9 789290 228745 Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys This document presents analysis of two most recent demographic and health surveys from Maldives. The document has made an attempt to identify trend and factors resulting in zero-dose vaccination status of children for measles-containing vaccine to help policy makers and program implementers to design interventions accordingly. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys ISBN: 978 92 9022 874 5 © World Health Organization 2021 Some rights reserved. 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Printed in India Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys iii Contents Foreword ....................................................................................................................v Acronyms ..................................................................................................................vi Summary .................................................................................................................. vii 1. Introduction............................................................................................................x 2. Methods ................................................................................................................ 2 2.1 Data source .................................................................................................. 2 2.2 Variables ....................................................................................................... 2 2.3 Statistical analyses ........................................................................................ 3 2.4 Ethical review................................................................................................ 3 3. Results ................................................................................................................... 4 3.1 Sociodemographic characteristics of children ................................................ 4 3.2 National and subnational trends in status of measles vaccination coverage ... 6 3.3 Factors associated with measles vaccination status in 2016–2017 and 2009 7 3.4 Equity gap in measles vaccination ................................................................. 7 3.5 Trends affecting measles vaccination status by different covariates ............. 11 3.6 Effects of covariates on measles vaccination coverage ................................ 13 4. Discussions .......................................................................................................... 16 5. Conclusion ........................................................................................................... 18 References ............................................................................................................... 19
Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys v Foreword It is my pleasure to present to you the analytical series on the trends and factors affecting zero-vaccination status of children for measles-containing vaccine in the WHO South-East Asia (SEA) Region using Demographic Health Survey data available from seven countries: Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal and Timor-Leste. Immunization is one of the most cost-effective public health interventions and most countries in the WHO SEA Region introduced the Expanded Programme on Immunization (EPI) in the late 1970s and some in the early 1980s. The efforts of countries to enhance vaccination coverage in the SEA Region has translated into impressive accomplishments against vaccine-preventable diseases: the Region has remained polio-free since 2014; and maternal and neonatal tetanus has been eliminated and sustained in all countries. Furthermore, five SEA Region countries – Bhutan, the Democratic People’s Republic of Korea, Maldives, Sri Lanka and Timor-Leste – have eliminated measles, and Maldives and Sri Lanka have also eliminated rubella. Nevertheless, important challenges remain. The benefits of immunization are unevenly shared: coverage varies widely among and within countries. Each year, a large number of infants do not receive a full course of even basic vaccines, and many more miss out on newer vaccines making them vulnerable to future outbreaks of vaccine-preventable diseases. Gaps and inequalities in immunization coverage exist not only between countries but also within countries for many reasons. Outbreaks of measles are stark reminders that strong immunization systems are necessary to sustain high levels of coverage and to eliminate and eradicate diseases. Since measles is highly infectious, its presence serves as a tracer (like the “canary in the coal mine”) of inadequate coverage and gaps in the health system. High coverage with measles vaccine is an indicator of a strong immunization programme, which may signal a solid foundation for primary health care services and serve as an indicator of the robustness of primary health care systems as envisioned in the Sustainable Development Goals and the WHO Thirteenth General Programme of Work. This document identifies trends and factors affecting zero-vaccination status of children for the measles-containing vaccine in the Region. It may be used as a reference by immunization programme managers, officers and teams across the Region to identify programmatic interventions to deal with the barriers identified by an analysis of the characteristics of vaccinated and not vaccinated children in the seven countries. This will definitely contribute towards achieving the regional goal of measles and rubella elimination by 2023. Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveysvi Acronyms ANC antenatal care BCG bacille Calmette–Guérin (vaccine) CrI credible interval DHS Demographic and Health Survey DTP diphtheria–tetanus–pertussis EPI Expanded Programme on Immunization GVAP Global Vaccine Action Plan MCV1 first dose of measles-containing vaccine MMR measles , mumps, rubella MR measles and rubella NHFS National Family Health Survey OPV oral polio vaccine PNC postnatal care SIAs supplementary immunization activities UIP Universal Immunization Programme Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys vii Summary Background Although a number of studies have reported findings on child full immunization, none of them have generated evidence about the sociodemographic factors associated with measles-containing vaccines among children aged 12–23 months. This study sought to capture the measles vaccine status over time using the two latest country representative Demographic and Health Survey (DHS) datasets. The study also aimed at investigating inequalities in measles vaccination status of children owing to variations in sociodemographic characteristics and over time. Methods The study sample consisted of the children surveyed in the 2016–2017 Demographic and Health Survey (DHS) and 2009 DHS in Maldives. From these datasets, overall prevalence and the trends of the independent variables of measles vaccine were estimated. Significant changes in the distribution of all variables were assessed and multiple logistic regression for both years were used to show the effect of covariates in the outcomes of the interest. For the equity analysis, we calculated rate differences (highest–lowest) as absolute measures of inequality and rate ratios (highest/lowest) as relative measures of inequality. Concentration index and concentration curve were used to identify socioeconomic inequality in DTP and MCV. We used a Bayesian regression model with non-informative prior to estimate the trends in indicators with time. The posterior predictive distributions were used to obtain projections (for national and subnational projections) and credible intervals (CrI) up to the year 2019, 2020 and 2021. Sample weights were included during the estimations of rates and “svy” command was applied in STATA 15.0 version to account for complex sampling design of DHS. R software was used for the national and sub national projection for coverage for DTP and MCV. Results The proportion of children aged 12–23 months who were vaccinated with measles vaccine decreased by six percentage points (from 95% to 88%) over the period with highest reduction in the North-Central region followed by the South region. Difference in measles vaccination coverage is pronounced for number of ANC visits of mother (17.8 percentage points in difference between mother having 4+ ANC visits and less than 4 visits). Differences in measles vaccination status are relatively higher for education of father (16.2 percentage points between father with no education and Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveysviii higher or secondary education), and mass media exposure of mother (18.0 difference between mother exposed to mass media and not exposed to mass media). Difference was also observed by regions (12.6 difference between North and South regions). The absolute inequality in measles vaccination increased among all covariates except sex of the child, birth order and place of delivery. The greatest increase in inequality was observed for the category of education of the father. The concentration index, which is a composite measure of inequality encompassing all wealth quintiles, increased to 0.000 (–0.104–0.103) from –0.033 (–0.0833–0.018) for measles vaccination coverage, reflecting a very small increase in poor-rich inequality. The study found that a large number of children with fathers having no education and with mothers not exposed to mass media have not received the measles vaccine. Furthermore, a large proportion of children whose mothers have had less than four ANC visits and who had no PNC visit were unvaccinated for measles. The likelihood of children not receiving measles vaccine was significantly lower in the Central region compared with other regions. Children whose mothers had mass media exposure at least once a week had lower risk of being measles unvaccinated compared with children whose mothers had no such exposure. Conclusions The study shows that the coverage of measles vaccination has reduced over time with the highest reduction evidenced in the North central followed by the South. Findings from the latest DHS revealed that the coverage of measles vaccination was significantly associated with education of the father and mass media exposure of the mother. Furthermore, 4+ ANC visits and PNC visit after delivery also showed a significant association with measles vaccine coverage. Therefore, to achieve maximum coverage of measles vaccination, it is required to address the issues impeding these vaccinations. The findings of the study recommend that special attention should be paid to low-performing regions, particularly the North-Central and South region. The findings further highlight the importance of utilization of maternal and child health care to boost measles vaccination coverage in Maldives. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys 1 1. Introduction The Republic of Maldives is an archipelago consisting of about 1200 islands within 26 geographical atolls situated in the Indian Ocean. These 26 geographical atolls are divided into 20 administrative atolls (1). According to the national census of 2014, Maldivians live widely dispersed over 188 inhabited islands, also considered as administrative atolls, and 109 resort islands and 128 industrial and other islands, also considered as non- administrative atolls. The population of the atolls varies. Felidhu Atoll (V) has a population as low as 1622 while 19 829 live on Addu Atoll (S). The census also revealed that the country’s capital Male’ is widely referred to as the urban centre and the rest of the atolls are considered rural areas. About 38% of the population live in Male’, which makes it the most populated island (2). In spite of the complexity of the geography and the scattered population on the far-flung islands, Maldives had thwarted measles ahead of the 2020 target of the WHO South-East Asia (SEA) Region and is actually one among the first two countries in the Region to do so (3,4). This success did not understandably come in a day, the strong leadership and political commitment showed by successive governments towards the achievement of the global immunization targets charted the roadmap to raising awareness and making the people accept and adhere to immunization schedules. Every citizen was guaranteed the right to universal and quality health care by the Constitution of Maldives in 2008, which was further bolstered by the introduction of universal health insurance in December 2011 and the launch of the Husnuvaa Aasandha – health insurance without any ceiling – in 2014. The Government of Maldives covers all vaccine and routine immunization costs (5). The government has also developed a mechanism to verify vaccination schedules during school enrolment since 1994, and this has also increased the felt need for vaccination in the community (3). The history of immunization in Maldives dates back to 1976 when, with the support of Scout Aid Denmark and WHO, the country launched its National Programme on Immunization and Travel Health (NIPTH). This programme included vaccination against diphtheria, whooping cough, tetanus, poliomyelitis and tuberculosis. Back then, measles vaccine was not included in the programme. It was only in 1985 that the first dose of measles-containing vaccine (MCV1) was included in NIPTH schedules, and this later continued as part of the National Expanded Programme on Immunization (EPI). The second dose of measles-containing vaccine (MCV2) was introduced as the measles, mumps and rubella (MMR) vaccine in 2007 and MCV1 was replaced with measles-rubella (MR) vaccine in 2017. Globally, immunization coverage rate for third dose of diphtheria-tetanus-pertussis (DTP3) vaccine, which is taken as the proxy for vaccination coverage and performance, has increased from 21% in 1980 to 86% in 2018 (5,6). However, it has been observed that global coverage of DTP3 has remained relatively constant from 2010 (84%) to 2018 (86%) (7,8). In Maldives, vaccination coverage of DTP3 was just 4% in 1980, which dramatically improved over the decade to 94%, and Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys2 in 2018, the coverage rate was 99%. All the atolls have achieved ≥80% DTP3 coverage. Similarly, MCV1 coverage increased from 47% in 1985 to 96% in 1990 and to 99% in 2018. All atolls have ≥90% coverage for MCV1 and MCV2 (9). Immunization has had a major impact on reducing measles deaths. Between 2000 and 2018, measles vaccine prevented an estimated 23.2 million deaths globally and global measles deaths decreased by 73% (5). Many countries in the world that had already achieved, or were close to achieving, elimination have seen a resurgence in the number of cases. The main reason for this was a drop in vaccine coverage. Though at the national level vaccine coverage seems to be increasing or is aligned with the global targets, there may be inconsistencies at the subnational level, which will leave clusters of susceptible people unprotected (10,11). Thus, Maldives should also learn from countries and try to maintain its high vaccine coverage. Data from the Maldives Demographic and Health Survey 2016–2017 has, however, been alarming: there has been a drop in overall vaccine coverage from 2009 to 2016– 2017 from 93% to 77%, and the number of overall unvaccinated children increased from 1% to 8%. Vaccine coverage of measles and DTP has also declined between the two MDHS (12,13). Though Maldives reported the last endemic case of measles in 2009 before being validated for measles elimination in 2017 by WHO, an outbreak was reported in January 2020 with 12 positive cases (14). Although a number of studies have reported findings on child full immunization, none of them have generated evidence about the sociodemographic factors associated with measles-containing vaccines separately among children aged 12–23 months. This study thus sought to capture the immunization status of children, particularly focusing on the measles vaccine using the two latest country representative Demographic and Health Survey (DHS) datasets. The main objective of this study is to review the characteristics and factors associated with measles vaccination in Maldives. The specific objectives of the study are to: (1) determine the characteristics of caretakers of vaccinated and unvaccinated children for measles-containing vaccines and their trends across years; (2) determine the significance of change and association among variables comparing vaccinated and unvaccinated children for measles-containing vaccines; (3) carry out the immunization equity analysis for measles vaccination; and (4) estimate the national and regional projections for coverage of measles vaccination for 2019, 2020 and 2021. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys 3 2. Methods 2.1 Data source The data used for the analysis are from the Demographic and Health Surveys. The study sample consisted of children surveyed in the 2016–2017 DHS and 2009 DHS in Maldives. Both DHS 2016–2017 and 2009 are cross-sectional, nationally representative household surveys that collect reliable data on health and nutrition, health services utilization, health knowledge and behaviours, maternal and child health, fertility, family planning, etc. These surveys selected households by a two-stage, stratified cluster sampling. Oversampling is performed in the less populated areas. In general, the DHS sampling method identifies clusters from both urban and rural areas by the probability proportional to size technique followed by a random selection of households from within the selected clusters. For administrative purposes, the 26 natural atolls of Maldives are classified into 21 groups, each of which is referred to as an administrative atoll. These 21 atolls are regrouped to form six regions. The target groups for the 2016–2017 and 2009 DHS were ever-married women aged 15–49 years who reside in randomly selected households across the country. They provided detailed information about their children under the age of 5. The 2016–2017 and 2009 DHS survey report with full details of methodology and general findings has already been published (12,13). This report presents further analysis of data on the measles vaccination status of children aged 12–23 months from these two DHS. The reference made to measles vaccinaiton or vaccination throughout the document refers to the vaccination with first dose of measles-containing vaccine and will have to be interpreted accordingly. 2.2 Variables Our outcome variable was measles (vaccinated and not vaccinated). The age groups of children we used for analysis was 12–23 months. The source of information on these vaccinations comes from the vaccination card shown by mothers to interviewers and the recall of the mother. The independent variables of the study were: (1) Geographical characteristics: (i) place of residence (urban or rural), (ii) subnational zones (division); (2) Demographic characteristics: (i) sex of child, (ii) age of mother, (iii) household wealth quintile, (iv) household size, (v) birth order; (3) Parental education and mass media exposure: (i) education of mother, (ii) education of father, (iii) mass media exposure of mother; Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys4 (4) Parental occupation: (i) mother’s current working status; and (5) Maternal and child health care utilization (i) at least four ANC visits, (ii) place of delivery, (iii) postnatal visits (within two months). 2.3 Statistical analyses We calculated estimates of overall prevalence and the trends of the independent variables for measles vaccination. The association between outcome variables and covariates for both years were presented using chi-square test. We also assessed the significance changes in the distribution of all variables from these two DHS. For this analysis, data from the recent (2016–2017) and last (2009) DHS were retabulated and difference between the years was tested for statistical significance using a Z-test disaggregated by different covariates. Similarly, multiple logistic regression for both years were used to show the effect of covariates in the outcomes of interest. P-value <0.05 and 95% confidence interval was used to show the level of significance for the regression model. Before gauging the final model, the collinearity effect among the variables was checked. For the equity analysis, we calculated rate differences (highest–lowest) as absolute measures of inequality and rate ratios (highest/lowest) as relative measures of inequality. The rate ratio is unitless and independent of average levels and scale, whereas the rate difference depends on both average levels and scale. These two commonly used measures of inequality are easy to understand, but comparisons are limited to two extreme groups rather than covering the full population spectrum. Reporting both absolute and relative measures of inequality is recommended to increase transparency, reduce systematic reporting biases, and improve the evidence base for policies aimed at reducing health inequalities. These were presented among all the selected variables in the study. Furthermore, concentration index and concentration curve were used to identify whether socioeconomic inequality exists in receipt of measles-containing vaccines by the children. Sample weights were included during the estimations of rates and “svy” command was applied in STATA 15.0 version to account for the complex sampling design of DHS. We have used the “R” software for the national and sub national projection of coverage for measles. 2.4 Ethical review DHS survey protocols undergo ethical review in the United States of America with ICF’s institutional review board. Informed consent was obtained from every respondent. De-identified data is available upon request from the DHS programme (https://www. dhsprogram.com/data/available-datasets.cfm). Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys 5 3. Results 3.1 Sociodemographic characteristics of children Table 1 shows the percentage distribution, by sociodemographic characteristics, of children aged 12–23 months in the two consecutive DHS surveys in Maldives. This study is limited to data collected about the children who were 12–23 months of age at the time of the survey, resulting in a final sample of 518 in 2016–2017 and 822 in 2009. The table shows that there had been some changes in the sociodemographic structure among children between the two surveys. In both surveys, the proportion of children residing in urban areas was 70% with the maximum number of children being from Male (30% in 2009 and 33% in 2016–2017) and least number from the Central regions (10% in 2009 and 9% in 2016–2017). A small increment in the number of male children and mothers above 30 years of age was observed over the years. The number of children living in a household with 4–5 members have increased and children living in a household with 6+ family members have decreased through the period. The proportion of children with 2–3 birth order has increased from 37% to 58% while birth order of 4+ children has notably reduced to 9% from 18%. The proportion of mothers having no education has suggestively decreased over seven years with a little over six in 10 (63%) of the mothers in 2016–2017 having completed secondary level of education and 22% having completed higher education by the time of the interview. This on the other hand was only at 52% and 6% respectively in 2009. Likewise, the number of fathers having no education decreased while the number of fathers having secondary and higher level of education has increased throughout the period. A huge improvement on the proportion of mothers who were exposed to mass media at least once a week was further observed. There was no change in the working status of the mothers in the previous 12 months. Over 95% of the mothers in both surveys did not have the recommended four or more ANC visits. Similarly, 81% of mothers in 2016–2017 and 61% in 2009 did not have the PNC visit within two months of delivery. In both surveys, 95–96% of children were delivered in a health facility. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys6 Table 1. Sociodemographic characteristics of children aged 12–23 months between two consecutive surveys, Maldives DHS 2009–2016/2017 Characteristics 2016–2017 DHS 2009 DHS N % 95% CI N % 95% CI Total 518 100 822 100 Geographical characteristics Place of residence Rural 171 33.1 [25.2,42.0] 243 29.6 [22.2,38.2] Urban 347 66.9 [58.0,74.8] 579 70.4 [61.8,77.8] Regions Male 171 33.1 [25.2,42.0] 243 29.6 [22.2,38.2] North 82 15.8 [11.1,21.9] 145 17.7 [12.4,24.5] North-central 74 14.3 [10.3,19.7] 105 12.8 [9.3,17.4] Central 45 8.7 [6.0,12.6] 82 10.0 [6.9,14.3] South-central 66 12.7 [9.5,16.7] 104 12.7 [9.4,17.0] South 80 15.4 [11.3,20.5] 142 17.3 [12.5,23.4] Demographic characteristics Sex of the child Male 272 52.5 [46.7,58.2] 413 50.3 [46.1,54.4] Female 246 47.5 [41.8,53.3] 409 49.7 [45.6,53.9] Age of mother <20 years 2 0.4 [0.1,1.0] 8 1.0 [0.4,2.4] 20–30 years 280 54.0 [48.0,59.8] 537 65.3 [61.6,68.9] 30–40 years 223 43.0 [37.2,49.1] 243 29.5 [26.3,32.9] >40 years 14 2.7 [1.5,4.7] 34 4.1 [2.8,6.2] Household wealth quintile Lowest 96 18.6 [15.0,22.8] 154 18.8 [15.3,22.8] Second 116 22.3 [18.3,26.9] 173 21.1 [17.7,24.9] Middle 125 24.0 [19.3,29.4] 170 20.7 [17.3,24.5] Fourth 94 18.2 [12.4,25.9] 164 19.9 [16.3,24.0] Highest 88 17.0 [10.9,25.5] 161 19.6 [14.4,26.0] Household size 1–3 15 2.9 [1.6,5.2] 25 3.1 [1.9,5.0] 4–5 118 22.8 [18.5,27.6] 152 18.5 [15.1,22.3] 6+ 386 74.4 [69.0,79.1] 645 78.5 [74.6,81.9] Birth order 1 168 32.4 [28.3,36.8] 370 45.0 [41.0,49.1] 2–3 302 58.2 [53.4,62.8] 308 37.4 [33.1,41.9] 4+ 49 9.4 [7.0,12.7] 144 17.6 [14.8,20.8] Parental education and mass media exposure Education of mother No education 6 1.1 [0.6,2.3] 94 11.6 [9.4,14.2] Primary 73 14.1 [10.4,18.8] 246 30.2 [26.6,34.1] Secondary 326 62.9 [56.4,68.9] 424 52.2 [48.0,56.3] Higher 114 21.9 [16.5,28.6] 49 6.0 [4.1,8.7] Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys 7 Characteristics 2016–2017 DHS 2009 DHS N % 95% CI N % 95% CI Education of father No education 9 1.9 [1.1,3.1] 132 18.0 [15.0,21.5] Primary 113 23.1 [18.2,28.8] 266 36.5 [31.8,41.6] Secondary 268 54.9 [48.5,61.1] 279 38.2 [33.4,43.3] Higher 98 20.1 [14.5,27.3] 53 7.2 [4.8,10.9] Mass media exposure of mother Not at all 11 2.1 [1.2,3.7] 220 28.1 [24.3,32.4] At least once a week 313 60.4 [54.7,65.8] 259 33.2 [28.9,37.9] Less than once a week 195 37.5 [32.2,43.2] 301 38.6 [34.8,42.6] Parental occupation Respondent currently working No 336 64.7 [59.1,70.0] 530 64.5 [60.4,68.4] Yes 183 35.3 [30.0,40.9] 292 35.5 [31.6,39.6] Maternal and child health care utilization At least 4 antenatal care visits Yes 12 2.9 [1.4,5.9] 11 1.5 [0.8,2.7] No 417 97.1 [94.1,98.6] 693 98.5 [97.3,99.2] Place of delivery Elsewhere 27 5.3 [3.3,8.4] 34 4.2 [2.6,6.6] Health facility 491 94.7 [91.6,96.7] 788 95.8 [93.4,97.4] Postnatal care visit (within 2 months) Yes 98 19.5 [15.3,24.4] 8 39.3 [17.6,66.3] No 406 80.5 [75.6,84.7] 12 60.7 [33.7,82.4] 3.2 National and subnational trends in status of measles vaccination coverage Fig. 1 and Table 2 show the trends in status of measles vaccination coverage at the national and provincial level between surveys in 2016–2017 and 2009. The proportion of children aged 12–23 months who were vaccinated for measles has decreased by six percentage points (from 95% to 88%). Table 2 shows that the proportion of children receiving the measles vaccine has reduced in all regions. The highest reduction was observed in North-central with a 16 percentage point reduction followed by South at 15 percentage points. The proportion of children receiving the measles vaccine was reduced by 6 percentage points in the South-central region. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys8 Table 2. National and subnational trends in status of measles vaccination coverage among children aged 12–23 months between two consecutive surveys, Maldives DHS 2009–2016/2017 Characteristics 2016–2017 DHS 2009 DHS Fully vaccinated Not vaccinated Fully vaccinated Not vaccinated % 95% CI % 95% CI % 95% CI % 95% CI National 89.1 [83.4, 91.9] 11.7 [8.1, 16.6] 94.6 [92.3, 96.2] 5.4 [3.8, 7.7] Regions Male 91.0 [73.5, 97.3] 9.0 [2.7, 26.5] 93.5 [85.8, 97.2] 6.5 [2.8, 14.2] North 96.4 [86.1, 96.8] 6.8 [3.2, 13.9] 94.0 [88.8, 96.8] 6.0 [3.2, 11.2] North-central 82.1 [71.4, 87.4] 19.4 [12.6, 28.6] 96.2 [91.4, 98.4] 3.8 [1.6, 8.6] Central 92.1 [84.9, 96.0] 7.9 [4.0, 15.1] 92.5 [88.2, 95.3] 7.5 [4.7, 11.8] South-central 90.5 [85.1, 94.1] 9.5 [5.9, 14.9] 96.4 [91.9, 98.4] 3.6 [1.6, 8.1] South 81.0 [68.7, 89.2] 19.0 [10.8, 31.3] 95.7 [89.1, 98.4] 4.3 [1.6, 10.9] 3.3 Factors associated with measles vaccination status in 2016–2017 and 2009 Table 3 shows the results from the bivariate analysis of measles vaccination coverage in the 2016–2017 and 2009 surveys. Measles vaccination coverage among children aged 12–23 months in the 2016–2017 survey differed significantly by education of father and mass media exposure of mother. The 2009 DHS showed that no covariate was significantly associated with measles vaccination coverage. In the 2016 survey, measles vaccination coverage was significantly highest among children whose fathers had a higher level of education compared with those who had no education (92% vs 57%). Measles coverage was also significantly higher among children whose mothers were exposed to mass media at least once a week (94%) and less than once a week (81%) compared with those who were not exposed at all (76%). No other covariate was found to be associated with measles vaccination coverage. 3.4 Equity gap in measles vaccination Table 3 also shows the inequality in measles vaccination status indicators presenting: rate difference (absolute inequality), rate ratio (relative inequality), and the relative concentration index. Absolute inequalities in measles vaccination based on rate differences in 2016–2017 In Maldives, differences in measles vaccination coverage are most pronounced for the education of father (34.9 percentage point difference between child born to father with no education and with higher education). Differences in measles vaccination status are also relatively stark for mass media exposure for mother (18.0 percentage point difference Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys 9 for mother with no media exposure and one with exposure of more than once a week), ANC visit of mother (17.8 difference between mother with 4+ visits and less than four visits) and regions (12.6 difference for North and South regions). Differences are moderate for education of mother, household size, and mother’s current working status. Absolute differences in measles vaccination coverage are not pronounced for place of residence, sex of child, birth order and education of mother (Table 3). Relative inequalities in measles vaccination based on rate ratios in 2016–2017 Overall, relative inequalities in measles vaccination status show the highest inequality of 1.6 by education of father. The relative inequalities were 1.2 by regions, mass media exposure of mother and number of ANC visits. The relative inequalities were 1.1 by age of mother, household wealth quintile, household size, education of mother, current working status of mother and PNC visit. Relative inequalities were not present for place of residence, sex of child, birth order and place of delivery (Table 3). Inequalities changes over time in measles vaccination The absolute inequality in measles vaccination increased among all covariates except sex of the child, birth order and place of delivery. The greatest increase in inequality was observed for education of the father (Table 3). The concentration index, which is a composite measure of inequality encompassing all wealth quintiles, increased to 0.000 (–0.104–0.103) in 2016–2017 from –0.033 (–0.083–0.018) in 2009, reflecting a small increase in poor–rich inequality (Table 3). Table 3. Measles vaccination coverage status among children aged 12–23 months by selected sociodemographic characteristics between two consecutive surveys, Maldives DHS 2009–2016/2017 Characteristics* 2016–2017 DHS 2009 DHS Vaccinated % Not vaccinated % P-value Vaccinated % Not vaccinated % P-value Total 88.3 11.7 94.6 5.4 Geographical characteristics Place of residence Rural 91.0 9.0 0.548 93.5 6.5 0.560 Urban 87.0 13.0 95.0 5.0 Rate difference 4.0 4.0 na 1.5 1.5 na Rate ratio 1.0 1.4 na 1.0 1.3 na Regions Male 91.0 9.0 0.194 93.5 6.5 0.714 North 93.2 6.8 94.0 6.0 North-central 80.6 19.4 96.2 3.8 Central 92.1 7.9 92.5 7.5 South-central 90.5 9.5 96.4 3.6 South 81.0 19.0 95.7 4.3 Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys10 Characteristics* 2016–2017 DHS 2009 DHS Vaccinated % Not vaccinated % P-value Vaccinated % Not vaccinated % P-value Rate difference 12.6 12.6 na 3.9 3.9 na Rate ratio 1.2 2.9 na 1.0 2.1 na Demographic characteristics Sex of the child Male 88.4 11.6 0.967 94.9 5.1 0.746 Female 88.3 11.7 94.2 5.8 Rate difference 0.1 0.1 na 0.7 0.7 na Rate ratio 1.0 1.0 na 1.0 1.1 na Age of mother 15–24 years 91.6 8.4 0.238 95.1 4.9 0.937 25–34 years 86.4 13.6 94.4 5.6 35–49 years 91.2 8.8 94.1 5.9 Rate difference 5.2 5.2 na 1.0 1.0 na Rate ratio 1.1 1.6 na 1.0 1.2 na Household wealth quintile Lowest 88.3 11.7 0.813 96.0 4.0 0.395 Second 89.5 10.5 97.6 2.4 Middle 85.7 14.3 93.5 6.5 Fourth 91.3 8.7 92.1 7.9 Highest 87.4 12.6 93.7 6.3 Rate difference 5.6 5.6 na 5.5 5.5 na Rate ratio 1.1 1.6 na 1.1 3.3 na Household size 1–3 83.5 16.5 0.592 89.3 10.7 0.610 4–5 90.6 9.4 93.4 6.6 6+ 87.8 12.2 95.1 4.9 Rate difference 7.1 7.1 na 5.8 5.8 na Rate ratio 1.1 1.8 na 1.1 2.2 na Birth order 1 86.9 13.1 0.786 96.7 3.3 0.141 2–3 89.1 10.9 92.1 7.9 4+ 88.8 11.2 94.3 5.7 Rate difference 2.2 2.2 na 4.6 4.6 na Rate ratio 1.0 1.2 na 1.0 2.4 na Parental education and mass media exposure Education of mother No education 95.5 4.5 0.167 89.5 10.5 0.396 Primary 86.7 13.3 95.9 4.1 Secondary 86.5 13.5 94.8 5.2 Higher 94.2 5.8 94.5 5.5 Rate difference 9.0 9.0 na 6.4 6.4 na Rate ratio 1.1 3.0 na 1.1 2.6 na Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys 11 Characteristics* 2016–2017 DHS 2009 DHS Vaccinated % Not vaccinated % P-value Vaccinated % Not vaccinated % P-value Education of father No education 57.4 42.6 0.060 90.7 9.3 0.505 Primary 89.9 10.1 95.9 4.1 Secondary 87.3 12.7 94.7 5.3 Higher 92.3 7.7 94.9 5.1 Rate difference 34.9 34.9 na 5.2 5.2 na Rate ratio 1.6 5.5 na 1.1 2.3 na Mass media exposure of mother Not at all 75.6 24.4 0.000 90.1 9.9 0.059 At least once a week 93.6 6.4 96.1 3.9 Less than once a week 80.6 19.4 96.3 3.7 Rate difference 18.0 18.0 na 6.2 6.2 na Rate ratio 1.2 3.8 na 1.1 2.7 na Parental occupation Respondent currently working No 90.8 9.2 0.113 93.6 6.4 0.196 Yes 83.8 16.2 96.3 3.7 Rate difference 7.0 7.0 na 2.7 2.7 na Rate ratio 1.1 1.8 na 1.0 1.7 na Maternal and child health care utilization At least 4 antenatal care visits Yes 71.4 28.6 0.081 84.2 15.8 0.107 No 89.2 10.8 95.1 4.9 Rate difference 17.8 17.8 na 10.9 10.9 na Rate ratio 1.2 2.6 na 1.1 3.2 na Place of delivery Elsewhere 92.5 7.5 0.435 84.1 15.9 0.121 Health facility 88.1 11.9 95.1 4.9 Rate difference 4.4 4.4 na 11.0 11.0 na Rate ratio 1.0 1.6 na 1.1 3.2 na Postnatal care visit (within 2 months) Yes 84.6 15.4 0.193 100.0 0.0 0.154 No 89.9 10.1 73.6 26.4 Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys12 Characteristics* 2016–2017 DHS 2009 DHS Vaccinated % Not vaccinated % P-value Vaccinated % Not vaccinated % P-value Rate difference 5.3 5.3 na 26.4 26.4 na Rate ratio 1.1 1.5 na 1.4 na na Concentration index (95% CI) 0.000 [–0.104, 0.103] na –0.033 [-0.083, 0.018] na *In each survey, the groups with the highest and lowest measles coverage will be used to calculate rate differences and rate ratios for equity analysis; P-value obtained from non-parametric chi-square test. Concentration curves The study used a concentration curve to identify whether socioeconomic inequality exists in measles vaccination and to examine whether it is more pronounced at one point than another. The analyses showed that the pro-rich inequality in measles vaccination had slightly increased over the last seven years. The results of the concentration curves in the two surveys showed that the number of children not vaccinated did not differ by household wealth quintile. Fig. 2. 2016–2017 DHS Fig. 3. 2009 DHS 3.5 Trends affecting measles vaccination status by different covariates Table 4 shows the trend of Measles vaccination coverage by different covariates. The measles vaccination coverage showed the greatest reduction in urban areas, in North- central and South region, among the mother’s age group of 25–34 years, in the second wealth quintile group, 6+ household size, and among first-born children. The measles vaccination coverage significantly reduced by 33 percentage points among fathers having no education. Similarly, it reduced significantly among mothers who were exposed to mass media less than once a week, who were currently working, and who had delivered in a health facility. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys 13 Table 4. Significant differences of different covariates on measles coverage of children aged 12–23 months between two consecutive surveys, Maldives DHS 2009–2016/2017 Characteristics 2016–2017 DHS P-value 2009 DHS P-value Vaccinated Not vaccinated Vaccinated Not vaccinated % 95% CI % 95% CI % 95% CI % 95% CI Total 88.3 [83.4,91.9] 11.7 [8.1,16.6] 0.000 94.6 [92.3,96.2] 5.4 [3.8,7.7] 0.000 Geographical characteristics Place of residence Rural 91.0 [73.5,97.3] 9.0 [2.7,26.5] 0.343 93.5 [85.8,97.2] 6.5 [2.8,14.2] 0.343 Urban 87.0 [83.1,90.2] 13.0 [9.8,16.9] 0.000 95.0 [93.0,96.5] 5.0 [3.5,7.0] 0.000 Regions Male 91.0 [73.5,97.3] 9.0 [2.7,26.5] 0.343 93.5 [85.8,97.2] 6.5 [2.8,14.2] 0.343 North 93.2 [86.1,96.8] 6.8 [3.2,13.9] 0.811 94.0 [88.8,96.8] 6.0 [3.2,11.2] 0.811 North-central 80.6 [71.4,87.4] 19.4 [12.6,28.6] 0.001 96.2 [91.4,98.4] 3.8 [1.6,8.6] 0.001 Central 92.1 [84.9,96.0] 7.9 [4.0,15.1] 0.935 92.5 [88.2,95.3] 7.5 [4.7,11.8] 0.935 South-central 90.5 [85.1,94.1] 9.5 [5.9,14.9] 0.111 96.4 [91.9,98.4] 3.6 [1.6,8.1] 0.111 South 81.0 [68.7,89.2] 19.0 [10.8,31.3] 0.000 95.7 [89.1,98.4] 4.3 [1.6,10.9] 0.000 Demographic characteristics Sex of the child Male 88.4 [82.6,92.5] 11.6 [7.5,17.4] 0.002 94.9 [91.3,97.0] 5.1 [3.0,8.7] 0.002 Female 88.3 [79.9,93.4] 11.7 [6.6,20.1] 0.007 94.2 [90.7,96.5] 5.8 [3.5,9.3] 0.007 Age of mother 15–24 years 91.6 [84.4,95.6] 8.4 [4.4,15.6] 0.037 95.1 [88.6,98.0] 4.9 [2.0,11.4] 0.037 25–34 years 86.4 [79.1,91.4] 13.6 [8.6,20.9] 0.000 94.4 [91.2,96.6] 5.6 [3.4,8.8] 0.000 35–49 years 91.2 [85.0,95.0] 8.8 [5.0,15.0] 0.204 94.1 [88.4,97.1] 5.9 [2.9,11.6] 0.207 Household wealth quintile Lowest 88.3 [82.6,92.4] 11.7 [7.6,17.4] 0.020 96.0 [91.7,98.1] 4.0 [1.9,8.3] 0.020 Second 89.5 [83.4,93.5] 10.5 [6.5,16.6] 0.003 97.6 [93.3,99.1] 2.4 [0.9,6.7] 0.003 Middle 85.7 [78.2,90.9] 14.3 [9.1,21.8] 0.026 93.5 [88.7,96.4] 6.5 [3.6,11.3] 0.026 Fourth 91.3 [75.6,97.2] 8.7 [2.8,24.4] 0.822 92.1 [84.9,96.0] 7.9 [4.0,15.1] 0.822 Highest 87.4 [67.7,95.9] 12.6 [4.1,32.3] 0.089 93.7 [83.0,97.8] 6.3 [2.2,17.0] 0.089 Household size 1–3 83.5 [62.6,93.9] 16.5 [6.1,37.4] 0.596 89.3 [52.2,98.5] 10.7 [1.5,47.8] 0.596 4–5 90.6 [82.7,95.2] 9.4 [4.8,17.3] 0.395 93.4 [85.6,97.1] 6.6 [2.9,14.4] 0.395 6+ 87.8 [81.6,92.1] 12.2 [7.9,18.4] 0.000 95.1 [92.6,96.8] 4.9 [3.2,7.4] 0.000 Birth order 1 86.9 [77.9,92.6] 13.1 [7.4,22.1] 0.000 96.7 [92.2,98.6] 3.3 [1.4,7.8] 0.000 2–3 89.1 [83.8,92.8] 10.9 [7.2,16.2] 0.204 92.1 [87.7,95.1] 7.9 [4.9,12.3] 0.204 4+ 88.8 [77.3,94.9] 11.2 [5.1,22.7] 0.195 94.3 [88.8,97.2] 5.7 [2.8,11.2] 0.195 Parental education and mass media exposure Education of mother No education 95.5 [72.5,99.4] 4.5 [0.6,27.5] 0.637 89.5 [79.0,95.1] 10.5 [4.9,21.0] 0.637 Primary 86.7 [74.0,93.7] 13.3 [6.3,26.0] 0.004 95.9 [92.6,97.7] 4.1 [2.3,7.4] 0.004 Secondary 86.5 [79.4,91.5] 13.5 [8.5,20.6] 0.000 94.8 [91.0,97.1] 5.2 [2.9,9.0] 0.000 Higher 94.2 [88.9,97.0] 5.8 [3.0,11.1] 0.940 94.5 [69.5,99.2] 5.5 [0.8,30.5] 0.940 Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys14 Characteristics 2016–2017 DHS P-value 2009 DHS P-value Vaccinated Not vaccinated Vaccinated Not vaccinated % 95% CI % 95% CI % 95% CI % 95% CI Education of father No education 57.4 [32.7,78.9] 42.6 [21.1,67.3] 0.002 90.7 [83.0,95.1] 9.3 [4.9,17.0] 0.002 Primary 89.9 [82.5,94.4] 10.1 [5.6,17.5] 0.023 95.9 [92.3,97.8] 4.1 [2.2,7.7] 0.023 Some secondary 87.3 [81.4,91.5] 12.7 [8.5,18.6] 0.002 94.7 [89.1,97.5] 5.3 [2.5,10.9] 0.002 Secondary and above 92.3 [76.8,97.7] 7.7 [2.3,23.2] 0.544 94.9 [71.0,99.3] 5.1 [0.7,29.0] 0.544 Mass media exposure of mother Not at all 75.6 [48.3,91.2] 24.4 [8.8,51.7] 0.127 90.1 [84.1,94.0] 9.9 [6.0,15.9] 0.127 At least once a week 93.6 [89.8,96.1] 6.4 [3.9,10.2] 0.183 96.1 [89.3,98.6] 3.9 [1.4,10.7] 0.183 Less than once a week 80.6 [69.8,88.2] 19.4 [11.8,30.2] 0.000 96.3 [93.4,97.9] 3.7 [2.1,6.6] 0.000 Parental occupation Respondent currently working No 90.8 [86.5,93.9] 9.2 [6.1,13.5] 0.127 93.6 [90.4,95.8] 6.4 [4.2,9.6] 0.127 Yes 83.8 [72.0,91.2] 16.2 [8.8,28.0] 0.000 96.3 [92.4,98.3] 3.7 [1.7,7.6] 0.000 Maternal and child health care utilization At least 4 antenatal care visits Yes 71.4 [38.5,90.9] 28.6 [9.1,61.5] 0.463 84.2 [51.0,96.5] 15.8 [3.5,49.0] 0.463 No 89.2 [84.8,92.5] 10.8 [7.5,15.2] 0.000 95.1 [92.7,96.7] 4.9 [3.3,7.3] 0.000 Place of delivery Elsewhere 92.5 [78.0,97.7] 7.5 [2.3,22.0] 0.319 84.1 [49.0,96.7] 15.9 [3.3,51.0] 0.319 Health facility 88.1 [83.0,91.8] 11.9 [8.2,17.0] 0.000 95.1 [93.0,96.6] 4.9 [3.4,7.0] 0.000 Postnatal care visit (within 2 months) Yes 84.6 [77.3,89.9] 15.4 [10.1,22.7] 0.231 100.0 - 0.0 - 0.231 No 89.9 [83.6,93.9] 10.1 [6.1,16.4] 0.070 73.6 [36.6,93.1] 26.4 [6.9,63.4] 0.070 Note: All estimates account for weighting and complex sample design. Figures in parentheses are based on 25–49 sample size and the estimate should be interpreted with caution. Sample size may vary slightly due to missing data. P-value obtained from Z-test for significance of change. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys 15 3.6 Effects of covariates on measles vaccination coverage In the adjusted model (Table 5), in the 2016–2017 DHS, the likelihood of children not receiving measles vaccine was significantly lower in the Central region compared with other regions (AOR = 0.2, P <0.05). Similarly, children whose mothers had had mass media exposure at least once a week had lower risk of not being vaccinated for measles (AOR = 0.3, P <0.001) compared with children whose mothers had no such exposure. On the other hand, mothers who were currently working showed higher odds of not vaccinating their children compared with those who were not working (AOR = 3.2, P <0.05). In the 2009 DHS, the likelihood of not receiving measles vaccine was significantly higher among children with 2–3 birth order (AOR = 5.2, P <0.001) and among 4+ birth order (AOR = 7.9, P <0.05) compared with first-born children. No influence of other covariates was observed on DTP vaccination in 2009. Table 5. Factors affecting measles vaccination status among children aged 12–23 months between two consecutive surveys, Maldives DHS 2009–2016/2017 Characteristics 201–2017 DHS 2009 DHS Vaccinated Not vaccinated Vaccinated Not vaccinated AOR 95% CI AOR 95% CI AOR 95% CI AOR 95% CI Geographical characteristics Place of residence Urban ref. ref. ref. ref. Rural 0.2 0.0–1.0 6.0 1.0–37.6 1.1 0.1–9.9 0.9 0.1–8.7 Regions Male ref. ref. ref. ref. North 3.4 0.9–12.5 0.3 0.1–1.1 0.5 0.1–2.3 1.9 0.4–8.0 North-central 1.2 0.5–3.0 0.8 0.3–2.0 0.9 0.2–4.0 1.2 0.2–5.4 Central 4.5* 1.2–17.0 0.2* 0.1–0.8 0.5 0.1–2.1 1.9 0.5–7.7 South-central 2.6 0.9–6.9 0.4 0.1–1.1 1.4 0.3–6.9 0.7 0.1–3.4 South - - - - - - - - Demographic characteristics Sex of the child Male ref. ref. ref. ref. Female 0.9 0.4–1.9 1.2 0.5–2.6 0.9 0.4–1.9 1.1 0.5–2.5 Age of mother 15–24 years ref. ref. ref. ref. 25–34 years 0.5 0.2–1.5 1.9 0.7–5.6 2.3 0.5–9.9 0.4 0.1–1.9 35–49 years 1.1 0.3–4.4 0.9 0.2–3.6 3.9 0.7–22.1 0.3 0.0–1.4 Household wealth quintile Lowest ref. ref. ref. ref. Second 0.8 0.3–2.1 1.2 0.5–3.0 3.0 0.5–17.6 0.3 0.1–1.9 Middle 0.7 0.3–1.6 1.4 0.6–3.2 0.5 0.1–1.9 2.0 0.5–7.5 Fourth 0.4 0.1–1.4 2.3 0.7–7.5 0.5 0.1–1.9 2.2 0.5–9.1 Highest 0.2 0.0–1.3 6.5 0.8–53.7 0.4 0.0–5.0 2.5 0.2–32.3 Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys16 Characteristics 201–2017 DHS 2009 DHS Vaccinated Not vaccinated Vaccinated Not vaccinated AOR 95% CI AOR 95% CI AOR 95% CI AOR 95% CI Household size 1–3 ref. ref. ref. ref. 4–5 0.9 0.2–3.8 1.2 0.3–5.1 0.3 0.1–1.6 2.9 0.6–14.2 6+ 0.8 0.3–2.5 1.2 0.4–3.6 1.3 0.2–6.5 0.8 0.2–4.0 Birth order 1 ref. ref. ref. ref. 2-3 1.3 0.6–2.9 0.8 0.3–1.7 0.2** 0.1–0.6 5.2** 1.7–15.3 4+ 2.0 0.3–11.5 0.5 0.1–3.0 0.1* 0.0–0.7 7.9* 1.5–41.0 Parental education and mass media exposure Education of mother No education ref. ref. ref. ref. Secondary 0.9 0.2–3.3 1.1 0.3–4.2 0.7 0.3–2.2 1.4 0.5–4.0 Higher 3.6 0.6–20.8 0.3 0.0–1.6 0.2 0.0–2.0 4.2 0.5–35.1 Education of father No education ref. ref. ref. ref. Primary - - - - - - - - Secondary 1.1 0.5–2.6 0.9 0.4–2.0 1.0 0.4–2.5 1.0 0.4–2.4 Higher 1.8 0.4–7.3 0.6 0.1–2.3 1.4 0.2–8.5 0.7 0.1–4.6 Mass media exposure of mother at least once a week No ref. ref. ref. ref. Yes 3.5** 1.5–8.0 0.3** 0.1–0.6 1.4 0.5–4.5 0.7 0.2–2.2 Parental occupation Respondent currently working No ref. ref. ref. ref. Yes 0.3* 0.1–0.8 3.2* 1.2–8.3 1.7 0.5–5.6 0.6 0.2–2.0 Maternal and child health care utilization Postnatal care visit (within 2 months) No ref. ref. ref. ref. Yes 1.2 0.6–2.4 0.8 0.4–1.7 *P <0.05, **P <0.001, ***P <0.0001, AOR: adjusted odds ratio, ref.: reference category; P-value obtained from t-statistic Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys 17 4. Discussions The number of children fully vaccinated with MCV1 has decreased significantly and that of children not vaccinated with MCV1 increased sharply over the time period of the study. The number of children vaccinated with MCV1 has decreased significantly in the North-central and South provinces, thus making these the provinces with the highest number of children not vaccinated in 2016. Not only children not vaccinated with DTP and MCV1 vaccine but the number of children not vaccinated with BCG at birth also increased from 0.8% in 2009 to 7.7% in 2016/17 (12,13). There can be severe consequences of the drop in vaccination coverage as these diseases have not been eradicated. Only smallpox has been totally eradicated from the world and there are still two countries in South Asia — Afghanistan and Pakistan — where polio remains endemic (15). As long as polio remains rife in these countries, no other country is safe. Similarly, measles outbreaks are also re-emerging in countries with measles elimination status (16,17). In Maldives too, the last measles outbreak occurred less than three years after WHO had conferred the country measles elimination status (18). Growing vaccine hesitancy can be one reason for the sharp increase in the number of children not vaccinated in Maldives. Vaccine hesitancy refers to concerns regarding the decision to vaccinate oneself or one’s children. A report from the WHO Strategic Advisory Group of Experts (SAGE) on Immunization of defines vaccine hesitancy as “delay in acceptance or refusal of vaccines despite the availability of vaccination services”(19). Vaccine hesitancy is on the rise globally (20,21). Refusing to vaccinate has been associated with outbreaks of measles and pertussis (22–26). Analysis of three years of data from the WHO-UNICEF Joint Reporting Form of 2015–2017 documented that the top three consistently cited reasons for vaccine hesitancy globally were: 1) assessment of risk–benefit; 2) lack of knowledge and awareness of vaccination and its importance; 3) religion, culture, gender and socioeconomic issues over vaccination (21). Maldives is a country where tourism is the single largest economic industry and millions of tourists arrive here every year. A drop in vaccination is particularly alarming and wields the potential to reverse the gains achieved through years of effort in vaccination. Our results further demonstrated that the mother’s exposure to mass media had no effect in 2009 but during the seven-year period since, it was found to be significantly associated with MCV1 vaccination of the children. There is an interesting finding about mass media exposure of the mother: the highest number of children not vaccinated belong to mothers who had had no mass media exposure at all; and the second highest number of children not vaccinated belong to mothers whose mass media exposure was less than once a week. Thus, having no exposure or less exposure to mass media are both critical for MCV1 vaccination. There are studies around the world which were associated with no mass media exposure of the mother with vaccination status (27–29). But exposure to mass media Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys18 may not always lead to children receiving their vaccines. A study done in a rural area of South India after MR supplementary immunization activities (SIAs) found that having a smartphone was one of the reasons for vaccine hesitancy (30). One study in particular stated that misinformation on social media was one of the prime factors that increased vaccine hesitancy (31). Maldives should consider exploring the possibility of misinformation about vaccination circulating in the social media and find ways to control it and increase the flow of positive information about the importance of vaccination. Additionally, our results also established that when all other covariates were controlled, children not vaccinated were 11 times higher among the highest wealth quintile than the lowest wealth quintile. In developing countries, it is mostly seen that vaccination coverage is usually higher in the highest wealth quintile group unlike in our studies (27,28,32–35). This can be a result of rich parents refusing to vaccinate their child. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys 19 5. Conclusion The study shows that the coverage of measles vaccination has reduced over time with the highest reduction evidenced in the North-central followed by the South region. Findings from the latest DHS revealed that the coverage of measles vaccination was significantly associated with the education of the father and mass media exposure of the mother. Furthermore, four or more ANC visits and PNC visit after delivery also showed a significant association with measles vaccine coverage. Therefore, to achieve maximum coverage of measles vaccination, it is required to address the issues hindering such vaccination. The findings of the study recommend that special attention should be given to low-performing regions, particularly the North-central and South. The findings further highlight the importance of utilization of maternal and child health care to boost the coverage of measles vaccination in Maldives. 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PLoS One. 2018;13(10):e0206766. 9 789290 228745 Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in Maldives: Analysis from two recent demographic and health surveys This document presents analysis of two most recent demographic and health surveys from Maldives. The document has made an attempt to identify trend and factors resulting in zero-dose vaccination status of children for measles-containing vaccine to help policy makers and program implementers to design interventions accordingly.