Vaccination Coverage Among Preschool Children in Germany: Trends, Regional Disparities, and Determinants from School Enrolment Examinations in Two Metropolitan Regions
The proportion of children with a complete vaccination status remained stable over the study period in both locations, with no evidence of post-pandemic decline, and this stability masks important heterogeneity in vaccine coverage patterns across sociodemographic groups.
Abstract
Background: Vaccinations are highly effective in preventing infectious diseases, which otherwise present a serious challenge to the health of individuals and public health. To identify potential gaps in vaccination coverage, we examined childhood vaccination levels in Frankfurt am Main (FFM) and the Rhein Neckar district (including Heidelberg city, RNHD) prior to, during and following the COVID-19 pandemic. Moreover, we explored various factors that appear to contribute to lower vaccination levels in specific communities in either or both locations. The results are intended to guide strategies for designing and improving vaccination services for specific groups in local health settings. Methods: A retrospective analysis was conducted to examine the vaccination rates of children in Frankfurt am Main and the Rhein Neckar district (including Heidelberg city) by using anonymized data from school entry examinations spanning the years 2017 to 2024. Data pre-processing, analysis, and visualization were performed using R (5.4.2). Frequencies and percentages were calculated for sociodemographic and vaccination rates (the completeness of the vaccination schedule recommended by STIKO for children). Multivariate logistic regression was performed to determine factors with a significant impact on vaccination uptake. Results: Multinomial logistic regression with ‘measles-only’ (Measles) as the reference category revealed distinct predictor patterns across vaccination levels. In both regions, children who completed preventive medical check-ups had higher odds of completing the schedule of vaccination plus at least one additional vaccine (ScheduledPlus) versus, measles-only vaccination. In RNHD, children from Eastern European language families and low- and medium-social-status backgrounds showed higher odds of completing the scheduled vaccinations without the recently introduced rotavirus vaccination (ScheduledNotRota), versus measles-only vaccination. In FFM, strong interaction effects were observed between medical examination completion and migration background, with children from non-German birthplaces showing dramatically reduced odds of complete vaccination when preventive care was incomplete. Discussion: The proportion of children with a complete vaccination status remained stable over the study period in both locations, with no evidence of post-pandemic decline. Nevertheless, this stability masks important heterogeneity in vaccine coverage patterns across sociodemographic groups. Systematic identification and modeling of interactions between nationality, parental employment, and healthcare utilization tell a compelling “double jeopardy” story that the effects of these risk factors are not additive but synergistic. Regular medical check-ups remain an important factor in ensuring high vaccination coverage among children until they start school and underscore the justification for such established preventive care programs. A nuanced understanding, however, is crucial for moving beyond simplistic, one-size-fits-all public health messaging.
Multiple socioeconomic, structural and operational factors were associated with unvaccinated rates, highlighting the relevance of healthcare service organization even in favorable social contexts and classifying municipalities into risk profiles may help guide interventions to improve coverage.
I. N. Schrarstzhaupt, F. A. Diaz-Quijano, F. Fontana Sutile Tardetti Fantinato et al.· medRxiv· 0 citations
INTRODUCTION
Global immunization initiatives aim for ≥ 90% national and ≥ 80% district-level vaccine coverage; however, uptake remains low in crisis-affected settings like Konye Health District, where only 31.5% of children are completely vaccinated. This study examined socio-demographic, health service, and contextual determinants of vaccination uptake, highlighting the importance of understanding context-specific barriers in settings affected by sociopolitical instability.
METHODS
A community-based cross-sectional mixed-methods study was conducted from March to May 2023 among 412 caregivers of children aged 0-59 months. Quantitative data were collected on sociodemographic characteristics, vaccination status, while qualitative data provided in-depth insights into caregiver experiences and contextual challenges. Four health areas were selected through multistage sampling, with caregivers systematically recruited. Community health workers (CHWs), healthcare providers, and facility leaders were purposively selected for qualitative interviews. Multivariable logistic regression identified independent factors associated with vaccination complete vaccination status. Qualitative data from three focus group discussions were transcribed and analyzed thematically to explain and complement quantitative findings.
RESULTS
From 412 participants, 58% were fully immunized. Vaccination completion was significantly associated with respecting all vaccination appointments (AOR = 20.37, 95% CI: 8.63-48.12), Higher household income (AOR = 3.38, 95% CI: 1.57-7.30) and recognizing vaccine side effects (AOR = 4.54, 95% CI: 2.23-9.25). Qualitative findings explained these patterns by highlighting the role of CHW engagement, reminders, and outreach services, alongside barriers such as long travel distances, transportation difficulties, fear of side effects, and conflict-related disruptions.
CONCLUSION
Vaccination uptake in the Konye Health District remains low due to a complex interplay of caregiver behaviors, socioeconomic conditions, and health system factors. Addressing these interconnected challenges through strengthened community-based approaches, improved service accessibility, and resilient health system strategies is essential for enhancing immunization coverage in the district.
Rosaline Manka, Samuel Nkengfua, Mambi Anna Tchoye et al.· BMC Public Health· 0 citations
Vaccination remains an effective and affordable disease-prevention measure, yet sociopolitical unrest in Cameroon’s North West Region hampers vaccine uptake. In Nkambe Health District, there is a dearth in data regarding coverage and challenges to vaccination. We aimed to determine the trends in vaccination coverage among children aged 0–11 months and identify the challenges faced by caregivers and healthcare providers in the uptake of vaccination in Nkambe Health District, North West Region, Cameroon. Review of hospital records was done to determine the trend of vaccination coverage between 2013 and 2019. A survey was conducted among caregivers of 385 children aged 0–11 months in the Nkambe Health District from January to July 2020 to determine the vaccination status of children, the coverage, challenges and associated factors using a structured questionnaire. We conducted in-depth interviews among healthcare providers to explore challenges of vaccination coverage. Quantitative data was analysed using Statistical Package for Social Sciences (SPSS) version 25 and qualitative data was analysed using NVivo version 15. Logistic regression analysis was used to identify the predictors of complete vaccination and triangulated with thematic analysis results. From 2013 to 2019, vaccination coverage increased to a peak of 82.0% in 2017 before declining sharply to 40.0% in 2019. Among the 385 children included in the 2020 survey, 330 (85.7%) had completed the recommended vaccination. Complete vaccination was significantly associated with living less than 5 km from a vaccination site (aOR = 3.2, 95% CI 1.81–5.82), antenatal care attendance (aOR = 5.25, 95% CI 1.52–18.34) and being married (aOR = 5.23, 95% CI 2.54–10.29). Awareness of the vaccination schedule was also associated with complete vaccination in the crude analysis (cOR = 2.57, 95% CI 1.43–4.60). Challenges included staff shortages, lack of cold chain, and socio-political unrest. Vaccination coverage in Nkambe Health District has sharply declined in recent years due to the ongoing crisis and other challenges; improving coverage will require stronger community engagement, sensitization, and expanded outreach services. Vaccination coverage declined from 82% in 2017 to 40% in 2019 amid sociopolitical unrest. Complete vaccination was strongly linked to proximity to vaccination sites and caregiver marital status. Coverage gaps were driven by staff shortages, weak cold chain, and socio-political unrest.
Benard Karachu Mbunwe, Samuel Nkengfua, Doreen Mbunwe et al.· Discover Public Health· 0 citations
Despite well-established childhood immunization programs in many high-income countries, vaccination series are often delayed or not completed. Gaps in vaccination coverage are more common among children from socioeconomically disadvantaged households, among whom they are associated with higher rates of related hospitalizations. We aimed to assess the extent of these gaps in Germany, as well as the presence of socioeconomic inequality and the factors accounting for it. Using health insurance claims data from Techniker Krankenkasse for 2016–2019, we examined vaccination coverage for a comprehensive set of STIKO-recommended childhood vaccinations in six birth-year cohorts (2011–2018; approximately 430,000 children; 2.5 million recommended vaccinations). Coverage was defined as completion of the recommended series with all doses administered within the recommended age window. Socioeconomic inequality was quantified using the Erreygers-corrected concentration index and decomposed into contributions from factors such as parental education and travel time to the treating physician. Approximately 80% of vaccination series in the sample were complete and administered within the recommended age window. Vaccination coverage showed a small but statistically significant socioeconomic gradient (concentration index = 0.024, 95% confidence interval: 0.023 to 0.025) favoring children from higher socioeconomic households. In the decomposition analysis, provider type accounted for the largest share of this gradient, with lower completion rates and timeliness among children whose outpatient care was mainly delivered by general practitioners compared with pediatricians. Parental education contributed to a lesser extent, and travel time contributed little to the observed inequality. Childhood vaccination coverage in Germany remains below national targets and shows a small socioeconomic gradient. The gradient appears to be less strongly related to logistical access barriers than to differences in how vaccinations are delivered in outpatient care outside pediatric settings. These provider-type differences in vaccination delivery may therefore be more relevant for narrowing the observed gradient than further reductions in travel time.
Christophe Nussbaum, L. Sundmacher, Wiebke Schuettig· BMC Medicine· 0 citations
BACKGROUND
Achieving the goals of Immunisation Agenda 2030 (IA2030) requires a clear understanding of vaccination timeliness and its determinants. We assessed vaccination timeliness and associated factors in two rural districts of northern Ghana.
METHODS
We conducted a community-based analytical cross-sectional study among 3371 caregivers of children aged 0-59 months in Gushegu (n = 1361) and Nanumba South (n = 2010) Districts, Northern Ghana, from 24 April to 4 May 2025. The study examined the timeliness of 19 vaccine doses in Ghana's national immunisation schedule. Vaccination status was classified as early, age-appropriate, delayed, unvaccinated, or up to date based on recommended age windows. Cox proportional hazards models were used to identify factors associated with vaccination timeliness.
RESULTS
Timely vaccination declined progressively across the immunisation schedule in both districts. Bacille Calmette-Guérin had the highest age-appropriate coverage (64.2% in Gushegu and 52.6% in Nanumba South), whereas timeliness decreased across multi-dose vaccine series. Age-appropriate coverage for pneumococcal conjugate vaccine declined from 60.9% to 20.5% in Gushegu and from 51.1% to 21.5% in Nanumba South between the first and third doses. Similarly, timely Pentavalent vaccination declined from 59.6% to 19.8% and from 52.1% to 23.0%, respectively. Rotavirus vaccine age-appropriate coverage dropped to 8.6% in Gushegu and 9.4% in Nanumba South for the third dose. Delays increased with successive doses and were greater in Nanumba South. Possession of a vaccination card was the strongest predictor of timely vaccination (Gushegu: aHR 30.82, 95% CI 12.02-79.03; Nanumba South: aHR 19.09, 95% CI 6.84-53.26). Higher caregiver education improved timeliness, while home or traditional birth attendant delivery reduced timeliness.
CONCLUSION
Timely vaccination remains suboptimal in both districts, with marked declines across the immunisation schedule. Strategies to improve vaccination card retention, caregiver education, access to vaccination services, and facility-based deliveries may enhance vaccination timeliness.
M. Konlan, R. Bhandari, M. Adjei et al.· Vaccine· 0 citations
The Sunampe district on the Peruvian coast faces challenges related to adherence to childhood vaccination schedules. This study aimed to assess whether non-compliance with vaccination correlates with an increased risk of vaccine-preventable epidemiological vulnerability and health system fragility among children under five, within the context of low coverage in Sunampe.
An analytical, correlational, cross-sectional study was conducted involving 123 families in Sunampe. Data on vaccination status, reported illnesses, and mortality of children aged 1 to 5 years were collected. Medical records were reviewed for vaccine-preventable diseases, and mortality data were obtained from the SINADEF database. Severe non-compliance was defined as vaccination discontinued by 6 months of age (≥3 missed key doses). Logistic regression with prespecified predictors (knowledge, fear, access) was used to identify determinants of severe non-compliance. Mortality data were obtained from the SINADEF database (2017–2022). Sensitivity analysis using Firth’s penalized logistic regression with dimension reduction (composite knowledge, fear, and access scores) addressed low events-per-variable (EPV = 4.5).
Some Peruvian districts had to improve health facilities, while families in Sunampe perceived the single local health center as insufficient. No active vaccine-preventable illnesses were reported among surveyed children, but SINADEF data showed 10 deaths in children under five between 2017 and 2022, including 6 around respiratory mechanics issues (Pneumococcus) and 1 with malnutrition (no clearly anemia). Also, it was shown the prevalence of illness and incomplete immunization, as well as increased rates of anemia in Peru. Logistic regression models had fair to good predictive power and identified two significant predictors of severe non-compliance: lack of knowledge about vaccination age (Q17: OR = 10.96, 95% CI: 3.40–35.36,
p
= 0.0001) and never attending a vaccine information session (Q18: OR = 3.32, 95% CI: 1.16–9.57,
p
= 0.026). Fear of reactions (reported by 99.2% of mothers) did not reach statistical significance. The model showed good discriminative ability (AUC = 0.852, accuracy = 76.4%). Firth penalized logistic regression on composite scores confirmed knowledge as the only significant predictor (OR = 3.84 per 1-point increase,
p
< 0.001), while fear (OR = 2.82,
p
= 0.082) and access (OR = 0.80,
p
= 0.512) were not significant.
Incomplete vaccination in Sunampe appears linked to parental knowledge gaps and concerns about vaccine side effects, despite most parents reporting no severe reactions. Fear of reactions did not predict behavior, suggesting that reported safety concerns may reflect social desirability bias rather than true barriers. These findings highlight the need, in clinical decision-making, for targeted education to improve vaccination adherence and reduce epidemiological vulnerability and health system fragility.
Margarita Norma Castro-Fuentes, Carlos Andrés Mugruza-Vassallo· Frontiers in Public Health· 0 citations