were children with the uptake of MCV2. The coordinate files (latitude and longitude) were also used since they were necessary during the analysis. To identify both small and large clusters and missed clusters containing more than the maximum limit, the maximum spatial cluster size of less than fifty percent of the population as the upper limit was used. The log-likelihood ratio (LLR) test with its p-value was reported. The likelihood function is maximized across all window locations and sizes, with the most likely cluster being the one with the highest likelihood. This is the cluster with the least likelihood of occurring by chance. The p-value is determined by comparing the rank of the maximum likelihood from the real data set to the maximum likelihood from the random data sets using Monte Carlo hypothesis testing [16]. Besides, the relative risk (RR) of uptake of MCV2 in a specific spatial window was calculated. The spatial window with the highest LLR test was considered the most likely cluster (primary cluster), a window with the lowest uptake of MCV2.

Ethical consideration

This study was conducted under the Declaration of Helsinki and since we were using publicly accessible data, ethical approval was not needed. However, by registering or online requesting, we accessed the data set from the DHS website (https://dhsprogram.com) and the dataset had no personal identifiers.

Results

Characteristics of study participants

Nearly three fourth of the study participants were in the age group 20–34 years with a mean age of 28 (SD±6.41) years. The majority (56.01%) of the respondents had no formal education and 94.20% of the participants were married during the survey. The majority of the respondents were from male-headed households (88.86%) and from households that did not possess radio (73.20%) and television (86.43%). Regarding recommended ANC visit, place of delivery, and baby’s postnatal checkup within 2 months, 59.84%, 52.21%, and 83.50% of the study participants had no recommended ANC visit, gave birth at home, and reported that the baby had checked within 2 months of delivery respectively. Only 44.86% of children had complete immunization for basic vaccines. The majority of the participants were rural dwellers (73.89%) and were from large central regions (88.06%) (Table 1).

Table 1. Characteristics of study participants.

Variables Frequency (N = 800) Percentage
Maternal age
 15–19 27 3.38
 20–34 590 73.79
 35–49 183 22.83
Highest educational level
 No education 448 56.01
 Primary 256 31.95
 Secondary & above 96 12.04
Religion
 Orthodox 269 33.66
 Protestant 252 31.52
 Muslim 269 33.62
 Other* 10 1.21
Marital status
 Married 753 94.20
 Unmarried 47 5.80
Wealth
 Poorest 169 21.19
 poorer 177 22.10
 middle 170 21.30
 richer 128 16.01
 richest 156 19.40
Sex of Household head
 Male 711 88.86
 Female 89 11.14
Household has television
 No 691 86.43
 Yes 109 13.57
Household has radio
  No 585 73.20
 Yes 215 26.80
Birth order
 1 156 19.45
 2–3 225 28.09
 4–5 195 24.39
 6&above 224 28.07
ANC visit
 No 479 59.84
 Yes 321 40.16
Place of delivery
 Home 418 52.21
 Health Facility 382 47.79
Baby postnatal check within 2 months
 No 668 83.50
 Yes 132 16.50
Sex of child
 Male 424 53.04
 Female 376 46.96
Full immunization for other vaccines
 Yes 359 44.86
 No 441 55.14
Place of residence
 Urban 209 26.11
 Rural 591 73.89
Region
 Large central 704 88.06
 Small peripheral 62 7.72
 Metropolitan 34 4.23
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Note: * = traditional, catholic, and other religions

The proportion of uptake of MVC2 in Ethiopia

In this study, based on maternal reports and using the vaccination card, the proportion of uptake of MCV2 was 9.84% (95%CI: 7.96%, 12.11%) (Fig 1).

Fig 1. Proportion of the uptake of measles-containing second dose vaccine among children aged 24 to 35 months in Ethiopia.

Fig 1

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Factors associated with uptake of MCV2 in Ethiopia

Fixed effect analysis

In the multilevel multivariable analysis, maternal age, birth order, and full immunization for the basic childhood vaccinations were significantly associated with MCV2 uptake. The odds of uptake of MCV2 were 81% (AOR = 0.19; 95%CI: 0.05, 0.69) and 79% (AOR = 0.21; 95%CI: 0.04, 0.90) lower among mothers in the age group 20–34 and 35–49 years as compared with young age mothers (aged 15–19 years) respectively. Being the 4th-5th and 6th and above child had 4.02 (AOR = 4.02; 95%CI: 1.45, 11.14) and 4.12 (AOR = 4.12; 95%CI: 1.42, 13.05) times higher odds of MCV2 uptake as compared to being the first child. Children who did not receive basic childhood vaccinations were 56% (AOR = 0.44; 95%CI: 0.25, 0.77) less likely to receive MCV2 as compared to their counterparts (Table 2).

Table 2. Multilevel analysis for assessing factors associated with uptake of MCV2 in Ethiopia.
Variables Null model Model 1 AOR (95%CI) Model 2 AOR (95%CI) Model 3 AOR (95%CI)
Maternal age
 15–19 1.00 1.00
 20–34 0.19 (0.05, 0.73) 0.19 (0.05, 0.69) *
 35–49 0.21 (0.04, 0.94) 0.21 (0.04, 0.90) *
Highest educational level
 No education 1.00 1.00
 Primary 0.72 (0.37, 1.42) 0.74 (0.38, 1.44)
 Secondary & above 1.97 (0.80, 4.84) 2.12 (0.86, 5.19)
Marital status
 Married 1.00 1.00
 Unmarried 1.13 (0.38, 3.33) 1.14 (0.39,3.32)
Wealth
 Poorest 1.00 1.00
 Poorer 1.88 (0.85, 4.18) 1.71 (0.77, 3.81)
 Middle 2.10 (0.88, 5.01) 1.85 (0.77, 4.47)
 Richer 1.91 (0.72, 5.05) 1.76 (0.65, 4.72)
 Richest 0.88 (0.21, 3.79) 0.82 (0.16, 4.08)
Religion
 Orthodox Christian 1.00 1.00
 Protestant 0.92 (0.45, 1.89) 0.96 (0.47,1.95)
 Muslim 0.76 (0.40, 1.45) 0.88 (0.45, 1.75)
 Other 2.21 (0.37, 13.30) 2.29 (0.40, 13.12)
Sex of household head
 Male 1.00 1.00
 Female 1.40 (0.68, 2.88) 1.54 (0.74, 3.20)
Household has television
 No 1.00 1.00
 Yes 1.36 (0.33, 5.52) 1.39 (0.34, 5.73)
Household has radio
 No 1.00 1.00
 Yes 0.57 (0.28, 1.14) 0.57 (0.28, 1.13)
Place of delivery
 Home 1,00 1.00
 Health facility 1.23 (0.66, 2.28) 1.24 (0.67, 2.30)
Birth order
 1 1.00 1.00
 2–3 2.16 (0.83, 5.64) 2.24 (0.86, 5.84)
 4–5 3.90 (1.41, 10.83) 4.02 (1.45, 11.14) *
 6 and above 4.22 (1.38, 12.83) 4.12 (1.42, 13.05) *
Sex of the child
 Male 1.00 1.00
 Female 1.20 (0.71, 2.03) 1.20 (0.71, 2.02)
Baby postnatal check within 2 months
 No 1.00 1.00
 Yes 1.30 (0.68, 2.47) 1.26 (0.67, 2.39)
Full immunization for other vaccines
 Yes 1.00 1.00
 No 0.44 (0.25, 0.77) 0.44 (0.25, 0.77) **
Place of residence
 Urban 1.00 1.00
 Rural 1.01 (0.51, 2.03) 1.02 (0.39, 2.66)
Region
 Large central 1.00 1.00
 Small peripheral 0.58 (0.32, 1.04) 0.64 (0.33, 1.26)
 Metropolitan 0.62 (0.28, 1.35) 0.80 (0.32, 2.02)
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Note: ** = p<0.01 and

* = p<0.05

Random effect analysis

The ICC in the null model revealed that about 10.8% of the variability in the uptake of MCV2 was attributed due to the difference between clusters. Besides, the MOR in the null model revealed that if we randomly select a child in two different clusters, the child from a cluster with higher uptake of MCV2 had 1.82 times higher odds of receiving MCV2 as compared with a child from a cluster with lower uptake. Besides, in model III the PCV was highest (88.2%), which revealed that model III best explains the variability of uptake of MCV2. Furthermore, model III was selected as the best-fitted model since it had the lowest deviance (Table 3). Therefore, all the interpretations, in this study, were based on model III, which incorporates both individual and community level factors simultaneously.

Table 3. Variability (random effect analysis) of uptake of MCV2 in Ethiopia.
Parameter Null model Model 1 Model 2 Model 3
Variance (SE) 0.397 (0.473) 0.167 (0.474) 0.302 (0.456) 0.047 (0.473)
ICC 10.8% 4.8% 8.4% 1.4%
PCV Reference 57.9% 23.9% 88.2%
MOR 1.82 1.47 1.69 1.23
LL -247.07 -226.67 -245.03 -223.83
Deviance 494.14 453.34 490.06 447.66
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Spatial analysis of MCV2 uptake

Spatial autocorrelation

The global spatial autocorrelation result revealed that MCV2 uptake was clustered in Ethiopia (Global Moran’s I = 0.074, p-value <0.01) (Fig 2).

Fig 2. Spatial autocorrelation showing the clustering of MCV2 uptake, Map produced using Arc GIS version 10.7.

Fig 2

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Spatial interpolation

The kriging interpolation result revealed that Somalia, Benishangul, western Oromia, and central and southeastern Afar regions had a higher predicted proportion of non-uptake of MCV2. However, Gambela, SNNPR, the border between Amhara and Tigray, the border between Afar and Oromia, and northeastern Oromia had a lower predicted proportion of non-uptake of MCV2 (Fig 3).

Fig 3. Kriging interpolation of non-uptake of MCV2 in Ethiopia, Map produced using Arc GIS version 10.7.

Fig 3

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Hot spot and cold spot analysis (Getis-Ord Gi*)

As shown in blue-coloured cluster points, Gambela, SNNPR, and the Northern end of the Amhara region were the cold spot areas (areas with higher rates of MCV2 uptake). While Benishangul-Gumuz was the hotspot region (a region with lower rates of MV2 uptake) (Fig 4).

Fig 4. Hot spot and cold spot analysis of non-uptake of MCV2 in Ethiopia, Map produced using Arc GIS version 10.7.

Fig 4

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SaTScan analysis

The SaTScan analysis detected a total of 27 significant clusters and all of them were primary clusters. The most likely SaTScan cluster (primary cluster) was detected in the Benishangul-Gumuz region with LLR = 10.05 and p = 0.011, centered at 5.856584 N, 43.726016 E with 402.89 km radius, and a RR of 1.11. This revealed that children within the spatial window had 1.11 times higher odds of non-uptake of MCV2 as compared to those children outside the spatial window (Fig 5).

Fig 5. SaTScan analysis of non-uptake of MCV2 in Ethiopia, Map produced using Arc GIS version 10.7 and SaTScan version 9.6.

Fig 5

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Discussion

In this study, we assessed the spatial variation and factors associated with the newly introduced MCV2 uptake among children aged 24 to 35 months in Ethiopia. The study showed that 9.84% (95% CI: 7.96%, 12.11%) of children took MCV2. It is far from the plan to reach 80% of MCV2 coverage by the end of 2025 and 68.1% of global MCV2 vaccination coverage [26]. The finding is also lower than the coverage in Guinea Bissau [27], Lebanon, and China where 93%, 60.9%, and 93.9% of children have been vaccinated for MCV2. The discrepancy in the MCV2 uptake might be due to the difference in the period of introduction of the vaccine and sociocultural characteristics of the respondents.

In the multivariable multilevel analysis maternal age, birth order, and full immunization for basic vaccines were significantly associated with the uptake of MCV2. Consistent with the studies conducted on the uptake of the first dose of the measles vaccine and other vaccines [28, 29], children from older mothers were less likely to get vaccinated as compared with children from younger mothers. This might be because older women are less likely than younger women to use different sources of information such as social media and learn about a newly launched vaccine.

Children with a higher birth order were more likely of getting MCV2 as compared to the first birth order child. However, it is contrary to the finding of the studies conducted elsewhere on other types of vaccinations [30–32]. This may be because mothers with higher birth orders have practical knowledge of the benefits of vaccinations from preceding pregnancies or childbirths.

In addition, children who fully took the other basic vaccinations were more likely to receive MCV2 as compared to their counterparts. This is because mothers may have received health education and other services during their children’s earlier vaccinations.

The spatial analysis revealed that Somalia, Benishangul-Gumuz, western Oromia, and central and southeastern Afar regions had a lower predicted proportion of MCV2 uptake. Based on the SaTScan analysis, the primary cluster was detected in the Benishangul-Gumuz region. The spatial variation among the regions might be due to the difference in access to health information, health facility, and socio-cultural difference in the settings. This regional variation of MCV2 uptake is also supported by other studies conducted in Ethiopia on the uptake of MCV1 [28].

The findings of the study could help policymakers and other responsible bodies to make appropriate interventions by focusing basic vaccine coverage and hotspot regions such as Benishangul-Gumuz region. Besides, it can be used as a baseline for future studies.

The study had many strengths. First, it is based on nationally representative data, and the data were weighted to restore representativeness and to get an appropriate statistical estimate. Second, we have employed the multilevel analysis which is an appropriate model to consider the hierarchical nature of the data. Lastly, assessing the spatial variation is helpful for policymakers to have a wise decision for appropriate intervention in light of limited resources. However, this study is not without limitation since it used the mini demographic and health survey data that misses some important variables such as distance from the health facility, women’s decision-making autonomy, and facility-level factors. Besides, since the vaccine is recently introduced (the time between the introduction of the vaccine and data collection is short), the proportion of MCV2 uptake may be underestimated.

Conclusion

The uptake of MCV2 in Ethiopia was low. A child from an older mother, a child with lower birth order and children who haven’t fully taken other vaccines were less likely to take MCV2. Besides, MCV2 uptake was clustered in Ethiopia and the primary cluster spatial window was located in the Benishangul-Gumuz region. Therefore, the special concern should be given to regions with the lower uptake of MCV2 with prioritization for the Benishangul-Gumuz region. Besides, it is better to give special attention to basic vaccination programs.

Acknowledgments

Our heartfelt thanks go to the MEASURE DHS Program, which permitted us to use EMDHS data and GPS/coordinate files.

List of abbreviations

ANC

Antenatal Care Visit

AOR

Adjusted Odds Ratio

CI

Confidence Interval

CSA

Central Statistical Agency

EAs

Enumeration Areas

EMDHS

Ethiopia Mini Demographic and Health Survey

ICC

Intra-class correlation coefficient

LLR

Log-Likelihood Ratio

MCV2

Second dose of Measles Containing Vaccine

MOR

Median odds ratio

PCV

Proportional Change in Variance

PNC

Postnatal Care

RR

Relative Risk

SNNPR

Southern Nation Nationalities and Peoples Region

WHO

World Health Organization

Data Availability

All relevant data are within the manuscript.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Tefera Chane Mekonnen

3 May 2022

PONE-D-22-01389Spatial distribution and factors associated with uptake of measles-containing second dose vaccine among children aged 24 to 35 months in EthiopiaPLOS ONE

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Reviewer #1: Review for PLOS ONE 28.01.2022

Paper tile: Spatial distribution and factors associated with uptake of measles-containing second dose vaccine among children aged 24 to 35 months in Ethiopia

FEEDBACK

General feedback

This manuscript has the potential to further contribute to understanding MCV2 vaccination inequalities in Ethiopia and ts findings could be used by policy makers to inform interventions aiming to improve MCV2 vaccination coverage in Ethiopia. The subject (MCV2 coverage) is of interest to many and can enrich the available literature on understanding MCV2 coverage determinants when published. The methods used are appropriate for the study. However, the manuscript requires a major revision including language editing before it will be suitable for publication. The data source for the manuscript seems inappropriate because data collection was started just one month after the introduction of MCV2 thereby likely biasing the true MCV2 coverage downwards.

Specific feedback

I think, at this stage, grouping my feedback into different themes would be more efficient than giving it line by line.

Language

This manuscript requires language editing to be suitable for publication.

Background

1. Mention the agenda referred in line 102.

2. I suggest reframing the objective (lines 103 – 104) to something like “…. to explore individual and contextual factors associated with the uptake of the second dose of a measles-containing vaccine among children aged 24 – 35 months in Ethiopia”.

Methods

1. Lines 109 – 110: Considering that routine MCV2 was introduced in Ethiopia in February 2019 and the data collection for the EMDHS (data source for this study) was conducted arch to June of the same year, it is possible that not all the children in the study sample had access to the vaccine before the data collection period. I suspect that this data source is inappropriate for objectives of this study as the time between the introduction of the vaccine and data collection are very close. Please indicate if the MCV2 dose was introduced through a campaign approach or otherwise. If it was not introduced trough a campaign approach, this limitation of the data source should be stated in the discussion/methodological considerations. If the vaccine was introduced in different regions in different dates, this should lo be indicated as it can also influence the coverage.

2. Line 129: I think the sample size (unweighted = 800 and weighted = 809) is referring to children 24 – 35 months not their mothers since it is the children’s dataset which is used.

3. Lines 136 – 142 (independent variables): I recommend mentioning how each variable was operationalized/categorized instead of the three indicated.

4. Lines 144 – 149 – Operational definition for region giving here is not the same as the one used in the spatial analysis. Going by the re-categorization explained here, one would expect a similar merging on the maps presented.

5. Lines 151 -155: Usually, the definition for full vaccination for basic vaccines is 1 dose of BCG, three doses of DPTCV/Penta, 3 doses of OPV, and 1 dose of MCV. I suggest using this definition since it is the same definition used in the EMDHS as can read from the report using the link below https://dhsprogram.com/pubs/pdf/FR363/FR363.pdf.

6. Line 161 and elsewhere: I suggest replacing “proportion of uptake of MCV2” with something like “MCV2 uptake” or “MCV2 coverage” or “proportion of children vaccinated with MCV2”, etc.

7. Lines 170 -171: I think this approach to variable selection is perhaps more useful for building predictive models. Though it is widely used, I think is better to include variables based on a priori and their availability in the dataset in this case because the significance level or effect of an independent variable in bivariable analysis may not be exactly the same when introduced in a multivariable regression model.

8. Lines 203 – 204: Perhaps it will be better to just mentioned that you used a secondary dataset and whether the EMDHS was ethically cleared.

Results

Line 221: Since vaccination card retention was reported to be low among the respondents for this study (26% - https://dhsprogram.com/pubs/pdf/FR363/FR363.pdf), I recommend doing a sensitivity analysis to assess the potential recall bias and report the results here and in the discussion.

Discussion

1. I suggest restructuring the discussion in the following order:

a. Summarize the key findings of the study in relation to the study objective.

b. Interpret (explain) the results taking into account the study objective, how the results compare with similar studies, etc.

c. Highlight the policy and research implications of the study.

d. Discuss the strengths and weaknesses of the study.

2. You may wish to consider including the following methodological limitations in your discussion:

a. The short time span between MCV2 introduction and the beginning of data collection for the EMDHS.

b. The potential of recall bias (depending on the results of the sensitivity analysis) considering the low card retention rate in the age cohort used in this study.

3. The explanation given in lines 289 – 292 for older mothers seems to be in conflict with the one given in lines 293 – 295 birth order number assuming that older mothers will generally have more children than younger mothers.

References

You may wish to consider the following points (they can be easily fixed):

1. Some of the references seem to be inappropriate where they are cited. For example,

a. References 8 & 9 would be better placed where reference 6 & 7 are because they are studies about inequalities in coverage but not deaths.

b. Reference 10 is about the prevalence of anemia but it is cited for how measles is spread.

2. Some references seem a bit too old to use. For example:

a. The refences (25 & 26) for MCV2 coverage in Africa are outdated in the sense that coverage has improved a lot now compared to the years referred (2014). That was at a time that many African countries had not introduced the second dose of the MCV2 dose.

Reviewer #2: Comments to Authors

Manuscript Number: PONE-D-22-01389

The authors investigated one of the packages included under primary health care services entitled “Spatial distribution and factors associated with uptake of measles-containing second dose vaccine among children aged 24 to 35 months in Ethiopia”. The issue has paramount importance to evaluate the national health sector commitments and SDGs. The authors also used a more of national representative data that may reflect inclusive picture of the nation.

General comments

1. The authors included children aged 24-35 months old. But the second dose of measles is given most of the time at the age of 15 months. Why they excluded children between 15-23 months of age as this could underestimate the vaccine uptake? They don’t have the confidence to say the intake is low and should reconsider this issue.

2. Background: This section is very lengthy, run out from the objective of the study. It lacks coherence and articulation of the research question. The author’s perspective may be better if they tried to see the existence of heterogeneity b/n individual, households and district or community level factors. There are also variables unforeseen and may have potential contributions for low intake of the MCV2.

3. Method: This section also needs substantial revision and clarity for readers. In some part the authors stated as the study is primary one but actually it is from dataset assembled for other purpose. Why the authors exclude one from two or more children per mother (may be twins or with very narrow birth interval). At all the conclusion is about children, excluding them from the analysis is irrational. The measurements of composite variables are not clearly mentioned. The criteria used for doing the random effect create confusion and not persuade for readers.

4. Results and discussion: The result section should be reorganized again by avoiding unnecessary narration and tabular representations. It should be without interpretations and methodological descriptions. The authors should move explanations of statistical analysis to the method section. The discussion is also not solid and analytical. The theoretical and practical implications of the main findings were not justified.

5. Overall the study needs extensive English language copy-editing.

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Attachment

Submitted filename: Spatial distribution and factors associated with uptake of measles-containing second dose vaccine among children aged 24 to 35 months in Ethiopia.docx

Click here for additional data file. (18KB, docx)
PLoS One. 2023 Jan 4;18(1):e0280083. doi: 10.1371/journal.pone.0280083.r002

Author response to Decision Letter 0

1 Oct 2022

Date: October 01, 2022

Authors response to the comments

Dear the Editor and the Reviewers, thanks for your comments and suggestions for the betterment of our manuscript. We have considered all your comments and suggestions in the revised manuscript as well as in the point by point response.

Response to comments on journal requirements

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

Authors response: Amended according to the journal guideline

2. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

- https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7529-z

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

Authors response: Thanks, we have considered it in the revised manuscript.

3. We note that Figure 2, 3 and 4 in your submission contain map images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright.

We require you to either (1) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (2) remove the figures from your submission:

a. You may seek permission from the original copyright holder of Figure 2, 3 and 4 to publish the content specifically under the CC BY 4.0 license.

b. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only.

Authors response: Thank you for the comment. The figures/maps are prepared using ArcGIS and SaTScan software after getting shape file from. https://spatialdata.dhsprogram.com/boundaries/#view=table&countryId=ET and coordinate files from the measure DHS program.

4. Please include a caption for figure 4.

Authors response: Thanks, we have added a caption for Figure 4.

Response to Reviewer #1 comments

The manuscript requires a major revision including language editing before it will be suitable for publication. The data source for the manuscript seems inappropriate because data collection was started just one month after the introduction of MCV2 thereby likely biasing the true MCV2 coverage downwards.

Authors response: Thank you very much for the important issue you raised. We have edited the over all manuscript. Besides, the data collection time was one month after the introduction of the vaccine and this is the limitation of the study and we put this as a limitation.

Background

1. Mention the agenda referred in line 102.

2. I suggest reframing the objective (lines 103 – 104) to something like “…. to explore individual and contextual factors associated with the uptake of the second dose of a measles-containing vaccine among children aged 24 – 35 months in Ethiopia”.

Authors response: Thanks. When we said the agenda, it was to mean MVC2 and now the overall background is modified accordingly. We also reframe the objective to read “to explore the spatial variations of the uptake of second dose measles-containing vaccine and to assess its individual and contextual factors among children aged from 24 to 35 months in Ethiopia”

Methods

1. Lines 109 – 110: Considering that routine MCV2 was introduced in Ethiopia in February 2019 and the data collection for the EMDHS (data source for this study) was conducted march to June of the same year, it is possible that not all the children in the study sample had access to the vaccine before the data collection period. I suspect that this data source is inappropriate for objectives of this study as the time between the introduction of the vaccine and data collection are very close. Please indicate if the MCV2 dose was introduced through a campaign approach or otherwise. If it was not introduced trough a campaign approach, this limitation of the data source should be stated in the discussion/methodological considerations. If the vaccine was introduced in different regions in different dates, this should be indicated as it can also influence the coverage.

Authors response: Thank you. It is given as a campaign approach and involved in a standard care as well in every region. Besides, since the time between the introduction of the vaccine and data collection short/very close, we acknowledge this as our study’s limitation in the last paragraph of the discussion section.

2. Line 129: I think the sample size (unweighted = 800 and weighted = 809) is referring to children 24 – 35 months not their mothers since it is the children’s dataset which is used.

Authors response: Thank you. We have amended it to read children.

3. Lines 136 – 142 (independent variables): I recommend mentioning how each variable was operationalized/categorized instead of the three indicated.

Authors Response: Thank you. Majority of the variables are straightforward and did not require operational definition. However, we have putted the categories for each variable in brackets.

4. Lines 144 – 149 – Operational definition for region giving here is not the same as the one used in the spatial analysis. Going by the re-categorization explained here, one would expect a similar merging on the maps presented.

Authors response: Thank you for raising an important issue. In the multilevel analysis we categorized region in to three based on previous researches and for ease of intervention. We found that fitting without categorizing is not good since some regions have higher observation and others have very low samples per cell. However, for the spatial analysis which is descriptive study, we did not categorize it since our intention was to map the distribution or clustering of the uptake in the regions. Besides, it is impossible to do a spatial analysis using the re categorized region.

5. Lines 151 -155: Usually, the definition for full vaccination for basic vaccines is 1 dose of BCG, three doses of DPTCV/Penta, 3 doses of OPV, and 1 dose of MCV. I suggest using this definition since it is the same definition used in the EMDHS as can read from the report using the link below https://dhsprogram.com/pubs/pdf/FR363/FR363.pdf.

Authors response: Thank you very much for the comment. You are right the definition for full vaccination/immunization is as you stated. However, in our case, all children took the first dose of MCV, it is a prerequisite for the second dose. Therefore, we have removed it in the definition.

6. Line 161 and elsewhere: I suggest replacing “proportion of uptake of MCV2” with something like “MCV2 uptake” or “MCV2 coverage” or “proportion of children vaccinated with MCV2”, etc.

Authors response: Thank you. We have amended it to read “MCV2 uptake”.

7. Lines 170 -171: I think this approach to variable selection is perhaps more useful for building predictive models. Though it is widely used, I think is better to include variables based on a priori and their availability in the dataset in this case because the significance level or effect of an independent variable in bivariable analysis may not be exactly the same when introduced in a multivariable regression model.

Authors response: Thank you. You are right. Considering your comment and the number of variables (limited number of variables) we conducted a re analysis and include all variables into the multilevel variables without considering the bivariable analysis.

8. Lines 203 – 204: Perhaps it will be better to just mentioned that you used a secondary dataset and whether the EMDHS was ethically cleared.

Authors response: Thank you. As you know DHS data is a well-known dataset, any information including ethical clearance is found in the Report (we put references in the method section under data source). But, our study used this easily accessible data set with no personal identifier inside.

Results

Line 221: Since vaccination card retention was reported to be low among the respondents for this study (26% - https://dhsprogram.com/pubs/pdf/FR363/FR363.pdf), I recommend doing a sensitivity analysis to assess the potential recall bias and report the results here and in the discussion.

Authors response: Thank you. The recall bias is less likely since the time period between the uptake of the vaccine and the data collection is short. Besides, in this study, only 10 children (around one percent) had vaccination card and it is difficult to fit the model to conduct a sensitivity analysis (See Figure 1).

Discussion

1. I suggest restructuring the discussion in the following order:

a. Summarize the key findings of the study in relation to the study objective.

b. Interpret (explain) the results taking into account the study objective, how the results compare with similar studies, etc.

c. Highlight the policy and research implications of the study.

d. Discuss the strengths and weaknesses of the study.

2. You may wish to consider including the following methodological limitations in your discussion:

a. The short time span between MCV2 introduction and the beginning of data collection for the EMDHS.

b. The potential of recall bias (depending on the results of the sensitivity analysis) considering the low card retention rate in the age cohort used in this study.

3. The explanation given in lines 289 – 292 for older mothers seems to be in conflict with the one given in lines 293 – 295 birth order number assuming that older mothers will generally have more children than younger mothers.

Authors response: Thank you. We have considered all the comments you raised in the discussion section.

References

You may wish to consider the following points (they can be easily fixed):

1. Some of the references seem to be inappropriate where they are cited. For example,

a. References 8 & 9 would be better placed where reference 6 & 7 are because they are studies about inequalities in coverage but not deaths.

b. Reference 10 is about the prevalence of anemia but it is cited for how measles is spread.

2. Some references seem a bit too old to use. For example:

a. The refences (25 & 26) for MCV2 coverage in Africa are outdated in the sense that coverage has improved a lot now compared to the years referred (2014). That was at a time that many African countries had not introduced the second dose of the MCV2 dose.

Authors response: We have considered your comments on Reference in the revised manuscript accordingly.

Response to Reviewer #2 comments

The authors investigated one of the packages included under primary health care services entitled “Spatial distribution and factors associated with uptake of measles-containing second dose vaccine among children aged 24 to 35 months in Ethiopia”. The issue has paramount importance to evaluate the national health sector commitments and SDGs. The authors also used a more of national representative data that may reflect inclusive picture of the nation.

General comments

1. The authors included children aged 24-35 months old. But the second dose of measles is given most of the time at the age of 15 months. Why they excluded children between 15-23 months of age as this could underestimate the vaccine uptake? They don’t have the confidence to say the intake is low and should reconsider this issue.

Authors response: Thank you for your important comment. Yes, the second dose of measles vaccine is recommended to be administered for children starting from 15 months of age and we can include children started from age 15 months. But including a 15 months aged child to our study leads to biased estimation that may end up with underestimation of vaccine coverage if the child didn’t take the vaccine at 15 months. Because the child is still in the recommended age (15-23 year) to get vaccinated.

2. Background: This section is very lengthy, run out from the objective of the study. It lacks coherence and articulation of the research question. The author’s perspective may be better if they tried to see the existence of heterogeneity b/n individual, households and district or community level factors. There are also variables unforeseen and may have potential contributions for low intake of the MCV2.

Authors response: we have considered your comments on the background section of the revised manuscript.

3. Method: This section also needs substantial revision and clarity for readers. In some part the authors stated as the study is primary one but actually it is from dataset assembled for other purpose. Why the authors exclude one from two or more children per mother (may be twins or with very narrow birth interval). At all the conclusion is about children, excluding them from the analysis is irrational. The measurements of composite variables are not clearly mentioned. The criteria used for doing the random effect create confusion and not persuade for readers.

Authors response: Thanks. We have amended the method section of the revised manuscript. Regarding selecting a child from a household with more than one child, the reason why we took the last child was since information such as ANC and other maternal characteristics are for the last child only.

4. Results and discussion: The result section should be reorganized again by avoiding unnecessary narration and tabular representations. It should be without interpretations and methodological descriptions. The authors should move explanations of statistical analysis to the method section. The discussion is also not solid and analytical. The theoretical and practical implications of the main findings were not justified.

Authors response: Thank you. We have revised manuscript according to the comments.

5. Overall, the study needs extensive English language copy-editing.

Authors response: we have edited the English write in the revised manuscript.

Attachment

Submitted filename: Point by point response final.docx

Click here for additional data file. (24.2KB, docx)

Decision Letter 1

Tefera Chane Mekonnen

20 Dec 2022

Exploring spatial variations and the individual and contextual factors of uptake of measles-containing second dose vaccine among children aged 24 to 35 months in Ethiopia

PONE-D-22-01389R1

Dear Dr.Teshale,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Tefera Chane Mekonnen, Master in Public Health(MPH)

Academic Editor

PLOS ONE

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: No

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Reviewer #1: Although my comments have been addressed, this manuscript would required proof reading before publication.

Reviewer #2: The authors have addressed my previous comments and the manuscript has been improved. It needs copyediting to make it more sound for readers of the scientific community.

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Reviewer #2: Yes: Tefera Chane Mekonnen

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Acceptance letter

Tefera Chane Mekonnen

26 Dec 2022

PONE-D-22-01389R1

Exploring spatial variations and the individual and contextual factors of uptake of measles-containing second dose vaccine among children aged 24 to 35 months in Ethiopia

Dear Dr. Teshale:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Kind regards,

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on behalf of

Dr. Tefera Chane Mekonnen

Academic Editor

PLOS ONE

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    Attachment

    Submitted filename: Spatial distribution and factors associated with uptake of measles-containing second dose vaccine among children aged 24 to 35 months in Ethiopia.docx

    Click here for additional data file. (18KB, docx)
    Attachment

    Submitted filename: Point by point response final.docx

    Click here for additional data file. (24.2KB, docx)

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