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PONE-D-20-10234

Proportion of children aged 9 – 59 months reached by the 2017 measles Supplementary Immunization Activity among the children with or without history of measles vaccination in Lilongwe district, Malawi.

PLOS ONE

Dear Dr. Kainga,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Kavita Singh Ongechi

Academic Editor

PLOS ONE

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Additional Editor Comments (if provided):

Dear Author,

Please see the reviewer comments and in addition I have a few comments.

1) Introduction: Explain more about there is measles resurgence every three years.

2) Methods: For some variables consider collapsing categories because of small cell size. For marital status consider categories of currently married and currently not married. For employment, what is the difference between housewife and unemployed. Could these categories be combined.

Sincerely,

Kavita Singh Ongechi

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is an interesting study with potentially important implications for assessing the effectiveness of supplemental immunization activities. The manuscript is well written with coherent flow of information and argument. The conclusions may be of interest to countries working to reach children that are consistently missed in routine and supplemental immunization services. I have no major issues with the paper and offer the following minor recommendations for revision:

Abstract

1. On line 1, include the month along with year the SIA was conducted.

2. The second sentence where the authors state "...20 households..." is inconsistent with the methods section and should be harmonized with the description in the methods.

3. Line 4 in the methods description in abstract where the authors refer to "true description of when and where the child was vaccinated." The word true is subjective and should be deleted as the data are based on self-report, without an objective way of validating the caregiver's report.

4. Define MOV at first mention.

Background

5. Second paragraph, the WHO recommendation referenced was updated in 2017 and removed the MCV1 threshold for introducing MCV2. This statement should be edited to include the current position. See: https://www.who.int/immunization/policy/position_papers/WHO_PP_measles_vaccine_summary_2017.pdf?ua=1

Methods

6. Last statement in the description of the study sample "Geographical access to all levels of health care has remained stagnant especially among under five children living in the urban slums and outskirts of the city" is unclear and should be edited for clarity.

7. Study design: Indicate the respective targets of the quantitative and qualitative portions of the study. As written, it appears like the quantitative and qualitative data were collected from the same sample.

8. Page 7, sampling procedure: "In each selected village, 19 eligible households were selected." This is inconsistent with what is stated in the abstract where the authors state that 20 household were selected in each village. This should be checked and harmonized for consistency.

9. Page 8, training of research assistants: indicate how many research assistants were trained.

10. Page 8, data collection and measurements: "a child was taken to have been vaccinated during the measles SIA if the caretaker gave a true description of when and where the child was vaccinated." Similar to my comment on the abstract, it is unclear how the research team/enumerators validated the veracity of these reports. This is a subjective statement and the word "true" should be deleted.

11. First paragraph on page 9, a rationale for how the required number of KIIs was determined should be provided.

12. Page 9, still on data collection and measurements: "The outcome variable in this study was measles vaccination during 2017 measles SIA to an eligible child who had no any contraindication to vaccination" Is the outcome referenced here referring to the KIIs or the household questionnaire? This needs to be clarified. Also delete the word "any" from the statement.

Results - from this point forward, for some reason, all pages are numbered "1" and should be fixed.

13. Paragraph 1: "Only 16% were gainfully employed." Authors should clarify what "gainfully" means in this regard. Employed for payment in monetary terms, in-kind, self-employed, agricultural work?

14. Table 1: In caretakers educational level, "no education is repeated.

15. In the description of factors associated with MOVs and possible reasone for non-vaccination, define "APR" at first mention.

16. Table 2, add a footnote to explain what estimates are in bold font face. In addition, there has be a better way of differentiating between employment and self-employment. Consider different verbiage

Discussion

17: Generally, arguments need to be better developed in discussion section. It is not enough to state that a finding concurs with that of some other study without providing plausible explanations for the findings.

18. In second paragraph of the discussion section: "This research revealed that the prevalence of MOV was 28% greater among children whose caretakers were unemployed than that of their counterparts from employed caretakers. Previous studies also found occupation to be important in influencing childhood immunization [8]." There have been mixed findings in this regard. A plausible counter-argument is that employment may preclude a mother from taking time to seek out immunization services. In the context of SIAs which are provided free to the user, what could be the protective effect of employment? There is a need to balance the evidence in support and against.

19. "The prevalence of MOV was lower among children with higher birth order than first born children. This is not consistent with the findings of most studies. The likely reason for this finding could be that some parents did not perceive any measles threat to their first born children, who most of them were old during this time unlike other children with high birth order." The point you are trying to make here is confusing and should be clarified.

20. Paragraph 4 of the discussion section: "According to the World Health Organization, sound and reliable information is the foundation of decision-making across all health system building blocks. Accurate information is essential for health system policy development and implementation, governance and regulation, health research, human resources, health education and training, service delivery and financing." A citation should be provided.

Conclusion

21. "The magnitude of missed opportunities for measles vaccination among eligible children was very high as a greater proportion of eligible children were not vaccinated during the 2017 measles supplementary immunization activity (SIA) in Lilongwe district." I believe this is an inaccurate interpretation. From these findings, more children were vaccinated than not (77 vs. 23%) during the measles SIA, and cannot be interpreted as "greater proportion of eligible children were not vaccinated."

22. The last statement in the conclusion appear out of place or does not flow coherently. I suggest it should be moved to just before the preceding statement ("And finally...").

Reviewer #2: Summary

There is great value in exploring reasons behind missed opportunities for vaccination (MOV). Since the 1980s, the WHO has had several iterations of methodology for assessing MOV. Since MOV is defined in the context of health systems failing to vaccinate an individual eligible for a vaccine, these tools are designed in the context of facilities. Moreover, MOV and supplementary immunization activities (SIA) are separate concepts where SIAs complement routine vaccination. This makes it rather confusing that the proposed study for publication explores MOV in the context of SIA. Individuals not reached through SIAs would not be MOV. If the focus of the study is to assess why children may not have been reached by the measles SIA, this would be different than examining MOV. There are issues with both the design and analysis proposed in the paper.

Specific edits

Background

• The WHO defines missed opportunities for vaccination (MOV) as an individual making contact with the health system and not receiving a vaccination they are eligible for. Supplementary immunization activities (SIA) are intended to complement routine vaccination and are not specifically considered a WHO strategy specifically for addressing MOV. These need to be clearly defined if the paper is framed in the context of MOV and SIA.

• Revisit literature on gaps in reaching children during mass measles vaccination coverage. There is documentation on how SIAs miss marginalized populations/gaps in coverage.

• Revisit citations 4-10 – these primarily look at reasons for MOV in the context of regular vaccination not people being missed through SIA.

• The background should include more robust information on measles coverage (and source) in Malawi and Lilongwe. The paper cited, which were vaccine coverage estimates based on surveillance data, is not the most appropriate data source compared to household survey and DHIS2 in Malawi. In Malawi, a DHS was conducted in 2015/16 and a SPA was conducted in2013/14. The Malawi progress report to Gavi, which includes the measles campaign cites DHS and DHIS2 data to describe measles coverage and measles surveillance data. DHIS2 data in Lilongwe during the SIA campaign period should be cited.

• It’s especially surprising that SPA findings are omitted from the paper given SPA has indicators directly related to MOV.

Methods

• Why was measles SIA not captured on vaccination cards? Recall by vaccination card is considered the best practice for determining vaccination coverage in a household survey and is preferable over self-reported recall. The WHO MOV guidelines specifically advise to not accept verbal vaccination recall from mothers.

• Insufficient justification why only eight KIIs were conducted. Were KIIs all with public health facility providers or CHAM/NGOs as well?

• Insufficient justification on how the IDI guides for both parents and health workers deviate from MOV suggested protocol and standard question approaches with core omitted questions such as “Has this child ever been vaccinated?” Also would be important to describe the choice of choosing a prompted approach for asking “why was the child not vaccinated against measles” instead of an unprompted approach since this is a core question for the study.

• Asking about sex of household head is different than asking who makes decisions in a household (preferred approach).

• Based on question wording in the KII guide, there is a potential that respondents may have confused campaign-related factors with health system-related factors that would impede in vaccination.

Results

• It is unclear how the authors define “missed the opportunity of receiving measles vaccine.” The results should cite the total number of children considered “eligible” or in need of vaccination and clearly define the denominator used for coverage estimates.

• As described above, “MOV” should not be used to describe children that were not reached by the SIA campaign.

• The qualitative interviews could be more robustly and systematically analyzed. For example, issues with the health information system are cited in the discussion as a major finding. However, the quote used to support the health information system is about flawed use of population estimates – which is independent of the health information system. Was the health officer referring to DHIS2 or census estimates? I believe DHIS2 sits with the Ministry of Health in Malawi, not the National Statistical Office, so the respondent could have been referring to just census estimates (not the health information system).

Discussion

• As described above, “MOV” should not be used to describe children that were not reached by the SIA campaign.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: PLOS_TA.docx

PONE-D-20-10234R1

Proportion of children aged 9 – 59 months reached by the 2017 measles Supplementary Immunization Activity among the children with or without history of measles vaccination in Lilongwe district, Malawi.

PLOS ONE

Dear Dr. Kainga,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

=============================

Please submit your Rebuttal Letter (Sometimes called a Response to Comments), a point by point explanation of how you responded to each of the reviewers' comments. (This had not been submitted with the revised paper.)  Also you inquired about a fee waiver. As an author from Uganda, you are eligible to apply for the PLOS Global Participation Initiative. Please do apply as you resubmit your paper with the response to comments. 

==============================

Please submit your revised manuscript by %October 30, 2020%. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Kavita Singh Ongechi

Academic Editor

PLOS ONE

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Proportion of children aged 9 – 59 months reached by the 2017 measles Supplementary Immunization Activity among the children with or without history of measles vaccination in Lilongwe district, Malawi.

PONE-D-20-10234R2

Dear Dr. Kainga,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Kavita Singh Ongechi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

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Reviewer #1: No