Determinants of zero-dose prevalence in Southern Madagascar: Evidence from community-level data
1
Charité Center for Global Health, Berlin, Germany
2
Doctors for Madagascar, Antananarivo, Germany
Popul. Med. 2026;8(Supplement Supplement 1):A1349
ABSTRACT
ABSTRACT:
Background. Zero-dose (ZD) children – defined as those who have not received a first dose of a diphtheria-tetanus-pertussis-containing vaccine (DTP1) – remain a major public health challenge. WHO/UNICEF estimates indicate that Madagascar has approximately 300000 ZD infants, placing it among the highest-burden countries globally. Within Madagascar, ZD prevalence is highest in the southern regions. This study uses secondary data from a large-scale community-based enumeration and vaccination-status verification activity to identify determinants of ZD prevalence. Methods. We analyzed data from a community-based immunization initiative implemented by a local NGO. Community health workers conducted household enumeration and vaccination-status verification of children under five across 3386 fokontany (i.e. villages) linked to 375 primary health facilities in 16 districts. ZD status was defined as absence of documented DTP1, based on written household, community registry, or facility level records. Data included aggregated fokontany-level ZD prevalence. Vaccination status and ZD prevalence were linked to community characteristics and health facility indicators of service availability and readiness. Determinants of ZD prevalence were assessed using multilevel regression models. Results. The dataset includes 368227 children under five enumerated, of whom 213173 (i.e. 58%) were DTP1 ZD. District-level ZD prevalence ranged from 23% to 85%. Preliminary analyses indicate a strong spatial gradient in ZD prevalence, increasing on average by approximately 1% for each additional kilometer from the nearest health facility. Several indicators of health facility service availability and readiness are associated with ZD prevalence, suggesting not only adaptive system-level responses in high-burden areas, but also persistent structural barriers to vaccination. Conclusion. Geographic distance and health system capacity are key drivers of ZD prevalence. Our results provide evidence to guide targeted immunization outreach and context-specific health system strengthening in high-burden, remote settings.
Background. Zero-dose (ZD) children – defined as those who have not received a first dose of a diphtheria-tetanus-pertussis-containing vaccine (DTP1) – remain a major public health challenge. WHO/UNICEF estimates indicate that Madagascar has approximately 300000 ZD infants, placing it among the highest-burden countries globally. Within Madagascar, ZD prevalence is highest in the southern regions. This study uses secondary data from a large-scale community-based enumeration and vaccination-status verification activity to identify determinants of ZD prevalence. Methods. We analyzed data from a community-based immunization initiative implemented by a local NGO. Community health workers conducted household enumeration and vaccination-status verification of children under five across 3386 fokontany (i.e. villages) linked to 375 primary health facilities in 16 districts. ZD status was defined as absence of documented DTP1, based on written household, community registry, or facility level records. Data included aggregated fokontany-level ZD prevalence. Vaccination status and ZD prevalence were linked to community characteristics and health facility indicators of service availability and readiness. Determinants of ZD prevalence were assessed using multilevel regression models. Results. The dataset includes 368227 children under five enumerated, of whom 213173 (i.e. 58%) were DTP1 ZD. District-level ZD prevalence ranged from 23% to 85%. Preliminary analyses indicate a strong spatial gradient in ZD prevalence, increasing on average by approximately 1% for each additional kilometer from the nearest health facility. Several indicators of health facility service availability and readiness are associated with ZD prevalence, suggesting not only adaptive system-level responses in high-burden areas, but also persistent structural barriers to vaccination. Conclusion. Geographic distance and health system capacity are key drivers of ZD prevalence. Our results provide evidence to guide targeted immunization outreach and context-specific health system strengthening in high-burden, remote settings.
| eISSN: | 2654-1459 |
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