A bibliometric analysis of childhood immunization research productivity in Africa since the onset of the Expanded Program on Immunization in 1974

The routine childhood immunization program was launched by the World Health Organization (WHO) in 1974, following the successful program for the eradication of small pox [1]. The program, known as the Expanded Program on Immunization (or EPI), consists of regularly scheduled services that reach each new cohort of children less than one year of age with vaccines at health facilities, scheduled outreach sites, or (in special circumstances) from door to door. The program is composed of a series of inter-related components, including service delivery, vaccine supply and quality, logistics, advocacy and communication, surveillance, financing, management and capacity building. During the past four decades national EPI programs have developed or adapted and implemented a broad range of strategies and activities aimed at bringing services closer to the targeted community, increasing demand for immunization services, reaching previously unreached children, and improving immunization data quality [2–6]. Through these efforts, the mean proportion of the annual birth cohort that received a full series of three doses of the diphtheria, tetanus and pertussis vaccine (DTP3) reached 77% in sub-Saharan Africa in 2010 [7, 8]. Ideally, the development or adaptation and implementation of these interventions should be informed by the best available local evidence [9–11]. The increase in childhood immunization coverage in Africa over the last four decades would, therefore, be expected to have been accompanied by similar growth in childhood immunization research from the continent.

Research publications have an important role in the scientific process providing a key linkage between knowledge generation, uptake and use [12–14]. For a long time, publications and their citation (that is, bibliometrics) have been the method of choice for quantitative assessments of academic research at international, national, institutional and individual levels [15–18]. Bibliometric analysis is also a feasible tool to comprehensively recognize the research advances in the past and future research trends in a specific field. In the context of the African continent to date, factors related to variation in immunization research productivity have not been examined, although bibliometric studies with data on Africa exist in other disciplines [16–30]. Therefore, this bibliometric study aims to fill some of the gaps in existing research by providing insights into the history and growth of childhood immunization research in Africa. We examined whether national immunization coverage or other country-level factors are associated with childhood immunization research productivity in Africa.

We found that childhood immunization research productivity in Africa is highly skewed. South Africa, Nigeria, The Gambia, Egypt and Kenya jointly account for almost half of the articles on childhood immunization indexed in PubMed between 1974 and 2010. There was a significant increase in the number of publications from all African sub-regions between 1974 and 2010. However, Africa's contribution to global childhood immunization publications has been minimal during the period studied. The Gambia, Guinea-Bissau, Sao Tome and Principe, Zimbabwe and Malawi had better records when the total research productivity was adjusted for gross domestic product. When controlled for total expenditure on health, South Africa, Nigeria, Kenya, Egypt and The Gambia were the most productive. Multiple medical schools and research institutions in South Africa, Nigeria and Egypt may account for the large number of publications from these three countries. Similarly, the presence of the British Medical Research Council, the Kenyan Medical Research Institute and a Danish research group (Bandim Health Project) may be the drivers of publications from The Gambia, Kenya and Guinea-Bissau, respectively.

In order to set our study in the context of other existing bibliometric studies, we searched PubMed, combining the terms "bibliometric" and "Africa". The search revealed 15 bibliometric studies with data on Africa [16–30]. These were either studies that had a global reach but reported data on Africa [19–29] or studies that focused on one or more African countries [16–18, 30]. None of these was a bibliometric study of childhood immunization research.

Rahman and Fukui studied factors related to worldwide variation in biomedical research productivity, and found that gross national product per capita and research and development expenditure were significant determinants of biomedical research productivity [37, 38]. We did not find these factors to be significant predictors of immunization research productivity in Africa. The most significant predictor of immunization research productivity in Africa was found to be out-of-pocket health expenditure. The latter refers to the sum of money spent on health by private entities, such as households, commercial or mutual health insurance, non-profit institutions serving households, and resident corporations with a health services delivery or financing function. Out-of-pocket health expenditure also includes gratuities and in-kind payments to health practitioners and suppliers of goods and services whose primary intent is to contribute to the restoration or enhancement of the health status of individuals or population groups. In addition, we confirm the findings of other authors that the contribution of authors from Africa to the global biomedical research literature is minimal [18–20, 22, 23]. This meager biomedical research literature from the continent appears to be dominated by non-communicable disease research [25].

Locally-relevant health research is needed to ensure the effectiveness, efficiency and equity of immunization policies in Africa [14, 39]. In general, health research helps to answer questions, to generate the evidence required to guide policy and to identify new tools. A descriptive analysis of study types, quality and outcomes was beyond the scope of our bibliometric analysis. However, in a related study, Machingaidze and colleagues conducted a detailed descriptive analysis of 881 childhood immunization research publications from Africa between 1970 and 2010 [40]. The studies were classified as clinical (n = 442, 50.2%) or operational (n = 439) research. Among clinical research studies, 41% were phase 1 to 4 controlled trials, 23% were burden of disease or epidemiology and 36% were other clinical studies. Among studies classified as operational research, 76% were on program management, 19% on immunization policy issues and 5% related to vaccine financing [40]. There is clearly a need for increased immunization research productivity from Africa, especially locally-relevant operational research. During the new decade of vaccines [41, 42], African countries should prioritize research capacity development in vaccinology. In general, Africa requires strong leadership and political commitment, going forward, in the development of research capacity on the continent.

PubMed has been widely used for bibliometric analyses, but it is important to note that the database is dominated by English-language journals, therefore, possibly contributing to selection bias due to language barriers. By using the author addresses listed in the by-lines of research articles, one can only identify countries and organizations where the authors were employed when the research was done or where the article was written, or both. These limitations notwithstanding, we believe that this study is a good reflection of research productivity in the field of childhood immunization in Africa.

There is an enormous range of locally-relevant research that could be undertaken to support routine childhood immunization programs in Africa [12, 14]. This would inform the development of strategic immunization plans whose implementation will raise immunization coverage and prevent disease, disability and death on the continent [12, 14]. This bibliometric study examined almost four decades of childhood immunization research production by authors from Africa. The results of the study show that the five most productive countries, in terms of absolute number of publications indexed by PubMed from 1974 to 2010, are South Africa, Nigeria, The Gambia, Egypt and Kenya. Based on the best possible estimate, the most significant determinant of immunization research productivity in Africa is private health expenditure. The lack of association between research productivity and immunization coverage may be an indication of the lack of interactive communication between health decision-makers, programme managers and researchers, to ensure that immunization policies and plans are always informed by the best available evidence.