What we know and don’t know about the immunization program of Ethiopia: a scoping review of the literature

At national level there were six national level surveys conducted to assess immunization coverage; four EDHS studies [8‐11] and two National EPI coverage surveys [5, 12]. In addition three FMOH administrative reports [13‐15] and two WHO/UNICEF reports were reviewed [16, 17]. These studies showed an upward trend in immunization coverage in recent years in Ethiopia. The recent EDHS 2016 report indicated that the national immunization coverage has reached 39% from the coverage reported in 2000 (14%) [11]. However, regional disparities exist since 2000 till now where emerging regions have very low immunization coverage consistently. There are also marked urban-rural differences in vaccination coverage over time. The full immunization coverage rates included in the EDHS surveys were found to be far below EPI coverage survey findings, administrative reports and WHO/UNICEF estimates [13, 14, 16, 17] [Table 1]. From the review findings, the overall access to vaccination services was low. Access to vaccination was lowest in the Afar and Somali regions [5, 10, 11]. The dropouts from immunization were not in the acceptable range evidenced by the recent EDHS report (20% for Penta). This dropout rate is very high as compared to the target set for 2020 under the comprehensive multiyear plan [4] [Table 1]. The percentage of children who have received no vaccination was also consistently high and stagnant from 2000 (17%) to 2016 (16%) [8, 11].

There were also 15 pocket studies that determined immunization coverage in different regions of the country. Among them two were done in Oromia region with full vaccination coverage of 22.9% [18] and 36% [19], while five were done in Amhara region with full immunization coverage ranging between 58.4 and 91.7% [20‐24]. Single study done in Afar [25], Somali [26] and Tigray [27] regions showed that the full vaccination coverage was 20.6, 36.6 and 51% respectively. The remaining four studies were conducted in Southern Nations and Nationalities (SNNP) region which showed immunization coverage ranging from 18.4 to 73.2% [28‐31]. Studies were not found from Gambella and Benshangul- Gumuz regions. A survey by USAID in four regions of the country also revealed that full immunization coverage was better than the findings of majority of the studies (69%) [6]. The studies generally showed that the vaccination coverage in majority of the studies were low and the progress was not uniform across different regions of the country. Differences in coverage could be attributed by differences in the sampling frame, design, sample size, representativeness of the sample, and selection methodology, as well as differences in the source of information. Similarly, the Penta3 coverage was much lower than the Penta I coverage in all the studies with unacceptable range of dropout rates resulting in higher number of partially vaccinated children. The percentage of children who have received no vaccination also varied from study area to study area much worsening in SNNP region [28, 29]. The results reported from these surveys were generally lower than the administrative reports and national estimates [14, 16] [Table 2].

Timeliness of the valid doses given, as defined by timely doses administered before 12 months of age, was also assessed in the three studies conducted at national level. Evidenced from the national EPHI study indicated that, valid dose of all basic vaccines under one year was 18.6% by 2012 [5]. The EDHS 2016 report also has shown that only 22% of children were vaccinated timely before their first birth day [11]. These findings are lower than the full immunization coverage of similar studies indicating that children are not getting the recommended vaccines as per the WHO recommendations. The evidence also indicated that timeliness of immunization is not given due attention in the national EPI program [5, 11, 12]. The trend in immunization coverage also revealed that the immunization coverage is far below the target (Fig. 2). Timeliness was also assessed in one local study which indicated that the timely full immunization coverage was 60% that has much better performance as compared with the timeliness coverage reported by national studies [6]. Except the one mentioned, none of the local studies reported evidence on timeliness of immunization.

Barriers and facilitators of immunization program were mainly tied to program acceptability, appropriateness, access and health system constraints. The main determinants associated with inequalities in coverage are multifaceted: From the existing evidence place of residence, region, maternal health services, access to media, distance from health facility and individual socio demographic characteristics of caregivers were found to be predictors of full immunization. There were a total of 6 national and 27 local studies on barriers and facilitators of immunization service uptake for which the findings are summarized below.