Zero-Dose Vaccination Status among Children in Malawi: Patterns, Predictors, and Geographic Hotspots

Zero-Dose Vaccination Status among Children in Malawi: Patterns, Predictors, and Geographic Hotspots | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Zero-Dose Vaccination Status among Children in Malawi: Patterns, Predictors, and Geographic Hotspots Donnie Mategula, Judy Gichuki, Akosua Sika Ayisi, Esther B Chirwa, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8491204/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Zero-dose children, defined as children who have not received any routine vaccination, are an important indicator of inequity in immunisation systems. Although Malawi reports high national vaccination coverage, little is known about the characteristics and spatial distribution of children who remain unvaccinated. We examined the determinants and geographic patterns of zero-dose status in Malawi. We analysed data from the 2015-16 Malawi Demographic and Health Survey, including 681 children aged 1 to 35 months. Zero-dose status was defined as receiving no routine childhood vaccine. Descriptive analyses and mixed-effects logistic regression were used to identify factors associated with zero-dose status, while adjusting for clustering at the enumeration area level. A binomial geostatistical model was applied to map fine-scale spatial variation across the country. Overall, 8.1 percent of children (n = 55) were zero-dose. Younger children were more likely to be unvaccinated, with one third of zero-dose children aged 1 to 11 months. In adjusted analyses, children aged 12 to 23 months and those aged 24 months or older had significantly lower odds of being zero-dose compared with children aged 1 to 11 months. Home delivery strongly increased the likelihood of being zero-dose (AOR = 4.28; 95 percent CI: 1.31 to 14.01). More than one antenatal care visit was associated with substantially lower odds of zero-dose status (AOR = 0.06; 95 percent CI: 0.01 to 0.31). Spatial modelling identified high-prevalence hotspots in Karonga, Nkhatabay, Nkhotakota, Mangochi, and parts of Chikwawa. Zero-dose children in Malawi are concentrated among those with limited maternal health system contact and in specific geographic areas with persistent access barriers. Strengthening antenatal and delivery services, improving early postnatal follow-up, and deploying spatially targeted outreach can help address these inequities and accelerate progress toward national and global immunisation goals. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research zero-dose children immunisation geostatistics Malawi DHS Figures Figure 1 Figure 2 Figure 3 Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 11 Mar, 2026 Reviews received at journal 06 Mar, 2026 Reviewers agreed at journal 22 Feb, 2026 Reviewers agreed at journal 17 Feb, 2026 Reviews received at journal 13 Feb, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers agreed at journal 19 Jan, 2026 Reviewers agreed at journal 17 Jan, 2026 Reviewers invited by journal 14 Jan, 2026 Editor invited by journal 05 Jan, 2026 Editor assigned by journal 02 Jan, 2026 Submission checks completed at journal 02 Jan, 2026 First submitted to journal 31 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8491204","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":576337272,"identity":"ad2ea27c-a147-40af-8549-d39241c082b2","order_by":0,"name":"Donnie 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2","display":"","copyAsset":false,"role":"figure","size":350699,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of zero-dose children in Malawi\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8491204/v1/244f52fa29f7c3c54dbb84f8.png"},{"id":100568136,"identity":"2d89242a-545a-4c4e-b66c-3c377430d3d2","added_by":"auto","created_at":"2026-01-19 09:16:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":40482,"visible":true,"origin":"","legend":"\u003cp\u003eGeostatistical model validation\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8491204/v1/a3178765e131674ec292c0b3.png"},{"id":100597328,"identity":"c39b8e5a-bc7c-45c9-8f1b-320e25c8c6a0","added_by":"auto","created_at":"2026-01-19 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Hotspots","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"zero-dose children, immunisation, geostatistics, Malawi, DHS","lastPublishedDoi":"10.21203/rs.3.rs-8491204/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8491204/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eZero-dose children, defined as children who have not received any routine vaccination, are an important indicator of inequity in immunisation systems. Although Malawi reports high national vaccination coverage, little is known about the characteristics and spatial distribution of children who remain unvaccinated. We examined the determinants and geographic patterns of zero-dose status in Malawi.\u003c/p\u003e \u003cp\u003eWe analysed data from the 2015-16 Malawi Demographic and Health Survey, including 681 children aged 1 to 35 months. Zero-dose status was defined as receiving no routine childhood vaccine. Descriptive analyses and mixed-effects logistic regression were used to identify factors associated with zero-dose status, while adjusting for clustering at the enumeration area level. A binomial geostatistical model was applied to map fine-scale spatial variation across the country.\u003c/p\u003e \u003cp\u003eOverall, 8.1 percent of children (n\u0026thinsp;=\u0026thinsp;55) were zero-dose. Younger children were more likely to be unvaccinated, with one third of zero-dose children aged 1 to 11 months. In adjusted analyses, children aged 12 to 23 months and those aged 24 months or older had significantly lower odds of being zero-dose compared with children aged 1 to 11 months. Home delivery strongly increased the likelihood of being zero-dose (AOR\u0026thinsp;=\u0026thinsp;4.28; 95 percent CI: 1.31 to 14.01). More than one antenatal care visit was associated with substantially lower odds of zero-dose status (AOR\u0026thinsp;=\u0026thinsp;0.06; 95 percent CI: 0.01 to 0.31). Spatial modelling identified high-prevalence hotspots in Karonga, Nkhatabay, Nkhotakota, Mangochi, and parts of Chikwawa.\u003c/p\u003e \u003cp\u003eZero-dose children in Malawi are concentrated among those with limited maternal health system contact and in specific geographic areas with persistent access barriers. Strengthening antenatal and delivery services, improving early postnatal follow-up, and deploying spatially targeted outreach can help address these inequities and accelerate progress toward national and global immunisation goals.\u003c/p\u003e","manuscriptTitle":"Zero-Dose Vaccination Status among Children in Malawi: Patterns, Predictors, and Geographic Hotspots","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-19 09:16:06","doi":"10.21203/rs.3.rs-8491204/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-12T02:18:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-06T11:23:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102383772350663784871280785193597317027","date":"2026-02-22T15:49:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336970161812353029689322923298534557736","date":"2026-02-17T18:24:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-13T09:57:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301441368977849611392333040720886436593","date":"2026-01-23T13:15:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210122595122737262117712004737601972497","date":"2026-01-22T06:50:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46920123378310634714045539122329682087","date":"2026-01-19T22:14:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"271806061334078115700388315145176986642","date":"2026-01-17T11:51:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-14T16:35:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-05T09:52:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-02T14:32:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-02T14:31:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-12-31T16:22:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7cf4bc89-f4ef-4b25-8416-80ab76b78a27","owner":[],"postedDate":"January 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":61321157,"name":"Health sciences/Diseases"},{"id":61321158,"name":"Health sciences/Health care"},{"id":61321159,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-04-16T07:40:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-19 09:16:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8491204","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8491204","identity":"rs-8491204","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}