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Ravi SJ, Vecino-Ortiz AI, Potter CM, Merritt MW, Patenaude BN. Group-based trajectory models of integrated vaccine delivery and equity in low- and middle-income countries. Int J Equity Health 2024; 23:5. [PMID: 38195588 PMCID: PMC10775446 DOI: 10.1186/s12939-023-02088-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/26/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Integrated vaccine delivery - the linkage of routine vaccination with provision of other essential health services - is a hallmark of robust primary care systems that has been linked to equitable improvements in population health outcomes. METHODS We gathered longitudinal data relating to routine immunization coverage and vaccination equity in 78 low- and middle-income countries that have ever received support from Gavi, the Vaccine Alliance, using multiple imputation to handle missing values. We then estimated several group-based trajectory models to describe the relationship between integrated vaccine delivery and vaccination equity in these countries. Finally, we used multinomial logistic regression to identify predictors of group membership. RESULTS We identified five distinct trajectories of geographic vaccination equity across both the imputed and non-imputed datasets, along with two and four trajectories of socioeconomic vaccination equity in the imputed and non-imputed datasets, respectively. Integration was associated with reductions in the slope index of inequality of measles vaccination in the countries analyzed. Integration was also associated with an increase in the percentage of districts reporting high measles vaccination coverage. CONCLUSIONS Integrated vaccine delivery is most strongly associated with improvements in vaccination equity in settings with high baseline levels of inequity. Continued scholarship is needed to further characterize the relationship between integration and health equity, as well as to improve measurement of vaccination coverage and integration.
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Affiliation(s)
- Sanjana J Ravi
- Center for Health Security, Johns Hopkins Bloomberg School of Public Health, 700 East Pratt Street, Suite 900, Baltimore, MD, 21202, USA.
| | - Andrés I Vecino-Ortiz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Suite E8527, Baltimore, MD, 21205, USA
| | - Christina M Potter
- Center for Health Security, Johns Hopkins Bloomberg School of Public Health, 700 East Pratt Street, Suite 900, Baltimore, MD, 21202, USA
| | - Maria W Merritt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Suite E8527, Baltimore, MD, 21205, USA
- Berman Institute of Bioethics, Johns Hopkins Bloomberg School of Public Health, 1809 Ashland Avenue, Baltimore, MD, 21205, USA
| | - Bryan N Patenaude
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Suite E8527, Baltimore, MD, 21205, USA
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, 415 North Washington Street, 5th Floor, Baltimore, MD, 21231, USA
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Cunha NSP, de Olinda RA, Fahrat SCL, Barbieri CLA, Braga ALF, Pamplona YDAP, Martins LC. Spatial analysis of vaccine coverage in children under the age of 1 year by mesoregions in Paraíba a northeastern Brazilian state. PLoS One 2023; 18:e0288651. [PMID: 37463166 DOI: 10.1371/journal.pone.0288651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/30/2023] [Indexed: 07/20/2023] Open
Abstract
Immunization is one of the most effective measures in public health, and it is responsible for the reduction of vaccine-preventable diseases. In the present study, vaccine coverage (VC) and the spatial dynamics of homogeneity of VC (HVC) were compared and analyzed in the terms of the immunobiologicals administered to children aged < 1 year in a state in Paraíba, Brazil. This is a mixed ecological study that used public-domain secondary data from the years 2016 and 2017 from the Information System of the Brazilian National Immunization Program (SI-PNI) and the Brazilian National Information System of Live Births (SINASC). VC rates were calculated by dividing the number of administered doses by the number of live births. Then, VC was classified into four categories. The Municipal HVC was considered adequate when the overall VC exceeds 75%. The study included a descriptive analysis and a spatial autocorrelation analysis for HVC using global and local Moran's statistics. The stratified VC analysis revealed a significant number of municipalities in each of the state's mesoregions with low or very low VC rates for all immunobiologicals, with the Mata Paraibana mesoregion having the worst percentages in both years studied. The spatial analysis of HVC revealed several clusters of inadequate homogeneity, with Mata Paraibana being the worst mesoregion in 2016. The analysis of spatial dynamics and spatial statistics techniques allows the precise identification of vulnerable areas, "vaccination pockets," making it possible to develop plans aimed at meeting the targets of the PNI.
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Affiliation(s)
- Nairmara Soares Pimentel Cunha
- Vaccine Observatory, Stricto Sensu Graduate Program in Collective Health of the Catholic University of Santos, Santos, São Paulo, Brazil
- Children's Institute, University Clinics Hospital, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Sylvia Costa Lima Fahrat
- Children's Institute, University Clinics Hospital, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Carolina Luisa Alves Barbieri
- Vaccine Observatory, Stricto Sensu Graduate Program in Collective Health of the Catholic University of Santos, Santos, São Paulo, Brazil
| | - Alfésio Luís Ferreira Braga
- Environmental Exposure and Risk Assessment Group, Stricto Sensu Graduate Program in Collective Health of the Catholic University of Santos, Santos, São Paulo, Brazil
| | - Ysabely de Aguiar Pontes Pamplona
- Vaccine Observatory, Stricto Sensu Graduate Program in Collective Health of the Catholic University of Santos, Santos, São Paulo, Brazil
- Environmental Exposure and Risk Assessment Group, Stricto Sensu Graduate Program in Collective Health of the Catholic University of Santos, Santos, São Paulo, Brazil
| | - Lourdes Conceição Martins
- Vaccine Observatory, Stricto Sensu Graduate Program in Collective Health of the Catholic University of Santos, Santos, São Paulo, Brazil
- Environmental Exposure and Risk Assessment Group, Stricto Sensu Graduate Program in Collective Health of the Catholic University of Santos, Santos, São Paulo, Brazil
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Datta SS, Martinón-Torres F, Berdzuli N, Cakmak N, Edelstein M, Cottrell S, Muscat M. Addressing Determinants of Immunization Inequities Requires Objective Tools to Devise Local Solutions. Vaccines (Basel) 2023; 11:811. [PMID: 37112723 PMCID: PMC10145207 DOI: 10.3390/vaccines11040811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/28/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Universal immunization substantially reduces morbidity and mortality from vaccine-preventable diseases. In recent years, routine immunization coverage has varied considerably among countries across the WHO European Region, and among different populations and districts within countries. It has even declined in some countries. Sub-optimal immunization coverage contributes to accumulations of susceptible individuals and can lead to outbreaks of vaccine-preventable diseases. The European Immunization Agenda 2030 (EIA2030) seeks to build better health in the WHO European Region by ensuring equity in immunization and supporting immunization stakeholders in devising local solutions to local challenges. The factors that influence routine immunization uptake are context specific and multifactorial; addressing immunization inequities will require overcoming or removing barriers to vaccination for underserved individuals or populations. Local level immunization stakeholders must first identify the underlying causes of inequities, and based on this information, tailor resources, or service provision to the local context, as per the organization and characteristics of the health care system in their countries. To do this, in addition to using the tools already available to broadly identify immunization inequities at the national and regional levels, they will need new pragmatic guidance and tools to address the identified local challenges. It is time to develop the necessary guidance and tools and support immunization stakeholders at all levels, especially those at the subnational or local health centre levels, to make the vision of EIA2030 a reality.
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Affiliation(s)
- Siddhartha Sankar Datta
- Vaccine-Preventable Diseases and Immunization Programme, World Health Organization Regional Office for Europe, DK-2100 Copenhagen, Denmark
| | - Federico Martinón-Torres
- Translational Pediatrics and Infectious Diseases, Hospital Clínico Universitario and Universidad de Santiago de Compostela, 15706 Galicia, Spain
| | - Nino Berdzuli
- Division of Country Health Programmes, World Health Organization Regional Office for Europe, DK-2100 Copenhagen, Denmark
| | - Niyazi Cakmak
- Vaccine-Preventable Diseases and Immunization Programme, World Health Organization Regional Office for Europe, DK-2100 Copenhagen, Denmark
| | - Michael Edelstein
- Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan 5290002, Israel
| | - Simon Cottrell
- Vaccine Preventable Disease Programme, Public Health Wales NHS Trust, Cardiff CF10 4BZ, UK
| | - Mark Muscat
- Vaccine-Preventable Diseases and Immunization Programme, World Health Organization Regional Office for Europe, DK-2100 Copenhagen, Denmark
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Perin L, Dal Zotto A, Savio M, Stano A, Bulegato L, Tribbia L, Donà R, Tomasi M, Fietta S, Ferro A, Baldo V, Saugo M, Cocchio S. Widening Disparities in Teen HPV Vaccinations during COVID-19 Pandemic: A Case Study from Veneto Region (Italy). Vaccines (Basel) 2022; 10:vaccines10122120. [PMID: 36560530 PMCID: PMC9782394 DOI: 10.3390/vaccines10122120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/29/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION In Local Health Unit 7, human papilloma virus (HPV) vaccination campaigns for 12-year-olds have long been implemented by the vaccination services of the Department of Prevention. Due to the pressure of the COVID-19 pandemic on these services, an emergency vaccination campaign was directly managed by primary care pediatricians (PCPs). An initial evaluation of this experience was conducted. MATERIALS AND METHODS Data on 12-year-olds assisted by PCPs belonging to the 2006 (pre-pandemic) and 2008 (pandemic) birth cohorts were extracted, along with HPV vaccination data. Health district, gender, citizenship, socioeconomic status, and PCPs were evaluated as possible influencing factors in a two-level logistic regression (second level: single PCP). RESULTS The HPV vaccination gap between males and females increased significantly for the 2008 birth cohort compared to the 2006 birth cohort (11 vs. 4 percentage points). As for PCPs, the vaccination uptake range was 4-71% for the 2008 birth cohort vs. 32-85% for the 2006 cohort. The proportion of variance explained at the second level was overall equal to 9.7% for the 2008 cohort vs. 3.6% for the 2006 cohort. CONCLUSIONS The vaccination campaign carried out during the peak of the COVID-19 pandemic increased the HPV vaccination gaps among Health Districts, genders, and individual PCPs, probably due to a lack of homogeneity in professional practices and attitudes toward HPV vaccination. Catch-up interventions are required in the immediate term, while an equity-lens approach should be taken for reprogramming the vaccination campaign. Greater involvement of schools and families could ensure a more equitable approach and a better uptake.
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Affiliation(s)
- Luca Perin
- Department of Prevention of Local Health Unit n. 7, Veneto Region, 31011 Venice, Italy
| | - Alessandra Dal Zotto
- Department of Prevention of Local Health Unit n. 7, Veneto Region, 31011 Venice, Italy
| | - Marta Savio
- Post-Graduate School of Hygiene and Preventive Medicine, Department of Environmental and Prevention Sciences, University of Ferrara, 44121 Ferrara, Italy
| | - Antonio Stano
- Department of Prevention of Local Health Unit n. 7, Veneto Region, 31011 Venice, Italy
| | - Lorenzo Bulegato
- Department of Prevention of Local Health Unit n. 7, Veneto Region, 31011 Venice, Italy
| | - Luca Tribbia
- Department of Prevention of Local Health Unit n. 7, Veneto Region, 31011 Venice, Italy
| | - Roberta Donà
- Department of Prevention of Local Health Unit n. 7, Veneto Region, 31011 Venice, Italy
| | - Matilde Tomasi
- Department of Prevention of Local Health Unit n. 7, Veneto Region, 31011 Venice, Italy
| | - Silvia Fietta
- Department of Prevention of Local Health Unit n. 7, Veneto Region, 31011 Venice, Italy
| | - Antonio Ferro
- Italian Society of Hygiene, Preventive Medicine and Public Health, 10126 Torino, Italy
| | - Vincenzo Baldo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padova, Italy
| | - Mario Saugo
- Department of Prevention of Local Health Unit n. 7, Veneto Region, 31011 Venice, Italy
- Correspondence:
| | - Silvia Cocchio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padova, Italy
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Kissi J, Owusu-Marfo J, Osei E, Dzamvivie K, Akorfa Anku V, Naa Lamiokor Lamptey J. Effects of coronavirus pandemic on expanded program on immunization in weija gbawe municipality (Accra-Ghana). Hum Vaccin Immunother 2022; 18:2129830. [PMID: 36194867 DOI: 10.1080/21645515.2022.2129830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The introduction of Expanded Program on Immunization (EPI) and the availability of vaccines have contributed to significant reduction in morbidity and mortality rate, particularly among infants and children under five years. The coronavirus pandemic has however interrupted vaccination systems, limiting access and coverage for children. This study assesses the effect of the coronavirus disease outbreak on the EPI activities. The study employed a cross-sectional study design. Purposive and convenience sampling methods were used to sample 510 health workers directly engaged in immunization activities from 15 health care facilities. Coverages for five selected antigens (Diphtheria, Tetanus, Pertussis, Poliomyelitis, Tuberculosis) and Measles in the year 2020 experienced an overall decline ranging from 38.8% for measles rubella vaccine to 53.1% for Penta vaccine. The year 2019 recorded coverages ranging from 69.1% for BCG vaccine to 78.4% for penta vaccine, relatively higher than 2020. EPI services patronization rose up after COVID-19 peaks periods for BCG vaccine 67.7% to 89.2% for penta vaccine. The COVID-19 pandemic disrupted the delivery of EPI services significantly. Healthcare stakeholders can envisage telehealth services in care delivery against pandemic outbreaks. This study contributes to empirical knowledge by recommending vital predictive factors during a pandemic outbreak.
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Affiliation(s)
- Jonathan Kissi
- School of Allied Health Sciences, Department of Health Information Management, University of Cape Coast, University Post Office, Cape Coast, Ghana
| | - Joseph Owusu-Marfo
- Department of Epidemiology, Biostatistics and Disease Control, University for Development Studies, Tamale, Ghana
| | - Ernest Osei
- Faculty of Health and Allied Sciences, Catholic University of Ghana, Sunyani, Ghana
| | - Kennedy Dzamvivie
- School of Allied Health Sciences, Department of Health Information Management, University of Cape Coast, University Post Office, Cape Coast, Ghana
| | - Vivian Akorfa Anku
- Department of Epidemiology and Disease Control, University of Ghana, Accra, Ghana
| | - Jessica Naa Lamiokor Lamptey
- School of Allied Health Sciences, Department of Health Information Management, University of Cape Coast, University Post Office, Cape Coast, Ghana
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Cunha NSP, Fahrat SCL, de Olinda RA, Braga ALF, Barbieri CLA, de Aguiar Pontes Pamplona Y, Martins LC. Spatial analysis of vaccine coverage on the first year of life in the northeast of Brazil. BMC Public Health 2022; 22:1204. [PMID: 35710366 PMCID: PMC9202142 DOI: 10.1186/s12889-022-13589-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Over time, vaccination has been consolidated as one of the most cost effective and successful public health interventions and a right of every human being. This study aimed to assess the spatial dynamics of the vaccine coverage (VC) rate of children aged < 1 year per municipality in the Brazilian Northeast at 2016 and 2017. Methods This is a mixed-type ecological study that use a Public domain data Health Information. Vaccine doses were obtained from the Information System of the Brazilian National Immunization Program, and live births from the Brazilian Information System of Live Births of the Brazilian Unified Health System. Descriptive analysis of the coverage of all the vaccines for each year of the study was conducted, and Mann–Whitney U test was used to compare VC between the study years. Chi-squared test was used to evaluate the association between the years and VC, which was stratified into four ranges, very low, low, adequate, and high. Spatial distribution was analyzed according to both each study year and vaccine and presented as thematic maps. Spatial autocorrelation was analyzed using Moran’s Global and Local statistics. Results Compared with 2017, 2016 showed better VC (p < 0.05), except for Bacillus Calmette–Guérin. In the spatial analysis of the studied vaccines, the Global Moran’s Index did not show any spatial autocorrelation (p > 0.05), but the Local Moran’s Index showed some municipalities, particularly the Sertão Paraibano region, with high VC, high similarity, and a positive influence on neighboring municipalities (p < 0.05). In contrast, most municipalities with low VC were concentrated in the Mata Paraibano region, negatively influencing their neighbors (p < 0.05). Conclusion Uneven geographic regions and clusters of low VC for children aged < 1 year in the State of Paraíba were spatially visualized. Health policy makers and planners need to urgently devise and coordinate an action plan directed at each state’s regions to fulfill the vaccination calendar, thereby reversing the vulnerability of this age group, which is at a higher risk of diseases preventable by vaccination.
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Affiliation(s)
- Nairmara Soares Pimentel Cunha
- Catholic University of Santos (Universidade Católica de Santos - Programa de Pós- Graduação strictu senso em Saúde Coletiva), Av. Conselheiro Nebias, 300, sala 106; Santos, São Paulo, CEP: 11.015-002, Brazil.,Instituto da Criança, Hospital das Clínicas - Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Sylvia Costa Lima Fahrat
- Instituto da Criança, Hospital das Clínicas - Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Alfésio Luís Ferreira Braga
- Catholic University of Santos (Universidade Católica de Santos - Programa de Pós- Graduação strictu senso em Saúde Coletiva), Av. Conselheiro Nebias, 300, sala 106; Santos, São Paulo, CEP: 11.015-002, Brazil
| | - Carolina Luisa Alves Barbieri
- Catholic University of Santos (Universidade Católica de Santos - Programa de Pós- Graduação strictu senso em Saúde Coletiva), Av. Conselheiro Nebias, 300, sala 106; Santos, São Paulo, CEP: 11.015-002, Brazil
| | - Ysabely de Aguiar Pontes Pamplona
- Catholic University of Santos (Universidade Católica de Santos - Programa de Pós- Graduação strictu senso em Saúde Coletiva), Av. Conselheiro Nebias, 300, sala 106; Santos, São Paulo, CEP: 11.015-002, Brazil
| | - Lourdes Conceição Martins
- Catholic University of Santos (Universidade Católica de Santos - Programa de Pós- Graduação strictu senso em Saúde Coletiva), Av. Conselheiro Nebias, 300, sala 106; Santos, São Paulo, CEP: 11.015-002, Brazil.
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Argaw MD, Desta BF, Tsegaye ZT, Mitiku AD, Atsa AA, Tefera BB, Rogers D, Teferi E, Abera WS, Beshir IA, Kora ZA, Setegn S, Anara AA, Sinamo T, Muloiwa R. Immunization data quality and decision making in pertussis outbreak management in southern Ethiopia: a cross sectional study. Arch Public Health 2022; 80:49. [PMID: 35164861 PMCID: PMC8842801 DOI: 10.1186/s13690-022-00805-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study was to investigate the quality of immunization data and monitoring systems in the Dara Malo District (Woreda) of the Gamo Administrative Zone, within the Southern Nations, Nationalities, and Peoples’ Region (SNNPR) of Ethiopia. Methods A cross-sectional study was conducted from August 4 to September 27, 2019, in Dara Malo District. The district was purposively selected during the management of a pertussis outbreak, based on a hypothesis of ‘there is no difference in reported and recounted immunization status of children 7 to 23 months in Dara Malo District of Ethiopia’. The study used the World Health Organization (WHO) recommended Data Quality Self-Assessment (DQS) tools. The accuracy ratio was determined using data from routine Expanded Program of Immunization (EPI) and household surveys. Facility data spanning the course of 336 months were abstracted from EPI registers, tally sheets, and monthly routine reports. In addition, household surveys collected data from caretakers, immunization cards, or oral reports. Trained DQS assessors collected the data to explore the quality of monitoring systems at health posts, health centers, and at the district health office level. A quality index (QI) and proportions of completeness, timeliness, and accuracy ratio of the first and third doses of pentavalent vaccines and the first dose of measles-containing vaccines (MCV) were formulated. Results In this study, facility data spanning 336 months were extracted. In addition, 595 children aged 7 to 23 months, with a response rate of 94.3% were assessed and compared for immunization status, using register and immunization cards or caretakers’ oral reports through the household survey. At the district level, the proportion of the re-counted vaccination data on EPI registers for first dose pentavalent was 95.20%, three doses of pentavalent were 104.2% and the first dose of measles was 98.6%. However, the ratio of vaccination data compared using tallies against the reports showed evidence of overreporting with 50.8%, 45.1%, and 46.5% for first pentavalent, third pentavalent, and the first dose of measles vaccinations, respectively. The completeness of the third dose of pentavalent vaccinations was 95.3%, 95.6%, and 100.0% at health posts, health centers, and the district health office, respectively. The timeliness of the immunization reports was 56.5% and 64.6% at health posts and health centers, respectively, while the district health office does not have timely submitted on time to the next higher level for twelve months. The QI scores ranged between 61.0% and 80.5% for all five categories, namely, 73.0% for recording, 71.4% for archiving and reporting, 70.4% for demographic information, 69.7% for core outputs, and 70.4% for data use and were assessed as suboptimal at all levels. The district health office had an emergency preparedness plan. However, pertussis was not on the list of anticipated outbreaks. Conclusion Immunization data completeness was found to be optimal. However, in the study area, the accuracy, consistency, timeliness, and quality of the monitoring system were found to be suboptimal. Therefore, poor data quality has led to incorrect decision making during the reported pertussis outbreak management. Availing essential supplies, including tally sheets, monitoring charts, and stock management tools, should be prioritized in Daro Malo District. Enhancing the capacity of healthcare providers on planning, recording, archiving, and reporting, analyzing, and using immunization data for evidence-based decision making is recommended. Improving the availability of recording and reporting tools is also likely to enhance the data accuracy and completeness of the community health information system. Adapting pertussis outbreak management guidelines and conducting regular data quality assessments with knowledge sharing events to all stakeholders is recommended. Supplementary Information The online version contains supplementary material available at 10.1186/s13690-022-00805-6.
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Affiliation(s)
- Mesele Damte Argaw
- USAID Transform: Primary Health Care Project, JSI Research & Training Institute, Inc, Addis Ababa, Ethiopia.
| | - Binyam Fekadu Desta
- USAID Transform: Primary Health Care Project, JSI Research & Training Institute, Inc, Addis Ababa, Ethiopia
| | - Zergu Taffesse Tsegaye
- USAID Transform: Primary Health Care Project, JSI Research & Training Institute, Inc, Addis Ababa, Ethiopia
| | - Aychiluhim Damtew Mitiku
- USAID Transform: Primary Health Care Project, JSI Research & Training Institute, Inc, Addis Ababa, Ethiopia
| | | | - Bekele Belayihun Tefera
- USAID Transform: Primary Health Care Project, Pathfinder International, Addis Ababa, Ethiopia
| | - Deirdre Rogers
- JSI Research & Training Institute, Inc. Boston, Boston, USA
| | - Ephrem Teferi
- USAID Transform: Primary Health Care Project, JSI Research & Training Institute, Inc, Addis Ababa, Ethiopia
| | - Wondwosen Shiferaw Abera
- USAID Transform: Primary Health Care Project, JSI Research & Training Institute, Inc, Addis Ababa, Ethiopia
| | - Ismael Ali Beshir
- USAID Transform: Primary Health Care Project, JSI Research & Training Institute, Inc, Addis Ababa, Ethiopia
| | - Zelalem Abera Kora
- USAID Transform: Primary Health Care Project, JSI Research & Training Institute, Inc, Addis Ababa, Ethiopia
| | - Sisay Setegn
- USAID Transform: Primary Health Care Project, JSI Research & Training Institute, Inc, Addis Ababa, Ethiopia
| | - Amare Assefa Anara
- USAID Transform: Primary Health Care Project, JSI Research & Training Institute, Inc, Addis Ababa, Ethiopia
| | - Tadelech Sinamo
- USAID Transform: Primary Health Care Project, JSI Research & Training Institute, Inc, Addis Ababa, Ethiopia
| | - Rudzani Muloiwa
- Department of Paediatrics & Child Health, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Bandara T, Neudorf C, Muhajarine N. An equity-based assessment of immunization-related responses in urban Alberta during the 2014 measles outbreak: a comparative analysis between Calgary and Edmonton. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2022; 113:422-432. [PMID: 35025101 PMCID: PMC9043142 DOI: 10.17269/s41997-021-00578-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 09/20/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVES This study investigates measles, mumps, and rubella (MMR) immunization rates during the measles outbreak in Calgary and Edmonton of 2014 stratified by four area-level socio-demographic indicators. This study also leverages this epidemiological data to assess the equity aspect of emergency measures instituted regarding immunization in those two cities. METHODS A mixed-methods comparative case study analysis methodology was employed to assess the neighbourhood-level immunization statuses before (2013), during (2014), and after (2015) an active measles outbreak in Calgary and Edmonton, Alberta, Canada. The epidemiological one-dose by age-2 MMR coverage data were stratified using four socio-demographic indicators: median household income, %-homeownership, %-Aboriginal population, and %-immigrant population. Document and content analysis was utilized to investigate the outbreak mitigation strategies deployed in each city. RESULTS The measles outbreak of 2013/2014 involved the entirety of Alberta and led to both provincial and city-specific interventions in which Calgary deployed three mass immunization clinics in 2014, where Edmonton did not. The Calgary coverage data showed an increase in coverage inequalities across all indicators and the Edmonton data showed mixed results in terms of equity gains/losses. Calgary's additive intervention of three mass immunization clinics in 2014 appears to have contributed to both the higher gross immunization rates in Calgary (90.77%) and an inequitable increase in coverage rates as compared with Edmonton (88.96%), in most cases. CONCLUSION Public health policy-makers must be cognizant that large-scale public health efforts must be optimized for accessibility across all socio-economic levels to ensure public and population health gains are realized equitably.
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Affiliation(s)
- Thilina Bandara
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK Canada
| | - Cory Neudorf
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK Canada
| | - Nazeem Muhajarine
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK Canada
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9
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Patel PN, Hada M, Carlson BF, Boulton ML. Immunization status of children in Nepal and associated factors, 2016. Vaccine 2021; 39:5831-5838. [PMID: 34456076 DOI: 10.1016/j.vaccine.2021.08.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nepal has made substantial improvements in childhood immunization uptake. However, vaccination levels are still below the country-specific Sustainable Development Goal target of 94.8% coverage by 2025 for children aged 12-23 months who received all immunizations recommended in the national immunization schedule by their first birthday. A better understanding of the predictors of full immunization can inform successful programmatic interventions to improve coverage while also guiding resource allocation to ensure all children are fully vaccinated. This study estimates childhood immunization coverage in Nepal and characterizes the association between immunization status and various sociodemographic predictors. METHODS Data from the 2016 Nepal Demographic and Health Survey were used to examine the immunization status of children aged 12-23 months. Immunization status was categorized as fully immunized (receiving all recommended doses), under-immunized (receiving at least one, but not all, recommended doses), and un-immunized (not receiving any doses of any vaccine). Associations between full and under-immunization and potential sociodemographic predictors were assessed using logistic regression. RESULTS Among 976 children, 78.2% were fully immunized, 21% were under-immunized, and 0.8% were un-immunized. Retention of an immunization card was significantly associated with full immunization status. Mothers who had completed a formal education above secondary school and mothers who were working at time of interview had increased odds of full immunization. Birthing in an institutional setting was also associated with higher odds of full immunization. CONCLUSIONS Overall, immunization coverage in Nepal is relatively high, although it varies by dose and sociodemographic factors. Almost 25% of Nepalese children were not fully immunized, leaving them at increased risk for vaccine-preventable disease related morbidity and mortality. Nepal must continue focused efforts to reach every child and minimize the equity gap; programs may focus on advocating for the use of immunization cards, education and empowerment for girls, and delivery in institutional settings.
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Affiliation(s)
- Pooja N Patel
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, USA
| | - Manila Hada
- Division of Epidemiology I, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD 20993, USA
| | - Bradley F Carlson
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, USA
| | - Matthew L Boulton
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, USA; Department of Internal Medicine, Division of Infectious Disease, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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10
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Decouttere C, De Boeck K, Vandaele N. Advancing sustainable development goals through immunization: a literature review. Global Health 2021; 17:95. [PMID: 34446050 PMCID: PMC8390056 DOI: 10.1186/s12992-021-00745-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 07/23/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Immunization directly impacts health (SDG3) and brings a contribution to 14 out of the 17 Sustainable Development Goals (SDGs), such as ending poverty, reducing hunger, and reducing inequalities. Therefore, immunization is recognized to play a central role in reaching the SDGs, especially in low- and middle-income countries (LMICs). Despite continuous interventions to strengthen immunization systems and to adequately respond to emergency immunization during epidemics, the immunization-related indicators for SDG3 lag behind in sub-Saharan Africa. Especially taking into account the current Covid19 pandemic, the current performance on the connected SDGs is both a cause and a result of this. METHODS We conduct a literature review through a keyword search strategy complemented with handpicking and snowballing from earlier reviews. After title and abstract screening, we conducted a qualitative analysis of key insights and categorized them according to showing the impact of immunization on SDGs, sustainability challenges, and model-based solutions to these challenges. RESULTS We reveal the leveraging mechanisms triggered by immunization and position them vis-à-vis the SDGs, within the framework of Public Health and Planetary Health. Several challenges for sustainable control of vaccine-preventable diseases are identified: access to immunization services, global vaccine availability to LMICs, context-dependent vaccine effectiveness, safe and affordable vaccines, local/regional vaccine production, public-private partnerships, and immunization capacity/capability building. Model-based approaches that support SDG-promoting interventions concerning immunization systems are analyzed in light of the strategic priorities of the Immunization Agenda 2030. CONCLUSIONS In general terms, it can be concluded that relevant future research requires (i) design for system resilience, (ii) transdisciplinary modeling, (iii) connecting interventions in immunization with SDG outcomes, (iv) designing interventions and their implementation simultaneously, (v) offering tailored solutions, and (vi) model coordination and integration of services and partnerships. The research and health community is called upon to join forces to activate existing knowledge, generate new insights and develop decision-supporting tools for Low-and Middle-Income Countries' health authorities and communities to leverage immunization in its transformational role toward successfully meeting the SDGs in 2030.
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Affiliation(s)
- Catherine Decouttere
- KU Leuven, Access-To-Medicines research Center, Naamsestraat 69, Leuven, Belgium
| | - Kim De Boeck
- KU Leuven, Access-To-Medicines research Center, Naamsestraat 69, Leuven, Belgium
| | - Nico Vandaele
- KU Leuven, Access-To-Medicines research Center, Naamsestraat 69, Leuven, Belgium
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11
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Ward VC, Weng Y, Bentley J, Carmichael SL, Mehta KM, Mahmood W, Pepper KT, Abdalla S, Atmavilas Y, Mahapatra T, Srikantiah S, Borkum E, Rangarajan A, Sridharan S, Rotz D, Bhattacharya D, Nanda P, Tarigopula UK, Shah H, Darmstadt GL. Evaluation of a large-scale reproductive, maternal, newborn and child health and nutrition program in Bihar, India, through an equity lens. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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12
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Ward VC, Weng Y, Bentley J, Carmichael SL, Mehta KM, Mahmood W, Pepper KT, Abdalla S, Atmavilas Y, Mahapatra T, Srikantiah S, Borkum E, Rangarajan A, Sridharan S, Rotz D, Bhattacharya D, Nanda P, Tarigopula UK, Shah H, Darmstadt GL. Evaluation of a large-scale reproductive, maternal, newborn and child health and nutrition program in Bihar, India, through an equity lens. J Glob Health 2020; 10:021011. [PMID: 33425335 PMCID: PMC7759017 DOI: 10.7189/jogh.10.021011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal and child health program among the most compared to the least marginalised women in Bihar, India. METHODS Utilising survey-weighted logistic regression, we estimated programmatic impact using difference-in-difference estimators from Mathematica data collected at the beginning (2012, n = 10 174) and after two years of program implementation (2014, n = 9611). We also examined changes in disparities over time using eight rounds of Community-based Household Surveys (CHS) (2012-2017, n = 48 349) collected by CARE India. RESULTS At baseline for the Mathematica data, least marginalised women generally performed desired health-related behaviours more frequently than the most marginalised. After two years, most disparities persisted. Disparities increased for skilled birth attendant identification [+16.2% (most marginalised) vs +32.6% (least marginalized), P < 0.01) and skin-to-skin care (+14.8% vs +20.4%, P < 0.05), and decreased for immediate breastfeeding (+10.4 vs -4.9, P < 0.01). For the CHS data, odds ratios compared the most to the least marginalised women as referent. Results demonstrated that disparities were most significant for indicators reliant on access to care such as delivery in a facility (OR range: 0.15 to 0.48) or by a qualified doctor (OR range: 0.08 to 0.25), and seeking care for complications (OR range: 0.26 to 0.64). CONCLUSIONS Disparities observed at baseline generally persisted throughout program implementation. The most significant disparities were observed amongst behaviours dependent upon access to care. Changes in disparities largely were due to improvements for the least marginalised women without improvements for the most marginalised. Equity-based assessments of programmatic impacts, including those of universal health approaches, must be undertaken to monitor disparities and to ensure equitable and sustainable benefits for all. STUDY REGISTRATION ClinicalTrials.gov number NCT02726230.
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Affiliation(s)
- Victoria C Ward
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jason Bentley
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kala M Mehta
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Wajeeha Mahmood
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Safa Abdalla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | | | | | | | | | | | | | - Dana Rotz
- Mathematica, Princeton, New Jersey, USA
| | | | - Priya Nanda
- Bill and Melinda Gates Foundation, Delhi, India
| | | | - Hemant Shah
- Bill and Melinda Gates Foundation, Delhi, India
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
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Abstract
In the World Health Organization (WHO) European Region, differences in uptake rates of routine childhood immunisation persist within and among countries, with rates even falling in some areas. There has been a tendency among national programmes, policymakers and the media in recent years to attribute missed vaccinations to faltering demand or refusal among parents. However, evidence shows that the reasons for suboptimal coverage are multifactorial and include the social determinants of health. At the midpoint in the implementation of the European Vaccine Action Plan 2015–2020 (EVAP), national immunisation programmes should be aware that inequity may be a factor affecting their progress towards the EVAP immunisation targets. Social determinants of health, such as individual and household income and education, impact immunisation uptake as well as general health outcomes – even in high-income countries. One way to ensure optimal coverage is to make inequities in immunisation uptake visible by disaggregating immunisation coverage data and linking them with already available data sources of social determinants. This can serve as a starting point to identify and eliminate underlying structural causes of suboptimal uptake. The WHO Regional Office for Europe encourages countries to make the equitable delivery of vaccination a priority.
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Affiliation(s)
- Tammy Boyce
- Independent consultant, Cardiff, United Kingdom
| | | | - Catharina de Kat
- Vaccine-preventable Diseases and Immunization programme, World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Mark Muscat
- Vaccine-preventable Diseases and Immunization programme, World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Robb Butler
- Vaccine-preventable Diseases and Immunization programme, World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Katrine Bach Habersaat
- Vaccine-preventable Diseases and Immunization programme, World Health Organization Regional Office for Europe, Copenhagen, Denmark
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14
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Geweniger A, Abbas KM. Childhood vaccination coverage and equity impact in Ethiopia by socioeconomic, geographic, maternal, and child characteristics. Vaccine 2020; 38:3627-3638. [PMID: 32253099 PMCID: PMC7171468 DOI: 10.1016/j.vaccine.2020.03.040] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/20/2020] [Accepted: 03/22/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ethiopia is a priority country of Gavi, the Vaccine Alliance to improve vaccination coverage and equitable uptake. The Ethiopian National Expanded Programme on Immunisation (EPI) and the Global Vaccine Action Plan set coverage goals of 90% at national level and 80% at district level by 2020. This study analyses full vaccination coverage among children in Ethiopia and estimates the equity impact by socioeconomic, geographic, maternal and child characteristics based on the 2016 Ethiopia Demographic and Health Survey dataset. METHODS Full vaccination coverage (1-dose BCG, 3-dose DTP3-HepB-Hib, 3-dose polio, 1-dose measles (MCV1), 3-dose pneumococcal (PCV3), and 2-dose rotavirus vaccines) of 2,004 children aged 12-23 months was analysed. Mean coverage was disaggregated by socioeconomic (household wealth, religion, ethnicity), geographic (area of residence, region), maternal (maternal age at birth, maternal education, maternal marital status, sex of household head), and child (sex of child, birth order) characteristics. Concentration indices estimated wealth and education-related inequities, and multiple logistic regression assessed associations between full vaccination coverage and socioeconomic, geographic, maternal, and child characteristics. RESULTS Full vaccination coverage was 33.3% [29.4-37.2] in 2016. Single vaccination coverage ranged from 49.1% [45.1-53.1] for PCV3 to 69.2% [65.5-72.8] for BCG. Wealth and maternal education related inequities were pronounced with concentration indices of 0.30 and 0.23 respectively. Children in Addis Ababa and Dire Dawa were seven times more likely to have full vaccination compared to children living in the Afar region. Children in female-headed households were 49% less likely to have full vaccination. CONCLUSION Vaccination coverage in Ethiopia has a pro-advantaged regressive distribution with respect to both household wealth and maternal education. Children from poorer households, rural regions of Afar and Somali, no maternal education, and female-headed households had lower full vaccination coverage. Targeted programmes to reach under-immunised children in these subpopulations will improve vaccination coverage and equity outcomes in Ethiopia.
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Affiliation(s)
- Anne Geweniger
- Center for Paediatrics and Adolescent Medicine, University Medical Center, Faculty of Medicine, University of Freiburg, Germany; Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, United Kingdom.
| | - Kaja M Abbas
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, United Kingdom.
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15
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Vyas P, Kim D, Adams A. Understanding Spatial and Contextual Factors Influencing Intraregional Differences in Child Vaccination Coverage in Bangladesh. Asia Pac J Public Health 2018; 31:51-60. [PMID: 30499306 DOI: 10.1177/1010539518813604] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In Bangladesh, policy discourse has mostly focused on regional inequities in health, including child immunization coverage. Knowledge of local geographical and contextual factors within regions, however, becomes pertinent in efforts to address these inequities. We used the Bangladesh Demographic and Health Survey 2011 to examine factors that influence intraregional differences in vaccination coverage using a multilevel analysis. We found that in spite of the provision of health facilities at each level of administrative governance, only distance to the Upazilla Health Complex was a consistent predictor for each dose of vaccine, highlighting the remote locations of the communities that remain underserved. Our analysis demonstrates the value of subregional analyses that identify the characteristics of communities that are vulnerable to incomplete immunization coverage. Unless specific policy actions are taken to increase coverage in these remote areas, geographic inequities are likely to persist within regions, and desired targets will not be achieved.
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Affiliation(s)
- Priyanka Vyas
- 1 University of California at San Francisco, CA, USA
| | - Dohyeong Kim
- 2 University of Texas at Dallas, Richardson, TX, USA
| | - Alayne Adams
- 3 Georgetown University, Washington, DC, USA.,4 BRAC University, Dhaka, Bangladesh
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16
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Jani B, Hokororo A, Mchomvu J, Cortese MM, Kamugisha C, Mujuni D, Kallovya D, Parashar UD, Mwenda JM, Lyimo D, Materu A, Omari KF, Waziri M, Laswai T, Juma H, Mlay J, Dogani J, Stephen E, Seugendo M, Nkumbi U, Lyakurwa A, Matojo A, Bendera E, Senyota J, Msingwa V, Fungo Y, Michael F, Mpamba A, Chambo A, Cholobi H, Lyamuya F, Chami I, Mchome E, Mshana AM, Mushi E, Mariki U, Chard R, Tuju D, Ambokile N, Lukwale F, Kyessi F, Khamis A, Michael I, Macha D, Saguti A. Detection of rotavirus before and after monovalent rotavirus vaccine introduction and vaccine effectiveness among children in mainland Tanzania. Vaccine 2018; 36:7149-7156. [PMID: 29655631 DOI: 10.1016/j.vaccine.2018.01.071] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/06/2018] [Accepted: 01/29/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Monovalent rotavirus vaccine (RV1) was introduced in Tanzania in January 2013 under the Reach Every Child initiative, to be given at ages 6 and 10 weeks. We used the sentinel hospital rotavirus surveillance system to examine the rotavirus detection rate before and after vaccine introduction and estimate vaccine effectiveness. METHODS Before vaccine introduction, rotavirus surveillance was established at two mainland hospitals; children admitted for acute diarrhea were eligible for enrollment and stools were tested for rotavirus antigen. We compared the rotavirus positivity rate in the pre-vaccine period (Tanga Hospital, 2009 and 2011; Bugando Medical Centre, 2012) to that from post-introduction years, 2014-2015. In 2013, surveillance was established at 9 additional hospitals. We examined rotavirus positivity among infants at these sites for 2014-2015. We obtained vaccine records and calculated vaccine effectiveness at 3 sites using case-test-negative control design. RESULTS At Tanga Hospital, the rotavirus positivity rate among infants was 41% (102/251) pre-vaccine and 14% (28/197) in post-vaccine years (rate ratio: 0.35 [95% CI 0.22-0.54]). At Bugando, the positivity rate was 58% (83/143) pre-vaccine, and 18% (49/277) post-introduction (rate ratio 0.30 [95% CI 0.210.44]). Results were similar among children <5 years. At the new sites, the median site rotavirus positivity rate among infants was 26% in 2014 (range 19-44%) and 18% in 2015 (range 16-33%). The effectiveness of ≥1 RV1 dose against rotavirus hospitalization among children 5-23 months was 53% (95% CI: -14, 81), and 66% (95% CI: 9-87) against hospitalization with intravenous rehydration. Following introduction, peak rotavirus activity occurred later in the year and appeared more concentrated in time. CONCLUSION Rotavirus surveillance data from Tanzania indicate that the rotavirus positivity rate among children hospitalized with diarrhea that were enrolled was substantially reduced after vaccine introduction. Low positivity rates among infants were detected at hospitals across the country. Overall, the data support that rotavirus vaccine has been successfully introduced and is effective in Tanzanian children.
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Affiliation(s)
- Bhavin Jani
- World Health Organization, Country Office, Dar Es Salaam, Tanzania
| | - Adolfine Hokororo
- Bugando Medical Center/Catholic University of Health and Allied Science, Mwanza, Tanzania
| | | | - Margaret M Cortese
- Divison of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | - Delphinius Mujuni
- Ministry of Health Community Development, Gender, Elderly and Children, Dar Es Salaam, Tanzania
| | - Dotto Kallovya
- National Health Laboratory Quality Assurance Training Centre, Dar Es Salaam, Tanzania
| | - Umesh D Parashar
- Divison of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jason M Mwenda
- Regional Office for AFRICA (WHO/AFRO), Brazzaville, Republic of Congo
| | - DaFrossa Lyimo
- Ministry of Health Community Development, Gender, Elderly and Children, Dar Es Salaam, Tanzania
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Grundy J, Rakhimdjanov S, Adhikari M. Policy opportunities and limitations of evidence-based planning for immunization: lessons learnt from a field trial in Bangladesh. WHO South East Asia J Public Health 2017; 5:154-163. [PMID: 28607244 DOI: 10.4103/2224-3151.206253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Despite success in scaling up immunization, the national immunization programme in Bangladesh remains challenged by persisting inequities in health access related to geographic location and social factors, including income and education status. In order to tackle these inequities in access, the national immunization programme has conducted a field trial of the evidence-based planning model in Bangladesh between 2011 and 2013, in 11 low-performing districts and 3 city corporations. The main elements of this intervention included bottleneck analysis in local areas, action planning and budgeting to correct the bottlenecks, and establishment of a monitoring system to track progress. Coverage improved in 8 out of 14 districts post intervention. The main success factors associated with the intervention included more analytic approaches to situation assessment and taking action on health inequities at the local level, as well as more considered use of local data to track immunization drop-outs. The main factors associated with coverage declines in trial areas (6 districts) included poor financial resourcing and supervisory support, and gaps and turnover in human resources. In order to sustain and improve coverage, it will be necessary in future to link pro-equity approaches to subdistrict planning to higher-level health-system-strengthening strategy and planning systems. This will ensure that local area planners have the required resources, comprehensive operational plans and political support to sustain implementation of corrective actions to address identified system bottlenecks and inequities in health access at the local level.
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Affiliation(s)
- John Grundy
- School of Health and Social Development, Deakin University, Melbourne, Australia
| | | | - Merina Adhikari
- United Nations Children's Fund (UNICEF) Country Office, Dhaka, Bangladesh
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Bosch-Capblanch X, Zuske MK, Auer C. Research on subgroups is not research on equity attributes: Evidence from an overview of systematic reviews on vaccination. Int J Equity Health 2017; 16:95. [PMID: 28592273 PMCID: PMC5463415 DOI: 10.1186/s12939-017-0587-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 05/22/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Equity remains a priority in the international health development agenda. However, major inequities in vaccination coverage jeopardise the achievement of the Sustainable Development Goals. We aim at comprehensively describing how research has addressed equity issues related to vaccination. METHODS We carried out an overview of systematic reviews (SRs) that explicitly explored the effects of interventions to improve vaccination in any context; for any vaccine and, in any language. We followed standard research synthesis methods to systematically search for SR, assess them for inclusion and extracting relevant data, particularly on vaccination related outcomes. To gather evidence on equity issues addressed in the SR, we used the PROGRESS-plus framework. FINDINGS Our search obtained 2,003 hits which resulted in 54 included SRs, published between 1994 and 2014. The quality of SRs was generally poor, with less than half complying with most of the quality criteria. Reported vaccines included, by order of frequency, influenza and Expanded Programme on Immunisation vaccines. The types of interventions more frequently reported were related to vaccination delivery strategies, financial support and information, education and communication. Most of the SRs suggested effects favouring intervention groups as opposed to comparison groups. The most frequently reported equity attribute was 'place of residence' and the least reported equity attributes were sexual orientation and religion. Very few estimates of effects actually measured differences or changes between groups having those attributes and all of them referred to the place of residence. No data was found about reducing equity gaps for vulnerable groups or minorities, or attributes such as sexual orientation, education or specific religious groups. CONCLUSIONS Although research on vulnerable populations as a subgroup is abundant, it fails to report on the interventions that will actually reduce inequities and consider how redistribution of health care resources could shrink the gap between the privileged and most vulnerable groups including minorities. Research, if aiming at being responsive to global health policy trends, needs to report not only on specific attributes but also on how a better redistribution of health care resources could contribute to alleviating the unjust situation of the most vulnerable populations.
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Affiliation(s)
- Xavier Bosch-Capblanch
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002 Basel, Switzerland
- Universität Basel, Petersplatz 1, 4003 Basel, Switzerland
| | - Meike-Kathrin Zuske
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002 Basel, Switzerland
- Universität Basel, Petersplatz 1, 4003 Basel, Switzerland
| | - Christian Auer
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002 Basel, Switzerland
- Universität Basel, Petersplatz 1, 4003 Basel, Switzerland
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Kc A, Nelin V, Raaijmakers H, Kim HJ, Singh C, Målqvist M. Increased immunization coverage addresses the equity gap in Nepal. Bull World Health Organ 2017; 95:261-269. [PMID: 28479621 PMCID: PMC5407251 DOI: 10.2471/blt.16.178327] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 12/05/2016] [Accepted: 12/08/2016] [Indexed: 12/02/2022] Open
Abstract
Objective To compare immunization coverage and equity distribution of coverage between 2001 and 2014 in Nepal. Methods We used data from the Demographic and Health Surveys carried out in 2001, 2006 and 2011 together with data from the 2014 Multiple Indicator Cluster Survey. We calculated the proportion, in mean percentage, of children who had received bacille Calmette–Guérin (BCG) vaccine, three doses of polio vaccine, three doses of diphtheria–pertussis–tetanus (DPT) vaccine and measles vaccine. To measure inequities between wealth quintiles, we calculated the slope index of inequality (SII) and relative index of inequality (RII) for all surveys. Findings From 2001 to 2014, the proportion of children who received all vaccines at the age of 12 months increased from 68.8% (95% confidence interval, CI: 67.5–70.1) to 82.4% (95% CI: 80.7–84.0). While coverage of BCG, DPT and measles immunization statistically increased during the study period, the proportion of children who received the third dose of polio vaccine decreased from 93.3% (95% CI: 92.7–93.9) to 88.1% (95% CI: 86.8–89.3). The poorest wealth quintile showed the greatest improvement in immunization coverage, from 58% to 77.9%, while the wealthiest quintile only improved from 84.8% to 86.0%. The SII for children who received all vaccines improved from 0.070 (95% CI: 0.061–0.078) to 0.026 (95% CI: 0.013–0.039) and RII improved from 1.13 to 1.03. Conclusion The improvement in immunization coverage between 2001 and 2014 in Nepal can mainly be attributed to the interventions targeting the disadvantaged populations.
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Affiliation(s)
- Ashish Kc
- United Nations Children's Fund, Nepal Country Office, PO Box 1187, UN House, Pulchowk, Lalitpur, Kathmandu, Nepal
| | - Viktoria Nelin
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Hendrikus Raaijmakers
- United Nations Children's Fund, Nepal Country Office, PO Box 1187, UN House, Pulchowk, Lalitpur, Kathmandu, Nepal
| | - Hyung Joon Kim
- United Nations Children's Fund, Nepal Country Office, PO Box 1187, UN House, Pulchowk, Lalitpur, Kathmandu, Nepal
| | - Chahana Singh
- United Nations Children's Fund, Nepal Country Office, PO Box 1187, UN House, Pulchowk, Lalitpur, Kathmandu, Nepal
| | - Mats Målqvist
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Wu JT, Peak CM, Leung GM, Lipsitch M. Fractional dosing of yellow fever vaccine to extend supply: a modelling study. Lancet 2016; 388:2904-2911. [PMID: 27837923 PMCID: PMC5161610 DOI: 10.1016/s0140-6736(16)31838-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The ongoing yellow fever epidemic in Angola strains the global vaccine supply, prompting WHO to adopt dose sparing for its vaccination campaign in Kinshasa, Democratic Republic of the Congo, in July-August, 2016. Although a 5-fold fractional-dose vaccine is similar to standard-dose vaccine in safety and immunogenicity, efficacy is untested. There is an urgent need to ensure the robustness of fractional-dose vaccination by elucidation of the conditions under which dose fractionation would reduce transmission. METHODS We estimate the effective reproductive number for yellow fever in Angola using disease natural history and case report data. With simple mathematical models of yellow fever transmission, we calculate the infection attack rate (the proportion of population infected over the course of an epidemic) with various levels of transmissibility and 5-fold fractional-dose vaccine efficacy for two vaccination scenarios, ie, random vaccination in a hypothetical population that is completely susceptible, and the Kinshasa vaccination campaign in July-August, 2016, with different age cutoff for fractional-dose vaccines. FINDINGS We estimate the effective reproductive number early in the Angola outbreak was between 5·2 and 7·1. If vaccine action is all-or-nothing (ie, a proportion of vaccine recipients receive complete protection [VE] and the remainder receive no protection), n-fold fractionation can greatly reduce infection attack rate as long as VE exceeds 1/n. This benefit threshold becomes more stringent if vaccine action is leaky (ie, the susceptibility of each vaccine recipient is reduced by a factor that is equal to the vaccine efficacy). The age cutoff for fractional-dose vaccines chosen by WHO for the Kinshasa vaccination campaign (2 years) provides the largest reduction in infection attack rate if the efficacy of 5-fold fractional-dose vaccines exceeds 20%. INTERPRETATION Dose fractionation is an effective strategy for reduction of the infection attack rate that would be robust with a large margin for error in case fractional-dose VE is lower than expected. FUNDING NIH-MIDAS, HMRF-Hong Kong.
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Affiliation(s)
- Joseph T Wu
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.
| | - Corey M Peak
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Gabriel M Leung
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Marc Lipsitch
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
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21
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Arsenault C, Harper S, Nandi A, Rodríguez JMM, Hansen PM, Johri M. An equity dashboard to monitor vaccination coverage. Bull World Health Organ 2016; 95:128-134. [PMID: 28250513 PMCID: PMC5327933 DOI: 10.2471/blt.16.178079] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 09/20/2016] [Accepted: 09/22/2016] [Indexed: 11/27/2022] Open
Abstract
Equity monitoring is a priority for Gavi, the Vaccine Alliance, and for those implementing The2030 agenda for sustainable development. For its new phase of operations, Gavi reassessed its approach to monitoring equity in vaccination coverage. To help inform this effort, we made a systematic analysis of inequalities in vaccination coverage across 45 Gavi-supported countries and compared results from different measurement approaches. Based on our findings, we formulated recommendations for Gavi’s equity monitoring approach. The approach involved defining the vulnerable populations, choosing appropriate measures to quantify inequalities, and defining equity benchmarks that reflect the ambitions of the sustainable development agenda. In this article, we explain the rationale for the recommendations and for the development of an improved equity monitoring tool. Gavi’s previous approach to measuring equity was the difference in vaccination coverage between a country’s richest and poorest wealth quintiles. In addition to the wealth index, we recommend monitoring other dimensions of vulnerability (maternal education, place of residence, child sex and the multidimensional poverty index). For dimensions with multiple subgroups, measures of inequality that consider information on all subgroups should be used. We also recommend that both absolute and relative measures of inequality be tracked over time. Finally, we propose that equity benchmarks target complete elimination of inequalities. To facilitate equity monitoring, we recommend the use of a data display tool – the equity dashboard – to support decision-making in the sustainable development period. We highlight its key advantages using data from Côte d’Ivoire and Haiti.
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Affiliation(s)
- Catherine Arsenault
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, Quebec H3A 1A2, Canada
| | - Sam Harper
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, Quebec H3A 1A2, Canada
| | - Arijit Nandi
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, Quebec H3A 1A2, Canada
| | | | | | - Mira Johri
- Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Canada
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22
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Hosseinpoor AR, Bergen N, Schlotheuber A, Gacic-Dobo M, Hansen PM, Senouci K, Boerma T, Barros AJD. State of inequality in diphtheria-tetanus-pertussis immunisation coverage in low-income and middle-income countries: a multicountry study of household health surveys. Lancet Glob Health 2016; 4:e617-26. [PMID: 27497954 PMCID: PMC4985563 DOI: 10.1016/s2214-109x(16)30141-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 02/05/2016] [Accepted: 06/21/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Immunisation programmes have made substantial contributions to lowering the burden of disease in children, but there is a growing need to ensure that programmes are equity-oriented. We aimed to provide a detailed update about the state of between-country inequality and within-country economic-related inequality in the delivery of three doses of the combined diphtheria, tetanus toxoid, and pertussis-containing vaccine (DTP3), with a special focus on inequalities in high-priority countries. METHODS We used data from the latest available Demographic and Health Surveys and Multiple Indicator Cluster Surveys done in 51 low-income and middle-income countries. Data for DTP3 coverage were disaggregated by wealth quintile, and inequality was calculated as difference and ratio measures based on coverage in richest (quintile 5) and poorest (quintile 1) household wealth quintiles. Excess change was calculated for 21 countries with data available at two timepoints spanning a 10 year period. Further analyses were done for six high-priority countries-ie, those with low national immunisation coverage and/or high absolute numbers of unvaccinated children. Significance was determined using 95% CIs. FINDINGS National DTP3 immunisation coverage across the 51 study countries ranged from 32% in Central African Republic to 98% in Jordan. Within countries, the gap in DTP3 immunisation coverage suggested pro-rich inequality, with a difference of 20 percentage points or more between quintiles 1 and 5 for 20 of 51 countries. In Nigeria, Pakistan, Laos, Cameroon, and Central African Republic, the difference between quintiles 1 and 5 exceeded 40 percentage points. In 15 of 21 study countries, an increase over time in national coverage of DTP3 immunisation was realised alongside faster improvements in the poorest quintile than the richest. For example, in Burkina Faso, Cambodia, Gabon, Mali, and Nepal, the absolute increase in coverage was at least 2·0 percentage points per year, with faster improvement in the poorest quintile. Substantial economic-related inequality in DTP3 immunisation coverage was reported in five high-priority study countries (DR Congo, Ethiopia, Indonesia, Nigeria, and Pakistan), but not Uganda. INTERPRETATION Overall, within-country inequalities in DTP3 immunisation persist, but seem to have narrowed over the past 10 years. Monitoring economic-related inequalities in immunisation coverage is warranted to reveal where gaps exist and inform appropriate approaches to reach disadvantaged populations. FUNDING None.
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Affiliation(s)
- Ahmad Reza Hosseinpoor
- Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland.
| | - Nicole Bergen
- Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland; Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Anne Schlotheuber
- Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
| | - Marta Gacic-Dobo
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | | | - Kamel Senouci
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Ties Boerma
- Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
| | - Aluisio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
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Herlihy N, Hutubessy R, Jit M. Current Global Pricing For Human Papillomavirus Vaccines Brings The Greatest Economic Benefits To Rich Countries. Health Aff (Millwood) 2016; 35:227-34. [DOI: 10.1377/hlthaff.2015.1411] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Niamh Herlihy
- Niamh Herlihy is a research assistant at the Centre Virchow-Villermé de Santé Publique, in Paris, France. At the time of this research, she was a master’s degree student at the London School of Hygiene and Tropical Medicine, in England
| | - Raymond Hutubessy
- Raymond Hutubessy is a senior economist in the Department of Immunization, Vaccines, and Biologicals, World Health Organization, in Geneva, Switzerland
| | - Mark Jit
- Mark Jit (
) is a reader in vaccine epidemiology in the Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine
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24
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Shen AK, Fields R, McQuestion M. The future of routine immunization in the developing world: challenges and opportunities. GLOBAL HEALTH: SCIENCE AND PRACTICE 2014; 2:381-94. [PMID: 25611473 PMCID: PMC4307855 DOI: 10.9745/ghsp-d-14-00137] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Vaccine costs in the developing world have grown from < US$1/child in 2001 to about $21 for boys and $35 for girls in 2014, as more and costlier vaccines are being introduced into national immunization programs. To address these and other challenges, additional efforts are needed to strengthen 8 critical components of routine immunization: (1) policy, standards, and guidelines; (2) governance, organization, and management; (3) human resources; (4) vaccine, cold chain, and logistics management; (5) service delivery; (6) communication and community partnerships; (7) data generation and use; and (8) sustainable financing.
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Affiliation(s)
- Angela K Shen
- United States Agency for International Development and United States Department of Health and Human Services, Washington, DC, USA
| | - Rebecca Fields
- Maternal and Child Survival Program, Washington, DC, USA
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Sissoko D, Trottier H, Malvy D, Johri M. The influence of compositional and contextual factors on non-receipt of basic vaccines among children of 12-23-month old in India: a multilevel analysis. PLoS One 2014; 9:e106528. [PMID: 25211356 PMCID: PMC4161331 DOI: 10.1371/journal.pone.0106528] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 08/05/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Children unreached by vaccination are at higher risk of poor health outcomes and India accounts for nearly a quarter of unvaccinated children worldwide. The objective of this study was to investigate compositional and contextual determinants of non-receipt of childhood vaccines in India using multilevel modelling. METHODS AND FINDINGS We studied characteristics of unvaccinated children using the District Level Health and Facility Survey 3, a nationally representative probability sample containing 65 617 children aged 12-23 months from 34 Indian states and territories. We developed four-level Bayesian binomial regression models to examine the determinants of non-vaccination. The analysis considered two outcomes: completely unvaccinated (CUV) children who had not received any of the eight vaccine doses recommended by India's Universal Immunization Programme, and children who had not received any dose from routine immunisation services (no RI). The no RI category includes CUV children and those who received only polio doses administered via mass campaigns. Overall, 4.83% (95% CI: 4.62-5.06) of children were CUV while 12.01% (11.68-12.35) had received no RI. Individual compositional factors strongly associated with CUV were: non-receipt of tetanus immunisation for mothers during pregnancy (OR = 3.65 [95% CrI: 3.30-4.02]), poorest household wealth index (OR = 2.44 [1.81-3.22] no maternal schooling (OR = 2.43 [1.41-4.05]) and no paternal schooling (OR = 1.83 [1.30-2.48]). In rural settings, the influence of maternal illiteracy disappeared whereas the role of household wealth index was reinforced. Factors associated with no RI were similar to those for CUV, but effect sizes for individual compositional factors were generally larger. Low maternal education was the strongest risk factor associated with no RI in all models. All multilevel models found significant variability at community, district, and state levels net of compositional factors. CONCLUSION Non-vaccination in India is strongly related to compositional characteristics and is geographically distinct. Tailored strategies are required to overcome current barriers to immunisation.
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Affiliation(s)
- Daouda Sissoko
- Department of Social and Preventive Medicine, Faculty of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Sainte-Justine Hospital Research Center, Montreal, Quebec, Canada
- International Health Unit (USI), Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
- * E-mail:
| | - Helen Trottier
- Department of Social and Preventive Medicine, Faculty of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Sainte-Justine Hospital Research Center, Montreal, Quebec, Canada
| | - Denis Malvy
- Département des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- INSERM 897 & Centre René-Labusquière, Université de Bordeaux, Bordeaux, France
| | - Mira Johri
- International Health Unit (USI), Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
- Department of Health Administration, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
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