Background: There is limited evidence on the link between routine immunisation (RI) and emergency vaccination during infectious disease outbreaks. We examined the relationship between RI systems and COVID-19 vaccination coverage in small island developing states.

Methods: We analysed immunisation and health system performance data available from the WHO/UNICEF estimates of national immunisation coverage database, the COVID-19 Vaccination Information Hub and World Bank indicators. Our primary outcome was COVID-19 vaccination coverage at four timepoints (June 2021, December 2021, June 2022, December 2022) in 55 countries. Independent variables were coverage of six childhood immunisations (5-year mean annual coverage, 2015–2019), pandemic-related disruptions to RI, new vaccine introductions, health system performance measures, and economic and demographic characteristics. We calculated Spearman correlations for continuous variables and mean COVID-19 vaccination coverage for categorical variables.

Findings: COVID-19 vaccination coverage was higher in countries that sustained pre-pandemic RI coverage in 2021 and 2022. There were few moderate correlations between COVID-19 vaccination and pre-pandemic RI coverage namely with the birth dose of hepatitis B vaccine (June 2022: r=0.421, p=0.007; December 2022: r=0.438, p=0.005) and first-dose of measles-containing vaccine (December 2021: r=0.420, p=0.002). COVID-19 vaccination coverage was higher across all timepoints where HPV, influenza and second-dose of measles-containing vaccine had been introduced. COVID-19 vaccination coverage was strongly correlated with the density of physicians (June 2021: 0.897, p<0.001; December 2021: 0.785, p<0.001) and moderately correlated with that of nurses and midwives (June 2021: 0.630, p=0.001; December 2021: 0.605, p=0.002).

Conclusions: Countries that achieved higher COVID-19 vaccination coverage also sustained RI coverage during the pandemic, demonstrating the ability to withstand shocks to the health system. A sufficiently-sized skilled health workforce and flexibility to quickly adapt service delivery to reach populations across the age spectrum are critical to achieve high vaccination coverage during outbreaks.

Background: Indonesia has high numbers of ‘zero-dose’ children, who have received no vaccines, and this number increased during the pandemic. This systematic review aimed to identify and synthesise parental barriers to routine vaccine uptake in children under 5 years in Indonesia since 2020.

Method: On 27 October 2023 we searched Medline, Embase, PubMed, Google Scholar, Portal Garuda, Sari Pediatri, Paediatrica Indonesiana, WHO database, and seven Indonesian university repositories for peer-reviewed studies published in English or Bahasa-Indonesian since January 2020. We appraised studies with the Mixed Methods Appraisal Tool (MMAT). Eligible studies described factors related to routine childhood immunisation among parents of children aged 0-5 years in Indonesia. We extracted data on factors’ reported association with uptake or description as either facilitators or barriers. We deductively categorised data into the UNICEF/WHO Behavioural and Social Drivers of Vaccination model.

Results: We included 144 studies with a total of 20,833 participants. Most studies targeted mothers and were cross-sectional. Many studies had a low MMAT rating due to inadequate reporting of results. Thinking and feeling domain facilitators included good caregiver knowledge of and attitudes towards immunisation, with barriers in this domain including concern about side effects and vaccine halal status. For social processes, husband and community support of immunisation were facilitators, whereas family and health worker support of immunisation had less consistent impact. Living close to health centres was a practical facilitator, while barriers included cost, busy caregivers, pandemic restrictions, and fear of COVID-19.

Conclusion: Since the start of the pandemic, routine childhood vaccination in Indonesia was affected by both access and acceptance barriers. Most barriers are modifiable and can inform tailored programs to increase vaccine uptake, such as those that involve education and community engagement at the local level.

Funding: Australian Department of Foreign Affairs and Trade.

Registration: Prospero ID: CRD42024518128.

Background:
Timor-Leste is a country of 1.3 million people approximately 700km from Australia. Despite being independent since 2002, the country still faces significant health challenges, with limited resources. Structural Operational Research Training in Timor-Leste (SORT-iT) was designed to teach practical skills to people with no research background to conduct and publish research to inform evidence-based decisions. It was introduced in 2019 through STRONG-TL (Surveillance, Training and Research Opportunities for Communicable Disease Control in Timor-Leste) and has been delivered to 4 cohorts since then. Training modules were adapted from World Health Organisation Tropical Diseases Research program (WHO/TDR).

Methods:
Using the WHO/TDR modules as the standard, the contents of each module were modified to fit Timor-Leste context, delivered in multi-lingual format and with practical examples from participants’ workplaces. Lectures were limited, with more focus on practical learning and one-to-one mentorship ‘AKOMPANHA’ with their selected and assigned mentor based on their topics and/or place of work. We introduced introductory training to potential participants one month before actual training to identify interested and committed candidates. Only those who then submitted Expression of Interest were selected for the training.

Results:
The SORT-iT training has contributed to strengthening around 70 Timorese healthcare workers’ knowledge and skills in operational research. More than 5 participants have successfully published their first scientific research in international journals, more than 10 have presented their studies in national and/or international conferences. In 5 years the number of Timorese teachers/mentors on the course has increased from 4 to 23.

Conclusion:
This simple and interactive operational research training has empowered Timorese health care workers in their knowledge and understanding of health research and to make evidence-based decisions in their workplace. The whole experience of two ways learning and side-by-side mentoring has created a long-lasting relationship in a new culture of research.

Introduction:
Cervical cancer is the second most common cancer among women in Timor-Leste, with an estimated incidence of 14.8 and an age-standardised mortality of 7.9 per 100,000 women. High-risk human papillomavirus (HPV) causes 99% of cervical cancers. Global WHO targets aim for 90% HPV vaccination coverage, 70% screening coverage, and 90% access to treatment by 2030. Timor-Leste needs to vaccinate 77,861 girls aged 9-14 years and screen 49,522 women aged 35-45 years to achieve this target. In 2024, the Government of Timor-Leste launched a national single dose HPV vaccination program.

Methods: The program targeted girls aged 11–14 years through a free of charge mass school-based vaccination campaign, aiming to reach 62,000 girls. Nearly 1,700 health workers received training to support the rollout. National advocacy meetings engaged stakeholders, including government officials, civil society organisations, and religious leaders. A nationwide public communication campaign leveraged community, school and church networks to promote vaccine uptake. Health education sessions were conducted in schools and religious settings to counter misinformation and address safety concerns.

Results:
Within three weeks, 56,350 girls (90% of the target population) were vaccinated. No significant adverse events following immunisation were reported. Key challenges included reaching remote communities, particularly due to challenging terrain and distance, and addressing vaccine hesitancy. Other barriers that may have influenced student participation include rumours and bureaucratic processes that affect timely implementation.

Discussion:
The program achieved high coverage through strong community engagement, multi-sectoral collaboration, and strategic communication. The involvement of leaders including the Prime Minister, Ministry of Education, and other agencies, encouraged the community especially parents to support HPV vaccination. Partnerships with religious and community leaders and the participation of volunteers was instrumental in overcoming vaccine hesitancy. Lessons from this program can inform future school-based vaccination programs and supplemental immunisation activities in Timor-Leste and similar settings.

Background: A Fiji National Immunisation Coverage Survey was conducted in September and October 2024. The primary objective was to quantify vaccination rates among children and adults according to the Fiji Immunisation Schedule.

Methods: The survey was conducted across 30 enumeration areas (EAs) in each division, as selected by the Fiji Bureau of Statistics (120 EAs nationwide). Teams used Computer Assisted Personal Interview devices for random selection of households and to conduct the interviews.

Results: In total, 6,076 households were surveyed (23,425 individuals). In total, 70.7% (95% CI: 65.0, 75.8) of children aged 24-35 months had received all vaccinations in line with the Fiji immunisation programme until 18-months of age, with variations between divisions. There were substantial differences in uptake between vaccines with early infant vaccines having strong uptake (BCG, 93.2%; 95% CI: 89.4, 95.7), compared with vaccines given at 12- (MMR1 90.5%; 95% CI: 86.5, 93.4) and 18-months (MMR2 75.1%; 95% CI: 69.5, 80.1). Overall, 15.9% (95% CI: 12.0, 20.8) of children received all vaccines on time. For children in Class 1, uptake rates for Td4 and MMR3 were 81.5% and 78.3%, respectively. National Td5 coverage in Class 6 was 78.3%, with notable differences across divisions, and 63.8% of eligible girls received an HPV vaccine. For adults, 53.3% (95% CI: 48.8, 57.9) of women received a Td vaccine during her most recent pregnancy. Uptake of COVID-19 and influenza vaccine during pregnancy was 43.8% (95% CI: 37.0, 50.9) and 24.3% (95% CI: 21.3, 27.6) respectively. Nationally, 83.1% of adults had received two doses of the COVID-19 vaccine.

Conclusion: The survey identified strengths and areas that need additional attention. Findings will inform tailored interventions, policies, and systems aimed at achieving equity and protection against vaccine-preventable diseases for all Fijians.

Background: A Fiji National Immunisation Coverage Survey was conducted in September and October 2024. One of the objectives of this survey was to understand the social and behavioural drivers of immunisation.
Methods: The survey was conducted across 30 enumeration areas (EAs) in each division, as selected by the Fiji Bureau of Statistics (120 EAs nationwide). Teams used Computer Assisted Personal Interview devices for random selection of households and to conduct the interviews.
Results: In total, 1,488 parents completed the ‘Knowledge, Attitudes and Practices sub-survey. During the COVID-19 pandemic, 80.5% of parents questioned childhood immunisation after hearing concerning information about the COVID-19 vaccines, 25.7% hesitated to vaccinate their child and 21.9% rejected a vaccine for their child. Children aged 24-35 months, were more likely to be vaccinated if their parents wanted them to receive all vaccines (p = 0.010). Parents who believe vaccines are important (p = 0.034), and safe (p = 0.0313) were more likely to have their children vaccinated. Trust in health workers (p = 0.049), a recommendation (p = 0.020), and the belief that most of their close family and friends wanted them to vaccinate their child (p = 0.005) were also associated with uptake. No statistical differences were found in motivation or thinking and feeling and vaccine uptake in Class 1 or Class 6. Parents who believed their close family and friends wanted them to vaccinate their child had higher up-to-date vaccination rates in Class 6 (p = 0.036). Similarly, a community leader's influence was also significant (p = 0.038). HPV vaccine uptake was higher for parents who wanted their children to receive all recommended vaccines (p = 0.013) and there was a marginally significant association (p = 0.051) in HPV vaccine uptake if parents believed vaccines were safe.
Conclusion: The survey identified social and behavioural factors related to vaccine uptake that can inform advocacy, policy and tailored interventions.

Background: Immunisation coverage data is collected via paper-based systems in most low-and-middle-income countries. Electronic immunisation registries (EIRs) can improve access to rich data for decision-making. We examined data use from paper-based systems for routine immunisation compared with an EIR for COVID-19 vaccination in Vanuatu.

Methods: We conducted a qualitative study, interviewing 16 key informants from the Vanuatu Ministry of Health at the national (n=7), provincial (n=3) and facility (n=1) levels, and international development agencies (n=5) in March 2024. We thematically identified data use actions and factors determining data use with the Performance of Routine Information System Management framework.

Results: Routine immunisation coverage data were used to identify coverage gaps, but use in planning service delivery or strategic decision-making was limited and inconsistent. In contrast, decision-makers used COVID-19 vaccination coverage data regularly to monitor the vaccination rollout, allocate resources, plan actions to deliver the program and assess adverse events. The COVID-19 EIR streamlined data processes, allowing data to be entered, analysed and shared at a faster pace. Barriers to using routine immunisation coverage data included inadequate data management processes, minimal performance feedback, lack of data use culture throughout the health system, poor data literacy and the workload of nurses. For COVID-19 vaccination, EIR data use was enabled by increased availability of human, financial and technical resources, adequately training workers on EIR use, greater demand and accountability for data by stakeholders, temporary improvements in internet connectivity, and a sense of urgency to achieve high COVID-19 vaccination coverage due to the pandemic.

Discussion: An enabling environment with skilled workers, adequate resources and demand for data was critical to foster data use in decision-making for COVID-19 vaccination. While the EIR enabled rapid access to data, health leadership, regular feedback and accountability to achieve targets were necessary to increase data use in decision-making.