The Challenge of Achieving Immunity Through Multiple-Dose Vaccines in Madagascar

Forrest K. Jones, Keitly Mensah, Jean Michel Heraud, Fidiniaina Mamy Randriatsarafara, C. Jessica E. Metcalf, Amy Wesolowski

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Administration of many childhood vaccines requires that multiple doses be delivered within a narrow time window to provide adequate protection and reduce disease transmission. Accurately quantifying vaccination coverage is complicated by limited individual-level data and multiple vaccination mechanisms (routine and supplementary vaccination programs). We analyzed 12,541 vaccination cards from 6 districts across Madagascar for children born in 2015 and 2016. For 3 vaccines-pentavalent diphtheria-Tetanus-pertussis-hepatitis B-Haemophilus influenzae type b vaccine (DTP-HB-Hib; 3 doses), 10-valent pneumococcal conjugate vaccine (PCV10; 3 doses), and rotavirus vaccine (2 doses)-we used dates of vaccination and birth to estimate coverage at 1 year of age and timeliness of delivery. Vaccination coverage at age 1 year for the first dose was consistently high, with decreases for subsequent doses (DTP-HB-Hib: 91%, 81%, and 72%; PCV10: 82%, 74%, and 64%; rotavirus: 73% and 63%). Coverage levels between urban districts and their rural counterparts did not differ consistently. For each dose of DTP-HB-Hib, the overall percentage of individuals receiving late doses was 29%, 7%, and 6%, respectively; estimates were similar for other vaccines. Supplementary vaccination weeks, held to help children who had missed routine care to catch up, did not appear to increase the likelihood of being vaccinated. Maintaining population-level immunity with multiple-dose vaccines requires a robust stand-Alone routine immunization program.

Original languageEnglish (US)
Pages (from-to)2085-2093
Number of pages9
JournalAmerican Journal of Epidemiology
Issue number10
StatePublished - Oct 1 2021

All Science Journal Classification (ASJC) codes

  • Epidemiology


  • diphtheria
  • immunization campaigns
  • pertussis
  • pneumococcal conjugate vaccine
  • rotavirus
  • routine immunization
  • tetanus
  • vaccination weeks


Dive into the research topics of 'The Challenge of Achieving Immunity Through Multiple-Dose Vaccines in Madagascar'. Together they form a unique fingerprint.

Cite this