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PLoS One. 2019 Feb 14;14(2):e0212049. doi: 10.1371/journal.pone.0212049. eCollection 2019.

The impact of supplementary immunization activities on routine vaccination coverage: An instrumental variable analysis in five low-income countries.

Author information

Department of Public Policy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America.
Department of Health Sciences, Wilfrid Laurier University, Waterloo, ON, Canada.
Department of Population, Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America.



Countries deliver vaccines either through routine health services or supplementary immunization activities (SIAs), usually community-based or door-to-door immunization campaigns. While SIAs have been successful at increasing coverage of vaccines in low- and middle-income countries, they may disrupt the delivery of routine health services. We examine the impact of SIAs on routine vaccine coverage in five low-income countries.


Data on the number and timing of SIAs conducted in various countries was compiled by WHO and obtained through UNICEF. Information on the coverage of vaccines not targeted by SIAs (e.g., DPT) was extracted from the Demographic and Health Surveys. We focus on SIAs that took place between 1996 and 2013 in Bangladesh, Senegal, Togo, Gambia, and Cote d'Ivoire, and examine outcomes for children aged 12-59 months. To avoid biases resulting from non-random placement and timing of SIAs, we use age of a child at her first SIA as an instrumental variable for total exposure to SIAs.


We find that SIA exposure reduced the likelihood of receiving routine vaccines in all the countries included in the study; the coefficients of interest are however statistically insignificant for Gambia and Cote d'Ivoire. In countries that witnessed statistically significant SIA-induced declines in the likelihood of obtaining DPT 3, measles as well as BCG, reductions ranged from 1.3 percentage points (Senegal) to 5.5 percentage points (Bangladesh).


SIA exposure reduced routine vaccination rates in study countries. Efforts should be made to limit the detrimental impact of SIAs on the services provided by routine health systems.

Conflict of interest statement

The authors have declared that no competing interests exist.

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