Vaccination strategies to identify and reach zero-dose and under- immunized children in crisis-affected states in Sudan: A qualitative study

Abstract Background In 2021, 18.2 million "zero-dose" children did not receive any DTP-containing vaccine. In 99 low-and middle-income countries, 20% of zero-dose children are conflict-affected. There is insufficient evidence on vaccination interventions to identify and reach zero-dose children in these settings. This study aimed to map and assess current vaccination strategies to identify and reach zero-dose and under-vaccinated children the crisis-affected states of South Kordofan, South Darfur and the Blue Nile in Sudan. Methods We conducted a cross-sectional qualitative study guided by the IRMA model framework (Identify-Reach-Monitor-Measure-Advocate), developed by Gavi. We conducted 20 individual semi-structured interviews during November and December 2022. We interviewed governmental and non-governmental vaccination stakeholders at federal, state and locality levels. We conducted a thematic analysis of interview transcripts. Results Zero-dose and under-immunized children in the study sites are concentrated in opposition-controlled areas, nomadic communities, and remote rural areas. Zero-dose and under-immunized children in accessible areas are identified through routine vaccination strategies and surveillance reports. Various strategies are used in inaccessible areas. This includes tasking local institutions and individuals trusted by communities to identify and reach children, and infrequent integration and co-delivery of routine vaccines with other health interventions such as COVID-19 vaccination and insecticidal net distribution. There is a lack of specific population analysis and guidance from ministries of health to measure and monitor zero-dose and under-immunized children. Advocacy is conflated with mobilization and broadly characterized as ad-hoc activities connected to immunization campaigns only Conclusions We conclude that there is a need for further research and testing and adapting innovative and tailored interventions in these settings, particularly in the areas of integrated vaccination delivery, community participation in vaccination, improved data generation and use and advocacy.