DECENTRALIZED IMMUNIZATION MONITORING: LESSONS LEARNED FROM FOUR STATES - NIGERIA.

Background: Low immunization coverage in Nigeria accounts for 2.3 million children with zero doses, increasing morbidity and mortality. The government prioritizes 100 local government areas for strategic interventions aiming for a 15% reduction in zero-dose (ZD) children by 2024.

Objective: We set out to track immunization performance, identify priority indicators, estimate coverage, and generate evidence for informed decision-making.

Methods: A cross-sectional study using the validated behavioral and social drivers of immunization (BeSD) and lot quality assurance sampling (LQAs) frameworks was used in Kano, Sokoto, Borno, and Bauchi states that included 4, 028 children across 106 wards.

Findings: The mean age of caregivers was 28 years (SD+ 6 years) - slightly lower in Bauchi 26 years and higher in Borno 30 years. Over 97% had Islam as their religion and married. The prevalence of Zero Dose was 30.7%. About 66% of caregivers had no formal education with 84% of ZD had no education. About 51% of ZD caregivers are not engaged nor have they any source of income. Average Monthly income was found to be 3 times higher in NZD Caregivers than ZD caregivers. Home Delivery was 54% with Sokoto and Kano having 72.5 and 66.4% respectively. However, 71% of ZD Caregivers delivered at Home. Overall, 79% Uptake. ANC uptake was higher amongst NZD Caregivers than ZD caregivers. Sokoto and Kano (Sumaila) had the lowest uptake. About 73% of Sample children received at least one immunization antigen. Sokoto had the least 46%. Penta 1 coverage was at 66% with Bauchi having 77%. About 68.5% of Zero dose caregivers reported little or no intention to be vaccinated with all the childhood vaccines. About 69% of caregivers trust healthcare workers who vaccinate children. 560 (45%) of zero-dose caregivers do not. About 69% of caregiver's vaccinators said payment is "moderately" or "very" easy for the vaccination of their child. 47% of ZD caregivers reported challenges in affording vaccines for their children. Bauchi & Sokoto had the highest number of access challenges. Over 57% of zero dose caregivers live within a short distance (trekkable distance) to an RI service delivery point.

Conclusion/recommendation: Targeted outreach with financial aid, education, community leader engagement, and social support promotion can increase vaccinations. Improving service delivery, accessibility, and clear centre location information is crucial. Keywords: Immunization, Zero-dose children, Vaccine hesitancy, Nigeria.