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Background: Childhood mortality in Afghanistan fell by half between 1990 and 2015, due in part to the government's commitment to improving pediatric immunization services. Although progress has been made, immunization coverage has nonetheless remained low with only 65% of children receiving the third dose of Diphtheria-Pertussis-Tetanus (DPT3) based on WHO estimates. This study aims to calculate the proportion of Afghan children aged 1-4 years who were fully vaccinated, under-vaccinated, or non-vaccinated with government-recommended Expanded Program on Immunization vaccines and identify predictors related to the family's sociodemographic status and maternal autonomy., Methods: Data from the 2015 Afghanistan Demographic and Health Survey was used to calculate the proportion of children who were fully vaccinated (i.e. received all recommended vaccines), under-vaccinated (i.e. received some, but not all), and non-vaccinated (i.e. did not receive any vaccines) according to WHO guidelines. A multivariable multinomial logistic regression model generated odds ratios for under-vaccination and non-vaccination versus full vaccination, and examined associations between independent factors and full vaccination status., Results: We found 40.6% of Afghan children age 1-4 were fully vaccinated, 42.4% under-vaccinated, and 17% non-vaccinated. Large disparities characterized immunization coverage among provinces and between urban and rural regions. Birthing in a government institution (vs. non-institutional setting), a higher number of antenatal care visits, and a visit to a health facility in the past 12 months were all associated with increased odds of full immunization. Factors related to maternal autonomy including maternal decision-making and maternal attitudes towards beating were also significantly associated with vaccination status., Conclusion: Approximately 60% of children in Afghanistan are under-vaccinated or non-vaccinated, leaving millions of children unnecessarily at risk for vaccine-preventable diseases. Engagement with community and religious leaders to create programs that increase women's autonomy and expand access to institutional delivery could lead to downstream increases in childhood vaccination coverage., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives India has more unvaccinated children than any other country despite provision of free vaccines through the government's Universal Immunization Program. In this study, we calculated the proportion of children aged 12-48 months who were fully vaccinated, under-vaccinated, or who had not received any vaccines. Childhood, household, and sociocultural factors associated with under-vaccination and non-vaccination were evaluated. Methods Using data from India's 4th District-level Health and Facility Survey, 2012-2013 (DLHS-4) and the 2012-2013 Annual Health Survey (AHS), we calculated the proportion of children who were non-vaccinated, under-vaccinated, or fully vaccinated with 1 dose of Bacillus Calmette-Guérin, 3 doses of oral polio vaccine, 3 doses of diphtheria-pertussis-tetanus, and 1 dose of measles-containing vaccine. The odds of full vaccination compared to non-vaccination and under-vaccination relative to various factors was assessed using a multivariable, multinomial logistic regression which accounted for survey design. Results Of 1,929,580 children aged 12-48 months, 59% were fully vaccinated, 34% were under-vaccinated, and 7% were non-vaccinated. Compared to children born in government institutions, children delivered in non-institutional settings with a skilled birth attendant present had higher odds of non-vaccination (OR 1.66) and those without a skilled attendant present had still greater odds of non-vaccination (OR 2.39) and under-vaccination (OR 1.11). Conclusions for Practice India's vaccination rates among children aged 12-48 months remains unacceptably low. The Indian government should encourage institutional delivery or birthing with a skilled attendant to ensure women receive adequate health education through antenatal care that includes the importance of childhood vaccination.

Highlights • A Turnbull estimator accounted for left and right censoring of vaccination dates. • Maternal recall was a more common source of vaccination in India. • Timeliness was 64% for DPT-1, 48% for DPT-2, and 35% for DPT-3. • Accounting for left-censored data improves measures. • In India, there is little increase in vaccination coverage after age one. Abstract Morbidity from vaccine-preventable diseases is high in India, but precise estimates of vaccination timeliness are difficult to compute because many children lack records of vaccination dates. This study assessed vaccination timeliness after accounting for right and left censoring of data. This cross-sectional study used the 2012–2013 District Level Household and Facility Survey in India. The outcome was vaccination timeliness for 9 vaccine doses: 1 dose Bacillus Calmette-Guérin (BCG), 4 doses oral polio vaccine, 3 doses diphtheria-pertussis-tetanus vaccine (DPT), and 1 dose measles-containing vaccine. Age-specific probabilities of vaccination were calculated using Turnbull estimators: children not yet vaccinated were right censored, and children vaccinated but without a recorded date were left censored. Data from 108,783 children under 5 years were available. For children 25–60 months, maternal recall was a more common source of information than a vaccination record with dates. At one month past the recommended vaccination age, estimated coverage ranged from 35% for DPT-3 to 55% for BCG. Accounting for censored data improved vaccination timeliness measures, and demonstrated little increase in vaccination coverage after age one. Efforts to reduce morbidity from vaccine-preventable diseases in India should focus on eliminating missed opportunities for vaccination and instituting special vaccination programs for older children. [ABSTRACT FROM AUTHOR]