Household expenditure for immunization among children in India: a two-part model approach

Potential impact of rotavirus vaccine introduction in India's Universal Immunisation Programme on private sector vaccine utilisation: an interrupted time series analysis

BACKGROUND

Despite free immunisation services through the Universal Immunisation Programme (UIP), around 14% of Indian households seek immunisation in the private sector. We examined the potential impact of rotavirus vaccine (RVV) introduction in the Universal Immunisation Programme (UIP) on private-sector rotavirus vaccine utilisation.

METHODS

We analysed nationally representative private-sector vaccine sales data. The intervention under consideration is RVV introduction in the UIP in selected Indian states. The outcome is the 'monthly RVV sales volume'-a proxy for vaccine utilisation. We performed a Poisson regression interrupted time series analysis to detect the pre-intervention trend, post-intervention level change and trend change relative to the pre-intervention for monthly rotavirus vaccine utilisation.

RESULTS

Poisson segmented regression analysis showed that immediately after RVV introduction in the UIP private-sector RVV sales showed a decline in Rajasthan by 37.4% (Incidence Risk Ratio (IRR): 0.626; 95% CI: 0.504-0.779), in Tamil Nadu by 26% (IRR: 0.740; 95% CI: 0.513-1.068), in Uttar Pradesh-East by 72.2% (IRR: 0.278; 95% CI: 0.178-0.436) and in Kerala by 3% (IRR: 0.970; 95% CI: 0.651-1.447). Rajasthan, Tamil Nadu and Kerala had sustained reduction in the postintervention trend relative to the preintervention trend by 20.1% (IRR: 0.799; 95% CI: 0.763-0.836), 6.4% (IRR: 0.936; 95% CI: 0.906-0.967) and 3.3% (IRR: 0.967; 95% CI: 0.926-0.960) per month, respectively. However, in Haryana and UP-west, in the first-month post-UIP introduction, the private-sector RVV sales increased by 101% and 3.8%, respectively which was followed by a sustained decrease of 14.2% (IRR: 0.858; 95% CI: 0.688-1.070) and 5.8% (IRR: 0.942; 95% CI: 0.926-0.960) per month, respectively. In terms of long-term impact, the private sector RVV sales post-UIP introduction decreased at a monthly rate of 4.4% (IRR: 0.956, 95% CI: 0.939-0.974) in Rajasthan but increased by 5.5% (IRR: 1.055; 95% CI: 1.040-1.070) in UP-east, 0.3% (IRR: 1.003, 95% CI: 0.976-1.031)) in Kerala and 0.2% (IRR: 1.002, 95% CI: 0.993-1.011) in Tamil Nadu whereas Haryana and UP-west had a reduction in RVV utilisation by 2.8% (IRR: 0.972; 95% CI: 0.955-0.990) and 1% (IRR: 0.990; 95% CI: 0.982-0.998), respectively.

CONCLUSIONS

The study provides evidence that access to RVV through UIP leads to a reduction in private-sector RVV utilisation. We recommend strengthening UIP to expand the basket of new vaccines.

Systematic review of social determinants of childhood immunisation in low- and middle-income countries and equity impact analysis of childhood vaccination coverage in Nigeria

BACKGROUND

Nigeria has a high proportion of the world's underimmunised children. We estimated the inequities in childhood immunisation coverage associated with socioeconomic, geographic, maternal, child, and healthcare characteristics among children aged 12-23 months in Nigeria using a social determinants of health perspective.

METHODS

We conducted a systematic review to identify the social determinants of childhood immunisation associated with inequities in vaccination coverage among low- and middle-income countries. Using the 2018 Nigeria Demographic and Health Survey (DHS), we conducted multiple logistic regression to estimate the association between basic childhood vaccination coverage (1-dose BCG, 3-dose DTP-HepB-Hib (diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type B), 3-dose polio, and 1-dose measles) and socioeconomic, geographic, maternal, child, and healthcare characteristics in Nigeria.

RESULTS

From the systematic review, we identified the key determinants of immunisation to be household wealth, religion, and ethnicity for socioeconomic characteristics; region and place of residence for geographic characteristics; maternal age at birth, maternal education, and household head status for maternal characteristics; sex of child and birth order for child characteristics; and antenatal care and birth setting for healthcare characteristics. Based of the 2018 Nigeria DHS analysis of 6,059 children aged 12-23 months, we estimated that basic vaccination coverage was 31% (95% CI: 29-33) among children aged 12-23 months, whilst 19% (95% CI:18-21) of them were zero-dose children who had received none of the basic vaccines. After controlling for background characteristics, there was a significant increase in the odds of basic vaccination by household wealth (AOR: 3.21 (2.06, 5.00), p < 0.001) for the wealthiest quintile compared to the poorest quintile, antenatal care of four or more antenatal care visits compared to no antenatal care (AOR: 2.87 (2.21, 3.72), p < 0.001), delivery in a health facility compared to home births (AOR 1.32 (1.08, 1.61), p = 0.006), relatively older maternal age of 35-49 years compared to 15-19 years (AOR: 2.25 (1.46, 3.49), p < 0.001), and maternal education of secondary or higher education compared to no formal education (AOR: 1.79 (1.39, 2.31), p < 0.001). Children of Fulani ethnicity in comparison to children of Igbo ethnicity had lower odds of receiving basic vaccinations (AOR: 0.51 (0.26, 0.97), p = 0.039).

CONCLUSIONS

Basic vaccination coverage is below target levels for all groups. Children from the poorest households, of Fulani ethnicity, who were born in home settings, and with young mothers with no formal education nor antenatal care, were associated with lower odds of basic vaccination in Nigeria. We recommend a proportionate universalism approach for addressing the immunisation barriers in the National Programme on Immunization of Nigeria.