Immunization Status and Challenges During COVID 19 and Associated Factors Among Children Aged 10-23 Months in South Nation Nationality and People Region, Ethiopia 2020


 BackgroundThe worldwide COVID-19 pandemic is overstressing health systems and Essential health services and vaccination services are disrupted. Immunization is a confirmed gizmo for governing and even eliminating communicable diseases. An immunization operation carried out by the World Health from 1967 to 1977 exterminated the usual existence of smallpox. When the program instigated, the disease endangered for 60% of the world's population and slayed every fourth victim. ObjectiveThis study aims to assess the challenge and status of immunization during Covid 19 and associated factors among children aged 10-23 months south Nation Nationality and People Region Ethiopia. Methods and Materialscommunity-based mixed quantitative and qualitative cross-sectional study was done in southwest Ethiopia. Data was collected using semi-structured questionnaires and in-depth interviews. After that, the data were edited, coded, and move in into Epi info version 7.2 for data management then transported to SPSS version 25 for analysis. The analyzed data were presented by tables, graphs, figures, and text form. Resultaccording to this study the prevalence of incomplete immunization was found to be 809(62.2%) with (95% CI: 59.5, 64.8). in multivariable analysis waiting time at a health facility (AOR=0.04, 95%CI 0.0001,0.004), education (AOR=5.08,95%CI2.31,11.14), place of delivery(AOR=2.34,95%CI 4.96,6.089), fearing of COVID19(AOR=3.62,95%CI 1.72,7.64) and do not understand the separation care of COVID 19 and other health services (AOR=2.85,95%CI1.38,5.9) were significantly associated factorsConclusionThe prevalence of incomplete immunization among children aged 10-23 months was very high in this study as compared to the other studies done in a different pocket of Ethiopia. Consecutively, reducing waiting time at a health facility, avoiding unnecessary fear of COVID 19, and promoting immunization in a different area of southwest Ethiopia along with health extension workers are recommended.

Ecological factors such as temperature and moisture play an signi cant role in the advancement and transmission of severe acute respiratory syndrome (SARS)-CoV infection with the virus holding its viability for about 5 days at temperatures of 22 0 Cto 25 0 C and virtual humidity (VH) of 40% to 50%. Higher temperatures and higher RH (38 0 C, and >95% RH) have been found to decrease virus capability (1,3).
From the daily health care services that are being interrupted by coronavirus disease 2019  in Africa is childhood immunization. Its disruption increases the jeopardy of epidemics of vaccinepreventable diseases, which possibly rise the child mortality (4,5).
Coronavirus disease 2019 is a respiratory disease instigated by a novel virus termed as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and it is so-called 2019 Novel (New) Coronavirus by WHO on Feb 11, 2020) The outburst of this disease was initially reported at the end of December 2019 in Wuhan, China and on March 13, 2020, in Ethiopia Addis Ababa who come from Japan. The virus can blowout from person to person via droplets or unclean surfaces and the maturation date is ranged from 2 to 14 days (4,6).
Globally Due to COVID 19, the person unable to get healthcare service for unvarying needs, like antenatal care, newborn immunization etc (7). Today about 3.5 million children are dying annually in developing countries from three of the expanded program of immunization target disease, namely measles pertussis, and neonatal tetanus. There are about 2500 children with lifelong disabilities due to poliomyelitis in the developing world. (5,6) .
It is known that children are omitted out on critical vaccines since of COVID 19. Vaccination promotions have been suspended following social separation measures, raising the danger of disease outbreaks. Decrease in routine immunization coverage, particularly if this continues means that many children will be unvaccinated or under-vaccinated, putting their lives at risk of vaccine-preventable diseases. (3,7,8) From the routine health services that are being interrupted by coronavirus disease  in Africa is childhood immunization. Its interruption increases the risk of epidemics of vaccine-preventable diseases, which could increase child mortality. Consequently, policymakers must rapidly ascertain vigorous and context-speci c tactics to promptly scale-up routine immunization to alleviate the impression of COVID-19 on their national immunization performance. To succeed this, we put forward a archetype transference towards systems thoughtful and the use of execution science in immunization policymaking (4,9). An estimated 472000 children still pass away each year earlier in their fth birthday mainly from vaccinepreventable.
As a result of 2013 immunization data report, the coverage of vaccine found to be 75%; and Ethiopia has the second-largest number of children having incomplete immunization(9). This incomplete immunization forestalls an estimated of two to three million death each year in all age groups from vaccine preventable disease like diphtheria, tetanus, pertussis, and measles. Furthermore, immunization underwrites a lot to a certain nation by decreasing the risk of incapacity from transmittable diseases such as poliomyelitis. (10). As much as my knowledge is concerned, studies in the area as well as in the country are limited. So this study very helps full for the scaling up of immunization of a child even if there is a fear of COVID 19.

Methods
A cross-sectional community-based survey supplemented by qualitative Design was conducted in southwest region to assess the incomplete immunization, challenges during COVID 19, and associated factors among children aged 10-23 months from September two to October twenty-one, 2020. All households with children aged 10-23months residing in southwest Ethiopia were the target inhabitants. The household with children in the age range of 10-23 months in the randomly selected zone was the study population. The sampling unit and study units were households and individuals respectively. The children with their mother or caregivers in southwest Ethiopia during the data collection were included in the study and Mother/caregivers unable to communicate verbally in the absence of a translator were left out from the study.
The sample size was calculated with both factors and percentage. From all calculated sample sizes the largest one was 1034 but 1300 is taken as the nal size due to the nal cluster sampling method of the sampling procedure used. From 15 zonal administrations of South Nation Nationality and people region, 7 of them were selected as a cluster. Finally, the eligible household in each zone was traced with the help of health extension workers. In households with more than one eligible child, only one child was included in the study by lottery method. Sample to detailed interview was nominated with the nonprobability purposive sampling method. A total of 10 detailed interviews were accompanied amongst caregiver mothers, fathers, besides priests in South West Ethiopia. The dependent variable of the study was immunization status and the independent variables were Socio-demographic features, obstetric characteristics, and health-related factors. The questionnaire was revised and adjusted from the Ethiopian EPI Survey and EDHS (10,11), and other interrelated previous studies (12)(13)(14). Twenty nurses and midwifery for data collectors and eight public health supervisors were recruited. Finally, the data were collected by head-on and detailed interviews for quantitative and qualitative data respectively. A detailed interview was implanted for collecting qualitative data. The detailed interview contained an unrestricted question about the challenge of EPI. The discussions were documented suitably by participant words, and the participants' dialogue was recorded by tape. Finally, their dialogue was transcribed into English words Operational and term de nition -A fully immunized:-a child aged 10 to 23 months old who received one BCG, at least three doses of PENTA-VALENT, oral poliovirus, pneumococcal conjugated vaccine (PCV); two doses of rotavirus, and 4 doses of polio vaccine and measles.
-Partially / incomplete immunized:-child who misses at least one dose of thirteen vaccines.
-Antenatal care follow-up: -attending care given during pregnancy at a health facility at least two visits.

Results
Socio-demographic characteristics of a women or caregivers in southwest Ethiopia The average age of the respondents were 37.5+SD of 2.5 years with a range of 15 to 45 years and the average number of children per household was 3.5 with SD of 1.2 Regarding occupation, more than 85% of a caregiver were housewife, and Majority of the respondents 1116 (85.8%) were married whereas the remaining 14.2% were widowed, divorced, and single 0. ( Table-1) Place of delivery and utilization of health service among the women having children aged 10-23 month during Covid 19 Among the respondents about 753(57.9%) of them were explain that other health service care like immunization, family planning, labor, and delivery, as well other medical cares were given together with the care COVID 19 or they do not understand the separation care of COVID19 and other health services. Near half of the respondents, 450(34.6%) regretted visiting the health facility for the fear of COVID 19 transmission by the health professionals ( Figure-1).
Health facility and obstetric characteristics of the respondents in South West 2020 Most of the caregivers 953(73.3%) spent time/ waiting after coming to the health facility was less than 10 minutes, The remaining 24%,1.2%, and 1.5% were 10 to 15,15 to 30 and greater than a 30-minute wait for getting immunization respectively (Figure-2).
More than 88% of the participants/ caregiver take their child to the health facility when their child was being sick but about 8% and 2% of the caregiver take their child to a traditional place and treat at home respectively ( Figure-3).
Immunization status of children aged from 10 to 23 months in southwest Ethiopia 2020 The prevalence of incomplete immunization was found to be 809(62.2%) (95% CI: 59.5, 64.8).of the total respondents1110 (85.4%) of them took both BCG and OPV vaccine, from 1110 BCG started children only 798 (71.8%) of the children complete their immunization. Of the total 1300 children, 190 (14.6%) of them were not taking any vaccine at all. Overall 1088(83.7%) of them received both PCV one and Penta one, 1082(83.2%) received rota1 and 798 (61.4%) received measles vaccine. The coverage rate was a decline for the consecutive dose, such as OPV zero (85.4%) to OPV three (73.7%), both Penta and PCV one (83.7%) to Penta and PCV three (71.9%).
Dropout rate: the overall dropout rate of immunization in the zone was BCG to measles, and the dropout rate of each subsequent vaccine was 13.6% for OPV0 to OPV3, 12.2% for PCV1 to PCV3 and 14% for pena1 to penta3 for more detail see on( Figure-5, Figure-6 and gure-7) In-depth/detail interview nding Them 1:fear of COVID 19 transmission during transportation to a health facility.
The rural mother of the child complains that during the transportation to the health facility we are asked to wear a face mask without the access of a face mask in the nearby area (20,34, 36, 40, years old rural mothers). Even if we wear a face mask we do not trust that will protect our child from COVID 19 and ourselves (26 and 32 years old mothers). As we hear that the virus stays everywhere such as on clothes, metal, and different surfaces, we fear the surface of the bus for contaminated with COVID 19 (35.37, 40 and 46 years old fathers of the children). Considering the health professions as a career of COVID 19 and the may transmit these COVID 19 to our children during immunization (27, 32, 35, 43 years old priests). We understand that the immunization service of the children was given together with the care of COVID 19 in the health facility, so we assume there was a high transmission of COVID 19 during getting the service and as the come up time at the health institution was too long to get the service, person to person transmission is very high at a health facility (this is the idea of all mother of the children). During waiting time at the health facility we fear individual-to-individual transmission of COVID 19 because the waiting area in the health facility was very condensed and not ventilated (30, 29, 34, and 41 years old father of the children).
Factors associated with immunization status of Children Aged 10-23 Months during COVID 19.
Bivariate logistic regression analysis shows that waiting time, educational status, delivery place, considering COVID 19 and other service is given at the same unit, fear of COVID 19 from health profession and means of transportation were all signi cantly accompanying with incomplete immunization at p-value 0.05. From all variables on marital status was not signi cantly associated.
However, on multivariable analysis except for marital status and means transportation, all the variables were identi ed as independently signi cant associated factors with incomplete immunization.
The women waiting time more than 30 minutes at a health facility for immunization were 96% more likely to have incomplete immunization than waiting less than 30 minutes (AOR=04, 95%CI .0001,.004). The odd of incomplete immunization of the children was 2.34 times higher in the women who deliver at home than deliver at a health facility (AOR =2.336, 95%CI 4.96, 6.089). The child who was born from women who cannot read and write were 5.08 times incompletely immunized than the child born from educated women( diploma, degree, and above) ( AOR=5.08,95% CI 2.31,11.14). The women who cannot understand the separation care of CIOVID 19 and other health service had 3.62 times incompletely immunized child than who understand the separation care of COVID 19 and another health service (AOR=3.62,95%CI 1.72,7.64). The odd of incomplete immunization of a child for the women who fear health professions as a source of COVID 19 was 2.85 times higher than did not fear the health profession (AOR=2.85,95%CI 1.38,5.9) ( Table-2) Discussion This is a cross-sectional community-based survey supplemented by a qualitative study that has attempted to determine Immunization status and challenges during COVIODN 19 and Accompanying Factors among Children Aged 10-23 Months.
The percentage of incomplete immunization among children aged from 10-23 months in this study was found to be 809(62.2%) (95% CI: 59.5, 64.8). This study is in similar with the study done by further analysis of 2016 EDHS (61.7%) (15). This consistency may be the current immunization practice of the women is regretted to the pervious poor immunization intention of the women. Because before 5 years back the immunization thinking of the women is so poor due to miss understanding of the advantage of immunization.
The outcome of this study was greater than the study done in a different part of Ethiopia like in Wonago Gedo(47.6.%), Deber Markos (28.3%), northwest Ethiopia(41.6%), Gondar (24.3%), Woldiya (11.3%), Sekota (22.6%), systematic and meta-analysis of immunization from 2003 to 2019 in Ethiopia (41.8%) another systematic and meta-analysis were done in 2020 Ethiopia (53%), at a tertiary-care hospital (University College of Medical Sciences and Guru Tegh Baha-dur Hospital, New Delhi, India (48%) and at Indonesia (2008-2013): a multilevel analysis(38.13%) (12,14,(16)(17)(18)(19)(20)(21)(22). The possible explanation for this can be almost all women have a misunderstanding of about the separation care of COVID 19 and other services like immunization, cost of transportation doubling up and fear of health professionals as a source of COVID 19 was the possible reason to decline the immunization as evidenced by an in-depth interview.
In this study, the women waiting more than 30 minutes at a health facility for immunization were 96% more likely to have incomplete immunization as compared with those women waiting less than 30 minutes (AOR=04, 95%CI .0001,.004). The reason may be as the women are busy in their duty; being staying more time in a health facility for immunization encourages discontinuous the immunization program. On the other thing also as waiting times increase in the health facility, overcrowding will increase; this will raise the transmission of COVID 19, nally, there was a drop out of immunization. This is supported by the study done in Sekota zuria district, Gondar city administration, Deber Markos town, and in North West Ethiopia (14,(19)(20)(21) The odd of incomplete immunization of the children was 2.34 times higher in the women who deliver at home as compared with the women delivered at a health facility (AOR =2.336, 95%CI 4.96, 6.089). The possible explanation may be the women deliver at health facilities have more information about the importance of immunization than home-delivered women. They also are educated and have a good attitude and knowledge for free utilization of health services. This is supported by a study done in Sekota zuria District, further analysis of EDHS 2016, and Northwest Ethiopia (15,19,20).On the other hand not supported by the ndings in Wonago Gedo zone, Deber Markos town (18,21) The child of uneducated women were 5.08 times more incompletely immunized as compared to the child of educated women( diploma, degree, and above) ( AOR=5.08,95% CI 2.31,11.14). The possible reason is as the women are educated; they easily identify the possible vaccine-preventable disease and easy approach to a health facility as well there is no misperception regarding health service utilization. This is supported by the nding further analysis of EDHS 2016 and Sekota District (15,19) but not supported by the study done in Northwest Ethiopia, Deber Markos Town, Wonago District, Gondar Town (14,18,20,21) The women who cannot understand the separation care of CIOVID 19 and other health service had 3.62 times incompletely immunized their child as compared to the women who understand the separation care of COVID 19 and other health services (AOR=3.62,95%CI 1.72,7.64) and The odd of incomplete immunization of a child for the women who fear health professions as a source of COVID 19 was 2.85 times higher as compared to the women who did not fear the health profession for the source of COVID 19 (AOR=2.85,95%CI 1.38,5.9). This is explained as the women did not understand the separation care of COIVID 19 and other health services as well did not aware about phone service of the health facility, they drop out from the service by fearing transmission of COVID 19 between the client and from health professions.

Conclusions
Based on the nding obtained in this study the prevalence of incomplete immunization in the South Nation Nationality and People region among children age 10-23 months was very high as compared to other studies.
Variables signi cantly associated with incomplete immunization among children aged10-23 months were time waiting at a health facility, place of delivery, educational status of the women, not understanding the separation care of COVID 19 and other health services, fear of health professionals as a source of COVID 19. Declarations Ethics approval and consent to participate Ethical clearance letter was obtained From the Ethical Review Committee of Midwifery, under the delegation of the institutional review board of Mizan Tepi University and submitted to each zonal administrative to obtained permission letter. Then each zonal administrative given written permission letter to the concerned bodies in the study set up and informed consent was obtained from respondents after giving them evidence about the perseverance of the study, con dential and anonymous

Consent for Publication
In this study not relevant Availability of Data and martial The data set used and/or investigated during the current study is available from the conforming author on realistic request.

Competing of interests
There are no competing interests as declared by the authors.

Funding
Any fund or bene ts are not received by the authors from industry or elsewhere to undergo this study.

Authors' contributions
AT was the principal author; made substantial contributions in the conception of selecting a design, DM, and S data collection as well as analysis and interpretation of data. Finally, AG and ZM were participated in revising and commenting on the paper. All authors read and check the nalize manuscript.