Introduction

The Expanded Programme on Immunization (EPI), introduced by the World Health Organization (WHO) in 1977 in Alma-Ata, is the most successful global public health program saving millions of lives of children every year [1]. Through vaccination, smallpox was eradicated, polio is on the verge of eradication, and neonatal tetanus incidence was reduced by 88%. The incidence of measles, rubella, diphtheria, pertussis, childhood TB, and hepatitis B is considerably low because of the implementation of EPI in 192 member states of WHO [2]. The recent addition of vaccines against human papillomavirus, rotavirus, yellow fever virus, pneumococcus, and Hemophilus influenzae in the EPI in different countries has been instrumental in reducing the burden of these diseases. Bangladesh launched EPI in 1979 and covered as much as 94.6% of live births in 2020 [3]. For its sustained high coverage and contribution in reducing child mortality, Bangladesh has been appreciated and awarded multiple times [1].

In 2017, a complex humanitarian crisis arose when Rohingya people living in Rakhaine state of Myanmar were forcibly displaced from their country through systematic human rights violations and military crackdown [4], and more than seven hundred thousand Rohingya refugees arrived to join two hundred thousand refugees already living in the camps in Cox’s Bazar, Bangladesh [2]. The makeshift settlements resided by the newly arrived refugees became overcrowded with a food shortage and a lack of access to health services. A public health emergency from infectious disease was imminent, with low vaccination coverage and malnutrition among the Rohingyas [5, 6]. Measles and diphtheria outbreak ensued in the Rohingya camps in between September and November 2017 and started to spread rapidly across camps [6–8]. However, the Government of the People’s Republic of Bangladesh (GoB) promptly responded to the crisis by starting mass vaccination campaigns to immunize Rohingya children against diphtheria, measles and other vaccine preventable diseases with the aid of global public health partners and vaccine alliances [8]. In addition, routine immunization through EPI was promoted, particularly by the voluntary health workers, to ensure wider coverage and sustain vaccination activities among the refugees [9, 10].

Studies conducted among different refugee and migrant population around the world identified a low vaccination rate, and various associated factors, including—duration of residence in the host country, citizenship status, country of origin, language, disease perceptions, belief & culture, literacy, knowledge, motivation, employment, socio-economic status, and health care & insurance provision [11–16]. One vaccination coverage and seroprevalence survey conducted [2] after immunization campaigns among the Rohingya community found that approximately 10 to 40% of children did not have seroprotection against measles, rubella, diphtheria, and tetanus, implying an inadequate coverage or non-response. Moreover, absence of seroprotection was significantly higher among children living in makeshift settlements compared to that of registered camps. However, a few studies explored the determinants of low vaccination rate among Rohingya children residing in Bangladesh. Therefore, the present study aimed to assess the practice of childhood immunization and associated factors among Rohingya parents to explore the reasons for the gap remaining in EPI coverage.

Methods

Result

A total of 63.1% (n = 154) of parents had good practice regarding vaccination of their children (completed EPI vaccination as per schedule) (Fig 1).

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Fig 1. Childhood immunization practice pattern among Rohingya refugee parents.

https://doi.org/10.1371/journal.pone.0283881.g001

The average age of the parents was 28.9 ± 7.4 years (±SD). Of all, 50.8% were female, and 49.2% were male. There was no difference in vaccination practice in relation to age and sex. Significantly more Rohingya parents (77%) staying at registered camps had good practices regarding EPI vaccination than FDMN parents (49.2%) staying at makeshift settlements (p<0.001). Among all respondents, 57.4% of mothers and 46.7% of fathers did not have any formal education. The vaccination practice was significantly lower among uneducated parents (p = 0.025 for mothers and p = 0.001 for fathers). Ninety-one percent of mothers were housewives. While the majority of fathers were day laborers (35.2%), and 20.9% of them did not have any job. Vaccination practice was significantly higher in proportion among those fathers who had jobs than those who did not have a job (p = 0.008). A significantly higher proportion of respondents with a monthly family income of ≥6000BDT had good vaccination practice (p = 0.016). Ninety-one percent of respondents had an electronic device, and 44.3% of families had >2 children. These factors were not associated with practice. Those who lost at least one of their children were significantly more likely to practice vaccination than those who did not fail (p = 0.009). Sixteen percent of respondents’ children had a previous history of admission, 48.4% had a large family (>4 members), 93.0% attended immunization session(s), 74.6% had good knowledge, and 94.7% had a positive attitude towards EPI vaccination. None of these characteristics showed a significant association with EPI vaccination practice (p>0.05 for all) (Table 1). More details on responses to the knowledge and attitude-related questions are available in S2 Table.

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Table 1. Participant characteristics in respect to childhood immunization practice of Rohingya parents.

https://doi.org/10.1371/journal.pone.0283881.t001

Table 2 enlists the output of univariate and multivariable logistic regression analysis carried out to assess factors associated with good childhood immunization practice among Rohingya parents. On univariate analysis, registered camp (cOR: 3.46; 95%CI: 1.99–6.02), employed father (cOR: 2.32; 95%CI: 1.24–4.35), educated mother (cOR: 1.85; 95%CI: 1.38–3.99), monthly family income of ≥6000 BDT (cOR: 2.04; 95%CI: 1.13–3.67), and any children lost (cOR:4.58; 95%CI: 1.32–15.82) were significant determinants of good immunization practice. On multivariable analysis, after adjustment for other factors, registered camp (aOR: 2.99; 95%CI: 1.41–6.32), and good knowledge level (aOR: 2.88; 95%CI: 1.32–15.82) remained as significant determinants of practice.

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Table 2. Logistic regression analysis to assess factors associated with good childhood immunization practice among Rohingya parents.

https://doi.org/10.1371/journal.pone.0283881.t002

Multivariable logistic regression analysis separated by two types of camps showed that good knowledge level (aOR: 3.62; 95%CI: 1.45–9.04) and >2 children (aOR: 3.71; 95%CI: 1.34–10.27) were independent determinants of good practice in registered camps. While father’s employment (aOR: 2.33; 95%CI: 1.34–6.72), father’s education (aOR: 3.00; 95%CI: 1.34–6.72) and presence of any electronic device (e.g., radio, television, mobile phone) (aOR: 4.01; 95%CI: 0.96–16.84) were significant factors associated with good childhood immunization practice among makeshift settlements (Table 3).

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Table 3. Multivariable logistic regression analysis to assess factors associated with good childhood immunization practice among Rohingya parents staying at registered and temporary camps.

https://doi.org/10.1371/journal.pone.0283881.t003

Discussion

There has been a substantial reduction of child mortality in the world after the introduction and implementation of EPI by WHO [19]. However, humanitarian emergencies often break down regular health service including routine vaccination programs. Consequently, displaced population are destined to live in crowded camps with poor water and sanitation, food shortage, and poor healthcare access, placing them at a high risk of morbidity and mortality due to outbreaks of vaccine preventable diseases [20]. The Rohingya ethnic minorities had been systematically deprived of human rights [4] and the EPI coverage in this population had already been low before fleeing to Bangladesh [21]. Moreover, measles and diphtheria cases broke out in the camps at the end of 2017 [6–8]. Considering all these factors, the Government of Bangladesh, with aid from WHO and other agencies, directed several mass vaccination-campaigns alongside the routine vaccine delivery through EPI.

We explored the current childhood immunization practice among Rohingya refugee parents as per EPI schedule as well as the determinants of good practice. Our analysis revealed that nearly two-third of Rohingya respondents immunized their children according to EPI schedule. This is higher than that previously estimated among Refugees in Kutupalong camps [22] where the vaccine uptake for different diseases ranged between 23% to 78.7%. We also found that parents living in the registered camps were significantly more likely to be vaccinating their children than those of makeshift settlements. Our finding is concordant with previous reports where recently arrived (i.e., during and after 2017) Rohingya refugees were reported to have lower vaccination rates than those who arrived earlier [2, 22]. In addition, the recently arrived refugees showed a lower coverage even after the mass immunization campaigns [2]. This phenomenon seems to be common among the refugee and migrant population throughout the world. Crawshaw et al [12] found that being a recent migrant or having a refugee status was associated with lower vaccination rates in European countries. Charania et el [13] reviewed the immunization coverage among migrant and non-migrant people around the world and found that the duration of residence in the host country is an important factor associated with vaccine uptake among the migrants. Newly arrived refugees take time to settle in and assimilate in the new habitat, while the host government and international agencies come forward to tackle the crisis. This probably explain the gap in vaccination coverage between old and new refugees. The Rohingya refugees living in the registered camps had been residing here since long before 2017. Hence, it is expected that they were more adapted to their new environment and socialized with the host community. Moreover, it is likely that they were aware about and taking service from routine vaccination programs from local health facilities, explaining why parents from these camps in our study were more likely have good childhood immunization practice.

There are several other determinants of vaccine coverage among Rohingya refugees. On bivariate analysis, in addition to camp type, we found several other significant determinants of vaccine coverage among the refugee children. Mother and father’s education, father’s occupation, monthly family income, and previous loss of children were discovered to be associated with good vaccination practice. Our findings are congruent with that of Debela, Garrett and Charania [23] who studied the determinants of vaccine hesitancy among resettled refugee parents in New Zealand and found that parents’ education were significantly associated with vaccine hesitancy. Moreover, mother or caretaker education appears to be important predictor of vaccine acceptance even in the native citizens of Bangladesh [24, 25], and of low and middle-income countries around the world [26]. Generally, economic status of mother or caretaker is considered an important determinant of vaccination coverage, which determines their ability to transport children to health facility and, avail vaccines where it is not freely available or covered by insurance [26]. However, as Rohingya refugees were mostly living on humanitarian aids and majority of the health facilities were within their reach, respondents’ monthly family income, rather than directly influencing their vaccination, might have indirectly influenced vaccination practice by affecting their awareness or knowledge. This also becomes obvious when the results of multivariable adjustments are taken into account. We found that living in registered camps and presence of good knowledge were independently associated with good immunization practice when adjusted for other factors. Which means parent’s education, father’s occupation and monthly income were reflected in their knowledge about the benefit of vaccination in the study respondents. Phillips et al [26] listed awareness as an important determinant of vaccination coverage in low and middle-income countries emphasizing the importance of it in determining the vaccine acceptance and, hence, coverage.

Noticeably an experience of loss of any children were found to associated with good practice. Loss of child is a significant life event for any parents, which could have brought about realization of the importance of protecting lives of the rest of their child by available means.

We carried out separate multivariable analysis for registered camps and makeshift settlements to understand the separate influence of factors influencing vaccination practice in these two areas. Our analysis revealed that knowledge level of parents and having more than 2 children were the determinants of good practice in registered camps. Which goes along our hypothesis that the past experience of living in the registered camps might have influence practice regarding childhood immunization. On the other hand, practice of vaccination among those newly arrived refugees settling in makeshift shelters were independently influenced by father’s occupation, father’s education and presence of any media devices. As Rohingya society is traditionally patriarchal [27], which means fathers play decision making role in the family. Therefore, father’s education is important in imparting awareness regarding importance of vaccine in preventing child deaths. Also, employed father are more likely to meet family needs. Presence of electronic device like TV, radio or mobile phone ensures that people get to know about the available vaccination services. Feldstein et al noted that vaccination campaigns among Rohingya refugees in 2017 could not reach some families because they were unaware about the campaign [2], indicating the importance of awareness about the health services in the target population.

Conclusion

The Rohingya ethnic minority went through a dire humanitarian crisis requiring external assistance to survive and thrive. Government of Bangladesh responded to the crisis with the utmost humane view and received hundreds of thousands of forcibly displace Rohingya people and gave them shelter, food, water and health services with assistance from WHO and other national and international NGOs. Any mass population displacement can increase the risk of vaccine-preventable disease outbreaks because of the limitation of health service, poor living conditions and malnutrition. Hence, mass vaccination campaigns are run in addition to strengthening of routine immunization services. This study found that vaccination coverage was low, particularly among those refugees living in unregistered camps, and those with poor knowledge about vaccination. Increasing knowledge about the importance of vaccination in reducing childhood morbidity and mortality is required to increase acceptance of vaccine among Rohingya parents. Therefore, we recommend taking necessary community-based strategy for increasing awareness among Rohingya communities to ensure proper vaccination of their children.

Supporting information

Acknowledgments

We acknowledge the contributions of the volunteer data collectors for their participation in data collection. We also acknowledge the local health authorities for giving us permission to collect from the camps. Finally, we would remain grateful to the parents for their participation in the study.