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Shiferie F, Gebremedhin S, Andargie G, Tsegaye DA, Alemayehu WA, Fenta TG. Decomposition Analysis of Socioeconomic Inequalities in Vaccination Dropout in Remote and Underserved Settings in Ethiopia. Am J Trop Med Hyg 2024; 111:196-204. [PMID: 38834055 PMCID: PMC11229642 DOI: 10.4269/ajtmh.23-0816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 03/07/2024] [Indexed: 06/06/2024] Open
Abstract
Despite increments in immunization coverage over the past decades, substantial inequality due to wealth status has persisted in Ethiopia. This study aimed to decompose the concentration index into the contributions of individual factors to socioeconomic inequalities of childhood vaccination dropout in remote and underserved settings in Ethiopia by using a decomposition approach. A wealth index was developed by reducing 41 variables related to women's household living standards into nine factors by using principal component analysis. The components were further totaled into a composite score and divided into five quintiles (poorest, poorer, middle, richer, and richest). Vaccination dropout was calculated as the proportion of children who did not get the pentavalent-3 vaccine among those who received the pentavalent-1 vaccine. The concentration index was used to estimate socioeconomic inequalities in childhood vaccination dropout, which was then decomposed to examine the factors contributing to socioeconomic inequalities in vaccination dropout. The overall concentration index was -0.179 (P <0.01), confirming the concentration of vaccination dropout among the lowest wealth strata. The decomposition analyses showed that wealth index significantly contributed to inequalities in vaccination dropout (49.7%). Place of residence also explained -16.2% of the inequality. Skilled birth attendance and availability of a health facility in the kebele (the lowest administrative government structure) also significantly contributed (33.6% and 12.6%, respectively) to inequalities in vaccination dropout. Wealth index, place of residence, skilled birth attendance, and availability of a health facility in the kebele largely contributed to the concentration of vaccination dropout among the lowest wealth strata. Policymakers should address vaccination inequality by designing more effective strategies.
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Affiliation(s)
- Fisseha Shiferie
- Project HOPE Ethiopia Country Office, Addis Ababa, Ethiopia
- School of Pharmacy, Addis Ababa University, Addis Ababa, Ethiopia
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Ntambue Malu E, Magazani AN, Kasonga JB, Mudipanu A, Kabamba Nzaji M, Ishoso DK, Nkamba DM. Correlates of Zero-Dose Status among Children Aged 12-23 Months in the Luambo Health District, Democratic Republic of Congo: A Matched Case-Control Study. Vaccines (Basel) 2024; 12:700. [PMID: 39066338 PMCID: PMC11281712 DOI: 10.3390/vaccines12070700] [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: 01/30/2024] [Revised: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 07/28/2024] Open
Abstract
(1) Background: "Zero-dose" (ZD) refers to a child who has not received any doses of the pentavalent (diphtheria-tetanus-pertussis-Haemophilus influenzae type b (Hib)-hepatitis B) vaccine. ZD children are vulnerable to vaccine-preventable diseases (VPDs). Luambo health district (HD) is one of 26 HDs in Kasai Central Province in Democratic Republic of the Congo and had the largest number of ZD children in 2021. This study was conducted to identify factors associated with ZD status among children in Luambo HD. (2) Methods: We conducted a mixed-methods study of children aged 12-23 months in Luambo HD. (3) Results: A total of 445 children aged 12-23 months were included in the study, including 89 cases and 356 controls. Children who were born in Angola (AOR = 3.2; 95% CI = 1.1 to 9.8; p = 0.046), born at home (AOR = 5.2; 95% CI = 2.1 to 12.5; p < 0.001), whose mothers did not receive antenatal care (AOR = 4.4; 95% CI = 1.2 to 16.3; p = 0.023), or did not know any vaccine preventable disease (AOR = 13.3; 95% CI = 4.6 to 38.4; p < 0.001) were more likely to be ZD than their counterparts. In addition, perceptions of children's parents influenced child immunization. (4) Conclusions: Factors associated with being a ZD child suggest inequalities in vaccination that need to be addressed through appropriate interventions. Maternal and child health services need to be strengthened while also targeting children's fathers. This will make it possible to considerably reduce the proportion of ZD and undervaccinated children and effectively fight against VPDs.
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Affiliation(s)
- Esperent Ntambue Malu
- Kasaï Central Provincial Health Division, Ministry of Public Health, Hygiene and Prevention, Kananga 05101, Democratic Republic of the Congo
| | - Alain Nzanzu Magazani
- African Field Epidemiology Network (AFENET), Kinshasa 01207, Democratic Republic of the Congo;
| | - Jean Bosco Kasonga
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa 01302, Democratic Republic of the Congo; (J.B.K.); (D.K.I.); (D.M.N.)
| | - Adèle Mudipanu
- United Nations International Children’s Emergency Fund (UNICEF) Country Office, Kinshasa 01204, Democratic Republic of the Congo;
| | - Michel Kabamba Nzaji
- Expanded Program of Immunization, Kinshasa 01208, Democratic Republic of the Congo;
| | - Daniel Katuashi Ishoso
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa 01302, Democratic Republic of the Congo; (J.B.K.); (D.K.I.); (D.M.N.)
- World Health Organization (WHO) Country Office, Kinshasa 01205, Democratic Republic of the Congo
| | - Dalau Mukadi Nkamba
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa 01302, Democratic Republic of the Congo; (J.B.K.); (D.K.I.); (D.M.N.)
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Mboussou F, Kada S, Danovaro-Holliday MC, Farham B, Gacic-Dobo M, Shearer JC, Bwaka A, Amani A, Ngom R, Vuo-Masembe Y, Wiysonge CS, Impouma B. Status of Routine Immunization Coverage in the World Health Organization African Region Three Years into the COVID-19 Pandemic. Vaccines (Basel) 2024; 12:168. [PMID: 38400151 PMCID: PMC10891650 DOI: 10.3390/vaccines12020168] [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: 11/16/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 02/25/2024] Open
Abstract
Data from the WHO and UNICEF Estimates of National Immunization Coverage (WUENIC) 2022 revision were analyzed to assess the status of routine immunization in the WHO African Region disrupted by the COVID-19 pandemic. In 2022, coverage for the first and third doses of the diphtheria-tetanus-pertussis-containing vaccine (DTP1 and DTP3, respectively) and the first dose of the measles-containing vaccine (MCV1) in the region was estimated at 80%, 72% and 69%, respectively (all below the 2019 level). Only 13 of the 47 countries (28%) achieved the global target coverage of 90% or above with DTP3 in 2022. From 2019 to 2022, 28.7 million zero-dose children were recorded (19.0% of the target population). Ten countries in the region accounted for 80.3% of all zero-dose children, including the four most populated countries. Reported administrative coverage greater than WUENIC-reported coverage was found in 19 countries, highlighting routine immunization data quality issues. The WHO African Region has not yet recovered from COVID-19 disruptions to routine immunization. It is critical for governments to ensure that processes are in place to prioritize investments for restoring immunization services, catching up on the vaccination of zero-dose and under-vaccinated children and improving data quality.
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Affiliation(s)
- Franck Mboussou
- World Health Organization, Regional Office for Africa, Brazzaville P.O. Box 06, Congo
| | | | | | - Bridget Farham
- World Health Organization, Regional Office for Africa, Brazzaville P.O. Box 06, Congo
| | - Marta Gacic-Dobo
- World Health Organization Headquarters, Avenue Appia 20, 1211 Geneva, Switzerland
| | | | - Ado Bwaka
- World Health Organization, Regional Office for Africa, Brazzaville P.O. Box 06, Congo
| | - Adidja Amani
- World Health Organization, Regional Office for Africa, Brazzaville P.O. Box 06, Congo
| | - Roland Ngom
- World Health Organization, Regional Office for Africa, Brazzaville P.O. Box 06, Congo
| | - Yolande Vuo-Masembe
- World Health Organization, Regional Office for Africa, Brazzaville P.O. Box 06, Congo
| | - Charles Shey Wiysonge
- World Health Organization, Regional Office for Africa, Brazzaville P.O. Box 06, Congo
| | - Benido Impouma
- World Health Organization, Regional Office for Africa, Brazzaville P.O. Box 06, Congo
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Fullman N, Correa GC, Ikilezi G, Phillips DE, Reynolds HW. Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children. Vaccines (Basel) 2023; 11:647. [PMID: 36992231 PMCID: PMC10056845 DOI: 10.3390/vaccines11030647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Understanding past successes in reaching unvaccinated or "zero-dose" children can help inform strategies for improving childhood immunization in other settings. Drawing from positive outlier methods, we developed a novel approach for identifying potential exemplars in reducing zero-dose children. METHODS Focusing on 2000-2019, we assessed changes in the percentage of under-one children with no doses of the diphtheria-tetanus-pertussis vaccine (no-DTP) across two geographic dimensions in 56 low- or lower-middle-income countries: (1) national levels; (2) subnational gaps, as defined as the difference between the 5th and 95th percentiles of no-DTP prevalence across second administrative units. Countries with the largest reductions for both metrics were considered positive outliers or potential 'exemplars', demonstrating exception progress in reducing national no-DTP prevalence and subnational inequalities. Last, so-called "neighborhood analyses" were conducted for the Gavi Learning Hub countries (Nigeria, Mali, Uganda, and Bangladesh), comparing them with countries that had similar no-DTP measures in 2000 but different trajectories through 2019. RESULTS From 2000 to 2019, the Democratic Republic of the Congo, Ethiopia, and India had the largest absolute decreases for the two no-DTP dimensions-national prevalence and subnational gaps-while Bangladesh and Burundi registered the largest relative reductions for each no-DTP metric. Neighborhood analyses highlighted possible opportunities for cross-country learning among Gavi Learning Hub countries and potential exemplars in reducing zero-dose children. CONCLUSIONS Identifying where exceptional progress has occurred is the first step toward better understanding how such gains could be achieved elsewhere. Further examination of how countries have successfully reduced levels of zero-dose children-especially across variable contexts and different drivers of inequality-could support faster, sustainable advances toward greater vaccination equity worldwide.
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Affiliation(s)
- Nancy Fullman
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - Gustavo C. Correa
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, Le Grand-Saconnex, 1218 Geneva, Switzerland
| | - Gloria Ikilezi
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - David E. Phillips
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - Heidi W. Reynolds
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, Le Grand-Saconnex, 1218 Geneva, Switzerland
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Johns NE, Kirkby K, Goodman TS, Heidari S, Munro J, Shendale S, Hosseinpoor AR. Subnational Gender Inequality and Childhood Immunization: An Ecological Analysis of the Subnational Gender Development Index and DTP Coverage Outcomes across 57 Countries. Vaccines (Basel) 2022; 10:vaccines10111951. [PMID: 36423046 PMCID: PMC9698767 DOI: 10.3390/vaccines10111951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022] Open
Abstract
The role of gender inequality in childhood immunization is an emerging area of focus for global efforts to improve immunization coverage and equity. Recent studies have examined the relationship between gender inequality and childhood immunization at national as well as individual levels; we hypothesize that the demonstrated relationship between greater gender equality and higher immunization coverage will also be evident when examining subnational-level data. We thus conducted an ecological analysis examining the association between the Subnational Gender Development Index (SGDI) and two measures of immunization-zero-dose diphtheria-tetanus-pertussis (DTP) prevalence and 3-dose DTP coverage. Using data from 2010-2019 across 702 subnational regions within 57 countries, we assessed these relationships using fractional logistic regression models, as well as a series of analyses to account for the nested geographies of subnational regions within countries. Subnational regions were dichotomized to higher gender inequality (top quintile of SGDI) and lower gender inequality (lower four quintiles of SGDI). In adjusted models, we find that subnational regions with higher gender inequality (favoring men) are expected to have 5.8 percentage points greater zero-dose prevalence than regions with lower inequality [16.4% (95% confidence interval (CI) 14.5-18.4%) in higher-inequality regions versus 10.6% (95% CI 9.5-11.7%) in lower-inequality regions], and 8.2 percentage points lower DTP3 immunization coverage [71.0% (95% CI 68.3-73.7%) in higher-inequality regions versus 79.2% (95% CI 77.7-80.7%) in lower-inequality regions]. In models accounting for country-level clustering of gender inequality, the magnitude and strength of associations are reduced somewhat, but remain statistically significant in the hypothesized direction. In conjunction with published work demonstrating meaningful associations between greater gender equality and better childhood immunization outcomes in individual- and country-level analyses, these findings lend further strength to calls for efforts towards greater gender equality to improve childhood immunization and child health outcomes broadly.
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Affiliation(s)
- Nicole E. Johns
- Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Katherine Kirkby
- Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Tracey S. Goodman
- Department of Immunization, Vaccines, and Biologicals, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Shirin Heidari
- Department of Immunization, Vaccines, and Biologicals, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Jean Munro
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, Le Grand-Saconnex, 1218 Geneva, Switzerland
| | - Stephanie Shendale
- Department of Immunization, Vaccines, and Biologicals, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Ahmad Reza Hosseinpoor
- Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
- Correspondence:
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