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Vaccine. 2019 Jul 18;37(31):4281-4290. doi: 10.1016/j.vaccine.2019.06.041. Epub 2019 Jun 22.

Opportunities to improve vaccination coverage in a country with a fledgling health system: Findings from an assessment of missed opportunities for vaccination among health center attendees-Timor Leste, 2016.

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ASPPH/CDC Allan Rosenfield Global Health Fellowship and PHI/CDC Global Health Fellowship, Atlanta, GA, USA; Centers for Disease Control and Prevention, Global Immunization Division, Atlanta, GA, USA. Electronic address:
World Health Organization, Country Office, Dili, Timor-Leste.
London School of Hygiene and Tropical Medicine, London, United Kingdom.
World Health Organization, Headquarters, Geneva, Switzerland.
Ministry of Health, Dili, Timor-Leste.
Centers for Disease Control and Prevention, Global Immunization Division, Atlanta, GA, USA; World Health Organization, Headquarters, Geneva, Switzerland.



Since its independence in 2002, Timor Leste has made significant strides in improving childhood vaccination coverage. However, coverage is still below national targets, and children continue to have missed opportunities for vaccination (MOV), when eligible children have contact with the health system but are not vaccinated. Timor Leste implemented the updated World Health Organization methodology for assessing MOV in 2016.


The MOV data collection included quantitative (caregiver exit interviews and health worker knowledge, attitudes, practices surveys (KAP)) and qualitative arms (focus group discussions (FGDs) with caregivers and health workers and in-depth interviews (IDIs) with health administrators). During a four-day period, health workers and caregivers with children <24 months of age attending the selected eight facilities in Dili Municipality were invited to participate. The researchers calculated the proportion of MOV and timeliness of vaccine doses among children with documented vaccination histories (i.e., from a home-based record or facility register) and thematically analyzed the qualitative data.


Researchers conducted 365 caregiver exit interviews, 169 health worker KAP surveys, 4 FGDs with caregivers, 2 FGDs with health workers, and 2 IDIs with health administrators. Among eligible children with documented vaccination histories (n = 199), 41% missed an opportunity for vaccination. One-third of health workers (33%) believed their knowledge of immunization practices to be insufficient. Qualitative results showed vaccines were not available at all selected health facilities, and some facilities reported problems with their cold chain equipment.


This study demonstrates that many children in Timor Leste miss opportunities for vaccination during health service encounters. Potential interventions to reduce MOV include training of health workers, improving availability of vaccines at more health facilities, and replacing unusable cold chain equipment. Timor Leste should continue to scale up successful MOV interventions beyond Dili Municipality to improve vaccination coverage nationally and strengthen the health system overall.


Coverage and equity; Healthcare utilization; Immunization; Missed opportunities for vaccination; Timor Leste; Vaccination coverage

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