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Abstract Background Since March 2020, the COVID-19 pandemic has shocked health systems worldwide. This analysis investigated the effects of the pandemic on basic health services utilization in the Democratic Republic of the Congo (DRC) and examined the variability of COVID effects in the capital city Kinshasa, in other urban areas, and in rural areas. Methods We estimated time trends models using national health information system data to replicate pre-COVID-19 (i.e., January 2017–February 2020) trajectories of health service utilization, and then used those models to estimate what the levels would have been in the absence of COVID-19 during the pandemic period, starting in March 2020 through March 2021. We classified the difference between the observed and predicted levels as the effect of COVID-19 on health services. We estimated 95% confidence intervals and p-values to examine if the effect of the pandemic, nationally and within specific geographies, was statistically significant. Results Our results indicate that COVID-19 negatively impacted health services and subsequent recovery varied by service type and by geographical area. COVID-19 had a lasting impact on overall service utilization as well as on malaria and pneumonia-related visits among young children in the DRC. We also found that the effects of COVID-19 were even more immediate and stronger in the capital city of Kinshasa compared with the national effect. Both nationally and in Kinshasa, most affected services had slow and incomplete recovery to expected levels. Therefore, our analysis indicates that COVID-19 continued to affect health services in the DRC throughout the first year of the pandemic. Conclusions The methodology used in this article allows for examining the variability in magnitude, timing, and duration of the COVID effects within geographical areas of the DRC and nationally. This analytical procedure based on national health information system data could be applied to surveil health service disruptions and better inform rapid responses from health service managers and policymakers. more...

Abstract The diagnostic yield of exome sequencing (ES) has primarily been evaluated in individuals of European ancestry, with less focus on underrepresented minority (URM) and underserved (US) patients. We evaluated the diagnostic yield of ES in a cohort of predominantly US and URM pediatric and prenatal patients suspected to have a genetic disorder. Eligible pediatric patients had multiple congenital anomalies and/or neurocognitive disabilities and prenatal patients had one or more structural anomalies, disorders of fetal growth, or fetal effusions. URM and US patients were prioritized for enrollment and underwent ES at a single academic center. We identified definitive positive or probable positive results in 201/845 (23.8%) patients, with a significantly higher diagnostic rate in pediatric (26.7%) compared to prenatal patients (19.0%) (P = 0.01). For both pediatric and prenatal patients, the diagnostic yield and frequency of inconclusive findings did not differ significantly between URM and non-URM patients or between patients with US status and those without US status. Our results demonstrate a similar diagnostic yield of ES between prenatal and pediatric URM/US patients and non-URM/US patients for positive and inconclusive results. These data support the use of ES to identify clinically relevant variants in patients from diverse populations. more...

Abstract Humanitarian crises represent a significant public health risk factor for affected populations exacerbating mortality, morbidity, disabilities, and reducing access to and quality of health care. Reliable and timely information on the health status of and services provided to crisis-affected populations is crucial to establish public health priorities, mobilize funds, and monitor the performance of humanitarian action. Numerous efforts have contributed to standardizing and presenting timely public health information in humanitarian settings over the last two decades. While the prominence of process and output (rather than outcome and impact) indicators in monitoring frameworks leads to adequate information on resources and activities, health outcomes are rarely measured due to the challenges of measuring them using gold-standard methods that are difficult to implement in humanitarian settings. We argue that challenges in collecting the gold-standard performance measures should not be a rationale for neglecting outcome measures for critical health and nutrition programs in humanitarian emergencies. Alternative indicators or measurement methods that are robust, practical, and feasible in varying contexts should be used in the interim while acknowledging limitations or interpretation constraints. In this paper, we draw from existing literature, expert judgment, and operational experience to propose an approach to adapt public health indicators for measuring performance of the humanitarian response across varied contexts. Contexts were defined in terms of parameters that capture two of the main constraints affecting the capacity to obtain performance information in humanitarian settings: (i) access to population or health facilities; and (ii) availability of resources for measurement. Consequently, 2 × 2 tables depict four possible scenarios: (A) a situation with accessible populations and with available resources; (B) a situation with available resources but limited access to affected populations; (C) a situation with accessible populations and limited resources; and (D) a situation with both limited access and limited resources. Methods and data sources can vary from large population-based surveys, rapid assessments of populations or health facilities, routine health management information systems, or data from sentinel sites in the community or among facilities. Adapting indicators and methods to specific contexts of humanitarian settings increases the potential for measuring the performance of humanitarian programs beyond inputs and outputs by assessing health outcomes, and consequently improving program impact, reducing morbidity and mortality, and improving the quality of lives amongst persons affected by humanitarian emergencies. more...

BackgroundSince March 2020, the coronavirus disease 2019 (COVID-19) pandemic has been a major shock to health systems across the world. We examined national usage patterns for selected basic, essential health services, before and during the COVID-19 pandemic in Uganda and Bangladesh, to determine whether COVID-19 affected reporting of service utilization and the use of health services in each country.MethodsWe used routine health information system data since January 2017 to analyze reporting and service utilization patterns for a variety of health services. Using time series models to replicate pre-COVID-19 trajectories over time we estimated what levels would have been observed if COVID-19 had not occurred during the pandemic months, starting in March 2020. The difference between the observed and predicted levels is the COVID-19 effect on health services.ResultsThe time trend models for Uganda and Bangladesh closely replicated the levels and trajectories of service utilization during the 38 months prior to the COVID-19 pandemic. Our results indicate that COVID-19 had severe effects across all services, particularly during the first months of the pandemic, but COVID-19 impacts on health services and subsequent recovery varied by service type. In general, recovery to expected levels was slow and incomplete across the most affected services.ConclusionOur analytical approach based on national information system data could be very useful as a form of surveillance for health services disruptions from any cause leading to rapid responses from health service managers and policymakers. more...

Abstract Background Nigeria has one of the highest under-five mortality rates in the world. Identifying the causes of these deaths is crucial to inform changes in policy documents, design and implementation of appropriate interventions to reduce these deaths. This study aimed to provide national and zonal-level estimates of the causes of under-five death in Nigeria in the 2013–2018 periods. Methods We conducted retrospective inquiries into the cause of deaths of 948 neonates and 2,127 children aged 1–59 months as identified in the 2018 Nigeria Demographic and Health Survey (NDHS). The verbal autopsy asked about signs and symptoms during the final illness. The Physician Coded Verbal Autopsy (PCVA) and Expert Algorithm Verbal Autopsy (EAVA) methods were employed to assign the immediate and underlying cause of deaths to all cases. Result For the analysis, sampling weights were applied to accommodate non-proportional allocation. Boys accounted for 56 percent of neonatal deaths and 51.5 percent of the 1–59-months old deaths. About one-quarter of under-5 mortality was attributed to neonatal deaths, and 50 percent of these neonatal deaths were recorded within 48 h of delivery. Overall, 84 percent of the under-5 deaths were in the northern geopolitical zones. Based on the two methods for case analysis, neonatal infections (sepsis, pneumonia, and meningitis) were responsible for 44 percent of the neonatal deaths, followed by intrapartum injury (PCVA: 21 percent vs. EAVA: 29 percent). The three main causes of death in children aged 1–59 months were malaria (PCVA: 23 percent vs. EAVA: 35 percent), diarrhoea (PCVA: 17 percent vs. EAVA: 23 percent), and pneumonia (PCVA: 10 percent vs. EAVA: 12 percent). In the North West, where the majority of under-5 (1–59 months) deaths were recorded, diarrhoea was the main cause of death (PCVA: 24.3 percent vs. EAVA: 30 percent). Conclusion The causes of neonatal and children aged 1–59 months deaths vary across the northern and southern regions. By homing on the specific causes of mortality by region, the study provides crucial information that may be useful in planning appropriately tailored interventions to significantly reduce under-five deaths in Nigeria. more...

Abstract Background Nigeria’s under-five health outcomes have improved over the years, but the mortality rates remain unacceptably high. The qualitative component of Nigeria’s 2019 verbal and social autopsy (VASA) showed that caregivers’ health beliefs about causes of illnesses and efficacious treatment options contribute to non-use/delay in use of facility-based healthcare for under-five children. This study explored how these health beliefs vary across zones and how they shape how caregivers seek healthcare for their under-five children. Methods Data for this study come from the qualitative component of the 2019 Nigeria VASA, comprising 69 interviews with caregivers of under-five children who died in the five-year period preceding the 2018 Nigeria Demographic and Health Survey (NDHS); and 24 key informants and 48 focus group discussions (FGDs) in 12 states, two from each of the six geo-political zones. The transcripts were coded using predetermined themes on health beliefs from the 2019 VASA (qualitative component) using NVivo. Results The study documented zonal variation in belief in traditional medicine, biomedicine, spiritual causation of illnesses, syncretism, and fatalism, with greater prevalence of beliefs discouraging use of facility-based healthcare in the southern zones. Driven by these beliefs and factors such as availability, affordability, and access to and perceived quality of care in health facilities, caregivers often choose one or a combination of traditional medicines, care from medicine vendors, and faith healing. Most use facility-based care as the last option when other methods fail. Conclusion Caregivers’ health beliefs vary by zones, and these beliefs influence when and whether they will use facility-based healthcare services for their under-five children. In Nigeria’s northern zones, health beliefs are less likely to deter caregivers from using facility-based healthcare services, but they face other barriers to accessing facility-based care. Interventions seeking to reduce under-five deaths in Nigeria need to consider subnational differences in caregivers’ health beliefs and the healthcare options they choose based on those beliefs. more...

Abstract Background Significant levels of funding have been provided to low- and middle-income countries for development assistance for health, with most funds coming through direct bilateral investment led by the USA and the UK. Direct attribution of impact to large-scale programs funded by donors remains elusive due the difficulty of knowing what would have happened without those programs, and the lack of detailed contextual information to support causal interpretation of changes. Methods This study uses the synthetic control analysis method to estimate the impact of one donor’s funding (United States Agency for International Development, USAID) on under-five mortality across several low- and middle-income countries that received above average levels of USAID funding for maternal and child health programs between 2000 and 2016. Results In the study period (2000–16), countries with above average USAID funding had an under-five mortality rate lower than the synthetic control by an average of 29 deaths per 1000 live births (year-to-year range of − 2 to − 38). This finding was consistent with several sensitivity analyses. Conclusions The synthetic control method is a valuable addition to the range of approaches for quantifying the impact of large-scale health programs in low- and middle-income countries. The findings suggest that adequately funded donor programs (in this case USAID) help countries to reduce child mortality to significantly lower rates than would have occurred without those investments. more...

Abstract Background Many low- and middle-income countries cannot measure maternal mortality to monitor progress against global and country-specific targets. While the ultimate goal for these countries is to have complete civil registrations systems, other interim strategies are needed to provide timely estimates of maternal mortality. Objective The objective is to inform on potential options for measuring maternal mortality. Methods This paper uses a case study approach to compare methodologies and estimates of pregnancy-related mortality ratio (PRMR)/maternal mortality ratio (MMR) obtained from four different data sources from similar time periods in Bangladesh, Mozambique, and Bolivia—national population census; post-census mortality survey; household sample survey; and sample vital registration system (SVRS). Results For Bangladesh, PRMR from the 2011 census falls closely in line with the 2010 household survey and SVRS estimates, while SVRS’ MMR estimates are closer to the PRMR estimates obtained from the household survey. Mozambique's PRMR from household survey method is comparable and shows an upward trend between 1994 and 2011, whereas the post-census mortality survey estimated a higher MMR for 2007. Bolivia's DHS and post-census mortality survey also estimated comparable MMR during 1998–2003. Conclusions Overall all these data sources presented in this paper have provided valuable information on maternal mortality in Bangladesh, Mozambique, and Bolivia. It also outlines recommendations to estimate maternal mortality based on the advantages and disadvantages of several approaches. Contribution Recommendations in this paper can help health administrators and policy planners in prioritizing investment for collecting reliable and contemporaneous estimates of maternal mortality while progressing toward a complete civil registration system. more...

Abstract Background A social mobilization (SM) initiative contributed to India’s success in polio elimination. This was the CORE Group Polio Project (CGPP) India, a partner of the Uttar Pradesh (UP) SM Network and which continued its SM activities, even during the polio-free period through a network of multi-level social mobilizers. This paper assesses the effects of this community-level SM (CLSM) intervention on the extent of community engagement and performance of polio Supplementary Immunization Activity campaigns (SIAs) during the post-polio-endemic period (i.e., from March 2012 to September 2017). Methods This study followed a quasi-experimental design. We used secondary, cluster-level data from CGPP India’s Management Information System, including 52 SIAs held from January 2008 to September 2017, covering 56 blocks from 12 districts of UP. We computed various indicators and performed Generalized Estimating Equations based analysis to assess the statistical significance of differences between the outcomes of intervention and non-intervention areas. We then estimated the effects of the SM intervention using Interrupted time-series, Difference-in-Differences and Synthetic Control Methods. Finally, we estimated the population influenced by the intervention. Results The performance of polio SIAs changed over time, with the intervention areas having better outcomes than non-intervention areas. The absence of CLSM intervention during the post-polio-endemic period would have negatively impacted the outcomes of polio SIAs. The percentage of children vaccinated at polio SIA booths, percentage of ‘X’ houses (i.e., households with unvaccinated children or households with out-of-home/out-of-village children or locked households) converted to ‘P’ (i.e., households with all vaccinated children or households without children eligible for vaccination), and percentage of resistant houses converted to polio acceptors would have gone down by 14.1 (Range: 12.7 to 15.5), 6.3 (Range: 5.2 to 7.3) and 7.4 percentage points, respectively. Community engagement would have reduced by 7.2 (Range: 6.6 to 7.7) percentage points. Conclusions The absence of CLSM intervention would have significantly decreased the level of community engagement and negatively impacted the performance of polio SIAs of the post-polio-endemic period. The study provides evidence of an added value of deploying additional human resource dedicated to social mobilization to achieve desired vaccination outcomes in hard-to-reach or programmatically challenging areas. more...

# Background Nigeria suffers from one of the world's highest child mortality rates, with about 900,000 deaths in a single year, despite being classified as a middle-income country. Over the past few years, substantial efforts have been made to reduce child mortality, with under-five mortality declining by 31.6% between 1990 and 2018. However, this decline is slower than needed to reduce child mortality significantly. This study presents the social autopsy component of the 2019 verbal and social autopsy (VASA) survey to provide an in-depth understanding of the social determinants of under-five mortality in Nigeria. # Methods The study was a cross-sectional inquiry into the social determinants of neonatal and 1-59 months child deaths from the 2018 Nigeria Demographic and Health Survey (NDHS) weighted to represent the Nigerian population. The social autopsy survey asked about maternal care for neonates and 1-59 months children during the final illness. # Results Child mortality in Nigeria in children aged 1-59 months is strongly associated with levels of wealth, place of residence, and maternal education. The association of these same socio-economic factors with neonatal mortality is weaker. While there were significant associations with wealth quintiles and geopolitical zones, higher maternal education was not significantly associated with lower neonatal death rates. Maternal complications in pregnancy and/or labour and delivery were common and strongly associated with stillbirths and deaths in the first two days. Severity scores at the inception of the illnesses did not show differences between children who only received informal care versus those who went to formal care providers. The main barriers to care were distance, cost, transport, and the need to travel at night, and these barriers were interlinked. More distant facilities usually required vehicle transport, which was expensive for low-income families. Travelling for an emergency at night was even more difficult in terms of finding and paying for transport and involving problems with insecurity and bad roads. # Conclusions The family, community, and health system factors related to neonatal and 1-59 months child deaths in Nigeria were highlighted in this study. Deaths were commonly associated with numerous factors, each of which could contribute to the sequence of events resulting in a preventable death. more...

Abstract Background Nationally representative household surveys are the gold standard for tracking progress in coverage of life-saving maternal and child interventions, but often do not provide timely information on coverage at the local and health facility level. Electronic routine health information system (RHIS) data could help provide this information, but there are currently concerns about data quality. This analysis seeks to improve the usability of and confidence in electronic RHIS data by using adjustments to calculate more accurate numerators and denominators for essential interventions. Methods Data from three sources (Ugandan Demographic and Health (UDHS) survey, electronic RHIS, and census) were used to provide estimates of essential maternal (> 4 antenatal care visits (ANC), skilled delivery, and postnatal care visit (PNC)) and child health interventions (diphtheria, pertussis, tetanus, and hepatitis B and Haemophilus influenzae type b and polio vaccination series, measles vaccination, and vitamin A). Electronic RHIS data was checked for quality and both numerators and denominators were adjusted to improve accuracy. Estimates were compared between the three sources. Results Estimates of maternal health interventions from adjusted electronic RHIS data were lower than those of the UDHS, while child intervention estimates were typically higher. Adjustment of electronic RHIS data generally improved accuracy compared with no adjustment. There was considerable agreement between estimates from adjusted, electronic RHIS data, and UDHS for skilled delivery and first dose of childhood vaccination series, but lesser agreement for ANC visits and second and third doses of childhood vaccinations. Conclusions Nationally representative household surveys will likely continue being the gold standard of coverage estimates of maternal and child health interventions, but this analysis shows that current approaches to adjusting health facility estimate works better for some indications than others. Further efforts to improve accuracy of estimates from RHIS sources are needed. more...

Abstract Background Understanding the global impact of medulloblastoma on health related quality of life (HRQL) is critical to characterizing the broad impact of this disease and realizing the benefits of modern treatments. We evaluated HRQL in an international cohort of pediatric medulloblastoma patients. Methods Seventy‐six patients were selected from 10 sites across North America, Europe, and Asia, who participated in the Medulloblastoma Advanced Genomics International Consortium (MAGIC). The Health Utilities Index (HUI) was administered to patients and/or parents at each site. Responses were used to determine overall HRQL and attributes (ie specific subdomains). The impact of various demographic and medical variables on HRQL was considered—including molecular subgroup. Results The majority of patients reported having moderate or severe overall burden of morbidity for both the HUI2 and HUI3 (HUI2 = 60%; HUI3 = 72.1%) when proxy‐assessed. Self‐care in the HUI2 was rated as higher (ie better outcome) for patients from Western versus Eastern sites, P = .02. Patients with nonmetastatic status had higher values (ie better outcomes) for the HUI3 hearing, HUI3 pain, and HUI2 pain, all P more...

Abstract Background This study explored the role of health facility availability as it relates to maternal and newborn PNC use in rural Malawi. Methods Malawi Demographic and Health Survey (MDHS) 2015–16 data, MDHS 2015–16 household cluster GPS data, Malawi Service Provision Assessment (MSPA) 2013–14 data and MSPA 2013–14 facility GPS data were used. Household clusters were spatially linked with facilities using buffers. Descriptive analyses were performed and generalized estimating equations (GEE) were used to determine the effects of having different types of facilities at varying distances from household clusters on receipt of maternal and newborn PNC in rural Malawi. Results In rural Malawi, around 96% of women had facilities providing PNC within 10 km of where they live. Among women who have clinic-level facilities within 5 km of where they live, around 25% had clinic-level facilities that provide PNC. For rural women who gave birth in the past 5 years preceding the survey, only about 3% received maternal PNC within 24 h and about 16% received maternal PNC within the first week. As for newborn PNC, 3% of newborns had PNC within 24 h and about 26% had newborn PNC within the first week. PNC mostly took place at facilities (94% for women and 95% for newborns). For women who delivered at home, having a health center providing PNC within 5 km was positively associated with maternal and newborn PNC. For women who delivered at facilities, having a health center providing PNC within 5 km was positively associated with maternal PNC and having a health center providing PNC between 5 km and 10 km was positively associated with both maternal and newborn PNC. Regardless of the place of delivery and distance band, having a clinic-level facility providing PNC did not have significant positive effects on maternal and newborn PNC. Conclusions Providers should be trained to perform quality PNC at all facilities. It would also be important to address concerns related to health workers. Lastly, it would be key to increase community awareness about the importance of seeking timely PNC and about the utility of lower-level facilities for receiving preventative PNC. more...

Abstract Background With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries. Methods A review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input. Results Twenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited. Conclusions Better data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs. more...

# Background The first 48 hours after birth is a critical window of time for the survival for both mothers and their newborns. Timely and adequate postnatal care (PNC) is being promoted as a strategy to reduce both maternal and newborn mortality. Whether or not a woman has received a postnatal check within 48 hours has been well studied, however, specific content and type of provider are also important for understanding the quality of the check. The objective of this paper is to understand who receives specific PNC interventions by type of provider in Bangladesh. # Methods Data from the 2014 Bangladesh Demographic and Health Survey (DHS) were used to study receipt of specific PNC interventions -- breast exam, vaginal discharge exam, temperature check and counseling on danger signs -- within 2 days of birth. Descriptive bivariate analyses and regression analyses using generalized estimating equations (GEE) were used to understand if receipt of an intervention differed by socio-economic and health-related factors. A key factor studied was the type of provider of the PNC. # Results The proportion of women receiving specific interventions during maternal PNC was mostly low (41.81% for breast exam, 39.72% for vaginal discharge, 82.22% for temperature check, 55.56% for counseling on danger signs and 16.95% for all four interventions). Findings from the regression analyses indicated that compared to having postnatal contact with formal providers (doctors, nurses, midwives and paramedics), having postnatal contact with village doctors was significantly associated with lower probabilities of receiving a breast exam, vaginal discharge exam and receiving all four interventions. PNC provided by NGO workers and other community attendants was significantly associated with a lower probability of receiving a vaginal discharge exam but a higher probability of receiving counseling on danger signs. # Conclusions During PNC, women were much more likely to receive a temperature check than counseling on danger signs, breast exams or vaginal discharge exams. Very few women received all four interventions. In the situation where Bangladesh is experiencing a shortage of high-level providers, training more types of providers, particularly informal village doctors, may be an important strategy for improving the quality of PNC. more...

Category: Midfoot/Forefoot Introduction/Purpose: Open reduction and internal fixation with transarticular screws to stabilize Lisfranc injuries may increase the risk of arthritis or affect outcomes. Extra-articular or bridge plating to stabilize these injuries avoids this articular damage. This study analyzes the functional outcomes and complications in patients who underwent this type of joint preserving fixation for Lisfranc injuries. Methods: A retrospective review of all patients treated for a Lisfranc injury at a level 1 trauma center from July 2008 to October 2015 was conducted. Patients over 18 years of age who were not incarcerated and did not have any concomitant procedures in the lower extremities were included. Patient electronic medical records were reviewed. Outcomes were analyzed with AOFAS scores. Results: There were 16 patients included in the study with an average follow up time of 57 months (15 - 102 months). Average AOFAS score was 79 (SD 16) and time to return to regular activities was 35 weeks (SD 25 weeks). Seven patients (44%) had their hardware removed during the follow up period. There was 1 complication which comprised of a screw backing out and needing to be removed. Conclusion: In the present case series, joint preserving fixation for Lisfranc injuries offered similar AOFAS scores as those reported for ORIF with transarticular screws, but with a decreased rate of hardware removal and need for mid-foot fusion. more...

Ensuring the sustained immunization of displaced persons is a key objective in humanitarian emergencies. Typically, humanitarian actors measure coverage of single vaccines following an immunization campaign; few measure routine coverage of all vaccines. We undertook household surveys of Syrian refugees in Jordan and Lebanon, outside of camps, using a mix of random and respondent-driven sampling, to measure coverage of all vaccinations included in the host country’s vaccine schedule. We analyzed the results with a critical eye to data limitations and implications for similar studies. Among households with a child aged 12–23 months, 55.1% of respondents in Jordan and 46.6% in Lebanon were able to produce the child’s EPI card. Only 24.5% of Syrian refugee children in Jordan and 12.5% in Lebanon were fully immunized through routine vaccination services (having received from non-campaign sources: measles, polio 1–3, and DPT 1–3 in Jordan and Lebanon, and BCG in Jordan). Respondents in Jordan (33.5%) and Lebanon (40.1%) reported difficulties obtaining child vaccinations. Our estimated immunization rates were lower than expected and raise serious concerns about gaps in vaccine coverage among Syrian refugees. Although our estimates likely under-represent true coverage, given the additional benefit of campaigns (not captured in our surveys), there is a clear need to increase awareness, accessibility, and uptake of immunization services. Current methods to measure vaccine coverage in refugee and displaced populations have limitations. To better understand health needs in such groups, we need research on: validity of recall methods, links between campaigns and routine immunization programs, and improved sampling of hard-to-reach populations. more...