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A substantial dropout from the first dose of diphtheria-tetanus-pertussis (DTP1) to the 3rd dose of DTP (DTP3) immunization has been recorded in Pakistan. We conducted a randomized controlled trial to assess the effects of providing a substantially redesigned immunization card, centre-based education, or both interventions together on DTP3 completion at six rural expanded programme on immunization (EPI) centres in Pakistan. Mother-child pairs were enrolled at DTP1 and randomized to four study groups: redesigned card, centre-based education, combined intervention and standard care. Each child was followed up for 90 days to record the dates of DTP2 and DTP3 visits. The study outcome was DTP3 completion by the end of follow-up period in each study group. We enrolled 378 mother-child pairs in redesigned card group, 376 in centre-based education group, 374 in combined intervention group and 378 in standard care group. By the end of follow-up, 39% of children in standard care group completed DTP3. Compared to this, a significantly higher proportion of children completed DTP3 in redesigned card group (66%) (crude risk ratio [RR] = 1.7; 95% CI = 1.5, 2.0), centre-based education group (61%) (RR = 1.5; 95% CI = 1.3, 1.8) and combined intervention group (67%) (RR = 1.7; 95% CI = 1.4, 2.0). Improved immunization card alone, education to mothers alone, or both together were all effective in increasing follow-up immunization visits. The study underscores the potential of study interventions' public health impact and necessitates their evaluation for complete EPI schedule at a large scale in the EPI system. [ABSTRACT FROM AUTHOR]

Objective In Pakistan, a high proportion of children fail to complete third dose of diphtheria-tetanus-pertussis (DTP3) after having received the first dose (DTP1). A cohort study was conducted to identify the factors predicting three doses of diphtheria–tetanus–pertussis (DTP3) completion among children who have received DTP1 at six centres of Expanded Programme on Immunization (EPI) in rural Pakistan. Method We analyzed a cohort of mother–child pairs enrolled at DTP1 between November 2005 and May 2006 in the standard care group of a larger randomized controlled trial. Data were collected from mothers on a structured questionnaire at enrolment, and each child was followed up at clinic visits for 90 days to record dates of DTP2 and DTP3. Multivariable log-binomial regression analysis was performed to identify the independent predictors of DTP3 completion. Results Only 39% (149/378) of enrolled children completed DTP3 during the follow-up period. After adjusting for the centre of enrolment in multivariable analysis, DTP3 completion was higher among children who were ≤60 days old at enrolment [adjusted risk ratio (Adj. RR) 1.39, 95% confidence interval (CI): 1.06–1.82], who were living in a household with monthly household income >Rs. 3000 (US$ 50) (Adj. RR 1.76, 95% CI: 1.16–2.65), and who were living ≤10 min away from EPI centre (Adj. RR 1.31, 95% CI: 1.04–1.66). Conclusions Interventions targeting childhood immunization dropouts should focus on bringing more children to EPI centres on-time for initial immunization. Relocation of existing EPI centres and creation of new EPI centres at appropriate locations may decrease the travel time to the EPI centres and result in fewer immunization dropouts. Objectivo: Identificar los factores que predicen el completar la DTP3 entre niños que han recibido DTP1 en seis centros del Programa Ampliado de Inmunización (PAI) en áreas rurales de Pakistán. Método: Estudio de cohortes de pares madre-hijo que recibieron DTP1 entre Noviembre 2005 y Mayo 2006 dentro del grupo de cuidados estándar de un ensayo aleatorizado y controlado más grande. Los datos fueron recolectados de las madres mediante un cuestionario estructurado en el momento de la inclusión en el estudio, y cada niño fue seguido mediante visitas clínicas durante 90 días para tomar datos de las fechas en las que recibieron DTP2 y DTP3. Se realizó un análisis de regresión binomial-logística múltiple para identificar vaticinadores independientes de completar DTP3. Resultados: Solo 39% (149/378) de los niños incluidos en el estudio completaron DTP3 durante el periodo de seguimiento. Después de ajustar para el centro de inclusión en un análisis multivariable, el haber completado DTP3 fue mayor entre los niños que eran ≤60 días en el momento de incluirles en el estudio (tasa de riesgo ajustada [Adj. RR] 1.39, 95% intervalo de confianza [IC]: 1.06-1.82), que vivían en una casa con un ingreso mensual >Rs. 3000 (US$ 50) (Adj. RR 1.76, 95% CI: 1.16-2.65), y que vivían a ≤ 10 minutos del centro de PAI (Adj. RR 1.31, 95% IC: 1.04-1.66). Conclusiones: Las intervenciones centradas en atacar el problema del abandono durante el proceso de inmunización infantil deberían centrarse en traer más niños a los centros de PAI a tiempo para la primera dosis. La reubicación de centros de PAI ya existentes y la creación de nuevos centros en lugares apropiados podría disminuir el tiempo de viaje a los centros PAI y resultar en menos abandonos. [ABSTRACT FROM AUTHOR]